[Senate Hearing 115-608]
[From the U.S. Government Publishing Office]
MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2018
----------
WEDNESDAY, JUNE 21, 2017
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 2:31 p.m. in room SD-124, Dirksen
Senate Office Building, Hon. Jerry Moran (chairman) presiding.
Present: Senators Moran, Murkowski, Hoeven, Collins,
Boozman, Capito, Rubio, Schatz, Tester, Murray, Udall, Baldwin,
and Murphy.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY
ACCOMPANIED BY:
POONAM L. ALAIGH, M.D., ACTING UNDER SECRETARY FOR HEALTH,
VETERANS HEALTH ADMINISTRATION
THOMAS J. MURPHY, ACTING UNDER SECRETARY FOR BENEFITS, VETERANS
BENEFITS ADMINISTRATION
RONALD E. WALTERS, INTERIM UNDER SECRETARY FOR MEMORIAL
AFFAIRS, NATIONAL CEMETERY ADMINISTRATION
MARK W. YOW, CHIEF FINANCIAL OFFICER, VETERANS HEALTH
ADMINISTRATION
opening statement of senator jerry moran
Senator Moran. Good afternoon. The subcommittee will come
to order.
Mr. Secretary, welcome.
This is our seventh subcommittee hearing of 2017. Thank you
all for being here today, and we are going to discuss the
fiscal year 2018 and 2019 budget requests for the Department of
Veterans Affairs.
As far as Federal domestic spending goes, in this year's
budget cycle, the Department of Veterans Affairs is in a more
comfortable place. With a $4.4 billion or 6 percent funding
increase for the Department, the budget request before us
today, in light of the circumstances of everyone else, could be
considered generous.
I have always believed, however, that the Department's
stewardship of those funds is the real issue at hand, not just
the dollar amount. And I want to hear today from the VA how it
plans to improve cost estimating, manage spending more
prudently and to be more transparent with Congress.
Most of us are aware there is a question before this
subcommittee and the Oversight Committee, of which I am also a
member, the Senate Veterans Affairs Committee, about additional
needs for this year, fiscal year 2017; and next year, fiscal
year 2018, in Community Care discretionary spending and the
Veterans Choice Program, which is mandatory spending.
I hope progress is being made on the authorizing side on
this problem as we speak. Efforts are underway, but I want to
hear from you today, Mr. Secretary, how we can help avoid
situations where you do not have the funds needed to provide
the care that veterans expect.
I hope today's hearing will cover all aspects of the VA and
urge my colleagues to leave no stone unturned. We will look
forward to hearing about the very recent decision on the
electronic health record system, a decision, Mr. Secretary,
that I commend you for making, your plans to decrease veteran
suicide and protect veterans from over-prescription of opioids;
how we can be of help in increasing access to care through
increasing internal VA care and improving care in the
community, especially in my world for rural veterans. And we
are also interested in hearing about your increased efforts in
regard to telemedicine. In your efforts also, Mr. Secretary, it
will be good to hear about the appeals backlog and modernizing
the disability claim appeals process.
As I have mentioned to you before, at our last hearing, Mr.
Secretary, and in all of our personal conversations, I hope you
take the opportunity today to talk about the needs and
constraints you have financially, as well as all the needs and
constraints you have statutorily. And your openness today will
help us best help you and the veterans that we all desire to
serve.
Let me introduce the panel. The panel is the Honorable
David J. Shulkin, M.D., the Secretary of the Department of
Veterans Affairs. He is accompanied today by Poonam Alaigh,
M.D., the Acting Under Secretary for Health at the Veterans
Health Administration; Mr. Thomas J. Murphy, the Acting Under
Secretary for Benefits at the Veterans Benefits Administration;
and Ronald E. Walters, the Interim Under Secretary for Memorial
Affairs at the National Cemetery Administration.
Welcome to all of you.
There are a number of other VA experts in the room as well,
and we are delighted to have them and we look forward to
whatever expertise they can provide you, Mr. Secretary, and us
as we discuss these issues.
[The statement follows:]
Prepared Statement of Senator Jerry Moran
Welcome to our seventh subcommittee hearing of 2017. The
subcommittee will come to order. Good afternoon. Thank you all for
being here today to discuss the fiscal year 2018 and the fiscal year
2019 budget request for the Department of Veterans Affairs.
As far as Federal domestic spending goes, in this year's budget
cycle, the Department of Veterans Affairs is in a comfortable place.
With a $4.4 billion or 6 percent funding increase for the department,
the budget request before us today is generous. I have always believed,
however, that the department's stewardship of those funds, rather than
the dollar amount, is the real issue at hand.
I want to hear from you today about how the VA plans to improve
cost estimating, manage spending more prudently and be more transparent
with Congress. Most of us are aware there is a question before this
subcommittee and the Senate Veterans Affairs Committee--also
responsible for oversight of the department--about additional needs
this year and next year in community care discretionary spending and
the Veterans Choice Program mandatory spending.
I know progress is being made over on the authorizing side on this
problem as we speak. I support these efforts, but I want to hear from
you today how we can help you avoid situations where you don't have the
funds needed to provide the care veterans expect.
I hope today's hearing will cover all aspects of VA, and I urge my
colleagues to leave no stone unturned. We look forward to hearing about
the very recent decision on the electronic health record system--a
decision, Mr. Secretary, I commend you for making--your plans to
decrease veterans suicide and protect veterans from the over
prescription of opioids; how we can help you increase access to care--
through increasing internal VA care and improving care in the
community--especially for our rural veterans coupled with your efforts
to increase telemedicine--issues this subcommittee cares very deeply
about; and your efforts to address the appeals backlog by modernizing
the disability claims appeals process.
As you I've mentioned to you before, at our last hearing with you,
Mr. Secretary, and in our personal conversations, I hope you take the
opportunity today to talk about the needs and constraints you have
financially as well as the needs and constraints you have statutorily.
Your openness today will help us know how to best help you.
I'd like to introduce our panel:
--A welcome back to the Secretary--the Honorable David J. Shulkin,
MD, is the Secretary of the Department of Veterans Affairs. He
is accompanied by:
--Poonam L. Alaigh, M.D., the Acting Under Secretary for Health at
the Veterans Health Administration;
--Mr. Thomas J. Murphy, the Acting Under Secretary for Benefits at
the Veterans Benefits Administration; and
--Mr. Ronald E. Walters, the Interim Under Secretary for Memorial
Affairs at the National Cemetery Administration. Welcome to all
of you.
I note there are quite a few other VA experts seated behind the
panel who are present today to support this hearing, and I thank you
for being here.
Senator Moran. I now recognize my colleague and friend, the
Senator from Hawaii, for his opening remarks.
OPENING STATEMENT OF SENATOR BRIAN SCHATZ
Senator Schatz. Thank you, Mr. Chairman. Thank you for
holding this hearing to review the VA's fiscal year 2018 budget
request and the 2019 advanced appropriation request. We have
had a number of important hearings over the last few months to
shape our appropriations bill, and I want to thank you for your
leadership and our great partnership.
This process, our process, stands in contrast to the way
our Republican colleagues plan to bring a healthcare bill to
the Floor next week. There have been no hearings or public
discussion. Americans are still left in the dark. Members of
the Senate are still left in the dark. This is not the way to
make a law impacting one-sixth of the economy.
We know that the House bill would be a disaster, and we
also know that the VA will not be spared from this bill,
including any proposed cuts to Medicaid that will likely affect
veterans' health care and possibly shift costs to VA. I am
hoping we can find a few Republican Senators who simply refuse
to vote for a bill for which there was no hearing. I hope they
will.
Secretary Shulkin, thank you for being here to discuss the
VA's budget request. I am glad to see VA's discretionary
funding is up $4.3 billion from last year. The administration's
increased request is driven almost solely by the demand for
more funding to cover the medical care accounts and a
recognition of the responsibility to pay for the growing
healthcare demands of veterans, even while it has proposed cuts
to almost all other domestic agencies.
I am worried, however, that the proposed increase may not
be enough but that it is paid for with cuts to other important
veteran programs, as well as other domestic accounts. Much of
the fault lies with Congress, which has refused to lift the
ridiculous BCA (Budget Control Act) caps. We need to lift them
so that we can pass an entire 2018 budget.
But the VA is also responsibility for the situation that we
find ourselves in today, and I have some concerns about whether
this budget is enough. The VA has encountered significant
unplanned costs since it submitted its budget, including an
unexpected surge in the use of Choice, which is now forecasted
to run out of money by the end of the fiscal year, resulting in
the need for an infusion of hopefully mandatory funding relief.
The VA has also decided not to appeal the judicial ruling
that holds VA responsible for the payment of veterans'
emergency care at non-VA facilities. I think that is the right
decision. And the VA has decided to pursue an electronic health
record contract that was not budgeted for in the request. And I
do not disagree with these decisions, but they are not
inexpensive.
I have concerns with the proposed funding distribution in
the budget request. For example, the request proposes an
increase in funding for about a half-a-billion for Medical
Services, which, as far as I can tell, does not account for
annualizing the cost of the medical care providers hired under
Choice or any other increase in utilization in in-house VA
services.
I also have concerns that hit closer to home. Dr. Shulkin,
top of the list for me is the status of a proposed one-stop-
shop community-based outpatient clinic in Hilo. I will submit a
question for the record that I would like to pursue with you,
but the bottom line is I want to know where VA is on getting a
new CBOC for Hilo because this is the highest priority for Big
Island veterans. This project has been in the VA's SCIP
pipeline for years.
I know there are very many worthy competing projects, but
you should know that our veterans in Hilo are currently
visiting a CBOC that has to move because it is in a tsunami
flood zone. We have unique circumstances. The VA leased a
temporary space in an industrial part of Hilo that it plans to
move into next year, but our veterans tell me--and I know--it
is hard to get to and, quite simply, too many of them will not
want to use it once the VA moves. This situation is not
acceptable and we need to fix it. If developing a one-stop-shop
CBOC in Hilo means that more veterans will feel encouraged to
utilize care that is the kind of access to care that the SCIP
process should take into consideration.
The VA also needs to invest even more in telehealth and
remote patient monitoring. You have done great work, but let us
try to find opportunities to do more. And I did appreciate
hearing from you about how VA is leading on telehealth.
Thank you, Secretary Shulkin. Thank you, Mr. Chairman. I
look forward to your testimony.
Senator Moran. Thank you, Senator Schatz.
Mr. Secretary, welcome, and I recognize you now for your
opening statement.
SUMMARY STATEMENT HON. DR. DAVID J. SHULKIN
Secretary Shulkin. Thank you. Mr. Chairman, Ranking Member
Schatz, thank you both for your opening statements. I think you
raised really important issues, and I think you are encouraging
us to have a candid conversation today, which I know we can do
and it will be productive.
And, Ranking Member Schatz, we will certainly get back to
you about Hilo. I understand the concern that you have over
making the right decision there, and I would be glad to talk
more about the SCIP process and telehealth and any of the other
issues that you have. If it is just the two of you, you will
have lots of time for questions and we can have a good
conversation.
I think you know my intent as the Secretary is really to
build an integrated healthcare system that provides veterans
with high-quality care when they need it and where they need
it, whether it is at the VA or in the high-performing Community
Care network. And I think that is what this budget that the
President has submitted is designed to do. It is not designed
to privatize VA. It is designed to provide veterans the best
care available in the most timely fashion.
The challenge is to balance those resources year to year to
meet the changing demands of care. More veterans are now coming
to VA for more of their care and more are also opting for
Choice. Since January 1, we have authorized over 8.2 million
Community Care appointments. That is 2.6 million more than last
year or a 46 percent increase. This past March, April, May were
the highest months ever for Choice usage. And that is why we
are asking for more Community Care funding for fiscal year
2018.
But, as I said before, that does not mean that we are
privatizing VA. So, let me be clear on what this budget says.
Perfect timing, Senator Tester, so we can go over these
numbers. For fiscal year 2018, we expect to spend over $50
billion on VA Medical Services and just $12.6 billion on
Community Care. So, when you count all the sources of funding,
that is our direct appropriations, carryover, transfers in and
out, or medical care collections and reimbursements, when you
count all of those, we are talking about an 8.3 percent
increase for Community Care versus a 5.7 percent increase in VA
Medical Services.
And I think, Senator Tester, one of the reasons why we
sometimes have different numbers, we are putting in not just
the appropriations but we are putting in our full budget
amount, which includes the carryovers and the collections and
other dollars.
So, let me just go over that again. The 8.3 percent
increase in Community Care is $965 million more in this year's
proposed budget. The 5.7 percent increase in Medical Services,
what the VA is getting, is $2.7 billion, so that is $965
million versus $2.7 billion, so in total dollars the Medical
Services is increasing three times the amount that is going to
Community Care.
Let me talk about another issue. Again, we are having to
shift funds among our many separate Community Care accounts to
cover our obligations. Two years ago, which I am sure you
remember well, we had to shift funds from the Choice account to
cover obligations in the Community Care accounts. Now, we are
doing this in reverse to cover our increased use of Choice.
The necessity of those shifts is a product of the
unpredictability of Community Care charges, charges that
fluctuate month to month. A single authorization for Community
Care can cover one, two, three or more appointments. The
authorization might never be used or the authorization might be
used 3 months after it was issued. VA might not get the bill
for many months after that.
The even bigger part of the problem is the fact that we
have so many accounts and so little flexibility in how we
manage them, our proposed veterans CARE program--remember, that
stands for Coordinated Access Rewarding Experience, the CARE
program--would solve this recurring problem permanently by
modernizing and consolidating all of our Community Care
accounts, Choice included.
The President's budget would address this problem in 2018
and 2019 by providing additional funds for Choice and the
necessary resources for continuing our ongoing modernization of
VA. The budget reflects the President's strong personal
commitment to the Nation's veterans. It requests $186.5 billion
for VA, $104.3 billion in mandatory funding, $82.1 billion in
discretionary funding for a total increase of $6.4 billion, or
3.6 percent over 2017. It provides $2.9 billion in mandatory
funding to continue the Choice program in 2018, plus a 7.1
percent increase in discretionary funding for VHA to improve
patient access and timeliness of care.
It supports the strengthening of our foundational services,
as well as the modernization and consolidation of VA Community
Care through the veterans' CARE program announced two weeks
ago, so veterans can make the right decisions about their care,
together with their provider, giving them yet another reason to
choose VA.
We are already taking many steps to move VA modernization
forward in accountability, transparency, same-day services,
online access, suicide prevention, and other areas. And I
detailed several of these in the State of the VA talk that I
gave at the White House last month.
But to keep up our modernization momentum, we need your
help. We have identified over 1,000 facilities that are vacant
or underutilized. We are working now to dispose of 142
facilities, and with your help, we could do many more.
We need Congress to fund our IT modernization to keep our
legacy systems from failing and to replace our Vista system
with the system in use by DOD called MHS GENESIS. This will
ultimately put all patient data in one shared system, enabling
seamless care between VA and DOD without the manual and
electronic exchange and reconciliation of data that we
currently do in our separate systems.
We also need Congress to authorize the overhaul of our
broken and failing claims appeals process. We have worked
closely with VSOs and other stakeholders to draft a proposal to
modernize the system, and we are very pleased to see the House
unite behind the bill passed last month. Now, we just need the
Senate to act.
Most of all, we need Congress to ensure the continued
success of choice for veterans. Veterans are responding to our
modernization effort by choosing VA more than ever. To keep up
with their choices, we need you to fully fund Choice and help
us modernize and consolidate VA community care through the
Veterans Choice program. The Veterans CARE program will
coordinate care so veterans get the right care at the right
time from the right provider whether in a VA facility or a
high-performing VA community care provider. We just need your
help to make it happen, including funding to keep up with the
veterans as they choose VA.
I would like to close on this note: VA's mission is to care
for veterans and their families. To me, that is what the VA
budget process is, a discussion that we make sure that we have
the right things for veterans, their families, and taxpayers. I
do not support any policy that will hurt veterans or their
families, so when it comes to discussions about offsets like
individual unemployability, we have heard from veterans and we
will work with Congress to find other solutions.
Thank you, and we look forward to your questions.
[The statement follows:]
Prepared Statement of Hon. David J. Shulkin, M.D.
Good morning, Chairman Moran, Ranking Member Schatz, and
Distinguished Members of the Subcommittee. Thank you for the
opportunity to testify today in support of the President's 2018 Budget
and 2019 Advance Appropriation (AA) Request and to define my priorities
to continue the dynamic transformation within the Department of
Veterans Affairs (VA). I am accompanied today by Dr. Poonam L. Alaigh,
Acting Under Secretary for Health; Thomas Murphy, Acting Under
Secretary for Benefits; and Ron Walters, Interim Under Secretary for
Memorial Affairs. I also want to thank Congress for providing the
Department its full 2017 budget prior to the start of the fiscal year--
this is significant and has been extremely beneficial to our ability to
provide services and care to Veterans. The 2018 budget request fulfills
the President's strong commitment to all of our Nation's Veterans by
providing the resources necessary for improving the care and support
our Veterans have earned through sacrifice and service to our country.
fiscal year 2018 budget request
The President's 2018 budget requests $186.5 billion for VA--$82.1
billion in discretionary funding (including medical care collections),
of which $66.4 billion was previously provided as the 2018 AA for
Medical Care. The discretionary request is an increase of $4.3 billion,
or 5.5 percent, over 2017. It will improve patient access and
timeliness of medical care services for over 9 million enrolled
Veterans, while improving benefits delivery for our Veterans and their
beneficiaries. The President's 2018 budget also requests $104.3 billion
in mandatory funding, of which $103.9 billion was previously provided,
such as disability compensation and pensions, and for continuation of
the Veterans Choice Program (Choice Program).
For the 2019 AA, the budget requests $70.7 billion in discretionary
funding for Medical Care and $107.7 billion in 2019 mandatory advance
appropriations for Compensation and Pensions, Readjustment Benefits,
and Veterans Insurance and Indemnities benefits programs in the
Veterans Benefits Administration. The budget also requests $3.5 billion
in mandatory budget authority in 2019 for the Choice Program.
This budget request will ensure the Nation's Veterans receive high-
quality healthcare and timely access to benefits and services. I urge
Congress to support and fully fund our 2018 and 2019 AA budget
requests--these resources are critical to enabling the Department to
meet the increasing needs of our Veterans.
modernizing va
As you all know, I was part of the VA team for the last year and a
half prior to being confirmed as the Secretary of Veterans Affairs. I
came to VA during a time of crisis, when it was clear Veterans were not
getting the timely access to high-quality healthcare they deserved. I
soon discovered that years of ineffective systems and deficiencies in
workplace culture led to these problems. I know that the organization
has made significant progress in improving care and services to
Veterans. But I also know that VA needs more changes to the way we do
business for Veterans and the country as a whole, in order for all to
say, ``That is a different organization now.'' VA needs to continue to
fix numerous areas of the business, including access, claims and
appeals processing, and many of our core functions, to ensure that the
basics are done correctly. Beyond that, VA has to deliver to Veterans
revolutionary leaps in care, benefits, and services. Congress, along
with our VA employees, Veterans Service Organizations (VSO), and
private industry, will play a critical role in making those
revolutionary leaps a reality.
Focus on Execution
Above all else, VA needs to perform its core functions well. When
Veterans arrive at a VA facility for care, they must be treated with
respect, see a clean and modern facility, be seen by their provider on
time, and understand what the next steps for their care will be.
Veterans should be able to receive clear and accurate information about
their claims and understand where they are in the process. We must
ensure that this is every Veteran's experience every time they interact
with VA. Where we fall short, we will hold employees accountable,
ensure we are good stewards of the taxpayer dollar, and ask for
Congress's support for legislative fixes where needed.
Make Bold Change
We know it is paramount that we increase our focus and intensify
the efforts to improve how we execute our mission--Veterans should and
do expect that from us. We also recognize that incremental change is
not sufficient to achieve the additional improvements VA and Veterans
need and demand for restoring the trust of Veterans and the American
public.
As I have noted, VA is a unique national resource that is worth
saving, and I am committed to doing just that. Veterans have unique
needs, and the services VA provides to Veterans often cannot be found
in the private sector. The Veterans Health Administration (VHA)
provides support to Veterans through primary care, specialty care, peer
support, crisis lines, transportation, the Caregivers program,
homelessness services, vocational support, behavioral health
integration, medication support, and a VA-wide electronic medical
record system. These services and supports are unparalleled. We also
know that VA hospitals perform well on quality compared to non-VA
hospitals. In a study published in the Journal of American Medical
Association (JAMA) Internal Medicine in April, researchers compared
hospital-level quality data on 129 VA hospitals and 4,010 non-VA
hospitals obtained through the Centers for Medicare and Medicaid's
website. They found VA hospitals had better outcomes than non-VA
hospitals on six of nine patient safety indicators, and there were no
significant differences on the other three indicators. VA hospitals
also had better mortality and readmission rates than non-VA hospitals.
With the continued support of Congress, VA will supplement its services
through private-sector healthcare, but we realize it is not a
replacement for the services VA provides to Veterans.
We are already implementing bold changes in the agency. We are
working hard to ensure employees are held accountable to the highest of
standards and working with Congress to provide us with greater
authority and flexibility to do that. We are also working with Congress
on appeals reform and on a long-term solution for providing greater
community care options. I will discuss these efforts in greater detail
below.
five priorities
As I prepared for my confirmation hearing earlier this year, I
identified my top priorities to address as Secretary. These areas have
shaped the first several months of my tenure and provide focus for our
attention and resources, and the foundation for rebuilding trust with
our Veterans. We will also use the budgeting process to support our
strategy by shifting resources toward our ``foundational services''
that make VA unique while maintaining support to our strategic
priorities.
greater choice for veterans
The Choice Program is a critical program that has increased access
to care for millions of Veterans. Coming into this new administration,
extending the Choice Program was one of my top priorities for quick
action, as VA anticipated that based on Veteran program participation,
there would be an estimated $1.1 billion in unobligated funds left on
the original expiration date of August 7, 2017. On April 19, 2017, the
President signed into law the Veterans Choice Program Improvement Act
(Public Law 115-26), allowing the Choice Program to continue until the
Veterans Choice Fund is exhausted. Without this legislation, VA would
have been unable to use funding specifically appropriated for the
Choice Program by Congress, so we commend Congress for passing this
legislation swiftly and in a bipartisan manner. This legislation also
provides VA and Congress more time to develop a long-term solution for
community care.
Since the start of the Choice Program, over 1.6 million Veterans
have received care through the program. In fiscal year 2015, VA issued
more than 380,000 authorizations to Veterans through the Choice
Program. In fiscal year 2016, VA issued more than 2,000,000
authorizations to Veterans to receive care through the Choice Program,
more than a fivefold increase in the number of authorizations from 2015
to 2016.
Looking at early data for 2017, it is expected that Veterans will
benefit even more this year than last year from the Choice Program. In
the first quarter of fiscal year 2017, we have seen a more than 30
percent increase from the same period in fiscal year 2016 in terms of
the number of Choice authorizations. In addition to increasing the
number of Veterans accessing care through the Choice Program, VA is
working to increase the number of community providers available through
the program. In April 2015, the Choice Program network included
approximately 200,000 providers and facilities. As of March 2017, the
Choice Program network has grown to over 430,000 providers and
facilities, a more than 150 percent increase during this time period.
As these numbers demonstrate, demand for community care is high. In
2018, VA plans to spend a total of $13.2 billion to support community
care for Veterans. Community care will be funded by a discretionary
appropriation of $9.4 billion for the Medical Community Care account
($254 million above the enacted advance appropriation), plus $2.9
billion in new mandatory budget authority for the Choice Program. As
stated in the budget request, this, combined with an estimated $626
million in carryover balances in the Veterans Choice Fund, would have
provided a total of $13.2 billion in 2018 for community care. However,
as of June 9, 2017, $9.2 billion of the Choice Fund has been obligated
and $7.1 billion has been expended. These levels represent a
significant acceleration of funds being expended from the Veterans
Choice Fund, and consequently, I have updated the estimates VA
previously put forth regarding when Choice Program funds would be fully
obligated.
In March 2017, VA issued the highest number of authorizations in a
month since the start of the program, followed closely by April and
May. Over the 3 month period between March and May 2017, VA issued
nearly 800,000 authorizations for Choice Program care, a 32-percent
increase over the same time period in 2016. As a result, VA anticipates
that Choice Program funds will be fully obligated sooner than
previously expected. Based on VA's latest risk-adjusted cost estimates
and volume projections, the program will be unable to carry over the
previously estimated $626 million, resulting in a need for the total
$3.5 billion in new mandatory budget authority to continue the Choice
Program in fiscal year 2018.
VA will continue to partner with Congress to develop a community
care program that addresses the challenges we face in achieving our
common goal of providing the best healthcare and benefits we can for
our Veterans. We have also worked with and received crucial input from
Veterans, community providers, VSOs, and other stakeholders in the
past, and we will continue doing so going forward. However, we do need
your help.
One such area is in modernizing and consolidating community care.
Veterans deserve better, and now is the time to get this right. We are
committed to moving care into the community where it makes sense for
the Veteran. The ultimate judge of our success will be our Veterans,
and our only measure of success will be our Veterans' satisfaction.
With your help, we can continue to improve Veterans' care in both VA
and the community.
Empower Veterans through Transparency of Information
We are also increasing transparency and empowering Veterans to make
more informed decisions about their healthcare through our new Access
and Quality Tool (available at www.accesstocare.va.gov). This Tool
allows Veterans to access the most transparent and easy to understand
wait-time and quality-care measures across the healthcare industry.
That means Veterans can quickly and easily compare access and quality
measures across VA facilities and make informed choices about where,
when, and how they receive their healthcare. Further, they will now be
able to compare the quality of VA medical centers to local private
sector hospitals. This Tool will take complex data and make it
transparent to Veterans. This new Tool will continue to improve as we
receive feedback from Veterans, employees, VSOs, Congress, and the
media.
modernizing our system
Infrastructure Improvements and Streamlining
In 2018, VA will focus on fixing VA's infrastructure while we
transform our healthcare system to an integrated network to serve
Veterans. This budget requests $512.4 million in Major Construction
funding as well as $342.6 million in Minor Construction for priority
infrastructure projects. This funding supports projects including a new
outpatient clinic in Livermore, CA, as well as gravesite expansions in
Sacramento, CA; Bushnell, FL; Elwood, IL; Calverton, NY; Phoenix, AZ;
and Bridgeville, PA. VA is also requesting $953.8 million to fund more
than 2,000 medical leases in fiscal year 2018, an increase of $141.9
million over the fiscal year 2018 AA, and $862 million for activation
of new medical facilities.In 2018, VA is seeking Congressional
authorization of 27 major medical leases. The majority of these leases
have been included in previous budget requests, some dating back to the
fiscal year 2015 budget submission. These major medical leases are
vital to establish new points of care, expand sites of care, replace
expiring leases, and expand VA's research capabilities.
The 2018 budget submission includes proposed legislative requests
that if enacted, would increase the Department's flexibility to meet
its capital needs. These proposals include: 1) increasing from $10
million to $20 million the dollar threshold for minor construction
projects; 2) modifying title 38 to eliminate statutory impediments to
acquiring joint facility projects with DoD and other Federal agencies;
and 3) expanding VA's enhanced use lease (EUL) authority to give VA
more opportunities to engage the private sector and local governments
to repurpose underutilized VA property.
The Department is also a key participant in the White House
Infrastructure Initiative to explore additional ways to modernize and
obtain needed upgrades to VA's real property portfolio to support our
continued delivery of quality care and services to our Nation's
Veterans. We are excited about the opportunity to transform the way we
approach our infrastructure.
Electronic Health Record Interoperability and IT Modernization
The 2018 Budget continues VA's investment in technology to improve
the lives of Veterans. The planned IT investments prioritize the
development of replacements for specific mission critical legacy
systems, as well as operations and maintenance of all VA IT
infrastructures essential to deliver medical care and benefits to
Veterans. The request includes $358.5 million for new development to
replace four specific mission critical legacy systems, including the
Financial Management System, and establish an Integrated Project Team
to develop the requirements and acquisition strategy for a new
enterprise health information platform. It also invests $340 million
for information security to protect Veterans' information and improve
VA's information networks' resilience.
The 2018 budget submission includes a proposed legislative request
that if enacted, would increase the Departments ability to apply agile
program management to the dynamics of modern Information Technology
development requirements. To do this, the Department recommends
advancing the transfer threshold from $1 million to $3 million between
development project lines, which equates to less than 1 percent of the
Development account. Through the Certification process, Congress will
maintain visibility of proposed changes.
VA recognizes that a Veteran's complete health history is critical
to providing seamless, high-quality, integrated care, and benefits.
Interoperability is the foundation of this capability, by making
relevant clinical data available at the point of care and enabling
clinicians to provide Veterans with prompt, effective care. Today, VHA,
the Veterans Benefits Administration (VBA), and the Department of
Defense (DoD) share more medical information than any public or private
healthcare organization in the country. We have developed and deployed,
in close collaboration with DoD, the Joint Legacy Viewer (JLV). JLV is
available to all clinicians in every VA facility. It is a web- based
user interface that provides clinicians with an intuitive display of
DoD and VA healthcare data on a single screen. VA and DoD clinicians
can use JLV to access the health records of Veterans, Active Duty, and
Reserve Servicemembers from all VA, DoD, and any third party community
providers who participate in Health Information Exchanges where a
patient has received care. Multiple releases of Community Care
applications, including JLV-Community Viewer, Community Provider
Portal, and Virtru Pro Secure Email have enhanced care coordination
with Community Providers through multiple methods of exchanging health
records and multiple modes of communication improving the care the
Veteran receives and allowing Community Providers not in Health
Information Exchanges the ability to share medical documentation.
VA will complete the next iteration of the VistA Evolution Program,
VistA 4, in 2018. VistA 4 will bring improvements in efficiency and
interoperability, and will continue VistA's award-winning legacy of
providing a safe, efficient healthcare platform for providers and
Veterans. VistA Evolution funds have enabled investments in systems and
infrastructure that support interoperability, networking and
infrastructure sustainment, continuation of legacy systems, and efforts
such as clinical terminology standardization. These investments are
critical to the maintenance and deployment of the existing and future
modernized VistA and essential to operational capability. That said our
current VistA system is in need of major modernization to keep pace
with the improvement in health information technology and
cybersecurity, and software development.
I promised a decision on our EHR system by July 1st, and I have
honored that commitment by announcing that, after much deliberation, VA
will adopt the same EHR system as DoD, now known as MHS Genesis, which
at its core consists of Cerner Millennium. VA's adoption of the same
EHR system as DoD will ultimately result in all patient data residing
in one common system and enable seamless care between the departments
without the manual and electronic exchange and reconciliation of data
between two separate systems. Still, VA has unique needs and many of
those are different from the DoD. For this reason, VA will not simply
be adopting the identical EHR that DoD uses, but we intend to be on a
similar Cerner platform. VA clinicians will be very involved in how
this process moves forward and in the implementation of the system.
Another critical system that will touch the delivery of all health
and benefits is our new financial management system, which is under
development. The 2018 budget continues modernizing our financial
management system by transforming the Department from numerous
stovepipe legacy systems to a proven, flexible, shared service business
transaction environment. The budget requests $83 million in Information
Technology funds and $61.6 million for business process re-engineering
to support Financial Management Business Transformation (FMBT) across
the Department.
focus resources more efficiently
Strengthening of Foundational Services in VA
VA is committed to providing the best access to care for Veterans.
To deliver the full care spectrum as defined in VA's medical benefits
package, VA will focus on its foundational services--those areas in
which it can excel--and build community partnerships for complementary
services. VA developed the following guiding principles, centered on
improving the health, well-being, and experience of Veterans receiving
care from VA and in the community. These principles include:
--Enabling VA to provide access to high-quality care for Veterans, by
balancing services provided by VA and the community given
changing demands for care and resource limitations;
--Promoting operational efficiency and simplicity, while supporting
VA's clinical care, education, and research missions; and
--Allowing facilities to meet the changing needs of Veterans in a
flexible way.
High-performing organizations cannot excel at every capability and
thus must make decisions about how best to invest its resources. VA
will therefore further define and grow its foundational services to
excel in the provision of clinical care to Veterans.
Investing in foundational services within the Department is not
limited to only healthcare. For over a decade, VA's National Cemetery
Administration (NCA) has achieved the highest customer satisfaction
rating of any organization--public or private--in the country. They
achieved this designation through the American Customer Satisfaction
Index six consecutive times. The President's 2018 Budget recognizes the
need to nurture and advance this unprecedented success with a request
for $306.2 million for NCA in 2018, an increase of $20 million (7
percent) over 2017. This request will support the 1,881 FTE needed to
meet NCA's increasing workload and expansion of services. In 2018, NCA
will inter approximately 133,600 Veterans and eligible family members,
care for over 3.7 million gravesites, and maintain 9,400 acres. NCA
will continue to memorialize Veterans by providing 366,000 headstones
and markers, distributing 702,000 Presidential Memorial Certificates
and expanding the Veterans Legacy program to communities across the
country. VA is committed to investing in NCA infrastructure,
particularly to keep existing national cemeteries open and to construct
new cemeteries consistent with burial policies approved by Congress. In
addition to NCA's funding, the 2018 request includes $255.9 million in
major construction funds for six gravesite expansion projects. When all
new cemeteries are opened, nearly 95 percent of the total Veteran
population--about 20 million Veterans--will have access to a burial
option in a Veterans' cemetery within 75 miles of their home.
VA/DoD/Federal Coordination
VA has proposed legislation to eliminate certain statutory
impediments to VA more effectively pursuing joint projects with other
Federal agencies, including DoD. Today, medical facilities that are not
specifically under the jurisdiction of the Secretary require specific
statutory authorization for optimal collaboration. I look forward to
working with Congress to: (1) enhance our ability to coordinate with
DoD and other Federal agencies; (2) improve the access, quality, and
cost effectiveness of direct healthcare provided to Veterans,
Servicemembers, and their beneficiaries; (3) permit joint capital asset
planning and capital investments to design, construct, and utilize
shared medical facilities; and (4) provide authority for VA to procure
the use of joint medical facilities for itself and other Federal
agencies like DoD, and to transfer funds between VA and other Federal
agencies for such initiatives.
Deliver on Accountability and Effective Management Practices
Another critical area in which VA is serious about making
significant changes relates to employee accountability. The vast
majority of employees are dedicated to providing Veterans the care they
have earned and deserve. It is unfortunate that certain employees have
tarnished the reputation of VA and so many who have dedicated their
lives to serving our Nation's Veterans. We will not tolerate employees
who deviate from VA's I-CARE values and underlying responsibility to
provide the best level of care and services to them. We support
Congress' ongoing efforts to provide VA with the tools it needs to take
timely action against employees who perform poorly or engage in
misconduct. Where employees engage in inappropriate behavior, do not
perform the duties of their job, are engaged in illegal activities, or
otherwise do not meet the standards we expect of VA employees, we want
the ability to ensure they can be promptly removed. Certain laws hamper
our ability to optimally hold our employees accountable and remove
those individuals that run afoul of my intent for the Department to
function as a high-performing organization. We support legislation that
is consistent with the following principles:
--Increase flexibility to remove, demote, or suspend VA employees for
poor performance or misconduct;
--Provide authority to recoup bonuses of employees for poor
performance or misconduct;
--Enable recovery of relocation expenses that occur through fraud or
malfeasance; and
--Ensure that VA has the ability to retain high performers by paying
them a salary that is competitive with the private sector and
performance awards that are commensurate with other Federal
agencies.
We thank the Senate for passing critical accountability
legislation, S. 1094,--all signs point to new accountability rules for
VA being the law of the land soon, but while that process continues, we
are also focused on updating internal hiring practices. VHA is the
largest healthcare system in the United States, and in an industry
where there is a national shortage of healthcare providers, VHA faces
competition with the commercial sector for scarce resources.
Historically, VA has followed hiring practices that have proven unduly
burdensome. Over the past year, VHA's business process improvement
efforts have resulted in a more efficient hiring process. We were able
to reduce the time it took to hire Medical Center Directors by 40
percent and obtained approval from the Office of Personnel Management
(OPM) for critical position pay authority for many of our senior
healthcare leaders. We recognize there is much work left to do. As we
strive to find internal solutions, we look forward to working together
on legislation to reform recruitment and compensation practices to stay
competitive with the private sector and other employers.
To ensure that VA's management practices are effective, I have
announced a major initiative to improve our ability to detect and
prevent fraud, waste, and abuse within VA. The initiative includes:
--forming a fraud, waste, and abuse advisory committee comprised of
experts from the private sector and other government
organizations;
--identifying cutting edge tools and technologies available in the
private sector; and
--coordinating all fraud, waste, and abuse detection and reporting
activities through a single office.
With these improvements, VA has the potential to save millions of
taxpayer dollars and more effectively serve America's Veterans. I look
forward to updating you in the future regarding this initiative.
improve timeliness of services
Access to Care and Wait Times
VA is committed to delivering timely and high quality healthcare to
our Nation's Veterans. Veterans now have same-day services for primary
care and mental healthcare at all VA medical centers across our system.
I am also committed to ensuring that any Veteran who requires urgent
care will receive timely care.
In March 2017, 96.82 percent of appointments, 5.15 million
appointments, were completed within 30 days of the clinically-indicated
or veteran's-preferred date, and as of April 15, 2017, VHA has reduced
and the Electronic Wait List from 56,271 entries to 22,383 entries, a
60.2 percent reduction between June 2014 and April 2017. The Electronic
Wait List reflects the total number of all patients for whom
appointments cannot be scheduled in 90 days or less.
In 2018, VA will expand Veteran access to medical care by
increasing medical and clinical staff, improving its facilities, and
expanding care provided in the community. The 2018 Budget requests a
total of $75.2 billion in funding for Veterans' medical care, which
includes the following:
--$69.0 billion in discretionary budget authority ($2.65 billion
above the 2018 AA enacted level of $66.4 billion and a $4.6
billion (7.1 percent) increase over the 2017 enacted level);
--$2.9 billion in mandatory budget authority to continue the Veterans
Choice Program; and
--$3.3 billion in medical care collections.
The 2018 request will support nearly 315,000 medical care staff, an
increase of over 7,000 above the 2017 level.
Through the Choice Program, VHA and its contractors created more
than 3.6 million authorizations for Veterans to receive care in the
private sector from February 1, 2016 through January 31, 2017. This
represents a 23 percent increase in authorizations when compared to the
period February 1, 2015 through January 31, 2016. When looking at
overall appointment data not specific to the Choice Program, the March
15, 2017, pending appointment data set shows VA has increased the
number of overall pending appointments ``in house'' by nearly 1.8
million over the same data the prior year. According to the same data,
the number of appointments scheduled greater than 30 days from the
Veterans clinically indicated data or preferred date has decreased by
3.9 percent (19,645) since the beginning of fiscal year 2017.
Accelerating Performance on Disability Claims
Since 2013, VA has made remarkable progress toward reducing the
backlog of disability compensation claims pending over 125 days and is
working to use more effectively the resources provided by Congress.
VBA's 2018 budget request of $2.8 billion allows VBA to maintain the
improvements made in claims processing over the past several years.
This budget supports the disability compensation benefits program for
4.6 million Veterans and 420,000 Survivors. VBA implemented new
professional standards for Veterans Service Representatives (VSR) on
March 1, 2017. In May 2016, VBA implemented the National Work Queue
(NWQ) process. This allows VBA to prioritize and quickly distribute
disability compensation claims according to processing capacity within
VBA's regional footprint, regardless of the Veteran's place of
residence. The NWQ process enables VA to more effectively balance the
workloads nationally, relative to the productive capacity at each
regional office. This means that Veterans who live in a location where
claims decisions take longer, VBA can appropriately adjust capacity to
match the changes in claims volume. In fiscal year 2017, VBA added non-
rating related claims to the NWQ. VBA has completed nearly 1.7 million
non-rating claims from October 2016 through the end of April 2017. The
effort to address non-rating claims has resulted in a 269,000 claim
reduction in the dependency claims inventory since August 2015, from
359,000 to less than 90,000.
To continue improving disability compensation claim processing, VBA
is currently piloting an initiative called Decision Ready Claims (DRC).
The DRC initiative offers veterans and survivors faster claims
decisions in which VSOs and other accredited representatives assist
Veterans with ensuring all supporting medical evidence is included with
the claim at the time of submission. The DRC initiative empowers
Veterans by allowing them to receive medical examinations as early as
possible in the claims process. This initiative also enhances
partnerships with VSOs by improving access and capabilities to assist
with gathering all required evidence and information to accelerate
claims decisions. Submission of claims submitted through the DRC
process will result in claim decisions within 30 days of submission to
VA.
Decisions on Appeals
The current VA appeals process undoubtedly needs further
improvements for our Nation's Veterans. As of April 30, 2017, VA had
470,546 pending appeals. The average processing time for all appeals
resolved by VA in fiscal year 2016 was approximately 3 years. For those
appeals that were decided by the Board of Veterans' Appeals (the Board)
in fiscal year 2016, on average, Veterans waited at least 6 years from
filing their Notice of Disagreement until the Board's decision was
issued that year.
The 2018 request of $155.6 million for the Board continues the
funding level enacted for 2017, which was a 42 percent increase over
2016. In combination with carryover resources from 2017, the requested
funding will support a total of 1,050 FTE, an increase of 164 FTE above
the 2017 estimate of 886 FTE. This request maintains the increased
budgetary authority the Board received in 2017. In addition, VBA's
request of $185 million for appeals processing maintains its current
level of appeals FTE at 1,495. This funding level in tandem with
sweeping legislative reform initiates a long-term strategy aimed at
improving the timeliness of appeals for Veterans and is the best policy
option for taxpayers.
Without significant legislative reform to modernize the appeals
process, Veteran wait times and the cost to taxpayers will only
increase. Comprehensive legislative reform is necessary to replace the
current lengthy, complex, confusing VA appeals process with a new
process that makes sense for Veterans, their advocates, VA, and other
stakeholders. This reform is crucial to enable VA to provide the best
service to Veterans and is one of my top priorities.
VA worked collaboratively with VSOs and other stakeholders to
design this new process for Veterans who disagree with a VA decision.
The result of that work was a legislative proposal that was introduced
in the 114th Congress and has been reintroduced in the 115th Congress.
The proposed process: (1) establishes multiple options for Veterans
instead of the single option available today; (2) provides early
resolution of disagreements and improved notice as to which option
might be best; (3) eliminates the inefficient churning of appeals that
is inherent in the current process; (4) features quality feedback loops
to VBA; and (5) improves transparency by clearly defining VBA as the
claims agency and the Board as the appeals agency in VA. This clear
definition between VBA and the Board also provides workload
transparency for better workload/resource projections, and efficient
use of resources for long-term savings.
The new process, described in the legislation currently pending,
will provide a modernized process going forward. However, VA is also
committed to concurrently reducing the pending inventory of legacy
appeals. VA has worked collaboratively with stakeholders to identify
opt-ins that would make the new process available to Veterans who would
otherwise have an appeal in the legacy process. After assessing these
various options, and collaborating with our partners, we have
identified two opt-ins that we intend to implement to address the issue
of the legacy appeals inventory.
The legislation must be enacted now to fix this process. It has
wide stakeholder support and the longer we wait to enact this
legislative reform, the more appeals enter the current, broken system.
The status quo is not acceptable for our Nation's Veterans. The new
process will provide much needed comprehensive reform to modernize the
VA appeals process and provide Veterans a decision on their appeal that
is timely, transparent, and fair.
suicide prevention--eliminating veteran suicide
Every suicide is tragic, and regardless of the numbers or rates,
one Veteran suicide is too many. Suicide prevention is VA's highest
clinical priority, and we continue to spread the word throughout VA
that ``Suicide Prevention is Everyone's Business.'' The 2018 Budget
requests $8.4 billion for Veterans' mental health services, an increase
of 6 percent above the 2017 level. It also includes $186.1 million for
suicide prevention outreach. VA recognizes that Veterans are at an
increased risk for suicide and implemented a national suicide
prevention strategy to address this crisis. VA is bringing the best
minds in the public and private sectors together to determine the next
steps in implementing the Eliminating Veteran Suicide Initiative. VA's
suicide prevention program is based on a public health approach that is
ongoing, utilizing universal, selective, indicated strategies while
recognizing that suicide prevention requires ready access to high
quality mental health services, supplemented by programs that address
the risk for suicide directly. VA's strategy for suicide prevention
requires ready access to high quality mental health (and other
healthcare) services supplemented by programs designed to help
individuals and families engage in care and to address suicide
prevention in high-risk patients.
As part of VA's commitment to put forth resources, services, and
technology to reduce Veteran suicide, VA initiated the Recovery
Engagement and Coordination for Health Veterans Enhanced Treatment
(REACH VET). This new program was launched by VA in November 2016 and
was fully implemented in February 2017. REACH VET uses a new predictive
model in order to analyze existing data from Veterans' health records
to identify those who are at a statistically elevated risk for suicide,
hospitalization, illnesses, and other adverse outcomes. Not all
Veterans who are identified have experienced suicidal ideation or
behavior. However, REACH VET allows VA to provide support and pre-
emptive enhanced care in order to lessen the likelihood that the
challenges these Veterans face will become a crisis.
Other than Honorable Expansion
We know that 14 of the 20 Veterans who on average commit suicide
each day did not, for various reasons, receive care within VA. Our goal
is to more effectively promote and provide care and assistance to such
individuals to the maximum extent authorized by law. In that regard, VA
intends to expand access to emergent mental healthcare for former
Servicemembers, who separated from active duty with other than
honorable (OTH) administrative discharges. This initiative specifically
focuses on expanding access to former Servicemembers with OTH
administrative discharges who are in mental health distress and may be
at risk for suicide or other adverse behaviors. VA estimates there are
more than 500,000 former Servicemembers with OTH administrative
discharges. As part of this initiative, former Servicemembers with OTH
administrative discharges who present to VA seeking mental healthcare
in emergency circumstances for a condition the former Servicemember
asserts is related to military service would be eligible for evaluation
and treatment for their mental health condition. Such individuals may
access the system for emergency mental health services by visiting a VA
emergency room, outpatient clinic, Vet Center, or by calling the
Veterans Crisis Line. Services may include: medication management/
pharmacotherapy, lab work, case management, psycho-education, and
psychotherapy. We intend to carry this initiative out within our
existing resources because it is the right thing to do for Veterans.
closing
Thank you for the opportunity to appear before you today to address
our 2018 budget and 2019 Advance Appropriations budget requests and to
provide you with the priorities that I am taking to ensure VA is viewed
with pride from Veterans and beneficiaries for the services provided to
them. I ask for your steadfast support in funding our full fiscal year
2018 and fiscal year 2019 AA budget requests and continued partnership
in making bold changes to improve our ability to serve Veterans. I look
forward to your questions.
Senator Moran. Secretary, thank you very much. It seems
like we have had these conversations in a couple of settings
numerous times over the last several weeks, and I appreciate
your testimony today. I appreciate it in the VA Committee, and
I appreciate the conversations that we have had.
But the topic I want to initially deal with, as you might
expect, is the funding shortfall. The shortfall that you
indicated when we were together last week, you said, ``If there
is no action by Congress to fund the Choice program, it will
dry up by mid-August.'' That would be mandatory spending, which
generally would involve the Authorizing Committee. And we had
this conversation there. I wanted to make sure that Senator
Tester was here while you and I had this conversation because
during our Authorizing Committee hearing, I indicated that
Senator Tester was wrong, and I enjoyed saying it, and it hurts
me to say that I now understand that Senator Tester is right.
Senator Tester. Could you repeat that? I did not hear that.
[Laughter.]
Senator Moran. The conversation you and I had, Mr.
Secretary----
Secretary Shulkin. Yes.
Senator Moran [continuing]. Involved a memo that was sent
out by the Department of Veterans Affairs on June 7 in which
the crux of what quit referring veterans to Choice because of
the lack of money available to pay for those Choice visits. You
then, or the Department rescinded that June 7 directive and
apparently replaced it by a June 12 memorandum.
And Senator Tester indicated in our Authorizing Committee
hearing that those two memos were the same. Where I disagreed
with Senator Tester was I thought they accomplished something
different because the second memo says, ``Continue to send
veterans with eligibility for the Veterans Choice program, as
identified in Veterans Access Choice and Accountability Act,
those eligible based on residence, 40 miles from their
residence to the closes VA facility, wait times of 30 days from
the clinically indicated date, or other criteria such as
special criteria for residents of Alaska, Hawaii, and New
Hampshire.''
That to me was different. I think you and I agreed that is
the crux of the difference between the June 7 and the June 12
memo.
Secretary Shulkin. Yes.
Senator Moran. In other words, Choice was reinstated.
Secretary Shulkin. Yes.
Senator Moran. My understanding of why it was--in part at
least why it was reinstated, I assume it is because it is good
for veterans for Choice to continue.
Secretary Shulkin. Yes.
Senator Moran. And you indicated to me and to others that
you would work with Congress to find a funding solution for
Choice and that, therefore, let us keep the program going while
we find that resolution of how to pay. Is that?
Secretary Shulkin. That is correct.
Senator Moran. A fair summary of where----
Secretary Shulkin. That is a good summary.
Senator Moran. Good. I was fearful that you would disagree
with me about Senator Tester and I would have to repeat that he
is correct. The reason I think he is correct is because the
evidence that I get from the field in the VA is veterans are
not now being referred to Choice. And so I am worried that,
while the memo says one thing, the actual practice at the VA is
another.
Secretary Shulkin. Yes. Right.
Senator Moran. And so my impression, based upon
conversations across the field from veterans and employees
within the VA is we are not referring individuals to Choice.
Secretary Shulkin. Yes.
Senator Moran. So, the reason I am fearful that Senator
Tester is right, while the words say one thing, the practice is
something different.
Secretary Shulkin. Right.
Senator Moran. You and I agreed in our conversation at the
Veterans Committee hearing that the outcome of not continuing
Choice, taking a hiatus from referring veterans to Choice would
very likely mean that the entities Health Net and TriWest,
which the VA has hired to manage Choice, our conversation was
that that network is important. And you agreed with me that if
we stopped providing patients for Choice, the networks will go
away and they will not be in a position to be helpful, their
networks will disappear, and when, if we are successful in
finding the money to fund Choice, then we have no network to
associate the program with. Is that a fair assessment of?
Secretary Shulkin. It is.
Senator Moran. Our conversation?
Secretary Shulkin. It is.
Senator Moran. So, Mr. Secretary, my question is what is
the status of this? Are veterans being referred to Choice? Is
this a matter of the VA memo saying one thing to placate me and
others and the practice to be something different? I do not
know that I want to go back there----
Secretary Shulkin. Yes.
Senator Moran [continuing]. But your predecessor indicated
that there were people within the VA he should not have relied
upon, and I do not know whether you are relying upon people who
are telling you one thing but the outcome is something
different. So, I take this development very seriously because I
think the VA is headed on a different path than what you
assured me they were on.
Secretary Shulkin. Yes. Okay. So, you wanted this to be a
candid discussion, and I see you started it out that way, which
is good. Everything that you have said is absolutely accurate.
And our intent is exactly the same, which is to keep the Choice
program going. We think it is very important for veterans, and
we want to see it fully funded.
I have described why we are in the situation that we are
today because more veterans than ever are accessing Choice. And
let me explain why that is. Our fiscal year 2017 budget was $2
billion less for Community Care than our 2016 budget. So, from
2016 to 2017, our budget was reduced in Community Care by $2
billion. That means that what we did was we created a program
called Choice First, which encouraged our medical centers,
instead of using Community Care, to go to the Choice program.
And that is why you have seen a large increase in the use of
Choice.
When the money started to run out quicker than we expected,
instead of it lasting til the end of the fiscal year--we
project that it will last to August 7. We wanted to clarify to
the field two things: Continue to use Choice, keep that network
alive, continue to use Choice because we believe in it for the
statutory reasons, the reasons why Choice was established, 40
miles, 30 days; but now, no longer use Choice first when you
have Community Care funds. So, the message was to try to
balance this out while we could work out the types of solutions
that you and I have talked about, to be able to fund Choice in
the level that we think that we need it.
So, our field, this is very confusing because we are
constantly having to readjust the way that we use these two
separate accounts, Community Care and Choice. It is not the
right way to manage. We are seeking to manage this under a
singular fund. We are trying to balance the need to keep the
Choice network and the Choice program active but also make sure
we do not interrupt veterans from getting the care that they
need.
I met yesterday with all of our network directors
personally to make sure that they understood what we were
trying to accomplish so that there would not be confusion in
the field, and certainly, we will continue to clarify this
policy. Our intent is to find a solution working with you so we
do not have to constantly be balancing these two accounts in
different ways.
Senator Moran. Are you agreeing with my assessment based
upon my conversations with people within the VA and veterans
across the country that Choice is not being utilized to the
degree that your memo says it should be?
Secretary Shulkin. No. We hope that the field is taking our
guidance on the memo, to continue to use Choice and to continue
to use Choice appropriately, certainly, as you have written the
law, the statutory requirements for Choice. What we are saying
is instead of using Choice for everything.
Senator Moran. Right.
Secretary Shulkin. Use Community Care.
Senator Moran. You know that those referrals are continuing
or are you just that is occurring?
Secretary Shulkin. Yes.
Senator Moran. Yes. Okay.
Secretary Shulkin. Yes. We see the activity every day.
Senator Moran. My time is well expired, but let me ask this
follow-up question. So where are you in the more--Senator
Schatz indicated that money available the end of the fiscal
year, we think it is actually mid-August when we extended the
Choice Act. We thought it was January. Those dates have altered
over a period of time. But where are you--what does OMB or the
administration tell you that they would support an increased
mandatory spending to fill the problem for fiscal year 2017 and
2018?
Secretary Shulkin. Well, 2017 and 2018, we have several----
Senator Moran. Yes, 2017 and 2018.
Secretary Shulkin [continuing]. Yes, 2017 and 2018. We have
several options on the table that you and I have discussed. One
is for us to just fix this problem administratively, stop using
Choice and use Community Care. We think that is the worst
option, and you and I agree; that would not be healthy for lots
of reasons.
The second option would be to transfer money from our
Medical Services account over to the Choice program. There are
concerns, legitimate concerns that Senator Tester, Senator
Murray and others have expressed about that, but that would be
an option for us to fill up the coffers in the Choice program.
And the third option would be for the appropriators, who we
are talking to right now, to look at an early appropriation for
2017 and 2018 and do that sooner. I think we should be
discussing all of those options.
Senator Moran. What I am being reminded----
Secretary Shulkin. Yes.
Senator Moran. And what I think is true, the appropriators
are responsible for discretionary spending, but you need
mandatory money
Secretary Shulkin. Yes.
Senator Moran. If you are going to keep the Choice program
alive.
Secretary Shulkin. I am sorry. In the mandatory fund, a
reauthorization of the Choice program, 2017, 2018. Thank you
for that correction. And all of those are options. I think they
all have advantages and disadvantages. We would like to work
with Congress to make sure that we are picking the right choice
between those options.
Senator Moran. In your conversations with the third-party
administrators, do they agree that the volume of Choice
referrals today is sufficient to keep them in business,
sufficient that they are breaking even?
Secretary Shulkin. No. No, I think that the Choice
contractors right now, since we have released that memo, are
experiencing significantly decreased volume than before.
Clearly, March, April, May were very good months for them, and
now, they have experienced decreased volume. And according to
some of my recent interactions with them, they are running at a
loss. And that is not our intent. We want to be good partners
with them. We value what they do. We would like to get this
situation corrected and fixed. We would like to be able to have
additional funds in the Choice program to be to continue using
it.
Senator Moran. The Right Honorable Senator Tester.
Senator Tester. Gosh, Mr. Chairman, I thank you very much.
And no offense taken in any of that stuff, and you know that.
And I very much appreciate your comments, and I want to thank
the ranking member for allowing me to go. I appreciate that,
too.
But one thing before I go, you know, if you keep treating
me this nice, I might end up supporting that bioresearch
facility in the middle of Tornado Alley, which happens to be in
Kansas.
But that aside, good to have you here, Secretary.
Secretary Shulkin. Thank you.
Senator Tester. Good to have your team here.
Secretary Shulkin. Thank you.
Senator Tester. I think it needs to be duly noted that Jake
is not here and make sure you point that out to him because,
you know, we will hold him accountable on that, okay?
Secretary Shulkin. Okay.
Senator Tester. Okay. So, I want to approach this budget
from a little different perspective today than I have in the
past, and I appreciate----
Secretary Shulkin. Yes.
Senator Tester [continuing]. Your opening statement and I
appreciate you talking about the direct care versus the
Community Care. But let us talk about some other issues----
Secretary Shulkin. Sure.
Senator Tester [continuing]. That are impacting the budget
that may not have been there when this budget was drafted,
okay?
Decision not to appeal the Staub decision, which I believe
was the right decision on your part, could cost the VA up to $2
billion. The decision to purchase electronic health record
system could run as high as $16 billion; addressing the holes
in Choice and Community Care, $4 billion; responding to the
influx of veterans after the repeal of the Affordable Care Act
could impact up to 700,000 veterans--I believe those are your
numbers--which would be extremely costly to the VA, but, quite
frankly, the cost of war and one that we need to pay for; non-
reoccurring maintenance for VA facilities to address $10
million in backlog code deficiencies; current inventory of
pending appeals, getting those down, $800 million.
All these items are compounded by the reality we have more
and more medical appointments projected each year, and we do
not have the doctors, nor the facilities or the professionals
on the ground to really get this done. And you are also seeing
aging veterans with more complex needs. We are seeing folks
that are surviving war that would never have survived before
that have some real issues that we have to deal with both
physically and mentally.
So, you are kind of boxed in. Your request needs to be
signed off by folks above you. But I do think you need to be
absolutely straightforward with us, and I think that if you
are, you know us well enough that if you tell us what the VA
needs now and into the future and you can justify that, I think
you are going to have receptive ears around this dais.
So, I think that if we continue talking about and throwing
budgets up that do not fully address the problems of our
veterans in this country--and we have been at war now for 15
years--and we have got Vietnam vets that are getting older and
you know the story; we have been through it before--I think we
just run a cycle of never getting to a point where we can
honestly sit down and say we are giving to veterans what they
have earned. Would you want to respond to that?
And by the way, you are not the only one. Ag, Interior, we
have to go to Energy in a minute, it is going to be the same
conversation where everything is cut, cut, cut with the
expectation that we are going to bring all this up. I do not
think we can bring it all up. And so would you want to respond
to that?
Secretary Shulkin. Sure. You certainly paint quite an
impressive picture there, and, you know, again, this is what
the budget process is about, to have these types of
discussions. And I think we needed to have these discussions in
years past because I think your history is right that we have
not requested the right type of budget to meet the demands of
our veterans, and that is where we have fallen short.
I do believe that this President's budget allows us to meet
the mission of the VA. I stand behind the President's budget. I
think there are a couple things as you went down that list. It
does not include a request for a new electronic medical record,
and that is the exception.
I think that some of the costs that you have talked about
are reasonable estimates, but they are higher than I would put
as estimates.
Senator Tester. You do not think Staub would be $2 billion?
Secretary Shulkin. I do not think Staub will be $2 billion.
Senator Tester. What are your projections on that? Not that
I will hold you to them but what are your projections on that?
Secretary Shulkin. Less than $2 billion.
[Laughter.]
Senator Tester. Oh, great.
Secretary Shulkin. Okay. You know, the appeals process, I
do not--although I gave a number of what it would cost if we
just wanted to hire people, I think we have broken processes. I
am not suggesting we throw more money at this right now.
So, I really do appreciate the spirit in which you are
addressing this because I know you want to meet the needs of
our veterans.
Senator Tester. Yes.
Secretary Shulkin. That is where you are coming from. I
actually think this budget is a good budget, and I will
appreciate the support for modernizing our IT systems.
Senator Tester. Well, I would just say that I think there
is some--and I am not doubting your word. I think you do
believe it is a good budget. I think there are some glaring
holes in it. And I would also tell you that this is about
veterans and it is not about the--it is about the budget as it
applies to veterans. And in the end when I go into a restaurant
in Montana and I am sitting there and I have a veteran that
comes up to me and says, you know what, your Choice program
stinks; I used to wait 30 days for an appointment; now I am
waiting 6 months. Those kind of things do not happen unless we
are screwing up, okay? And so I just bring that up.
I am going to put the rest of my questions for the record,
but they all revolve around the first question I asked.
Once again, thank you all for being here.
Secretary Shulkin. Thank you.
Senator Moran. Senator Boozman.
Senator Boozman. Thank you, Mr. Chairman.
First of all, I want to thank you for coming to
Fayetteville, Arkansas, and seeing the VA. The feedback was
excellent. I think you got to visit with a number of different
groups in the sense of visiting with the Administration,
visiting with providers, and most importantly, visiting with
veterans. And so, again, that seemed to go very, very well.
Secretary Shulkin. Yes.
Senator Boozman. And I know you are a busy guy, but I do
appreciate the fact that you are somebody that is out in the
facilities doing--I do not think there is any substitute for
that, and certainly, that is what we are all about.
I would like to ask you a couple things about eye care, and
one of them has to do with the eye care in the status of the
eye care centers. DOD is a doing a registry, but VA seems to be
lagging, maybe marginalizing that. Would you look into that for
me and see what the deal is?
Secretary Shulkin. Yes, sir.
Senator Boozman. And again, I think that really is very,
very important.
The other thing that I would like to talk to you about is
the Technology-Based Eye Care Services (TECS) program in
Atlanta. This is a program, a pilot program. What they do is
they use a reliance on the autorefractor. This is a machine,
that you look through and it tells you what your prescription
is. The problem is that it has got about 23 percent error rate,
but the manufacturers themselves say that this is not
appropriate to use in that manner as far as prescribing
glasses.
The concern is also that the people actually doing that,
there is no licensure for them also doing that. And then the
other problem is after that you have got a situation where many
of them need an appointment because of inconsistencies that are
found, so you are kind of double-dipping. They see them, get
kind of a third-world experience, and that truly is a third-
world--there is no example of this going on in private practice
in America, okay----
Secretary Shulkin. Okay.
Senator Boozman. In the way that it is being done from what
I understand. I think the better choice, something that we
really need to look at, we have got a problem. Eye care is
growing tremendously because people are doing a good job and
veterans are seeking out, but I really wish that you would look
at how it is being delivered. I think the idea that we are
using technology is excellent, and you are coming up--you and
your teams are coming up with out-of-the-box thinking. But I
really think you ought to look at the way that eye care is
being delivered and put the technology in the hands of the
optometrists, the ophthalmologists that are in place and again
give them the support staff, and then they will be able to see
more patients in an effective manner and cut out all this other
stuff because we really do have some problems in that area, but
that is the way to go as opposed to this other.
Secretary Shulkin. Okay.
Senator Boozman. Can you comment on that at all? I do not
know if you know anything about it.
Secretary Shulkin. Yes, not nearly as much as you do.
Senator Boozman. Well, I did it for 23 years. So I have
gotten a good and we are very proud of that.
Secretary Shulkin. Yes. It is really a terrific. First of
all, I would like to comment on Arkansas. First, what a
beautiful State. And we were there not only to visit the
Fayetteville VA, which is a five-star facility and doing
tremendous things
Senator Boozman. That is a recent acquisition and yes they
have made great progress but also to learn from Walmart and to
learn about their logistics and the challenges of how they are
having to change their business model as the world evolves. So
that was extraordinarily helpful to learn from really best
practices and to learn from industry outside the health care,
so thank you. Thank you for helping us arrange that trip, and
certainly, Representative Womack as well.
The eye care issue I will look into it. I really do not
know that much about it. We are trying to use technology. I
have seen where we are using tele-retinal exams and, you know,
leveraging our professionals using tele-technology, but I will
look into the TECS programming in the eye care model.
Senator Boozman. Good. And, you mentioned seeing other
companies, other people that have done a good job thinking
outside the box. That is certainly the direction that we need
to go. And again, I compliment you on getting out and exploring
all different avenues in the sense of trying to move us in the
right direction in a very efficient manner.
So many industries, and it does not matter if it is the eye
care business or the VA business or whatever it is, many of
these have changed more in the last 10 or 15 years than since
the creation of the business to begin with.
Secretary Shulkin. Yes. Right.
Senator Boozman. And so it is just a constant battle. And
certainly, with, you know, an entity the size of the VA, it is
a real challenge.
Thank you, Mr. Chairman.
Senator Moran. Senator Schatz.
Senator Schatz. Thank you, Mr. Chairman.
Mr. Secretary, thank you for your service. Thank you to
your team.
I want to follow up on the question of unanticipated costs.
You have said that the budget that we are working with is a
good budget. I will not get into a dispute about that, but I
will just offer unanticipated costs. You have decided I think
appropriately to move forward with a new Electronic Health
Records (EHR) system. You have decided I think again rightly on
Staub and Choice is running out of money, so it seems to pretty
plain to see that we do not have enough money in this budget.
Is that accurate?
Secretary Shulkin. Well, I think that what you have
suggested is that we are going to continue to bring forth
recommendations as we see the need to modernize this system and
to do better for veterans. So, the electronic medical record, a
decision 17 years in the making we are bringing forward, we do
not know the cost of it yet so we were not able to build it
into this budget.
On the Staub case, that is the right thing to do, and I am
willing to absorb those costs into our budget because it is
consistent with what we should be doing, consistent with the
court ruling.
Financial projections we have to do better on. We have a
financial management system that is over 20 years old that we
now decided to start replacing that will help us do a better
job. And we also have some accountability for that as well.
So, you know, all that we can do is make our best
projections. I wish we were perfect. Today, as I sit here right
now, I feel comfortable with the President's budget, but you
may be right and I may be wrong.
Senator Schatz. Well, I think the thing is, you know, let
us say it is not $2 billion for Staub. It is also not zero
right?
Secretary Shulkin. You are right.
Senator Schatz. And let us say you do not know how much the
Electronic Medical Records (EMR) system is going to cost. You
have got to do specs, you have got to work with DOD, and I know
you want to measure twice, cut once, both on the tech side and
on the clinical side, so I understand you do not want to just
pick a number. But it is not zero.
Secretary Shulkin. It is not zero.
Senator Schatz. And we are about to mark this bill up, and
it is difficult to do a markup. When lacking information, we
are expected to sort of book it at zero. And so how do we work
with you to get some fidelity to not overfund a priority that
is not yet well-articulated? But it makes me extremely nervous
that you say you can absorb these costs because, especially
with Staub, you are actually not providing more care; you are
reimbursing people who improperly had to, you know, do their
own copayments. And so that is a pretty hard cost.
And then the EMR thing is a brand new hard cost. I mean,
you are going to have to cannibalize your budget to some extent
in order to pay for those two things, are you not?
Secretary Shulkin. Well, on the EMR, we have in this budget
$200 million to start the process of change management. The
majority of the cost of the EMR, especially in the first 2
years, is going to be all internal change management to get
ready for the installation of a new EMR. So, we will come in
the 2019 budget with firm numbers so that we can have the
appropriate discussion about whether this is something that you
can support. In the 2018 budget I believe we have the dollars
to start preparing for this process.
You know, the Staub case and a number of other things that
will happen over the course of this year are management
accountabilities that we are going to have to assume the
responsibility for. And part of what I have said when I took
over this department is that we cannot continue to always come
to you and ask for more and more money. We have seen that over
the past decade that this budget has doubled for VA. And we
also see what is happening in some of the other domestic
budgets and that I know you are very aware of. And every dollar
that we get means that there is a dollar for something else
that I think is, you know, equally as important.
So, we are trying to be fiscally responsible while at the
same time making sure that we are doing better for veterans. A
6.3 percent increase in our budget we think is a reasonable
number.
Senator Schatz. In my limited time left, can you walk me
through from the veterans' perspective, setting aside budget
and appropriations, from the veterans' perspective how are they
going to be informed of their rights under your Staub decision?
Do they get a letter? Is there any case management? Do you
track down the copay they--I am not sure that that is even
possible. If I am an individual veteran and you know, 4 years
ago I paid through private pay, I paid $250 for an ER visit,
how do I even know that I am entitled to reimbursement?
Secretary Shulkin. Right. So right now, a veteran files a
claim, and now is the worst of all processes. They are just put
into a pending status. We have 600,000 claims pending. It is my
intention--and I have been clear on this--I want to start going
through those claims and paying those claims. So, we have sent
over to OMB an interim final rule. That was the very fastest
way that I could go about starting the process for rulemaking
so I am allowed to pay those bills. So, as soon as we get that
through OMB--and I do not know exactly how long that is going
to take--but as soon as we possibly can, we are going to start
paying those 600,000 claims. And that is when the veterans will
get notified of exactly what our payment obligation is. I do
not know any way to do this faster.
Senator Schatz. But at the mechanical level, you figure out
who was responsible for the original claim and the private
payer then.
Secretary Shulkin. Yes. Remember, this case relates only to
veterans with other health insurance so there is a primary
payer, whether it is Medicare or a private insurer, that has
paid their obligation hopefully, and then there is a leftover
portion.
Senator Schatz. Right.
Secretary Shulkin. We will then apply the law as you wrote
it and as was upheld in the Staub case to VA's paying its
portion of that.
Senator Schatz. Okay. And I will take the rest for the
record, but I would like you to maybe walk us through how it
works for the individual veteran so that we can talk about it.
Secretary Shulkin. Sure.
Senator Schatz. I am not sure that our constituents who are
veterans actually would understand whether they just wait or
they go through a process or they have to file a claim. How
does this all work? And I would appreciate that for the record.
Senator Moran. Senator Collins.
Senator Collins. Thank you, Mr. Chairman.
Dr. Shulkin, it is good to see you again. I want to follow
up on my colleague from Arkansas in thanking you again for
coming to Maine and follow up on the questions raised by the
chairman about the Choice program.
As you are probably not surprised to learn, I have
significant concerns about the recent policy changes regarding
Choice and access to Community Care. When you last appeared
before this committee in May, Dr. Yehia noted that the model in
northern Maine developed during the ARCH program should be used
as a standard-bearer for how VA coordinates Community Care.
But now, my understanding that the Maine VA will no longer
be permitted to use provider agreements to purchase care from
providers, as they had been doing, which in some cases may
force our veterans to travel literally hundreds of miles for
specialty care, 250 miles from Aroostook County to the Togus VA
in Augusta or even an additional 160 miles beyond that to the
VA in Boston.
I am concerned also that the veterans are now having to go
through Health Net, something they have not had good experience
with, instead of dealing directly with Cary Memorial Hospital
and the Caribou CBOC. And these changes really disrupt the
continuity of care for veterans in a system that was working
really well.
So, my question for you--and I realize your financial
constraints are a terrible problem--but if Congress were to
authorize additional emergency funding or more flexibility for
you to transfer funds among accounts, would the VA be able to
revert back to its earlier practices with regard to Choice and
Community Care, and would you do so?
Secretary Shulkin. The easiest question I will get all day.
Yes. We agree with you, Senator that the system was working
well, and we want desperately to continue to have a system that
works that way. And the solutions that you talked about, either
one of those would work for us.
Senator Collins. Thank you. The second issue that I want to
bring up with you concerns a hearing that I chaired just last
week before the Senate Aging Committee on military and veteran
caregivers, of which there are some 5.5 million in this
country. And we had extraordinarily moving testimony from the
spouses of veterans who were suffering from traumatic brain
injury, from ALS, from posttraumatic stress disorder and the
RAND Corporation also released a report that was commissioned
by the Elizabeth Dole Foundation. And Elizabeth Dole has done
so much extraordinary work in this area.
In March, you expressed support for expanding the VA's
program of comprehensive assistance to family caregivers to
veterans of all eras. I just do not understand why it only
applies to post 9/11 veterans rather than veterans from all
eras and conflicts.
And Senator Murray and I have introduced legislation again
this Congress that would authorize this expansion, and we hope
this is something we can accomplish. And I really wish every
Member of the Senate could have been at our hearing. It was so
moving listening. It happened to be three wives who are taking
care of their husbands, and all I could think of is they are
allowing them to stay at home. That is so much less expensive
than institutional care.
So, I know that there is concern about cost, but I am going
to ask you a leading question here. But do you not agree that
increasing the availability of caregiver support for veterans
can reduce VA expenditures in other areas, especially for
institutional care?
Secretary Shulkin. Well, I was wrong. This question is
easier than the last one.
[Laughter.]
Secretary Shulkin. Yes, I do agree.
Senator Collins. Then, let us do it. Let us get it done. As
I said, I so wish every Member could have been there. It was
just so moving to listen to the sacrifices made by these
spouses for their husbands and all that they were doing to keep
them home.
Secretary Shulkin. Yes. First of all, Senator Dole is an
amazing person, and her foundation is doing amazing work. And
I, too, have had the experience--I am sorry I was not at your
hearing, but I have had the experience of spending time with
our caregivers of our veterans, and they are just incredible
people and very moving.
We are very supportive of this. As you know and Senator
Murray certainly knows, we have suspended our rules and we were
talking to Senator Murray and her staff about this to get this
right. The one area of our budget that I remain a little bit
concerned about is the amount that we have allocated for 2018
for caregivers. We took the 2017 projections and we just
increased it a little bit. But I am concerned that it may not
be enough, so I have instructed our financial officer to begin
to look for additional funds that we could move towards
caregiving because I think it is not only the right thing to
do, but I do think it is cost-effective, particularly among
veterans whose only alternative is to leave their home into
institutional care.
Senator Collins. Thank you very much. And thank you, Mr.
Chairman.
Senator Moran. Thank you, Senator Murray.
Senator Murray. Well, first of all, Senator Collins, thank
you for raising that, and I am delighted to be working with you
on that. We do have concerns about a number of caregivers who
have been told that they are no longer eligible this year. To
me, as the daughter of a World War II veteran whose mother
stayed home to care for him when he was in a wheelchair, this
is absolutely critical and it should go to all eras. So, thank
you for working, and we have got a lot of work to do
Secretary Shulkin. Yes.
Senator Murray. At the VA on this. We will continue to do
it.
Secretary Shulkin, let me go back to a discussion we have
had here and that you and I talked about last week, and that is
the Choice program shortfall. As a result of the problems in
the Choice program, VA is no longer going to have $626 million
in carryover as expected for fiscal year 2018. And according to
a VA briefing, to cover that shortfall of $260 million, the VA
is asking our hospitals to delay important equipment purchases
and facility maintenance projects, and your budget documents
actually show you have already transferred $600 million from
Medical Services to Community Care, correct?
Secretary Shulkin. Those are our collections, which come
into our Medical Services, and then we transfer into Community
Care.
Senator Murray. So, that is another change in the budget
for those needs. If that is not enough, VA would then take from
Medical Services and Medical Collections, taking away from
expected carryover in those budgets.
Secretary Shulkin. Yes.
Senator Murray. So that will be something that you have to
carry over.
Secretary Shulkin. Yes.
Senator Murray. But my question is your budget submission
for next year is based on those hundreds of millions of dollars
of carryover being available, so exactly how much money will VA
need above what is in the Choice and Community Care accounts?
Secretary Shulkin. Yes. Well, first of all, you have done a
good job on understanding those numbers, so I think you have it
correct, but to make sure that I am going to add up all your
numbers, correct, Mark, what--our chief financial officer
probably is going to do better at this.
I think the question is what is the total amount of
carryover dollars that we had expected that we may end up
using?
Senator Murray. That you will no longer have.
Secretary Shulkin. Yes.
Mr. Yow. We had in the budget $1.652 billion in Medical
Services carryover from fiscal year 2017 into fiscal year 2018.
Right now, we believe we can resolve the problem with the
Choice shortfall in fiscal year 2017 without dipping into
that----
Senator Murray. No, my question is you are not going to
have the carryover money for 2018 that you were expected. So,
what is now the shortfall for 2018 from your budget request
that is before this committee today?
Mr. Yow. Yes, ma'am, but we believe we have other offsets
internally in 2017 that will provide us----
Senator Murray. Somebody else is going to lose out.
Mr. Yow. I am sorry.
Senator Murray. Somebody else will lose out? You are going
to take money from somebody to make up this.
Mr. Yow. Well, we have taken money from the National
Reserve, about $104 million, and we have taken $220 million
that has been offered up by our VISN directors as being
available for this. It is more important than what they had it
set aside for.
Senator Murray. Well, my understanding is it is about $4
billion or a little bit more than that that you will need in
the Choice and Community Care account.
Secretary Shulkin. For 2018.
Senator Murray. For 2018, about $4 billion. So, Mr.
Secretary, my question for you is why have you not submitted a
request for additional appropriations for this year?
Secretary Shulkin. Well, because I think that we will be
able to cover this year, as Mark was saying, that we have
identified the $260 million in unobligated spending from our--
asking our VISNs what they are not going to be spending. We
have taken the $104 million from our National Reserve, and we
will be able to cover this year rather than make an emergency
supplemental request for this year.
Senator Murray. So you have created a huge hole for next
year. Because you have taken away the carryover that you are
expecting and put into your budget request for this year?
Secretary Shulkin. We have. At least by $626 million, yes.
Mr. Yow. In Choice.
Secretary Shulkin. What is that?
Mr. Yow. In Choice.
Secretary Shulkin. In Choice, yes.
Senator Murray. In Choice.
Secretary Shulkin. Yes.
Senator Murray. So this year's budget request is not
enough?
Secretary Shulkin. It is.
Senator Murray. It seems to me the right thing would be to
do is to ask for a request for this year for the shortfall
Secretary Shulkin. One of the options to resolve this
problem would be to have the authorizers of which you are one,
consider that as an option for doing it now for 2017, 2018.
Senator Murray. Have you requested that?
Secretary Shulkin. We are in discussions with you about how
you would prefer to do this. I think that is one of the
options, and the other option, as you are saying, is that we
could fix this through transfers, but there are consequences to
that. So, each of the options have advantages and
disadvantages, and I believe that this needs to be a dialogue
about where we want to go with this. But we want to see this
fixed. I know you do, too, and we should come to the best
conclusion as to the way to fix this.
Senator Murray. It seems to me if the Administration makes
the request, it will be better served.
Secretary Shulkin. Okay.
Senator Murray. Secretary Shulkin, I am very concerned
about your budget for Medical Services. You are requesting
barely a 1 percent increase, and that does not cover the basic
medical inflation, increasing use of health care by veterans.
It does not replenish the $600 million VA transferred to
Community Care, and it does not account for delays in equipment
purchases and maintenance projects. So how do you meet the
veterans' needs for health care?
Secretary Shulkin. Yes. Senator Murray, I have different
numbers than you have. I have a much larger increase in Medical
Services. Mark, would you please----
Senator Murray. For your budget request?
Secretary Shulkin. Yes.
Senator Murray. For 2018?
Secretary Shulkin. Yes.
Mr. Yow. Yes, ma'am. What you are looking at is only the
appropriation amount. We have five sources of funds. We have
the appropriation, which obviously is the largest, but we also
have the funds from the Choice law both for the Choice program
and for the section 801 VACA funds that are applicable to
Medical Services. We have medical care collections, we have
reimbursements, and we have carryover. So when you look at the
total obligations that we have got in the budget from 2017 to
2018, our Medical Services account grows by 5.7 percent, and
our Community Care account grows by 8.2 percent.
Senator Murray. Okay. Well, what I am hearing you say is in
all those accounts that you now are expecting a carryover from
that you will not have, you are counting those in to this?
Mr. Yow. Right now, the only one we do not expect to have
it in is in Choice, which would reduce the amount of growth for
Community Care. It would not impact----
Senator Murray. But you are taking money from those other
accounts for Choice?
Mr. Yow. In the current year, 2017.
Secretary Shulkin. Not in 2018.
Mr. Yow. Not in 2018.
Senator Murray. Okay. Well, that is Choice, which is
private sector. Inside VA, it is 1.2, correct?
Mr. Yow. No, ma'am.
Secretary Shulkin. Mark, let me just try it because he
helped me with this.
If you are looking only at the appropriation amount, it
would be the amount you are talking about, but when he adds in
his other five sources, it is 5.7 percent inside VA for Medical
Services.
Senator Murray. Okay. Well, I will just conclude. You said
you will defend this budget?
Secretary Shulkin. Yes.
Senator Murray. Your job is to defend veterans----
Secretary Shulkin. Yes.
Senator Murray [continuing]. And they are the ones that
this committee cares about.
Secretary Shulkin. Yes.
Senator Murray. So thank you.
Secretary Shulkin. Thank you.
Senator Moran. Senator Hoeven.
Senator Hoeven. I would like to thank all the witnesses for
being here. Secretary Shulkin, thank you for being here and for
your work on behalf of veterans.
One of the subjects you and I have talked about before is
making sure that veterans can get access to nursing care close
to home. Also, we want to make sure that they can access home-
based health care, right?
Secretary Shulkin. Yes.
Senator Hoeven. So, the whole concept behind the Veterans
Choice legislation is that veterans can get care in the local
community when there is not a VA institution nearby that has
the service they need, right?
Secretary Shulkin. Yes.
Senator Hoeven. And so you have been hard at work
implementing that. We worked with the healthcare providers. You
have been very good about helping us set up a pilot program in
our State that has really empowered our local VA healthcare
center in Fargo, which serves North Dakota and half of
Minnesota, to cut through the red tape and some of the problems
we have had with the third-party providers and really cut down
the wait time for veterans to get appointments and get in to
get health care, and also, through the Veterans Care
Coordination Initiative, which is what we call it, to make sure
that providers get paid so they will provide that service to
veterans in the local communities. It is working. You have made
a real difference.
We need to do that now with long-term care and with home-
based care, and we cannot right now because in some cases you
are not and in some cases you probably do not have authority to
enter into provider agreements with nursing homes and home-
based care service providers. Tell me how we are going to--you
know that this is something I am trying to move in legislation,
and I would like your thoughts on how we are going to get this
done because this is a fundamental issue of veterans getting
long-term care in their homes and in their communities.
Secretary Shulkin. Yes.
Senator Hoeven. And I would like you to address that
because this is something we need folks on both sides of the
aisle working together to get done, just like we did on
Veterans Choice.
Secretary Shulkin. Yes. Mark, I am going to ask again, I
thought we were making progress on being able to utilize our
Choice funds for both home health aides and our long-term care
facilities.
Mr. Yow. Right now, sir, what I think you are talking
about, though, is expanding it beyond Choice. We do have that
authority for the Choice program. What we do not have is the
authority to do it outside of Choice, and we would really like
to have that for other normal Community Care accounts.
Senator Hoeven. Right, for really any of the funds that you
receive.
Secretary Shulkin. Yes.
Senator Hoeven. Right now, we are already--I mean, that is
another one of my questions, how long until you run out of
funding under the Choice program, which we need to make sure is
appropriated for. We need to be able to make sure that--I mean,
are you entering into those type of provider agreements with
your Choice funds?
Mr. Yow. Only with Choice, but again with Choice they have
done quite a bit so far.
Secretary Shulkin. Yes.
Senator Hoeven. How far is that taking you?
Mr. Yow. There were 600 valid agreements that had been put
into----
Senator Hoeven. So you are saying then for any nursing home
that wants--to be able to take VA reimbursement, they should be
working with you under the Choice funding, and you will do
that? And that restricts them how?
Secretary Shulkin. Right.
Mr. Yow. We have the authority to use the sharing
agreements for the community home health care that is not
institutional. It is not the institutional care.
Senator Hoeven. So you cannot do it with--the nursing
homes?
Mr. Yow. Right. Not for nursing homes.
Senator Hoeven. So, you are not doing it with nursing
homes?
Mr. Yow. It is for non-institutional care.
Senator Hoeven. Only for home-based care?
Mr. Yow. Yes, sir.
Senator Hoeven. Okay. So, for home-based care we are making
progress?
Secretary Shulkin. Yes. We have proposed with technical
assistance a revision to the Choice program that we are hoping
that you will consider that we call the CARE program that
actually builds in your concepts of working with the nursing
homes under a single set of funds for Community Care so there
is not separate Choice and Community Care funds.
Senator Hoeven. And that would enable you to enter into
provider agreements----
Secretary Shulkin. Provider agreements?
Senator Hoeven [continuing]. With either nursing homes or
home care providers?
Secretary Shulkin. Right. Exactly. Yes.
Senator Hoeven. Okay. And you are doing that where?
Secretary Shulkin. Well, now that the Choice program
legislation is going to expire, we are hoping to work with you
to replace it with a more effective program.
Senator Hoeven. And include that provision in the
legislation?
Secretary Shulkin. Yes. And we provide the technical
assistance for that.
Senator Hoeven. So you will work with us to include that in
the legislative proposal?
Secretary Shulkin. Yes. That is correct.
Senator Hoeven. Thank you. I appreciate it.
Senator Moran. Senator Baldwin.
Senator Baldwin. Thank you.
Secretary Shulkin, I wanted to thank you for fully funding
the Jason Simcakoski Memorial Opioid Safety Act and PROMISE
Act. I also want to say that I am closely monitoring the
implementation of Jason's law and efforts to reduce opioid
dependency at the VA.
The VA has been making good progress on this issue, and
there are still big milestones coming up with regard to
implementation of the law. I would appreciate it if we could
set up a meeting with the folks that you have implementing
these provisions to go over some of the details of
implementation. If we could work together on that, that would
be great.
Secretary Shulkin. Absolutely.
Senator Baldwin. I also want to acknowledge my partner on
this legislation also on this committee, Shelley Moore Capito,
and you would be welcome to join the briefing.
On June 1, Congresswoman Gwen Moore and myself wrote to you
regarding a mistake that the VA made that is now affecting 11
veterans who are all police officers----
Secretary Shulkin. Yes.
Senator Baldwin [continuing]. At the Zablocki VA Medical
Center in Milwaukee. A little bit of background on this, in
2015 the St. Louis Regional Benefit Office reviewed and
approved an on-the-job officer apprenticeship program
certifying that each veteran's eligibility to participate in
the program and using their post 9/11 GI benefits. In February
of this year, a VA auditor found that the VA erred in approving
these veterans because they were past their first 3 years of
employment.
These veterans are now receiving letters from the VA
telling them that they each owe upwards of $20,000. The VA has
requested financial information from these veterans and their
spouses in an attempt to collect on what was the VA's mistake.
These veterans have families; they have mortgages. They do not
have $20,000 laying around for a mistake that the VA made.
So, Secretary Shulkin, since I wrote you on June 1, can you
advise me as to whether the VA has made any progress on fixing
this?
Secretary Shulkin. Yes. Well, first of all, thank you for
bringing this to our attention. I think you have it correct.
The VA made the mistake, and this was our administrative error,
and we are not going to seek recoupment of those funds from
those 11 employees. We apologize for the mistake, and we thank
you for bringing it to our attention.
Senator Baldwin. Well, I appreciate hearing that. I know
particularly these veterans who are police officers are going
to be particularly relieved to hear that.
Secretary Shulkin. Yes.
Senator Baldwin. I take it since you have said it here
publicly, it is now public and we will certainly work with you
to relay that good news.
Secretary Shulkin. Thank you.
Senator Baldwin. Thank you.
Now, another issue, numerous Wisconsin veterans have
brought to my attention the fact that it is nearly impossible
to speak with a live human being when a veteran calls the Debt
Management Center. In March, after hearing some of the
complaints, a member of my staff endeavored to replicate this
experience. It took him over two weeks and 15 phone calls to
finally get through to the Debt Management Center phone line.
And the wait time once the connection was made was 36 minutes.
This is obviously unacceptable.
Secretary Shulkin. Right.
Senator Baldwin. Especially when you think about the fact
that there are veterans with PTSD or other ailments who really
do not need to deal with this type of dysfunctional system,
adding stress and frustration in their lives.
So, my understanding is that the President's budget request
calls for an increase of 14 full-time employees at the Debt
Management Center. I am concerned that this additional staff
will be sort of a bandaid. It will prop up what is a failing
technological telecom system. So, I would like to hear from you
what the VA plan is to identify a commercial callback solution
to eliminate the veterans needlessly waiting on hold and
experiencing the anxiety of not being able to get through.
Secretary Shulkin. Yes. Senator, we have a new system that
is in the process of being installed. It will be installed in
August of this year. I do not have the exact date, but that is,
you know, a few months away. And that includes as part of the
system something called a virtual hold, which is the veteran
can essentially hang up and will be called back in the order
that they have received the call so that in the situation that
you are talking about, they will receive a call back and not
have to wait on the phone because we agree; that is an
unacceptable wait.
Now, as to whether this will all be solved by technology or
whether the 14 FTEs are enough, I am going to have Mr. Murphy
just comment on that.
Mr. Murphy. Senator, we have got some lessons learned from
what we do at the National Call Center with VBA, and what we
found out is a combination of two things: technology in terms
of how much call volume we were getting, and the second one was
our staffing was not aligned with--we discovered we had our
people working Monday through Friday and veterans do not only
call Monday through Friday, so we realigned our staffing. We
put the mix--we put a few part-time employees in. The new
technology we put in place allowed us to identify demand on the
part of the veteran, and then we lined up our staffing model to
the demand of when the phone calls came.
We are using that same process and technology and putting
it in here, the Debt Management Center, so we expect a very
quick resolution of this.
Senator Baldwin. Well, I will be looking forward to a
report in August. Thank you.
Senator Moran. Senator Capito.
Senator Capito. Thank you, Mr. Chairman. And thank you all
of you, and thank you, Dr. Shulkin, for your service and your
leadership.
I wanted to ask a question so I understand your proposed
CARE Act. You just alluded to it. Because I think we are all
proud of the Choice program, but I think you have initiated the
CARE program to sort of supplant this. Am I reading that
correctly?
Secretary Shulkin. Yes. Choice 2.0.
Senator Capito. Choice 2.0, which means you would be
combining Community Care and Choice?
Secretary Shulkin. Yes.
Senator Capito. The aspect of it that I wanted to ask you
about is under the proposed CARE program it is my understanding
that the veteran would not be able to access a private provider
in their community without explicit permission from a VA
clinician who would first assess their needs and then tell them
where and when and how they could go. Now, to me, is that
another step that is in there or--just give me the rationale
for that and how you think that will work better than the
system that we have now.
Secretary Shulkin. Yes. So, first of all, our system that
we have now makes the veteran go out to a third party, makes it
go out to a TPA and get----
Senator Capito. Right. And there are some issues with that.
Secretary Shulkin. And there are some issues with that.
This is returning to a system that is used every day in the
private sector, which is a conversation between a patient and a
provider. Now, it does not mean that a veteran is going to need
to always come in and be evaluated and clinically assessed. If
the service is not provided, of course, they go out to Choice.
If the service is a convenient service closer to the patient
and is easy to get, they will be authorized--that is a new
benefit that we will be adding to do that. Sometimes it is
simply a phone call or a quick conversation. Other times, it is
a clinical assessment.
Senator Capito. And you think this will add more
efficiencies and get more direct better quality? Obviously,
that is the goal.
Secretary Shulkin. I think this changes it from what we
have today, which is a system choice based on administrative
rules 40 miles, 30 days.
Senator Capito. Yes. Right.
Secretary Shulkin. Back to a clinical system of care, which
is what healthcare systems should be doing, assessing and
providing clinical care based on the needs of their patients.
Senator Capito. Okay. Thank you. I would like to know in
the budget and also Senator Baldwin mentioned the Jason
Simcakoski bill built around the VA's reaction to
overprescribing and other issues. Obviously, the VA is a
reflection of the general population. There is a huge drug and
opioid abuse--and I know it is high in the veteran population.
What kind of resources are you putting into this at the VA to
try to meet these challenges?
Secretary Shulkin. Yes. I am going to ask again our CFO
what our CARA budget was. I think it is like $150 million.
Mr. Yow. Actually, sir, it is less than that. The CARA
amount for 2018 is $56 million, and then for the 2019 advanced
appropriation it is $47 million.
Senator Capito. So that is coming--the vehicles, the CARA
bill that we passed here.
Secretary Shulkin. Yes.
Mr. Yow. Now, the budget was submitted prior to the $50
million that came in the omnibus, so that was not included in
the budget submission.
Senator Capito. So outside of the CARA bill, does the VA
have other targeted resources to this?
Secretary Shulkin. Oh, sure.
Senator Capito. Yes. I mean, are you seeing that reflected
in your population? I am sure you are.
Secretary Shulkin. Sure we are. And the VA has been hard at
work on this issue since 2010 where we launched our initiatives
on opioid safety. And we have seen since then over a 35 percent
reduction in the use of opioids throughout the population.
Senator Capito. So you have got a concentrated initiative
to divert from prescribing opioids to other pain therapies?
Secretary Shulkin. Yes, other modalities absolutely. And in
cases where patients are on opioids, dose reduction and
reduction of concomitant use of benzodiazepines.
Senator Capito. Right. Okay. Another question I have and
Secretary McDonald brought this to our attention. I do not
think he was the first one, but I am wondering where you are on
this issue. He mentioned antiquated facilities that are no
longer being used but still owned by the VA that is a money
drag on you and your inability to either sell or repurpose or--
can you give us the status on that? Because in my view--we are
talking about tight resources--that could be a good way to free
I think some of the VA resources to a more productive delivery
of care.
Secretary Shulkin. Yes. We agree with that. Yesterday, I
put out a press release saying I am moving forward on exactly
that issue. We have identified 1,100 facilities that are either
vacant or underutilized. I announced that in the next 2 years I
will deal with those 1,100 facilities, starting with 142
facilities right now that I am proceeding with disposal or
essentially destruction of those buildings so that we no longer
are paying for maintaining--you know, vacant buildings.
Senator Capito. Right. Good. Well, I am certainly
supportive of that initiative.
And just last, I would like to thank the VA for the
relocation of the community-based outpatient clinic in
Lewisburg, West Virginia, to Ronceverte where there were some
workplace issues. It is a beautiful facility. We cut the ribbon
on it just several weeks ago, and I know it will enjoy a lot--I
mean, the veterans in that area are very, very pleased, and I
thank you for that.
Secretary Shulkin. Sure. Good. Thank you.
Senator Capito. Thank you.
Senator Moran. Senator Udall.
Senator Udall. Thank you, Chairman Moran.
Secretary Shulkin, thank you very much for joining us
today, and I look forward to continued cooperation, making
improvements, and addressing ongoing challenges facing the VA.
In March of this year I sent you a letter expressing my
concerns regarding staffing shortages across the VA medical
system, including several facilities in New Mexico. In April,
you responded and said that the VA had addressed this issue by
increasing pay for several positions. Can you give me an update
whether or not you are seeing positive results from these pay
increases?
Secretary Shulkin. There is mixed news on this. We have 24
vacancies still, physician vacancies I am talking about. The
six in emergency medicine we have made offers and have
acceptances. We are still looking for a director of emergency
medicine. In some of the other areas, even though we have done
market salary surveys and made adjustments, we are still
challenged to find healthcare professionals, like many parts of
the country that have shortages. And in New Mexico we still
continue to see shortages.
So, we are making some progess, but I think we are still
concerned that we are going to be able to do this as quickly as
we all want to do it.
Senator Udall. Yes. Thank you for that. And thank you for
your effort there.
In the same letter, I asked you to address the severe
shortage of mental health practitioners within the VA and
specifically in New Mexico. You responded that in New Mexico a
staffing shortage and broken air-conditioning unit were to
blame for reduced capacity, substance abuse, trauma, and
rehabilitation residents. Can you update me whether the full-
time staff positions were filled by the end of May?
Secretary Shulkin. Yes. I know that we fixed the air-
conditioner. That certainly is done. And the full-time people
are now on board so that we are able to get that corrected as
well.
Senator Udall. And besides pay increases, what measures is
the VA taking to increase training, scholarships, residences,
and other options that could help address these chronic
personnel shortages especially in the rural areas of our State
and across the Nation?
Secretary Shulkin. Yes. You know, we continue to be
challenged with this. We do know that several of our programs
that we use are effective. Educational debt reduction, which
you will see in the 2018 budget we have asked for additional
funds for, that is a very effective tool to attract health care
professionals. But the truth is that there is a shortage right
now of trained healthcare professionals, and we are looking for
ways to attract people to the VA. So, one of the thoughts that
we have is to work with you to expand our graduate medical
education program in the VA, and in exchange for expansion have
a payback service in the VA particularly to underserved areas.
The Department of Defense does this quite effectively. The
Public Health Service does this quite effectively. We think it
is a model we should be looking at.
Senator Udall. Yes. And basically, your model there is many
of these new doctors that come out medical school have big
debts, and so in exchange for helping them with their debt,
they then go into underserved areas and many of the places you
have not been able to find doctors to----
Secretary Shulkin. Yes. I think we do that. That is our
Educational Debt Reduction Program. And we are talking about
actually expanding it to a new idea.
Senator Udall. Okay.
Secretary Shulkin. What is happening now is there are more
U.S. medical school graduates than there are spots to train
them in, so we have a mismatch.
Senator Udall. Yes.
Secretary Shulkin. VA under the Choice Act, actually you
helped expand the number of residency programs.
Senator Udall. Right.
Secretary Shulkin. We would like to go further this time
and expand more and use that potentially so that those who
train in the residency program would then enter the VA for a
specified period of time to practice.
Senator Udall. Great. Senator Tester and I introduced a
bill to expand the Rural Veterans Coordination Pilot Grant
Program. Can you just give me an update on the expansion of
that program and how it is going?
Secretary Shulkin. Yes. We are just getting the study
results in now. We are in the process of data analysis. We
should have that in the next 30 days. We would like to come
back and share that with you.
Senator Udall. Great. Thank you very much.
Secretary Shulkin. Thank you.
Senator Udall. I have an additional question for the record
on Master Sergeant Jessey Baca and burn pits but I will submit
that for the record.
Secretary Shulkin. Okay. Thank you.
Senator Udall. And thank you, Mr. Chairman.
Senator Moran. Thank you, Senator Udall.
Senator Rubio.
Senator Rubio. Thank you.
Thank you, Dr. Shulkin. Thanks for being here.
My understanding is the President is going to sign the VA
accountability bill on Friday?
Secretary Shulkin. Yes.
Senator Rubio. I wanted him to do it last Friday. But my
sense is that you are prepared to begin to quickly implement
the flexibility that it gives you for accountability?
Secretary Shulkin. Absolutely. And we certainly thank you
for your leadership in that. This is something that I think all
of us feel is important for moving forward.
Senator Rubio. Yes. The one thing I would note is that we
had tremendous bipartisan support on it.
Secretary Shulkin. Yes.
Senator Rubio. The people came together. Senator Tester,
Senator Moran were part of that as well.
Secretary Shulkin. Yes.
Senator Rubio. And it just troubles me--and again, it does
not matter. I did not have to put my name in it--but how little
coverage it got. And I bet you if we had fought over it a
little bit, they might have talked about it. It is important
when good things happen at the agency or here in Congress that
people mention it, particularly in this case because there has
been so much negativity over the last three or four years about
the VA system and that every opportunity we can to catch people
doing things right, that we point to that as well.
And the great thing about accountability is it is not
really a punitive measure. It is designed in many ways to
reward the people who are doing things the right way. It is not
fair to a good employee to be saddled with the consequences of
someone who is not doing a good job----
Secretary Shulkin. Yes. We have actually seen a fair amount
of coverage on it. It may not have come to your attention,
but----
Senator Rubio. Maybe it is the stations I watch.
Secretary Shulkin. Exactly. But it is exactly the points I
make, Senator. I believe this is going to help us improve
morale. It is going to help us improve recruitment because
people want to work alongside people that share their values.
And the vast majority of people who work in the VA are
dedicated people who are there for the right reason.
Senator Rubio. Yes. So one of the things that concerns me,
and I think these numbers are right; I am pretty sure they are.
We have a little under 1,000 nursing home beds in Florida for
long-term.
Secretary Shulkin. Yes.
Senator Rubio. And I think if you take the number of
veterans and extrapolate that out to the general population
understanding, we would love for people to age in place. We
want as many as possible to be home with their loved ones, and
then we know there are instances in which that is no longer
possible. Either the family can no longer sustain it or the
patient actually would not benefit from it. How are we planning
for that, the baby boomer, surge that will ultimately impact
veterans, particularly of the Vietnam era? How are we planning
for that moving forward? Obviously, Florida is a place where--I
mean, this is not very well-known, but we have a lot of
retirees. Many of them served in the military obviously. And so
how are we planning for that need in the years to come?
Secretary Shulkin. Yes.
Senator Rubio. And by the way, when I say nursing home and
long-term care facilities, we say in many instances that is
someone who is a senior, but unfortunately, in some cases with
concussive brain injuries and the like, it may come much sooner
than anticipated. So, what is our plan moving forward on that?
Secretary Shulkin. Yes. Well, first of all, Florida, as you
know, is one of our fastest-growing States in terms of veterans
and retired veterans, so we are doing several things. First of
all, I made the decision about 2 months ago to eliminate the
Federal requirements on the States for building State nursing
homes or State facilities with Federal money. So, what we used
to do is we used to give out grants to the State--and Florida
was actually the case example for us--where we would tell them
exactly how they had to build these things. And it was costing
them 40 percent more than the States could do it if we would
just get out of the way.
And so we have now changed that to allow Florida and all
other States to rely upon their own regulations so they are
able to build with the same amount of money, 40 percent more
beds for residents, so I think that is going to start helping.
And there are two of these facilities under construction in
Florida right now.
Secondly, we do believe with the use of technology and home
health technology that we can keep more people at home than
ever before because we can provide services that previously had
to be in institutions in the home.
And third, we do believe in the extended use of caregivers
where people want to remain in their homes and not go and seek
institutional care. But, as you said, we are going to have to
continue to expand capacity, and that is why we are working
with States, we are working with nonprofit organizations, and
the VA itself is also building community living centers.
Senator Rubio. And then one of the things we have learned
in the sort of, you know, stay-at-home model is there are needs
from time to time for someone to be able to go to a daytime
facility while the caregiver works or what have you. Do these
centers have the flexibility to provide that service, or is
it--basically, it is up to the State to design based on State
regulation?
Secretary Shulkin. Yes, that is what we have said. It is
now up to the State.
Senator Rubio. So you are providing the money, and then
they are building it as if it were any facility operating in
the State.
Secretary Shulkin. Exactly. Yes.
Senator Rubio. Under their guidelines?
Secretary Shulkin. Yes, and I was on a call with all the
State directors yesterday going over this, and States have
different philosophies about this. I happen to think that
partial-day programs and the type of adult daycare that you are
talking about may not be a great----
Senator Rubio. I am sorry. When you extrapolate the long-
term need with the dollars in the budget, do we have sufficient
funding in that program to keep pace with what we think will be
the need in the years to come?
Secretary Shulkin. Well, the States think that the Federal
Government should be helping more. I have told them that this
is important to us, that we will maintain our funding
commitments to it, that we will certainly look and advocate for
more dollars but that the Federal budgets are under
considerable, you know, stress. And we are going to have to
look for all sorts of sources of funding to meet the needs.
Senator Rubio. I think the right answer to those questions
is always yes, is it not? Yes, we need more money. But I
understand your perspective.
Secretary Shulkin. Yes.
Senator Rubio. The States want the Federal share to be
higher.
Secretary Shulkin. Sure.
Senator Rubio. Got it. Thank you.
Senator Moran. Let me ask Dr. Alaigh a question. This
subcommittee held a hearing on April the 27th on veteran
suicide, more specifically, veteran suicide prevention. Dr.
Clancy and Dr. Kudler were the VHA lead witnesses. We spent a
lot of time talking about the OIG report, which was in February
of 2016, and that report was highly critical of the operations
of the veterans' service line. At our hearing, which was more
than a year after the report, we learned that none of the seven
IG recommendations for action were closed.
And then, can you, Dr. Alaigh, bring us up to date on the
status of those important recommendations. My understanding is
that six of the seven now have been completed, have been
closed. Will you proactively pursue number six, which is not
closed?
And then, since then, the IG produced a second report on
the crisis line, March of this year. It has 16 recommendations
for the VHA. Are you aggressively pursuing tackling those
recommendations? And what will you do to keep us informed of
your progress?
Dr. Alaigh. Thank you, Mr. Chairman. Nice meeting you and
talking to you. And thank you for raising this issue because,
as you know, suicide prevention is our number-one clinical
priority. Many times, we say that, you know, we take care of
our veterans, but this is a time that if we do not take care of
our veterans, we are going to lose them, so there is nothing
more important for us than to take care of this.
As far as the initial IG recommendations, the seven, we
have closed six and a seventh one is being closed by June 30
because that was related to a new contract award for our
rollover contract, so we just wanted to make sure, based on the
IG recommendations, that the performance, the quality measures,
the operational measures were all consistent with our own
program. And so for that, we had to go into contractual
negotiations and modifications so that it will be signed on
June 30, so we would be in compliance with closure of that
recommendation by July 1.
Senator Moran. Doctor, before you answer the second part of
my question, would you assure me or is it your belief that
compliance with those recommendations has actually improved the
responsiveness and the effectiveness of the crisis line?
Dr. Alaigh. Yes, absolutely, because what we have done is
transitioned the suicide prevention crisis line to really a
clinical coordination and a clinical crisis solution. So, what
we have done is we have added clinical oversight, we have
embedded clinicians. We are doing warm transfers when we find a
veteran in crisis to a clinician in the medical facility. We
have seen rollover rates of 30 percent in the last quarter of
the last calendar year now moving to less than 2 percent. Our
response rate has improved to about eight seconds. Ninety
percent of our calls we respond in less than eight seconds.
So, we have seen operational efficiency, we have seen
clinical improvement, and we have been able to tie that whole
program together to make it more robust and truly serving our
veterans.
Senator Moran. So, it is not just a matter of meeting the
IG recommendations; it is a matter of increasing the
opportunities for us to prevent suicide?
Dr. Alaigh. It is about saving lives for our veterans.
Senator Moran. And the second part of my question, the
March recommendations?
Dr. Alaigh. Yes, the March recommendations, there were 16
recommendations. We have submitted four for closure. We still
have 12 recommendations. A lot of those recommendations are
around training and putting standardized processes and policies
in place, and those recommendations do require data gathering
and analysis and, again, reinforcing that we are meeting our
targets. So, it does take time, three to six months to collect
that data and report it, but we are on track to close all the
recommendations by the end of this calendar year, by December
of 2017.
Senator Moran. The challenge in doing so is not a financial
one. It is not a budget issue. It is a matter of timing of
getting the reports completed.
Dr. Alaigh. Right.
Senator Moran. Thank you for your commitment to that
effort. And I would again ask you to keep us informed of your
progress.
Dr. Alaigh. Absolutely.
Senator Moran. Thank you.
Dr. Alaigh. Thank you.
Senator Moran. And now, let me turn to Mr. Walters. Mr.
Walters, I understand that my House colleagues reduced major
construction account in their mark by $102 million, which lines
up with cutting funding for 2018 for three out of your six
major construction cemetery projects. I understand the goal is
to provide veterans--your goal is to provide veterans with
burial options within 75 miles of their residence. Would this
reduction impact your ability to accomplish that goal? And
without the funds, would you be able to move forward with those
three expansion projects?
Mr. Walters. As you mentioned, Mr. Chairman, NCA's goal is
to provide 95 percent of the veteran population with reasonable
access to a burial option in either a national or State
Veterans cemetery within 75 miles of where they live. We
accomplish that by establishing new national cemeteries and,
perhaps more importantly, keeping existing cemeteries open. In
fact, our number-one construction priority is to make sure that
we have sufficient funds for the timely expansion of existing
cemeteries.
The six grave site expansion projects that are included in
the budget are at locations that will have at least one type of
burial option that will deplete by the year 2020. We requested
funds in 2018 to ensure that we had sufficient leeway to
address any unanticipated problems that we might encounter
during the construction process to ensure that we delivered the
grave sites in a timely manner.
The cut of the three expansion projects would place those
locations at a much higher risk for a possible interruption of
burial service. This is not insignificant. The three cemeteries
that were taken out of the request service approximately 1.2
million veterans. That is about 6 percent of the veteran
population, so it is something that is of a concern to us.
Regarding your second question, without the requested major
construction funding, we would have to significantly reduce the
scope of the three projects that were deleted to include the
removal of necessary infrastructure repairs and reallocate a
large portion of our minor construction budget for stop-gap
expansion projects. And this would also require frequent
follow-up with additional minor projects to make sure that we
do not deplete in the future.
We feel that this is not the most cost-effective or
efficient way to address the expansion needs of these three
locations at this time.
Senator Moran. Thank you very much.
Let me turn to Senator Schatz.
Senator Schatz. Thank you, Mr. Chairman. Excuse me.
Secretary Shulkin, the Department's request for
nonrecurring maintenance is $1.8 billion, $700 million over the
year 2017. I am happy to see this investment into the program,
especially given the current deficiencies. Based on the VA's
latest facility condition assessment estimate, what is the
total cost of code violations and deficiencies at VA hospitals
and clinics across the country?
Secretary Shulkin. A lot more than that. I think that our
total capital deficit across the country is estimated to be
somewhere near $50 billion. A lot of that includes our seismic
deficiencies that are of concern to us. Some do include, you
know, infrastructure repair. But it is a large capital deficit.
We do think that this NRM program, along with a request
that we would make to increase our NRM cap from $10 million up
to $20 million will make a substantial impact on some of the
more severe deficiencies.
Senator Schatz. I am a little concerned about the lack of
investment into other capital accounts, major and minor
construction accounts. And I want to be reassured here that, as
you know, your capital expenditures reflect your long-term
programmatic priorities where they should. And because you have
this reduction in the major and minor construction accounts, I
want to be reassured that this is not reflective or predictive
of your view as to where services are going to be provided, in
other words, at VA facilities or not at VA facilities but
rather, due to fiscal constraints, you just had to make tough
choices. I want to know that this is not a reflecting sort of
view of the political winds here in terms of privatizing
services. I want to know what your thinking was here in
reducing these accounts.
Secretary Shulkin. Yes. You know, the way I would say it is
that our thinking is that we were not doing this very well. And
so with the fiasco in construction in Denver, we made several
changes. One was to get the Corps involved, and secondly, to
cut back on our appetite for having such big construction
projects and look for alternative ways to continue to have new
facilities for our veterans and to be able to provide state-of-
the-art facilities for them.
So, it absolutely is not a philosophy towards
privatization. This is a philosophy that we have to do business
differently. We have to do it smarter. I believe the future is
going to involve several things when it comes to facilities.
One is we are going to have to build different types of
facilities. The days of building big bed towers are over. Where
most care is delivered is in ambulatory settings, and we are
going to have to construct different types of facilities. So,
most of our facilities were built more than 50 years ago, and
we need the newer, modern-type design.
Secondly, we need to look at private-public partnerships.
And thanks to your authorization, we have five pilots that we
can do this on. We have announced one in Omaha which took 10
percent of taxpayer dollars compared to what we were going to
build, which was a big bed tower.
And third I would say is we need to do our leasing
differently. Now, when we do not construct as much--and maybe
Hilo is going to be a good example of this--we are looking
towards leasing and having the private sector build this for
us. We have 27 leases now or 24 leases?
Mr. Yow. Twenty-seven.
Secretary Shulkin. How many?
Mr. Yow. Twenty-seven.
Secretary Shulkin. Twenty-seven leases that have not been
authorized by Congress yet. So, when things are not working--
and it has been difficult for you because of the CBO scoring
over a 20-year period of time. It is counted as one big piece
of capital. When things are not working, we have to do things
differently. So, we are approaching GSA to take over the
inventory of our leases and get out of the business of being in
the leasing business and let them do that.
I hope that that will be productive and allow us to open up
these leases, and we will look at Hilo of course. But this is
certainly--we will continue to look at where veterans need new
facilities and advanced facilities and continue to advocate for
them.
Senator Schatz. Thank you. And I will leave this one with
you for the record. First of all, thank you for what you are
doing in telehealth and telemedicine. I just want to know if
there is anything either on the authorizing side--not my side
of the shop--but either on the authorizing side or in the next
markup that we can do to help you to expand telehealth and
telemedicine and specifically to get telemedicine into
veterans' homes.
Secretary Shulkin. Yes.
Senator Schatz. I am very interested in that and where we
can be of assistance. I am sure we will be likely to help, so--
--
Secretary Shulkin. Well, we have proposed again in
technical assistance a legislative fix to allow us to do that,
and we would appreciate your support for that.
Senator Schatz. Right. We are working on it.
Secretary Shulkin. Thank you.
Senator Schatz. Thank you.
Senator Moran. Dr. Shulkin, Senator Murkowski is on her way
back, which gives me the opportunity, which I had intended to
take, regardless of additional questions. But I certainly do
not consider these stalling.
On the topic of construction, I had raised three issues
with the VA. The Leavenworth VA has, for a long time, had a
plan to do a public-private partnership. I would encourage you
to take a look at that project. The Johnson County CBOC, that
is the suburbs of Kansas City, groundbreaking in March, we do
not yet know what kind of services that CBOC is going to
provide, if you could help us answer that question.
And then finally, for a long time, going back to my days in
the House, there was a DOD VA joint project between McConnell
Air Force Base and the Dole VA in Wichita for a new facility
that apparently has fallen through the cracks.
It has been a priority on-again, off-again for a long time,
and I would appreciate being updated on those three items.
Secretary Shulkin. Yes. I would be glad to do that.
Senator Moran. I want to come back and talk about Choice,
but let me first turn to the Senator from Alaska.
Senator Murkowski. Thank you, Mr. Chairman. And sorry that
I have been popping in and out.
Dr. Shulkin, thank you for being here. I am sorry that I
was not able to hear your comments regarding Choice. I will ask
you a couple. But before we do that, I want to talk about
Wasilla and the Wasilla CBOC and the sad state of affairs. I do
not understand why, for 3 years, we have not been able to find
a single doctor to permanently support this facility. This is a
clinic that should be staffed with two permanent doctors, and
we have not been able to keep a single doctor there, and it has
been 3 years. And it is not like Wasilla is the end of the
road. Wasilla is on the road system. Wasilla is a thriving
community.
Becker's Hospital Review rates the Mat-Su Regional
Hospital, which is just down the road, as one of the 150 best
places to work in health care. The southcentral facility, the
clinic there gets rave reviews, has extraordinary
professionals. We cannot figure out why we are not able to get
a permanent full-time VA physician assigned there.
So, I have to believe that those who are looking at this
just think that this is a bad place to be, that the VA is not
an employer of choice for potential employees who have a
choice. I mean, we have included language in the appropriations
bills now for a couple years running. I do not know what to say
to either the VA senior leader who is frustrated. I do not know
what to say to our veterans about what the problem is. I just
do not get it.
And we have looked at the issues relating to salary and to
pay and to benefits and everything else. We cannot get anybody.
Secretary Shulkin. Yes. Listen, I hope we have a big
viewing audience because you made a compelling reason why this
is a great place to practice. Of course, you know, I have been
up there and I think it is a great place to practice. It is
frustrating. I will say that the VA had its recruitment and
retention dollars cut in half to pay for the CARA legislation.
And that was not helpful to us because we need every tool
available to us and every dollar available to us to be able to
go out and to recruit physicians.
The last time I was in Alaska, we had three physicians who
we brought up there and we lost all three to the private
sector. And so it is very competitive, and we are competing
directly against really good private institutions that have
what seems to be a much greater ability to use recruitment and
retention dollars than we have, so we would like to work with
you on this.
Senator Murkowski. Well, you know that I am willing to work
with you on it, but I am beyond frustrated. I do not know what
else we need to do. And again, it makes me think that it is
just something systemically within the VA that is chasing good
men and women away from these opportunities. And in the
meantime, it is our veterans that do not get that level of
service.
Secretary Shulkin. Well, we had a net increase last year of
1,500 physicians. This is one of our priorities. You have given
us a new challenge. Listen, I sense your frustration, and it is
way too long. And our veterans deserve much better up there.
So, let us work on this together. I hope by the next time we
sit at a hearing like this, we have filled the position.
Senator Murkowski. I hope we can say that was past tense.
Secretary Shulkin. Yes.
Senator Murkowski. But I have been thinking that every year
now for 3 years.
So, Choice, over the past several years, we have been
talking also in these hearings about the Choice program and its
shortcomings in the State. You have had an opportunity to visit
the State. I think you are familiar with the challenges that
the VA faces in delivering health care there. You know we are
remote. You know that some of our communities define remote.
I guess, you know, there has been a lot of frustration with
how Choice has kind of come about, how it was written quietly
behind closed doors, presented at the last minute. Recognizing
that there was probably not a--I do not think that there was a
transparent process there, recognizing now that we are dealing
with Choice 2.0, this major nationwide reform of existing
Choice. What do you think? What do you think Alaska's veterans
and healthcare providers want to see in Choice 2.0 up in the
State? What is achievable? What can we do?
Secretary Shulkin. Well, first of all, I think Alaska's
healthcare system was working well prior to Choice and so----
Senator Murkowski. I think so, too.
Secretary Shulkin. Yes.
Senator Murkowski. And that has been the frustration.
Secretary Shulkin. And we heard that loud and clear. There
is no question about it. And so because of the national program
imposed, I think Alaska took a real hit in its customer service
in the step backwards. So, we have been working hard thanks to
you and Senator Sullivan who have been making us clear that
this has to improve, to change the system back to where it was.
And I think that we have gotten pretty close to where we are.
We have also signed, as you know, new agreements with the
Indian Health Service and the tribal agreements.
And Alaska is unique. There are other parts of the country
that are unique. I know Kansas has some challenges in rural
areas as well, so what we learned is there is not one model of
health care for this country, and every geography needs to have
some variation in how they implement this program. And Choice
2.0 allows us for that type of independent geographic
customized design for the healthcare system.
Senator Murkowski. Well, and as you point out, we pioneered
that. We were doing that in Alaska.
Secretary Shulkin. Yes.
Senator Murkowski. That is what got the attention of the
rest of the country. And you move to that and then you say the
only way forward is the way that we design it. You took away--
or that flexibility was taken away.
Secretary Shulkin. Right.
Senator Murkowski. So, again, you know that there is a lot
of frustration up north because we have challenges. We are a
place that is born and bred to meet challenges with great
ingenuity and some enthusiasm. But when we are told basically
that this is how it will be done, we know best in Washington,
D.C., we are not interested in hearing that. We have been told
we are unique so many times we just do not even listen to it
anymore. We know we are. We know that we need flexibility. And
my hope is that there is an understanding to allow within
Alaska the opportunity to define the solutions, as we did
pretty well before, and if we can do that, our veterans I think
will be in a better place.
Secretary Shulkin. Yes.
Senator Murkowski. Mr. Chairman, thank you for letting me
air-drop in at the end. I appreciate it.
Senator Moran. Well, I was glad you were here. I was
fearful I was going to run out of the opportunity to ask
questions.
Mr. Secretary, let me try to bring this hearing to a
conclusion with just a bit more conversation about Choice.
First of all, I would indicate that what Senator Collins talked
about, her ARCH circumstance in Maine is the same circumstance
in Kansas.
Secretary Shulkin. Yes.
Senator Moran. We are one of those four pilot programs who
have been utilizing Community Care. No longer is it eligible.
Secondly, in just a more broad conversation about where I think
we are, a reason--I guess not the--I suppose this is the reason
I suggested to you that you withdraw your mandate that Choice
go away, which was the fear that in the absence of Choice, we
will have an absence of third-party providers, third-party
administrators.
Secretary Shulkin. Administrators, yes.
Senator Moran. And so you were in my view wise enough to
withdraw that, but it has been replaced with something that yet
does not solve the problem of keeping the third-party
administrators in place. I do not know what the timeframe is
that they will continue or can continue to operate, but I know,
based upon what you said, they are losing money.
Secretary Shulkin. Yes.
Senator Moran. And there is at least a rumor that they are
in the process of notifying their employees that their
employment may come to an end. And so, you know, primarily what
we are here about is veterans, so I am not here on behalf of
the third-party administrators, but in their absence, I do not
know how we have a Choice program that works for veterans.
Your response to the Senator from North Dakota about
community-based care was we are going to pursue this in long-
term reauthorization of Choice. I am interested in that. I am
for that, and I am part of the effort to make sure that Choice
is reauthorized in the long term, but I am worried that we are
not going to have anything in place; we will be starting from
scratch and Choice will disappear.
Secretary Shulkin. Well, I think we all agree if we act
quickly--and I want to be part of the solution. I know you do,
too. I truly thank you for raising this to the type of urgency
to resolve this as it deserves. And you were the first one to
reach out and say that this needs to be resolved.
We need to do this quickly because I do not want to see the
third-party administrators take their networks down. But more
importantly, and I know you agree with this, we do not want to
see veterans at all impacted by our inability to manage
budgets. This is not the veterans' fault. This is the fact that
we have financial systems that are very difficult to maneuver
and to get correct in these last couple months of the budget
year. I believe we have two ways to approach this, and I am
willing to work with you on either way, as long as we can work
on it quickly, because, inevitably, I think we all agree it
needs to be done, so we might as well do it sooner rather than
later so that we do not have unintended consequences.
Senator Moran. Well, is there a way in the interim that you
can return to providing more guidance to your VISNs to continue
using Choice beyond
Secretary Shulkin. Well. Beyond the statutory? I do not
feel comfortable asking them to return to a Choice-first policy
because I now have less than $800 million of unobligated funds
in that account. And I can do the math that that will not make
it till October 31, so I am trying to be responsible and make
sure that we do not get to a point where we just have to stop
the Choice program. That would be even worse than where we are
now.
Senator Moran. I think you testified today that the date is
now August the 7th?
Secretary Shulkin. Yes.
Senator Moran. And I think the last time we talked, it was
August the 15th?
Secretary Shulkin. August 7, August 15, I wish I could be
that precise that it mattered. I mean, it is mid-August.
Senator Moran. So there is not some new factor, some----
Secretary Shulkin. No. No, no, no.
Senator Moran. It is still in the same ballpark.
Secretary Shulkin. In fact, extending it so that I did not
mean to shorten it on you.
Senator Moran. Should be going?
Secretary Shulkin. It probably is actually longer than when
we had talked about.
But, you know, it does not reach till October 31-September
30 and so we do need to do something different.
Senator Moran. So what is missing in getting this resolved?
When you and I say I want to work with you and you say you want
to work with me, what is not happening that moves this process
to a quick resolution?
Secretary Shulkin. Yes. I would say to you that if you and
your colleagues have a preferred path to go down, we would like
to work with you on that.
Senator Moran. And you have had that conversation with the
leadership of the authorizing committee?
Secretary Shulkin. Yes, I have.
Senator Moran. Okay. And is there something that we could
assure ourselves that if we go down that path that the
administration, OMB, the White House would say we support that
effort?
Secretary Shulkin. Yes, we are in discussions with OMB. I
had breakfast with the chairman of the authorizing committee
this morning, and he is certainly supportive of resolving this.
And we are in discussions with OMB and the administration
making sure that they understand where our discussions are. I
think all of us, all the way up to the President, want to see
this resolved.
Senator Moran. But the administration has not chosen one of
those options or another one that we have not talked about?
Secretary Shulkin. No.
Senator Moran. Okay. Mr. Secretary, it is always my
practice to give you or any of your team the opportunity to
tell us anything that we did not ask you or did not talk about
or you want to modify or correct to improve my understanding.
Secretary Shulkin. I think we are all ready to go home.
Senator Moran. You know, you indicated this could be a long
hearing with the two of us having a conversation.
Secretary Shulkin. Yes.
Senator Moran. I think almost every member of the
subcommittee was here. It demonstrates the importance of the
Department of Veterans Affairs to our constituents and to our
country, and it indicates a significant interest in your
success in leading the Department of Veterans Affairs. We want
you to succeed and we want to help you accomplish that.
Secretary Shulkin. The only thing I would like to add
besides thanking you for those last comments is that one thing
that I think that veterans across the country appreciate and
certainly we do at VA is the bipartisan nature in which issues
with veterans are approached. And we know increasingly how
difficult that is in the environment, but when it comes to VA,
we have seen you act in a singular fashion in veterans'
interests, and we hope and believe that is really important to
continue.
Senator Moran. In my time in Congress, those arenas in
which that bipartisanship still exists and works well has
diminished. There used to be a larger array of areas.
Secretary Shulkin. Yes.
Senator Moran. We certainly would not want to lose that in
this setting.
Secretary Shulkin. Thank you.
Senator Moran. Again, I appreciate you being here, and I
again look forward to working with you on issues of concern for
our veterans and our country.
ADDITIONAL COMMITTEE QUESTIONS
I would ask that members of the subcommittee who have any
questions for the record, they should turn them into
subcommittee staff no later than June the 28th.
Questions Submitted by Senator Mitch McConnell
Question. I welcomed our recent discussion regarding the status of
the new Louisville VA Medical Center, and I look forward to another
update in the near future. In the meantime, can you please provide an
updated timeline for the design, construction, and completion of the
facility? This project was announced in 2006, and Kentucky's veterans
have had to wait for too long to begin receiving care at this new
facility.
Answer. Design of the replacement Robley Rex VA Medical Center
(VAMC) in Louisville, Kentucky, is ongoing. As outlined in the final
Environmental Impact Statement (EIS) for the replacement VAMC project,
VA identified the Brownsboro Road site as the preferred alternative for
the project. VA has not changed the preferred alternative site at this
time. The Record of Decision (ROD), which is the final step of the EIS
process, is undergoing VA's review. Once the ROD is finalized, VA will
then move forward with completion of the design, which is projected for
2018. VA construction of the replacement facility is dependent on
funding availability, and will be decided in future budget submissions.
Question. It has been brought to my attention that some VA
healthcare facilities lack the capability to provide care that meets
the specific medical needs of female veterans. With this in mind, what
efforts is the VA taking to ensure that all of its healthcare
facilities are fully equipped to provide quality care to female
veterans? What plans are being made to ensure that the new Louisville
VA Medical Center is able to provide quality medical care to female
veterans?
Answer. VA is enhancing facilities, training healthcare staff, and
improving access to services to meet the current and future healthcare
needs of women Veterans. More than 400,000 women Veterans are currently
enrolled in the VA healthcare system.
We understand that women Veterans have unique health needs. Women
Veterans can receive primary care, specialty care, and preventive care,
such as breast and cervical cancer screenings. They can also get
prenatal and maternity care, prescription coverage, mental healthcare,
home healthcare, and geriatric and extended care, as well as medical
equipment and prosthetics coverage.
Subject to the availability of funding and future budget
submissions, it is anticipated that the new Louisville VAMC replacement
hospital will include a Women's Health Clinic with four Patient Aligned
Care Teams (PACT). The clinic is planned to include a dedicated
reception and waiting area, gynecology examination rooms with private
restrooms, general examination rooms, TeleHealth examination rooms,
PharmD consultation/examination, behavioral health consultation,
nutritional consultation, a phlebotomy laboratory, a procedure room
with a private restroom, and an imaging suite. The imaging suite is
planned to include equipment needed for women's healthcare including
Ultrasound, Bone Densitometry, and Mammography. In addition, the
Women's Health Clinic is planned to have dedicated support space for
all assigned staff. For cases in which a woman Veteran would like to
see a provider not assigned specifically to the Women's Health Clinic,
all other PACT modules are expected to include gynecology examination
rooms with private restrooms.
Question. To assist the VA as it continues with reform efforts to
improve and expedite care for our nation's veterans, Congress recently
passed and the President signed into law the Department of Veterans
Affairs Accountability and Whistleblower Protection Act of 2017. This
bill authorizes the creation of a new Office of Accountability and
Whistleblower Protection and provides new authority for additional
accountability measures. Will you please provide a timeline of the VA's
plans to implement these new authorities to ensure that veterans
receive the quality care they deserve and bad actors are held
accountable?
Answer. The Department is working to satisfy the requirements of
Public Law 115-41, the ``Department of Veterans Affairs Accountability
and Whistleblower Protection Act of 2017'' signed into law in June
2017.
office of accountability and whistleblower protection (oawp)
On May 25, 2017, following an Executive Order signed by President
Trump, OAWP was established. By June 12, 2017, employees of the former
Office of Accountability Review were realigned to OAWP.
OAWP is headed by a politically-appointed Executive Director, who
is working on establishing OAWP, commensurate with the law.
OAWP has also developed a website: https://www.va.gov/
accountability. Whistleblowers may also now make a disclosure to OAWP
by email at vacoaccountabilityteam@va.gov; fax at 202-495-5601; and
toll-free hotline at 866-429-6669.
Other key actions for implementing the authorities are as follows:
On or around July 6, 2017, the Secretary issued VA policies
implementing the accountability authorities provided under the Act,
including 38 United States Code (U.S.C.) Sec. 713, as amended, 38
U.S.C. Sec. 714, and the revised timelines and procedures for Title 38
employees provided for under the Act. VA has and continues to provide
training to managers and senior executives on the accountability
authorities and the implementing policies.
The other accountability measures as outlined in Title II of the
Act are under review and will be implemented.
Question. Mental health issues remain a significant challenge for
many veterans. What programs are in place to assist and support
veterans suffering from mental health issues, particularly as they may
relate to suicide prevention? Are there any additional authorities that
the VA needs from Congress in order to provide effective treatment and
care to veterans suffering from mental health issues?
Answer. The VA Fact Sheet below provides information regarding many
of VA's mental health services.
medication-assisted treatment for opioid use disorders
Question. As you may be aware, the opioid and heroin epidemics have
hit Kentucky particularly hard and continue to be a challenge for many
veterans. What programs have been implemented by the VA to treat
substance use disorders, and particularly opioid abuse, by veterans?
What programs have been most effective in providing successful
treatment to veterans?
Answer. The Veterans Health Administration (VHA) has responded to
growing demand for opioid use disorder treatment by increasing access
to Medication-Assisted Treatment (MAT). MAT includes counseling or
psychotherapy; close patient monitoring; and medication using
buprenorphine/naloxone, methadone (administered through an Opioid
Treatment Program), or extended-release injectable naltrexone.
Buprenorphine/naloxone and extended-release injectable naltrexone are
on the VHA National formulary. These are available at VHA facilities
and through non-VA purchased care options in the community. Methadone
is administered and dispensed through 32 VHA Opioid Treatment Programs
across the Nation and through non-VA purchased care options at many
facilities.
VHA has been expanding access to MAT for patients with opioid use
disorders. In the year ending in the second quarter of fiscal year (FY)
2016, VA treated 23,117 patients with MAT, up from 19,333 patients in
the year ending in the fourth quarter of fiscal year 2014, a 20-percent
increase in patients treated in just 1 and a half years. This expansion
is the result of a comprehensive and integrated approach. The
Buprenorphine in VA Initiative provides clinician education through
monthly webinars, newsletters, a SharePoint site with educational
resources, individual consultations, and a national community of
practice supported by an e-mail group. The Psychotropic Drug Safety
Initiative (PDSI) combines use of informatics tools and a national
quality improvement collaborative to improve the evidence-based use of
psychotropic medications. One of the PDSI program's many impacts has
been significantly increased rates of using opioid agonist therapy
among Veterans with Opioid Use Disorder. In addition, VA Pharmacy's
Academic Detailing service is developing an Opioid Use Disorder
campaign using informatics tools and individual provider support to
increase Veteran access to MAT.
VHA offers several medication assisted treatments for opioid use
disorder. Opioid Agonist Treatment includes prescription of methadone
or buprenorphine delivered either in a licensed clinic or office-based
setting, as well as injectable depot naltrexone.
opioid safety
VA has implemented a number of programs to address the epidemic of
opioid related adverse events.
1. The VA's Opioid Safety Initiative (OSI) was implemented nation-
wide in August 2013, and is producing the intended results. The
basis for OSI is to make the totality of opioid use visible at
all levels in the organization. OSI includes key clinical
indicators, such as the number of VA pharmacy users who have
been dispensed an opioid, the number of VA pharmacy users
receiving long-term opioids who also receive a urine drug
screen, the number of VA pharmacy users receiving an opioid and
a benzodiazepine (which puts them at a higher risk of adverse
events) and the average morphine equivalent daily dose of
opioids. Overall, VA has seen a 30-percent reduction in the
number of Veterans who have received opioids for greater than
or equal to 90 days.
2. VA deployed two state-of-the art tools to help providers manage
risk for Veterans receiving opioids. These tools are available
now to all staff in VA facilities.
The Opioid Therapy Risk Report (OTTR) is a national dashboard
to help primary care teams manage Veteran patients on long term
opioid therapy. It includes information about the dosages of
opioids and other sedative medications, significant medical
problems that could contribute to an adverse reaction, and
monitoring data to aid in the review and management of complex
patients.
The Stratification Tool for Opioid Risk Mitigation (STORM) was
designed to identify higher risk patients receiving opioid
prescriptions for proactive care management and review. STORM
incorporates predictive models to estimate the risk that a
patient with an opioid prescription will experience a suicide-
related event or overdose, respiratory depression event, or an
accident or fall. STORM generates a nightly-updated report,
including: current risk estimates, a list of clinical and
prescription risk factors, a tailored checklist of recommended
risk mitigation strategies, and information for care
coordination. STORM can also provide risk estimates for any VHA
patient considering opioid therapy, estimating their risk of
adverse events if they were to initiate a low, medium, or high
dose trial of opioid medication. These estimates can help guide
risk-benefit discussions and shared decisionmaking regarding
pain management plans.
3. VA has implemented the Opioid Overdose Education and Naloxone
Program. As of March, 2016, VA had dispensed over 70,000
naloxone kits to Veterans.
4. VA has implemented the Psychotropic Drug Safety Initiative to
foster quality improvement efforts for mental health
prescribing. PDSI includes efforts to increase access to
pharmacological treatments for substance use disorder, and
reduce prescribing of benzodiazepines.
Question. The Army is in the process of replacing the Ireland Army
Community Hospital (IACH) at Fort Knox with a new facility. Will you
please provide an update on the VA's plans to replace the Fort Knox VA
facility currently located at the IACH, and what are the VA's plans to
ensure area veterans see no disruption in care currently provided at
this facility?
Answer. The VA Community Based Outpatient Clinic located at Fort
Knox, Kentucky, is responding to the Army's Plan to build a new
healthcare facility that will replace the existing Ireland Army
Community Clinic. Currently, VA occupies space, via a sharing
agreement, within the existing Ireland Army Community Clinic. The new
project will consist of a site that is 4.1 acres in area adjacent to
the new Army health facility. The project is planned to be an 18,134
gross square feet facility, and offer primary care and mental health
services to Veterans in the Fort Knox area.
VA's current project schedule anticipates the design build
``Request for Proposal'' to be solidified by August 2017, with a
construction contract to be awarded by December 2017.
The project was awarded to the Army Corps of Engineers in order to
coordinate both projects and ensure seamless transition from the
existing site to the new site of care. In collaboration with the
Department of Defense (DoD)/IACH to support care process
transformation, the services have 1 year to move the clinics prior to
DoD's readiness for demolition of the existing IACH. VA foresees no
disruption in care at Fort Knox VA Clinic.
Question. Your recent announcement regarding the VA's decision to
transition to the same Electronic Health Record system used by the
Department of Defense (DoD)--referred to as MHS GENESIS--was welcome
news to many veterans. Can you please provide a timeframe for
proceeding with this transition, and how will you ensure that veterans'
health records are protected during the process?
Answer. The Electronic Health Record (EHR) modernization effort is
anticipated to take several years to be fully complete, and will
continue to be an evolving process as technology advances are made to
provide seamless care for Veterans. VA is in the midst of focused
negotiations to finalize a contract.
Safeguarding Veterans' personal information will remain of
paramount importance as VA plans for a multi-year transition effort.
Once an EHR contract is in place and an implementation approach is
established, we will have more information to share.
______
Questions Submitted by Senator Brian Schatz
medicaid
Question. The President's budget assumes hundreds of billions of
cuts to Medicaid. According to a recent study released last month by
Families USA and Vote Vets, about 1.75 million veterans have Medicaid
as a source of health coverage, and about 340,000 veterans receive
coverage through the ACA's Medicaid expansion.
Has the VA forecasted what a cut of this magnitude to Medicaid
would do to VA's utilization rates or costs?
Answer.Although we are closely monitoring policy discussions, the
impact on utilization and costs is unclear until more information is
known about the final version of the healthcare reform bill and how the
states may react to changes in Federal policy.
Question. Secretary Shulkin, you are a clinician with years of
experience running healthcare systems. In your view, do you believe
that significant cuts to Medicaid will have an impact on the number of
veterans seeking and relying on care through the VA's healthcare
system?
Answer. The Department of Veterans Affairs' (VA) primary concern
for Veterans healthcare is that Veterans retain access to quality
healthcare throughout the country, along with financial support for
that care where needed. VA would be concerned about any policy changes
that negatively affect health insurance coverage for Veterans,
including those currently reliant upon Medicaid for their healthcare.
These Veterans, typically those with a relatively lower income, may
have few if any other means to pay for their care if they lose Medicaid
coverage.
Question. Does the fiscal year 18 budget request assume any new
costs due to an increase in veterans coming to the VA system because of
cuts to Medicaid?
Answer. The fiscal year (FY) 2018 budget request was based upon
current policies. Since changes to Medicaid have not been implemented,
the fiscal year 2018 budget did not include costs due to pending
healthcare reform proposals.
electronic health records
Question. You recently announced that VA would move to purchase the
same electronic health record as DoD. If done right, implementing an
electronic health record has the potential to be transformational.
However, your current platform, Vista, is an integral part of almost
everything VHA does--including telehealth. In short, this is more than
just an EHR procurement; it's a culture change which will impact
current work patterns and management.
Leaving the technical requirements aside, what are you doing to
engage with clinicians and other healthcare workers now to ensure you
have buy-in by the end of this process?
Answer. The current Electronic Health Record (EHR) modernization
effort is anticipated to take several years to be fully complete, and
will continue to be an evolving process as technology advances are
made. The input from multi-disciplinary clinical teams from VA will be
central to how VA implements the new EHR system. We are standing up an
inter-agency Governance board to maintain a single common EHR solution
between VA and the Department of Defense (DoD) to drive VA's
requirements for implementation and to work jointly with DoD to keep
the two agencies in sync for seamless care.
VA's longstanding history in field-based IT innovation will be
leveraged and clinicians and healthcare workers have already begun
engaging at various levels with the modernization effort. Development,
technical, and clinical staff with experience in VistA/CPRS and other
clinical applications will be central to the EHR modernization effort.
VA encourages and recognizes the need for employee engagement and
support as we prepare for this substantial organizational change.
Question. How are you engaging with DoD to ensure that you can
leverage their expertise in acquisition and learn from their
experiences?
Answer. VA and DoD are committed to partnering in this effort and
understand that the mutual success of this venture is dependent on the
close coordination and communication between the two Departments. To
that end, DoD is making available current and former senior
acquisition, testing, and project management experts who were
instrumental in the beginning phases of DoD's own transformation to
assist VA with contracting and initial implementation. This will allow
VA to capitalize on the experience and expertise of individuals who
supported previous modernization and EHR implementation efforts,
including adopting DoD's best practices and lessons learned through the
requirements and acquisition phase.
Moving forward, VA has established a dedicated Program Executive
Office (PEO), which will be staffed with VA's most knowledgeable
technical and functional subject matter experts in contracting, health
IT, and business innovation. The newly established PEO will be led by
the former DoD EHR Program Manager who successfully led the acquisition
of the DoD EHR solution and related services. Hence, the lessons
learned from DoD's past efforts will be applied throughout the various
stages of the VA acquisition and implementation processes.
Question. To what extent, if any, will Vista remain in use at the
VA and how will that impact telehealth platforms that tie information
back to Vista?
Answer. The new EHR system will bring needed modern functionality
and infrastructure integrated into a single experience with fewer
products. This will help simplify healthcare delivery for both Veterans
and clinical providers. The EHR will be designed to accommodate the
aspects of healthcare delivery that are high priority or unique to VA,
while bringing industry best practices to improve VA care. As VA plans
for a multi-year transition effort, VA will continue to use existing
clinical systems and identify which of the existing associated
applications and which VistA modules, in addition to all the clinical
ones, will be replaced. The impact of telehealth as it relates to EHR
modernization is still being determined. Once an EHR contract is in
place and an implementation approach is established, we will have more
information to share.
Question. On the budgetary side, clearly your decision was made
after the fiscal year 2018 budget was developed. When do you expect to
know overall costs and schedule?
Answer. VA is in the midst of focused negotiations to finalize a
contract. Though the contract negotiations will likely take 3-6 months,
PEO EHRM should be able to offer an anticipated budget request in
September to support funding requirements and alignment to support the
anticipated contract award and related Electronic Health Record
deployment schedule and implementation functions. Once an EHR contract
is in place and an implementation approach is established, we will have
more information to share.
Question. Are there specific funds in your fiscal year 18 budget
that are currently identified for modernization projects that are now
no longer needed--and if so, do you plan to move that funding over to
your new acquisition plan in fiscal year 2018?
Answer. As part of the overarching EHR Modernization effort,
Veterans Health Administration (VHA) and the Office of Information &
Technology subject experts are evaluating modernization efforts that
are currently underway with the goal of determining which efforts will
continue, be paused, or be cancelled. VA will also be examining our
overall contracts portfolio in the coming months to assess capability
gaps in support of acquiring and implementing a commercial EHR. Once an
EHR contract is in place and an implementation approach is established,
we will have more information to share.
grants for the construction of state extended care facilities
Question. One of VA's most popular programs with States is the
grant program for construction of State extended care facilities.
Before a project is eligible to receive a grant the State must provide
35 percent in matching funds. In my home State, we have one project,
construction of a new 120 bed facility in Honolulu, which has received
matching funds and is currently on the priority one grant list. While I
am encouraged that the project made it on the priority one list and is
now eligible to receive a grant, it is nevertheless concerning that the
amount being requested by the Department for the program falls severely
short of what is needed to meet demand. In fact, the VA is only
requesting $90 million for this program, despite having more than $600
million in priority one grant applications in fiscal year 2017 alone.
These are projects that have met the requirements of the program and
have State matching funds.
Can you please describe how the budget is developed for this
program--especially given that demand is so high, yet the request is
barely enough to make a dent in the priority list?
Answer. VA's priority for the Grants for Construction of State
Extended Care Facilities is to protect Veterans from those conditions
that threaten the lives and safety of residents in existing facilities.
In addition to funding, VA also needs different types of strategic
partnerships to be able to bring the type of facilities that we need to
Veterans, and that means working with local government, with academic
affiliates, other Federal agencies, and private sector partnerships.
VA establishes a priority list of applications for State home
grants each fiscal year. First priority is provided to feasible
applications where States have provided sufficient State funds so that
the project may proceed upon award of the grant. The first priority is
further prioritized as follows: (1) Remedies for life/safety
deficiencies; (2) States that have not previously applied for a
construction grant for a nursing home; (3) Great need for beds in a
State; (4) Renovation other than (1); (5) Significant need for beds in
a State; and (6) Limited need for beds in a State. After VA receives
the annual appropriation for the State Home Construction Grant program,
projects are funded in the order of priority ranking on the list until
Federal funds are spent.
telehealth
Question. Earlier this year, this Subcommittee held a hearing on
VA's telehealth program. As I mentioned at that hearing, VA has long
been a leader in leveraging telehealth technology to provide better
access to veterans. In fact, this is an area where I believe the
Department far exceeds what is happening in the private sector.
Given VA's past successes, how is the Department looking to expand
telehealth and remote patient monitoring in fiscal year 2018?
Answer. VA has multiple telehealth expansion plans that will
enhance VA healthcare accessibility and the Veteran's experience
including VA Video Connect, which provides secure web-enabled video
visits, and regional telehealth clinical resource hubs offering
telehealth providers to fill temporary or longer term service gaps for
primary care, mental health, and specialty care services.
With its new Home Telehealth (HT) technology contracts in 2017,
Veterans have even greater flexibility for innovative HT solutions to
include tablets, mobile monitoring applications, and video--to add to
the already established HT solutions like hub devices, interactive
voice response, and web-enabled browser technologies. With these
additional solutions for case management, VA plans to expand HT to
Veterans who are more tech-savvy and looking for more flexible and
portable options. Additionally, these tools will be used to expand the
Low Acuity/Low Intensity monitoring program that offers another level
of case management for Veterans who need less assistance than currently
provided by HT, but more coaching, guidance, and monitoring than a
mobile self-management application would provide.
Question. What, if any, help do you need from Congress to bring
telehealth into veterans homes?
Answer. On August 3, 2017, the Secretary announced VA is beginning
to implement nationally VA Video Connect, a software solution that
facilitates the delivery of real time video communications on personal
computers and mobile technologies (phones, tablets). This new
technology will enable VA to more easily deliver services at locations
most convenient for Veterans, be it in their homes or any other secure
location where they have their mobile technology. VA still needs to
establish the unambiguous authority for providers to deliver VA
clinical services to Veterans irrespective of the provider or Veteran's
locations. Considering the critical priority assigned to this need and
its direct relation to expanding clinical services, VA has pursued all
known avenues to establish this authority. VA expects to issue a notice
of proposed rule-making in the fall of 2017. Depending on public
comments, VA expects to have a final, legally effective rule in early
fiscal year 2018.
While VA is using its existing authority to amend its regulations
in consideration of telehealth, it still believes that a clear
statement in statute of Federal Supremacy by Congress would be the
ultimate protection for providers and could expand VA's authority to
deliver comprehensive Telehealth services to Veterans in any location.
Currently, VA providers delivering telehealth across State lines have
no clear protection from the enforcement of State laws that require
local licensure or limit the practice of telehealth. VA needs
legislation that explicitly authorizes VA providers to care for
Veterans using telehealth irrespective of the location of the provider
or Veteran.
hilo cboc
Question. The VA Pacific Island Health Care System has proposed a
new one-stop-shop style CBOC for Hilo. As I mentioned at the hearing,
the project has been in the VA's SCIP pipeline for years despite the
fact that the existing CBOC in Hilo has to move because it is in a
tsunami risk area. The VA has leased a temporary space in an industrial
part of Hilo that it is building out and plans to move into next year,
but veterans tell me that it is hard to get to, and too many of them
will not utilize this space once the VA moves there.
What is the status of the VAPIHCS's proposed one-stop-shop CBOC for
Hilo and when does the VA expect to fund this project?
Answer. Fiscal year 2018 was the first year that the Hilo CBOC
minor construction project was submitted and scored through the
Strategic Capital Investment Planning (SCIP) process. Prior to this,
the project was listed as a potential out year project in the
facility's long-range plan. Out year projects are not considered for
funding request purposes. While the proposed CBOC is a valid
requirement, the project was not approved for funding in 2018. Due to
limited resources, VA had to prioritize projects. This included
emphasizing VA's non-recurring maintenance program over other
construction programs, including minor construction. The majority of
VA's fiscal year 2018 minor request is directed towards completing the
backlog of previously-started minor construction projects. VA requested
funding for only six new minor projects in the fiscal year 2018 budget.
VA plans to consider the Hilo CBOC project in future budget years.
Question. To what extent does the SCIP process consider the impact
on access to care for veterans that would utilize a new project as
compared to the status quo when it is prioritizing proposals?
Answer. SCIP business cases for new capital investments are
submitted for prioritization, and must address how a project will meet
an identified performance gap(s), including deficiencies in access,
space, utilization, and condition. Potential alternatives to meeting
needs include leasing, new construction, renovation, contracting out,
and purchasing an existing facility. If a performance gap exists,
status quo is not a viable option. If there is no performance gap
identified, then status quo would be an acceptable course of action.
Minor gaps may be met by maintaining the status quo, and supplementing
by other available means.
SUBCOMMITTEE RECESS
Senator Moran. This hearing is now adjourned.
[Whereupon, at 4:29 p.m., Wednesday, June 21, this hearing
is concluded and the subcommittee was recessed, the reconvene
subject to the call of the Chair. ]