[Senate Hearing 116-137]
[From the U.S. Government Publishing Office]
S. Hrg. 116-137
FISCAL YEAR 2020 BUDGET AND 2021 ADVANCED APPROPRIATIONS REQUESTS FOR
THE DEPARTMENT OF VETERANS AFFAIRS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
MARCH 26, 2019
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
36-913 PDF WASHINGTON : 2020
COMMITTEE ON VETERANS' AFFAIRS
Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas Jon Tester, Montana, Ranking
John Boozman, Arkansas Member
Bill Cassidy, Louisiana Patty Murray, Washington
Mike Rounds, South Dakota Bernard Sanders, (I) Vermont
Thom Tillis, North Carolina Sherrod Brown, Ohio
Dan Sullivan, Alaska Richard Blumenthal, Connecticut
Marsha Blackburn, Tennessee Mazie K. Hirono, Hawaii
Kevin Cramer, North Dakota Joe Manchin III, West Virginia
Kyrsten Sinema, Arizona
Adam Reece, Staff Director
Tony McClain, Democratic Staff Director
C O N T E N T S
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March 26, 2019
SENATORS
Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........ 1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana...... 3
Manchin, Hon. Joe, III, U.S. Senator from West Virginia.......... 21
Cramer, Hon. Kevin, U.S. Senator from North Dakota............... 23
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 25
Moran, Hon. Jerry, U.S. Senator from Kansas...................... 27
Boozman, Hon. John, U.S. Senator from Arkansas................... 31
Hirono, Hon. Mazie K., U.S. Senator from Hawaii.................. 33
Blackburn, Hon. Marsha, U.S. Senator from Tennessee.............. 34
Murray, Hon. Patty, Chairman, U.S. Senator from Washington....... 36
Tillis, Hon. Thom, U.S. Senator from North Carolina.............. 38
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 40
Sullivan, Hon. Dan, U.S. Senator from Alaska..................... 42
WITNESSES
Wilkie, Hon. Robert L., Secretary, U.S. Department of Veterans
Affairs; accompanied by Paul R. Lawrence, Ph.D., Under
Secretary for Benefits, Veterans Benefits Administration;
Richard A. Stone, M.D., Executive in Charge, Veterans Health
Administration; and Jon Rychalski, Assistant Secretary for
Management and Chief Financial Officer......................... 6
Prepared statement........................................... 8
Response to posthearing questions submitted by:
Hon. Johnny Isakson........................................ 47
Hon. Jon Tester............................................ 50
Hon. Sherrod Brown......................................... 71
Hon. Richard Blumenthal.................................... 143
Hon. Mazie K. Hirono....................................... 154
Hon. Joe Manchin III....................................... 160
Hon. Kyrsten Sinema........................................ 175
APPENDIX
Co-Authors of the Independent Budget; prepared statement......... 177
FISCAL YEAR 2020 BUDGET AND 2021 ADVANCED APPROPRIATIONS REQUESTS FOR
THE DEPARTMENT OF VETERANS AFFAIRS
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TUESDAY, MARCH 26, 2019
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:09 a.m., in
room 418, Russell Senate Office Building, Hon. Johnny Isakson,
Chairman of the Committee, presiding.
Present: Senators Isakson, Moran, Boozman, Cassidy, Rounds,
Tillis, Sullivan, Blackburn, Cramer, Tester, Murray, Brown,
Blumenthal, Hirono, Manchin, and Sinema.
OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN,
U.S. SENATOR FROM GEORGIA
Chairman Isakson. I call the Senate Veterans' Affairs
Committee to order and welcome everybody to the Committee
today. Thank you to Secretary Wilkie, in particular, and all
the members of the VA staff for being here today. You are going
to get a lot of questions, I know, and hopefully give us a lot
of good answers. Then, we will hopefully get some good results
at the end of the year and be moving in the right direction.
The Committee and the VA had a good year last year. We got
a lot of things squared away that had been needed to be
addressed for some time. We get some laws passed you all wanted
for some time, you said you needed for some time, and we want
to--we gave them to you and we are going to look for the
results this year. That is what we are going to be reviewing,
is making sure we are making progress with results, not just
promises, and I think we will be able to do that.
This is an important hearing today. This is our annual
review of the budget. The President's budget came out a few
days ago. The VA's budget is a significant one, and
significantly increased.
We have a unique situation. We get more money than anybody
in increases every year, as a percentage, however you want to
calculate it. Money is not our problem. Now I know there are
some people in this room who say, ``Oh, yes, it is. I need this
much more. I could do this,'' but we have been--we have looked
out for our veterans. We know we are paying for benefits they
have earned and we know we have got to finance them. I am proud
the President's budget is up 9.1--is that right?--9.5, and $220
billion. Right? That is a huge budget.
But, what I want to do this morning, in my opening remarks,
is really just focus a little bit on this year and then how we
came to where we are.
The first thing I want to do is thank the VSOs. I changed
the way we do this meeting. Used to be they came in as a second
panel. The first panel was the Secretary, the second panel was
all the VSOs. That took a lot of time, it diminished the value
of each person's testimony, and we have just finished with
meetings with all the VSOs--almost all the--well, all the VSOs,
over the last 5 weeks anyway.
So, the important thing I asked the VSOs to do was to
submit their testimony in writing and submit the questions they
want specifically to have answered in writing, and then we get
those. They submitted some terrific questions, which prompted
great thought on my part and other Members' part as we went
over those and reviewed those questions. They will be sent for
answers to the Secretary; and, Mr. Secretary, I am going to
expect an answer on all of them.
I want to thank the VSOs for the time they put into it, and
make sure you know that just because I did not include you in
terms of verbal testimony at this meeting, it is not because we
did not want to hear from you. I wanted to see that what we
heard from you actually got done. So, I asked you to submit it
in writing and we will submit that to the VA and then we will
follow up on it, rather than having it lost somewhere in the
ecosystem once you have set it here and it is gone wherever it
goes.
The second thing I want to do today is talk about two
meetings we have coming up that I am going to insist on. I
promised Members; I try to keep my promises. We have done
amazingly well on that, and it is because we have cooperation
by all of the Committee, particularly the Ranking Member. But,
number 1, Senator Manchin had asked for a discussion on burn
pits and toxic exposure, et cetera. We are going to have a
meeting on toxic exposure. It will come later in the year,
after we have begun to swallow the Blue Water Navy. My
understanding is that--is this true, Secretary Wilkie, that the
Blue Water Navy court decision is not being challenged? Is that
right.
Secretary Wilkie. That would be my recommendation from VA.
Chairman Isakson. VA has recommended that, which I
appreciate, and I have offered that opinion as well. I think
that is what is going to end up happening. If that happens, we
are going to be in the process of beginning to swallow a big
bite, and chew it, and dissolve it, and get it--I was happy to
learn from the Secretary that 51 people have already been
treated, that would have been eligible, that benefited--Blue
Water Navy benefited anyway. Is that correct?
Secretary Wilkie. Fifty-one thousand.
Chairman Isakson. Fifty-one thousand. I appreciate the
Secretary and the VA doing such a thorough job as far as Blue
Water Navy is concerned, and in anticipation of what this
Committee and the other Committee in the House did on Blue
Water Navy. Hopefully, that will continue.
The other topic is access standards. The big fellow sitting
to my right has made it clear to me that access standards are a
big thing with him. Well, they are a big thing with me too,
because if you really think about it, if the recently-
published-for-comment rules and standards for access of
community care, once those are finished then in Alaska and in
Kansas and North Dakota, South Dakota, Georgia, Montana,
everywhere, our more rural veterans in more rural areas--how it
is working for them to get them the care they need as quickly
as we can, get a system that works so doctors want to be a part
of it. Get a third-party administrator working to make sure
that they have got a good repertoire of doctors available, to
be chosen from, to meet the standards. It is just terrific.
So, I am going to focus on access standards at our next
meeting, which we have on April 10. Is that right?
Mr. Reece. Yes, sir.
Chairman Isakson. We are going to focus on access
standards. I want to encourage everybody to be there, because
if we do one thing this year, if we can get that working--that
is the part of Choice that was hard, that is the part of Choice
that had the most problems--if we can get it working right for
the VA and veterans, and right for us, then we are going to
have taken care of our single biggest problem in terms of
operations out there on a daily basis, which are veterans'
benefits.
With that said I will end my opening remarks and turn to--I
guess I should--have I welcomed the Secretary yet? I will let
you have your opening run and then I will welcome the
Secretary.
Senator Tester.
OPENING STATEMENT OF HON. JON TESTER, RANKING MEMBER, U.S.
SENATOR FROM MONTANA
Senator Tester. Thank you. Thank you much, Mr. Chairman. I
do not want to beat you to the punch, but I want to welcome
Secretary Wilkie, Dr. Lawrence, and Dr. Stone----
Chairman Isakson. I think you just did.
Senator Tester [continued]. Mr. Rychalski to the hearing
today. I look forward to learning from you today and I want to
thank your team, and thank you for what you guys do every day.
The Chairman talked about access standards and access
standards will be talked about a lot today. We have talked
about privatization. Nobody around this table, and I do not
believe any of you want to see that happen. But, it is
something I am very concerned about because the big boss talks
about it all the time, and in the end we need to make sure
that, as the VSOs told us a couple of a week ago during joint
House and Senate Veterans' Affairs Committee, they prefer the
care that you guys provide.
That is a good thing. I think that is a very good thing.
That means you guys are doing some things right, OK? We will
talk about a few things you might not be doing so right today,
and I will apologize ahead of time, but the truth is that these
are folks that have served our country and we need to make sure
we live up to the promises, as you well know, Mr. Secretary,
the promises we made to them.
Look, over the past few years this Committee has heard from
the VA about what it needs to be successful. We have engaged
with VSOs, as we did for the last couple of weeks, to see what
they wanted in their VA, and I will tell you this Committee
listened, and we acted, leading the way on a number of
monumental reforms that, quite frankly, a lot of people did not
think we could ever get done, but we did last Congress, on
behalf of our Nation's veterans.
This is an important part of our job, providing you, the
VA, with the tools that you need to do your job. Equally
critically, though, is your job of deciding how the new
authorities, and the resources, are executed and utilized,
which is where, as I have said already, my concerns tend to
lie. In my view, the level of commitment from Congress to
address health care vacancies and critical infrastructure needs
at the VA needs to be matched by the Department.
I have talked about my parochial interest in Montana--and I
am going to talk about it again today--Fort Harrison. By the
way, if you run back about 15 years, it was one of the top VA
facilities in the country. Fort Harrison today has one primary
care physician, a part-time doctor who sees a handful of
patients. I have got CBOCs in Montana, as you know, Mr.
Secretary, with no primary care doctors, no advanced primary
care clinicians, and where that care is only provided through
telehealth.
Now I am going to tell you--telehealth is a great
innovation and it does some great things with folks that have
mental health issues--but it cannot replace all types of health
care. So, you get my frustration, that VA primary focus seems
to be expanding eligibility and investments in the community
care, but I do not want it to be at the expense of capacity-
building initiatives.
I am going to say that again. I do not want our investments
in community care to be at the expense of capacity-building
initiatives.
As you and I have discussed, there is certainly a role for
the private sector, especially in a rural State like Montana. I
am sure Senator Sullivan would agree in Alaska, and other
States, too. But, I think we have got to be careful that we do
not take the Department down a dangerous path. And, when it
comes to veterans, you can outsource the care but you cannot
outsource the responsibility. When they are sent to the
community care option without first knowing if that care can be
provided in a timely manner and if it is quality care, we are
going to pay the price for that later, because, quite frankly,
the veteran is going to come back and ask, ``Why?''
So, I think we need to hold our VA providers to one set of
standards and community care providers to that same set of
standards. After all, none of us want a flood of veterans going
to community care if it is lower and less--lower quality and
less timely. And, we certainly cannot head down a path without
a firm grasp on how much it is going to cost the American
taxpayer.
For example, we received multiple estimates from the
Department on how much it would cost to implement access
standards in the month leading up to the budget request. None
of those estimates matched the number that finally appeared in
the budget request, and as we go forth I would like you to
clarify that if you could, why that is.
It is not clear how that estimate came about. It is also
not clear whether the technology you need to implement this
program, such as the decision support tool, will be ready in
time for implementation. I have been receiving conflicting
reports about the readiness of this tool. I am frustrated we
continue to hear about IT solutions that may not be executed
properly. There is a huge chunk of money in this budget for IT.
If it is not spent properly we have wasted taxpayer dollars and
we have not delivered the services to our veterans that they
have earned.
As you know, the VA has struggled for many years in the
field of IT, earning a place on the GAO's high-risk list this
year again. I recently had a great meeting with Jim Gfrerer but
there is no OIT representation from the Department here today,
so I hope that is not a reflection of how this issue is being
prioritized. I know the table is short so you have to pick and
choose. But, we have seen how flawed IT rollouts impact
veterans and the progress the VA is making on replacing an
antiquated system that cannot afford to be plagued with
shortcuts.
By the way, we are here today with the MISSION program as a
direct result of IT failures in Arizona. So, this is a big
thing. We need to work. You have got a great team around you,
Mr. Secretary. I have said it before and I will say it again. I
think you are a great guy. I think you are the right guy for
this job, and I am glad you are there. But, we need to find out
the details of this budget, and as we move forward I certainly
do not want to see VA care dollars transferred to community
care because we ran out of money in the community care budget.
With that I would just say thank you all for being here.
Thank you, Mr. Chairman, for the opportunity to speak, and I
look forward to this hearing.
Chairman Isakson. Thank you, Senator Tester. For
everybody's benefit here I think I heard, without exception, at
our hearings with the VSOs, ``We ain't going to privatize''
said 100 times. I did not have a single person write me, call
me, trip me up, throw me down the steps, or anything else,
wanting to privatize the VA, and I have no interest in doing
so. So, let us just put that sign behind the bathroom door
rather than the front door, and let us talk about making the VA
the best VA we can make it and be what our veterans want it to
be.
Jon is right. They like their VA and that is why they call
it ``my VA.'' They just want it to be a little bit better,
which is what we want to make it, a little bit better--better
in its accountability and better in its results. So, that is
what we will be talking about.
With that said, talking about better, we have the best guy
you could ever have, in terms of Secretary of the VA. Robert
Wilkie--I did not know Mr. Wilkie until he was nominated, I
guess. That is the first time we met. I have heard quite
frequently that he has got a good bedside manner. He is really
easy to talk to. He just has a resonant voice. He is very easy-
going, knows some great jokes. They are all clean. He is just a
terrific guy all the way around. But, the good thing about it
is he does not just have a good personality and a good
demeanor, he likes to get the job done, and he talks in
measures that are accountable, that hold himself accountable. I
appreciate that.
I think with his type of persona we already are seeing
improvements and results with the VA. We have got a long way to
go, but they do a lot of things well and we are proud of those
things. We want to do the things we do not do well better and
take some of our problems that have been hanging on with us for
a long time and get those problems solved. I think Robert
Wilkie is the man to do it and I am really pleased to work with
him, plus Senator Tester, and the Members of our Committee in
the Senate to see to it we finish the job--we will never finish
the job--but continue the job of improving the Veterans
Administration for the benefit of our vets.
With that said I could go over your military background,
the fact that you are a good Southern boy, and all those good
things, Robert, but instead I would just like to say we have a
great Secretary of the Veterans Administration and I am proud
to work with Robert Wilkie, I appreciate what he does, and I am
proud to introduce him for as much time as he might consume,
except remind him that how much he does consume may consider
how much we enjoy what he has to say, so do not take too much
of it.
Secretary Wilkie. Well----
Chairman Isakson. Introduce your other----
Secretary Wilkie [continuing]. Yes, sir.
STATEMENT OF HON. ROBERT L. WILKIE, SECRETARY, U.S. DEPARTMENT
OF VETERANS AFFAIRS; ACCOMPANIED BY PAUL R. LAWRENCE, PH.D.,
UNDER SECRETARY FOR BENEFITS, VETERANS BENEFITS ADMINISTRATION;
RICHARD A. STONE, M.D., EXECUTIVE IN CHARGE, VETERANS HEALTH
ADMINISTRATION; AND JON RYCHALSKI, ASSISTANT SECRETARY FOR
MANAGEMENT AND CHIEF FINANCIAL OFFICER
Secretary Wilkie. Well, first of all, thank you for the
courtesy and thank you for the kindness that you have shown me.
I am going to take a point of personal privilege and thank you
and Senator Tester for all the support that you have given me.
As you know, I came to this position having been the Under
Secretary of Defense for Personnel and Readiness. I was raised
in the military world. My service, compared to my ancestors, is
incredibly modest, but it is service, nonetheless, and I have
been privileged to see the military life from many angles.
There is no higher honor than to be sitting here before you.
I am pleased to have with me, and I will start on the left
side, Jon Rychalski, who is our project guru, our Assistant
Secretary for Management and our Chief Financial Officer; Dr.
Richard Stone, who is our Executive in Charge of VHA; and our
most recent award winner, who has just received an award for
being the government's best senior executive, and that is Dr.
Paul Lawrence, our Under Secretary for Benefits, and I thank
them for coming.
When I last reported to this Committee, Mr. Chairman, in
December, I said that the state of VA is better. I believe,
from the statements that you have made and from the statements
Senator Tester has made that you believe that as well. I count
that to the support of this Committee.
Earlier this morning, I addressed the House Doctors Caucus,
and I said the changes made in VA were not driven by the
Executive branch. The changes made in the VA came from the two
authorizing committees. I argue that it is the most
transformative period in the history of this Department, going
all the way back to Omar Bradley's day, and I do not believe
that we are any longer on the cusp of transformation. We are
actually in the middle of it.
Before I talk about that I do want to talk about the
trajectory that VA is on. In the last month we have had--the
last few months--we have had some excellent news. In most of my
career in and out of government VA has always been rated 16 of
17 or 17 out of 17 in terms of the best places in government to
work. The Partnership for Public Service, for the first time,
said we are no longer there. We are in the top third and we are
actually moving in a higher direction. So, if we have customer
service amongst ourselves we will provide good customer service
to those that we are honored to serve.
The Annals of Internal Medicine said, as Senator Tester
implied, that the medical care that VA gives is good or better
than any medical care in any region of the country, and we are
proud of that. And last, the Journal of the American Medical
Association said that our wait times in the four most important
categories of medical care or as good or better than any in the
private sector. That is an indication as to where we are headed
in our Department.
The major driver of transformation is the MISSION Act. As
you know, it simplifies and consolidates VA's seven Community
Care Programs into a single, streamlined, simple-to-use
program. It extends the Choice Program, expands the Caregiver
Program, and provides a new urgent care benefit as well as
other access improvements. Regulations setting new access
standards, ensuring greater choice for veterans, will be
completed in June. We have proposed a 30-minute average drive
time standard for primary care and mental health care and a 60-
minute average drive time standard for specialty care.
We have also proposed appointment wait time standards of 20
days for primary care and mental health care and 28 days for
specialty care from the date of request, with certain
exceptions, and I want to also begin to address the
privatization argument. Obviously, I come from the conservative
Republican side of the aisle. The issue that has been raised
many times about privatization is just not borne out by our
budget, by the directions of this Committee, and I am here to
say, as Senator Tester said, that the care in the private
sector, 9 times out of 10, is probably not as good as care in
VA.
I will give you an example. One of your colleagues gave an
interview in one of his State's newspapers, saying that he was
disappointed in the wait times for certain services at VA in
one of his major metropolitan areas. The wait time was 12 days
for VA. In the major metropolitan area it was 78 days. That
also is an indication that we are moving in the direction that
you have pointed for us and the direction that veterans
deserve. Things are not always greener on the other side of the
hill.
At the same time, we are trying to move out in making VA a
modern 21st century health care administration. No longer will
we have an ad hoc supply chain. We are tying in with the
Department of Defense and their computerized systems for
medical supplies. The days where VA doctors at the DCVA have to
run across the parking lot to MedStar to find equipment have to
be over if we are going to continue the road of improvement.
The other part of our major transformation is the
electronic health record, where we tie in with the DOD the
minute that young American walks into the military entrance
processing station, so that we have a complete picture of that
veteran's health.
The Chairman mentioned burn pits. For the first time, when
this is online, VA doctors will be able to see everything that
had happened in that soldier's life, from exposures to toxins
overseas, from exposures to toxics in the continental United
States, and we will then know better how to serve that veteran.
I have been asked to lead the National Suicide Prevention
Task Force. That is one of three areas that VA is moving out on
in response to this Committee. For Senator Manchin it is the
opioid epidemic, and how we begin to change the way we treat
our veterans when it comes to the use of opioids.
Homelessness is another area; and then finally, suicide
prevention. In the last year we have hired over 3,900 mental
health professionals. We now provide same-day mental health
service for veterans in need.
As part of the continued transformation we are also
engaging in the creation of a modern H.R. system. Right now
there are 140 H.R. offices across VA. We are consolidating
those down to 18, and for the first time bringing in H.R.
professionals to create a modern human resource capability that
will send doctors, nurses, and health care professionals to
those parts of the country where they are most needed.
As for the budget, the Chairman is right, a $220 billion
budget. That is a 9.5 percent increase over what VA had last
year. That is $97 billion in discretionary spending, a $123.2
billion in mandatory spending, and funding for 393 full-time
employees, which is an increase in 13,000 for those working at
VA.
That means that for the MISSION Act, 19 percent of the
funding will go to community care but 81 percent for VA care;
$1.6 billion to the electronic health record; $184 million for
a modern, integrated financial acquisition management system;
and $36 million for us to continue to adopt the Defense Medical
Logistics Standard Support system; $8.1 million to continue the
improvement in customer service, the prime directive for those
in VA; $547 million for women's health; and $1.6 billion for
capital investment.
The last item on my list is to continue my pledge to you
that we be an open department. We are joined at the hip with
this Committee and with the Committee of the House of
Representatives. We all have the same mission in mind. Again, I
thank you for your courtesy. I thank you for allowing me the
honor of serving in this capacity, and I look forward to your
questions.
[The prepared statement of Mr. Wilkie follows:]
Prepared Statement of Hon. Robert L. Wilkie, Secretary,
U.S. Department of Veterans Affairs
Good morning, Chairman Isakson, Senator Tester, and distinguished
Members of the Committee. Thank you for the opportunity to testify
today in support of the President's Fiscal Year (FY) 2020 Budget for
the Department of Veterans Affairs (VA), including the FY 2021 Advance
Appropriation (AA) request. I am accompanied today by Dr. Richard
Stone, Executive in Charge, Veterans Health Administration (VHA), Dr.
Paul Lawrence, Under Secretary for Benefits, and Jon Rychalski,
Assistant Secretary for Management and Chief Financial Officer.
I begin by thanking Congress and this Committee for your continued
strong support and shared commitment to our Nation's Veterans VA. In my
estimation, two Federal Government departments must rise above partisan
politics--the Department of Defense (DOD) and VA. The bipartisan
support this Committee provides sustains that proposition. To continue
VA's momentum, the FY 2020 budget request fulfills the President's
strong commitment to Veterans by providing the resources necessary to
improve the care and support our Veterans have earned through sacrifice
and service to our country.
fiscal year (fy) 2020 budget request
The President's FY 2020 Budget requests $220.2 billion for VA--
$97.0 billion in discretionary funding (including medical care
collections). The discretionary request is an increase of $6.8 billion,
or 7.5 percent, over the enacted FY 2019 budget. It will sustain the
progress we have made and provide additional resources to improve
patient access and timeliness of medical care services for the
approximately 9 million enrolled Veterans eligible for VA health care,
while improving benefits delivery for our Veterans and their
beneficiaries. The President's FY 2020 budget also requests $123.2
billion in mandatory funding, $12.3 billion or 11.1 percent above 2019.
For the FY 2021 AA, the budget requests $91.8 billion in
discretionary funding including medical care collections for Medical
Care and $129.5 billion in mandatory advance appropriations for
Compensation and Pensions, Readjustment Benefits, and Veterans
Insurance and Indemnities benefits programs in the Veterans Benefits
Administration (VBA).
For VA Medical Care, VA is requesting $84.1 billion (including
collections) in FY 2020, a 9.6 percent increase over the 2019 level,
and a $4.6 billion increase over the 2020 AA, primarily for community
care and to transition the Choice Program workload to VA's
discretionary Medical Community Care account. This Budget will provide
funding for treating 7.1 million patients in 2020.
This is a strong budget request that fulfills the President's
commitment to Veterans by ensuring that they receive high-quality
health care and timely access to benefits and services while
concurrently improving productivity and fiscal responsibility. I urge
Congress to support and fully fund our FY 2020 and FY 2021 AA budget
requests--these resources are critical to enabling the Department to
meet the evolving needs of our Veterans and successfully execute my top
priorities.
customer service
It is the responsibility of all VA employees to provide an
excellent customer service experience (CX) to Veterans, Servicemembers,
their families, caregivers, and survivors when we deliver care,
benefits, and memorial services. I am privileged to champion this
effort.
Our National Cemetery Administration has long been recognized as
the organization with the highest customer satisfaction score in the
Nation. That's according to the American Customer Satisfaction Index
ACSI). And that's across all sectors of industry and government. We
need to work to scope that kind of success across all benefits and
services.
That's why I incorporated CX into the FY 2018-2024 VA Strategic
Plan. Last year, I issued VA's first customer service policy. That
policy outlines how VA will achieve excellent customer service along
three key pillars: CX Capabilities, CX Governance, and CX
Accountability. I am holding all VA executives, managers, supervisors,
and employees accountable to foster a climate of customer service
excellence. We will be guided by our core VA Values of Integrity,
Commitment, Advocacy, Respect, and Excellence (I-CARE). These values
define our culture of customer service and help shape our standards of
behavior.
Because of VA's leadership in customer experience, our Veterans
Experience Office has been designated Lead Agency Partner for the
President's Management Agenda (PMA) Cross-Agency Priority (CAP) Goal on
Improving Customer Experience across government.
Our goal is to lead the President's work of improving customer
experience across Federal agencies and deliver customer service to
Veterans we serve that is on par with top private sector companies.
This is not business as usual at VA. We are changing our culture
and putting our Veteran customers at the center of our process. To
accomplish this goal, we are making investments in Customer Service,
and we are making bold moves in training and implementing customer
experience best practices.
Veterans Experience Office. The Veterans Experience Office (VEO) is
my lead organization for achieving our customer service priority and
providing the Department a core customer experience capability. VEO
offers four core customer experience capabilities, including real-time
customer experience data, tangible customer experience tools, modern
technology, and targeted engagement. For FY 2020, VEO is shifting from
a full reimbursable authority (RA) funding model to a hybrid of a RA
and budget authority (BA) model. The FY 2020 request of $69.4 million
for the VEO ($8.6 million in BA and $60.6 million in RA) is $8.1
million above the FY 2019 enacted budget. The budget increase and the
transition to a BA highlights VA's commitment to customer service and
the institutionalization of CX capabilities within the Department to
improve care, benefits and service to Veterans, their families,
caregivers and survivors.
mission act implementation
The VA MISSION Act of 2018 (the MISSION Act) will fundamentally
transform elements of VA's health care system, fulfilling the
President's commitment to help Veterans live a healthy and fulfilling
life. It is critical that we deliver a transformed 21st century VA
health care system that puts Veterans at the center of everything we
do. The FY 2020 budget requests $8.9 billion in the VA Medical Care
program for implementation of key provisions of the MISSION Act: $5.5
billion for continued care of the Choice Program population; $2.9
billion for expanded access for care based on average drive time and
wait time standards and expanded transplant care; $272 million for the
Urgent Care benefit, and $150 million to expand the Program of
Comprehensive Assistance for Family Caregivers.
Access to Care. Over the past few years, VA has invested heavily in
our direct delivery system, leading to reduced wait times for care in
VA facilities that currently meet or exceed the quality and timeliness
of care provided by the private sector. And VA is improving access
across its more than 1,200 facilities even as Veteran participation in
VA health care continues to increase.
From FY 2014 through FY 2018, VA saw an increase of 226,000 unique
patients for outpatient appointments (a four percent increase). Since
FY 2014, the number of annual appointments for VA care is up by 3.4
million. There were over 58 million appointments in VA facilities in FY
2018--620,000 more than the prior fiscal year. We have significantly
reduced the time to complete an urgent referral to a specialist. In FY
2014, it took an average of 19.3 days to complete an urgent referral
and in FY 2018 it took 2.1 days, an 89 percent decrease. As of
December 2018, that time was down to about 1.6 days.
Still, our patchwork of multiple separate community care programs
is a bureaucratic maze that is difficult for Veterans, their families,
and VA employees to navigate.
The MISSION Act empowers VA to deliver the quality care and timely
service Veterans deserve so we will remain at the center of Veterans'
care. Further, the MISSION Act strengthens VA's internal network and
infrastructure so VA can provide Veterans more health care access more
efficiently.
Transition to the New Community Care Program. We are building an
integrated, holistic system of care that combines the best of VA, our
Federal partners, academic affiliates, and the private sector.
The Veterans Community Care Program consolidates VA's separate
community care programs and will put care in the hands of Veterans and
get them the right care at the right time from the right provider. On
January 30, 2019, we announced proposed access standards that would
determine if Veterans are eligible for community care under the access
standard eligibility criterion in the MISSION Act to supplement care
they are provided in the VA health care system. The proposed regulation
for the program (RIN 2900-AQ46) was published in the Federal Register
on February 22, 2019, and was open for comments through March 25, 2019.
New Veterans Community Care Program Eligibility Criteria
1. VA does not offer the care or services the Veteran requires;
2. VA does not operate a full-service medical facility in the State
in which the Veteran resides;
3. The Veteran was eligible to receive care under the Veterans
Choice Program and is eligible to receive care under certain
grandfathering provisions;
4. VA is not able to furnish care or services to a Veteran in a
manner that complies with VA's designated access standards;
5. The Veteran and the Veteran's referring clinician determine it
is in the best medical interest of the Veteran to receive care or
services from an eligible entity or provider based on consideration of
certain criteria that VA would establish; or
6. The Veteran is seeking care or services from a VA medical
service line that VA has determined is not providing care that complies
with VA's standards for quality.
Proposed Access Standards. VA's proposed access standards--proposed
for implementation in June 2019--best meet the medical needs of
Veterans and will complement existing VA facilities with community
providers to give Veterans access to health care.
1. For primary care, mental health, and non-institutional extended
care services VA is proposing a 30-minute average drive time from the
Veteran's residence.
2. For specialty care, VA is proposing a 60-minute average drive
time from the Veteran's residence.
3. VA is proposing appointment wait-time standards of 20 days for
primary care, mental health care, and non-institutional extended care
services and 28 days for specialty care from the date of request,
unless a later date has been agreed to by the Veteran in consultation
with the VA health care provider.
------------------------------------------------------------------------
Primary/Mental Health/
Non-institutional Specialty Care
Extended Care
------------------------------------------------------------------------
Appointment Wait Time...... Within 20 Days Within 28 Days
------------------------------------------------------------------------
Average Drive Time......... Within 30 Min Within 60 Min
------------------------------------------------------------------------
VA remains committed to providing care through VA facilities as the
primary means for Veterans to receive health care, and it will remain
the focus of VA's efforts. As a complement to VA's facilities eligible
Veterans who cannot receive care within the requirements of these
proposed access standards would be offered community care. When
Veterans are eligible for community care, they may choose to receive
care with an eligible community provider, or they may continue to
choose to get the care at their VA medical facility.
The proposed access standards are based on analysis of practices
and our consultations with Federal agencies--including the DOD, the
Department of Health and Human Services, and the Centers for Medicare &
Medicaid Services--private sector organizations, and other non-
governmental commercial entities. Practices in both the private and
public sector formulated our proposed access standards to include
appointment wait-time standards and average drive time standards.
VA also published a Notice in the Federal Register seeking public
comments, and in July 2018, VA held a public meeting to provide an
additional opportunity for public comment.
With VA's proposed access standards, the future of VA's health care
system will lie in the hands of Veterans--exactly where it should be.
Urgent Care. This budget will also invest $272 million in
implementing the new urgent (walk-in care) benefit included in the VA
MISSION Act. On January 31, 2019, VA published a proposed rule that
would guide the provision of this benefit using the provider network
available through national contracts. Under the new urgent care
authority, we will be able to offer eligible Veterans convenient care
for certain, limited, non-emergent health care needs.
Caregivers. The MISSION Act expands eligibility for VA's Program of
Comprehensive Assistance for Family Caregivers (PCAFC) under the
Caregiver Support Program, establishes new benefits for designated
primary family caregivers of eligible Veterans, and makes other changes
affecting program eligibility and VA's evaluation of PCAFC
applications. Currently, the Program of Comprehensive Assistance for
Family Caregivers is only available to eligible family caregivers of
eligible Veterans who incurred or aggravated a serious injury in the
line of duty on or after September 11, 2001. Implementation of the
MISSION Act will expand eligibility to eligible family caregivers of
eligible Veterans from all eras.
Under the law, expansion will begin when VA certifies to Congress
that VA has fully implemented a required information technology system.
The expansion will occur in two phases beginning with eligible family
caregivers of eligible Veterans who incurred or aggravated a serious
injury in the line of duty on or before May 7, 1975, with further
expansion beginning two years after that.
Over the course of the next year, VA will be establishing systems
and regulations necessary to expand this program. Caregivers and
Veterans can learn about the full range of available support and
programs through the Caregivers website, www.caregiver.va.gov, or by
contacting the Caregiver Support Line toll-free at 1-855-260-3274.
The FY 2020 Budget for the Caregivers Support Program is $720
million, $150 million of which is specifically requested to implement
the program's expansion because of the MISSION Act.
Telehealth. VA is a leader in providing telehealth services. VA
leverages telehealth technologies to enhance the accessibility,
capacity, and quality of VA health care for Veterans, their families,
and their caregivers anywhere in the country. VA achieved more than one
million video telehealth visits in FY 2018, a 19 percent increase in
video telehealth visits over the prior year. Telehealth is a critical
tool to ensure Veterans, especially rural Veterans, can access health
care when and where they need it. With the support of Congress, VA has
an opportunity to continue shaping the future of health care with
cutting-edge technology providing convenient, accessible, high-quality
care to Veterans. The FY 2020 Budget includes $1.1 billion for
telehealth services, a $105 million or 10.5 percent increase over the
2019 current estimate.
Section 151 of the MISSION Act strengthens VA's ability to provide
even more telehealth services because it statutorily authorizes VA
providers to practice telehealth at any location in any State,
regardless of where the provider is licensed. VA's telehealth program
enhances customer service by increasing Veterans' access to VA care,
while lessening travel burdens.
In FY 2018, more than 782,000 Veterans (or 13 percent of Veterans
obtaining care at VA) had one or more telehealth episodes of care,
totaling 2.29 million telehealth episodes of care. Of these 782,000
Veterans using telehealth, 45 percent live in rural areas. VA's major
expansion for telehealth and telemental health over the next five
years, for both urban and rural Veterans, will focus on care in or near
the Veteran's home. VA's target is to increase Veterans receiving some
care through telehealth from 13 percent to 20 percent using telehealth
innovations like the VA Video Connect (VVC) application, which enables
private encrypted video telehealth services from almost any mobile
device or computer. VVC will be integrated into VA clinicians' routine
operations to provide Veterans another option for connecting with their
care teams.
Strengthening VA's Workforce. Recruitment and retention are
critical to ensuring that VA has the right doctors, nurses, clinicians,
specialists and technicians to provide the care that Veterans need. The
FY 2020 Budget strengthens VHA's workforce by providing funding for
342,647 FTE, an increase of 13,066 over 2019. VA is also actively
implementing MISSION Act authorities that increased VA's ability to
recruit and retain the best medical providers by expanding existing
loan repayment and clinical scholarship programs; it also established
the authority to create several new programs focused on medical school
students and recent graduates. VA is also implementing additional
initiatives to enhance VA's workforce, such as the expanded utilization
of peer specialists and medical scribes.
business transformation
Business transformation is essential if we are to move beyond
compartmentalization of the past and empower our employees serving
Veterans in the field to provide world-class customer service. This
means reforming the systems responsible for claims and appeals, GI Bill
benefits, human resources, financial and acquisition management, supply
chain management, and construction. The Office of Enterprise
Integration (OEI) is charged with coordination for these efforts.
Office of Enterprise Integration. The scale and criticality of the
initiatives underway at VA require management discipline and strong
governance. As part of OEI's coordination role in VA's business
transformation efforts, we have implemented a consistent governance
process to review progress against anticipated milestones, timelines,
and budget. This process supports continuous alignment with objectives
and identifies risks and impediments prior to their realization.
For example, our VA Modernization Board recently initiated a
leadership integration forum to synchronize deployment schedules across
three major enterprise initiatives: adoption of Defense Medical
Logistics Standard Support (DMLSS), financial management business
transformation, and our new electronic health record. This forum
allowed us to assess the feasibility of a concurrent deployment and
identify an alternate course of action. By implementing strong
governance and oversight, we are increasing accountability and
transparency of our most critical initiatives.
Appeals Modernization. The Veterans Appeals Improvement and
Modernization Act of 2017 (AMA) was signed into law on August 23, 2017
and took effect on February 19, 2019. The Appeals Modernization Act
transforms VA's complex and lengthy appeals process into one that is
simple, timely, and fair to Veterans and ultimately gives Veterans
choice and control over how to handle their claims and appeals.
The FY 2020 request of $182 million for the Board of Veterans'
Appeals (the Board) is $7.3 million above the FY 2019 enacted budget
and will sustain the 1,125 FTE who will adjudicate and process legacy
appeals while implementing the Appeals Improvement and Modernization
Act. The Board continues to demonstrate its commitment to reducing
legacy appeals and decided a historic number of appeals--85,288--in FY
2018, the highest number for any fiscal year. The Board is on pace to
decide over 90,000 appeals in 2019.
To ensure smooth implementation, the Board launched an aggressive
workforce plan to recruit, hire, and train new employees in FY 2018.
The Board on-boarded approximately 242 new hires, including 217
attorneys/law clerks and approximately 20 administrative personnel.
The new appeals process features three decision-review lanes:
1. Higher-Level Review Lane: A senior-level claims processor at a
VA regional office will conduct a new look at a previous decision based
on the evidence of record. Reviewers can overturn previous decisions
based on a difference of opinion or return a decision for correction.
VBA has a 125-day average processing goal for decisions issued in this
lane.
2. Supplemental Claim Lane: Veterans can submit new and relevant
evidence to support their claim, and a claims processor at a VA
regional office will assist in developing evidence. VBA has a 125-day
average processing goal for decisions issued in this lane.
3. Appeal Lane: Veterans who choose to appeal a decision directly
to the Board of Veterans' Appeals (Board) may request direct review of
the evidence the regional office reviewed, submit additional evidence,
or have a hearing. The Board has a 365-day average processing time goal
for appeals in which the Veteran does not submit evidence or request a
hearing.
In addition to focusing on implementation of the Appeals
Modernization Act, addressing pending legacy appeals will continue to
be a priority for VBA and the Board in FY 2019. VBA's efforts have
resulted in appeals actions that have exceeded projections for fiscal
year to date 2019. VBA plans to eliminate completely its legacy, non-
remand appeals inventory in FY 2020 and significantly reduce its legacy
remand inventory in FY 2020.
Finally, VBA is also undertaking a similar, multi-pronged approach
to modernize its appeals process through increased resources,
technology, process improvements, and increased efficiencies. VBA's
compensation and pension appeals program is supported by 2,100 FTEs.
VBA added 605 FTEs in FY 2019 to process legacy appeals and decision
reviews in the modernized process. As of October 1, 2018, to best
maximize its resources an enable efficiencies, VBA centralized these
assets to conduct higher-level reviews at two Decision Review Operation
Centers (DROC). VBA will convert the current Appeals Resource Center in
Washington, DC, into a third DROC using existing assets.
Forever GI Bill. Since the passage of the Harry W. Colmery Veterans
Educational Assistance Act of August 16, 2017, VA has implemented 28 of
the law's 34 provisions. Twenty-two of the law's 34 provisions require
significant changes to VA information technology systems, and VA has
202 temporary employees in the field to support this additional
workload.
Sections 107 and 501 of the law change the way VA pays monthly
housing stipends for GI Bill recipients, and VA is committed to
providing a solution that is reliable, efficient and effective. Pending
the deployment of a technology-based solution, Veterans and schools
will continue to receive GI Bill benefit payments as normal. By asking
schools to hold fall enrollments through the summer and not meeting the
implementation date for the IT solutions of Sections 107 and 501, some
beneficiaries experienced delayed and incorrect payments.
In accordance with the Forever GI Bill Housing Payment Fulfillment
Act of 2018, VA established a Tiger Team tasked to resolve issues with
implementing sections 107 and 501 of the Forever GI Bill. This month we
awarded a new contract that we believe will provide the right solution
for implementing Sections 107 and 501. By December 2019, we will have
Sections 107 and 501 fully implemented. By spring 2020, all enrollments
will be processed according to the Colmery Act. We will recalculate
benefits based on where Veterans take classes, and we will work with
schools to make Sections 107 and 501 payments retroactive to the first
day of August 2018, the effective date.
The Department is committed to making sure every Post-9/11 GI Bill
beneficiary is made whole based on the rates established under the
Forever GI Bill, and we are actively working to make that happen. We
got the word out to Veterans, beneficiaries, schools, VSOs, and other
stakeholders that any Veteran who is in a financial hardship due to a
late or delayed GI Bill payment should contact us immediately.
In December 2018, we updated the housing rates like we normally
would have in August. Those rates were effective for all payments after
January 1, 2019. Additionally, we processed over 450,000 rate
corrections, ensuring that any beneficiary who was underpaid from
August through December received a check for the difference. We have
completed the spring peak enrollment season without any significant
challenges. We worked with schools to get enrollments submitted as
quickly as possible.
As VA moves forward with implementation, we will continue to
regularly update our Veteran students and their institutions of
learning on our progress and what to expect. Already, VA has modified
its definition of ``campus'' to better align itself with statutory
requirements, and in doing so has lessened the administrative burden on
schools to report to VA housing data.
Information Technology Modernization. The FY 2020 budget request of
$4.343 billion continues VA's investment in the Office of Information
Technology (OIT) modernization effort, enabling VA to streamline
efforts to operate more effectively and decrease our spending while
increasing the services we provide. The budget allows OIT to deliver
available, adaptable, secure, and cost-effective technology services to
VA--transforming the Department into an innovative, twenty first
century organization--and to act as a steward for all VA's IT assets
and resources. OIT delivers the necessary technology and expertise that
supports Veterans and their families through effective communication
and management of people, technology, business requirements, and
financial processes.
The requested $401 million funds for development will be dedicated
to mission critical areas, continued divestiture of legacy systems such
as the Benefits Delivery Network and the Burial Operations Support
System, and initiatives that are directly Veteran-facing. Funds will
continue to support Veteran focused initiatives such as Mental Health,
MISSION Act and Community Care, and the continued transition from the
legacy Financial Management System (FMS) to the new Integrated
Financial and Acquisition Management System (iFAMS). The Budget also
invests $379 million for information security to protect Veterans'
information.
Financial Management Business Transformation (FMBT). As mentioned
above, a critical system that will touch the delivery of all health and
benefits is our new financial and acquisition management system, iFAMS.
In support of the Financial Management Business Transformation (FMBT)
program, the FY 2020 budget requests $66 million in IT funds, $107
million in Franchise Fund Service Level Agreement (SLA) funding from
the Administrations and other Staff Offices to be paid to the Financial
Services Center (FSC), and General Administration funding of $11.9
million.
Through the FMBT program, VA is working to implement an enterprise-
wide financial and acquisition management system in partnership with
our service provider, CGI Federal Inc. VA will utilize a cloud hosted
solution, configured for VA, leveraging CGI's Software as a Service
(SaaS) model. VA will gain increased operational efficiency,
productivity, reporting capability, and flexibility from a modern
Enterprise Resource Planning (ERP) cloud solution. The new cloud
solution will also provide additional security, storage, and
scalability.
Infrastructure Improvements and Streamlining. I want to thank
Congress for providing $2 billion in additional funding for VA
infrastructure in 2019. This additional funding for minor construction,
seismic corrections, and non-recurring maintenance will enhance our
ability to address infrastructure needs. In FY 2020, VA will continue
improving its infrastructure while transforming our health care system
to an integrated network to serve Veterans. This budget allows for the
expansion of health care, burial and benefits services where needed
most. The request includes $1.235 billion in Major Construction
funding, as well as $399 million in Minor Construction to fund VA's
highest priority infrastructure projects. These funding levels are
consistent with our requests in recent years.
Major and Minor Construction
This funding supports major medical facility projects including
providing the final funding required to complete these projects: New
York, NY--Manhattan VAMC Flood Recovery, Bay Pines, FL--Inpatient/
Outpatient Improvements, San Juan, PR--Seismic Corrections, Building 1;
and Louisville, KY--New Medical Facility. The request also includes
continued funding for ongoing major medical projects at San Diego, CA--
Spinal Cord Injury and Seismic Corrections, Reno, NV--Correct Seismic
Deficiencies and Expand Clinical Services Building, West Los Angeles,
CA--Site utilities for Build New Critical Care Center, and Alameda,
CA--Outpatient Clinic & National Cemetery.
The 2020 request includes additional funding for the completion of
the new cemetery at Western New York Cemetery (Elmira, NY) and the
replacement of the cemetery at Bayamon, PR (Morovis), and expansion
project at Riverside, CA. The national cemetery expansion and
improvement projects at Houston and Dallas, TX and Massachusetts
(Bourne, MA) are also provided for. The FY 2020 Budget provides funds
for the continued support of major construction program including the
seismic initiative that was implemented in 2019 to address VA's highest
priority facilities in need of seismic repairs and upgrades.
The request also includes $399 million in minor construction funds
that will used to expand health care, burial and benefits services for
Veterans. The minor construction request includes funding for 131 newly
identified projects as well as existing partially funded projects.
Leasing
VA is also requesting authorization of seven major medical leases
in 2020 to ensure access to health care is available in those areas.
These leases include new leases totaling $33 million in Colombia, MO
and Salt Lake City, UT as well as replacement leases totaling $104
million in Baltimore, MD; Atlanta, GA; Harlingen, TX; Jacksonville, NC;
and Prince George's County, MD. VA is requesting funding of $919
million to support ongoing leases and delivery of additional leased
facilities during the year.
Repurposing or Disposing Vacant Facilities
To maximize resources for Veterans, VA repurposed or disposed of
175 of the 430 vacant or mostly vacant buildings since June 2017. Due
diligence efforts (environmental/historic) for the remaining buildings
are substantially complete, allowing them to proceed through the final
disposal or reuse process.
suicide prevention
Suicide is a national public health issue that affects all
Americans, and the health and well-being of our Nation's Veterans is
VA's top priority. Twenty (20) Veterans, active-duty Servicemembers,
and non-activated Guard or Reserve members die by suicide on average
each day, and of those 20, 14 had not been in our care. That is why we
are implementing broad, community-based prevention strategies, driven
by data, to connect Veterans outside our system with care and support.
The FY 2020 Budget requests $9.4 billion for mental health services, a
$426 million increase over 2019. The Budget specifically invests $222
million for suicide prevention programming, a $15.6 million increase
over the 2019 enacted level. The request funds over 15.8 million mental
health outpatient visits, an increase of nearly 78,000 visits over the
2019 estimate. This builds on VA's current efforts. VA has hired more
than 3,900 new mental health providers yielding a net increase in VA
mental health staff of over 1,000 providers since July 2017.
Nationally, in the first quarter of 2019, 90 percent of new patients
completed an appointment in a mental health clinic within 30 days of
scheduling an appointment, and 96.8 percent of established patients
completed a mental health appointment within 30 days of the day they
requested.
Preventing Veteran suicide requires closer collaboration between
VA, DOD, and the Department of Homeland Security (DHS). On January 9,
2018, President Trump signed an Executive Order (13822) titled,
``Supporting Our Veterans During Their Transition from Uniformed
Service to Civilian Life.'' This Executive Order directs DOD, VA, and
DHS to develop a Joint Action Plan that describes concrete actions to
provide access to mental health treatment and suicide prevention
resources for transitioning uniformed Servicemembers in the year
following their discharge, separation, or retirement. On March 5, 2019,
President Trump signed the National Roadmap to Empower Veterans and End
Suicide Executive Order (13861), which creates a Veteran Wellness,
Empowerment, and Suicide Prevention Task Force that is tasked with
developing, within 1 year, a road map to empower Veterans to pursue an
improved quality of life, prevent suicide, prioritize related research
activities, and strengthen collaboration across the public and private
sectors. This is an all-hands-on-deck approach to empower Veteran well-
being with the goal of ending Veteran suicide.
For Servicemembers and Veterans alike, our collaboration with DOD
and DHS is already increasing access to mental health and suicide
prevention resources, due in large part to improved integration within
VA, especially between the VBA and VHA. VBA and VHA have worked in
collaboration with DOD and DHS to engage Servicemembers earlier and
more consistently than we have ever done in the past. This engagement
includes support to members of the National Guard, Reserves, and Coast
Guard.
VA's suicide prevention efforts are guided by our National Strategy
for Preventing Veteran Suicide, a long-term plan published in the
summer of 2018 that provides a framework for identifying priorities,
organizing efforts, and focusing national attention and community
resources to prevent suicide among Veterans. It also focuses on
adopting a broad public health approach to prevention, with an emphasis
on comprehensive, community-based engagement.
However, VA cannot do this alone, and suicide is not solely a
mental health issue. As a national problem, Veteran suicide can only be
reduced and mitigated through a nationwide community-level approach
that begins to solve the problems Veterans face, such as loss of
belonging, meaningful employment, and engagement with family, friends,
and community.
The National Strategy for Preventing Veteran Suicide provides a
blueprint for how the Nation can help to tackle the critical issue of
Veteran suicide and outlines strategic directions and goals that
involve implementation of programming across the public health
spectrum, including, but not limited to:
Integrating and coordinating Veteran Suicide Prevention
across multiple sectors and settings;
Developing public-private partnerships and enhancing
collaborations across Federal agencies;
Implementing research informed communication efforts to
prevent Veteran suicide by changing attitudes knowledge and behaviors;
Promoting efforts to reduce access to lethal means;
Implementation of clinical and professional practices for
assessing and treating Veterans identified as being at risk for
suicidal behaviors; and
Improvement of the timeliness and usefulness of national
surveillance systems relevant to preventing Veteran suicide.
Every day, more than 400 Suicide Prevention Coordinators (SPC) and
their teams--located at every VA medical center--connect Veterans with
care and educate the community about suicide prevention programs and
resources. Through innovative screening and assessment programs such as
REACH VET (Recovery Engagement and Coordination for Health--Veterans
Enhanced Treatment), VA identifies Veterans who may be at risk for
suicide and who may benefit from enhanced care, which can include
follow-ups for missed appointments, safety planning, and care plans.
VHA has also expanded its Veterans Crisis Line to three call
centers and increased the number of Veterans served by the Readjustment
Counseling Service (RCS), which provides services through the 300 Vet
Centers, 80 Mobile Vet Centers (MVC), 20 Vet Center Outstations, over
960 Community Access Points and the Vet Center Call Center (877-WAR-
VETS). In the last two fiscal years, clients benefiting from RCS
services increased by 14 percent, and Vet Center visits for Veterans,
Servicemembers, and families increased by 7 percent.
We are committed to advancing our outreach, prevention, and
treatment efforts to further restore the trust of our Veterans and
continue to improve access to care and support inside and outside VA.
electronic health record modernization (ehrm)
We made a historic decision to modernize our electronic health
record (EHR) system to provide our Nation's Veterans with seamless care
as they transition from military service to Veteran status. On May 17,
2018, we awarded a ten-year contract to Cerner Government Services,
Inc., to acquire the same EHR solution being deployed by DOD that
allows patient data to reside in a single hosting site using a single
common system to enable sharing of health information, improve care
delivery and coordination, and provide clinicians with data and tools
that support patient safety. The FY 2020 Budget includes $1.6 billion
to continue to support VA's EHRM effort to create and implement a
single longitudinal clinical health record from active duty to Veteran
status, and to ensure interoperability with DOD.
The request provides necessary resources for post Go-Live
activities completion of Office of Electronic Health Record
Modernization's (OEHRM) three Initial Operating Capability (IOC) sites
and full deployment of the remaining sites in Veterans Integrated
Service Network (VISN) 20, the Pacific Northwest region. Additionally,
it funds the concurrent deployment of waves comprised of sites in VISN
21 and VISN 22, the Southwest region. The solution will be deployed at
VA medical centers, as well as associated clinics, Veteran centers,
mobile units, and other ancillary facilities.
We are working closely with DOD to synchronize efforts as we deploy
and test the new health record. We are engaging front-line staff and
clinicians to identify efficiencies, hone governance, refine
configurations, and standardize processes for future locations. We are
committed to a timeline that balances risks, patient safety, and user
adoption while also working with DOD in providing a more comprehensive,
agile, and coordinated management authority to execute requirements and
mitigate potential challenges and obstacles.
Throughout this effort, VA will continue to engage front-line staff
and clinicians, as it is a fundamental aspect in ensuring we meet the
program's goals. We have begun work with the leadership teams in place
in the Pacific Northwest. OEHRM has established clinical councils from
the field that will develop National workflows and serve as change
agents at the local level.
supply chain transformation
VA has embarked on a supply chain transformation program designed
to build a lean, efficient supply chain that provides timely access to
meaningful data focused on patient and financial outcomes. We are
pursuing a holistic modernization effort which will address people,
training, processes, data and automated systems. To achieve greater
efficiencies by partnering with other Government agencies, VA will
strengthen its long-standing relationships with DOD by leveraging
expertise to modernize VA's supply chain operations, while allowing the
VA to remain fully committed to providing quality health care and
applying resources where they are most needed. The FY 2020 budget
includes $36.8 million in IT funding to support this effort.
As we deploy an integrated health record, we are also collaborating
with DOD on an enterprise-wide adoption of the Defense Medical
Logistics Standard Support (DMLSS) to replace VA's existing logistics
and supply chain solution. VA's current system faces numerous
challenges and is not equipped to address the complexity of
decisionmaking and integration required across functions, such as
acquisition, logistics and construction. The DMLSS solution will ensure
that the right products are delivered to the right places at the right
time, while providing the best value to the government and taxpayers.
We are piloting our Supply Chain Modernization program initially at
the Captain James A. Lovell Federal Health Care Center (FHCC) and VA
initial EHR sites in Spokane and Seattle to analyze VA enterprise-wide
application. On March 7th, 2019, we initiated the pilot kickoff at the
FHCC for VA's business transformation and supply chain efforts. This
decision leverages a proven system that DOD has developed, tested, and
implemented. In the future, DMLSS and its technical upgrade LogiCole
will better enable whole-of-government sourcing and better facilitate
VA's use of DOD Medical Surgical Prime Vendor and other DOD sources, as
appropriate, as the source for VA medical materiel.
veterans homelessness
The FY 2020 Presidents Budget (PB) continues the Administration's
support of VA's Homelessness Programs, with $1.8 billion in funding,
which maintains the 2019 level of funding, including $380 million for
Supportive Services for Veterans Families (SSVF).
Over the past five years, VA and its Federal partners have made a
concerted effort to collaborate at the Federal level to ensure
strategic use of resources to end Veteran homelessness. Coordinated
entry systems are the actualization of this coordinated effort at the
local level. Coordinated entry is seen, and will continue to be seen,
as the systematic approach that is needed at the community level to
ensure that resources are being utilized in the most effective way
possible and that every Veteran in that community is offered the
resources he or she needs to end their homelessness. All homeless
Veterans in a given community are impacted by the coordinated entry
system given that its framework is designed to promote community-wide
commitment to the goal of ending homelessness and utilizing community-
wide resources (including VA resources) in the most efficient way
possible for those Veterans who are in most need. This includes the
prioritization of resources for those Veterans experiencing chronic,
literal street homelessness. The number of Veterans experiencing
homelessness in the United States has declined by nearly half since
2010. On a single night in January 2018, fewer than 40,000 Veterans
were experiencing homelessness--5.4 percent fewer than in 2017.
Since 2010, over 700,000 Veterans and their family members have
been permanently housed or prevented from becoming homeless. As of
December 19, 2018, 69 areas--66 communities and three states--have met
the benchmarks and criteria established by the United States
Interagency Council on Homelessness, VA, and the Department of Housing
and Urban Development to publicly announced an effective end to Veteran
homelessness.
Efforts to end Veteran homelessness have greatly expanded the
services available to permanently house homeless Veterans and VA offers
a wide array of interventions designed to find homeless Veterans,
engage them in services, find pathways to permanent housing, and
prevent homelessness from occurring.
opioid safety & reduction efforts
In October 2017, the President declared the opioid crisis in our
country a public health emergency. Opioid safety and reduction efforts
are a Department priority, and we have responded with new strategies to
rapidly combat this national issue as it affects Veterans. Success
requires collaboration among VA leadership and all levels of VA staff--
from medical centers to headquarters--Congress, and community partners
to ensure we are working with Veterans to achieve positive, life-
changing results. The fact that opioid safety, pain care
transformation, and treatment of opioid use disorder all contribute to
reduction of suicide risk makes these efforts particularly important.
The FY 2020 Budget includes $397 million, a $15 million increase over
2019, to reduce over-reliance on opioid analgesics for pain management
and to provide safe and effective use of opioid therapy when clinically
indicated.
VA's Opioid Safety Initiative has greatly reduced reliance on
opioid medication for pain management, in part by reducing opioid
prescribing by more than 50 percent over the past four years. Most of
this progress is attributable to reductions in prescribing long-term
opioid therapy by not starting Veterans with chronic, non-cancer pain
on opioid therapy and, instead utilizing multimodal strategies that
manage Veteran pain more effectively long-term such as acupuncture,
behavioral therapy, chiropractic care, yoga, and non-opioid
medications.
We are committed to providing Veteran-centric, holistic care for
the management of pain and for promoting well-being. We are seeing
excellent results as sites across the country deploy this ``Whole
Health'' approach. Non-medication treatments work as well and are often
better than opioids at controlling non-cancer pain. We want to assure
Congress--and Veterans on opioid therapy--that Veterans' medication
will not be -decreased or stopped without their knowledge, engagement,
and a thoughtful discussion of accessible alternatives. Our goal is to
make sure every Veteran has the best function, quality of life, and
pain control.
women's health
VA has made significant progress serving women Veterans in recent
years. We now provide full services to women Veterans, including
comprehensive primary care, gynecology care, maternity care, specialty
care, and mental health services. The FY 2020 Budget requests $547
million for gender specific women Veterans' health care, a $42 million
increase over 2019.
The number of women Veterans using VHA services has tripled since
2000, growing from nearly 160,000 to over 500,000 today. To accommodate
the rapid growth, VHA has expanded services and sites of care across
the country. VA now has at least two Women's Heath Primary Care
Provider (WH-PCP) at all of VA's health care systems. In addition, 91
percent of community-based outpatient clinics (CBOCs) have a WH-PCP in
place. VHA now has gynecologists on site at 133 sites and mammography
on site at 65 locations. For severely injured Veterans, we also now
offer in vitro fertilization services through care in the community and
reimbursement of adoption costs.
VHA is in the process of training additional providers so every
woman Veteran has an opportunity to receive primary care from a WH-PCP.
Since 2008, 5,800 providers have been trained in women's health. In
fiscal year 2018, 968 Primary Care and Emergency Care Providers were
trained in local and national trainings. VA has also developed a mobile
women's health training for rural VA sites to better serve rural women
Veterans, who make up 26 percent of women Veterans. This budget will
also continue to support a fulltime Women Veterans Program Manager at
every VHA health care system who is tasked with advocating for the
health care needs of women Veterans.
VA is at the forefront of information technology for women's health
and is redesigning its electronic medical record to track breast and
reproductive health care. Quality measures show that women Veterans who
receive care from VA are more likely to receive breast cancer and
cervical cancer screening than women in private sector health care. VA
also tracks quality by gender and, unlike some other health care
systems, has been able to reduce and eliminate gender disparities in
important aspects of health screening, prevention, and chronic disease
management. We are also factoring care for women Veterans into the
design of new VA facilities and using new technologies, including
social media, to reach women Veterans and their families. We are proud
of our care for women Veterans and are working to increase the trust
and knowledge of VA services of women Veterans, so they choose VA for
benefits and services.
national cemetery administration (nca)
The President's FY 2020 budget positions NCA to meet Veterans'
emerging burial and memorial needs through the continued implementation
of its key priorities: Preserving the Legacy: Ensuring ``No Veteran
Ever Dies;'' Providing Access and Choosing VA; and Partnering to Serve
Veterans. The FY 2020 Budget includes $329 million for NCA's operations
and maintenance account, an increase of $13.2 million (4.2 percent)
over the FY 2019 level. This request will fund the 2,008 Full-Time
Equivalent (FTE) employees needed to meet NCA's increasing workload and
expansion of services, while maintaining our reputation as a world-
class service provider. In FY 2020, NCA will inter an estimated 137,000
Veterans and eligible family members and care for over 3.9 million
gravesites. NCA will continue to memorialize Veterans by providing
383,570 headstones and markers, distributing 634,000 Presidential
Memorial Certificates, and expanding the Veterans Legacy Program to
communities across the country to increase awareness of Veteran service
and sacrifice.
VA is committed to investing in NCA's infrastructure, particularly
to keep existing national cemeteries open and to construct new
cemeteries consistent with burial policies approved by Congress. NCA is
amid the largest expansion of the cemetery system since the Civil War.
By 2022, NCA will establish 18 new national cemeteries across the
country, including rural and urban locations. The FY 2020 request also
includes $172 million in major construction funds for three gravesite
expansion projects (Houston and Dallas, TX and Bourne, MA) and
additional funding for the replacement cemetery in Bayamon, PR, the
gravesite expansion project in Riverside, CA, and the new national
cemetery in Western NY. The Budget also includes $45 million for the
Veteran Cemetery Grant Program to continue important partnerships with
States and tribal organizations. Upon completion of these expansion
projects, and the opening of new national, State and tribal cemeteries,
nearly 95 percent of the total Veteran population--about 20 million
Veterans--will have access to a burial option in a national or grant-
funded Veterans cemetery within 75 miles of their homes.
accountability
The FY 2020 Budget requests direct appropriations for the Office of
Accountability and Whistleblower Protection (OAWP) for the first time
since it was established. The total request for OAWP in FY 2020 is
$22.2 million, which is $4.5 million, or 25 percent higher than the
2019 funding level. This funding level demonstrates VA's commitment to
improving the performance and accountability of our senior executives
through thorough, timely, and unbiased investigations of all
allegations and concerns. This funding level will also enable OAWP to
continue to provide protection of valued whistleblowers against
retaliation for their disclosures under the whistleblower protections
provisions of 38 U.S.C. Sec. 714. In FY 2018, OAWP assessed 2,241
submissions, conducted 133 OAWP investigations, and monitored over
1,000 referred investigations. These efforts are part of VA's effort to
build public trust and confidence in the entire VA system and are
critical to our transformation.
The FY 2020 budget also requests $207 million, a $15 million
increase over 2019, and 1,000 FTE for the Office of Inspector General
(OIG) to fulfill statutory oversight requirements and sustain the
investments made in people, facilities, and technology during the last
three years. The 2020 budget supports FTE targets envisioned under a
multi-year effort to grow the OIG to a size that is more appropriate
for overseeing the Department's steadily rising spending on new complex
systems and initiatives. The 2020 budget request will also provide
sufficient resources for the OIG to continue to timely and effectively
address the increased number of reviews and reports mandated through
statute.
conclusion
Thank you for the opportunity to appear before you today to address
our FY 2020 budget and FY 2021 AA budget request. VA has shown
demonstrable improvement over the last several months. The resources
requested in this budget will ensure VA remains on track to meet
Congressional intent to implement the MISSION Act and continue to
optimize care within VHA.
Mr. Chairman, I look forward to working with you and this
Committee. I am eager to continue building on the successes we have had
so far and to continue to fulfill the President's promise to provide
care to Veterans when and where they need it. There is significant work
ahead of us and we look forward to building on our reform agenda and
delivering an integrated VA that is agile and adaptive and delivers on
our promises to America's Veterans.
Thank you.
Chairman Isakson. Thank you very much, Mr. Secretary. We
appreciate it and I appreciate your acknowledgment of what I
had said earlier about the amount of money we were talking
about. We are not here complaining about what we have to spend
it on. We are looking for answers to spend it better and to see
our veterans get better services, and we will work it out
better all along. We have got a good budget to work with. We
are not begging for more. We are looking for results.
Which brings me to my first question that I will ask. The
private sector today, in health care, the whole answer to
most--whatever the question is, the answer is outcomes. They
are trying to measure outcomes for everything, from
reimbursement, to being a network, to anything else.
When you refer to the improvements that you referred to,
how do you measure your outcomes in the VA? Do you take them
from the senior person in charge or do you take them from
evaluations or do you take them randomly? How do you gauge your
outcomes for the services you provide to our veterans?
Secretary Wilkie. A combination, Mr. Chairman. I really
look to the veterans first. I have been very aggressive in the
8 months that I have been in this chair, in reaching out to
veterans in terms of surveys, in terms of interviews. What I
have seen is that our customer satisfaction rates are moving in
an upward direction, where we have, I think, an 89 percent
customer satisfaction rate amongst veterans.
In terms of other metrics, opioids is the outstanding
example. How are we changing the way that we approach this
national tragedy? We approach it in changing the way that we
treat our veterans, by providing things that would have been
anathema to somebody like my father, 30 or 40 years ago, with
alternative medicines, tai chi, acupuncture, yoga. We are on
the cutting edge both of alternative treatments to our
veterans, we are on the cutting edge of telehealth, as Senator
Tester said, and we are on the cutting edge in terms of
tackling the national epidemic of suicide and homelessness.
So, the answer is: it is a combination of things, but for
me the most important is listening to what our veterans say.
Chairman Isakson. On that answer let me say this. In your--
in the budget, in the recommendations you have, it includes
funding for retiring two IT systems that currently exist within
the VA. You and I have talked about this before, but it seems
like the VA is a place where you collect software and systems,
where people have bought things over the years, and they have
piled up. They do not talk to each other, they do not work
together, and we are not getting good bang for our buck.
You obviously are trying to clean that up, and I would like
for you to talk about those two recommendations in terms of
retiring those programs and the overall picture in terms of
VA's IT system, getting it improved and getting it better.
Secretary Wilkie. Well, I told you 8 months ago that the
overall condition of VA's IT system was bad. As a result of
that, this Committee is looking at, as Senator Tester said, a
massive increase in our budget, $4.2 billion, I believe. But,
that money, in the past, has been spent on redundant systems,
going down the same road that led to the failure in the Forever
GI Bill as well as other systems.
What we are doing, and you, I believe, will have the CIO up
here for testimony in the next few weeks, is we are beginning
to migrate our legacy systems out and bring the VA in line with
the rest of America, through the cloud. We now have 8,000
employees who are dedicated simply to that transition. We will
ask for a bit of patience on some of these, but the migration
to the cloud is the wave of the future and it is the way that
we will maintain, I think, the trajectory that VA has undergone
in terms of its overall customer service.
But, you are absolutely right. The reason the Forever GI
Bill crashed and burned, the directions from this Committee
were placed on a 40-year-old IT system. It was bound to fail,
which is one of the reasons why I stopped us going down that
same old road and pivoted just so we can make sure that our
veterans got their checks.
Chairman Isakson. Well, let me say one thing. I am not
going to ask you another question, but I am going to make a
statement, and I will make an admission, too.
The State of Georgia brought me in when they lost their
superintendent of schools in the middle of an election cycle,
to take over the Board of Education in Georgia, and the
Department of Education, going through Y2K. Now I had a pretty
good company in terms of dealing with technology and stuff like
that, and I learned that you can buy every trick in the book
when the salespeople come in and start talking to you, because
they have got an advantage. They know what they are talking
about and you do not know, and you do not understand it. If you
are as old as I am, you really do not understand digits and
clouds and all the other stuff.
I want to find that damn cloud one of these days too. I
want to see where that thing is. Everybody always says that is
the solution. Well, I think it may be the problem. I just
cannot find it anywhere.
Anyway, my point is this. So many times when we go to clean
up a system of technology and information, we end up buying
more stuff to clean up the mess, and we have a bigger mess when
it is over than we had before, plus we have not solved the main
problem, which is the workability and the interoperability of
the IT systems we had. So, let me just encourage you to make
sure we have got the right people, who know what they are
talking about, making the decisions or the recommendations to
you on the final decision, those that understand technology and
what it can and cannot do, and do not buy every bid and promise
that comes through the front door, because that gets expensive
and it can cause you lots of problems.
The VA is so big, the number of employees is so large, the
budget is so big, you are talking about any little problem in
the VA is a big cost, particularly if it is the IT system. So,
I encourage you to continue what you are doing and I appreciate
what you are doing on that.
Mr. Tester.
Senator Tester. I will yield to Senator Manchin.
Chairman Isakson. Senator Manchin.
HON. JOE MANCHIN III,
U.S. SENATOR FROM WEST VIRGINIA
Senator Manchin. Thank you, Mr. Chairman, and, Secretary,
thank you for being here. I have not met a veteran yet in my
State--and we have a high percentage of veterans--who want the
VA to be privatized. I have not heard that from any of you all
and I do not think you do either.
But, here is the troubling thing that we have. Your request
is a 44 percent decrease in funding levels for construction
programs. That was in the budget that you all submitted. I know
that we are investing heavily in Community Care. We are leaving
our current VA facilities. Let me give you a few examples.
In a rural State such as mine, in West Virginia, our rural
mobile unit in Clarksburg is totally inoperable, totally
inoperable. Our medical centers have not had any update nor
increase in residential rehab centers since the '50s and '60s.
Most of our facilities require basic maintenance, deferred
maintenance as we call it, for roofs, HVAC, all of the above.
I am worried that even though our intent in the verbal
agreement that we have, that we do not want to privatize
because of starving some of the things, people are going to
say, ``Well, I would rather not go to VA because it does not
have proper services. They do not have updated equipment.''
It leads me right into another question, is that there are
over 40,000 vacancies at any time, in any moment, in the VA.
This morning there were 138 positions posted on USA Jobs, in my
State--138. I have got pulmonologists, cardiologists in
Huntington, psychology in Beckley, practitioners in
Martinsburg. We are hurting all over the board.
So, even though the intent might not be there it looks like
the signs we are moving in that direction because of demand
from our veterans. If our veterans are not getting the care
they are going to say, ``I just need better care. I am not
getting it.'' And, if a facility is not worth even going to
because it is not in good enough shape--so you can see the
concern, Mr. Secretary, of what we have and what we have to
answer to. They are still totally, overwhelmingly supportive of
the VA.
Secretary Wilkie. Well, let me take your comments seriatim.
First, I would be lying to you if I told you that we are
anywhere near turning the corner on capital investment. My
estimate is that we need $60 billion over the next 5 years to
come up to speed. That is an incredible number.
Let me tell you what else we are dealing with. More than
half of the buildings that I am responsible for age in range
from over 50 years to 100 years. This Committee has provided
the way forward. We are now engaged--and I believe it was
Senator Moran's idea--with market assessments of our national
infrastructure and our human resource needs that will then
inform, when they are done, what this Committee told us to
create, and that is the Asset Infrastructure Review Commission,
to bring our facilities up to speed where the veterans are.
Again, this is a monumental problem. My first job is to do
as much as I can to ensure that the basic health needs of the
veterans are taken care of, and, unfortunately, there are cost/
benefit analyses that have to be made. I cannot come to you and
say, ``Give me $60 billion to repair all of those facilities.''
As for the human resource side, you are absolutely right,
but let me tell you where we have been and where we are headed.
My first week in office I had two senior leaders give me two
different numbers as to how many employees we had. Now that is
outrageous. And, I asked a military question--where is your
manning document? A manning document in the military is one
where you have your requirements and you have the people to
match them. We never had one.
Finally, we now have a modern H.R. team in place that has
come on in the last few months, at my direction. I have
consolidated, or am in the process of consolidating 140
individual H.R. offices into 18, so that we have an even
distribution of resources across the enterprise.
We have asked for the resources to hire 13,000 people. As
Senator Tester knows, my emphasis, as the head of VA, has been
for rural America, rural America and native America, those two
sections of the country that provide the highest per capita
number of men and women in uniform, and for the native
populations, the population that provides the highest number of
holders of the Medals of Honor and combat decorations.
So, it is a complex problem, as I said. I would be lying to
you if I think we are anywhere near turning the corner, but I
understand it.
Senator Manchin. Let me just say--and I am sorry, my time
is up, but I just want to make this comment. I speak to
veterans all over my State and anywhere I can, and I tell them,
``I do not believe that we intend to build brand-new VA
facilities.'' Then, they say, ``Can't you at least take care of
what we have?'' That is the biggest concern they might have,
and I would hope that you all would understand it. They are
scared to death that they are being set up, that this thing is
going to go private because the demand will switch. Demand will
switch if the facilities are not adequate enough to give them
the service they need.
Secretary Wilkie. Mr. Chairman, let me--let me ask your
indulgence. That means we have to be much more creative.
Senator Tillis is here, and he has one of the fastest-growing
veteran populations in the country. In Fayetteville, my
hometown, which sits underneath Fort Bragg, two massive VA
facilities. The new one is leased. The VA center director does
not have to worry about HVAC, does not have to worry about the
lawn. He concentrates on taking care of veterans.
We have to be more creative in terms of two things: one,
how we manage our infrastructure, which the MISSION Act tells
us to do better; and two, giving more incentives--and I want to
come to this Committee and talk about it--something like a
veterans' Peace Corps, to get medical professionals out into
areas like rural West Virginia, western North Carolina, and
provide the means to serve those veterans in communities that
are hard to reach, yet provide the highest percentage of
service of anyone in the country.
Senator Manchin. Thank you. Sorry, Mr. Chairman.
Chairman Isakson. Thank you, Senator Manchin.
Senator Cramer.
HON. KEVIN CRAMER, U.S. SENATOR FROM NORTH DAKOTA
Senator Cramer. Thank you, Mr. Chairman, and thank you, Mr.
Secretary, for being here. Thank you for our previous
discussion and to all of those who are with you.
I will ask my questions specifically to you and you can
defer them to others if it is more appropriate. You mentioned--
you talked a fair bit in your testimony about alternatives to
pain management, alternatives certainly to opioids, and you
talked about some things like acupuncture and other types of
care. You did not mention hyperbaric oxygen chamber treatment,
particularly for pain. We have found it to be quite effective,
I think, in other types of treatments, particularly Post
Traumatic Stress, brain injuries, things common to veterans,
athletes, and others. I just wonder why and what do you think
the potential is for that?
Secretary Wilkie. Well, it certainly was not for lack of
appreciation of the treatment. I pledge to you that I will be
out in Fargo to look at the headquarters of one of America's
largest hyperbaric chambers.
No, we have to be more creative, particularly as treatments
become more complex for more complex injuries, particularly the
injuries of the brain. I think we are not even at the Sputnik
stage when it comes to exploring the brain and how it responds
to trauma, how it recovers. Dr. Stone is probably the better
expert when it comes to the actual medical conditions that that
treatment addresses.
Dr. Stone. Certainly, as a practitioner who has spent much
of my career doing wound management, hyperbaric oxygen is
something we have worked with for a long time. Using hyperbaric
oxygen to actually heal the brain or to do some of the work
that you have been discussing is work that has been studied for
at least a decade, in both the DOD as well as in VA.
What we know is that hyperbaric oxygen chambers have a
dramatic effect in improvement of individuals with both PTSD as
well as brain injuries. What we do not understand is what the
addition of oxygen to the presence in that chamber does. There
have been multiple studies done by all three uniformed services
as well as by the VA, demonstrating that, and we look forward
to further research on it. Brain rest remains one of the
mainstays at this time, and certainly going into a chamber
where there is silence has great value. Whether the addition of
oxygen under pressure remains in debate.
Senator Cramer. That would be interesting to see, because
my understanding is that the presence of more oxygen could have
the alternative impact, because, of course, it is stimulative,
I would guess.
Dr. Stone. Senator, I agree with you, and as a practitioner
who has done wound management in the presence of trying to
penetrate oxygen into wounds, that is exactly correct.
Senator Cramer. Well, we would love to help you with that
experimentation in Fargo, so we can talk further about that
later.
The other thing I wanted to mention, because you have
mentioned it both in your testimony and in your answer to
Senator Manchin, you talked about 13,000 more people. You are
in the people business. It requires practitioners to do the
work that you do, and they do it very well. And, by the way,
they do it really well in Fargo. We are very pleased and proud
of the service they provide our veterans.
But, it is getting harder to find good people and to
attract them, to keep them, and particularly, in an economy
like North Dakota has, as you are aware, it is even really
elevated there. The challenge is amplified, I think, in an
economy and in a region like ours, and, probably like other
rural States.
That said, can you elaborate a little bit on specific
programs, whether it is loan repayments--what are some of the
tools that you have available, or that we could, you know, help
you with, to attract and maintain and keep good people?
Secretary Wilkie. Well, I will say the Chairman and the
Ranking Member inserted into the MISSION Act the first
monumental step in addressing the needs of rural veterans by
giving us the authority--extra authorities on relocation pay,
reimbursement, the ability to pay off medical school loans up
to $200,000. Those are absolutely needed.
My goal, though, is to try to even--to try to create even a
more robust relationship with our universities and also with
the armed services. General Bradley's goal is to have at least
half of the doctors and nurses coming off of active duty coming
into VA. General Mattis and I spoke a great deal about that. We
are now telling doctors that when they decide to leave active
service, come to VA to continue your service to those who have
worn the uniform. I want to go back to the future on that, but
this Committee has given us a start, particularly when it comes
to rural America.
Senator Cramer. Thank you, and thank you, Mr. Chairman.
Chairman Isakson. [Off microphone]--for all of his games.
It must work some--he is a pretty good quarterback. I just
heard that. I do not know if that is true or not. It sounds
good.
Mr. Moran. No. Mr. Blumenthal. I am sorry, and then it is--
OK.
HON. RICHARD BLUMENTHAL,
U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. Thanks, Mr. Chairman. I hesitate to
interrupt Senator Moran, but I will.
Senator Moran. I am anxious to hear what you have to say.
Senator Blumenthal. Thanks, Mr. Chairman. Thank you,
Senator Moran. Thank you, Secretary Wilkie, and your team for
being here today. I want to congratulate and thank you on your
announced decision that you would not be appealing the ruling
of the court in the Blue Water Navy case.
Secretary Wilkie. That is my recommendation. I do not know
what other departments will do.
Senator Blumenthal. Well, I think your recommendation will
be key; it is instrumental. I would, perhaps, with all due
respect, Mr. Chairman, express on my behalf, and I hope on
behalf of the Committee on Veterans' Affairs, that that
recommendation be adopted and endorsed heartily to bring
fairness and justice to our Blue Water Navy veterans. It would
culminate a crusade that has been bipartisan, involving almost
everyone on this Committee. It has been a team effort and I am
grateful to you for making that recommendation.
I also want to submit, for your consideration, the Agent
Orange Exposure Fairness Act, which would extend the basic
principles of that court decision, and suggest also that there
are other toxic chemicals and poisons on today's battlefield
that are worth the research and attention that the VA should
give them in deciding what kinds of benefits and disability
compensation our veterans deserve. The potential for poisons on
the battlefield is one of the great challenges of our time, one
of the areas of unknown consequences to our heroes in uniform,
and as the father of two veterans who have fought in recent
wars and a friend of many, I hope that we can carry forward the
spirit of that court decision and of your support for it.
I want to move to the Veterans Affairs' health care system,
especially, in particular, the VA facility in West Haven. I
think you are familiar with my letters to you on this topic. I
understand that sterilization processes there essentially have
been stalled so that the operating facilities are at one-third
of capacity. To put it very bluntly, two-thirds of the veterans
who need surgery at the West Haven facility are either sent
elsewhere or their surgeries are delayed or possibly denied.
That is because the sterilization capacity is limited.
The surgical facilities were closed for about 3 months
because of flooding. They are back open now, but the tools and
equipment used in those surgeries cannot be properly
sterilized. A mobile trailer is planned for a year from now.
That is way too long. A permanent facility, 5 years from now--
much too long. I would like to know what the plans are, Mr.
Secretary, for expediting the availability of that surgical
capacity, in other words, the sterilization process facility.
Secretary Wilkie. I know how important West Haven is. Dr.
Stone is supervising that.
I do want to step back, though, and say I agree with you,
and some of your earlier statements about burn pits. We do not
want to go through what we went through with Agent Orange. I
certainly saw that in my family. I worked for Senator Tillis on
the Burn Pit Registry legislation that he and Senator Klobuchar
introduced and had passed a few years ago. So, it is important
to me. Now I will let Dr. Stone talk about West Haven.
Senator Blumenthal. Thank you.
Dr. Stone. Senator, we appreciate your role and your
activism in this, in the recovery of West Haven.
Clearly this goes back to the fact that this is an older
facility. We have got a steam line running underneath the
sterilization area, and as we have worked to recover that
facility let me reassure you that the surgery being performed
in that facility today is safe and sterilization is a safe
process.
Senator Blumenthal. I do not doubt that it is safe, and I
want to emphasize that the docs, physicians, staff are doing
their best. They have one hand tied behind their back. In no
way are they compromising the safety or effectiveness of the
surgeries they do. They are to be commended. But, I think the
VA here is failing them by failing to expedite the
sterilization processes which limits their capacity.
Dr. Stone. My understanding is that the mobile trailers
that would bring the ionized water and the sterilization
materials in will be installed by June of this year, and that
the major hold-up was because of utility issues on that area as
well as the building of the trailer. The actual funding of a
new sterilization facility will take 3 to 5 years. That said,
my expectation is that as soon as that mobile unit is installed
this June we will begin to recover the surgery that needs to be
done at that facility.
Senator Blumenthal. Will it go to 100 percent?
Dr. Stone. That is my intention, absolutely.
Senator Blumenthal. Can you make that commitment?
Dr. Stone. I have--absolutely.
Senator Blumenthal. Thank you.
Secretary Wilkie. I will make it.
Senator Blumenthal. Thank you, Mr. Secretary, and I would
like to continue our conversation--my time has expired and I
thank the Chairman--about the possibility of expediting a more
permanent facility, but I appreciate your commitment today.
Chairman Isakson. Thank you.
Senator Moran.
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. Chairman, thank you. Thank you and Senator
Tester for conducting this hearing. Mr. Secretary, thank you
for being here. I join both the Ranking Member and the Chairman
in expressing my gratitude for your continued service to those
in uniform and I appreciate the job that you are doing at the
Department of Veterans Affairs.
I will have a chance, in Senator Boozman's Appropriations
Subcommittee here in a few days to have more conversations
about the spending and the budget recommendations. I have a
couple of things that I think are timely that I want to ask you
today, while I have this chance.
First of all, I would like to highlight for you, in 2014,
we authorized legislation. We are now working with Senator
Brown of Ohio in furthering this legislation. The National
Academy of Medicine was required to do a toxic exposure
analysis to determine if there is any medical and scientific
evidence related to, or whether there needs to be further study
on this topic of the relationship between affliction, problems,
now challenges effecting generations of the service man or
woman now face as a result of that toxic exposure. We look
forward to continuing to find the answer to that question.
There may be a whole other generation. It saddens me
because I cannot imagine anyone served their country thinking
they may harm their children or their grandchildren by their
service, but that very well may be the case and we are working
to get the medical and scientific evidence to demonstrate that.
I also want to highlight a piece of legislation that
Senator Tester led, and I joined him in introducing related to
mental health and suicide prevention, and I look forward to
getting input from all my colleagues, with Senator Tester's
leadership on it.
Secretary Wilkie. That is the Guard and Reserve issues.
Senator Moran. Actually, there are two of them. That is one
of them and in addition to that the Commander John Scott Hannon
Veterans Mental Health and Suicide Prevention Act, John Scott
Hannon being a veteran who lived in the State of Montana.
For my two questions on the timeliness of this hearing,
staff of this Committee, the House Committee, and the staff of
our individual Senators on the Committees met with your staff
in regard to the Veterans Hearing Aid Access and Assistance
Act. For as poorly as Senator Tester and I get along this is
another one that he and I sponsored. It was passed into law in
December 2016.
And, the takeaway from that meeting--first of all I should
indicate that that legislation in 2016, the law mandates that
the Department of Veterans Affairs determine the criteria for
hearing aid specialists, then with the goal of integrating them
into the care of veterans that the VA serves.
But, the unfortunate circumstance is that since 2016, we
can find no evidence of the VA taking any steps to implement
that mandate, and the meetings that I think I would describe
the takeaway as little interest in meeting that mandate. I
highlight, and the reason it is timely is that we asked for a
response from VA officials by today's hearing, knowing that you
would be here, yet we have received none to date. Perhaps--Dr.
Stone appears to be interested in talking about this
conversation.
Dr. Stone. Senator, thank you. I appreciate it. I was
unaware of the letter. If we have not responded you have my
apologies. We will correct that today.
Senator Moran. I had intended to send a letter. We did not
send a letter. It was a conversation with officials at the VA,
saying, ``OK, the Secretary is going to be here on Tuesday.
Could you please get back to us by then? Otherwise, we need to
raise this topic with the Secretary.''
Dr. Stone. You happened to be looking at a hearing-
compromised veteran from my combat service, so I am deeply
appreciative of what the VA has brought to me and my family, as
we have sought care for my hearing loss due to combat. So, I am
well aware of the issues that you bring up. Let me say to you
that we, last year, performed over 1 million visits for
hearing-compromised veterans, with our audiologists and our
technicians. We have continued to grow that. We refer out about
38,000 visits a year and we appreciate the legislation on
hearing aid specialists.
But, the question is do we need to move into the specialist
area? Clearly you and I may have a different understanding of
the role of the specialist. Today I have enough audiologists
and enough technicians in order to provide that vast, vast
majority of the care that is needed, including less than a 10-
day waiting period in order for veterans to come in for care or
for their appliances. In addition, we have an under-two-week
waiting period in order to take outside prescriptions and fill
them on behalf of the veterans.
Senator Moran. Let me suggest this, Dr. Stone, that maybe
with Senator Tester and I's staff we could have this
conversation. In the zero seconds I have left, Mr. Secretary, I
am in Emporia, KS, on Saturday, 4 days from now. Emporia has a
CBOC. The CBOC has 2 days of service and rarely has a
physician. It has a mid-level practitioner. The Department, the
Eastern Division in Kansas, has announced the closure of that
CBOC. One would expect me to be angry about the closure of that
CBOC. I am hopeful that with the closure of the CBOC and
conversations with the VA that the MISSION Act now provides
additional opportunities for care for veterans, because we go
from a 2-day CBOC with virtually--with often no physician and
one mid-level, to an opportunity for a multitude of community
resources being available to those veterans in that area.
I am going to meet with--your folks in Kansas are joining
me in Emporia on Saturday. What message would you like for me
to deliver about the opportunities that MISSION or the VA now
can provide?
Secretary Wilkie. The MISSION Act is about veteran-centric
care. It is not about protecting the institution or guarding
the status quo. It is about giving that veteran the option to
be the guardian of his own or her own future. For rural
America, offering the widest aperture possible on access to
medical care is meeting the intention of this Committee. As
long as we keep the veteran's health at the center of
everything that we do then the system will work.
Senator Moran. I will convey that to those veterans who
join me on Saturday.
Mr. Chairman, thank you.
Chairman Isakson. In keeping with our bipartisan Committee
commitment I am going to excuse myself for just a minute and
turn it over to Senator Tester to continue the hearing, and it
is also his turn to ask questions. I will be back in a second.
Senator Tester?
Senator Tester [presiding]. Thank you, Mr. Chairman. I
assume that means I can just expand the time that I use.
Chairman Isakson. It means you have to behave.
Senator Tester. Oh, I have to behave. Damn it.
Thank you all for being here once again. I hesitate to talk
history with somebody who probably knows history far better
than I do, especially military history; nonetheless, this is
pretty elementary.
In the 1930s, this country did not want to go to war.
President Roosevelt turned our car factories into airplane
manufacturing and prepared for war, and then came the bombing
of Pearl Harbor and we were ready for war. Pretty simple.
Pretty ingenious.
Everybody on this Committee, I believe, has said no
privatization, and all the VSOs have said no privatization. The
President has said something different. You have said no
privatization and your staff has also said that.
The questions are asked here today, and I have talked about
our vacancies in Montana. Manchin talked about his vacancies,
his facilities, that needed improvement. Blumenthal talked
about West Haven surgical that was at one-third capacity. Even
Senator Moran, even though is not mad about it, is talking
about a CBOC that is going to be closed because of the lack of
staffing. Everything that I am hearing and everything I am
seeing says something different.
Then, I look at the budget and the budget--and you had said
earlier that you needed $60 billion in capital investments--and
the budget request for major and minor construction was
decreased by 43 percent for major construction and 50 percent
for minor construction. We are talking about the needs that are
out there. By the way, we can go down the list in Montana. It
is pretty reflective.
I was at the meeting 6 days ago when you guys said you
cannot get the money out the door; nonetheless, you talked
about $60 billion in capital expenditures and reducing those
accounts by 40 and 50 percent.
Putting all that together, how can we justify that?
Mr. Rychalski. Senator Tester, I can probably shed some
light on that. First let me say that as Department CFO I feel
dirty not asking for more money, to be honest. But, the fact--
--
Senator Tester. The issue is not that you are just asking
for more money. I do not care if you ask for more money, but if
you have got $60 billion in needs over the next 5 years, and we
are reducing those same accounts that will meet those capital
expenditures, something does not jive. That is all.
Mr. Rychalski. Let me explain. I was being a little bit
facetious.
The fact of the matter is we do have a requirement. There
is no question. We have older facilities and we do have a
substantial facility requirement. As you know, we had a
substantial plus-up in 2018 and 2019. The fact of the matter is
that we sort of, very quickly, executed our shovel-ready
projects and they are in the works. We are at a point now, when
you sort of divide the amount of money we have in the works by
the number of facilities, we have about 19 to 20 projects per
facility going, and they have limited capacity in a lot of
areas, of moving clinics around, moving people around. We are
now hearing from a number of facilities, they have actually
some shovel-ready projects that they just cannot execute
because it is too disruptive.
We are going to end up carrying some of that money forward,
from 2019 into 2020, and we are going to carry about $1 billion
of the plus-up in NRM. We are also going to carry some minor
construction money for----
Senator Tester. Gotcha. So, I am going to do some quick
math for you, not that you do not know this already. If you
divide 60 by 5, it is $12 billion a year. And, if that need is
out there and we cannot execute the amount of money we have got
so far, how do we not privatize the VA?
Secretary Wilkie. Well, we do not privatize the VA because
we still have the largest health care system in the country----
Senator Tester. Got it.
Secretary Wilkie [continuing]. 170 hospitals.
Senator Tester. Yep.
Secretary Wilkie. Our veterans are voting with their feet.
Let me just say, this is not a libertarian VA. If it were,
I would be giving myself a card that says ``veteran'' and I go
out in the private sector and get anything I want.
Senator Tester. I hear you.
Secretary Wilkie. That is not happening. Again, I fall
back, not on anecdote but on the stats. Our veterans are happy.
They are going where people speak their language and their
culture. I support that and this Committee supports that.
Senator Tester. Mr. Secretary, I agree with you, but I go
back to the example of history. If we are short on manpower, if
our facilities are short and substandard, if we are not making
the HVAC additions that we need to, eventually those veterans
that are going to the VA, they are going to say, ``Nope. Not
anymore.''
Secretary Wilkie. Well, you gave me--this Committee gave me
the answer, and that is the market assessments----
Senator Tester. Yes.
Secretary Wilkie [continuing]. And then the Asset
Infrastructure Review Committee, which does exactly what you
said, and I think I am going to come to you and ask to
accelerate the beginning of that commission.
Senator Tester. Of the AIR Act?
Secretary Wilkie. Yes, so that it moves more rapidly than
the timeline that this Committee has given it.
Senator Tester. Really quickly, I do not have a problem
with that. Can you give me an idea on how quick--because it is
set to go into effect in 2021 or 2022? OK.
Secretary Wilkie. I would like to do that earlier because
our market assessments are already underway.
Senator Tester. I would love to visit with you about that,
moving forward. OK.
Now we have Senator Boozman.
STATEMENT OF HON. JOHN BOOZMAN,
U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you very much, and we do appreciate
you and Senator Isakson. We can be very proud that the 2019
appropriations, because of your two's leadership in the
Committee, was significantly increased, and I think again we
are going to see that going into the next fiscal year. We
appreciate your leadership, Secretary Wilkie, and your team,
especially in grappling with the Forever GI Bill and getting
that under control. I know that was a hard thing to do. Also
your work with veteran suicide. I think that we are coming up
with a method now that is going to have significant results, so
we really do appreciate that and appreciate that in your
leadership style, again with your team.
One thing I would like to understand, I was in Arkansas
last week in a lot of our smaller communities that will be
impacted by the MISSION Act. I guess what I would like to
understand is there is a little bit of confusion as to what is
going to happen in June. So, we will have the rules and
regulations in place, going forward. For the veteran in
Mountain Home, AR, who is being told he is ineligible for
Choice because of the nearby location of the CBOC, even though
it does not provide the medical service he needs, what is going
to happen to him in June, if anything? Will he be able to talk
to VA on June 6 to get authorized for care from a private
hospital, or what is the process?
Dr. Stone. The process is that the veteran will continue to
talk to his provider or his scheduler in order to really
authorize care and make the best decision on behalf of the
veteran. Frankly, June 6 should also be a non-event for the
veteran. Today we authorize--well, today we will do over
300,000 visits in our direct care system. We will authorize
about 50,000 visits in the community care system. That is all
done on a manual basis by our providers and schedulers.
On June 6, it is our hope to have something called a
decision support tool that will automate that process. Should
we fail with the decision support tool it will look just
exactly like it does today. Now, there will be an enhanced
number of veterans eligible to make a decision of whether they
want to go out for care or not, but the system will look very
similar to what it does today, as far as a veteran sitting in
front of a provider or a scheduler or on the phone, making a
decision on whether they stay or they go out for care.
Senator Boozman. So, for those that are eligible on June 6
for--theoretically for enhanced care, in the sense that, you
know, they are going to fall into the new parameters, if they
call will they be told ``do this and this,'' or will it be ``We
are phasing this in. Call back?''
Dr. Stone. Senator, this will be--they will be told what
they need to do for care. There should be no increase in wait
times. There should be no increase in wait for care.
Now our problem is that in most areas of America the
commercial health care system is not as responsive as we are.
Please remember, of those 300,000 visits we are going to
conduct today over 22 percent are same-day visits. In the
commercial space it is not as responsive. As the Secretary has
said previously, in an urban area in the Southeast, it was
found that the wait time for the commercial space was
dramatically higher than ours.
Senator Boozman. I would like to talk--and again, mine was
more in the context of the travel time versus the wait time,
but we will talk about that.
The veteran suicide, the collaboration with these groups
that seem to be doing a good job, the Secretary and I were in a
meeting earlier this morning and one of the Congressmen talked
about a program that they had a 70 percent reduction in suicide
as a result of. Can you talk about the efforts of the
collaboration so that we can get these public-private
partnerships going that seem to work well? Again, we need to
make sure the metrics are there and all of those things.
Secretary Wilkie. Yes, sir. So, the budget calls for $222
million for suicide prevention programs. I have just been named
as the chair of the National Task Force on Suicide Prevention.
You know the terrible statistics--20 veterans a day take their
lives, 14 of those are outside of our VA.
I think the most important part of the task force, other
than a whole health approach to suicide prevention, is the
opening of the window for monies to flow into the States and
localities, to help us find those veterans.
Example--I was in Alaska with Senator Sullivan. More than
half of the veterans in Alaska are not in the VA system. I
asked the Alaska Federation of Natives to double the number of
VA tribal representatives that they have, to go out into the
hinterland of Alaska and help us find those veterans who are
not in our system. It sounds simple. Sometimes simple solutions
are the better solutions. The States and localities know better
than we do, in many of these instances, where veterans are and
where they are in need.
A couple of things. I am not going to give you a metric
saying that we are going to achieve zero suicides. The majority
of veterans who take their own lives are Vietnam era, my
father's generation. Some of these Americans have problems that
began building when Lyndon Johnson was President. We are not
going to be able to cure all of that, but we can--and if the
Chair will indulge me--as the former Under Secretary of Defense
for Personnel, General Mattis and I both began a system of
education throughout an individual's military career that
focused on mental health wellness and taught a soldier, sailor,
airman, Marine, to look for the signs of danger, so that for
the first time in our military history we actually have people
coming out of the service who at least have had some
educational grounding throughout their term of service in what
to look for, when to ask for help, not only for themselves but
for others.
The deepening of the relationship between VA and DOD is
absolutely essential, so we never again have those numbers that
we have now, that began to build in Southeast Asia 50 years
ago.
Senator Tester. Thank you.
Senator Hirono.
HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII
Senator Hirono. Thank you, Mr. Chairman. Mr. Secretary,
thank you for recommending that the Blue Water decision not be
appealed. At this point, appealing that decision is not what we
should be using our resources for, so use your persuasive
powers to make sure that that happens.
There was an article recently--oh, by the way, I understand
that the Chairman is going to have a hearing later on your
proposed access standards. That is good because a lot of us
have expressed concerns about how those standards were
developed and the fact that we heard from many VSOs that they
were not consulted during that process. So, that will be
happening in April, I understand.
A few weeks ago, Mr. Secretary, the New York Times
published a story with the heading, ``Treated like a piece of
meat: Female veterans endure harassment at the VA.'' Have you
read that article?
Secretary Wilkie. I have.
Senator Hirono. So, it paints a pretty dire picture of the
kind of experiences and harassment that the women veterans who
go to the VA endure. What is the VA going to do to make sure
women veterans are respected by the VA staff and other
patients? I realize that there needs to be some kind of a
cultural change, but I do not know. Posting signs, whatever you
need to do so that this is not the horrendous experience of
women veterans, as described in this article.
I want to know whether the VA is conducting any research
into the best practices or models of care that increase women
veterans' utilization of and satisfaction of VA services. Your
testimony mentions that 91 percent of VA's community-based
outpatient clinics have a women's health primary care provider.
So, when can we expect that number to be 100 percent, because
you are almost there? Can you respond to those two?
Secretary Wilkie. Well, that is certainly the goal, and in
our--Senator, in our previous relationships, from my former
capacity as the Under Secretary of Defense, you and I discussed
that the first thing that I had to do as the Under Secretary
was promulgate the first DOD regulations on sexual harassment
and equal opportunity, which we did. So, that tells you my
commitment.
You hit on it. It is a cultural change. I do not believe
that what was in the New York Times story is apparent in all of
our VA facilities. I am not going to be able to tell you with a
straight face that I can change the attitudes of every person
who works in the VA, but we are changing the culture. We are
putting in women's health centers in all of our VA hospitals.
One of my goals is to make sure that there is an actual
privacy barrier, separate entrances, that in the case of this
New York Times story, those things will probably less likely to
occur just by changing the way we bring our women veterans into
the system.
I can say that we now--we had 500,000 appointments last
year for women veterans. That is a sea change. I will also say
that the culture that you talked about is now beginning to
change within DOD. I think the longer that that goes on, the
less likely you will see an end product such as you described
in VA. But, I think we are on the right path.
Senator Hirono. One would think that when you make those
cultural changes that you may not need to expend resources on
separate kinds of facilities, but obviously that is something
that the women veterans very clearly want at this point.
I want to get to the lack of progress that I have heard on
various VA health care projects. For example, the Advanced
Leeward Outpatient Healthcare Access, the ALOHA project, in
Hawaii, on Oahu, was scheduled for a lease award early calendar
year 2018, but has been delayed a number of times and a lease
has still not been awarded.
The project was scheduled to be completed originally by
fiscal year 2020, and I know that these kinds of outpatient
clinics are really helpful because they are usually closer to
where the veterans live, and in Hawaii the Tripler Hospital is
very crowded, you can hardly get any parking, and it is a pain
in the okole, as we say in Hawaii.
So, you know, can you commit to seeing that the ALOHA
project is completed on time with no further additional delays?
Secretary Wilkie. Senator, as you know I spent a great deal
of time in Hawaii last year. I talked with the Governor about
this lease. I will get you more information. My understanding
was that there were contractual problems with those responsible
for improving the facility. That was what I discussed back in
December in Honolulu, but I will get you more information on
that.
Senator Hirono. Thank you, because I would like to see this
and other CBOCs come through.
Thank you, Mr. Chairman.
Chairman Isakson [presiding]. Thank you, Senator Hirono.
Senator Blackburn.
HON. MARSHA BLACKBURN, U.S. SENATOR FROM TENNESSEE
Senator Blackburn. Thank you, Mr. Chairman, and I want to
thank you all for being here. Secretary Wilkie, I thank you for
the time you have spent with me prior to this, to talk about
the needs that some of our veterans in Tennessee have, and to
look at how we fulfill that promise of providing for them and
for their health care.
I want to start with the EHRs (electronic health records)
and your deployment, the modernization that you are doing
there. As we have talked, many of our folks would like very
much to be able to, under the MISSION Act, seek that care at
home, because they are a good distance away from a facility.
And, as we have talked before, interoperability is an
imperative in making this work.
I want to know where you are, what control measures you
have that have been implemented to ensure that you are going to
meet your milestones as you go through this deployment, as that
begins to take place.
Secretary Wilkie. Senator, we will go live in March of next
year in the Pacific Northwest to reach our initial operating
sites. That is on schedule. There are issues that we need to
work our way through. These are old facilities. We need to
rebuild our communication closets, and that is going to go on
this summer. We also need to work our way through all of the
internet of medical devices and make sure that they are
appropriately----
Senator Blackburn. OK. Let me ask you this. As you are
doing that, are you working on a plan so that when someone
enlists, day one, they begin a cloud-based, encrypted record
that will follow them the rest of their life.
Secretary Wilkie. Yes. That is the goal. I use my father as
an example. The days of somebody carrying around an 800-page
paper record are gone.
Senator Blackburn. Right. But, I think it would be
instructive and helpful to us if you could provide us with your
timeline of when you are going to achieve this.
Now, in the Health Committee today, they are doing a
hearing on the EHRs, and we know that whatever you do that you
have to have a strategy so that this is going to be
interoperable with commercial best practices. So, you have that
in place.
Secretary Wilkie. Yes, we do, and obviously you mentioned
the goal is to begin building that record the minute that young
American walks into a military entrance processing station, and
then there is a handoff. I expect--and I do not know when there
will be new changes in leadership at the Department of Defense,
that I will continue the relationship that I had with General
Mattis. I expect to come to this Committee with the
announcement of a joint program office, which will be the
first--I believe the first joint program office between two
departments, so that we combine the resources of both
departments to build this record.
Senator Blackburn. OK.
Secretary Wilkie. It will be interoperable. I did--I would
have never approved it if it could not be interoperable with
the private sector.
Senator Blackburn. OK. Telehealth. I was recently in
Gallatin, TN, to open a veterans clinic there, which is one of
the whole-of-life clinics. The day after that I was over at the
Nashville VA for the new mental health center. We were walking
through that. I think that those are important components to
have, because the telehealth helps to bring those services to
them, especially in behavioral health.
I want to know how you are--what is your strategy and your
timeline on moving more facilities so they are functioning with
telehealth and have that whole-of-life approach to the clinic.
We have got a lot of clinics, people cannot get to health care,
long waiting lists, and this helps to speed the process.
Dr. Stone. You are exactly correct. About three-quarters of
a million veterans consumed telehealth visits last year. That
is about 13 percent of the veterans that are enrolled with us.
This year's budget will move that to 20 percent. We believe
that in order to keep veterans in their homes, especially at-
risk veterans, instead of hospitalization, expanding telehealth
services is absolutely essential. So, we will move to 20
percent under this budget.
Secretary Wilkie. I would say this Committee has given us
authority that no other health care system in the country has,
and it allows our doctors to practice across State lines. This
is the front line of our attack on the problems of mental
health, as you mentioned, with behavioral health. It provides
our veterans with the opportunity to stay at home, stay in a
comforting surrounding, and stay with people who look after
them, their friends, their families, without forcing them to go
into a larger facility.
Senator Blackburn. I appreciate that. I know my time has
expired. I just want to say listening to you all, as you talk
about the budget and you talk about urgent needs, things should
never have gotten into this shape--never--and it comes from
mismanagement. My hope is, as you set these timelines for
implementing technologies that are going to enable greater
access, that you also are utilizing technology to make certain
that there is not the gross mismanagement that has taken place
in times past.
Chairman Isakson. Senator Murray.
HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Mr. Chairman, and
thank you, Secretary Wilkie, and your team for being here. Let
me start with the fact, Caregivers. I am sure you are shocked I
am going there. But, the October 1 deadline that the
Caregivers' IT system was to be certified to begin the
expansion process is quickly approaching, and the VA still has
a lot of work to do before then. We have now heard rumors in
the press and in briefings that the VA might not make that
deadline. I do really appreciate your personal understanding of
the challenges caregivers face. I know you can appreciate how
much our prior era caregivers and veterans need this support.
For the record, will you meet the October 1 deadline to
certify the IT system and begin expanding eligibility for the
caregivers program?
Secretary Wilkie. If I do not I will be back up here, but
let me take a step back. The reason that I made the decision
not to remove anyone from the Caregiver program was because of
not only your work and your insistence but because this process
has been mismanaged in the past. So, that was the right thing
to do, and that is why I made that decision, based on your
recommendation.
The date is October 1. The statute says that I have to
certify that the system is working. If I do not certify that no
one will be removed. We will continue to manually process the
checks. Right now there are 24,000 stipends that go out. It is
manually done. But, as long as those checks get to our veterans
that is fine with me.
We do have a new commercial office shell technology, and if
you have not been briefed I will get you someone to brief it--
--
Senator Murray. OK.
Secretary Wilkie [continuing]. That we brought on board
February 22. That is the template that we will be using,
hopefully, to be ready on October 1.
The other side of this is that we have increased the
budget, primarily because of your work, to about $720 million.
I expect that to go up in the next few years. But, we are also
using that money to hire professionals to staff out our
Caregiver program.
Senator Murray. OK.
Dr. Stone. Senator, if I might add, this is a manual
program today and there are over 24,000 families receiving
benefits. Their checks are manually written every day. As we
move to this commercial office shell software system, what we
will need to do is to migrate all of the data over and then
assure that we can then, on an automated basis, write the
checks every month before we are ready to expand. And, although
we have made a decision on a software system, the migration of
that data we have not recommended a certification date yet on
the software system and the expansion.
Secretary Wilkie. I am not going to do it unless it is
right.
Senator Murray. OK. I appreciate that. At first glance,
your request for Caregivers looks strong and appears
comprehensive. However, several components of the program are
in need of resources. You mentioned staffing, the IT system,
the planned expansion of support services provided to
caregivers. All of those will need an increase during
expansion. And, your budget requests $150 million for expansion
of the Caregiver program, leaving $555 million for the needs of
the existing program. As I have made clear in previous
settings, I want to be sure this request is not individually
underfunding expansion or the needs of the existing program.
I wanted to ask you, how will this funding, especially for
the expansion, be allocated, and to which areas of need?
Dr. Stone. The basic management structure of this program
was done at individual medical centers, resulting in
dramatically different criteria for inclusion and removal from
the program. The first thing you will see is a stand-up of a
regionalized management system to look at who is eligible and
who will be removed. No one will be removed until we can assure
you that we are doing this in a clear manner that is
transparent to America's veterans and to the American people.
As we stand up that regionalized process, that will occur
under the chief medical officer of each VISN. We will move from
the individual caregiver being the gatekeeper of this program
to a regionalized board process, and then institute an appeal
process at the VA central office.
So, the entire management structure, in order to do this to
the Secretary's standards and the standards that you expect,
needs to be stood up and put together. We have introduced this
concept to the VISN leadership last week and have begun talking
to the chief medical officers about the hiring and stand-up of
this system.
Now----
Secretary Wilkie. Let me--the last thing I will say,
Senator--I have used your time--we are retraining our clinical
staff across the country with the most modern techniques and
information on how to deal with families and caregivers. I
would say that I think VA is really the only health care system
in the country that has concentrated on this. As the son of a
Vietnam soldier it is vital to me.
Senator Murray. OK. I appreciate it, and I know this is
something you personally care about, too.
As you know, I am going to stay absolutely on top of this.
We want to implement it. We want to implement it correctly. We
do not want to deny people this care that they have been
waiting for, this help and this support. I appreciate your
response today, but I will stay in close touch. Thank you very
much.
I do have other questions, Mr. Chairman, that I will submit
for the record.
Chairman Isakson. Thank you, Senator Murray.
Senator Tillis.
HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA
Senator Tillis. Thank you, Mr. Chair. Gentlemen, welcome.
Secretary Wilkie, it is great to see you.
First off, I want to thank you all for, in your budget
request, funds to expand the CBOC down in Jacksonville. How do
you see that--well, first off, for people who would suggest
that there is a trend in the VA, or Members of Congress to
privatize, it seems like budget requests for the expansion of
the CBOC, the opening of 1 million square feet in three
different health care centers in North Carolina, with a
different model, that you mentioned earlier when I was here,
seems to suggest that you believe the brick-and-mortar VA
presence is a very, very important part of the future.
So, I would not--I would like you to maybe touch on that.
But, tell me how that CBOC expansion in Jacksonville, in
combination with the PACT teams, are going to help improve care
there, and then how do you leverage the PACT model for the rest
of the veterans across the country?
Secretary Wilkie. Well, Senator, let me talk about business
processes that have led us to that stage. As I mentioned
earlier, we are in the process of doing market assessments
across the country to lead into the Asset Infrastructure Review
Commission. The demographic changes that I see for veterans are
changes that mirror those in the rest of the country. By 2027,
North Carolina will have the fourth-highest number of veterans
in the country. It will begin to nip at the heels of
California.
Senator Tillis. And, it will be the eighth-largest State.
Secretary Wilkie. Yes. For those--like Senator Brown just
came in--Ohio remains in the top 10. Because of the large
populations in those States--and Georgia is in the top 10, as
far as we can see in the future--we have to be more creative.
We have to not only combine the brick-and-mortar facilities
that we have, we have to manage them more efficiently, but we
also have to create an environment where our teams can reach
rural areas of our States and be more creative when it comes to
things like telehealth. But, we are moving our resources to
where the veterans are, and I think Dr. Stone has your PACT
answer.
Dr. Stone. The PACTs will continue to expand across the
Nation as we hire. In Montana alone we have 38 primary care
providers. We have got offers out to 8 additional primary care
providers that will come in and expand that rural area.
The Secretary is exactly correct, that we are seeing growth
in north Florida, we are seeing growth in south Georgia, we are
seeing growth in your State, sir, and we will continue to
expand this.
Now let me talk about brick-and-mortar. Veterans are not
different than the rest of Americans. Our parents' generation
stayed in the same house on a generational basis. We do not and
our children do not. They move. We must be able to move from
place to place in order to follow where the veterans go.
Therefore, lease authorities are incredibly important to us,
and enhanced lease authorities that would allow us not just to
provide housing, but to also be able to provide ambulatory
medical facilities that we can move every 5 to 10 years as to
follow where America's veterans are.
Much of the non-recurring maintenance that you hear about
and the cost of our infrastructure is for our inpatient
facilities. Our inpatient facilities, in many cases, are aged
and need substantial improvements, but our ambulatory
facilities, more than 1,000 of them, need to be able to be
mobile when the veteran moves each decade.
Senator Tillis. Thank you. I want to talk a little bit
about access standards and the MISSION Act. I think I could
infer, at least, from some comments from some of my colleagues
that it is almost like we are giving some of our veterans too
much choice. In some States I think you have 100 percent access
to Choice if you want it, which there may be a variety of
reasons why you need that. My colleague just came in from
Alaska. He has got a very diverse population over a geography
that almost spans the United States, from tip to toe, so I can
see why you have to have a different solution for different
States.
But, what would happen, what would be the negative
consequence if Congress succeeded in rolling back the access
standards that you are putting in place now, in combination
with the MISSION Act?
Secretary Wilkie. Well, Senator, it would no longer be a
veteran-centric, patient-centric approach to health care. That
was the clear mandate of the MISSION Act, not institutional
prerogative, but the health care of a veteran.
So, let me beg the Chair's indulgence and describe what
this is not, as I mentioned earlier. This is not a libertarian
VA. This is not giving Dr. Stone or me a card and saying,
``Thank you very much. Go out and find whatever doctor you want
to take care of you for the rest of your life.'' What this says
is that if we cannot provide a service then you have the option
to seek that service in the private sector.
I will give you an example. If there is no rheumatologist,
and there probably is, in Fayetteville, and you meet the
criteria for that service, then we tell you that you have the
option to go to Duke or to Chapel Hill or to Cape Fear Valley,
in my hometown, to get that service. It is based on the needs
of the veteran, and veterans come first. If we cannot do what
the veteran needs then we will provide him the opportunity to
seek that.
Senator Tillis. I think it is very important, Mr. Chair,
just to close out my questions, that is why I think a broader
understanding of what you are trying to accomplish with the
patient aligned care teams. It is not like you are giving them
a card and sending them on their way. I mean, you are going to
spend a lot of time making sure that the outcomes are going in
the right direction, that they are getting their appointments
filled when they need to, and you will always have that brick-
and-mortar presence, if necessary. I, for one, think the access
standards need to continue to move forward and the work that
you are layering on top of it is going to provide a better
standard of care for the veterans. I thank you for your work.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Tillis.
Senator Brown.
HON. SHERROD BROWN, U.S. SENATOR FROM OHIO
Senator Brown. Thank you, Mr. Chairman. Secretary Wilkie,
thanks for your letter back to me regarding the VA History
Center at the VA in Dayton, OH. We are excited to get the next
phase of this project up and running. My staff and I look
forward to a briefing on how this project is progressing. We
will be in touch with you about that.
I will be brief. I have a number of questions. Senators
Tester and Boozman and I have been working for years to push VA
to track and report an overpayment in veteran debt. I have had
constituents who have reported a change in status or a
dependency to VA and VA did not take action, leading to an
overpayment in debt. We were able to get some provisions
through last year, as you know. Last week we introduced our
updated bill to clearly outline the reporting process for
veterans and their families to foster better interagency
coordination, reduce overpayments.
I would like your commitment that VA will continue to work
with the three of us.
Secretary Wilkie. Yes, sir.
Senator Brown. Thank you.
Over the past month--this is a bit of a follow-up to
Senator Moran's comments and question about toxic exposure.
Over the years you and I have discussed this issue, whether it
is Agent Orange or burn pits. It took this country far too long
to come to terms with Agent Orange, so each veteran did not
have to apply individually and go through that pain. I
appreciate the decision not to appeal on the Blue Water Navy.
That is really important.
Secretary Wilkie. That is my recommendation, Senator. I do
not know what other departments are doing.
Senator Brown. That is your recommendation. OK.
My question is this, I would like to know when VA intends
to make a decision regarding the National Academy's
recommendations on Agent Orange bladder cancer,
hyperthyroidism, hypertension, and Parkinson's-like syndromes.
Dr. Stone. Yeah. We are working our way through that right
now and it would be my hope within the next 90 days that we
will have some decisions made.
Senator Brown. OK. Then, you make the decision and it
quickly is ratified by Secretary Wilkie. Is that how it works?
Dr. Stone. Sir, I would not presume when the Secretary
would----
Senator Brown. He is sitting right next to you. You might
ask him.
Dr. Stone. Yeah.
Senator Brown. OK. Thank you.
Secretary, thank you for that. You said that Congress put
real expectations on an outdated IT system for the Forever GI
Bill. Respectfully, sir, VA's IT and programmatic offices
should be able to flag these issues for leadership, and
leadership should respond accordingly and update Congress.
Secretary Wilkie. If I said that I probably misspoke. I
should have said that the VA systems were not capable of
handling the changes that Congress mandated.
Senator Brown. But, they will be.
Secretary Wilkie. They will be, yes.
Senator Brown. VA went through similar issues with IT for
caregivers expansion. Why did that take 6 to 7 months as well?
Secretary Wilkie. That I cannot tell you, based on my
tenure here. What I--my short tenure. What I can tell you is
that, once again, because we were not ready to implement the
programs required to support our caregivers I made a command
decision, based on my discussions with Senator Murray, to make
sure that no one was removed from the program, that the checks,
the stipends that went out to 24,000 caregiver families were
done manually, but they were done, and I do expect to come to
this Congress by the deadline on October 1, hopefully
certifying that the commercial, off-the-shelf technology that
we purchased to support caregivers is in place.
But, I will say I am not going to certify anything that
does not work. We have been down that road before and that led
to the problems with the Forever GI Bill. That led to the
problems with caregivers. So, you have my commitment that
nothing moves unless we are convinced that it helps veterans.
Senator Brown. Thank you, and I want to reiterate what the
Chairman said about the legacy IT systems, getting them to work
together, to work for all of our veterans. That is so
important.
One more comment and one last question. The comment is--
well, the question is when can we expect nominees for Deputy
Secretary and Under Secretary for Health? When is that going to
happen?
Secretary Wilkie. Hopefully soon. We have made the
recommendations, and I hope there will be an announcement from
the White House shortly. I will thank the Committee for
approving the nominees for the Office of Whistleblower
Protection and CIO.
I do want to say one thing, though. There is an added layer
of approval for the Under Secretary for Health. The law, unlike
for any other position in Federal Government, requires the
convening of a commission to meet, deal with candidates,
deliberate, and then pass a recommendation on to me. That was
the reason for the delay in the 8 months that I was here,
because the commission had to be convened.
Senator Brown. My last comment. I heard your--thank you,
Mr. Chairman, for your forbearance--I heard your Senator, your
junior Senator from North Carolina, his laying out Choice and
privatization, and I know how he stands on that. I have been
disappointed that you are not quite as opposed to privatization
as I thought you were during the nomination process. I just ask
you--I am not asking a question, particularly, but just ask you
to listen to the veteran service organizations and what they
think about this President's philosophical commitment to
privatization that I hope the VA does not follow.
Secretary Wilkie. I will say, Senator, with your
permission, Mr. Chairman, I think I have been very clear about
where I stand and where I think the Department is heading. I
think the legislation was right on target when it said that the
veteran is at the center of everything that we do. I also think
that the veteran is voting with his feet, or her feet. Our
customer satisfaction rates are at an all-time high. I look at
that as the gauge as to how well we are doing.
I also believe, and I am not one to use a lot of anecdotes
but I can say, as someone who has spent an entire life in and
amongst the military, that our veterans, no matter what age
they are, will go primarily to someplace where people speak the
language and understand the culture, because there is nothing
else like it in the United States. And, I stand by what I have
done in the last 8 months.
Senator Brown. I understand and appreciate that, but I also
understand that the way that Congress appropriates or withholds
money can have a whole lot to do with people voting with their
feet, so I hope you will keep that in mind.
Thank you, Mr. Chairman.
Chairman Isakson. Senator Sullivan.
HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA
Senator Sullivan. Thank you, Mr. Chairman, and, Mr.
Secretary and your team, thank you for being here. I also am
interested in the nominees, you know, for Under Secretary, very
important, so we need to get those out the door. I also want to
mention to my Democratic colleagues they also need not to delay
the nominees once they are on the floor. There has been very,
very unprecedented obstruction of very basic nominees for their
confirmation. So, we get them out the door and we will have
guys like Senator Brown move them quickly as opposed to
delaying them, because that is not helping at all. It was not a
nice try. It is actually a really serious issue, so they need
to help. They cannot just say, ``Give us nominees'' and then
delay them for 10 months. It is ridiculous, and that is what
has been happening.
Let me mention--first of all, congratulations on these
national awards. I think that what you are talking about for
your team, it should be commended. Sometimes you guys come
here, you get the wrath of the Congress, and we rarely
recognize when there has been improvement. I am going to
recognize it and I appreciate it. So, keep up the good work on
these things.
You may have also noticed the Alaska VA health care system
was also awarded, with the most improved inpatient experience
for the entire country in 2018. I want to thank all of you for
that.
Secretary Wilkie. Dr. Ballard is one of the best.
Senator Sullivan. Dr. Ballard does a great job. But, it is
help from the top. You know, the VA out in the Mat-Su Valley, a
huge veteran population, finally has not just one, not just
two, but three doctors. It only took 5 years but now we have
some doctors. Thank you for that, and, Mr. Secretary, I also
want to thank you--it is not exactly in your purview but you
may have seen my Alaska Native Vietnam Veterans Equity
Allotment Act was recently signed into law, and when the
President cited the broader bill it was in he highlighted this
very important bill for Alaska that helped our Vietnam veterans
overcome a huge injustice----
Secretary Wilkie. May I----
Senator Sullivan [continuing]. And the fact that the
President highlighted that in his signing ceremony made me very
happy.
Secretary Wilkie. I will add to that, Senator. I mentioned
that the caregiver legislation closes one of the last loops of
the Vietnam era. Sadly it has been 44 years since the fall of
Saigon. I think the Alaska allotment issue was one that sadly
took almost as long, and I think that also closes a loop,
particularly for a State that has the highest per capita number
of veterans in the country.
Senator Sullivan. Well, I appreciate that, Mr. Secretary,
and you weighing in on that, former Secretary Zinke weighing in
on that. Again, previous administration, remarkably they were
opposed to it, so you guys at the Cabinet level weighing in
really helped make it happen. Thank you for that.
I wanted to talk about what the Veterans Benefits
Administration is working on--and I know it is a big issue for
you--identifying off-the-VA-grid veterans who have yet to make
contact with the VBA and its services. I know you are looking
at possibly doing a case study in Alaska. You know; you have
been out there. So, thank you. I look forward to your visit and
Dr. Stone's visit here soon again.
Can you just talk a little bit about that, whether it is
the pilot program in Alaska. We do have enormous challenges on
this issue, but also how you are working it in other rural
communities throughout the country.
Mr. Lawrence. Certainly. You may recall that at
confirmation time when I visited with you, you spoke about your
reference to engage your constituents. So, after I was
confirmed I did not forget that conversation. I set in motion
to try to figure out how we might actually do that, our
presence augmented by our relationship with the county and
State VSOs, as well as tribal and communities to better
understand how that network should be set up so that if you
cannot touch us you can touch somebody who can touch us.
That is what we are trying to do, and we are using Alaska
by engaging those groups to figure out exactly how the workings
of that take place and what we can do in terms of the ways we
communicate and the effectiveness by way we are able to do
that. So, we are trying to use that in understanding how do we
mobilize all the resources that are in the veteran community,
VSOs included, to figure out how we do those touches and engage
folks effectively.
Senator Sullivan. How about the pilot program you are
looking at in Alaska?
Mr. Lawrence. It is just--I am happy to come brief you on
some of the details. We are just getting started, in terms of
how that all works.
Senator Sullivan. OK. Well, I appreciate you guys focusing
on that.
Mr. Secretary, I know you have been asked earlier by
Senator Boozman and others on how you are feeling with regard
to the MISSION Act launch date. You know, Alaska has been
carved out, its own region, Region 5. There have been some
concerns that we are behind the power curve there a little bit
relative to the rest of the country. Can you just give me a
quick update on that and how you are feeling about that launch?
Dr. Stone. Actually, because of the uniqueness of the
geography and the dispersion of the population I worry about it
a lot. We are on schedule, though, for getting out the
contract. So, when I say that the bid should be out, I think it
is this fall.
Senator Sullivan. What can we do to ameliorate your
concerns and worries? I share them.
Dr. Stone. I think just a continuing dialog with your staff
and yourself. I am looking forward to my visit up there where
we can dialog and really walk our way through it. But, it is a
unique area with geographical challenges, and you are exactly
correct, in our previous conversations. It should be handled
locally.
Secretary Wilkie. And, I will add, if you go down the
list--and I have said this to folks in Alaska, the Federation
of Natives, and I have said it on Alaska television--if you go
down the list and look what we are prototyping in VA, my
philosophy on electronic health, on logistics, on VBA, and here
with MISSION is: if we can make it work in Alaska it will work
anywhere, because of the unique challenges that Alaska presents
by its massive size, but also because of the impact that
veterans have on the population of the State. It is a unique
situation.
Senator Sullivan. Thank you. Well, we look forward to you
getting back up there, Mr. Secretary, and Dr. Stone, your visit
as well. Thank you.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Sullivan.
Senator Moran had one additional question, so if you do not
mind, Mr. Secretary, and I will have one very short statement
after his question.
Senator Moran. Unfortunately, the Chairman almost tells the
truth. I have two. One developed while I was waiting to ask the
one.
Chairman Isakson. We better hurry.
Senator Moran. Yes, sir.
I wanted to go back to the hearing aid specialists, just
for a moment, and this really is to you, Mr. Secretary. I
understood what Dr. Stone said, that the VA may have reached
the conclusion it does not believe that additional
professionals in this arena are necessary. But, I want to
highlight a complaint I have had with the Department of
Veterans Affairs for as long as I--which is now 23 years that I
have been on a Committee on Veterans' Affairs, is can we get
the Department to abide by the Congressional law, the mandate
that you have, and the issue of whether or not the specialists
are necessary at the VA, that is a different issue than abiding
by the law that requires you to determine what the
qualifications would be for that profession at the VA.
I do not want to diminish this issue. It is important to
many people and it is important to many people who are hearing
specialists who want to provide those services, who want to
serve our veterans. It is important to veterans that they have
the care necessary. Knowing you, Mr. Secretary, I want to
highlight the importance of the folks who work for you not
making an independent decision whether or not they get to abide
by the law, the mandate that Congress gave them to act in any
particular way.
Secretary Wilkie. Yes, sir. I did not know that that was
occurring. That is my honest answer, and you know my background
so they will be told to abide by Congressional will.
Senator Moran. I think it is true when you were confirmed--
it is true as I recall it--every confirmation hearing for
Secretary at the VA that my question has been, ``Will you make
certain that the people who work for you work with Congress,
provide the information that we need, answer our letters,''
and, of course, a given is abide by the law. I just want to
highlight for you the importance of that.
We raised the issue of toxic exposure and I told you about
a study that was completed by the National Academy of Medicine
in November 2018. That law that created that study requires
you, Mr. Secretary, to determine, based upon that report,
within 90 days, if--there is a trigger in that law. It requires
you to make a determination about now how to proceed. I just
learned that March the 22nd, which is just a day ago, you have
sent a letter to the Committee. You are now--you were not in
compliance, I do not know, at the 90 days, but you are in
compliance by responding, and I appreciate that. You now have a
responsibility that I want to work with you to make certain
that there is action taken. Again, we are talking about the
generational consequences. The National Academy determined
there is no medical research that determines the relationship
between toxic exposure and the next generation of the veteran.
There is a great opportunity, and a necessary opportunity,
for you and the Department of Defense to proceed in determining
that relationship, but also getting the facts in place so that
we can determine who those veterans are, and you are a perfect
person with your relationship and history at the Department of
Defense to accomplish this goal.
I will digest your March 22 letter in a more timely
fashion, but this is something I wanted to highlight for you.
Thank you.
Thank you, Chairman.
Chairman Isakson. You are welcome. Senator Sullivan was
inspired to ask one more question, and I want to grant him that
privilege.
Senator Sullivan. Thank you, Mr. Chairman, and it will just
be one.
Mr. Secretary, this goes to the issue of infrastructure
improvements, streamlining expansion, where you see the
populations that are growing in certain areas of the country
and States, populations that are declining. And again, in
your--I know that broadly the VA has repurposed or disposed of
175 of 430 vacant or mostly vacant buildings since June 2017. I
think that makes a lot of sense. But, you have also talked to
me about, you know, areas. If the VA is looking at expansion
with regard to leases or even facilities, I know you were
struck by some of what was going on in Alaska in that way,
given that you mentioned not only more vets per capita, the
size, but also I think we are one of the few States that does
not have a full-service VA hospital, not even one.
Can you just give me an update on what you are thinking
with the VA's prioritization of leases that are in the budget
request? We have--in Fairbanks, we are looking at the
possibility of a new campus and also outside of JBER, you may
remember that kind of big parking lot area that we were talking
about after our tour.
Secretary Wilkie. The simplest answer is that we are going
where the veterans are, and this is only the first step. The
legislation requires market assessments to be done throughout
the country. We are in the process of doing that. That develops
a knowledge base on population trends, the services available
in those areas to inform an Asset Infrastructure Review
Commission. I mentioned earlier that I expect to come to this
Committee to ask for an accelerated date for the beginning of
the deliberations on the Asset Infrastructure Review
Commission, because we have to go where the veterans are.
I also mentioned earlier that what you said is only the
beginning of many different processes. More than half of our
buildings, 57 percent, are between the age of 50 and 130 years
old. Because of that, the leasing option and co-locating--and I
am not going to say that we are in the process of doing, but I
saw a number of facilities in Alaska that present us with an
opportunity to be more creative about co-locating with entities
outside of the Federal structure.
Senator Sullivan. Thank you. Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Sullivan.
Let me conclude the meeting by thanking the Secretary and
his staff and each of the department heads for their being here
today and for your thorough answers. I appreciate what you all
are doing for our vets. We all have the vets at heart, the vets
in mind, and the vets in soul, and we are going to see to it
they are taken care of as best as possible.
I want to thank the VSOs for not being offended by my
request for them not to testify, but rather to submit questions
and statements. Mr. Fuentes is sitting in the back of the room
and just taking copious notes, and I am sure he is going to
make sure that I keep every promise I have made, just like they
are going to keep every promise that they make. But, I want the
VSOs to be sure to remember that. I have asked you to submit
the question you want answered.
Mr. Secretary, I not going to give you a deadline because
that does not do any good, I do not think, but I want to give
you the encouragement to, as quickly as possible, answer those
questions and copy the Committee staff with the answers to
those questions.
Secretary Wilkie. Yes, sir.
Chairman Isakson. They are very good and they are very
thoughtful, particularly on the priorities of the budget and
what some of the statements, and your statements have meant,
and what actually, when they materialize, will mean. So, it is
very important.
If this works well I think we will get better responses
because we consume so much time when we have too many witnesses
that we do not get to points that we really need to get to, as
demonstrated by Mr. Sullivan and Mr. Moran, who had instant
thoughts toward the end. They were both very good and
appreciative.
I want to thank you for being here, thank all of our
veterans for the service they provide to all of us. I wish all
of you a very nice day and a very happy week, and I look
forward to seeing you soon. Please recognize the record will
stay open for 5 days on submissions to the Committee for this
hearing, and the Secretary will respond as quickly as possible
to the questions. If you will get those questions to the
Committee they will make sure that it gets to the Secretary,
and that we have a copy to trail.
Thank you very much.
Secretary Wilkie. Thank you, sir.
[Whereupon, at 12:04 p.m., the Committee was adjourned.]
Response to Posthearing Questions Submitted by Hon. Johnny Isakson to
U.S. Department of Veterans Affairs
Question 1. At its March 11 budget briefing, VA officials stated
that the FY 2020 budget request was predicated on a carryover of
approximately $3 billion from FY 2019 appropriations, but offered no
details or further explanation.
Question 1a. Exactly, how much ``carryover'' is assumed in the FY
2020 budget request and how did VA determine less than halfway through
FY 2019 that such a large amount of funding could not be used to meet
veterans health care needs?
Response. Please see details of the Budget-assumed carryover into
FY 2020 for the Veterans Health Administration's (VHA) accounts and
programs in the table below:
------------------------------------------------------------------------
Projected
Account Unobligated Start CJ Page
of Year ($000)
------------------------------------------------------------------------
Base Carryover:
Medical Services....................... $1,000,000 VHA-34
Medical Community Care................. $300,000 VHA-34
Medical Support & Compliance........... $50,000 VHA-34
Medical Facilities..................... $150,000 VHA-34
------------------------------
Total Base Carryover................. $1,500,000
Medical Facilities Infrastructure:
P.L. 115-141 sec 255................... $402,801 VHA-34
P.L. 115-244 sec 248................... $624,305 VHA-34
------------------------------
Total Infrastructure Carryover....... $1,027,106
Mandatory
The Veterans Access, Choice, and $34,887 VHA-34
Accountability Act of 2014 (VACAA) sec
801...................................
Veterans Choice Fund................... $781,500 VHA-35
------------------------------
Total Mandatory Carryover............ $816,387
------------------------------
Grand Total VHA Medical Care $3,343,493
Carryover...........................
------------------------------------------------------------------------
Carryover estimates for the four main accounts in the base were
informed by actual carryover levels in recent years. In addition, VA
carried more than $1.34 billion in the Medical Services appropriations
from 2018 into 2019. This, combined with Congress's enactment of a
generous 2019 advance appropriation, yielded the large estimated
carryover into 2020.
Regarding the no-year Infrastructure funding in the Medical
Facilities account, Congress directed VA to fully fund the total costs
to complete an identified list of maintenance projects. The carryover
reflects the timing of these projects' phased execution. Mandatory
carryover estimates reflect remaining Section 801 funds for unawarded
leases and future graduate medical education program growth, as well as
the planned wind-down costs associated with the sunset of the Veterans
Choice Program.
Question 1b. What are the specific dollar amounts being carried
over and from what specific accounts, and into what accounts and for
what purposes will this carryover funding be used in FY 2020?
Response. Carryover in the four main accounts will be used to meet
Veteran demand for care, both in the direct care system and the
community. The carryover no-year Infrastructure funding will support
continuation of the specifically identified projects. Carryover in the
Veterans Choice Fund will be used for the leases and the Graduate
Medical Education (GME) program as well as wind-down costs associated
with the sunset of the Veterans Choice Program.
Question 2. As discussed above, VA officials indicated that there
would be zero new dollars necessary for the Medical Community Care
account as a result of the new wait time access standards proposed
because VA assumes it will be able to meet those standards 100 percent
of the time within VA facilities. VA indicated it will do this through
workload recapture, greater efficiency, and a 30 percent increase in
the total number of VA primary care providers.
Question 2a. What new initiatives will VA undertake and what are
the specific increases in productivity that each will achieve?
Response. The Office of Veterans Access to Care is partnering with
several VHA program offices to lead an initiative called Increasing
Capacity, Efficiency, and Productivity (ICEP).
The main goals of ICEP are the following:
Ensure accuracy of labor mapping, person class code, and
Primary Care Management Module data;
Ensure sustainment plan for maintaining continued accuracy
for the data in sub-bullet one;
Balance supply and demand by using present resources and
full care teams more efficiently by maximizing individual providers
capacity for direct patient care; and
Partner with workforce development to hire additional
staff where applicable.
Overall, the focus of ICEP Phase 1 for Primary Care is to review
the expected versus actual bookable time in direct patient care. This
includes face-to-face (F2F) appointments, video appointments, telephone
care, and secure messaging. Sites that need improvement can expect up
to a 10 percent increase in productivity together in these four
appointment modalities. For Primary Care, some sites are seeing an
appropriate increase in panel sizes that meets national benchmarks. A
similar review is being done for Mental Health and Specialty Care, with
increases of up to 10 percent in productivity expected at some sites.
Additionally, VA is enhancing Same Day Primary Care and Mental
Health services and leveraging virtual care modalities to provide
Veterans convenience while increasing access.
Question 2b. What are VA's detailed plans and projections for
increasing primary care providers by 30 percent, and how will these new
providers be in place at the beginning of FY 2020?
Response. There is a national shortage of Primary Care (PC)
providers, thus VA competes with the private sector to recruit this
limited resource. VA facilities will increase their efforts to
aggressively recruit for PC providers through the following incentives:
Tier exception for increased salary in hard-to-recruit
areas;
Utilization of Relocation, Recruitment, and Retention
bonuses; and
Expand opportunities for telework via telehealth.
VHA is challenging facilities to follow the support staffing
guidelines for core Nursing and Administrative staff as well as
extended team members including Clinical Pharmacists, Social Workers,
Psychologists, and Dieticians. This enables PC providers to focus on
their important patient care activities and work at the top of their
licenses.
Facilities are also increasing efforts to work with their
University affiliates to provide a meaningful outpatient experience in
their VA continuity clinics in an effort to recruit our trainees.
Question 3. What factors did VA consider in reaching its decision
to cut research spending for the emerging field of genomics research in
FY 2020 by 2 percent at a time when medical research inflation is
estimated to be 2.8 percent?
Response. The FY 2020 Congressional Justification does not reflect
a reduction in funding for genomics research from FY 2019 to FY 2020.
Requested funding for the Million Veteran Program (MVP) increased from
$83.9 million in FY 2019 to $85 million in FY 2020 (Volume II, Page
361), an increase of 1.3 percent.
The FY 2019 appropriation enacted a onetime addition of $27 million
for collaboration with Department of Energy (DOE) on a big data science
initiative and high capability computing (this funding is enacted with
a 5-year period of funding expiring in 2023).
The total request for research in FY 2019 is $752 million. For FY
2020, VA requested an increase of $10 million to support the growth of
all other initiatives, from $752 million to $762 million. That $10
million growth represents an overall program growth of 2 percent.
Question 4. In the full budget documents made available on
March 18, the Veterans Benefits Administration budget request seeks
appropriations to support the exact same level of FTE for FY 2020 as it
does in FY 2019. However, the Direct Labor estimate for the Disability
Compensation program shows a decrease of 51 FTE in FY 2020. This small
decrease in claims processors occurs at a time that the VA budget is
projecting that number of pending claims for disability compensation
will rise to over 450,000 by the end of FY 2020, almost a 50 percent
increase in just the past three years.
Question 4a. Why is VA requesting fewer claims processing staff in
FY 2020 when its own data shows that the number of pending claims is
rising dramatically?
Response. VA's FY 2020 budget request reflects a small decrease
(51) in Compensation Direct Labor full-time employees (FTE). While the
bulk of Compensation Direct Labor FTE are Veterans Service
Representatives and Rating Veterans Service Representatives, direct
labor FTE also include a significant number or Claims Assistants,
quality review staff, and coaches not directly related to rating-
related claims production. The decrease in Compensation Direct Labor
FTE will not impact the FTE directly responsible for processing rating-
related claims. Despite this small decrease in direct labor FTE, VBA
expects that rating-related production for compensation claims in FY
2019 will be sustained in FY 2020. The reported year-end inventory
increase for all claims results from an expected substantial increase
in receipts. In FY 2020, VA will continue its commitment to look for
innovative ways to improve claims processing through people, processes,
and technology to mitigate the projected growth in inventory.
Question 5. VA budget documents state that the Vocational
Rehabilitation and Employment (VRE) program will meet and sustain the
congressionally-mandated goal of 1:125 counselor-to-client ratio.
However, the latest data in the VA budget document also shows that from
2016 to 2018, the number of VRE participants fell from 173,606 to
164,355, more than a five percent decrease. During that same period,
VRE's caseload also dropped from 137,097 to 125,513, an 8.4 percent
decline. It would appear that VRE is able to meet the 1:125 goal by
serving fewer veterans.
Question 5a. Given how important and beneficial the VRE program is
to disabled veterans--providing many of them with the ability to
increase their economic independence--why are fewer veterans taking
advantage of this program?
Response. In 2018, Vocational Rehabilitation and Employment (VR&E)
program participants achieved over 15,000 positive outcomes while
participants decreased by 5 percent. VR&E Service attributes the
decrease to a combination of the following factors:
Applicants found eligible for the VR&E program are not
reporting to their initial orientation and, therefore, not entering a
plan of services; and
The number of Veterans successfully exiting the program
have increased each year (positive outcomes).
With the number of new plans remaining stagnant and despite the
steady mix of eligible and entitled applicants, more Veterans are
exiting the program than entering. However, VR&E continues to work on
plans to hire additional Vocational Rehabilitation Counselors (VRC) to
reach a Veteran-to-Counselor ratio of 125 to 1 or below, implement a
new case management system, and use other technological solutions to
keep Veterans engaged throughout the lifecycle of their program
participation (remote entitlement, VA Video Connect (tele-counseling),
appointment reminders, etc.). These changes are expected to increase
the number of participants.
Question 5b. Has VRE instituted any new policies or practices that
have deterred disabled veterans from seeking VRE services and what
actions is VRE taking to increase awareness about the availability and
benefits of VRE services?
Response. No, VA's VR&E program has not instituted any new policies
or practices that would deter Servicemembers or Veterans with service-
connected disabilities from seeking VR&E benefits and services. To the
contrary, over the past several years, VR&E has taken several actions
to meet Servicemembers and Veterans where they are and in the manner
they wish to be met. These actions, coupled with legislative changes,
were expected to increase participation in the VR&E program. These
actions include the following:
1. In accordance with Public Law 114-223, Section 254, Veteran-to-
Counselor ratio should not exceed 125 to 1. VA's VR&E Program began the
process of reducing the average Veteran-to-Counselor ratio to 125 to 1
or below through the hiring of 169 VRCs. This will help improve service
to Veterans with service-connected disabilities and employment
barriers, as well as help provide them with expanded services to
improve their ability to transition to the civilian workforce.
2. The placement of 145 VRCs on 71 military installations across
the Nation provides outreach and rehabilitation services to
Servicemembers and their families prior to discharge from active duty
service.
3. The placement of 87 VRCs on 104 college campuses across the
Nation provides outreach and rehabilitation services to Servicemembers,
Veterans, and their dependents.
4. On September 29, 2018, the Department of Veterans Affairs
Expiring Authorities Act of 2018, Public Law 115-251, Section 126, made
the authority to provide automatic entitlement to VR&E benefits and
services to Servicemembers who are awaiting discharge due to a severe
illness or injury incurred during active duty service.
5. VR&E expanded its Tele-counseling policy to allow its use during
all aspects of the rehabilitation process. This practice allows VR&E
VRCs to meet virtually with a VR&E participant via an application that
can be used on a computer or smart device. This practice saves travel
time for the participant and allows for greater access to the program.
VR&E continues to increase awareness and share information on VR&E
benefits and services. VR&E reviews and updates all VR&E fact sheets
and Web sites each year as needed as well as promotes, monthly, all the
marketing material that is available on line. VR&E promotes the online
marketing materials in a variety of ways, including by email, social
media, outreach events, and conference calls with VR&E's field staff.
They have developed an overview whiteboard video which was distributed
to the field offices. The video provides an overview of VR&E's benefits
and the types of assistance available and is a tool for the VRCs to
promote the VR&E program. VR&E has also provided numerous trainings on
how to promote early intervention into VR&E to active duty members on
the military installations. Last, VR&E is changing the performance
standards for the VRCs on military installations to focus more on
ensuring Servicemembers are entering the VR&E program.
______
Response to Posthearing Questions Submitted by Hon. Jon Tester to
U.S. Department of Veterans Affairs
During the hearing, Dr. Stone indicated that the impact of
construction projects on health care operations was a consideration
that factored into how much construction funding VA can execute each
fiscal year. In other words, he indicated facilities cannot do all the
construction projects they want in a given year because they would
disrupt care delivery.
Question 1. Please provide a list of the top ten projects from a
patient safety perspective that are in need of construction work but
are hampered by the competing priority of not wanting to take the space
out of use due to the impact on care delivery.
Response. A list of projects is not available as it is site-
specific and more of a coordination issue that creates a maximum volume
of construction that a single facility can handle. For any given
renovation to take place in space that is providing care, something
must be done with that service during construction, to which there are
a set number of options available.
The first option is to relocate to ``swing space'' on campus
(vacant space specifically set aside for this purpose). Issues with
this approach are that it simply may not be available as most
facilities do not have the square footage to spare for this purpose.
Also, this space may need to be renovated itself prior to use,
increasing cost of the original construction project and swing space is
usually in a less than ideal location, adding inconvenience to the
patients.
The second option is to bring in temporary space in the form of
modular buildings or trailers; this is, however, dependent on land
being available on campus in a suitable location. This type of space is
also not always ideal for health care and will add cost as the expenses
of renting this space is required to be included in the total project
cost of construction.
Another option is to contract out care during construction, which
adds significant costs and creates an issue with staff needing assigned
to other areas. There is also a loss of synergy with other services
offered at the VA facility.
The last option is to simply reduce the capacity of the department
under construction. For instance, when renovating an Inpatient Medical
Ward, the facility can choose to temporarily reduce the number of
available operating beds and phase the project over several years.
Question 2. Please provide details regarding the VA's use of swing
space, temporary medical units, trailers, etc. as a strategy to ensure
medical care continues to be delivered uninterrupted while construction
projects move forward at VA medical facilities.
Question 2a. Please describe the cost to use these types of
temporary space options and explain the considerations VA takes into
account when determining whether to use the temporary space units, etc.
at a particular facility and/or project.
Response. As detailed in the response to question 1, VA has the
option to use swing space as well as temporary medical units and
trailers to provide care while construction occurs within the space
where clinical services are normally offered. When the need for use of
these options arise, any financial costs occurred (rental costs,
renovating swing space, etc.) must be included within the total project
cost of construction and be accounted for as an impact cost to
construction. This further limits the funds available for actual
construction when impact costs are used as it is accounted for within
the same budget and program limits as the construction itself.
The monetary cost for swing space involves any renovation necessary
to make the space usable as well as the cost to physically relocate the
staff and equipment needed to provide care. For temporary units or
trailers, there is a cost for making the required utilities available
as well as the recurring costs to rent the unit. The issues needing
consideration beyond the financial cost are the difficult-to-measure
impacts on patients, such as the space being less than ideal for health
care or in a location on campus that is inconvenient to locate or
travel to.
Question 2b. At what level of the organization are temporary space
decisions made within the organization (facility, VISN, VACO) and is
there a dollar threshold on the cost of temporary space options that
determines decisionmaking authority?
Response. The decision to use temporary space is made at the
facility level with Veterans Integrated Services Network (VISN) and VA
Central Office (VACO) support offering guidance and recommendations. As
the temporary space being required is a result of a specific project,
the costs associated with them are deemed to be an impact to that
project and all expenses count toward the total cost of that
construction. These costs are therefore limited by the program limit of
the construction type (currently $20 million for Non-Recurring
Maintenance renovations and Minor Construction projects).
Question 3. In Senate Report 115-130, which accompanied S. 1557 in
the 115th Congress, the Committee on Appropriations included language
stating ``the Committee directs VHA to form a corporate planning
function patterned after high performing commercial healthcare delivery
systems. Such function must include representation from VHA clinical
leadership, and leaders from VHA offices that control, oversee, or
manage facility investments, transition, facility operations, and
organizational change, as well as the appropriate VA offices that are
dedicated to the planning and procurement of capital infrastructure,
whether built or leased by VA.'' Senate Report 115-269, which
accompanied S. 3024 contained similar language.
What is the status of the formation of the corporate planning
function and the other requirements of this section of the report
language?
Response. VHA actions to meet the corporate planning function
requirement are the following:
Strategy: Market Area Health System Optimization Workgroup
(MAHSOW) produced an eight-step methodology for VISNs and VA medical
centers to drive market area health system optimizations, which will
inform VISN action plans, national realignment strategy, capital
investments, and removal of legislative barriers;
Corporate planning function: MAHSOW, which includes
representation from all appropriate VA and VHA offices, managed by VHA
Office of Policy and Planning, which is responsible for corporate
planning activities related to a high-performing integrated health
network; and
Vision: ``To deliver a high-performing provider network to
better serve Veterans. This network consists of all VA health care
assets in VISNs, federally-affiliated providers in the Department of
Defense (DOD), federally Qualified Health Centers (FQHC), Academic
Affiliates, and other community providers and health systems with a
track record of providing high quality health care and understanding
the needs of Veterans.''
Goals:
1. Veterans choose VA for easy access, greater choices, and
clear information to make informed decisions;
2. Veterans receive timely and integrated care and support
that emphasizes their well-being and independence throughout
their life journey;
3. Veterans trust VA to be consistently accountable and
transparent; and
4. VA will modernize systems and focus resources more
efficiently to be competitive and to provide world-class
capabilities to Veterans and employees.
Question 4. What resources does the budget provide specifically for
the support of VistA over the next decade to ensure a safe patient
experience?
Response. VA's Office of Electronic Health Record Modernization
(OEHRM) is working the overall pivot strategy in cooperation with the
Office of Information and Technology (OIT) to ensure continuous care
for our Veterans as we transition from the various VistA-based legacy
systems to the new Cerner Millennium EHR platform. VistA and Millennium
will operate in parallel for a period of time, with efficiencies and
corresponding strategies/plans for the sunsetting and/or transitioning
of legacy systems. It currently costs VA approximately $426 million to
sustain VistA in FY 2019. As part of the final pivot strategy
development, OEHRM will include projected sustainment costs for VistA
over the 10-year Cerner implementation, as well as sustainment cost for
the Cerner Millennium solution following the initial 10-year contract
period. Currently there is no VistA sustainment cost reduction directly
tied to the electronic health record (EHR) rollout. VistA will be in
operation until all VA medical centers have migrated to Millennium, at
which time the redundant VistA modules will be decommissioned. VistA
modules that are not replaced by the Cerner solution will be maintained
until replacement solutions are developed/ deployed.
------------------------------------------------------------------------
Funding Type FY 2019
------------------------------------------------------------------------
HPS
FTE's..................................................... 106
Burdened Rate............................................. $153,967
FTE Pay................................................... $16,320,502
DME....................................................... $--
O&M....................................................... $22,292,477
-------------
Total................................................. 38,612,979
=============
EPMD
FTE's..................................................... 275
Burdened Rate............................................. $153,967
FTE Pay................................................... $42,340,925
DME....................................................... $21,028,161
O&M....................................................... $34,082,695
-------------
Total................................................. 97,451,781
=============
ITOPS
FTE's..................................................... 419
Burdened Rate............................................. $153,967
FTE Pay................................................... $64,512,173
DME....................................................... $--
O&M....................................................... $224,758,359
-------------
Total................................................. 289,270,532
=============
Grand Total
FTE's..................................................... 800
Burdened Rate............................................. $155,507
FTE Pay................................................... $123,173,600
DME....................................................... $21,028,161
O&M....................................................... $281,133,531
-------------
Total................................................. 425,335,292
------------------------------------------------------------------------
FY 2019
------------------------------------------------------------------------
$ FY19
Sub-Project [BF Line] Amount
------------------------------------------------------------------------
Ancillary and Surgery Requirements Updates................ $7,957,121
CPRS Enhancements Phase 2................................. $4,000,000
Fileman 24 Interface...................................... $1,427,752
Methadone Dispensing Tracking Phase 2..................... $2,800,000
National Clozapine Coordination Phase 3................... $3,000,000
Pharmacy Re-Engineering -PRE Inbound ePrescribing Version $1,843,288
3........................................................
-------------
Total................................................. $21,028,161
------------------------------------------------------------------------
FY 2019
------------------------------------------------------------------------
$ FY19
Sub-Project [BF Line] Amount
------------------------------------------------------------------------
Medication Permissions and Dispensing Updates............. $1,691,000
Methadone Dispensing Tracking............................. $2,044,377
National Clozapine Coordination Phase 3................... $3,712,000
Pharmacy Re-Engineering--PRE Inbound ePrescribing......... $1,905,612
Pharmacy Re-Engineering--PRE Inbound ePrescribing......... $1,123,353
Pharmacy Re-Engineering--PRE Medication Order Check Health $1,325,000
care Application (MOCHA).................................
Pharmacy Re-Engineering--PRE Medication Order Check Health $2,154,527
care Application (MOCHA) Phase 2.........................
Pharmacy Re-Engineering--PRE Pharmacy Product System $1,230,000
National (PPS-N).........................................
Pharmacy Safety Updates Phase 2........................... $3,146,007
Standards and Terminology Services (STS).................. $3,711,000
Veterans Data Integration and Federation VDIF............. $3,205,350
VistA Computerized Patient Record System (CPRS)........... $400,000
VistA Integration Adapter (VIA)........................... $1,059,999
VistA Scheduling Enhancements Phase 2..................... $3,892,000
VistA Security Remediation................................ $3,482,470
-------------
Total................................................. $34,082,695
------------------------------------------------------------------------
FY 2019
------------------------------------------------------------------------
Sub-Project [BF Line] $ FY19 Amount
------------------------------------------------------------------------
Enterprise Application Maintenance...................... $6,559,226
Occupational Health Record-Keeping System (OHRS)........ $310,353
Primary Care Management Module Rehost--PCMMR............ $9,949
VistA Imaging........................................... $3,771,868
VistA Maintenance....................................... $11,641,081
---------------
Total............................................... $22,292,477
------------------------------------------------------------------------
FY 2019
------------------------------------------------------------------------
$ FY19
Sub-Project [BF Line] Amount
------------------------------------------------------------------------
Dental Record Mgr (DRM)................................... $1,606,305
Event Capture............................................. $1,276,919
Fee Basis................................................. $24,681,528
Insurance Buffer Card (IBC)............................... $7,653,055
Intersystems Cache........................................ $87,843,032
Maintenance of VistA and VistA Imaging (MSV III).......... $39,211,999
Mental Health SW Maint.................................... $4,319,051
Release of Information (ROI).............................. $3,144,017
VistA Maintenance......................................... $39,211,999
Central VistA Imaging Exchange............................ $320,700
Vista Integration Adapter................................. $387,139
Veterans Health Information Systems and Technology $196,571
Architecture (VistA) VistAWeb............................
Vista Blood Establishment Computer Software............... $2,616,978
Vitria/VistA Interface Engines............................ $4,889,466
Vista Maintenance Project................................. $1,441
VistA--e-Pharmacy Claims software/ VistA--Electronic $51,284
Claims Management Engine.................................
VistA--Functional Independence Measurement................ $70,558
VistA--Home Based Primary Care............................ $20,007
IAA with DOI--(GS35F0701M) Financial Interface Tech $923,760
Support Contract.........................................
R1/2/3 DISA DECC.......................................... $5,963,000
R4 RDC.................................................... $14,650
VistA Migration contractor................................ $319,200
Backup Tapes for VistA imaging............................ $35,700
-------------
Total................................................. $224,758,359
------------------------------------------------------------------------
FY Annual Labor Rates
--------------------------------------------------------------------------------------------------------------------------------------------------------
VA On-Board VA New Hires*
--------------------------------------------------------------------------------------------------------------------------------------------------------
%
Fiscal Year VA Increase GS-09 GS-11 GS-12 GS-13 GS-14 GS-15
--------------------------------------------------------------------------------------------------------------------------------------------------------
2018................................................ $152,443 1.00% $82,852 $100,242 $120,147 $142,870 $168,830 $198,588
2019................................................ $153,967 1.00% $83,680 $101,244 $121,349 $144,299 $170,518 $200,574
2020................................................ $155,507 1.00% $84,517 $102,257 $122,562 $145,742 $172,223 $202,580
2021................................................ $157,062 1.00% $85,362 $103,279 $123,788 $147,199 $173,945 $204,605
2022................................................ $158,633 1.00% $86,216 $104,312 $125,026 $148,671 $175,685 $206,651
2023................................................ $160,219 1.00% $87,078 $105,355 $126,276 $150,158 $177,442 $208,718
2024................................................ $161,821 1.00% $87,949 $106,409 $127,539 $151,659 $179,216 $210,805
2025................................................ $163,440 1.00% $88,828 $107,473 $128,814 $153,176 $181,008 $212,913
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source:
VA On-Board
Budget Database / Forms / Budget and Contract Administration Forms / Labor Rates
* OPM salary data based on Grade / Step-5; Washington Locality Pay; 30% to cover benefits; added
VA amount updated and based on actual Station 116 salary expense / on-board FTE
Future years are an increase of 1% per year, which is an estimate only for projections
Question 4a. Please provide amounts for both development and
sustainment.
Response. It currently costs VA approximately $426 million to
sustain VistA in FY 2019. VistA will be operated until all VA medical
centers have migrated to Millennium, at which time the redundant VistA
modules will be decommissioned. VistA modules that are not replaced by
the Cerner solution will be maintained until replacement solutions are
developed/deployed.
Question 5. According to VA officials, a report on the
recommendations for a joint governance structure between the VA and the
Department of Defense (DOD) was submitted to the Department on
February 28th.
Question 5a. When will that report be made available to this
Committee?
Response. On March 1, 2019, the Federal Electronic Health Record
Modernization Working Group (FEHRM WG) presented the draft Plan of
Action and Milestones (POA&M) to leadership from DOD and VA. The report
will be made available to the Committee once the internal process is
complete.
Question 5b. What process was utilized, and who participated, in
the creation of this report?
Response. In response to the September 2018 DOD/VA Joint Commitment
Statement, DOD and VA chartered the FEHRM WG, consisting of governance
and subject matter experts, and key DOD/VA leaders, to make
recommendations for a joint governance structure. The FEHRM WG meets on
a weekly basis to provide progress updates and discuss key decisions to
advance the analysis.
Question 5c. If a decision has been made as to what joint
governance structure VA and DOD will be utilizing, please provide
details as to who made this decision and what criteria was used.
Response. Executive leaders within the FEHRM WG preliminarily
approved the POA&M draft. The FEHRM WG applied the following evaluation
criteria for each course of action in the POA&M: rapid decisionmaking,
agile decisionmaking, EHR deployment risk, and change management risk.
FEHRM is working to jointly select a lead and deputy with concurrence
from both Departments. The lead will act as a neutral arbiter ensuring
timely decisionmaking regarding the requisite architecture and
operations to support the core technology.
Question 6. When will VA be providing a full accounting of how many
veterans were affected by late and inaccurate GI Bill payments last
fall?
Response. VA underpaid approximately 322,000 beneficiaries an
average of $202 for the fall of 2018 terms.
Question 6a. Provide details as to what extent these veterans were
affected and when they will be made whole.
Response. On December 8, 2018, VA installed the 2018 uncapped
monthly housing allowance rates. Until the information technology (IT)
solution is in place, VA will pay students the current year's uncapped
rate. Beneficiaries who were underpaid from the fall 2018 term received
a separate payment for any difference owed to them. Veterans who were
overpaid were not held liable for any debts. On December 1, 2019, all
VA processing systems will be updated functionality to process claims
in accordance with sections 107 and 501. For section 501, the rate
tables will be expanded to house both the capped and uncapped rates.
The IT solution will also allow training facilities to accurately
report all locations where their students are attending the majority of
their classes, so VA can process housing payments in accordance with
section 107.
Question 7. This budget states that the Office of Electronic Health
Record Modernization (OEHRM) plans to reach a goal of hiring 170 out of
230 FTE by the end of 2019
Question 7a. When does OEHRM anticipate completing the hiring
process of all 230 permanent FTE?
Response. OEHRM's approved organizational chart has a total of 274
FTEs as of January 10, 2019. OEHRM anticipates that all permanent FTE
will be onboarded by third quarter FY 2020.
Question 7b. How many of these hires are anticipated to be
previously detailed or matrixed personnel who have been permanently
reassigned to OEHRM? And from what departments were these FTE
reassigned?
Response. OEHRM expects to permanently reassign 41 FTEs previously
detailed or matrixed personnel to OEHRM from VHA, OIT, Office of
Management, and Office of Finance.
Question 8. There are several programs/projects that have received
a cut in funding for both Development and Operations and Maintenance in
this budget. Please provide justification, including what specific IT
functions or projects will not be funded, for the decreases in the
following programs:
Digital Health Platform
Purchased Care
Education Benefits
Human Resources
Data Integration and Management
VA Response.
Digital Health Platform (DHP)--There are several key
factors affecting the FY 2020 Budget request for this Congressional
Project. As project development comes to an end, the priorities shift
to sustainment, which can sometimes be accomplished at a much lower
cost. Additionally, with the acquisition of the Cerner Millennium
product, it is anticipated that some associated work will be funded via
OEHRM.
In the FY 2020 President's Budget request, VA assumed that FY 2020
funding would decrease due to the following reasons:
(1) The Cerner migration.
(2) Contractor support carryover into FY 2020 (one-year's savings).
Of note: In FY 2019, the DHP program has $25M in requirements and a
current Budget Operating Plan (BOP) of $17.558M, giving the program a
$5.009M Unfunded Requirement (UFR). Ancillary, Surgery, and VistA
Security Remediation are major pieces of the reduced FY 2020 budget
request.
Ancillary is still in the award phase of its initial
contract and plans to have support carryover in FY 2020 resulting in a
reduced request (one-time savings).
VistA Security Remediation was broken into three parts:
VistA Security Remediation, Enterprise Encryption Key Management System
(EEKMS), and VistA Security Scanning. The program manager is discussing
the possibility of IT Operations (ITOPS) supporting EEKMS and Office of
Electronic Health Record Modernization (OEHRM) will fund Eagle6 (VistA
Security Scanning).
The efficacy of one critical technology demonstrated by the DHP was
the Application Programming Interface (API). Using the DHP as a
baseline technology demonstration platform for APIs, VA has delivered a
developer portal, a Benefits Intake API, a Facilities API and a
Veterans Health API. VA's Veterans Health API is part of VA's
commitment to health IT modernization, and contributes to VA's
electronic health record modernization program since much of the data
exchanged between Cerner and the VA health data stores will be through
APIs, rather than complicated custom-built interfaces.
Purchased Care--The Congressional Project includes the
Medical Care Collections Fund (MCCF) sub-project that has been ongoing
for years, which has improved the efficiency and effectiveness of the
system. As such efficiencies are realized, the project does not require
as much development funding to move forward.
Education Benefits--The funding decrease within the
Congressional Project ``Education Benefits'' from FY 2019 to FY 2020 is
based on the plan to execute the largest portions of required work in
FY 2018 and FY 2019, therefore there was a larger request in 2019. In
addition to this, the FY 2020 request reflects the realignment of a
sub-project (eFolder enhancements) and its funding into another
Congressional Project (Benefits Systems), which more appropriately
aligns to where the work is being performed. Therefore, the FY 2020
request for Education Benefits was reduced in comparison to FY 2019.
Human Resources--The Congressional Project Human Resources
includes the following Human Resources (HR) Smart Phase 4 and Talent
Management System (TMS) Upgrade sub-projects:
TMS Upgrade--TMS has closed its Development efforts
in 2018 and has transitioned to sustainment funding supported
by the Franchise Fund.
HR Smart Phase 4--During the 2020 budget cycle, it
was determined that development work would conclude in
August 2019, therefore additional funding was not requested for
2020 and beyond. The current system is maintained in the VA
Enterprise Cloud (VAEC).
Data Integration and Management--The FY 2020 budget
request for this Congressional Project actually increased due to the
new sub-project Enterprise Cloud Solutions in the amount of $50 million
in operations and maintenance, which is a high priority modernization
effort.
Question 9. At recent congressional staff briefings, VA officials
have stated that there are 11 different IT projects underway related to
VA MISSION Act implementation. The Secretary's March 4, 2019, letter to
Appropriations Committee and Subcommittee leadership--which requests
authority to transfer $95.94 million to the IT Systems account to
support the development of these projects in fiscal year 2019--
identifies 9 of those 11 projects. What are the other two projects not
listed below?
Decision Support Tool
HealthShare Referral Manager
Provider Profile Management System
Enterprise Program Reporting System
Integrated Billing and Accounts Receivable
Community Care Reimbursement System
Automated solution to query state prescription drug
monitoring program websites
Caregiver Application Tracker database
Customer Relationship Management Platform
Response. The other two projects are the following:
Consult Toolbox; and
Enrollment and Eligibility.
Question 10. Please provide descriptions of the ``integrated
billing and accounts receivable'' project, the ``customer relationship
management platform,'' and the two other projects not listed above, as
the letter to the Appropriations Committee did not provide adequate
detail on these projects.
Response. The Integrated Billing (IB) and Accounts Receivable (AR)
(IB/AR) module project includes system enhancements to Vista packages
to implement long-term administration of Urgent Care (UC) Copays and
provides modifications to billing systems to enhance collections
capabilities, retrieve the VA Maintaining Internal Systems and
Strengthening Integrated Outside Networks Act of 2018 (MISSION) Copay
status, and ensure proper processing and reporting regarding billing.
The Customer Relationship Management (CRM) module creates a backend
platform to support stakeholder engagement. This facilitates innovation
sourcing and engagement at scale leveraging technology instead of
manual human effort. Implementing the CRM software in VA contact
centers allows VA to collect and preserve the context of interactions
and automate processes to enhance performance. The CRM platform
functionality provides VA employees a consolidated interface and means
of answering, tracking and reporting calls from Veterans,
Beneficiaries, and applicable Veteran stakeholders to enhance customer
service. The platform supports call center performance improvement and
enhanced service delivery across administrations and business lines.
Consult Toolbox is a consult management tool that integrates with
VistA to support Community Care consult creation. Consult Toolbox
provides additional data fields that standardize consult data and
provide critical content to the Community Care consult. Consult Toolbox
is also used to initiate the Decision Support Tool.
The Eligibility and Enrollment System provides Veteran Community
Care eligibility information to downstream systems and will be enhanced
to support MISSION specific eligibility requirements for June 6th,
2019.
Question 11. Please provide documentation of the overall timeline
and expected dates of key milestones related to the delivery of the
Decision Support Tool (DST) for the Veterans Community Care Program
(VCCP)--from contract solicitation to release of the final product.
Response. VA expects between 10,000 and 15,000 clinical consults
per day, where anywhere from one to three staff members accessing each
consult. The latest DST statistics show there is an average of 38,000
technical uses of DST per day, which is in line with expectation of
high user adoption.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 12. According to the March 1, 2019, U.S. Digital Service
(USDS) sprint report on VA MISSION Act community care, VA only began
actively developing the DST about six weeks earlier, and the DST
project development timeline assumes a May 23, 2019, production
release. As the USDS report points out, this leaves very little time to
correct any errors or performance issues before the new Veterans
Community Care Program (VCCP) must be implemented on June 6, 2019.
Question 12a. Given that the majority of the eligibility criteria
for VCCP were set forth in the VA MISSION Act (with the exception of
the designated access standards that the Secretary recently proposed),
why did VA wait until January 2019 to begin developing the DST?
Response. The MISSION Act legislation was signed into law June 6,
2018, and discussions of implementation plans and related IT solutions
began immediately. Technical requirements evolved with the development
of regulation and policy proposals, and solution development was then
able to begin in January 2019.
Question 13. This budget reflects a continued, steady increase in
VA's mental health budget.
Question 13a. How is VA tracking the effectiveness of its mental
health and suicide prevention programs?
Response. The Clay Hunt Suicide Prevention for American Veterans
(SAV) Act (Public Law No. 114-2) requires an annual, independent 3rd
party evaluation of VA's mental health care and suicide prevention
programs. The first report was completed in December 2018. The reports
are to:
include evaluations of opioid prescribing/safety and
services for women Veterans;
consider effectiveness, cost effectiveness, and Veteran
satisfaction;
propose best practices including practices suggested by
other Federal departments or agencies; and
use metrics that are common and useful for practitioners.
Suicide prevention activities span a broad public health approach
in which implementation factors are measured in the short term, and
long-term outcomes are tracked over time. Measurement plans for
interventions, including both performance/implementation metrics, and
effectiveness/impact outcomes, aimed at the universal, selected, and
indicated levels are underway.
Question 13b. How will this increased funding be used to recruit
and retain more mental health professionals?
Response. The Office of Mental Health and Suicide Prevention
(OMHSP) continues to work collaboratively with Workforce Management and
Consulting (WMC) in enhancing hiring processes and opportunities across
the enterprise.
As of January 31, 2019, the Mental Health Hiring
Initiative (MHHI) resulted in an increase of 1,045 mental health
providers onboard in VHA with total hires of 3,956.
Between June 2017 and March 2019, Suicide Prevention
Coordinators increased from 360 to 444.
In FY 2018, VHA awarded 253 Mental Health Retention Education Debt
Reduction Program (EDRP) awards, which was 23 percent of all EDRP
awards. As a group, psychologists received the third most EDRP awards.
Recent OMHSP and WMC efforts have included collaboration with the
Office of Academic Affairs (OAA) establishing recruitment fairs for VHA
trainees. Initial efforts focused on recruiting psychology trainees,
and as the academic year progresses, efforts will focus on medical
residents (psychiatry).
Question 13c. Is this funding sufficient to provide mental health
care to newly eligible veterans, such as those with other than
honorable discharges or those within the first year of transition?
Response. The overall influx of newly eligible Veterans associated
with recent eligibility expansion efforts is unfamiliar territory for
VHA. However, OMHSP has an established population health staffing model
which allows for near real-time monitoring of staffing needs across
VHA. Increases in Veteran demand for services will be reflected in
decreasing Staff-To-Patient (SPR) ratios. VHA anticipates sufficient
funding mechanisms are in place which allow VACO and individual VISNs
the flexibility to rapidly address critical staffing shortages due to
increased demand.
Question 13d. How will VA fund the President's newly signed
Executive Order aimed at reducing veteran suicide?
Response. The Task Force roles and leads for the lines of effort
(enabling support, state and local action to include grant structure,
and the research strategy) are in the process of being determined. Role
determinations and associated kick-off meetings are planned to occur in
May 2019.
Question 14. This budget request includes $54 million for
Comprehensive Addiction and Recovery Act Programs.
Question 14a. While the budget justification documents provide an
overview of what VA has done to address opioid addiction, it does not
include details on how the $54 million will be spent or what outcomes
VA is attempting to achieve. Please provide clarity on what CARA
programs will be improved with this funding.
Response.
A. Funding
------------------------------------------------------------------------
Dollars in
Program FY 2020
------------------------------------------------------------------------
Pain and Opioid Management (10P11)........................ $16,405,311
Office of Patient Advocacy, Comprehensive Addiction and $7,458,689
Recovery Act (CARA) Section 924 (10H)....................
CARA Section 933:
Pilot Program on Integration of Complementary and
Integrative Health and Related Issues for Veterans and
Family Members of Veterans and CARA Section 931
Expansion of Research and Education on and Delivery of $30,190,000
Complementary and Integrative Health to Veterans,
``Creating Options for Veteran's Expedited Recovery''
or COVER (10NE)........................................
-------------
Total................................................. $54,054,000
------------------------------------------------------------------------
pain and opioid management cara improvements
The Pain Management Program in the Office of Specialty
Care Services (10P11) has historically received a partial allocation of
the Comprehensive Addiction Recovery Act of 2016 (CARA) budgeted funds.
If a similar amount is available in FY 2020, Specialty Care Services
(SCS) anticipates supporting the following CARA and Opioid related
programs:
- Expansion of the Opioid Overdose Education and Naloxone
Distribution (OEND) program through funding Naloxone free to
the field, development and delivery of new educational and
training materials, and providing support to the expansion of
Naloxone to first responders and in AED kits.
- Supporting the development and site integration of the
CARA-mandated interdisciplinary pain management teams through
training, education, and material resources such as equipment,
supplies, or personnel time to assist in setting up and
managing the teams.
- Support and strengthen the VA/DOD Joint Pain Management
Workgroup through funding personnel time, new training
development, and support the JEC in developing, monitoring and
tracking a strategic goal related to Opioid awareness between
the agencies.
- Expanding and enhancing the implementation of high-risk
patient reviews before prescribing opioids and during and after
treatment utilizing tools such as Stratification Tool for
Opioid Risk Mitigation (STORM) and Opioid Therapy Risk Report
(OTRR).
- Supporting Federal initiatives to address the Opioid Crisis
including the ODNCP National Drug Strategy, the President's
Plan to Address the Opioid Crisis, and the Recommendations
resulting from the White House Commission on Addressing the
Opioid Epidemic.
- Supporting the expansion of the Stepped Care Opioid Use
Disorder Training the Training (SCOUTT) initiative to sites
beyond the original pilot sites and increase the number of VA
providers with X-waivers to dispense and treat patients with
buprenorphine for Opioid Use Disorder (OUD). This will include
training material, resource time, and supplies to support the
program expansion.
whole health system cara improvements
Section 933 of the CARA legislation requires demonstration
projects on integrating the delivery of Complementary and Integrative
Health (CIH) services with other health care services provided by VA
for Veterans with mental health conditions, chronic pain, and other
chronic conditions. Rather than just adding these approaches into
primary care, CIH approaches are delivered through a Whole Health
System. This approach improves access and reduces the burden on primary
care. Whole Health is an approach to health care that empowers and
equips people to take charge of their health, well-being, and to live
their life to the fullest, and is the primary delivery vehicle through
which Veterans can access CIH services.
The Whole Health System includes the following three
components:
- Empower: The Pathway--in partnership with peers, empowers
Veterans to explore mission, aspiration, and purpose, and begin
personal health planning;
- Equip: Well-being Programs equip Veterans with self-care
tools, skill-building, and support. Services may include
proactive CIH approaches such as yoga, tai chi, or mindfulness.
- Treat: Whole Health Clinical Care--in VA, the community, or
both, clinicians are trained in Whole Health and incorporate
CIH approaches based on the Veteran's personalized health plan.
VA staff has been working with Veterans around the country to bring
elements of this Whole Health approach to life. In conjunction with the
CARA legislation, VA began implementation of the full Whole Health
System in 18 Flagship Facilities in the beginning of FY 2018, the first
wave of facilities in the national deployment of Whole Health. Flagship
facility implementation of the Whole Health System will proceed over a
3-year period (FY 2018-FY 2020) and is supported by a well-proven
collaborative model which drives large-scale organizational change.
In FY 2020, Whole Health System (WHS) implementation and
deployment will continue to make progress in the following areas:
- Continue to disseminate a comprehensive standardized Whole
Health System model, deployment strategy, implementation guide,
and resources for use by all field sites.
- Provide third year of funds to support the development and
deployment across 18 Flagship facilities. Flagship sites were
funded at $3.9 million over 4 years.
- Continue to train Veteran peers in the Introduction to
Whole Health sessions for Veterans. Continue to train VA
employees in Whole health. Over 10,000 VA employees trained in
Whole Health to date; 5,500 more in FY 2019; Building VA's core
faculty in Whole Health- 60 faculty trained thus far.
- Continue over 100 ongoing national Community of Practice
Calls focused on learning from the field and sharing lessons
learned. This strategy has proven to be a highly effective
method of advancing Whole Health across the field.
- Continue to respond to all facilities requesting Whole
Health support, requiring intensive work, onsite consultation,
ongoing education, and provision of Whole Health tools and
resources.
- Continue a robust Whole Health research agenda evaluating
and addressing: patient outcomes, implementation, cost and
utilization, and health care workforce across the 18 Flagship
facilities.
- Continue to lead a robust, intentional effort to increase
collaboration and build coalitions both internally and
externally. These include strong partnerships with other
national program offices, including: Mental Health and Suicide
Prevention, Spinal Cord Injury, Women's Health, Primary Care,
National Center for Health Promotion and Disease Prevention,
Social Work, Patient Care Services, Nutrition and Food
Services, Nursing, Chaplaincy, Connected Health, and HSRD.
- Continue random survey of Veterans with chronic pain at the
18 WH Flagship sites (Veterans Health and Life Survey) with a
target of 10,000 respondents. Expecting preliminary findings on
impact on Veteran quality of life, pain, patient engagement,
life meaning, and purpose from this large cohort within the
next 6 months.
- Continue research and dissemination of evidence of
effectiveness for Battlefield Acupuncture (BFA), a specific
ten-point auricular acupuncture protocol developed in DOD and
now being widely used in VA used for pain. Data from a national
outcome study on BFA looking at over 11,000 Veterans being
treated shows on average a 2-point drop on the 0-10 pain scale
from before to immediately after BFA treatment. BFA is also
equally effective in patients on opioids as it is on patients
not on opioids. To date, 2,400 VHA clinicians have been trained
to offer BFA, and demand for this service continues to
increase.
office of patient advocacy (opa) improvements
As per section 924 of CARA, the new Office of Patient
Advocacy was established and directly reports to the Under Secretary
for Health. OPA is tasked with ensuring the following:
- Patient Advocates truly advocate on behalf of Veterans with
respect to health care received and sought when managing
complaints;
- Responsibilities of the Patient Advocate are carried out at
VA Medical facilities as per CARA requirements; and
- Patient Advocates receive consistent training.
standardized complaint resolution process
In process of standardizing the complaint resolution
processes across the system with a goal that complaints will be
resolved at the lowest level possible, preferably at the point of
service. If that is not possible, the patient advocate will advocate on
behalf of the Veteran to come to a resolution.
patient advocate tracking system--replacement (pats-r)
Partnered with the VA Veterans Experience Office to
develop a more user-friendly web-based system to manage Veteran
complaints.
Will more efficiently connect service lines to expedite
resolution of Veteran complaints at the point of service.
Shifts VHA organizational culture to resolving Veteran
complaints at the point-of-service, in collaboration with Patient
Advocates.
Leverages technology to improve communication between all
points of service no matter where Veteran is seen, to allow timely and
efficient resolution.
Will provide accurate and timely reports communicating
trends on Veteran complaints at the facility, VISN and national levels.
Will roll out in May 2019.
staffing methodology
Partnered with the VA Center for Healthcare Organizations
and Implementation Research (CHOIR) and VHA Workforce Management to
develop an evidence-based patient advocacy staffing model.
This model will account for facility size, complexity and
geographic region.
training & education
Community of Practices Calls are held monthly to provide
live, consistent information and education to Patient Advocates.
Continue to provide funding to the field to support VISN-
level meeting/conferences/trainings focused on Patient Advocacy with
focuses on Opioid Safety; Suicide Prevention; and/or Lesbian, Gay,
Bisexual, and Transgender (LGBT) Care.
New educational modules are currently under development in
partnership with VHA Employee Education Systems (EES) focusing on the
VHA Directive for Patient Advocacy Programs and New Patient Advocate
Orientation.
Question 15. Public Law 115-182, the VA MISSION Act of 2018,
authorized a higher ceiling for individual loan repayment under the
Educational Debt Reduction Program.
Question 15a. Please describe how the Department developed its
estimate of $5.5 million in increased usage as a result of the law's
higher reimbursement amount.
Response. At the end of FY 2018, there were approximately 4,100
active participants in Educational Debt Reduction Program (EDRP);
nearly 3,500 of these participants were approved in the last 4 fiscal
years following the implementation of Choice Act changes. In FY 2018,
physicians received the most EDRP awards, nurses ranked second, and
psychologists were third.
VA projected $5.5 million in FY 2020, in addition to planned
program growth, for the initial year of the increased award amounts
based on the number of current program participants with awards
exceeding $20,000 per year. Preceding MISSION Act 2018, the maximum
award was $24,000 per year and 10 percent of participants receiving an
EDRP award exceeded $20,000 per year. Therefore, VA projected 10 -15
percent (150-200) of applicants would be eligible for an increased
award of up to $40,000 per year. $5.5 million only includes estimates
for FY 2020; future year costs will increase to sustain recently
approved participants and new applicants (The FY 2021 estimate is $7.5
million).
As anticipated, implementation of the $200,000 limit in FY 2019
authorized by MISSION Act is impacting new award costs. Awards for new
participants under the $200,000 award amount are currently averaging
$114,000, up from $77,000 under the previous $120,000 limit. VA medical
centers are actively utilizing EDRP to fill VA's hardest to fill
physician positions as demonstrated by the significant increase in
physician awards which are near 50 percent of all EDRP awards received
thus far for 2019.
Question 15b. How does VA ensure that funding is available for
hard-to-fill positions even if a medical center director does not make
a request for funding such positions?
Response. VA uses several processes to ensure funding is available
for hard-to-fill positions identifying top shortage occupations at the
facility level annually and monitoring each facility's usage of
recruitment and retention incentives and EDRP awards toward those
occupations throughout the year, shifting resources as needed.
Question 16. Section 212 of Public Law 115-46, the VA Choice and
Quality Employment Act, authorized competitive pay for Physician
Assistants.
Question 16a. Please provide the amount of funding in the budget
request that will allow VA to provide this increased pay to Physician
Assistants.
Response. A conversion average based on nine employees being paid
from three different Physician Assistant (PA) schedules was used to
arrive at this costing average. To arrive at an average upon
conversion, the lowest pay schedule (the GS Rest of the US Locality Pay
schedule) and two special rate schedules (Durham and San Francisco)
were used. The costing was intended to show an average of the
conversion costs only. In a sampling, the average PA will receive
$5,108 upon conversion to the Nurse Locality Pay System. Employees at
step 1 upon conversion will receive no increase. All other PAs at steps
2 through 10 will be placed at the first step that equals or exceeds
their current rate of pay immediately prior to conversation; this will
normally result in a 1 or 2 step increase. This would be a one-time
cost of $12.3 million dollars to move all PAs to the Nurse Locality pay
system. The 12.3 million represents an estimate of obligations and not
a budget request number. This would increase the pay for all current
PAs (steps 2-10) and then would revert to normal step increases which
would be in line with current practices, which is why there is no cost
for the future.
The average increase of $5,108 times the number of PAs currently at
steps 2--10 was used--2,400 Physician Assistants in VHA at steps 2--10
x $5,108 = 12,259,200.00, or approximately $12 million.
This costing only provides an average of the initial cost increase
upon conversion. It does not consider the ability of Medical Center
Directors to subsequently adjust rates at any time they deem necessary
post conversation.
Question 17. Since 2017, Congress has stepped in three times to
provide additional funding so the Department would not exhaust Veterans
Choice Program funding. In at least two of the instances, veterans were
needlessly stressed and inconvenienced while VA sorted out its
budgeting issues.
Question 17a. In detail, please provide how VA developed the
estimate of funds necessary to carry out the Veterans Community Care
Program.
Response. The Veterans Community Care Program projection in the
2020 President's Budget was developed by summing the following
components:
A base actuarial model (referred to as the Enrollee Health
Care Projection Model [EHCPM]). The EHPCM is based on 2017 actuals and
projects costs from demographic changes, intensity of medical services,
and unit price changes.
An incremental EHCPM run for the expanded access standards
as stated in the Access Regulatory Impact Analysis.
An incremental EHCPM run for the new Urgent Care benefit
as stated in the Regulatory Impact Analysis.
Adjustments for more recent actuals and programs excluded
from the EHCPM. Programs that are excluded from the EHCPM but added
after including CHAMPVA and the Long-Term Services and Supports (LTSS)
State Home programs.
Additional detailed information on the forecasting of the MISSION
Act may be found within the Regulatory Impact Analysis documents.
Question 17b. How has VA improved its process for projecting how
much it needs for this type of a program since 2017?
Response. The estimates from the EHCPM supporting the 2020 VA
health care budget and the MISSION Act are informed by VA's experience
under Choice. The actual health care utilization experience of the
Choice enrollees since the onset of the Choice program has provided
invaluable insight into the reliance changes that are expected to
continue for this population into the future. This experience also
informed the expectations for the enrollees that will become eligible
for similar community care access under the new MISSION Act drive-time
standards.
Question 18. At the hearing, Secretary Wilkie briefly discussed the
market area assessments that VA is currently undertaking, which will
inform the VA MISSION Act's Asset and Infrastructure Review Commission.
It is my understanding that through the market area assessment process,
VA is evaluating its own current and future capacity, and the capacity
of the community, to deliver health care services that will meet the
needs of veterans in 96 regional markets nationwide. At a recent staff
briefing, VA officials provided an overview of the Department's four-
stage market assessment methodology: data collection, data validation,
site visits, and development of recommendations.
Question 18a. At the staff briefing, VA officials said that the
site visits the Department plans to conduct in each market would last
between one half to one full day, and they would cover interviews with
VA facility leadership, community providers, and area veterans service
organizations. So that I can better understand VA's planned approach,
please provide a sample site visit schedule, to include a list of
topics that will be addressed during each of the interviews that will
take place during each half-day to full-day site visit.
Response. A sample site visit interview schedule and a list of
topics that will be addressed during each of the interviews are
attached.
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Question 18a (response continued)
All site visits to VA Medical Center (VAMC) parent facilities are
full day visits. The team will also be visiting a limited number of
Health Care Centers (HCC), VAMC child facilities, and multi-service
Community-Based Outpatient Clinics (CBOC) that are key points of care
in certain markets. These visits will be half-day visits consisting of
facility walk-throughs and conversations with VA staff.
At each VAMC full day visit, the team will be meeting with each
member of the executive leadership team, including the Director, Chief
of Staff, and Associate/Assistant Director. The team will also meet
with all service line directors, including but not limited to the
Directors/Chiefs of Education, Research, Primary Care, Mental Health,
Medicine, Surgery, Extended Care, Rehab Community Managed Care/
Purchased Care, the Nurse Executive, and the Group Practice Manager. In
addition, the team will be meeting with the facility planner, engineer,
and any other role that is either recommended to the team or is
integral to the facilities service offerings or critical support
service.
Topics the interview team will address will vary depending on the
interviewee and market conditions. The focus of the interviews is to
obtain the interviewees' outlook of the future and to understand the
local VAMC perspective on the needs of Veterans in their market, both
now and in the future. In conjunction with collaborative data review
sessions, these interviews will provide market assessment teams a
holistic view of the market while developing high-performing networks
of care.
Question 18b. Please provide VA's planned schedule of site visits
for all 96 markets.
Response. The planned schedule to visit all 96 markets is divided
into three phases. One-third of all VISNs are evaluated in each phase.
Phase 1 is ongoing and includes markets in VISNs 2, 4, 5, 6, 16, and
17. Each VISN has a dedicated market assessment team, and site visits
occur concurrently among all six VISNs. Ideally, each team will have
time between visits to collaborate and share notes on previous site
visits before traveling to the next market.
Question 18c. Does VA expect that the market area assessments will
result in any observations or recommendations related to the condition
of VA facilities or infrastructure (in general or on a facility-by-
facility basis)?
Response. The purpose of the Market Assessments is to develop high-
performing networks of care that include VA as the primary provider of
care, supplemented by care in the community. Facility/infrastructure
conditions will be considered when developing high-performing networks
but will not be the sole factor under consideration. It is difficult to
anticipate future opportunities until the process is complete. We
anticipate the process will yield observations and opportunities in
facilities and infrastructure, given their role in health care
delivery.
Question 18d. If facility/infrastructure conditions will be part of
the market assessments, what are the qualifications of those personnel
(be they VA employees or VA contractors) doing the market assessments
when it comes to evaluating the facilities and infrastructure?
Response. The purpose of the Market Assessments is to develop high-
performing networks of care that include VA as the primary provider of
care, supplemented by care in the community. Facility/infrastructure
conditions will be considered, including building ages, active capital
projects, and VA-provided Facility Condition Assessments (FCA) when
developing opportunities.
The market assessment team, consisting of both VA and contractor
employees, includes degreed professionals covering the entire range of
architectural, engineering, health care planning, and construction
management expertise. Team credentials include professional engineers
and registered architects. These professionals have significant
experience in VA, other Federal, and commercial health care facilities
planning and management.
Question 18e. What degrees and credentials do they have, what pre-
visit research will they conduct on the facilities' infrastructure, and
how much time during each visit is allocated to infrastructure review?
Response. The purpose of the Market Assessments is to develop high-
performing networks of care that include VA as the primary provider of
care, supplemented by care in the community. Facility/infrastructure
conditions will be considered when developing high-performing networks
but will not be the sole factor under consideration. Degrees and
credentials for market assessment team members are indicated in the
response to question 18d. The team also includes clinicians and data
analysts to provide comprehensive analysis of each market.
Pre-visit research includes a review of VA-provided Facility
Conditions Assessment (FCA) information, major, minor, and non-
recurring maintenance projects; a review of VA Office of Inspector
General (OIG) facility-related findings; a review of building
engineering system studies commissioned by the VAMC or VISN Capital
Asset Manager where available; a review of campus master planning
documents; a review of the campus facility inventory, square footage,
subsequent major capital improvements, historic designation; and a
site-by-site review of this material with each facility chief health
care engineer and strategic planner or appropriate designee as well as
an onsite tour of the facility during the site visit.
Market assessments are a collaborative process between VISN and
facility leadership, the Office of Policy and Planning, Office of
Construction and Facilities Management, and a contractor team. The
review process for each market spans months, and infrastructure review
for each facility is integrated into the broader review process to
develop high-performing networks of care. Facility infrastructure
review is included in comprehensive data assessments, pre-visit market
meetings, site visit interviews, and post-visit collaboration sessions
and out briefs. In addition to a site visit tour, facility and space
considerations are addressed in each interview.
Question 18f. To what extent are engineers involved in this aspect
of the market area assessments?
Response. Engineers and health care architects from the VAMC, VISN,
Office of Construction and Facilities Management, and contract team are
involved in all facility-related aspects of the market assessments as
the team develops opportunities for high-performing networks of care.
This includes assessments of existing data, pre-visit market meetings,
site visit interviews, and post-visit collaboration sessions and out
briefs. The collective expertise of these professionally-degreed team
members is used to evaluate the medical functional state for key
infrastructure elements within each major facility.
______
Response to Posthearing Questions Submitted by Hon. Sherrod Brown to
U.S. Department of Veterans Affairs
Question 1. When will the Department decide to act on your
recommendation not to appeal the Procopio decision?
Response. Prior to issuance of the court's decision in Procopio, VA
began researching some of the complexities related to determining the
Veteran population that served within the 12 nautical miles of the
Republic of Vietnam and assessing the potential workload. VA spoke with
members of the U.S. Navy and the National Archives Records
Administration to determine the available service records, such as deck
logs. VA provided its regional offices with procedural guidance to
ensure that claims received for Blue Water Navy (BWN) Veterans are
properly tracked in its system of records. In addition, VA's internal
work groups are developing policy guidance, training, and strategic
outreach materials that will ensure these Veterans are aware of their
eligibility for benefits and services. VA is also updating its costing
for mandatory funding to support benefits paid to BWN Veterans as well
as the additional administrative costs and personnel that are necessary
to address all Veteran claims. VA anticipates a surge in claims and
appeals that will result in significant claims Therefore, VA's
implementation must include plans to maintain an acceptable level of
claims processing for all Veteran claimants. These ongoing efforts are
necessary in order to comply with the court's order.
Question 1a. Please provide me with a detailed breakdown of VA's
decisionmaking process related to the National Academies
recommendations regarding bladder cancer, hyperthyroidism, hypertension
and Parkinson's like symptoms?
Response. VA uses the process described in the attached directive--
VA Directive 0215. The first step is the formation of a technical
workgroup comprised of subject matter experts who review the report
(e.g. Veterans and Agent Orange 2018--Vol. 11) from the National
Academy of Medicine (NAM, note this used to be called the Institute of
Medicine) in depth and also consider scientific evidence published
since the NAM's cutoff date for new literature for that report. This
technical workgroup then summarizes the findings and makes potential
recommendations to report them to the NAM Strategic Workgroup (made up
of Agency leaders and other experts).
The NAM Strategic Workgroup then makes recommendations on its
findings to the VA Task Force composed of Agency Leaders, who in turn
discuss the conclusions and make the final recommendations (including
any potential presumptions) to the Secretary.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 1b. Please provide me with VA's analysis regarding total
number of veterans effected, and the cost associated with extending
service connection to each specific illness.
Response. VA's estimates for the cost and number of Veterans
impacted by the Procopio decision are being finalized. Once VA's
estimates are finalized, estimates will be shared with the Committee.
VA's estimates for the cost and number of Veterans impacted by
potential presumptive conditions associated with Agent Orange are being
finalized. If the Secretary decides to add any presumptive conditions,
VA's estimates will be shared with the Committee.
Question 2. Please provide me with the following information for
all the VAMCs in Ohio:
Question 2a. The extent to which directors have utilized the direct
hiring authority provided by OPM?
Response. On January 24, 2018, VA was granted direct hiring
authority by the Office of Personnel Management (OPM) for the following
occupations: accountant, boiler plant operator, general engineer,
health science specialist (Veterans Crisis Line), health technician,
histopathology technician, human resource assistant, human resource
specialist, information technology specialist, personnel security
specialist, police officer, realty specialist, utility systems
operator, and utility systems repair. On October 11, 2018, OPM granted
direct hiring authority for an additional eighteen STEM positions.
Since January 2018, there have been 74 people hired into Ohio
medical facilities for the occupations granted direct hiring authority,
22 percent were hired using the direct hiring authority.
Question 2b. The extent to which the directors have utilized the
student loan repayment increase that Congress provided in the MISSION
Act to incentivize healthcare professionals to work at VA.
Response. VAMCs are actively utilizing EDRP to fill VA's hardest to
fill physician positions as demonstrated by the significant increase in
physician awards which are nearly 50 percent of all EDRP awards
received thus far for 2019, up from 31 percent overall for FY 2018.
Question 3. Throughout Ohio, we have heard that staffing shortages
have cause excessive wait times for vitals, EKG's, blood draws, longer
stays in the emergency department. We have also heard that VAMC
director and clinical management decisions meant in-patient units could
not receive inpatient care. I have several workforce management
questions and would like information from all the VAMCs in Ohio.
Question 3a. What is the optimal nursing and ancillary staffing
model?
Response.
Primary Care Teams (PACT) the model is 3:1, 2
professional/clinical staff (RN and LPN or Health technician) and 1
clerical/admin support staff for each provider (MD or APRN).
Inpatient and Long-Term Care units, staffing levels are
determined based on the type of unit, acuity of care and support
services available in the facility. The model uses hours per patient
day (HPPD) for units that provide 24/7 care. The hours are based on the
clinical skill level of staff required (RN, LPN, and Nursing
Assistant). Each unit has a staff panel that formally makes
recommendations to facility executive leadership for staffing every 2
years or earlier if the patient population, acuity level, or volume
changes. Facility leadership reviews the recommendations and provides
concurrence or guidance for adjustments.
Below are national averages for skill mix percentages across VHA,
Data source: VSSC national average Feb YTD FY 2019 for Critical Care
Clusters, Medical, Surgical Clusters and CLC Clusters (excluding Small
houses).
- Critical Care Units: 93 percent RN, 7 percent Nursing
Assistant or Health Technician.
- Medical and Surgical Units: 68-70 percent RN, 5 percent LPN
and 21-25 percent Nursing Assistant.
- Long Term Care Units: 34 percent RN, 21 percent LPN and 44
percent Nursing Assistant.
Question 3b. What is the ratio of RNs, LPNs, NAs, Health
Technicians and ancillary providers to patients in all direct patient
care areas?
Response. Ratio models are not used since ratios do not reflect
patient acuity or support services available within the facility in
determining appropriate staffing levels.
Question 3c. What is the call-off rates and injuries rates
associated with direct patient care and ancillary care?
Question 3d. Please breakdown the number of many managers and
clinicians who have been redirected from direct patient care to
administrative tasks?
Question 3e. Does this cause a disproportionate manager/supervisor
ratio to employee?
Response. Please see table that follows for questions 3c-3e.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chillicothe VAMC Cincinnati VAMC Cleveland VAMC Columbus VAMC Dayton VAMC
--------------------------------------------------------------------------------------------------------------------------------------------------------
Question 3c What is the call- I do not have Direct patient care Nursing averages 4.7 Our OSHA recordable FY18 call-off rates
off rates and these call-off rate for FY unexpected absences injury rate for (measured as a percentage
injuries rates statistics. 18 is: 14% including per 100 employees FY18 was 2.07, and of call-off per FTE of 1664
associated with RNs, NAs & HTs. for the past 12 the lost time direct care hours) for
direct patient month in direct claims rate (call nursing were as follows:
care and patient care. off rate) was 0.0. Acute/Specialty Care--
ancillary care? 7.62%, Mental Health--
6.70%, and CLC--9.46% with
an overall nursing rate of
8.36%.
For FY18, there were 65
cases where clinical
employees were injured, per
the OSHA 300 log. We had
217 total injuries (rate of
.09 with 2444 FTE) through
our current reporting
system but are unable to
easily separate clinical
and administrative staff in
this database. We will be
able to distinguish this
information in the future,
as our database has changed
and provides for a more
robust reporting ability.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Question 3d Please breakdown None. The Inpatient Managers may No managers have 3, reassignments For FY18, 3 Nurse Managers
the number of numbers of be pulled from their been permanently and 4 Registered Nurses
many managers managers and primary redirected from within Nursing Service.
and clinicians assistant nurse responsibilities to direct patient care
who have been managers are cover the NOD, HUC, to administrative
redirected from determined in Telemonitor, and tasks. There are
direct patient the Staffing Virtual Monitor. We do currently 4 direct
care to Methodology not currently capture patient care
administrative calculations. the hours they are employees who have
tasks? staffing HUC, been temporarily
Telemonitoring, and assigned
Virtual Monitoring. administrative
The managers have been tasks.
used in the NOD role,
during their regular
tour 5% of their
regularly scheduled
hours.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Question 3e Does this cause No. When this occurs, it No. No. No.
a reduces the manager:
disproportionat employee ratio by 25%
e manager/ resulting in 3
supervisor managers covering 5
ratio to units.
employee?
--------------------------------------------------------------------------------------------------------------------------------------------------------
Question 3f. Provide a breakdown of employees disciplined or
terminated under section 714 of the VA Accountability and Whistle
Blower Act. Please include by race, grade, discipline, and issue that
led to termination.
Response. Please see tables below.
Chillicothe 3f Response
------------------------------------------------------------------------
Grade Discipline Issue
------------------------------------------------------------------------
GS-5................. Removal Unexcused absence
GS-11................ Removal Unexcused absence
GS-6................. Removal Unexcused absence
WG-2................. Removal Unexcused absence
GS-9................. Removal Medical Inability
WG-2................. Removal Unexcused absence
------------------------------------------------------------------------
Cincinnati 3f Response
------------------------------------------------------------------------
Grade Offense Action Cases
------------------------------------------------------------------------
GS-4 Disrespectful or abusive Removal................ 1
language/conduct
GS-4 Drug/Alcohol related Removal................ 1
GS-5 Conduct Unbecoming a Probationary 1
federal employee Termination.
GS-5 Disrespectful or abusive Probationary 1
language/conduct Termination.
GS-5 Failure to follow policy Probationary 1
Termination.
GS-5 Failure to properly request Probationary 1
leave Termination.
GS-5 Improper conduct on VA Probationary 1
premisis without VA Termination.
endorsement
GS-5 Unexcused or unauthorized Probationary 3
absence/tardiness Termination.
GS-5 Failure to meet a condition Removal................ 1
of employement
GS-5 Unexcused or unauthorized Removal................ 7
absence/tardiness
GS-6 Performance Issues Probationary 1
Termination.
GS-6 Conduct Unbecoming a Removal................ 1
federal employee
GS-6 Unexcused or unauthorized Removal................ 3
absence/tardiness
GS-8 Failure to follow policy Demotion............... 1
Title 38 Failure to meet a condition Probationary 1
of employement Termination.
Title 38 Unexcused or unauthorized Probationary 1
absence/tardiness Termination.
Title 38 Conduct Unbecoming a Removal................ 1
federal employee
Title 38 Failure to maintain Removal................ 1
licensure requirements of
position
Title 38 Unauthorized delivery of Removal................ 1
care
Title 38 Conviction Suspension--Indefinite. 1
WG-1 Failure to maintain a Probationary 1
regular work schedule Termination.
WG-1 Unexcused or unauthorized Probationary 4
absence/tardiness Termination.
WG-1 Unexcused or unauthorized Removal................ 2
absence/tardiness
WG-2 Disrespectful or abusive Probationary 1
language/conduct Termination.
WG-2 Unexcused or unauthorized Probationary 5
absence/tardiness Termination.
WG-2 Disrespectful or abusive Removal................ 1
language/conduct
WG-2 Drug/Alcohol related Removal................ 1
WG-2 Failure to meet a condition Removal................ 1
of employement
WG-2 Unexcused or unauthorized Removal................ 6
absence/tardiness
WG-3 Unexcused or unauthorized Probationary 1
absence/tardiness Termination.
WG-3 Unexcused or unauthorized Removal................ 2
absence/tardiness
WG-5 Conviction Suspension--Indefinite. 1
WG-6 Disrespectful or abusive Probationary 1
language/conduct Termination.
---------
57
------------------------------------------------------------------------
Cleveland 3f Response
------------------------------------------------------------------------
Position Title Grade Type of Discipline Charge(s)
------------------------------------------------------------------------
Nursing Assistant.... 5 15 Day Suspension. AWOL, Failure to
Follow Proper Leave
Request Procedures &
Failure to Follow
Instructions
LPN.................. 6 Removal........... Conduct Unbecoming a
LPN (7 Spec); Failure
to Follow Instruction
Nursing Assistant.... 3 Last Chance 15 charges AWOL, 5
Agreement. charges failure to
follow proper leave
request procedures &
2 charges failure to
follow instructions
LPN.................. 6 Proposed Removal.. AWOL (15 Specs)
Failure to Follow
Leave Procedures (10
Specs)
Nursing Assistant.... 5 Removal........... Carelessness in the
Performance of Duties
(5 Spec); Conduct
Unbecoming a Federal
Employee
Health Technician.... 7 Notice to Effect Violation of last
Removal. chance-Inappropriate
Conduct
Health Technician.... 6 15 Day Suspension. 2 charges conduct
unbecoming & 1 charge
failure to timely
transport patient
Health Technician.... 6 Removal........... 1 charge inappropriate
conduct
LPN.................. 6 Removal........... Medical Inability
Nursing Assistant.... 5 Last Chance 3 charges AWOL & 2
Agreement. charges failue to
follow proper leave
request procedures
Nursing Assistant.... 5 Removal........... Inappropriate
Interaction with
Patient (3 specs)
LPN.................. 6 Last Chance 3 charges
Agreement. inappropriate conduct
Nursing Assistant.... 5 Last Chance 3 charges
Agreement. inappropriate
conduct, 1 charge
AWOL & 1 charge
failure to follow
proper leave request
procedures
Nursing Assistant.... 5 Removal........... Failure of critical
element, 1 charge
AWOL , 1 charge
failure to follow
proper leave request
procedures, 1 charge
lack of due care & 1
charge making
unfounded statements
Nursing Assistant.... 6 Removal........... Carelessness in the
Performance of Duties
(2 Spec); Conduct
Unbecoming a Federal
Employee
Health Technician.... 6 Removal........... AWOL (3 Spec); Failure
to Follow Leave
Request Procedures (3
Spec); Inappropriate
Conduct (4 Spec)
------------------------------------------------------------------------
Columbus 3f Response
----------------------------------------------------------------------------------------------------------------
714 Disciplinary Proposal and Decision
Issue(s) Actions Grade
----------------------------------------------------------------------------------------------------------------
Muni-Court Conviction........................................ Proposed Removal/Removal Decision...... GS-5
Off duty misconduct (domestic violence)...................... Proposed Removal/Resignation prior to GS-11
issuance of decision.
Unacceptable Conduct (Threatening Behaviors)................. Proposed Removal/Removal Decision...... GS-5
Sleeping on duty/Inappropriate Comments...................... Proposed Demotion/Demotion Decision.... GS-7
Off duty misconduct (domestic violence)...................... Proposed Removal/Resignation prior to NV-2
issuance of decision.
AWOL, Lack of Candor......................................... Proposed Removal/Removal decision...... GS-06
Conduct unbecoming a federal employee........................ Proposed Removal/Resignation prior to GS-9
issuance of decision.
Privacy violation............................................ Proposed Removal/(1) day suspension GS-09
decision.
Unacceptable Disrespectful Conduct........................... Proposed Removal/(14) day suspension GS-06
decision.
Unacceptable Disrespectful Conduct........................... Proposed Removal/Employee retired prior GS-09
to issuance of decision.
Failure to disclose or provide accurate information.......... Proposed Removal/Removal decision (MSPB NV-3
filed--Settlement Agrmt--Employee
returned to a different vacant
position).
Conduct unbecoming a federal employee........................ Proposed Removal/DAB held/EE returned GS-06
to former position.
Leave and Attendance Issues.................................. Proposed Removal/(5) day suspension GS-06
decision.
Insubordination.............................................. Proposed Removal/(7) day suspension NV-02
decision.
Unsatisfactory Performance................................... Proposed Demotion/Demotion Decision to GS-12
a different vacant position.
Unprofessional Conduct....................................... Proposed Removal/Written counseling GS-06
decision.
AWOL......................................................... Proposed Removal/Employee retired prior GS-09
to issuance of decision.
Conduct unbecoming a federal employee........................ Proposed Removal/(5) day suspension GS-06
decision.
Failure to meet standard of care............................. Proposed Removal/Demotion Decision to a GS-05
different vacant position.
Medical Inability to Perform................................. Proposed Removal/Removal Decision...... GS-15
Unauthorized possession of firearm on VA property/Unfit for Proposed Removal/Removal Decision(MSPB GS-09
Duty. filed--Settlement Agreement Employee
will be returning to a different
vacant position).
Conduct unbecoming........................................... Proposed Removal/(5) day suspension NV-01
decision.
Failure to Supervise......................................... Proposed Demotion/Demotion Decision.... GS-06
Sleeping on duty/Conduct unbecoming.......................... Proposed Removal/currently awaiting NV-03
Director's decision.
AWOL/Failure to follow leave procedures/Failure to provide Proposed Removal/ OAWP complaint filed GS-06
accurate information. pausing Director's decision.
----------------------------------------------------------------------------------------------------------------
Dayton 3f Response
----------------------------------------------------------------------------------------------------------------
Non-
Issue Grade Clinical Clinical Type of Discipline
----------------------------------------------------------------------------------------------------------------
AWOL, Failure to Follow Leave Requesting VN-2 x Suspension
Procedures.
HIPAA/Privacy Violations................. VN- 2 x Suspension
Loss of Controlled Substance............. GS-7 x Indefinite Suspension
Untimely Documentation, Failure to Follow VM-15 x Discharge
Supervisor Instruction, Unethical
Conduct, Endangering Safety of a Veteran
Patient.
Failure to follow supervisory GS-6 x Removal
instructions.
AWOL/Failed Last Chance Agreement........ WG-2 x Removal
AWOL..................................... GS-7 x Removal
Inappropriate Conduct.................... VN-2 x Discharge
AWOL, Failure to Follow Leave Requesting WG-3 x Removal
Procedures.
Unauthorized Use of PIV Card; Accessing WG-2 x Removal
an Unauthorized Area; Unauthorized
Possession of Govt property.
AWOL; Failure to Follow Leave Requesting GS-5 x Removal
Procedures.
Negligence; Inappropriate Conduct........ WG-10 x Removal
Inappropriate Conduct, Failure to Follow VM-15 x Discharge
VA Directive.
Failure to Follow Supervisory WS-3 x Removal
Instructions/Poor Workmanship.
AWOL..................................... WG-2 x 21-Day Suspension
Using an Unauthorized Area for Research WG-8 x Removal/Failed Last Chance
and Breaks; Sleeping on Duty. Agreement
Using an Unauthorized Area for Research WG-10 x Removal
and Breaks.
----------------------------------------------------------------------------------------------------------------
Question 4. Last year's MILCON-VA appropriations bill, Pub. L. 115-
244, direct VA to do a pilot program related to hospice care to develop
best practices and techniques for Vietnam era veterans.
It has come to my attention that VA decided to use the $1 million
of funding associated with this provision on salaries, and not on the
broad implementation of the pilot program with non-profit hospice and
palliative care providers with Vietnam veteran centric programs as
directed in report language.
Question 4a. How $1 million budget remains?
Response. The entire $1 million has been obligated to implement a
strategic plan that has included collaboration with non-profit hospice
and palliative care providers.
Question 4b. Does VA plan to reprogram that funding to allow non-
profit hospice and palliative care providers with Vietnam veteran
centric programs to ramp up its care delivery yet this year and help
actual Vietnam veterans on the ground?
Response. VHA implementation of this initiative has included
collaboration with non-profit hospices. The prolonged government
contracting process would not have permitted effective implementation
of identified best practices for this 1-year initiative. If additional
funding becomes available, competitive bid contracting to engage high
performing community hospices that have a demonstrated commitment to
the care of Veterans could significantly expand the dissemination of
the best practices and techniques identified in this first year of the
initiative.
Multifaceted Approach to Improve Care
As outlined in the 180-day report to Congress on this initiative,
VHA is rapidly moving forward to the following:
Identify the unique characteristics and quality elements
at end of life for Vietnam-era Veterans through analysis of medical
records and bereaved family surveys;
Develop three ``Train the Trainer'' curricula on
identifying and addressing Post Traumatic Stress Disorder (PTSD), Moral
Injury, and Suicide intent specifically for Vietnam-era Veterans on
hospice; and
Collaborate with the National Hospice and Palliative Care
Organization (NHPCO) to conduct semi-structured interviews with
Vietnam-era Veterans on hospice and their families to learn about
quality issues directly from hospice users.
Additionally, VHA has collaborated with NHPCO to survey community
hospice partners in the We Honor Veterans program
(www.WeHonorVeterans.org) to learn more about their best practices and
insights on how to improve the care Vietnam-era Veterans.
Initial Findings
The initial findings from analysis of qualitative open-ended
comments from 2,781 inpatient decedent Vietnam-era Veterans' family
members has identified the following themes as highly valued:
compassionate staff, ceremonies that honor the life of the Veteran,
information on VA benefits, accommodations for family, genuine
expressions of condolence, and attendance at memorial services. Several
of these themes (e.g., compassionate care) are similar to those desired
elements voiced by non-Veterans and their families. A small number of
family members of Vietnam-era Veterans reported war-era specific
concerns such as the following: the need for greater assistance for
Veterans' struggles with PTSD, sensitivity to triggers for PTSD, and
greater recognition of the impact of exposure to Agent Orange. VA will
further explore these Vietnam-era specific concerns.
Preliminary analysis of nearly 100,000 VA inpatient decedents
indicate that there are unique characteristics among Vietnam-era
Veterans (e.g., increased Agent Orange exposure and higher prevalence
of substance use disorder) as compared to pre-Vietnam-era Veterans.
Other notable characteristics among Vietnam-era Veterans (e.g.,
increased prevalence of depression and anxiety), may reflect emerging
challenges in Veterans of subsequent war eras. For example, unadjusted
scores on bereaved families' perceptions of end of life care show
Vietnam-era Veteran families rate care lower in quality than pre-
Vietnam (WWII, Korean and Post-Korean). However, these differences are
negligible after accounting for differences in Veteran age at death.
Further analyses are required to determine meaningful trends on quality
perceptions and elements.
Actions to Improve Care and Next Steps
Translating the findings from these analyses into actionable
protocols while empowering community hospices is the next major step
for this 1-year initiative. For example, VHA has identified high-
performing facility teams to be trained and then disseminate the newly
developed Train-the-Trainer curricula to community hospices (with a
projection of more than 1,000 front-line staff to receive these
trainings by the end of the year) and build collaborative networks of
care to support enhanced access to telehealth for Veterans receiving
community hospice care. In collaboration with the National Hospice and
Palliative Care Organization and the National Partnership for Hospice
Innovation, VHA will develop best practice hospice protocols based on
the substantial evidence revealed as part of this initiative and pilot
these over the final months of this fiscal year to determine
feasibility for broader dissemination.
Question 4c. It has also come to my attention that VA decided to
focus areas of care on suicide prevention, moral injury and PTSD
therapy. How did VA make that decision, and was it made in consultation
with the Committees regarding congressional intent of the underlying
hospice care provision?
Response. VHA has responded to all Committee inquiries into this
initiative and has sought to meet or exceed the intent of any guidance
provided by the Committees. The development and dissemination of
expertise in the three areas mentioned above is only part of VHA's
actions for this initiative, however, the decision to develop ``Train
the Trainer'' curricula on PTSD, Moral Injury, and Suicide Prevention
specifically for Vietnam-era Veterans in hospice was made in
collaboration with subject matter experts from the following VHA
programs: Palliative and Hospice Care, National Center on PTSD and
Suicide Prevention, Office of Mental Health, Office of Care
Coordination, Office of Patient Centered Care and Culture
Transformation, National Chaplaincy Center, and the Office of Nursing
Service, as well as incorporating guidance from the National Hospice
and Palliative Care Organization. These offices and community hospice
partners agreed that reducing the suffering in these three areas was
and is a top priority for this initiative as outlined ``. . . to
develop the techniques, best practices and support mechanisms to serve
these veterans . . . .'' For example, in a survey of community
hospices, many shared they do not screen for nor have the capacity to
address the symptoms of PTSD, Moral Injury, and Suicide Intent. Through
dissemination of expertise in these three areas, community hospices
will be more empowered to meet the specific needs of Vietnam-era
Veterans in hospice.
Question 5. On December 20, 2018, I signed onto a letter led by
Senator Carper regarding the closure of Education Corporation of
America schools and its impact on veterans and their families. My
colleagues and I have not yet received the answer to Questions from
that letter and have included them here for a thorough response.
Question 5a. When did ECA notify the VA about the planned closures
for each campus?
Response. VA received a letter from Education Corporation of
America's (ECA) chief executive on December 12, 2018, officially
advising VA of the closure and the effective date of closure for each
of its locations.
Question 5b. When and how did the VA notify GI Bill recipients
about the closures for each campus?
Response. Once VA was officially aware of the school's closure
(December 12, 2018), VA notified affected students within the 5
business days required by law. All students impacted by the closure
received a notice at their address of record. VA also posted notices of
the closure on its Web site and social media pages with the following
message and active link to more information on December 7th:
``VA is aware of the abrupt closure of facilities associated
with Education Corporation of America (ECA), which operated
several chains of schools, to include Virginia College,
Brightwood College, Golf Academy of America, and Ecotech
Institute, throughout the Nation. VA is coordinating with the
various State Approving Agencies (SAA) and is in the process of
gathering the specific details surrounding this closure.''
Additionally, the assistance provided to students by VA is in the
form of the links and information contained in the 5-day outreach
letter to students. A copy of this letter is attached below. Education
Call Center agents were available to answer questions and provide
assistance to students with school closure questions. Last, VA
coordinated with Veterans Service Organizations (VSOs) to notify any
affected students or provide support services.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 5c. How many Post-9/11 GI Bill recipients were enrolled at
ECA colleges at the time of the announced closure? Please provide GI
Bill enrollment data for each campus.
Response. There were 1,389 students enrolled at ECA colleges who
were using Post-9/11 GI Bill benefits at the time of closure. Please
see the enrollment data spreadsheets below.
ECA School List
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
ECA Colleges by Institution Name
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Brightwood Institutes by State
------------------------------------------------------------------------
------------------------------------------------------------------------
Brightwood Career Institute................... 28119823 MN
Virginia College.............................. 21004336 OK
Brightwood College............................ 24918414 IN
Brightwood College............................ 24931614 IN
Brightwood College............................ 24986435 OH
Brightwood College............................ 24955442 TN
Virginia College.............................. 21904042 TN
Golf Academy of America....................... 24201010 FL
Virginia College.............................. 249F1410 FL
Virginia College.............................. 219B6110 FL
Virginia College.............................. 24994410 FL
Golf Academy of America....................... 24113440 SC
Virginia College.............................. 21802440 SC
Virginia College.............................. 21802640 SC
Virginia College.............................. 21802340 SC
Virginia College.............................. 21802740 SC
Virginia College.............................. 21802840 SC
Golf Academy of America....................... 24929403 AZ
Virginia College.............................. 21917211 GA
Virginia College.............................. 21917811 GA
Virginia College.............................. 21917311 GA
Virginia College.............................. 21917611 GA
Virginia College.............................. 21001418 LA
Virginia College.............................. 21001618 LA
Virginia College.............................. 24801424 MS
Virginia College.............................. 24801324 MS
Virginia College.............................. 21802301 AL
Virginia College.............................. 21952301 AL
Virginia College.............................. 21953101 AL
Virginia College.............................. 21958101 AL
Virginia College.............................. 21014146 VA
Brightwood Career Institute................... 24956438 PA
Brightwood Career Institute................... 24939438 PA
Brightwood Career Institute................... 24942438 PA
Brightwood Career Institute................... 24940638 PA
Brightwood Career Institute................... 24961438 PA
Brightwood College............................ 24912133 NC
Virginia College.............................. 21905133 NC
Brightwood College............................ 24801005 CA
Brightwood College............................ 24005705 CA
Brightwood College............................ 24804405 CA
Brightwood College............................ 24008205 CA
Brightwood College............................ 24001805 CA
Brightwood College............................ 24003305 CA
Brightwood College............................ 24936405 CA
Brightwood College............................ 24832005 CA
Brightwood College............................ 24804605 CA
Brightwood College............................ 24831905 CA
Golf Academy of America....................... 24909105 CA
Brightwood College............................ 25011906 CO
Ecotech Institute............................. 21014806 CO
Brightwood College............................ 25106731 NM
BRIGHTWOOD COLLEGE-ARLINGTON.................. 24037343 TX
BRIGHTWOOD COLLEGE-BEAUMONT................... 24036043 TX
BRIGHTWOOD COLLEGE-BROWNSVILLE................ 24036243 TX
BRIGHTWOOD COLLEGE-CORPUS CHRISTI............. 24042043 TX
BRIGHTWOOD COLLEGE-DALLAS..................... 249J2143 TX
BRIGHTWOOD COLLEGE-EL PASO.................... 24036643 TX
BRIGHTWOOD COLLEGE-FORT WORTH................. 249L8143 TX
BRIGHTWOOD COLLEGE-FRIENDSWOOD................ 24036343 TX
BRIGHTWOOD COLLEGE-HOUSTON.................... 24042143 TX
BRIGHTWOOD COLLEGE-LAREDO..................... 24037543 TX
BRIGHTWOOD COLLEGE-MCALLEN.................... 24035643 TX
BRIGHTWOOD COLLEGE-SAN ANTONIO INGRAM......... 24036443 TX
BRIGHTWOOD COLLEGE-SAN ANTONIO SAN PEDRO...... 24036143 TX
Golf Academy of America....................... 24038643 TX
Virginia College.............................. 24033943 TX
Virginia College.............................. 24039243 TX
Brightwood College............................ 24921720 MD
Brightwood College............................ 24921520 MD
Brightwood College............................ 24921920 MD
------------------------------------------------------------------------
Question 5d. Please describe the specific steps the VA has taken to
identify and assist Post-9/11 GI Bill recipients affected by ECA
closures.
Response. VA uses the data contained in its VA Online Certification
of Enrollment (VA-ONCE) system to identify impacted Veterans; this is
the system the schools used to certify Veteran attendance. The
assistance provided to students by VA is in the form of the links and
information contained in the 5-day outreach letter to students. A copy
of this letter is attached to this reply. Education Call Center agents
were available to answer questions and provide assistance to students
with school closure questions. Last, VA coordinated with Veterans
Service Organizations (VSOs) to notify any affected students or provide
support services.
Question 5e. Under the Forever GI Bill, will ECA veterans be
eligible for an additional housing allowance, and, if so, what is the
duration of that relief?
Response. Students attending ECA locations that terminated their
operations during the term will be eligible to receive their housing
allowance until what would have been the conclusion of the term in
which they were enrolled, or for 120 days, whichever comes first.
Question 5f. Please describe how the VA is coordinating with SAAs,
the U.S. Department of Education, or ECA to provide information to GI
Bill recipients on their transfer options.
Response. VA works closely with State Approving Agencies (SAA) to
ensure that VA was aware of the ECA closure and allow for prompt
notification to students regarding entitlement restoration; in ECA's
case, VA also received a letter from the institution, which was helpful
as ECA had numerous campuses in many states. VA does not work directly
with Department of Education (ED) but is aware that ED posted
information for students to notify them of options and VA monitors EDs
activities. Please see https://studentaid.ed.gov/sa/sites/default/
files/education-corporation-america.pdf.
Individual SAAs may post information directly on their Web site to
assist students but often rely on their Higher Education Departments to
post information for students. For an example, please see https://
osar.bppe.ca.gov/closures/brightwood.shtml.
Question 5g. Please describe how the VA is ensuring that transfer
options do not put student veterans at risk of further harm--such as
providing guidance regarding institutions that have active caution
flags on the GI Bill Comparison Tool.
Response. The 5-day letter VA sends to students upon notice that an
institution has closed directs students to VA's Comparison Tool where
caution flags can be found when researching prospective new
institutions.
Question 5h. How much funding from the VA did each of ECA's schools
receive in academic years 2014-2015, 2015-2016, 2016-2017, and 2017-
2018?
Response.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Please refer to the chart above for a summary total of payments paid to
ECA schools for each academic year from 2014-2018. The latest available
data to date for academic year 2018 is only available through 01-31-19.
The accompanying pdf document below further expands payments by
individual training institution, facility code, and academic year. Only
school payment data (tuition and fees and Yellow Ribbon) is presented
in the dataset.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 5i. Post-9/11 GI Bill beneficiaries have recently
experienced delays and underpayments in housing benefits this year. How
many students impacted by the ECA closures were also affected by delays
in housing payments, and will ECA students who may have received
incorrect housing allowances be retroactively reimbursed?
Response. VA is unable to tell how many ECA student were impacted
by the fall 2018 delays in housing payments; however, ECA's closure did
not impact VA's ability to correct those payments by January 1, 2019,
in the event they were incorrectly paid. However, in the event an ECA
student was attending a campus under section 107, ECA would need to
report this information to VA for VA to re-adjudicate the claim to
determine if additional funds should be issued to a student. VA will
work individually with those ECA students who report an improper
housing payment under section 107 in the event ECA in unwilling or
unable to report due to their closure.
Question 5j. Please provide information on any efforts by the VA to
limit, suspend, or withdraw ECA's participation in the Post-9/11 GI
Bill program prior to their announced closure and within the last five
years.
Response. There was no effort by VA to limit, suspend, or withdraw
ECA's participation in the Post-9/11 GI Bill program prior to their
announced closure or within the last 5 years; however, VA may not be
aware of efforts on the part of individual SAAs in this regard. VA was
not aware of any issues that would have impacted its approval status,
financial stability is not a requirement for the approval of accredited
programs, and VA has no statutory authority to limit, suspend, or
withdraw a school's GI Bill approval because the school closes some of
its campuses.
Question 5k. Please provide information on the overall number of
student veteran complaints to the GI Bill Feedback System about schools
owned by ECA and the VA's efforts to address them since 2014.
Response. Since 2014, Education Service (EDU) received a total of
28 complaints from students within the GI Bill Feedback System about
schools owned by ECA. VA addressed each of the 28 complaints through
initial contact with the student to gain additional details of the
issue. VA then contacted the appropriate ECA institution with the
issues and requested they respond within 45 days. Of the 28 complaints,
22 were resolved in a timely manner and six cases were identified as
information only. Each of the cases are stored electronically and
available to establish trends in support of the overall EDU strategy to
safeguard the integrity of the GI Bill. Furthermore, the EDU Oversight
and Accountability division has completed 128 compliance survey visits
at the ECA institutions since 2014.
Question 6. In the last year, there have been two waves of school
closures and the practical collapse of a most of the Dream Center
Education Holdings (DCEH) campuses, affecting thousands of students
across the country.
Question 6a. How many Post-9/11 GI Bill recipients were enrolled at
DCEH schools at the time of the July 2018 reports that DCEH would stop
enrolling students at 30 campuses and shut down those locations? Please
provide GI Bill enrollment data for each campus. How many, if any,
Post-9/11 GI Bill recipients transferred to online-only offerings when
those 30 campuses ceased on campus offerings?
Response. Please see the excel spreadsheet for Dream Center
Education Holdings (DCEH) student count by school at the time of the
July 2018 reports that DCEH would stop enrolling students at 30
campuses and shut down those locations. Additionally, VA determined
that 20 Chapter 33 education beneficiaries have transferred to online-
only training.
------------------------------------------------------------------------
Distinct
Facility Name Student
Count
------------------------------------------------------------------------
ARGOSY UNIVERSITY......................................... 1
Argosy University Atlanta................................. 2
Argosy University San Francisco Bay Area--Alameda CA...... 9
Argosy University--American Samoa......................... 5
ARGOSY UNIVERSITY--CHICAGO................................ 1
ARGOSY UNIVERSITY--DENVER................................. 9
Argosy University--Honolulu HI............................ 24
ARGOSY UNIVERSITY--INLAND EMPIRE.......................... 20
Argosy University--Los Angeles CA......................... 7
ARGOSY UNIVERSITY--NASHVILLE.............................. 11
Argosy University--Organe CA.............................. 8
ARGOSY UNIVERSITY--SAN DIEGO.............................. 17
ARGOSY UNIVERSITY--SARASOTA............................... 1
Argosy University--Tampa FL............................... 14
ARGOSY UNIVERSITY--TWIN CITIES............................ 2
The Art Inst of Atlanta................................... 3
The Art Inst of Austin.................................... 25
The Art Inst of California San Diego...................... 15
The Art Inst of Dallas.................................... 24
The Art Inst of Houston................................... 12
The Art Inst of Pittsburgh................................ 1
The Art Inst of Pittsburgh Online......................... 20
The Art Inst of Virginia Beach............................ 6
The Art Inst San Antonio.................................. 28
The Art Inst Tampa........................................ 5
THE ART INSTITUTE OF CALIFORNIA--INLAND EMPIRE--A CAMPUS 4
OF ARGOSY UNIV...........................................
THE ART INSTITUTE OF LAS VEGAS............................ 9
THE ART INSTITUTE OF SEATTLE.............................. 17
-------------
Distinct Grand Total.................................. 298
------------------------------------------------------------------------
Question 6b. What communication did VA have with Post-9/11 GI Bill
recipients enrolled in DCEH schools after the July 2018 reports of
campus closures?
Response. VA did not provide any specific communications for DCEH's
announcement in July 2018 that it would be closing some of its campuses
as part of strategy to reduce its physical footprint. DCEH announced
that it was suspending the enrollment of new students, and existing
students were allowed to complete their classes, switch to another
campus, or continue pursuing their programs online. This was a
different scenario than the abrupt, mid-term closure in March 2019
which also included the online campuses of Argosy University and the
Art Institutes.
Question 6c. How many Post-9/11 GI Bill recipients were enrolled at
Argosy University and Art Institutes campuses that closed on March 8,
2019? Please provide the GI Bill enrollment data for each campus.
Response. VA's official count stands at 1,782 students who were
using Post-9/11 GI Bill benefits, after a review of all received
enrollment certifications from the associated schools. Please see
accompanying pdf document with enrollment data for each campus.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 6d. When and how did VA notify GI Bill recipients about
the closure for each DCEH campuses?
Response. VA informed GI Bill beneficiaries of actions taken by the
Department of Education on three occasions through email and social
media accounts (Facebook):
March 1--Notified students of Department of Education's
termination letter of Title IV funding to Argosy University (Facebook
posted on February 28).
March 8--Notified students of Dream Center Education
Holdings motion with the court requesting permission for emergency sale
or closure of its Argosy and Art Institute campuses on March 8.
March 13--Notified beneficiaries of the closure of 25
Dream Center Education Holdings campuses and that VA was coordinating
with the various State Approving Agencies (SAA) and gathering the
specific details surrounding the closures. Also, informed students VA
would contact current students attending institutions that closed
advising them of their options and the possibility of having benefits
restored within 5 days of official notification from its SAA partners.
The GI Bill restoration team completed all 5-day closure
notification letters by March 21, 2019.
Question 6e. Describe the steps VA has taken to identify and assist
Post-9/11 GI Bill recipients affected by the DCEH closures.
Response. VA reviewed its enrollment and payment records to
identify students who were attending one of the impacted schools during
the month of March 2019. They were then notified on three occasions
through email and social media accounts. VA's notifications contained
links to potential resources that could be of assistance to impacted
students as shown below. Below, we have included copies of the original
and updated notification letter being used as of May 20, 2019.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 6f. How much VA funding did each DCEH campus (including
those that have no yet closed) received in the past five academic
years?
Response. Please see the excel spreadsheet below for DCEH school
payments for chapter 33 benefits as of April 12, 2019. Please note the
information provided is by fiscal year and not academic year.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 6g. Describe how VA coordinated with SAAs, the U.S.
Department of Education, or the DCEH to inform GI Bill recipients of
their transfer and/or discharge options.
Response. VA informed GI Bill beneficiaries of actions taken by the
Department of Education and DCEH on three occasions through email and
social media accounts. The GI Bill Restoration Team has reached out to
impacted individuals by letter to notify them and provide information
on their options moving forward.
Additionally, VA coordinated with SAAs by supplying all relevant
information received from the accreditor, the Department of Education,
and the school itself within three business days of receipt.
Question 7. In November 2016, the Consumer Financial Protection
Bureau (CFPB) issued ``A snapshot of servicemember complaints'' noting
that veterans had reported ``being targeted with aggressive
solicitations by lenders to refinance'' their home loan using a
Department of Veterans Affairs (VA) product. Veterans also reported
that solicitations were ``potentially misleading.'' One year later, the
CFPB and VA issued a joint Warning Order about aggressive and
potentially misleading advertising of VA home loan refinances.
Most recently, the VA published an advanced notice of proposed
rulemaking (ANPR) and a subsequent interim final rule on cash-out
refinances on VA loans, in compliance with Section 309 of Public Law
115-174, the Economic Growth, Regulatory Relief, and Consumer
Protection Act. Both documents indicated that potential lender abuses
remain a substantial problem. That ANPR stated that ``perhaps more than
50 percent of [VA] cash-out refinances remain vulnerable to predatory
terms and conditions'' and that ``some lenders are pressuring veterans
to increase artificially their home loan amounts when refinancing,
without regard to the long-term costs to the veteran and without
adequately advising the veteran of the veteran's loss of home equity.''
Question 7a. What tools does VA currently have to ensure that all
VA lenders are in compliance with VA regulations and policies?
Response. VA conducts post audits of closed loans to ensure that
lenders comply with regulations and policies. VA's loan system
automatically identifies and selects loans to review based on specific
selection criteria and/or on a random sample basis. If a loan goes into
default within the first 6 months after loan closing, VA reviews 100
percent of these cases to ensure that the lender followed VA policies
and procedures. VA field staff can also request loans to review from
lenders if there is an identified issue to examine based on data or
findings from previous loan reviews. VACO staff also analyze program
data for anomalies to identify which lenders to review to ensure
compliance with program requirements.
Additionally, VA conducts onsite operational audits of lenders to
test compliance with applicable laws, regulations, policies, and
procedures that have direct material impact on the VA home loan
benefit. These operational audits consist of: Quality Control of loan
underwriting and closing; the Lender Appraisal Processing Program;
Early Claims Loans; and Declined Loan reviews.
Question 7b. Does the VA have the oversight and enforcement
authorities and resources it needs to hold lenders accountable and
ensure that veteran homeowners aren't subject to predatory refinances?
Response. VA's oversight and enforcement authority are limited. For
example, 38 United States Code (U.S.C.) Sec. 3702 provides that certain
lenders have authority to close loans on an automatic basis. It also
provides that VA may, with 30-days' notice, require such lenders to
begin submitting their loan packages for prior approval. The authority
does not, however, expressly provide VA's authority to establish
consequences, such as suspension from the program, for lenders,
holders, or servicers who engage in predatory lending practices or
dubious marketing practices.
Section 3710(g) provides a framework for establishing civil
penalties against lenders who violate VA's underwriting rules and loan
processing standards. Yet the authority is not necessarily broad enough
to include conduct that falls outside the analysis of individual loan
packages. By taking an expansive approach to address ``novel lending
products'' and misleading solicitations, VA is at risk of facing legal
challenges that could easily be avoided with additional statutory
clarification. Another example is 38 U.S.C. Sec. 3703(c)(1), a
provision on which VA relies heavily to regulate the guaranteed loan
program. This provision requires that VA-guaranteed loans be payable
upon such terms and conditions as may be agreed upon by the parties
(i.e., the Veteran and the lender), subject to the provisions of
chapter 37 of title 38, U.S.C., and regulations issued by the
Secretary. Although the provision can be given a broad interpretation,
VA believes that more affirmative authority to promulgate rules could
be extremely helpful when facing litigation challenges.
Please note that most lenders and loan servicers complete VA
mortgage transactions in a responsible manner and VA does not want to
impede benefits delivery to Veterans. VA generally guarantees 25
percent of the loan to help entice lenders to offer Veterans favorable
loan terms (including a no down-payment mortgage and low interest
rates), as part of Veterans' earned benefit entitlement. VA relies on
private sector lenders to provide the earned benefit to Veterans
through delegated authority and want to ensure that Veterans can
continue to enjoy access to mortgage credit, while also holding
unscrupulous lenders and servicers accountable.
Question 8. In April 2017, VA issued guidance for affordable loan
modifications for VA-guaranteed loans in Circular 26-17-10. The
guidance in this circular replaced options available under the VA Home
Affordable Modification Program with the VA Affordable Modification
Program (VAAM). But the circular also rescinded the guidance effective
April 1, 2019, and, to date, VA has not issued an updated circular
regarding the rescission date, putting affordable modifications for
veterans at risk.
Other Federal mortgage insuring and guaranteeing agencies have
adopted similar loan modification programs that have been or are
proposed to be made permanent. The Federal Housing Administration has
created a permanent FHA Home Affordable Modification Program (FHA-HAMP)
to provide affordable modifications, while the United States Department
of Agriculture (USDA) has proposed a new modification program for
single-family loans.
Question 8a. Does VA intend to continue VAAM on a temporary or
permanent basis? If not, why not?
Response. Circular 26-17-10 will expire, but the VA Affordable
Modification (VAAM) will continue as is. VA will continue VAAM on a
permanent basis. VAAM has now been included as a loss mitigation option
in the VA Servicer's Handbook (VA Manual 26-4, Chapter 5: https://
www.benefits.va.gov/WARMS/M26-4.asp).
Question 8b. If VA does not intend to renew VAAM, will VA create a
new modification program to prevent avoidable and costly foreclosures?
Response. Please see response to question 8a.
______
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal
to U.S. Department of Veterans Affairs
Question 1. In December 2018, the OIG published an audit to
determine if VA and State Approving Agencies (SAAs) were effective in
their review of education programs where Post-9/11 GI Bill
beneficiaries were enrolled.
Question 1a. What actions has VBA taken, in coordination with the
SAAs, to implement the OIG's recommendations?
Response. VA implemented a workgroup consisting of VA and SAA
staff. The workgroup has met in-person and by teleconference numerous
times to develop draft recommendations that will allow for
implementation of the recommendations. VA worked closely with SAAs and
schools to ensure Recommendation 3 was remedied, and it has been
closed.
Question 1b. Please provide an update on the status of
implementation of each of the OIG's recommendations
Response. Please see the attached most recent VBA update memo.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 2. Do you agree that VBA has an administrative and
financial responsibility to protect students' and taxpayers' interests
by monitoring the SAA's performance effectively?
Response. Yes, VA agrees it has an administrative and financial
responsibility to protect students' and taxpayers' interests by
monitoring the SAA's performance effectively. Additionally, VA has a
statutory responsibility, per 38 U.S.C. Sec. 3674A to monitor SAA
performance. VA does so by ensuring the terms of the annual cooperative
agreement are met through review of SAA approval packages, compliance
survey findings, and other deliverables. Once reviewed, VA will assign
an annual rating and ensure that any deficiencies are mitigated. If
deficiencies are not adequately addressed, VA may decide not to enter
into a future agreement with the SAA to perform the work outlined in
chapter 36 of title 38, U.S.C.
Question 3. What steps has VBA taken to improve their quality
reviews of SAA program and modification approvals, as well as their
evaluation of SAA decisions regarding a programs' eligibility and
compliance with Federal laws?
Response. VA formed a workgroup consisting of VA and SAA staff that
is drafting recommendations to ensure that quality reviews are
performed on program approvals and compliance surveys. The compliance
survey quality reviews are set to begin this month (April 2019).
Additionally, VA is reviewing approval data to develop requirements of
the documentation that SAAs will need to provide VA to substantiate
that all approval requirements are met. This will be negotiated for
inclusion in the FY 2020 SAA/VA agreement.
Question 4. What changes has VBA made to its compliance survey
process since December 2018 to ensure programs are meeting the
conditions necessary for approval?
Response. VA is in the final stages of revising compliance surveys
to strengthen and improve assessment of program approval requirements.
The revisions cannot be fully implemented until modifications to the
VA/SAA cooperative agreement are negotiated. The target date for
completion is October 1, 2019.
Question 5. Does the VA's budget request for FY 2020 account for
improving VBA's oversight of SAA reviews of Post-9/11 GI Bill benefits?
Response. VA is working to improve and increase oversight of SAAs
utilizing existing resources in the FY 2020 budget.
Question 6. Has VA awarded a Software Development and System
Integration (SISD) contract?
Response. VA is committed to implementing sections 107 and 501 of
the Colmery Act by December 2019. To that end, VA awarded a Software
Development and Systems Integration contract to Accenture Federal
Services (AFS) February 15, 2019. AFS will be responsible for
delivering a complete IT solution to support sections 107 and 501.
Question 7. How can you ensure that IT modernization efforts in
Education Services won't be sidelined by other IT projects, such as the
Electronic Health Records Modernization?
Response. Modernization of Education Services efforts have their
own dedicated resources and funding. IT architecture of Education
systems is segmented and separate from the other IT efforts to minimize
impact by other IT priorities. The efforts supporting modernization of
Education IT solutions have regular and direct engagement with OIT
senior leadership to ensure any conflicts are resolved.
Question 8. Is it correct to assume that all veterans who were
underpaid have now been reimbursed? If not, about how many veterans are
awaiting reimbursement?
Response. On December 8, 2018, VA installed the 2018 uncapped
monthly housing allowance rates. All impacted students were updated to
the correct MHA rate and if underpaid received a payment for the
difference. Veterans who were overpaid were not held liable for any
debts. Until the IT solution is in place on December 1, 2019, VA will
pay students the current year uncapped rate. Upon implementation the IT
solution will allow schools to accurately report all campus locations s
where their students are attending the majority of their classes, so VA
can process housing payments in accordance with sections 107 and 501
Question 9. Is VA on track to meet the May 31, 2019 deadline?
Response. VA is on track to meet the December 2019 deadline set by
the Secretary in his November 29, 2018, announcement resetting the
implementation of sections 107 and 501 of the Colmery Act.
______
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
U.S. Department of Veterans Affairs
Question 1. The Maui Minor Replacement CBOC project has been in
progress for several years. The State Department of Education has
offered land for the project and the Department of Veterans Affairs
(VA) Central Office approved the land. My office was notified that a
Memorandum of Understanding (MOU) would be executed in the second
quarter of Fiscal Year 2019.
Question 1a. Has this MOU been completed?
Response. The draft Memorandum of Agreement (MOA) between the
Veterans Affairs Pacific Island Health Care System (VAPIHCS) and the
State of Hawaii Department of Education (HIDOE) was drafted and
published for review by each of these agencies on August 30, 2018.
There have been several reviews with key staff at various levels and
with corporation consuls requesting clarifying points of interests that
have been responded to over the course of the last 7 months. In the
last month, HIDOE completed a final review with the State Attorney
General's office in preparation for the final MOA sign off and to
present to the State Board of Land and Natural Resources to consummate
the property extended land lease.
Question 1b. If not, can you please explain the delay?
Response. Part of this delay can be attributed to the fact that
this extended property land lease between the State and VAPIHCS is
precedent setting. Dubbed ``the Maui Doctrine,'' Federal funds and
ultimately a permanent Federal facility will be designed, planned,
constructed, and operated on State land and not Federal or purchased
land owned by VAPIHCS. Legal sufficiency has been provided by VACO
along with the State of Hawaii's respective legal counsels since both
Federal (Maui Community Outpatient Clinic and Maui Vets Center) and
state entities (Maui Office of Veterans Services) will be operating
under the same roof. This MOA sets forth a structure in which both
parties will work in a mutually beneficial manner to advance an
educational and academic program with the purpose of providing
voluntary internships and training primarily in health care disciplines
to students at Maui High School. HIDOE, Maui High School, and VAPIHCS
will have a shared responsibility for the academic enterprise.
Question 2. Compared to their nonveteran peers, women veterans have
a higher rate of suicide than men. This difference in suicide rates
suggests that strategies for preventing suicide among women veterans
need to include consideration of gender-based risk factors.
Question 2a. Do you think that VA's suicide prevention and mental
health efforts are adequately tailored to reach and treat women
veterans?
Response. VA recognizes the urgent need to address the increasing
rates of suicide among women Veterans and is committed to ensuring that
appropriate services are available to meet the treatment needs of women
Veterans who may be at risk for suicide. The Office of Mental Health
and Suicide Prevention (OMHSP) has focused on developing trainings in
gender-sensitive mental health approaches and implemented multiple
initiatives to bolster mental health services for women Veterans,
including those at risk for suicide.
Examples of innovative clinical training initiatives:
The Women's Mental Health Mini-Residency is a 3-day
training that covers a broad range of topics related to the treatment
of women Veterans, such as understanding suicide risks in female
patients and working with women whose mental health problems are
influenced by hormonal changes.
The STAIR (Skills Training in Affective and Interpersonal
Regulation) training teaches clinicians to deliver a trauma treatment
that focuses on strengthening emotion regulation and relationship
skills. These areas of functioning are often disrupted in women who
have experienced severe interpersonal traumas, such as sexual assault.
Research suggests that emotion dysregulation is associated with
suicidal ideation and behaviors.
Parenting STAIR training teaches therapists to deliver a
component of the STAIR treatment that is designed to help Veterans who
have persistent trauma-related reactions that negatively impact their
parenting and parent-child relationships.
The Multidisciplinary Eating Disorder Treatment Team
training aligns with the Joint Commission's rigorous standards for the
outpatient treatment of eating disorders. Eating disorders are
associated with increased risk for suicide attempts and death by
suicide.
The National Women's Mental Health Monthly Teleconference
Series is a monthly clinical training designed to enhance knowledge of
gender-tailored treatment approaches, including prescribing practices.
Physiological changes across women's reproductive lifecycles can affect
her mental health and suicide risk. For example, women who have
premenstrual dysphoric disorder (PMDD) have a greater likelihood of
having suicidal thoughts, plans, and attempts. Treating PMDD is
different than treating depression. Only some antidepressants are
effective for PMDD, and dosing only during the luteal phase (2nd half,
after ovulation) of the menstrual cycle is effective. Proper
recognition, diagnosis, and treatment of PMDD can substantially reduce
suicide risk for this subset of women Veterans.
Examples of clinical programs and resources to enhance services for
women Veterans:
Studies have shown links between MST (Military Sexual
Trauma) and suicidal ideation, suicide attempts, and death by suicide.
VA's universal screening program, in which every Veteran seen for
health care is asked about experiences of MST, is an important way of
identifying individuals potentially at increased risk for suicide. VA's
specialized MST-related services are key means of preventing suicide
among at-risk women Veterans who have experienced MST.
VA offers a continuum of care and a national network of
Women's Mental Health Champions who disseminate information, facilitate
consultations, and develop local resources.
Specialty care programs target problems such as PTSD,
substance use, depression, and MST--each of which has been associated
with heightened suicide risk. Evidence-based therapies for conditions
such as PTSD, including Prolonged Exposure and Cognitive Processing
Therapy, have been shown to decrease suicidal ideation and are
available at every VAMC.
Additional VA suicide prevention and mental health
resources for women Veterans include 24/7/365 immediate crisis
intervention and support through the Veterans Crisis Line and Suicide
Prevention Coordinators located at every VA facility and large
community-based outpatient clinics.
Question 2b. Are you at all concerned the reported harassment and a
sexist culture at VA is indirectly contributing to the elevated suicide
risk by discouraging women veterans from seeking care?
Response. VA strives to create an environment in which all Veterans
feel welcome and safe. VA also recognizes that harassment and sexism
occur and can be disruptive to Veterans' access to care and overall
patient experience.
As VA continues to promote respect for women Veterans, it has
expanded efforts to address forms of harassment, including sexual
harassment (e.g., lewd comments or gestures) and gender harassment
(e.g., sexist remarks, being dismissive of a woman's military service).
VA launched an End Harassment program at every medical center in the
summer of 2017. This large-scale effort is designed to increased
awareness, disseminate education, improve reporting, and promote a
culture of accountability throughout VA. As part of this campaign, VA
have launched messaging such as ``it's not a compliment, it's
harassment'' directed primarily at educating male Veterans that these
actions are harmful and unacceptable. Employees have received training
to increase sensitivity to this issue and to ensure that any VA
employee who witnesses harassment knows how to effectively intervene
and respond. Culture change efforts continue as VA develops updated
resources, training, and associated messaging.
VA also continues to develop initiatives and strategies to
facilitate women Veterans' access to gender-sensitive mental health
care. Resources are now in place to improve women Veterans' ease and
comfort navigating the health care system, and confidence in the
competency of VA providers to address their specific needs. For
example, VA has recently established a national infrastructure of
Women's Mental Health Champions who serve as a local point of contact
for Women's Mental Health within each VA health care system. Champions
disseminate information, facilitate consultations, and develop local
resources in support of gender-sensitive mental health care. Every VA
health care system also has a designated MST Coordinator who serves as
the local point person for MST-related issues. Additionally, as
detailed in response to Question 2a, extensive clinical training
initiatives are in place to ensure that VA mental health providers have
the expertise and specific competencies to address women Veterans'
treatment needs.
Question 3. VA's Medical and Prosthetic Research helps improve
veterans' health care by focusing on veteran-unique conditions. This
research is especially vital to understand new and emerging issues and
to assess how to care for a diversifying veteran population. Due to
inflation, funding for VA research would need to be increased by $22
million over the 2019 baseline just to maintain current research
levels. However, instead of investing in VA's research capacity, the
President's Budget proposes a $17 million decrease in funding.
What areas of research is VA going to scale back to accommodate
this decrease in funding? Please provide a justification for those
decisions.
Response. The FY 2019 appropriation included a one-time addition of
$27 million for collaboration with DOE on a big data science initiative
and high capability computing. The $27 million provided for the DOE
collaboration was provided to cover a 5-year period of availability
through FY 2023. The remainder of the request for research in FY 2019
was $752 million (total $779 million). For FY 2020, VA requests to grow
support for all other initiatives from $752 million to $762 million.
That $10 million growth represents an overall program growth of 2
percent.
Question 4. Over three weeks ago I signed a letter with twelve of
my colleagues to the Department of Education regarding the sudden
closure of Argosy University that has affected an estimated 18,000
students nationwide--including 800 students in Hawaii, some of whom are
veterans. In the letter we urged the Department of Education to work
with the VA ``to ensure that accurate information is being provided to
GI Bill beneficiaries regarding students' remaining benefits, including
housing, and their options to have their benefits restored'' before the
school closed.
Question 4a. In the wake of Argosy's collapse, has the Department
of Education taken any steps to coordinate with the VA on this issue?
Response. The Department of Education has coordinated with VA on
its actions via teleconference, as well as updates to its Federal
Student Aid (FSA) Web site located here: https://studentaid.ed.gov/sa/
about/announcements/dream-center#motion-for-closure.
Question 4b. If so, then can you elaborate on how the Departments
have coordinated?
Response. VA was invited to multiple teleconferences and received
numerous emails outlining the steps that the Department of Education
has and is taking regarding Argosy University. VA has taken steps to
inform students via social media and through the GI Bill Comparison
Tool as new information has been shared.
Question 4c. If not, how does VA plan to make sure that student
veterans affected by Argosy's closure in Hawaii and elsewhere have the
resources they need?
Response. As stated in the previous responses, VA is working
closely with the Department of Education to provide information and
assistance to GI Bill beneficiaries. In addition, the 5-day letter that
VA sent to students upon notice that an institution has closed also
provides contact information and resources.
Question 5. Generally speaking what resources does the VA make
available for student veterans affected by school closures?
Response. VA has the authority, provided by section 109 of the
Harry W. Colmery Veterans Educational Assistance Act of 2017, to
restore entitlement to qualifying beneficiaries. The specific details
and process for entitlement restoration due to school closures can be
found online at https://www.benefits.va.gov/gibill/fgib/
restoration.asp.
VA provides the following information in its letters to students:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 6. I have received information that the VA has updated its
online tools and resources and notified student veterans who were
affected.
Question 6a. Can you provide further information about what steps
the Department has taken?
Response. VA has ensured restoration information on the GI Bill Web
site was up to date: https://www.benefits.va.gov/gibill/fgib/
restoration.asp. Additionally, VA posted announcements and regular
updates to the GI Bill Web site--https://www.benefits.va.gov/GIBILL/
news.asp--and the GI Bill Facebook page--https://www.facebook.com/
gibillEducation/.
Question 7. I have also received information that the VA has
identified 716 GI Bill beneficiaries who were attending schools that
closed.
Question 7a. Is this number still accurate, or have more
beneficiaries been identified?
Response. The identification of ``716 students'' corresponds to the
Department of Education's notification revoking Argosy University's
approval for Federal Student Aid, on February 27, 2019, and that number
did not include VA students enrolled at the Art Institute campuses that
also subsequently closed. The number of impacted students identified
following the closure of the Argosy University and Art Institute
campuses, on March 8, 2019, is 1,782, which includes the 716
individuals identified previously.
Question 7b. If more have been identified, which campuses did they
attend and in which states?
Response. As indicated in our previous response, 1,782 students
were identified after the schools closed. Please see accompanying pdf
document below for campus and state information.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question 8. I have received information that the VA has been
coordinating with state approving agencies. What kind of coordination,
if any, has there been with the state approving agency in Hawaii?
Response. VA does not have a signed cooperative agreement with the
state of Hawaii and, therefore, VA is acting as the SAA for that state.
VA has taken withdrawal actions as necessary for the state of Hawaii
and Veterans in that state have been provided all relevant information.
Question 9. Last Congress this Committee worked to pass the Forever
GI Bill, which expanded access to educational opportunities for student
veterans, servicemembers, families, and survivors, and changed how
housing allowances are calculated for these students. However, we have
seen challenges to implementation, which have resulted in students
receiving inaccurate or delayed payments. The Department's Inspector
General recently concluded that even as VA missed implementation
deadlines there was no accountable official overseeing these changes.
Question 9a. Since these challenges have been identified, what
steps has the VA taken to notify students who were affected, and what
resources has VA provided for these students?
Response. Immediately following the Secretary's November 2018
announcement on resetting implementation, VA notified schools, Veterans
Service Organizations, and other stakeholders on its efforts moving
forward. This included an email notification to almost one million GI
Bill beneficiaries on November 28, 2018 and December 4, 2018 and
multiple social media posts. VA also held seven online webinars for
Veterans throughout December 2018 and January 2019 to provide
additional details and resources.
Question 9b. What more does VA plan to do to address this issue for
students going forward?
Response. VA will continue to regularly update students through
social media, targeted email notifications, and webinars regarding the
implementation of sections 107 and 501. In April 2019, VA began to host
a series of Roundtable Discussions with schools and stakeholders on
implementation and will follow these sessions with updates on its Web
site and social media.
Question 10. The VA Office of Health Equity was established in 2012
to advance health equity and reduce health disparities for
disadvantaged veterans. Part of the goal when establishing the office
was to conceptualize and release a blueprint for achieving these ends,
which it did with the March 2016 release of the VHA Health Equity
Action Plan (HEAP).
Question 10a. Since the introduction of HEAP, has the VA achieved
any of the deliverables outlined in the plan?
Response. The HEAP describes many activities that the Office of
Health Equity should do on an ongoing basis and a few activities that
have discrete deliverables. In general, the Office of Health Equity is
involved with most of the indicated ongoing activities and has produced
many of the specific deliverables.
Question 10b. If so, which?
Response. The HEAP is organized around 5 focus areas: Awareness,
Leadership, Health system and life experience, Cultural and linguistic
competency, and Data, research, and evaluation.
Awareness: As planned in the HEAP, the Office of Health Equity
leads a Health Equity Coalition, has developed many partnerships for
implementing the HEAP, and presents data on disparities (monthly fact
sheets and quarterly cyber seminars). Specific goals to develop a
communication plan and initiate 5 partnerships and 2 projects have been
completed.
Leadership: As planned in the HEAP, the Office of Health Equity
reviews all VHA policies and directives, promotes a culture of dialog
about equity, coordinates resources to support the HEAP, and directly
funds health equity projects. Specific goals to include Health Equity
Coalition members on the National Leadership Council and support VAMCs
to participate in Health Equity Impact assessments have been achieved.
Health system and life experience: As planned in the HEAP, the
Office of Health Equity tracks many measures of access and quality,
identifies disparities, supports interventions to reduce disparities,
and promotes understanding of Veterans' life experiences,
decisionmaking, and social determinants of health. Specific goals to
report on and disseminate findings on disparities have been completed.
Cultural and linguistic competency: As planned in the HEAP, the
Office of Health Equity shares information and supports training on
cultural competency, unconscious bias, and Culturally and
Linguistically Appropriate Services (CLAS). Specific goals to support
rollout of the VA Talent Management System's Cultural Competency Module
and Clinical Look at Unconscious Bias training have been completed.
Data, research, and evaluation: As planned in the HEAP, the Office
of Health Equity monitors and tracks disparities, fills information
gaps on disparities, promotes data sharing, and develops tools and
dashboards to increase equity. Specific goals to develop standards for
disparities reporting and to report on disparities among Veterans have
been achieved in the first National Veteran Health Equity Report.
Question 11. The majority of the deliverables in HEAP rely on an
understanding of what populations are experiencing disparities, yet the
most recently available data outlining race/ethnicity, gender, age,
geography, and mental health status among veterans receiving care is
from 2013.
Response. The 2013 data are the most recent VHA data that the
Office of Health Equity has reported to the public. Within VHA, working
with VHA Central Office, VISN, and VAMC partners to reduce disparities,
much more recent data are used. A second National Veteran Health Equity
Report is planned for release in 2019 and will report on 2017 data.
Question 11a. How does the Department intend to address disparities
in health care provision and outcomes without understanding what
disparities actually exist?
Response. Identifying disparities in health care provision and
outcomes is at the core of efficient quality improvement. The Office of
Health Equity is working with VHA Central Office, VISN, and VAMC
partners to develop an Equity Guided Improvement Strategy (EGIS) that
identifies measures and populations with the largest quality deficits
and thereby allows facilities to target quality improvement toward
these specific Veteran groups with specific conditions. EGIS also
allows the application of optimal interventions for these specific
Veteran groups with specific conditions.
Question 11b. Do you believe that the Office of Health Equity can
credibly fulfill their mission without updated, relevant data?
Response. Yes, the Office of Health Equity is fulfilling its
mission because we currently have access to updated, relevant data that
allows identification of disparities in health care processes and
outcomes for many Veteran groups. For some Veteran groups, such as
Lesbian, Gay, Bisexual and Transgender (LGBT) and disabled Veterans,
systematic identification is limited in VHA data. The Office of Health
Equity is involved in activities to improve data on these groups
through use of and data linkage with non-VHA data.
Question 11c. If not, please provide a plan for updating the data.
Response. As VHA modernizes to the new EHR system, the Office of
Health Equity will work to ensure that data needed to identify
disparities for different Veteran groups is available.
______
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to
U.S. Department of Veterans Affairs
Question 1. Secretary Wilkie, in your testimony we discussed my
concern with investment in infrastructure and construction projects,
especially in rural States like West Virginia. I used the Rural Mobile
Unit (RMU) in Clarksburg as an example. According to our recent RFI, a
replacement RMU is the only true long term solution costing $600k.
Question 1a. This RMU is the only VA facility for many of our rural
Veterans. Will you make this RMU replacement a priority in your 2020
budget?
Response. The Office of Rural Health (ORH) does not currently have
an enterprise wide funding program for Rural Mobile Units (RMU). ORH
ceased funding RMUs in 2014 after VHA suspended mobile medical unit
acquisitions in the wake of an unfavorable audit by the VA Office of
the Inspector General (VAOIG-13-03213-152). Although the suspension has
since been lifted, ORH's FY 2020 funding is completely committed to
other programs. However, we will revisit the funding opportunities for
RMUs in FY 2021.
Question 2. I'm concerned that as we are investing in community
care, we will leave rural facilities in WV behind.
Question 2a. What are you doing to decrease the project backlog and
making sure that our VA facilities in rural communities are not waiting
in a never-ending list of projects?
Response. In order to be fair, equitable, and transparent, VISN 5
takes a multifaceted approach to the distribution of construction
funding each fiscal year:
High Cost High Tech (HCHT) equipment funding and
procurement are often on rigid timelines. This equipment has a direct
impact on patient care and access. As such, the HCHT equipment site
prep projects are funded off the top of the VISN construction
allocation.
Each facility in VISN 5 submits business cases for their
top five projects each fiscal year. Each facility then scores the other
facility business cases against a list of criteria. This yields a
prioritized list of all the VISN-5 projects submitted. Those projects
that fall above the cumulative budget line get funded that fiscal year;
the others are subject to the availability of funding. This process is
transparent and gains the consensus of all the facilities.
A portion of the overall construction appropriation is
distributed to each facility for station level projects. The
distribution is prorated, based on each facility's Facility Condition
Assessment (FCA) backlog. Each facility determines how the station
level funds are spent, based on locally identified priorities.
Each facility in VISN 5 gets their HCHT site prep funded, each
facility gets a fair shot at getting their top 5 projects funded, and
each facility receives an allowance to spend at their discretion on
local priorities.
Question 3. As of today, there were 138 open positions posted on
USAJOBS for the VA in West Virginia. Our CBOC in Petersburg especially
is having a hard time recruiting and retaining staff.
Question 3a. Do you have some type of vacancy action plan for rural
communities who have a hard time competing with neighboring States?
Response. VA implements targeted solution-driven approaches to
increase the overall care to 2.8 million Veterans living in rural
communities who rely on VA health care. VA remains fully engaged in a
fiercely competitive clinical recruitment market and has employed a
multi-faceted strategy to attract qualified candidates for rural
facilities including the following:
Expanding the ability of all clinicians to practice at the
full extent of their licenses;
Increased maximum physician salaries;
Utilization of recruitment/relocation and retention (3R)
incentives and the Education Debt Reduction Program (EDRP);
Targeted Nation-wide recruitment advertising and
marketing;
Expanding opportunities for telemedicine providers;
DOD/VA effort to recruit transitioning Servicemembers; and
Exhibiting regularly at key health care conference and job
fairs.
Question 4. Mr. Secretary, you know that the opioid epidemic is my
number one issue. The VHA in WV is treating over 1,300 Veterans for
opioid use disorder I want assurances that when Veterans go outside of
the VA under these new access standards, we have rock-solid agreements
and oversight with non-VA care providers that ensures over-prescription
of opioids will not occur. I know we have the formulary and other
safeguards to prevent against abuse now.
Are there ways that we can improve these safeguards and
coordination given your commitment to increased access to care in the
community?
Response. Section 131 of the VA MISSION Act requires VA to ensure
that all community providers are furnished a copy of and certify that
they have reviewed the evidence-based guidelines for prescribing
opioids set forth by VA's Opioid Safety Initiative. It further requires
VA to implement a process to ensure that VA submits to community
providers the available and relevant medical history of the Veteran and
a list of all medications prescribed to the Veteran as known by VA.
Community providers must submit medical records, including records of
any opioid prescriptions to VA in the timeframe and format specified by
VA. VA must report annually on the compliance of covered health care
providers with the requirements of this section. If VA determines that
the opioid prescribing practices of a community provider, when treating
covered Veterans, meet certain conditions, VA must take appropriate
action to ensure the safety of all Veterans receiving care from the
provider. Finally, VA must ensure any network contracts include
language authorizing the contractors to take similarly appropriate
action. All Community care providers will follow the same opioid
prescribing practices as VA providers.
Question 5. With respect to the access standards and community
care. My biggest concern is that the VA is not adequately preparing
communities for these new access standards.
Question 5a. What are you doing to investigate whether communities,
especially rural communities like in my State, are prepared for more
Veterans coming to them from the VA?
Response. Providers joining the Community Care Network (CCN) are
required to take training in the unique needs and cultural aspects of
the Veteran population. Additionally, VHA works closely with CCN Third
Party Administrators (TPA) to assist them in understanding the network
adequacy requirements and how that applies to the Veteran population.
Part of evaluating network adequacy includes factoring in an equitable
allotment of Veteran patients into the community provider's practice.
This is done through close collaboration with the TPA and utilizing
both internal metrics as well as industry standard calculations.
For both Primary Care and Mental Health there are many sites that
are presently meeting wait time standards. These sites will be able to
retain Veterans and not need to send them to the community for care.
VA's goal is to achieve and sustain 100 percent in both categories.
See data summary below.
------------------------------------------------------------------------
% of sites with less than
As of 4/23/19 20 days avg. wait for new
patients
------------------------------------------------------------------------
MH.......................................... 98.58%
PC.......................................... 57.5%
------------------------------------------------------------------------
VA continues to work to strengthen direct care delivery. The Office
of Veterans Access to Care is partnering with several VHA program
offices to lead the ICEP initiative. This includes facilities in rural
sites. The main goals of ICEP are the following:
Ensure accuracy of labor mapping, person class code, and
Primary Care Management Module data;
Ensure sustainment plan for maintaining continued accuracy
for the data in sub-bullet one;
Balance supply and demand by using present resources and
full care teams more efficiently by maximizing individual providers
capacity for direct patient care; and
Partner with workforce development to hire additional
staff where applicable.
MISSION Act section 401 also helps to prepare facilities for access
standards:
Section 401 of the MISSION Act requires VA to identify and
develop plans to address underserved facilities. Some of the facilities
VA identified as underserved are rural facilities. In collaboration
with VISN Directors, VA is developing a program leveraging system-wide
resources to support improvement in facilities designated as
underserved.
Some of these resources particularly used in rural
facilities include maximizing hiring incentives to attract and retain
providers to these areas by offering the following:
- Recruitment, Retention, and Relocation awards;
- Education Debt Reduction Program offering student loan
reimbursement to employees with qualifying loans;
- Compressed/flexible work schedules; and
- Retirement waivers that offset the required salary offset
to reemploy retired staff members on a temporary basis.
Difficulties hiring providers in rural areas are also
addressed by the following:
- Maximizing current resources and capacity;
- Leveraging interagency relationships;
- Using Mobile Medical Units;
- Offering training opportunities such as the national
consultative program, academic detailing programs, as well as
continuing education opportunities and scholarship programs;
and
- Using direct hiring authority.
Additionally, many rural facilities identified as
underserved leverage technology and telehealth strategies such as the
following:
- Increasing the use of VA Video Connect;
- Establishing/expanding Clinical Resource Hubs;
- Using Store and Forward Telehealth where clinical health
data is retrieved by a VA provider at another VA location for
clinical evaluation and follow up; and
- Establishing/expanding ATLAS (Advancing Telehealth through
Local Access Stations).
Additionally, VA is enhancing Same Day Primary Care and Mental
Health services and leveraging virtual care modalities to provide
Veterans convenience while increasing access. Proposed budgets in FY
2020 and FY 2021 further support the Clinical Contact Centers for
virtual care. Currently, nearly half of all VISNs have licensed
independent practitioners, expanding access to care by addressing
patient needs via telephone or video appointment. These services are
especially useful for Veterans in rural communities.
Question 5b. Will you be communicating to Veterans if you deem
certain communities unprepared to accept Veterans as patients?
Response. At the time of scheduling, if a community provider is
unable to accept Veterans within the metrics defined by the CCN
contract, the Veteran is given the opportunity to select another
provider. The inability for a provider to accept a patient within the
metrics negatively impacts the third-party administrator's (TPA)
performance and is reflected in a percentage decrease in payment to the
TPA. Network adequacy is monitored monthly to identify gaps. When gaps
are identified, the TPA is required to submit a plan outlining how they
intend to resolve the issue and bring the network into compliance.
Question 6. I applaud the VA for investing in alternative pain
management prevention programs, such as acupuncture, chiropractic
services, Tai Chi, and Yoga. In West Virginia, these programs are
growing in demand but don't seem to be widely implemented at all the
VAMCs.
Question 6a. What are your plans for growing these potentially
life-saving programs so all Veterans have access to them?
Response. As a preliminary point of clarification, we generally now
use the terms ``complementary'' or ``integrative'' to describe this
category of therapies rather than ``alternative.'' This is to make
completely clear that we do not endorse using these therapies to the
exclusion of evidence-based conventional approaches, but rather in
addition to and in support of these.\1\
---------------------------------------------------------------------------
\1\ For the same reason, the National Center for Complementary and
Alternative Medicine at NIH has now changed its name to ``National
Center for Complementary and Integrative Health.''
---------------------------------------------------------------------------
VHA requires that all VA facilities have at least one evidence-
based psychological/behavioral therapy available at the facility as
part of the integrated and interdisciplinary pain management teams at
each facility. This mandate was established as part of VA's
implementation of CARA. The teams also include access to physical
medicine and rehabilitation providers and integrated access to
assessment of opioid use disorder, if clinically indicated with access
to providers skilled in addiction medicine who provide evidence-based
treatment.
Substantial progress has been made in building infrastructure to
support increased access to Complementary and Integrative Health (CIH)
services for Veterans with pain and other conditions. On May 19, 2017,
VHA Directive 1137 ``Provision of Complementary and Integrative
Health'' was approved, establishing internal policy regarding the
provision of CIH approaches. The current list of approved CIH
approaches covered by the Veterans Medical Benefits package includes
acupuncture, meditation, yoga, tai chi/qi gong, biofeedback, hypnosis,
guided imagery, and massage as covered benefits if appropriate as part
of the Veterans care plan. Chiropractic care was previously approved
for use at VA in 2004 so was not included in this list but its use
across VA continues to increase. Chiropractic care has been shown to
correlate with decreased opioid use in Veteran and general populations,
and currently over 110 VA facilities operate on-station chiropractic
clinics.
The availability of CIH approaches in VA has also continued to grow
as the infrastructure (including policy, qualifications standards,
tracking/coding/billing mechanisms, position descriptions, etc.) has
been developed to support the ability to deliver, manage, and track
these services. Most notable is the recently approved qualification
standard for massage therapists, which will allow licensed and
certified massage therapists to be hired across VHA for the first time,
and a qualification standard for licensed acupuncturist which was
approved in February 2018 and which will greatly improve in-house
delivery of acupuncture. In FY 2018 there were 181,961 total
acupuncture encounters (a 20 percent increase from FY 2017) and 131,547
unique Veterans receiving acupuncture (a 60 percent increase from FY
2017) across the enterprise.
In addition, VHA has trained over 2,400 battlefield acupuncture
(BFA) providers and has 78 active BFA instructors. BFA is a limited
acupuncture protocol applied just to the ears designed to relieve acute
and chronic pain. Standards have also been developed for facilities to
use in identifying staff properly trained to deliver each of the CIH
approaches, and CIH Skills Training programs are being developed to
increase capacity of VA staff to deliver these in the future.
Additionally, CIH champions from facilities across the country have
been identified and included on VISN Pain Management Committees to
support inclusion of CIH approaches as a routine part of pain
management. This group meets monthly with the Office of Patient
Centered Care and Cultural Transformation/10NE (OPCC&CT) Integrative
Health Coordinating Center to discuss VISN level best practices and
concerns and to gain new information related to CIH to take back to
their VISNs. The Integrative Health Coordinating Center is also working
closely with VHA Office of Community Care to develop standards and
protocols for the delivery of CIH services in the community where
necessary.
Section 933 of the CARA legislation requires demonstration projects
on integrating the delivery of CIH services with other health care
services provided by VA for Veterans with mental health conditions,
chronic pain, and other chronic conditions. Rather than just adding
these approaches into primary care, CIH approaches are delivered
through a Whole Health System. This approach improves access and
reduces the burden on primary care. Whole Health is an approach to
health care that empowers and equips people to take charge of their
health, well-being, and to live their life to the fullest, and is the
primary delivery vehicle through which Veterans can access CIH
services.
The Whole Health System includes three components: 1) Empower: The
Pathway--in partnership with peers, empowers Veterans to explore
mission, aspiration, and purpose and begin personal health planning; 2)
Equip: Well-being Programs equip Veterans with self-care tools, skill-
building, and support. Services may include proactive CIH approaches
such as yoga, tai chi, or mindfulness; and 3) Treat: Whole Health
Clinical Care--in VA, the community, or both, clinicians are trained in
Whole Health and incorporate CIH approaches based on the Veteran's
personalized health plan. VA staff has been working with Veterans
around the country to bring elements of this Whole Health approach to
life. In conjunction with the CARA legislation, VA began implementation
of the full Whole Health System in 18 Flagship Facilities in the
beginning of FY 2018, the first wave of facilities in the national
deployment of Whole Health. Flagship facility implementation of the
Whole Health System will proceed over a 3-year period (FY 2018-FY 2020)
and is supported by a well-proven collaborative model which drives
large scale organizational change.
The Whole Health approach is well-integrated with the VA Opioid
Safety Initiative (OSI) and the National Pain Program's Stepped Care
Model, both of which emphasize redesigning pain care with a focus on
non-pharmacological approaches, self-care, skill building, and support.
Preliminary data shows a decrease in opioid prescription costs among
Veterans with two or more Whole Health encounters; we continue to focus
on the mitigation of opioid overuse as a priority goal for the Whole
health initiative.
An important delivery strategy is making Whole Health and CIH for
pain and other conditions available via telehealth, and we have made
significant progress in this area. In FY 2017, 770 Whole Health/CIH
Encounters were offered to 160 unique Veterans at 9 VAMCs across VHA;
In FY 2018, 4,354 Whole Health/CIH encounters have been offered to
1,004 unique Veterans via Telehealth at approximately 26 VAMCs across
VHA. We continue to see significant growth in utilization of Whole
Health via telehealth in FY 2019 to date as well.
In addition, the VA Whole Health Education Program provides
education and skills-based practice on Whole Health and CIH approaches;
to date over 20,000 VA staff have participated in one or more Whole
Health education offerings. One example of the many educational
opportunities is Whole Health for Pain and Suffering: this 2-day course
teaches evidence-informed, safe, and effective non-pharmaceutical
approaches to pain care. Participants learn how mind-body approaches
and self-management can support coping and wellbeing for people with
pain, including acupuncture, dietary supplements, and manual therapies.
Clinician self-care, burnout prevention, and enhancing resilience are
also emphasized. To date 1,274 VA staff have completed the Whole Health
for Pain and Suffering course, with an additional 704 projected to
attend through the end of FY 2019.
Along with identifying the challenges and successes of CIH
implementation at VA facilities, our research partners from VA HSR&D
continue to examine many patient-reported health outcomes, clinical
outcomes, and Veteran satisfaction measures in their comprehensive
study of the flagship sites. We will be able to better understand the
health outcomes as well as cost impact upon conclusion of their
evaluation efforts. VA plans to continue to expand Veteran access to
complementary and integrative approaches for pain through all our
successful strategies to date, including infrastructure development,
hiring of CIH providers, telehealth, community care coordination,
education, and research.
One specific example, in 2018, the Office of Patient Centered Care
& Cultural Transformation adopted the Institute for Healthcare
Improvement (IHI) Learning Collaborative model and launched the first
Learning Collaborative for the 18 Whole Health flagship facilities to
support the delivery and implementation of the Whole Health System. To
further support national deployment, The Whole Health Learning
Collaborative Two: Driving Cultural Transformation begins in the spring
of 2019 and will support 36 more facilities in continuing to accelerate
Whole Health delivery and innovation across VA. On March 12, 2019,
guidance via the Office of the Deputy Under Secretary for Health for
Operations and Management was distributed requesting that each VISN
identify two additional sites to help further Whole Health deployment
in their VISN. Teams from each of the participating sites will join
three face-to-face meetings during the 18-month collaborative, as well
as monthly calls and virtual meetings as part of this Learning
Collaborative process.
Telehealth modalities are continuing to grow to facilitate a
smoother Provider and Veteran experience of Whole Health and CIH. The
most recent innovation is the VA Video Connect modality which is
popular among both group and one-on-one TeleWholeHealth encounters such
as Tele-Coaching, Tele-Facilitated Groups, and TeleWholeHealth Clinical
Care encounters. With this modality, Veterans can access their Health
Coach or Provider from anywhere they have an internet connection. The
provider and Veteran enter a virtual medical room where they can
complete the encounter.
We are also planning for continued growth in our education program,
which is critical to expanding access to CIH services for pain. We have
trained 60 VA clinical faculty across the country to date to teach the
Whole Health curriculum as a means to scale implementation. This coming
year, we will train an additional 40 field-based faculty to continue
this expansion. In addition, we anticipate continued increase in the
hiring of CIH providers across VA to provide pain treatment options.
For example, we expect on-station chiropractic clinics at a minimum of
50 percent of all VAMCs in each VISN by December 2021.
VA is also committed to expanding its research efforts in the area
of CIH and Whole Health for pain. In 2016, VA HSR&D held a state-of-
the-art Conference on non-pharmacological approaches to chronic pain.
This conference convened VA researchers and clinical experts to
identify which CIH and other non-pharmacological approaches had
sufficient evidence to be provided across the system and which require
further research. Based on the findings of this conference, the VA
Office and Research and Development will continue to support research
on the use of this type of approaches for the management of pain
conditions.
Question 6b. What other alternative pain-treatments do you think
could be effective in preventing opioid addiction?
Response. VA's approach to preventing opioid addiction in patients
with chronic pain has been to promote safer, more effective pain care
that minimizes reliance on opioid medication for treatment of both
acute and chronic, non-end-of-life pain conditions. Instead, VA's
approach relies on non-opioid pharmacological and non-pharmacological
pain treatment modalities that have greater safety and long-term
benefits than opioid pain medication.
The VA/DOD Clinical Practice Guideline on Opioid Therapy for
Chronic Pain, updated in 2017, makes the following recommendations to
prevent opioid addiction for patients with chronic non-end-of-life
pain:
``We recommend against initiation of long-term opioid
therapy for chronic pain.
We recommend alternatives to opioid therapy such as self-
management strategies and other non-pharmacological treatments.
When pharmacologic therapies are used, we recommend non-
opioids over opioids.
We recommend alternatives to opioids for mild-to-moderate
acute pain.
We suggest use of multimodal pain care including non-
opioid medications as indicated when opioids are used for acute pain.
If take-home opioids are prescribed, we recommend that
immediate-release opioids are used at the lowest effective dose with
opioid therapy reassessment no later than 3-5 days to determine if
adjustments or continuing opioid therapy is indicated.''
The full clinical practice guideline is available at this Web site:
https://www.healthquality.va.gov/guidelines/Pain/cot/.
In November 2016, VA held a state-of-the-art conference titled
``Non-Pharmacological Approaches to Chronic Musculoskeletal Pain
Management'' to obtain expert consensus on evidence-based treatment
modalities to guide policy recommendations. The attached summary report
was published in the Journal of General Internal Medicine in 2018, by
Kligler et al. Categorized under the three groups of psychological/
behavioral therapies, exercise/movement therapies, and manual
therapies, the following recommendations were made to be implemented
across the VHA system as part of pain care:
Cognitive behavioral therapy;
Acceptance and commitment therapy;
Mindfulness-based stress reduction;
Exercise therapy;
Tai Chi;
Yoga;
Acupuncture;
Manipulation; and
Massage.
The complementary and integrative health modalities are outlined
above in the response to Question 6a. Regarding behavioral/
psychological therapies, VHA has rolled out a national treatment manual
to administer cognitive behavioral therapy for chronic pain (CBT-CP)
with 12 standardized session modules. This was then adapted to a brief
CBT-CP protocol suitable for mental health providers embedded within
Primary Care, with 30-minute sessions for 4-6 appointments.
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Question 7. How will the initiatives in the President's new
Executive Order creating a roadmap for suicide prevention, issuing
community grants, and increasing mental health research be funded?
Response. Task Force roles and leads for the lines of effort
(enabling support, state and local action to include grant structure,
and the research strategy) and grant structure are in the process of
being determined. Role determinations and associated kick-off meetings
will occur in May 2019.
Question 7a. We're all waiting on the FCC to issue a report on the
feasibility of a 3-digit ``N11'' number from legislation we passed last
year. Have you been given any update from the FCC on the status of
creating a 3-digit suicide hotline number for Veterans?
Response. Per the timeline included in the signed legislation, the
Federal Communications Commission (FCC) has until August 2019 to submit
the final report to Congress. This report will include responses by the
Veterans Crisis Line (VCL), the Substance Abuse and Mental Health
Services Administration (SAMHSA), and requested organizations such as
the North American Numbering Council (NANC). VCL has submitted the
original report to FCC on January 28, 2019, and the secondary NANC
request on March 22, 2019. James Wright, VCL Chief of Staff, presented
to NANC at FCC on March 28, 2019, to share a summary of both responses
by VCL. Upon completion of the meeting, NANC requested additional
information (3 points of interest) that VCL is currently completing.
After receiving all requested information, NANC will submit their
technical report to FCC for inclusion in the final report. The National
Suicide Hotline Improvement Act of 2018 does not mandate the creation
of a 3-digit code for Veterans or community services. The Act
specifically calls for FCC to study the feasibility of designating a 3-
digit dialing code, including recommendations on the number, costs
associated with designation, and logistics to include infrastructure
and operation needs.
Question 7b. How quickly can this be implemented?
Response. VCL does not have information regarding the actual
creation of a 3-digit code, as the legislation does not mandate that
outcome. Depending on the FCC final report, recommendations will be
included on potential impact of such a designation. Additional steps
post report would need to be taken to move toward implementation if a
3-digit code expansion was feasible, including expansion requirement
with state vs. national guidelines, along with financial, marketing,
training, and infrastructure needs.
Question 8. The Vocational Rehabilitation and Employment (VR&E)
program is a good news story that a lot of folks do not hear about
often. A key focus of mine in the Senate has been working to reduce the
Veterans unemployment rate has and the VR&E program is a big player in
our successes. The latest VA data shows that from 2016 to 2018, the
number of VRE participants fell from 173,000 to 164,000 a decrease of
more than 5%.
Question 8a. Given how important this program is to disabled
Veterans, why are fewer using this service?
Response. In 2018, Vocational Rehabilitation and Employment (VR&E)
program participants achieved over 15,000 positive outcomes while
participants decreased by 5 percent. VR&E Service attributes the
decrease to due to a combination of the following factors:
Applicants found eligible for the VR&E program are not
reporting to their initial orientation and, therefore, not entering a
plan of services; and
The number of Veterans successfully exiting the program
have increased each year (positive outcomes). Positive Outcomes were
introduced as a performance measure fourth quarter FY 2015 (July 1,
2015), and were fully implemented effective FY 2016 (October 1, 2015).
Year-over-year results and increases are as follows:
------------------------------------------------------------------------
Positive %
FY Outcomes
------------------------------------------------------------------------
2016...................................... 14,351 NA
2017...................................... 15,528 +8.20%
2018...................................... 15,998 +3.03%
------------------------------------------------------------------------
With the number of new plans remaining stagnant and despite the
steady mix of eligible and entitled applicants, more Veterans are
exiting the program than entering. However, VR&E continues to work on
plans to hire to additional Vocational Rehabilitation Counselors (VRC)
to reach a Veteran-to-Counselor ratio of 125 to 1 or below, implement a
new case management system, and use other technological solutions to
keep Veterans engaged throughout the lifecycle of their program
participation (remote entitlement, VA Video Connect (tele-counseling),
appointment reminders, etc.). These changes are expected to increase
the number of participants. With the number of new plans remaining
stagnant and despite the steady mix of eligible and entitled
applicants, more Veterans are exiting the program than entering. VR&E
is embarking on a multiyear modernization effort that will serve as the
solution to improve participation of Veterans in the program. These
efforts will address Veteran's understanding of the program through
outreach and the administrative burden counselors have in the field.
VR&E will expand outreach through social media, engagement with
VSOs at conferences, expanding briefings at TAP, and through Vet
Success on Campus Counselors at Institutes of Higher Learning. This
will aid in decreasing the 66% of discontinuances the Service has due
to Veteran's misunderstanding of what the VR&E program does. As for
administrative burden, VR&E Service research discovered over 60 percent
of a counselor's day is spent in administrative tasks and functions.
Modernization initiatives such as the new case management system, an
electronic virtual assistant that will provide 24/7 scheduling and
administrative support to counselors and Veterans, and e-invoicing will
dramatically decrease that administrative burden. This will increase
the ability of counselors to have direct-facing veteran services and
increased capability to follow up with Veteran clients. Those services
are essential to Veterans persistently participating in the program.
Question 8b. Have you instituted new policies or taken any actions
that would have led to decreased usage?
Response. No, VA's VR&E program has not instituted any new policies
or taken any actions that would have led to decreased usage. To the
contrary, over the past several years VR&E has taken several actions to
meet Servicemembers and Veterans where they are and in the manner they
wish to be met. These actions, coupled with legislative changes, were
expected to increase participation in the VR&E program. These actions
include the following:
In accordance with Public Law 114-223, section 254,
Veteran-to-Counselor ratio should not exceed 125 to 1. VA's VR&E
Program began the process of reducing the average Veteran-to-Counselor
ratio to 125 to 1 or below through the hiring of 169 VRCs. This will
help improve service to Veterans with service-connected disabilities
and employment barriers, as well as help provide them with expanded
services to improve their ability to transition to the civilian
workforce.
The placement of 145 VRCs on 71 military installations
across the Nation provides outreach and rehabilitation services to
Servicemembers and their families prior to discharge from active duty
service.
The placement of 87 VRCs on 104 college campuses across
the Nation provides outreach and rehabilitation services to
Servicemembers, Veterans, and their dependents.
On September 29, 2018, the VA Expiring Authorities Act of
2018, Public Law 115-251, section 126, made permanent the authority to
provide VR&E benefits and services to Servicemembers who are awaiting
discharge due to a severe illness or injury incurred during active duty
service.
VR&E expanded its Tele-counseling policy to allow its use
during all aspects of the rehabilitation process. This practice allows
VR&E VRCs to meet virtually with a VR&E participant via an application
that can be used on a computer or smart device. This practice saves
travel time for the participant and allows for greater access to the
program.
VR&E continues to increase awareness and share information on VR&E
benefits and services. VR&E reviews and updates all VR&E fact sheets
and Web sites each year as needed as well as promotes, monthly, all the
marketing material that is available online. VR&E promotes the online
marketing materials in a variety of ways, including by email, social
media, outreach events, and conference calls with VR&E's field staff.
They have developed an overview whiteboard video which was distributed
to the field offices. The video provides an overview of VR&E's benefits
and the types of assistance available and is a tool for the VRCs to
promote the VR&E program. VR&E has also provided numerous trainings on
how to promote early intervention into VR&E to active duty members on
the military installations. Last, VR&E is changing the performance
standards for the VRCs on military installations to focus more on
ensuring Servicemembers are entering the VR&E program.
______
Response to Posthearing Questions Submitted by Hon. Kyrsten Sinema to
U.S. Department of Veterans Affairs
Question 1. Can I count on your support to ensure the VA takes
steps to make family members aware of benefits available to their loved
ones?
Response. Yes. VA continues to proactively conduct outreach to the
families of Servicemembers and Veterans through face-to-face
interactions, social media, and email correspondence. VA's outreach
services include attendance at various types of national and local
events, stakeholder presentations, and collaboration efforts with other
Federal and state agencies, Veterans Service Organizations, private
partners, and non-profit organizations such as the Tragedy Assistance
Program for Survivors. VA works to promote information on benefits and
services available to family members and proactively disseminates
information in the same manner as its recent VA Benefits Bulletin
newsletter sent on April 5, 2019, to over 5.5 million recipients with
specific information pertaining to a VA Survivors and Burial Benefits
Kit.
Question 2. What is your long term plan to be able to fully staff
the VA with the adequate number of medical professionals and retain
them long term to serve those that served us?
Response. VHA's workforce challenges mirror those of the health
care industry as a whole. There is a national shortage of health care
professionals, especially for physicians and nurses. The American
Association of Colleges of Nursing, Association of American Medical
Colleges, and other national health care organizations have written
about this workforce shortage at length. VHA remains fully engaged in a
fiercely competitive clinical recruitment market. VHA has been
successful in increasing the number of clinical providers including
hard-to-recruit-and-retain physicians such as psychiatrists.
While there are many approaches to projecting staffing of medical
professionals and support staff across large health care systems at the
national level, forecasting at the local level remains challenging due
a multitude of factors. Nationally, Veteran enrollment is projected to
grow by 1.6 percent from 2017 to 2026 even though the Veteran
population is declining. The VHA workforce has consistently grown by
approximately 3 percent annually over the last 5 years. Integration of
existing resources with community care as well as the expansion of
telehealth capabilities will be a critical driver in assessing future
resource requirements.
In FY 2018, VHA formally stood-up the VHA Manpower Management
Office (MMO). VHA has an aggressive schedule for establishing manpower
capabilities, which includes establishing staffing models for all
functional areas; benchmarking staffing, quality, and access at similar
health care systems; developing predictive recruitment models; and
identifying facilities in danger of low staffing levels.
VHA staffing plans account for normal rates of workforce turnover,
retirement, and growth, and the expectation that there will always be
vacant positions. VHA is taking several key steps to attract qualified
candidates, including the following:
Mental Health and other targeted hiring initiatives;
increased maximum physician salaries;
utilization of 3R incentives and the Education Debt
Reduction Program (EDRP);
targeted Nation-wide recruitment advertising and
marketing;
``Take A Closer Look at VA'' trainee outreach recruitment
program;
expanding opportunities for telemedicine providers;
DOD/VA effort to recruit transitioning Servicemembers; and
exhibiting regularly at key health care conferences and
job fairs.
The MISSION Act also provides additional authority that VA will
leverage for recruitment and retention of medical professionals,
including the following:
Awarding 50 scholarships per year for people enrolled in a
medical or dental school;
increasing the maximum award amount for the Education Debt
Reduction Program (EDRP),
expanding program eligibility to additional mental health
providers;
offering recent medical school graduates loan repayment
opportunities in exchange for service in VAMCs through the Specialty
Education Loan Repayment Program (SELRP);
initiating a pilot scholarship program targeted toward
Veterans for medical school education; and
increased the overall sums authorized for VA bonus awards
and funding 3Rs.
VA recently achieved our goal of adding 1,000 more mental health
providers to serve Veterans, adding 1,045 more mental health providers
as of January 31, 2019. VA made this commitment in June 2017 as part of
VA's #1 clinical priority to eliminate Veteran suicide and used a wide
variety of strategies to recruit and retain the mental health
workforce. This included VA's first-ever virtual trainee hiring fair,
which resulted in 74 mental health trainees accepting job offers. The
second trainee hiring event is currently underway and will connect
current VA psychology trainees with available positions at VHA
facilities using the non-competitive hiring process. Building a
clinical trainee pipeline of qualified health care professionals is
crucial to future VA recruitment and sustainment efforts.
Each year, VHA hires more employees than it loses to replace
turnover and keep up with the growth in demand for services. VHA
turnover rates compare favorably with the health care industry,
including for those occupations identified as mission critical. In FY
2018, VHA's annual turnover rate for full-time and part-time employees
was 9.5 percent, which compares well to the health care industry
turnover rate of 20-30 percent.
The best indicators of adequate staffing levels are Veteran access
to care and health care outcomes, and VHA continues to make substantial
progress on these measures. As identified by external research and
studies, in general, Veterans are receiving the same or better care at
VAMCs as patients at non-VA hospitals.
Question 3. Mr. Secretary, are you aware of the recent United
States Digital Service findings on the issues surrounding the new
software to determine eligibility under the MISSION Act?
Response. Yes.
Question 3a. What steps is the VA taking in response to the USDS
study?
Response. The United States Digital Service (USDS) identified
several key points and recommendations that OIT could use to enable a
better product development effort for MISSION Act and more specifically
for the Decision Support Tool (DST). OIT and VHA are using USDS's
recommendations to improve DST and other MISSION Act IT needs.
A P P E N D I X
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Joint Statement of The Co-Authors of the Independent Budget
Chairman Isakson, Ranking Member Tester, and Members of the
Committee, The co-authors of The Independent Budget (IB)--DAV (Disabled
American Veterans), Paralyzed Veterans of America (PVA), and Veterans
of Foreign Wars (VFW)--are pleased to present our views regarding the
President's funding request for the Department of Veterans Affairs (VA)
for Fiscal Year (FY) 2020, including advance appropriations for FY
2021.
Last month, prior to the Administration's budget request, the IB
released our comprehensive VA budget recommendations for all
discretionary programs for FY 2020, as well as advance appropriations
recommendations for medical care accounts for FY 2021.\1\ The
recommendations also include funding to implement the VA MISSION Act of
2018 (P.L. 115-182) and other reform efforts. The IB believes that
Congress must continue vigorous oversight of VA to ensure an accurate
assessment of its true needs. Our own FY 2020 estimates affirm that
these needs continue to grow.
---------------------------------------------------------------------------
\1\ The full IB budget report addressing all aspects of
discretionary funding for VA can be downloaded at
www.independentbudget.org.
---------------------------------------------------------------------------
After reviewing the Administration's budget request for VA and
comparing it to the IB recommendations, particularly in light of the
requirements of the VA MISSION Act, we believe that the request falls
short of meeting the needs of veterans seeking care through VA.
Although the budget request provides a seven percent increase in the
level of discretionary funding, when factoring in VA's own estimates of
the cost of implementing the VA MISSION Act, the shift of $5.5 billion
from mandatory to discretionary funding from the Choice program, and
the increased cost for providing medical care due to inflation and
other factors, VA will not have sufficient resources to meet the health
care needs of America's veterans.
The Administration's request of $84 billion for Medical Care is $4
billion less than the IB estimates is necessary to fully meet the
demand by veterans for health care during the fiscal year. For FY 2020,
the IB recommends approximately $88.1 billion in total medical care
funding and approximately $90.8 billion for FY 2021. This
recommendation reflects the necessary adjustments to the baseline for
all Medical Care program funding in the preceding fiscal year, and
assumes the Choice program is fully replaced at the beginning of FY
2020 by the Veterans Community Care Program (VCCP).
For FY 2020, the IB recommends $56.1 billion for VA Medical
Services. This recommendation is a reflection of multiple components
including the current services estimate, the increase in patient
workload, and additional medical care program costs. The current
services estimate reflects the impact of projected uncontrollable
inflation on the cost to provide services to veterans currently using
the system. This estimate also assumes a 2.1 percent increase for pay
and benefits across the board for all VA employees in FY 2020.
Our estimate of growth in patient workload is based on a projected
increase of approximately 90,000 new unique patients. These patients
include priority group 1-8 veterans and covered non-veterans. We
estimate the cost of these new unique patients to be approximately $1.3
billion.
The IB believes that there are additional projected medical program
funding needs for VA. Those costs total over $1.2 billion.
Specifically, we believe there is a real need for funding to address an
array of issues in VA's Long-Term Services and Supports (LTSS) program,
including the shortfall in non-institutional services due to the
unremitting waitlist for home and community-based services; to provide
additional centralized prosthetics funding (based on actual
expenditures and projections from the VA's Prosthetics and Sensory Aids
Service); funding to expand and improve services for women veterans;
funding to support the recently approved authority for reproductive
services, to include in vitro fertilization (IVF); and initial funding
to implement extending comprehensive caregiver support services to
severely injured veterans of all eras.
The Administration's request for VA Medical Services of $51.4
billion is approximately $4.7 billion below the IB recommendation. To
better understand the shortfall, it should be noted that the IB does
not include anticipated receipts from VA's Medical Care Collections
Fund in its recommendation. Although the Administration's request
reflects an apparent increase of three percent, the IB believes that
when taking into account the increased cost to maintain current
services and anticipated increases in workload, as well as increased
costs inside VA due to the VA MISSION Act that apparent increase will
ultimately result in a shortfall.
Of great concern to our organizations and members, the
Administration's budget request makes clear that VA will fail to meet
the VA MISSION Act's very clear timetable for expanding its
comprehensive caregiver support program to severely injured WWII,
Korean, and Vietnam War veterans and their family caregivers. These men
and women have waited nearly a decade for equal treatment and it is
simply unacceptable to ask them to wait longer.
The VA Caregiver Support Program currently uses the IT system known
as the Caregiver Application Tracker (CAT), which was rapidly developed
due to time constraints on implementing the program and was not
designed to manage a high volume of information as is required today.
We are aware VA has requested a reprogramming of nearly $96 million in
Medical Care funding to the IT Systems account, which includes just
over $4 million to continue development and stabilization of CAT, while
in its FY 2020 budget submission, VA is requesting $2.6 million to
update the Caregivers Tool (CareT) to support the first phase of
expansion. As this Committee is aware, VA notified Congress in
April 2017 that CareT, which at that time was expected to fully
automate the application and stipend delivery process for the program,
experienced significant delays associated with external dependencies
and lost prioritization among competing projects. As a result, a new
contract had to be drafted to continue work pushing the delivery of
CareT out one year to June 2018.
We are deeply troubled at VA's apparent lack of commitment to
accomplish this IT task correctly and on time and that these funding
requests appear to uncaringly prioritize caregiver expansion behind
that of the VCCP. Moreover, the delay in certifying the IT
infrastructure for expansion of the caregiver program until at least
2020 raises troubling concerns about VA's ability to fully deploy the
significant IT infrastructure needed to properly implement the more
expansive VCCP in a shorter timeframe.
In terms of funding, the Administration included $150 million to
expand VA's comprehensive caregiver program. This figure is over $100
million less than the IB recommendation of $253 million to fully
implement phase one of the caregiver expansion in FY 2020. The IB's
recommendation is based on the Congressional Budget Office estimate for
preparing the program, including increased staffing and IT needs, and
the beginning of the first phase of expansion.
For Medical Community Care, the IB recommends $18.1 billion for FY
2020, which includes the growth in current services, estimated spending
under the Choice program, and additional obligations under the VA
MISSION Act of $3.7 billion. The Administration's FY 2020 request for
$15.3 billion in discretionary funding appears to be a $5.9 billion
increase in funding for Community Care. However, VA has indicated that
$5.5 billion of that increase merely represents shifting $5.5 billion
that would otherwise be necessary to pay for the Choice program, from
mandatory funding. Considering that VA estimated the VA MISSION Act
will require $2.6 billion in new funding for expanded access based on
new access standards, expanded transplant care, and $271 million for
urgent care, there appears to be a significant shortfall for VA
community care programs.
Furthermore, during VA's budget briefing on March 11, VHA officials
stated that there would be no Medical Community Care funding required
to implement the new wait time access standards, that VA would be able
to fully meet those standards within VA facilities; therefore, not one
veteran would get VCCP eligibility due solely to the wait time
standard. However, VA has also stated that the current median wait time
for primary care is 21 days, which would mean that approximately half
of all veterans seeking primary care appointments today have a greater
than 20 day wait time. Yet, VA's budget request assumes that they would
achieve 100 percent compliance with the wait time standard through
greater efficiency and an approximate 30 percent increase in VA primary
care providers. We have serious doubts about whether this is realistic
given the national shortage of primary care providers and the time
needed to recruit, hire, and onboard new employees; and certainly,
whether it is achievable by the first day of the next fiscal year, just
over six months from today.
The Administration's FY 2020 request for VA's construction programs
of $1.8 billion dollars is a 44 percent reduction from FY 2019 funding
levels, and a disappointing retreat in funding to maintain VA's aging
infrastructure. For major construction in FY 2019, VA requested and
Congress appropriated a significant increase in funding for major
construction projects--an approximate $700 million increase. While
these funds will allow VA to begin construction on key projects, many
other previously funded sites still lack the funding for completion.
Some of these projects have been on hold or in the design and
development phase for years. Additionally, there are outstanding
seismic corrections that must be addressed. Thus, the IB recommended
$2.78 billion in major construction, nearly $1 billion more than VA's
total construction request.
To ensure that VA funding keeps pace with all current and future
minor construction needs, the IB recommends that Congress appropriate
an additional $761 million for minor construction projects. It is
important to invest heavily in minor construction because these are the
types of projects that can be completed faster and have a more
immediate impact on services for veterans. Previously, these changes
fell under facilities similar to Non-Recurring Maintenance (NRM), but
the IB recommends these specific modifications be under a different
authority to ensure their priority.
In addition, the Administration's FY 2020 Medical Facilities
request of $6.1 billion, which includes critical NRM to ensure VA
facilities have the space to provide care, is a $660 million cut
compared to FY 2019 levels. The IB recommends $6.6 billion for FY 2020.
This includes nearly $400 million for NRM and leases, which provides
funding to address VA research NRM needs. VA uses major and minor
leases in lieu of facility construction to address access needs and
space gaps to quickly respond to health care advances, and adopt
changing technology in order to provide state-of-the-art health care to
veterans when a lease is better aligned with the Department's overall
capital strategy.
The Administration's request of $762 million for Medical and
Prosthetic Research is nearly $80 million below the IB recommendation
of $840 million. The request represents a 2 percent cut, at a time when
medical research inflation is estimated to be 2.8 percent. The VA
Medical and Prosthetic Research program is widely acknowledged as a
success, with direct and significant contributions to improved care for
veterans and an elevated standard of care for all Americans. This
research program is also an important tool in VA's recruitment and
retention of health care professionals and clinician-scientists to
serve our Nation's veterans. This reduction would diminish VA's ability
to provide the most advance treatments available to injured and ill
veterans in the future, one of VA's core missions.
Overall, the IB believes that the Administration's FY 2020 budget
request for VA will neither allow the Department to fully and
faithfully implement the VA MISSION Act, nor will it fully meet the
rising demand by veterans for care within VA hospitals and clinics. The
IB veterans services organizations (IBVSOs) are left with significant
questions regarding both the assumptions on which the request was made
and how the VA intends to meet the requirements of not only the VA
MISSION Act, but also other requirements to provide the health care,
benefits, and services that veterans have earned. Below are some of the
questions about VA's budget request that have not been answered.
At its March 11 budget briefing, VA officials stated that
the FY 2020 budget request was predicated on a carryover of
approximately $3 billion from FY 2019 appropriations, but offered no
details or further explanation. Exactly, how much ``carryover'' is
assumed in the FY 2020 budget request and how did VA determine less
than halfway through FY 2019 that such a large amount of funding could
not be used to meet veterans' health care needs? What are the specific
dollar amounts being carried over and from what specific accounts, and
into what accounts and for what purposes will this carryover funding be
used in FY 2020?
As discussed above, VA officials indicated that there
would be zero new dollars necessary for the Medical Community Care
account as a result of the new wait time access standards proposed
because VA assumes it will be able to meet those standards 100 percent
of the time within VA facilities. VA indicated it will do this through
workload recapture, greater efficiency, and a 30 percent increase in
the total number of VA primary care providers. What new initiatives
will VA undertake and what are the specific increases in productivity
that each will achieve? What are VA's detailed plans and projections
for increasing primary care providers by 30 percent, and how will these
new providers be in place at the beginning of FY 2020?
What factors did VA consider in reaching its decision to
cut research spending for the emerging field of genomics research in FY
2020 by 2 percent at a time when medical research inflation is
estimated to be 2.8 percent?
In the full budget documents made available on March 18,
the Veterans Benefits Administration budget request seeks
appropriations to support the exact same level of FTE for FY 2020 as it
does in FY 2019. However, the Direct Labor estimate for the Disability
Compensation program shows a decrease of 51 FTE in FY 2020. This small
decrease in claims processors occurs at a time that the VA budget is
projecting that number of pending claims for disability compensation
will rise to over 450,000 by the end of FY 2020, almost a 50 percent
increase in just the past three years. Why is VA requesting fewer
claims processing staff in FY 2020 when its own data shows that the
number of pending claims is rising dramatically?
VA budget documents state that the Vocational
Rehabilitation and Employment (VRE) program will meet and sustain the
congressionally-mandated goal of 1:125 counselor-to-client ratio.
However, the latest data in the VA budget document also shows that from
2016 to 2018, the number of VRE participants fell from 173,606 to
164,355, more than a five percent decrease. During that same period,
VRE's caseload also dropped from 137,097 to 125,513, an 8.4 percent
decline. It would appear that VRE is able to meet the 1:125 goal by
serving fewer veterans. Given how important and beneficial the VRE
program is to disabled veterans--providing many of them with the
ability to increase their economic independence--why are fewer veterans
taking advantage of this program? Has VRE instituted any new policies
or practices that have deterred disabled veterans from seeking VRE
services and what actions is VRE taking to increase awareness about the
availability and benefits of VRE services?
Last, the IBVSOs strongly oppose four legislative proposals
included in the budget that would reduce benefits to disabled veterans
that were earned through their service:
1. Round-Down of the Computation of the Cost of Living Adjustment
(COLA) for Service-Connected Compensation and Dependency and
Indemnity Compensation (DIC) for Five Years:
In 1990, Congress, in an omnibus reconciliation act, mandated
veterans' and survivors' benefit payments be rounded down to
the next lower whole dollar. While this policy was initially
limited to a few years, Congress continued it until 2014. While
not significant at the onset, the overwhelming effect of
twenty-four years of round-down resulted in veterans and their
beneficiaries losing billions of dollars.
In the Administration's proposed budget for FY 2019, the
Administration sought legislation to round-down the computation
of COLA for ten years. This would have cost beneficiaries $34.1
million in 2019, $749.2 million for five years, and $3.11
billion over ten years.
The Administration's proposed budget for FY 2020, is seeking
to round-down COLA computations from 2020 to 2024. The
cumulative effect of this proposal levies a tax on disabled
veterans and their survivors, costing them money each year.
When multiplied by the number of disabled veterans and DIC
recipients, millions of dollars are siphoned from these
deserving individuals annually. All told, the government
estimates that it would cost beneficiaries $34 million in 2020
and $637 million for five years and $2 billion over ten years.
Veterans and their survivors rely on their compensation for
essential purchases such as food, transportation, rent, and
utilities. Any COLA round-down will negatively impact the
quality of life for our Nation's disabled veterans and their
families, and we oppose this and any similar effort. The
Federal budget should not seek financial savings at the expense
of benefits earned by disabled veterans and their families.
2. Clarify Evidentiary Threshold for Ordering VA Examinations:
This proposal would increase the evidentiary threshold at
which VA, under its duty to assist obligation in 38 U.S.C.
Sec. 5103A, is required to request a medical examination for
compensation claims. Section 5103A(d)(2) requires VA to ``treat
an examination or opinion as being necessary to make a decision
on a claim'' if the evidence of record, ``taking into
consideration all information and lay or medical evidence . . .
(A) contains competent evidence that the claimant has a
current disability, or persistent or recurrent symptoms of
disability; and (B) indicates that the disability or symptoms
may be associated with the claimant's active military, naval,
or air service; but (C) does not contain sufficient medical
evidence for the Secretary to make a decision on the claim.''
The Court of Appeals for Veterans Claims (CAVC), in McLendon
v. Nicholson, 20 Vet. App. 79 (2006), determined that in
disability compensation claims, VA must provide a VA medical
examination when there is:
Competent evidence of a current disability or
persistent or recurrent symptoms of a disability, and
Evidence establishing that an event, injury, or
disease occurred in service or establishing certain diseases
manifesting during an applicable presumptive period for which
the claimant qualifies, and
An indication that the disability or persistent or
recurrent symptoms of a disability may be associated with the
veteran's service or with another service-connected disability,
but,
Insufficient competent medical evidence on file for
the secretary to make a decision on the claim. It notes that
the requirement of (3) is a low threshold.
We oppose this proposal as it would be inherently detrimental
to the VA claims process for all veterans. The Administration
asserts the holdings by the CAVC, specifically in McLendon v.
Nicholson, are inconsistent and too low a bar when compared to
38 U.S.C. Sec. 5103A(d)(2). However, that is not correct. As
noted above, the statutory requirements for a VA examination
are consistent with the CAVC's holding. The Administration's
proposed legislation would intentionally raise the bar of the
VA's Duty to Assist and allow the VA to hold veterans to a much
higher threshold and result in fewer examinations with more
claim denials. This would lead to more Higher Level Review
requests, supplemental claims, and appeals directly to the
Board of Veterans' Appeals. Ultimately, this will result in an
increased number of veterans never receiving the benefits they
earned.
The Administration's proposal would reduce anticipated
disability compensation to veterans by $233 million in 2020,
$1.3 billion over five years, and $2.8 billion over ten years.
We strongly oppose this attempt to limit the due process rights
of veterans, particularly when the result will be billions of
dollars in lost disability compensation for those who were
injured or made ill in service.
3. VA Schedule for Rating Disability (VASRD) Effective Dates:
VA seeks to amend 38 U.S.C. Sec. 1155 so that when VASRD is
readjusted, such changes would apply to any new or pending
claims and may include action to decrease an existing
evaluation. Under section 1155, ``The Secretary shall from time
to time readjust this schedule of ratings in accordance with
experience. However, in no event shall such a readjustment in
the rating schedule cause a veteran's disability rating in
effect on the effective date of the readjustment to be reduced
unless an improvement in the veteran's disability is shown to
have occurred.''
Currently, if a diagnostic code rating criteria changes, the
veteran can only be granted an increased evaluation under the
old rating criteria up to the date of the change to the new
rating criteria. The new rating criteria must be applied from
the date of the change. The Administration's proposal would
eliminate a veteran's ability to receive an increased
evaluation up to the date of the change and only apply the new
criteria.
This proposal would have a negative impact on veterans and
would clearly be in contrast to 38 CFR Sec. 3.103, which
states, ``Proceedings before VA are ex parte in nature, and it
is the obligation of VA to assist a claimant in developing the
facts pertinent to the claim and to render a decision which
grants every benefit that can be supported in law while
protecting the interests of the Government.''
The Administration's proposed budget does not show any
estimate of budgetary savings based on this legislative
proposal and mentions only that it would make it easier for VA
rating personnel to make decisions on veterans' claims.
However, this proposal will eliminate any potential increased
evaluations prior to the change of the rating criteria;
thereby, lowering the earned benefit for affected disabled
veterans. We oppose this proposal as it will have negative
consequences on veterans.
4. Elimination of Payment of Benefits to the Estates of Deceased Nehmer
Class Members and to the Survivors of Certain Class Members:
VA seeks to amend 38 U.S.C. Sec. 1116 to eliminate payment of
benefits to survivors and estates of deceased Nehmer class
members. If a Nehmer class member, per 38 CFR Sec. 3.816,
entitled to retroactive benefits dies prior to receiving such
payment, VA is required to pay any unpaid retroactive benefits
to the surviving spouse or subsequent family members. This
proposed legislation would deny veterans' survivors and
families' benefits that would have otherwise been due to their
deceased veteran family member as a result of exposure to these
toxic chemicals while in service. It is outrageous that the
Administration would deny compensation payments due to a
surviving spouse. We adamantly oppose this or any similar
proposal that may be offered.
The IBVSOs do support one of VA's legislative proposals regarding
VA approved Medical Foster Homes (MFH). This proposal would require the
VA to pay for service-connected veterans to reside in VA approved MFHs.
MFHs provide an alternative to long-stay nursing home (NH) care at
a much lower cost. The program has already proven to be safe,
preferable to veterans, highly veteran-centric, and half the cost to VA
compared to NH care. Aligning patient choice with optimal locus of care
results in more veterans receiving long-term care in a preferred
setting, with substantial reductions in costs to VA. This proposal
would require VA to include MFH in the program of extended care
services for the provision of care in MFHs for veterans who would
otherwise encumber VA with the higher cost of care in NHs.
Many more service-connected veterans referred to or residing in NHs
would choose MFH if VA paid the costs for MFH. Instead, they presently
defer to NH care due to VA having payment authority to cover NH, while
not having payment authority for MFH. As a result of this gap in
authority, VA pays more than twice as much for the long-term NH care
for many veterans than it would if VA was granted the proposed
authority to pay for MFH. This proposal would give veterans in need of
NH level care greater choice and ability to reside in a more home-like,
safe environment, continue to have VA oversight and monitoring of their
care, and preferably age in place in a VA-approved MFH rather than a
NH. The proposal does not create authority to cover veterans who reside
in assisted living facilities.
MFH promotes veteran-centered care for those service-connected
veterans who would otherwise be in a nursing home at VA expense, by
honoring their choice of setting without financial penalty for choosing
MFH.
Thank you for the opportunity to submit our views on the
Administration's budget request for VA. We firmly believe that unless
Congress acts to substantially increase VA's funding for FY 2020,
veterans will be forced to wait longer for care, whether they seek care
at VA or in the community, leaving unfulfilled the promises made to
veterans in the VA MISSION Act.
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