[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
A CALL TO ACTION: MEETING THE NEEDS
OF THE SPINAL CORD INJURY AND
DISORDERS (SCI/D) VETERAN COMMUNITY
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, JUNE 13, 2024
__________
Serial No. 118-69
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
56-243 WASHINGTON : 2025
-----------------------------------------------------------------------------------
COMMITTEE ON VETERANS' AFFAIRS
MIKE BOST, Illinois, Chairman
AUMUA AMATA COLEMAN RADEWAGEN, MARK TAKANO, California, Ranking
American Samoa, Vice-Chairwoman Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
NANCY MACE, South Carolina MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina SHEILA CHERFILUS-MCCORMICK,
C. SCOTT FRANKLIN, Florida Florida
DERRICK VAN ORDEN, Wisconsin CHRISTOPHER R. DELUZIO,
MORGAN LUTTRELL, Texas Pennsylvania
JUAN CISCOMANI, Arizona MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia NIKKI BUDZINSKI, Illinois
Jon Clark, Staff Director
Matt Reel, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
THURSDAY, JUNE 13, 2024
Page
OPENING STATEMENTS
The Honorable Mike Bost, Chairman................................ 1
The Honorable Mark Takano, Ranking Member........................ 3
WITNESSES
Panel I
Dr. Erica Scavella, Assistant Under Secretary for Health for
Clinical Services, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 4
Accompanied by:
Mr. Jeffrey London, Executive Director, Medical Disability
Examination Office, Veterans Benefits Administration,
U.S. Department of Veterans Affairs
Mr. Steve Bracci, Director, Claims and Medical Exams Benefits
Inspection Division, Office of Inspector General, U.S.
Department of Veterans Affairs................................. 6
Panel II
Mr. Robert Thomas, National President and Chairman of the Board,
Paralyzed Veterans of America.................................. 21
Mr. Carl Blake, Chief Executive Officer, Paralyzed Veterans of
America........................................................ 23
Ms. Sonya Sotak, Chief Government Affairs Officer, I AM ALS...... 24
Dr. B. Jenny Kiratli, Member, American Federation of Government
Employees...................................................... 26
APPENDIX
Prepared Statements Of Witnesses
Dr. Erica Scavella Prepared Statement............................ 37
Mr. Steve Bracci Prepared Statement.............................. 42
Mr. Robert Thomas Prepared Statement............................. 49
Mr. Carl Blake Prepared Statement................................ 55
Ms. Sonya Sotak Prepared Statement............................... 68
Dr. B. Jenny Kiratli Prepared Statement.......................... 72
Statements For The Record
MitoSense, Inc. Prepared Statement............................... 75
Christopher and Dana Reeve Foundation Prepared Statement......... 78
Neuralink Prepared Statement..................................... 80
A CALL TO ACTION: MEETING THE NEEDS
OF THE SPINAL CORD INJURY AND
DISORDERS (SCI/D) VETERAN COMMUNITY
----------
THURSDAY, JUNE 13, 2024
Committee on Veterans' Affairs,
U.S. House of Representatives,
Washington, DC.
The committee met, pursuant to notice, at 10:47 a.m., in
room 360, Cannon House Office Building, Hon. Mike Bost
(chairman of the committee) presiding.
Present: Representatives Bost, Bergman, Miller-Meeks, Van
Orden, Luttrell, Takano, Brownley, Cherfilus-McCormick,
Ramirez, Landsman, and Budzinski.
OPENING STATEMENT OF MIKE BOST, CHAIRMAN
The Chairman. Good morning. The committee will come to
order, and I want to welcome the witnesses to our hearing
today. I do want to apologize for the late start, but we are
going to get started here. Today, we will be discussing the
care and benefits available to veterans living with spinal cord
injuries and disorders. You know, we have not had a hearing on
this issue during my time on this committee, and the oversight
in this area, it has been long overdue.
Before we dive into it, though, there is something that I
want to say, and I think it is important that I do. I am very
disappointed to see that the U.S. Department of Veterans
Affairs (VA) did not send a witness from the Spinal Cord Injury
and Disorder, or the SCI/D, system. That is what this hearing
is all about. For the VA, should have prioritized having
someone here from that office that is tasked with helping the
veterans and their availability to receive those benefits. I
think it is important that the people in this room, the
veterans as well as the taxpayers and the veterans who are
watching this hearing, this is the third time this year where
we have been declined by the VA to have the witnesses that we
requested. It does not matter whether we are Republican. It
does not matter whether we are Democrat. It does not matter
whether the ranking member, when he was in the majority. It is
really upsetting whenever the VA makes decisions to overrule
our decision on who we want and accept your judgment over ours.
It is the responsibility of this committee to make sure VA
takes care of all veterans. It is our responsibility for doing
that to give oversight, and we actually do understand who we
need to talk to. It is the third time this year that VA has
tried to make a decision over this committee on who we need to
talk to. That is not fair to the veterans and it is not fair to
the taxpayers.
What you need to understand is we are the Congress of the
United States. You are an agency, yes, agency controlled by the
administration, but your budget is ours. Oversight is ours. We
have to do our job for the American people, whether it is a
Republican sitting here or a Democrat sitting here. It is not
the job of the VA to decide who is going to sit before us. It
is our job to request and your job to deliver. I hope I am
really clear on what I just said.
With that, VA has long been recognized for its unique
ability to provide top-notch SCI/D care. VA has 25 SCI/D
centers across the country, each specifically designed to meet
the--just a minute, to meet the veterans issues head on and
meet those veterans with spinal cord injuries where it is
convenient for them. Let me put in perspective what I mean.
One of the centers is in Hines, Illinois, which is about 3
hours from the top of my district, which means it is 6 hours
from the bottom of my district. That is a long time to drive
for an appointment. I want to ensure VA is meeting the veterans
where they are with the healthcare they have earned. It is that
simple.
Now, we have heard stories from veterans about missing
doctors' appointments due to late or inadequate transportation
with no coordination from VA. Those missed appointments have
contributed to about $4 billion cost to the Department from
what we can calculate.
We have also heard concerns about staffing shortages that
have prevented SCI/D centers from operating at full capacity,
as well as issues with patient safety practices in the VA's
facilities. Some of the VA's shortfalls in this area are
addressed in H.R. 8371, the Elizabeth Dole Act, including home
care, long-term care, and access to SCI/D systems of care. It
is incredibly important that we pass this important legislation
to ensure VA can meet the need of all veterans. I hope my
colleagues on the other side of the aisle, and I am sure they
will, will put politics aside and support this life-saving
bill.
Today, we will also examine VA's failure to ensure all
disability exams are conducted in properly equipped facilities.
A recent VA Inspector General (IG) report showed that a large
number of contract exam facilities did not comply with Federal
disability law. In this day and age, that is unacceptable.
Let us be perfectly clear. This is not a mere suggestion
for the Department. It is what we expect. VA must ensure that
the veterans they serve have access to accessible and safe exam
facilities. Without that, veterans are being restricted from
the benefits they have earned. We know that disability claims
processing itself is difficult to navigate. Veterans should not
also face physical barriers to getting an exam.
Access to benefits, including VA's Specialty Adaptive
Housing Grant program, are also crucial. Yet we understand that
the application, the wait times for this program can present
challenges for veterans and their families that they need help.
Veterans are required to receive three estimates before they
can get approval, and it can be difficult to find builders to
do the work, especially if you are in a rural area. The
advantage of keeping disabled veterans in their homes not only
saves money, but it also gives the veterans and their families
peace of mind. Congress has recently invested in this program.
VA must make the rubber meet the road so severely disabled
veterans continue to have access to the benefits that they have
earned.
Now, I am eager to hear from the VA today about how they
plan to fix these years-long problems. We will also learn from
the expert witnesses who will speak about what more we can do
to improve access to care and services for catastrophic
disabled veteran community. I also want to welcome the many
members of the Paralyzed Veterans of America (PVA) who are
attending the hearing here today. Thank you all for making the
trip to DC, and I appreciate that you are spending some time
here with us this morning.
Now I would like to recognize Ranking Member Takano for his
opening comments.
OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER
Mr. Takano. Well, thank you, Mr. Chairman. I am pleased to
be here today to examine how we are meeting the needs of
veterans with spinal cord injuries and disorders, sometimes
referred to as SCI/D.
It is estimated that around a quarter of those with spinal
cord injuries and disorders are veterans. Many patients live
with the effects of these injuries for decades. It is crucial
that VA can provide resources and help meet the needs of
veterans with spinal cord injuries and disorders at each stage
in their lifetime of care. Now, this includes access to
equipment to assist them with mobility, ensuring a high level
of care coordination to provide appropriate care for both
preventative and chronic healthcare needs, and access to long-
term care in settings that make the most sense for the veteran
and their loved ones.
As you will hear from many of our witnesses today, VA is
uniquely positioned among healthcare systems to provide this
standard of care. Its hub-and-spoke model is intended to help
ensure that veterans are connected to the same high standard of
care regardless of where they live. This does not happen by
accident. VA's position as the best provider of care for
veterans with spinal cord injuries relies on continual
investments in VA's infrastructure, workforce, long-term care
services and supports, and other benefits for veterans with
spinal cord injuries and their caregivers.
I share the concerns of some of our second panel witnesses
about VA's ongoing strategic pause in hiring and the impact it
is having on staffing and care for veterans with spinal cord
injuries. The highly specialized training and staffing ratios
necessary to provide appropriate care to veterans with spinal
cord injuries means that it can be challenging to fully staff
VA's SCI/D system of care. However, workforce shortages lead to
beds going unfilled, decreased access to care, and worse
outcomes for veterans with spinal cord injuries. We must remain
vigilant and sure that vacancies at SCI/D centers are
continuously filled.
Now, because of the advanced training required of
healthcare providers that are caring for veterans with spinal
cord injuries, special attention must be paid to bolstering the
workforce pipeline. It is vital to ensure VA is training and
retaining an appropriate workforce for this population, and I
look forward to discussing ways VA is doing this.
Now, improving VA's infrastructure has long been a priority
of mine, but the importance of this goal cannot be overstated
when it comes to serving veterans with spinal cord injuries. VA
must focus on infrastructure projects that build more capacity
for SCI/D beds and ensure additional access within the hub-and-
spoke model. At the same time, many existing VA facilities are
in need of repairs or retrofits to ensure that they meet
evolving standards of care for SCI/D veterans. Now, meeting
both these needs will take thoughtful investment and planning,
both from Congress and VA, and I look forward to working with
VA on these vital projects.
Finally, veterans need to be able to receive care in the
venue that best fits their lives and needs, and many veterans
rely on home-and community-based services for healthcare and
support. Through the Veteran Directed Care program, veterans
with spinal cord injuries have the ability to hire their own
personal care aides and engage in decisions about their care
that ensures it fits their needs and their lives. Most
importantly, it is crucial that veterans receive the care that
they need in the community without being subject to statutory
spending caps that could drive them to institutionalized
settings of care.
Now, my colleague, Congresswoman Julia Brownley's bill, the
Elizabeth Dole Home Care Act, H.R. 542, meets these needs. It
passed the House in December, and I urge the Senate to do the
right thing, to move it forward. I agree with Chairman Bost
that the politics must be set aside. The last I heard, his
party is in the majority, and they could bring a bill to the
floor at any time to address those needs. I would ask that he
bring such a bill to the floor without the sort of--well, with
a bipartisan agreement, basically, on what it contains. There
is bipartisan agreement on H.R. 542.
I just want to thank all of our witnesses for being here
today. I look forward to hearing from each of you about how we
can ensure the well-being of all veterans living with spinal
cord injuries.
I thank the chairman again, and I yield back.
The Chairman. I thank the ranking member for his opening
statement. We will now turn to our witnesses.
Testifying before us today we have Dr. Erica Scavella, the
Assistant Under Secretary for Health for Clinical Services, and
she is accompanied by Mr. Jeffrey London, the Executive
Director of the Medical Disability Examinations Office. Also on
the panel, we have Mr. Steve Bracci, the Director of Claims and
Medical Exams Benefits Inspection Division of the Office of
Inspector General (OIG).
Dr. Scavella, you are recognized for 5 minutes to give your
opening testimony.
STATEMENT OF ERICA SCAVELLA
Dr. Scavella. Good morning, Chairman Bost, Ranking Member
Takano, and committee members. My name is Dr. Erica Scavella. I
am the Assistant Under Secretary for Health for Clinical
Services, and in that role I directly, through my Deputy
Assistant Under Secretary, oversee the Spinal Cord Injuries and
Disorders System Executive Director. I am accompanied by Mr.
Jeffrey London, the Executive Director for the Medical
Disability Examination Office with the Veterans Benefits
Administration. Thank you for this invitation to testify before
you today.
Spinal cord injuries and disorders, or SCI/D, present
unique challenges and complexities, often requiring specialized
care and support. At VA, we are dedicated to addressing the
diverse needs of veterans with spinal cord injury and
disorders, ensuring access to rehabilitative services,
specialty benefits and services, and assistive technologies.
VA's SCI/D system of care is a comprehensive network
designed to deliver exceptional care. This system operates
under a hub and spokes model wherein 25 regional SCI/D Centers
serve as hubs providing comprehensive care, while primary care
services are rendered at VA Medical Centers, acting as spokes,
by the SCI/D patient-aligned care teams. Mental health services
are seamlessly integrated into the care plan, ensuring a
holistic approach. Mobility interventions and walking aids,
including walkers and canes, manual and motorized wheelchairs,
and exoskeletons, are tailored to fit the individual needs of
veterans, enhancing their independence and quality of life. The
system also offers a range of long-term care options, including
noninstitutional and home-based care, as well as support
through the Caregiver Support Program, ensuring a continuum of
care for those in need.
While serving as a Marine on his second tour in the Vietnam
War, Mr. Ron Kovich suffered a spinal cord injury that left him
paralyzed from the chest down. For the past 53 years, Mr.
Kovich has received his primary and specialty care through VA.
This past July, on his 78th birthday, Mr. Kovich penned an open
letter sharing his thoughts on his VA experiences. In his
letter, he stated, ``I have been a patient in the Long Beach VA
spinal cord injury hospital for the past week for a bladder
infection. The care has been excellent. Aides, nurses, doctors
have been terrific. Things have vastly improved over the years
over here. Ever since I was a patient in 1971, I have had to
come to this hospital many times over the years and I have seen
many changes. I can honestly say that the care here of our
veterans is now second to none.''
VA strives to ensure every veteran's experience echoes that
of Mr. Kovich. To accomplish this, we provide various
initiatives and programs to improve the accessibility in
medical facilities, including providing eligible veterans with
reimbursement for self-arranged travel, special mode
transportation, door-to-door appointments, and funding for the
Highly Rural Transportation Grant service for travel
coordination in highly rural counties. VA often continuously
upgrades its facilities, integrates assistive technologies, and
deploys mobile units for accessibility, prioritizing women
veterans' unique needs with specialized facilities for their
privacy, comfort, and tailored care. Outside of the facility,
VA provides disability compensation, independent living
training, and housing benefits, including the Special Adaptive
Housing Grant program you mentioned, providing financial
assistance for home modifications to address accessibility
needs.
Additionally, we oversee contract examinations to ensure
facility safety, cleanliness, and accessibility, and we work to
increase the examination of our care through telehealth and
acceptable clinical evidence exams. The Veteran Readiness and
Employment Program additionally assists disabled veterans in
preparing for, obtaining, and maintaining suitable employment.
Finally, one of our most successful and impactful programs,
the VA Adaptive Sports Clinics, provides the ability to empower
veterans with spinal cord injury and disorders and engages them
in physical activities tailored to their unique needs and
abilities. These programs, which I have witnessed myself, allow
veterans the opportunity to participate in a variety of sports
and recreational activities, promoting physical fitness, social
interaction, and overall well-being, completing the continuum
of care.
Chairman Bost, Ranking Member Takano, this concludes my
testimony. My colleague and I are ready to answer any questions
you may have.
[The Prepared Statement Of Erica Scavella Appears In The
Appendix]
The Chairman. Thank you, Dr. Scavella.
Mr. Bracci, you are recognized for 5 minutes to give the
OIG's testimony.
STATEMENT OF STEVE BRACCI
Mr. Bracci. Chairman Bost, Ranking Member Takano, and
committee members, I appreciate the opportunity to discuss our
review of Veterans Benefits Administration's (VBA) oversight of
the contract medical exam facilities used for veterans
disability claims.
VBA has paid contractors billions of dollars since 2017 for
these exams, which may be needed to decide claims. The exams
are typically conducted at the medical examiner's place of
business, and those facilities must be accessible, safe, and
clean. The four exam vendors that VBA uses are required to
inspect these facilities for compliance with American with
Disabilities Act (ADA) and Occupational Safety and Health
Administration (OSHA) standards. We focused on veterans'
feedback and experiences regarding the accessibility, safety,
and cleanliness of the contract exam facilities. While we are
not ADA or OSHA compliance officials able to cite specific
violations, we did identify deficiencies at 113 of the 135
facilities we visited. These deficiencies created needless
burdens and safety concerns for veterans with mobility issues
and those with spinal cord injuries and disorders. We found
that the deficiencies went largely undetected by Medical
Disability Examination Office (MDEO) because that office did
not provide sufficient oversight of the vendors' self-
certification of ADA and OSHA compliance.
In 2021, VA modified the vendors' contracts by removing the
requirement for MDEO to conduct random as well as complaint-
based site visits. Notably, in Fiscal Year 2022, MDEO did not
conduct any site visits based on veterans' complaints. Our
finding was bolstered by four determinations.
First, MDEO lacked independent access to the current
inventory of contract facilities. By depending on the vendors
to provide this information, MDEO could have incomplete lists.
In fact, two vendors could not provide a definitive number of
exam locations. Our first recommendation asked MDEO to maintain
a list of the contracted facilities. While this may be the
contractor's proprietary information, VA routinely handles this
critical information like this in other areas and can protect
this information in the same manner.
Second, MDEO allowed the vendors to give customer
satisfaction surveys rating their own performance to veterans
instead of using an independent survey vendor. This may have
resulted in VBA lacking a full picture of veterans'
experiences. Therefore, we recommended that veterans receive
the comment cards directly from an impartial survey provider.
Third, MDEO lacked formal guidance for staff conducting
exam facility site visits. MDEO staff were not trained on the
standards of review and their checklists were not specific
enough. For example, MDEO staff did not know specific criteria,
like the minimum space needed for a wheelchair to turn. Also,
we found their site visits were based on general observation of
the facilities. We made three recommendations to develop formal
site visit procedures, update checklists, and create
standardized training for staff.
Fourth, MDEO did not validate the vendors' self-
certification of ADA and OSHA compliance. The vendors' self-
certification process was not comprehensive or reliable, likely
contributing to the deficiencies. Importantly, MDEO was not
doing reviews based on veterans' complaints. We recommended
that VBA conduct complaint-based inspections and enforced the
requirement for vendors to inspect and recertify the
accessibility, safety, and cleanliness of all facilities.
Because of accessibility deficiencies, some veterans could not
complete exams at those facilities. Additionally, some
facilities had safety deficiencies, including locations with
blocked exit routes or expired fire extinguishers. Other
facilities lacked clean common areas or single-use medical
supplies.
ADA deficiencies at facilities may make them unable to
accommodate veterans with mobility issues. Our report has
numerous examples of facilities where wheelchair users could
not enter the location, so an exam was not possible.
Rescheduling exams after veterans have needlessly traveled to a
facility takes time and could delay their claim. We recommended
that VBA analyze all veterans' complaints and create action
plans to remedy them.
Our last recommendation asked VBA to work with its vendors
to determine if a veteran requires accessibility arrangements
before the exam. All recommendations are open and we will
monitor VBA's progress on implementing the corrective action
plans to address the hardships and safety issues that veterans
with mobility challenges have experienced during medical exams.
Mr. Chairman and members of the committee, I am happy to
answer any questions that you may have.
[The Prepared Statement Of Steve Bracci Appears In The
Appendix]
The Chairman. Thank you, Mr. Bracci. We are now going to go
to questions, and I will yield myself 5 minutes for the first
questions.
Dr. Scavella, we have heard that VA transportation is often
inconsistent and not accessible to SCI/D veterans, which result
in missing medical appointments. Can you tell me how many
missed appointments are the result of VA transportation issues?
Dr. Scavella. Thank you for that question. Our goal is to
make sure we are providing access to our veterans, so we do
have a number of vehicles to be used by our veterans who may be
trying to get to appointments. If a veteran who has spinal cord
injury and disorders self-schedules their appointment, we will
reimburse them. If they live in a highly rural program or area,
we have a highly rural transportation program. We also operate
a Veterans Transportation Program through volunteers, and then
we do have the beneficiary travel as well as the Veterans
Transportation Program. I will need to ask for a number. I do
not have a number of how many veterans may have missed an
appointment.
The Chairman. Okay. That is something we need to know from
the committee. Also, with that, if you can check your records
and have try to get a calculation, because we try to get our
calculation, I said in my opening statement, we believe it is
$4 million that it has cost to miss those appointments. The
number of appointments and then how much it has actually cost,
how much it has ran over.
Mr. Bracci, can you please explain to me the problems with
the audio booth that is pictured right here behind me?
Mr. Bracci. Yes, sir. There are a couple of issues with
that particular audio booth that we saw. The first is
accessibility. There was not a ramp available where a veteran
in a wheelchair could get up into the booth. The second issue
is the actual size of the booth. It was not large enough to
accommodate a veteran in a wheelchair. The minimum dimensions
are 60 inches in diameter, and it did not meet that standard.
This is an important issue because we did identify
instances where veterans had accidents and they tripped and
fell trying to get in and out of an audio booth like this, and
ended up--we saw one case where a veteran fractured their hip
and required surgery. It is not just a matter of complying with
standards. It has real impact on veteran safety.
The Chairman. You answered my second question. That would
have been, have there been injuries and even severe injuries
occur because of things like this?
Mr. Bracci. Yes, based on the work we have done, there
certainly have been. We identified--I think we have three
examples in our report that showed issues where veterans have
had accidents and have been harmed.
The Chairman. Thank you. Dr. Scavella, what is the average
time it takes from when a veteran applies for special housing
adaption to when the contractors begin construction of that
adaption?
Dr. Scavella. Thank you for that question. I am going to
turn that over to Mr. London, who is the executive for the
Veterans Benefits Administration.
Mr. London. Thank you very much for the question. Of
course, it is variable, depending on the types of adaptations
that a veteran needs to meet his or her or their needs. Also
the location of the particular residence that is being modified
and availability of contractors. Generally speaking, it can
take over 90 days in many cases to accomplish what you asked.
The Chairman. Then the follow-up question on that is, and I
know you cannot do anything about location, but what else can
we do to speed up the process? Every day is a bad day with not
having access to this.
Mr. London. I understand the question, and I agree with
your sentiment. Some of the things that we have done to
expedite the process to assist the veteran, because one of the
things that needs to happen is the veteran has to choose the
contractor, but we do not leave the veteran by his or herself
to make that decision. We have a list of contractors that have
successfully completed projects in the area to help expedite
the process, and they also have familiarity with the details of
what is required for these special needs.
The Chairman. Thank you. Dr. Scavella, I am concerned about
the staffing level at SCI/D centers. Do you believe that VA
medical facilities are properly staffed for all SCI/D beds?
Dr. Scavella. Thank you for that question. Our goal is to
make sure we are providing the care that the veterans need. We
do have strategic hiring and spinal cord injury disorders is
one of the areas that we have specifically communicated we
expect those areas to be fully staffed. We currently have a 9
percent vacancy rate across the country, which is a decrease in
the past 5 years. If you look at our statistics between Fiscal
Year 2019 and Fiscal Year 2024, we have over 232 percent growth
in that particular area across the country to include all
staff.
The Chairman. Well, that is, I guess, how you would respond
to the VA facilities. There are a lot of claims out there that
you are short staff nurses in and around the country.
Dr. Scavella. There is a healthcare shortage generally,
both within and outside of VA, which we are contending with. We
are being creative in our salaries, making sure that we are
being competitive, making sure that we provide the opportunity
for growth once employed by VA, to make sure that our
environment of working is something that is desirable by people
so that they will be willing to come into VA. We are making
sure that our benefits packages for employees are enticing as
well.
We are also collaborating with university affiliates to
make sure that we bring in the top talent into our
organization. We realize that people who train within VA, like
myself, tend to come to VA to work permanently.
The Chairman. My time has expired by over a minute, but
thank you very much for the--and I will now recognize the
ranking member for his questions.
Mr. Takano. Thank you, Mr. Chairman. Mr. Bracci, thank you
for the recent OIG report on accessibility and safety at
contract facilities for disability exams. Veterans may only use
these facilities for a one-time exam, yet OIG found physical
barriers that hindered access for veterans who use wheelchairs,
among other things. Now, I am concerned that there may be
similar issues with private sector providers that veterans are
referred to once they start using the VA healthcare system. Has
OIG looked at VA's community care network providers and whether
they are meeting ADA and OSHA standards?
Mr. Bracci. To my knowledge, we have not looked at that
issue.
Mr. Takano. Okay. Well, thank you. Would you tell the
Inspector General Missal that I would like him to look into
this issue?
Mr. Bracci. Yes, I will.
Mr. Takano. Thank you. Dr. Scavella, I understand that as
of last month, only 153 of the 181 long-term care beds that VA
is required to have in operation at its SCI/D centers are
actually available for veterans. Can you explain why?
Dr. Scavella. Thank you for that question, Congressman
Takano. We have some challenges in some places, doing staffing,
and then there are a variety of reasons that may affect our
ability to have a bed open. If we do have a bed available, but
it is occupied by a veteran who may have a certain infectious
disease, we may have to not use the other beds in that room.
Mr. Takano. Okay. I am hearing staffing, though, is the
kind of predominant reason, lack of staff. These beds are empty
because there is no one there to staff the veterans who might
fill them. Just to be clear, veterans with SCI/D need access to
long-term care beds at VA. Is there a waiting list?
Dr. Scavella. We do not have patients who are waiting to
get in. If we are unable to provide the care within our
organization because of the acute need of this illness that
they have, we will make sure that we coordinate with our
community partners, recognizing or transfer to other facilities
within our VA.
Mr. Takano. You are saying there is no waiting list because
you place them in community partners?
Dr. Scavella. If we are unable to house them within one of
our hubs or provide care in our spokes--it is a complicated
answer.
Mr. Takano. Okay. Yes, I could go into whether or not those
community care facilities rise or meet the level that is
provided at VA. I want to go down another train of thought
here.
I am sure you understand that my concern that VA is
proposing to move up to $10 billion from direct care and
medical facility infrastructure to community care in Fiscal
Year 2025 to cover an expected shortfall. Now, this certainly
will not help fill the vacancies in staffing that we are
talking about in VA's SCI/D system of care. How can VA make the
needed investments in the SCI/D workforce to provide the best
care for veterans if we are diverting so much funding to
community care?
Dr. Scavella. As I have said earlier, our goal is to try to
keep our veterans in our system. We want to make sure that we
are providing the care for veterans. We have increased our
staffing in spinal cord injuries and disorder by over 230
percent in the past 5 years, and we are making sure that we are
enticing employees to come into our system as a provider of
choice.
Mr. Takano. I get that. The administration is making a
decision to move money out of direct care, which you need you
need the staffing. Beds are empty, and that is forcing you to
put people into the community already.
I share the concerns that PVA expresses in its testimony
about VA's decision to severely limit hiring in fiscal years
2024 and 2025. VA issued a May 31 memo directing facilities to
continue filling vacancies in VA's Spinal Cord Injury System of
Care. How is VA going to hold the field accountable and ensure
that there is sufficient workforce to meet the needs of SCI/D
veterans?
Dr. Scavella. Thank you for that question. We are coming on
the heels of a remarkable 61,000--over 61,000 employees who
have been brought into our system, mostly in direct care
positions, and we have increased the staffing in our spinal
cord injury and disorders. We only have a 9 percent vacancy,
which is lower than it has been. We continue to prioritize that
through our strategic hiring to make sure that we are providing
that care.
Mr. Takano. Excuse me for interrupting, but have you set a
target date for the field to address staffing challenges that
led to the closure of long-term care beds specifically? I mean,
is there a target for that?
Dr. Scavella. The request is to make sure we are
strategically hiring, realizing that it takes time to bring in
nurses and physicians, specifically because of the requirements
to make sure that their credentials are what they say. We have
a directive or memo from the Undersecretary for Health
regarding how we should be moving forward. It is clear to our
organizations, and the expectation is that those direct care
appointments and opportunities would be provided first. Our
plan is to get those employees out there.
Mr. Takano. I am glad it is prioritized, but has he set a
target date?
Dr. Scavella. I would have to look back at the memo to give
you that date.
Mr. Takano. Could you get back to me on that? I hope, if
there is not one, that there will be a concrete target date set
to fill these beds--to staff these beds.
I yield back, Mr. Chairman.
The Chairman. Thank you, Ranking Member.
Dr. Miller-Meeks.
Ms. Miller-Meeks. Thank you very much, Chairman Bost. Thank
the witnesses for being here.
It is a little bit surreal to me because I started out my
career as a second lieutenant nurse in the Army, stationed at
Walter Reed on Ward 10, the neurosurgery floor. Taking care of
traumatic brain injuries, which we did not call them that at
the time, spinal cord injuries, I flipped my share of Stryker
frames and also worked with halos. My husband, interestingly
enough, got out of the military to get his Bachelor of Science
in Nursing (BSN). He was an E6 Licensed Practical Nurse (LPN)
when we met, and took care of a spinal cord injured veteran as
a private LPN to do that before the VA provided that care. I
know how challenging this can be.
Dr. Scavella, according to some of the data obtained by
committee staff, we know that 18 percent of patients seen in
the past 3 years for spinal cord injuries and disorders were
also seen for substance use disorder or had that diagnosis. Do
you believe that the VA has the capacity provide inpatient
mental health and substance use disorder care?
Dr. Scavella. Dr. Miller-Meeks, thank you for that
question. We do feel as if we have that ability because we are
an integrated healthcare system. Mental health is embedded in
the patient-aligned care teams that provide primary care for
this population of veterans. If they require substance use
disorder on an inpatient setting, we are able to provide that
care as well. We do have systems across the--services across
the system.
Ms. Miller-Meeks. Are the SC--and this is, again,
reminiscent of the old, old Walter Reed. Are the SCI/D units
using four patient bed models in their centers, and do you
believe that having four patients in a room is appropriate for
minimizing risk of infection and creating a healing
environment?
Dr. Scavella. Yes. Congresswoman Miller-Meeks, thank you
for that question. We have older facilities, as you just
reminded us of, that do have four beds in some rooms. We are
constructing facilities that do not have that configuration.
Our goal is to try to reduce the size of the rooms to make sure
that we are giving patients the privacy both from, you know, a
mental capacity and from a healthcare capacity.
That is not the standard at this point in construction.
When and where possible, we will not use all four beds in a
room to make sure that we are giving patients the privacy that
they require.
Ms. Miller-Meeks. Thank you. Just to follow up on
Representative Takano's question, what are the main barriers,
and you may have answered this, to staffing SCI/D centers as
opposed to other VA medical facilities?
Dr. Scavella. Yes. Thank you for that question. We
understand that this is a highly skilled area, as you just
mentioned, during your experience. These veterans require lots
of care, lots of patience, and so it takes a certain type of
clinician or professional to be a provider of that care. Making
sure that we recruit, retain the highest skilled employees in
those areas is really important. We want to make sure that they
have the highest quality and so we review that on a regular
basis through our ongoing professional practice evaluation. We
also want to make sure that once we bring them in, that we are
giving them the tools to grow as professionals, to make sure
that they stay with us and continue to serve veterans.
Ms. Miller-Meeks. I would say it was some of the most
rewarding medical care as a nurse or a doctor that I had ever
administered.
Mr. Blake, the committee is aware of a few promising
technologies. I think we cannot have this hearing without
mentioning the innovation that is occurring in this space,
mainly brain-machine interfaces, which hold immense promise for
catastrophically disabled veterans. What research or outreach
has PVA done in this space and technology and its key players?
Excuse me, second panel. Thank you very much. I yield back
my time, but I will submit the questions for the record.
The Chairman. Representative Brownley.
Ms. Brownley. Thank you. Dr. Scavella, you testified, I
think, in response to the chairman's question, that you do not
know how many missed appointments there are due to
transportation. Why would you ever turn down a catastrophically
disabled veteran who had travel issues once they got to the VA?
Why would you ever turn them down for his or her appointment?
Dr. Scavella. Thank you for that question. I am not aware
of us turning anybody away, and that is why I do not think I
can answer that question. We would make sure that we are
providing that care, whether they are late, by a day or by a
minute. It is important that we are providing the care when and
where they need it.
If we are, for whatever reason, whatever the condition is
of that veteran, if they are too ill for the capabilities of
the facility that they show up in, we will make sure that we
get them to the appropriate level of care, whether it is in the
VA system or in the community. Obviously, our goal is to try to
keep them within our system because of all the things I have
talked about with continuity, making sure that we can provide
that care, not just for whatever the issue is, but the whole
health of the veteran.
Ms. Brownley. What are your--how would you describe your
best practices for the LGBTQ community for women who are
catastrophically disabled?
Dr. Scavella. Thank you for that question. We appreciate
legislation that has helped us to ensure that women veterans
who have spinal cord injury and disorders can receive the care
in-house or at home that they require, as well as for things
such as mammography, which is difficult related to positioning
them. We are very grateful for that.
Our goal, through the messaging from the Secretary through
to each employee, is to make sure that we are providing care
for every veteran who has served. Our mission statement has
changed to reflect that, and both the Secretary, the Deputy
Secretary, who is very concerned about us, making sure that we
are here for women veterans who may not see their place, that
we are providing that open and welcome care.
Ms. Brownley. What about the LGBTQ?
Dr. Scavella. LGBTQ, we have several different projects
related to making sure that we are being open. Currently, June
is Pride Month, so we are recognizing our population of both
employees and veterans during this month to make sure that we
are providing that care, that people know that they can see
themselves as their authentic selves here at work. There are a
lot of things ongoing to make sure that we are being open and
responsive to the population.
Ms. Brownley. My understanding is when women with spinal
cord injuries or disorders show up at a health clinic or a
medical center, that they are then required to go to an SCI/D
center first in order to be referred to by an ob-gyn. Is that
true?
Dr. Scavella. We are going to try to provide the care to a
veteran who may show up in whatever care place she may show up.
Ms. Brownley. I understand that is your goal, but I want to
know what the reality is happening today.
Dr. Scavella. When we have a new patient come in, if they
are coming in for their care, if they are spinal cord injury
and disorder disorders veteran, we would want to make sure that
we are tying them in with that population to provide that care.
If they are coming in for women's health services and we can
provide that care in the women's health clinic, we will do
that.
Ms. Brownley. Basically, you are saying that is not really
happening. If they show up at a medical center or health
clinic, they are not getting referred to an SCI/D center?
Dr. Scavella. Unless you have a specific instance that you
would like me to look into, I am unaware of that.
Ms. Brownley. Okay, Okay. Can you speak a little bit to the
differences between the Elizabeth Dole 21st Century Healthcare
and Benefits Improvement Act and the standalone bill, that was
supported in bipartisan way, I will add, the Elizabeth Dole
Home Care Act. Can you talk a little bit about the differences
in what the VA really supports in terms of those two bills?
Dr. Scavella. Thank you for that question, Congresswoman
Brownley. I will have to take that back. I do not have the
Department's technical review of those at my fingertips at this
point, so I cannot speak freely about that.
Ms. Brownley. Great. Well, the last thing I will just say,
too, is having had a meeting in my office yesterday, that I
know that there are PVA members in this room who have
personally experienced being turned away after traveling to VA
appointments. I would really encourage you to speak with them
and hear their stories because I think what you are saying and
what we are hearing from PVA members do not line up. Obviously
we need to get to the bottom of that. I would appreciate it.
With that, I yield back.
The Chairman. Thank you, Representative Brownley.
Representative Luttrell, you are recognized.
Mr. Luttrell. Thank you, Mr. Chairman. Dr. Scavella, if I
were you, I would take a hard look at the room behind you
before you get out of here and leave, because they were shaking
their heads to Ms. Brownley's point. That is something you are
going to want to have an answer to when you engage with the
committee. Okay? How long have you been in this position?
Dr. Scavella. I have been in this position since January
2022. I have been at the VA for 25 years.
Mr. Luttrell. Twenty-five years. Mr. Barachi, that IG
report, are there any bullet points on that report that have
been replicated over previous years?
Mr. Bracci. Some common themes. You know, as far as the
contract exam program, we have been focusing on that for
several years now because of the millions of veterans that
impact----
Mr. Luttrell. What discrepancies that we are seeing in the
VA system that are ongoing?
Mr. Bracci. I would say that just the oversight by MDEO, we
see that continuously. I will say that they address issues as
we identify them and as we make recommendations, but it is the
proactive oversight up front.
Mr. Luttrell. Well, the oversight report that you submitted
and the previous oversights report that we have engaged with
are stating the same thing over and over again. Dr. Scavella,
can you tell me why the VA system is, I guess in my opinion, I
am going to say, taking this kind of haphazardly and not
engaging with--I mean, when you have spinal cord injuries--
again, I am saying because I am looking behind you and I am
seeing everybody. Right?
I really want to know why this--and the Secretary's number
one priority is suicide, and I appreciate that wholeheartedly.
When our veterans have lost the ability to be mobile, amongst
other things, everyone is neck and neck. If we continue to have
an IG report that is pretty much beating the hell out of the
VA, I want to know why the leadership is not taking advantage
of the situation and fixing the problem.
You have not given us any dates. I have listened to the
committee members, including the ranking member, ask questions.
What are the dates? The dates. In the military, we ask for
dates. Those are hard lines because we function that way. That
is how we operate. I want to know when the VA is going to throw
us a hard time and say, hey, this is when we are going to fix
this. Can you answer that question for me?
Dr. Scavella. Thank you for that question, Congressman
Luttrell. We are making sure that we are answering the mail
when it comes to these findings. I am in the Veterans Health
Administration (VHA).
Mr. Luttrell. Well, what does that mean?
Dr. Scavella. I am going to turn this question over to the
Veterans Benefit Administration, who runs this program. I do
not oversee it.
Mr. Luttrell. Mr. London.
Mr. London. Congressman Luttrell, thank you very much for
the question. To answer your question specifically, the
recommendations that OIG identified in the report, will all be
satisfied by the end of this fiscal year, so by September 30.
Three of the recommendations we have already implemented, and
we will provide all of the evidence to OIG after they are
completed on September 30.
Mr. Luttrell. September 30, that is a hard time. That OIG
report is going to be completely resolved?
Mr. London. Yes, sir, and, yes, sir. Last year, when I
testified before your subcommittee, you challenged me to make
sure that you were going to hold me accountable. You can hold
me accountable for those dates as well.
Mr. Luttrell. Absolutely. Thank you, sir. I respect your
leadership and honesty. Thank you for doing that.
My second question is, I ran into a lovely young lady. She
was over here in the Longworth Building. She had--and for life
of me, I cannot remember the exact mechanism that she--she has
a robotic mechanism that allows exoskeleton. Thank you, Mr. Van
Orden. Hearing her story of what she had to go through to get
that, she ended up having to pay for it on her own, her and her
family. She was telling me the story. She was a Marine, by the
way, so you can only imagine how engaging that story was. My
curiosity is, why has not the VA stepped up in that space?
Dr. Scavella. Sure. Thank you for that question, Mr.
Luttrell. When it comes to exoskeletons, because of the level
of independence that is required, there are certain
requirements that need to be in place in order to determine
which veterans are best suited to actually have an exoskeleton.
We have to weigh the benefits and the risks. The benefits are
increased mobility and increased autonomy. However, the
manufacturers of exoskeletons require the assistance of another
person. Even though a veteran may be moving around, in order to
get into and out of that equipment, they do require another
person to be around. That is stated by our veterans as the
largest barrier to them, actually.
Mr. Luttrell. Sure. Yes, her father was with her. I think
there may be a communication breakdown because the VA did not
come through with her, and she benefits greatly because of her
exoskeleton. I do not know by, with, and through the
organization how we need to move the pieces on the chessboard
to fix this. I think there is a way to do that to fix this
problem set. I just would ask the VA to take a harder look at
the advancements in technology for our members in need.
Dr. Scavella. Thank you for that statement. We are
continuing to look at innovative projects and programs to
support our veterans. In 2016, I am not sure when she received
her exoskeleton, we did devise a specific type of evaluation
for those veterans who are interested in exoskeleton. There are
a number of other types of innovative technologies to include
neurostimulation and other types of equipment that can help our
veterans who have spinal cord injury and disorder. Again,
everything is evaluated on a case-by-case basis to make sure
that it is the safest for veterans.
The downside, unfortunately, of some of these is because of
the mobility issues, is that they can have skin breakdown,
which can lead to infections and other problems, as well as
some other neuromotor issues that can happen with spinal cord
injury disorders veterans. We need to make sure that we are
providing care that is not only what they want, but what we
think is safe.
Mr. Luttrell. Thank you, Doctor.
I yield back, sir.
The Chairman. Representative Landsman., you are recognized.
Mr. Landsman. Thank you, Mr. Chair, and thank you for the
hearing, and thank you all for being here.
The U.S. Government Accountability Office (GAO) report that
my colleagues have been talking about, we are talking about
here the number of deficiencies. You know, something like 85
percent of the facilities had one or more deficiencies. I do
not want to get into that. I mean, I appreciate the comment
about the report and the fact that the recommendations will be
dealt with in some period of time.
I have a larger question which I typically ask around
continuous improvement and hospitals in general. We think of
them as places where, you know, good things happen and bad
things do not, though we know and you all know, the folks here
know, that bad things happen all the time. The bad things are
really bad in some instances. I mean, these are adverse events
or serious safety events, medical errors, these kinds of
things.
I bring those up because in Cincinnati, we have a
Children's Hospital which is now ranked, I believe, number one,
but it is one, two, three every year. They got that way based
on a commitment to being the best at getting better. That is
what the board decided. That is what the leadership decided.
That is what surgeons and nurses and everyone affiliated with
the Children's Hospital in Cincinnati decided. It took them
years, but they started with the serious safety events, and
they wanted to get that to zero, because the only number that
was acceptable is zero. They have not had a serious safety
event in over 2 years, and it led them to get very serious
about everything, from post-surgical infection rates, to the
customer experience and things like this, this GAO report and
deficiencies.
They, you know, so, for example, they had a million--they
got a 96 percent satisfaction rate. One of the board members 1
year said that that is good, but we see a million people every
year, so that means 40,000 people were unsatisfied. Let us do
better. It was that attitude. Now they are--you know, they have
much higher satisfaction rates.
I am curious about, you know, because you all deal with
some of the most significant and complicated medical issues,
and I am curious, what approach do you all have now as it
relates to getting better, the measures that you use? What does
it look like in terms of the culture? How would you describe
where you are at now versus where you would like to be?
Dr. Scavella. Yes, thank you for that question, Mr.
Landsman. We are constantly striving to improve the care we
provide within our organization, and we also have the same type
of stretch goal, to have no complications, no falls, no
infections, things like that. We have a continuous improvement
process that takes place at the medical centers individually.
I do want to make a distinction that the concerns raised in
the report were related to the oversight of external
organizations that we are sending veterans to as opposed to our
medical centers themselves as--.
Mr. Landsman. Yes, to that. This was just one data point,
and it had to do with care unrelated to yours. The adverse
events or medical errors associated with community providers
was 2X in one particular area. We have contracts with those
organizations and presumably they could, you know, ascribe to
or be required to ascribe to the same continuous improvement
and performance measures as us. What does that look like?
Dr. Scavella. Right. One of the things I will talk, and I
will let Mr. London add to this answer, is that we are
increasing the number of visits that we are conducting to the
those facilities. You know, this is coming off the tail of the
pandemic where first we did not travel because it was unsafe
and then there was still a restriction on travel.
Mr. London, would you like to add to that?
Mr. London. Yes. Very similarly, we started traveling in
April 2022 to do site visits. Since that time, we have done
over 700, including an additional 300 virtual visits. We plan
to continue to do those and increase the number of visits that
we are going to have going forward to make sure that we are
continuously improving.
Mr. Landsman. I appreciate it. My time is up. Thank you. I
yield back.
The Chairman. Mr. Van Orden.
Mr. Van Orden. Thank you, Mr. Chairman.
Dr. Scavella, we keep hearing the same words and phrases
all the time: continuously improving, doing our best, we are
shooting this. We keep hearing the same stuff over and over and
over again. We are trying to get better. We are trying. We are
trying.
Will you turn around, please? I would like you to get the
view that--I am serious. Will you please turn around? This is
the view that Congressman Luttrell had of these people that are
permanently assigned to having to have artificial apparatuses
to function and live. As your Department continuously strives
to improve and get better and do all this stuff, and the IG
report just says you are not, they are still stuck in those
chairs, ma'am, while you get to go home, and while your staff
that is continuously improving gets to go run in a field with
their family, and they do not get to do that.
I am thoroughly unimpressed with your Department's
performance. I think that the IG report says that you guys are
failing. When is someone at the Veterans Affairs, when is
someone at the VA going to be held accountable to the point
where they are not working there anymore?
Dr. Scavella. Thank you for that question. When we do see
performance issues, we have to document those and go through a
process to separate someone from employment. In those
instances, whether it is related to poor care or poor
coordination of care, we take those actions.
Mr. Van Orden. When is the last time you have fired someone
from the VA for poor performance?
Dr. Scavella. I am not overseeing direct patient care, so
my answer to that question would not really be illustrative of
what is happening in the field.
Mr. Van Orden. Okay. For what period of time did you not do
performance oversight visits during the COVID-19 public health
emergency? Was it the entire time?
Dr. Scavella. I will have to turn that over to Mr. London
because these were for the Benefits Administration.
Mr. London. Thank you very much for the question. Up until
from March 2020 to April 2022, we were precluded from in-person
travel.
Mr. Van Orden. Okay, so what happened during that period of
time? The vendors have been doing stuff the whole time, right?
Mr. London. Yes, sir. The vendors were responsible
contractually to ensure that each facility that they are used
to send our veterans for examinations were safe, sound, and met
the requirements of the contract to include OSHA and ADA.
Mr. Van Orden. Did you sign an employment contract, sir?
Mr. London. Did I sign an employment contract?
Mr. Van Orden. Yes. Like it says, Department of Veterans
Affairs.
Mr. London. I am employed by the Department of Veterans
Affairs, yes, sir.
Mr. Van Orden. Okay. You signed an employment contract to
be held accountable to the people that are sitting behind you,
essentially in wheelchairs. Correct? Yet you failed to do your
job during the entire COVID-19 thing, but you expected other
people to do theirs, is that right?
Mr. London. Mr. Van Orden, I appreciate your question. I
want to make clear that I joined this office in December 2021.
As soon as we were required or allowed to travel, I actually
went with the team and did site visits personally to make sure
that these sites met requirements. As soon as I was able----
Mr. Van Orden. Who is your predecessor?
Mr. London [continuing]. under my accountability, sir, that
is what I am here to do.
Mr. Van Orden. Mr. London, who is your predecessor?
Mr. London. My predecessor is now retired.
Mr. Van Orden. Okay. Did they retire with full benefits?
Mr. London. I am unaware of his situation.
Mr. Van Orden. Okay. I think you are seeing where I am
going here.
Mr. London. I do, sir.
Mr. Van Orden. Consistently, the theme that I get from the
Veterans Affairs Administration is that the Veterans Affairs
Administration is putting the Veterans Affairs Administration
above the veterans. That is not why you are here. It is not why
we are here. You guys have to understand, your bureaucracy is
not more important than the people sitting behind you in
wheelchairs who are trapped in that reality, and they cannot
escape that reality.
They are clapping for the hope that there will be
accountability in the Veterans Affairs Administration. I join
them.
With that, I yield back, Mr. Chairman.
The Chairman. Representative Budzinski.
Ms. Budzinski. Thank you, Mr. Chairman, and good afternoon,
everyone. I am glad we are having this important conversation
today about the unique issues that are affecting our veterans
with spinal cord injuries and disorders, SCI/D.
As my colleagues have spoken to and the OIG report
outlined, there is a lot of work to be done for this vulnerable
community. I want to focus on an area that I am particularly
interested in seeing improvements, which is with the veterans--
the women veterans living with SCI/D. I have attended several
congressional women veterans roundtables with VSOs who are
leading in the women's space, including Paralyzed Veterans of
America.
I just recently hosted my second women veterans roundtable
at home in my district and have heard specific concerns related
to today's topic. Women veterans already face very unique
barriers when seeking care, and those barriers are only
exacerbated among women veterans living with SCI/D. Many of our
health clinics or specialty areas within VA continue to lack
basic accessibility measures for those with of SCI/D, and the
cooperation among the SCI/D system and women's health
facilities continues to be severely lacking.
As you know, one of the main SCI/D centers in the midwest
is located in the St. Louis VA system, which serves many
veterans, including many in the southern part of my district in
Illinois, and I want to ensure we are equipping it with the
resources needed to provide adequate care for women vets living
with SCI/D.
Dr. Scavella, I believe that the VA continues to be the
best system for our vets with SCI/D to get care, but we have to
improve what I believe to be communication between systems. My
first question for you is, you know, what steps is the VA going
to take to ensure better cooperation and continuum of care
between SCI/D systems and women health clinics in particular?
Dr. Scavella. Thank you for that question. We continue to
partner with our women's health clinics to make sure that they
are able to meet the unique needs of the spinal cord injury and
disorder community. We are making sure that facilities have the
appropriate equipment as well as space to make sure that our
veterans who are women coming in for gender-specific care or
other care are afforded the privacy, the comfort that they are
entitled to. Those are things that are undergoing.
The Women's Health Innovation and Staff Enhancement (WHISE)
funding has been particularly useful in making sure that we
have the ability to provide that care, as well as other pieces
of legislation that specifically address mammography and access
for women who are spinal cord injury and disorders.
Ms. Budzinski. Is there anything specifically that you
could speak to just in observations on what women's health
clinics are equipped with today that would be something
immediately helpful to help those women veterans with SCI/D
kind of better integrate into a women's health clinic?
Dr. Scavella. Yes, thank you for that question. When we are
constructing newer facilities, we are ensuring that doorways
are wide enough, that rooms are able to be modified and
transitioned so that we can accommodate veterans who may be
coming in using motorized wheelchairs, which tend to be larger.
Then we can do appropriate gender-specific care in those spaces
with our employees who are skilled and trained in those areas.
That is what we are doing with our newer facilities. We do
recognize that some of our older facilities have some more
challenging navigation, especially for some of the newer
motorized wheelchairs that may not be able to get through those
spaces.
Ms. Budzinski. Okay. I wanted to highlight, there have been
instances of women with SCI/D getting a late diagnosis because
they had to put off appointments due to these accessibility
issues at their nearest women's VA clinics. This is especially
true, as you have just highlighted, for women with SCI/D who
are using wheelchairs.
Dr. Scavella, how is the VA going to improve access? You
talked about the needs, but what are kind of immediate next
steps that we can do regarding access to gender-specific care
for women living with SCI/D and how can we ensure facilities?
Again, you pointed out the things that need to happen, but what
can we do to take immediate action to make sure that is
guaranteed so our women veterans get the care they need?
Dr. Scavella. Yes, so we will make sure that we talk to
each of our veterans to understand exactly what they need. One
thing that we are making sure is happening is for veterans who
are coming in with spinal cord injury and disorders, we want to
make sure that all routine annual screening is completed,
whether we are talking about our women or our men, and that
those things are not afterthoughts. As part of their patient-
aligned care teams, they are specialized in spinal cord injury
and disorders. At those spokes or those centers, those hubs, we
are making sure that that is part of the care.
It may look different. We may not bring you physically to a
place to get that care. We can provide that care to you either
in the facility, in the hospital, or in your home. Then there
is telehealth as well as other modalities to make sure that we
are doing what we need to do.
Ms. Budzinski. Okay, thank you. Last, PVA leaders testified
at a recent Senate hearing that when providers are made
available to SCI/D clinics to provide ob-gyn services, they are
often general practitioners that are unable to answer questions
specific to women vets living with SCI/D.
Dr. Scavella, again, what can the VA do to better prepare
practitioners to provide culturally competent care for women
veterans living with SCI/D that need these services?
Dr. Scavella. Thank you for that question. We do have a
number of gynecologists, obstetrician/gynecologists who are
employed by VA. Then we do have a number that are in partner
with our university affiliates providing that care. Those are
two of the ways we can make sure they are receiving the highly
skilled gender-specific care that they require.
Then if we do have an internist or another specialty that
has the skills and the training to provide gender-specific
care, we just make sure that they are educated on this
particular population. We have ongoing engagement with the
Spinal Cord Injuries and Disorders National Program Office to
provide training specific to our veterans as well as other
types of engagements face-to-face, virtual, on an ongoing basis
as well as a community of practice. We are really making sure
that we are giving our employees the skills that they need, as
well as bringing in the skilled providers, physicians to
provide that care.
Ms. Budzinski. Thank you very much. I yield back my time.
The Chairman. Thank you. Thank you, Dr. Scavella and Mr.
London and Mr. Bracci for testifying today. You are excused.
We need to--we would like the second panel of witnesses to
approach the witness table and get ready. Thank you.
I would like to welcome Mr. Robert Thomas, the national
president and chairman of the board of the Paralyzed Veterans
of America. Accompanying him is Mr. Carl Blake, the executive
officer for Paralyzed Veterans of America.
Mr. Thomas, if you would, I would recognize you for 5
minutes to give your PVA's testimony.
STATEMENT OF ROBERT THOMAS
Mr. Thomas. Thank you. Chairman Bost, Ranking Member
Takano, and members of the committee, I appreciate the
opportunity to testify on behalf of the tens of thousands of
veterans with spinal cord injuries and disorders who rely on
the benefits and healthcare available through the Department of
Veteran Affairs.
For nearly 35 years, I have navigated the VA health care
and benefits system following the spinal cord injury I
sustained while on active duty. The care and benefits available
through the VA not only saved my life, but have given me the
ability to have a family, work, and serve my fellow veterans,
most recently, as you stated, as Paralyzed Veterans of America,
national president and chairman of the board.
I received my medical care through VA's direct care system.
However, about 10 years ago, I was in a motor vehicle accident.
I was taken to the nearest community hospital for immediate
care. I recall the emergency room doctor asking me if I was in
pain from the accident. I told the doctor that I was paralyzed
and unable to feel such pain. Without further examination, I
was given pain medication and just released. I knew that I
needed to get to the VA, where I later received the proper
examination. I know firsthand why people with spinal cord
injuries who did not serve tell me that they wish they could
access the care and support available through the VA.
Without the VA's SCI/D system of care, I do not know where
I would have been, and many of the men and women sitting here
behind me would say exactly the same thing if they were
speaking today. That is why we become so concerned when the
SCI/D centers have to close beds because they do not have
enough nurses to properly staff them.
Veterans Health Administration Directive 1176 provides the
staffing guidelines to allow healthcare professionals to
properly care for veterans with SCID. Depending on the function
level of an acute SCI patient, a nurse may spend an hour or
more each time with the veteran's room. That is why it is
important for SCI/D centers to have higher staffing levels than
other wards. We need every level of VHA, including Central
Office, Veterans Integrated Service Networks (VISN), and the
individual medical facilities, to take seriously the
requirements of VHA's Directive 1176. We need the VA to
properly deploy its resources and request the funding needed to
provide the level of care outlined in the directive. If the VA
system of care is not properly funded to ensure the staffing
levels meet the needs of the veterans with SCI/D, then our
government is defaulting on a promise made to care for us who
become catastrophically injured or ill in our service to this
great Nation.
It is not just acute post injury or diagnosis that we
depend on. It is also the lifelong care that allows us to
remain independent.
Caregivers are tremendously important for veterans with
catastrophic disabilities. My wife, LaShon, is not only my
spouse, she is also my caregiver. I mentioned Andrew, a veteran
with Amyotrophic Lateral Sclerosis (ALS), when I testified in
March. It is only because of the tremendous advocacy of
Andrew's wife, Lisa, that he is still receiving care at home.
Recently, she took the exceptional steps of petitioning
directly to the undersecretary of health, which compelled his
local facility to recalculate the cost of his care in an
attempt to delay his reaching the statutory cap. No family
should be forced to take such aggressive measures.
The Elizabeth Dole Home Care Act would fix this problem. We
need Congress to pass the Senator Elizabeth Dole's 21st Century
Veterans Healthcare and Benefits Improvement Act, which
includes this important legislation. I and my fellow paralyzed
veterans believe that the backing of every major veterans
organization should be enough to get H.R. 8371 through Congress
without further delay. Andrew cannot wait anymore. Lisa cannot
wait anymore. We cannot wait anymore for Congress to do the
right thing and pass this bill.
I am grateful for the support I received through the VA,
but my fellow veterans and I are concerned about the future of
the VA SCI/D system of care. Without a robust system, we are in
danger of living diminished, shortened lives. This is not what
we fought for and it is not what we will settle for. Thank you
for the opportunity to provide you with my perspective on VA's
SCI/D system of care and I will be happy to answer any
questions.
[The Prepared Statement Of Robert Thomas Appears In The
Appendix]
The Chairman. Thank you Mr. Thomas.
Mr. Blake. Mr. Blake, you are now recognized for 5 minutes.
STATEMENT OF CARL BLAKE
Mr. Blake. Thank you Mr. Chairman. You know, I have been
here a long time and you mentioned earlier how long you have
been here and do not recall a hearing on SCI/D. I have been
here a lot longer than you have and I cannot recall an
oversight hearing on this. I certainly thank the committee for
its willingness to address this issue today.
I sat there last night and I was trying to think what could
I tell you that would get your attention. That we get people to
listen and understand what Robert was just saying. I have never
told my story ever. It is just a personal thing I do not do
because it is personal, but I am going to share a little bit of
my story.
I am a PVA member. I have a combat-related spinal cord
injury. I was told by the Army once, if I do not die, I will
never walk again. I was told by a private medical facility
there is no chance this person will ever walk again. I rolled
into the VA SCI center in Richmond, Virginia, on a gurney and I
walked out of there after 12 months of rehab. VA did that.
While the VA gets a bad rap and gets beat up, it is a valuable
system to our members.
I do want to say I appreciate Dr. Scavella's testimony.
Clearly, she spent a lifetime committed to veterans and the VA,
and she is to be commended for that. I think it is important
that we step back now and realize what is really going on in
the SCI system of care.
The fact is, the SCI system is at a breaking point. We
survey all of the SCI centers on an annual basis. Every month
we do bedding/staffing survey of the SCI system of care. This
is what we know to be true. There are staffing shortages all
over the system. It is not 9 percent, it is more like 30
percent. There is a severe lack of resources dedicated to this
system of care.
The VA has a larger financial problem that, for whatever
reason, no one is willing to admit and accept. The VA has been
given a lot of money over the years. We recognize that fact,
especially in recent years. What the hell they have done with
it, we do not know. Where it has been directed is not toward
the SCI system of care.
We met with the SCI leadership from all over the country a
couple of months ago, and here is what they told us: they
cannot hire anyone, not just because there are not providers
available. There are no incentives to bring people on. There
are people who are interested in working in the system, and
those are the most dedicated people. The system is not set up
to bring those people on board in an efficient manner, and most
of the time they are lost. The HR process is broken. It does
not serve the needs of the system to bring people in in an
expeditious manner.
We have heard a lot about net zero growth in VA because of
the fiscal challenges it has. It is not net zero, it is net
negative. This is what is happening in the SCI system of care.
When a position comes open, it is not only not being filled, in
some cases it is being abolished, taken off the books. The VA's
handbook 1176 expressly says, this is what the staffing
methodology and model should be for VA, and these are the
policies and processes that should be followed for providing
direct care. Those leaders across the system told us that they
have been told at the local level and even up to the VISN level
we do not care what 1176 says. We are not beholden to that. It
is not the law. That is bulls--.
If you are going to craft a policy and a process to deliver
care, then you should follow it. If you are unwilling to do so,
admit why. As it is, our members are struggling to get the care
that they need, and the system is at a breaking point. We do
not want to ask Congress for more money. We recognize the
challenges that is faced across the entire spectrum. Resources
are going to have to be put in the system somehow to ensure
that they are able to staff, provide the equipment, and build
the capacity that they need.
There are centers that are actively being degraded today.
They are actively closing beds today. The system is shrinking.
The population that needs this service is not. Yes, it is
getting older. That does not mean the population is shrinking.
Some real effort needs to be put into rejuvenating this system
or it is going to collapse on itself and everyone in this room
and everyone listening and all of our members are going to
suffer because of it.
There were questions about women's healthcare. They will be
irrelevant if we do not fix this system before it is too late.
That is close to where we are now. It is important that we all
understand the VA has a vital role to our members, to all
veterans. If veterans want to go out into the community, PVA
does not have an express opposition to veterans getting care in
the community. It is a necessary tool for the VA.
That option is not available to our members. It is only the
SCI system of care that makes their care possible and we have
to invest in it. If we do not, there are much worse horror
stories that could come from it. We are here pleading with you
to actually put the emphasis behind it. All the memos in the
world, all the policy directives in the world do not do any
good if it is not being enforced. It is all well and good to
say we support the system of care. Well, show it to us, because
we do not feel like that is what is happening today. Thank you,
Mr. Chairman.
[The Prepared Statement Of Carl Blake Appears In The
Appendix]
The Chairman. Thank you, Mr. Blake.
I now recognize Ms. Sonya Sotak, the chief government
affairs officer of I AM ALS, for 5 minutes to deliver your
testimony.
STATEMENT OF SONYA SOTAK
Ms. Sotak. Good afternoon. Chairman Bost, Ranking Member
Takano, and members of the committee, it is my honor to be
invited to testify today on behalf of I AM ALS and the ALS
community, including the approximately 6,000 veterans living
with ALS in the United States.
ALS, commonly known as Lou Gehrig's disease, is a 100
percent fatal neurodegenerative condition. Upon diagnosis,
individuals are told, get your affairs in order, go home and
prepare to die, with the current survival rate being 2 to 5
years. ALS strips away a person's independence, gradually
robbing them of the ability to walk, speak, and eventually the
inability to breathe. Tragically, every veteran diagnosed with
ALS will succumb to this disease. Regardless of how hard they
fight or how hard their valor is, every veteran will lose their
battle against ALS.
As this committee is aware, ALS in veterans has been
determined to be 100 percent service-connected, with veterans
being twice as likely as civilians to develop the disease, and
post 9-11 Air Force veterans showing a tenfold increase in
incidents. It is estimated that 5,000 to 6,000 of the 30,000
individuals living with ALS in the United States are veterans,
roughly 16 percent of cases. However, these figures are
approximate due to challenges in accurately diagnosing ALS.
After being diagnosed, many of our veterans and their
families must take significant time to advocate for themselves
while managing the disease. Frequently, it is to explain to the
VA what their VA benefits are as a veteran with ALS. To help
veterans navigate this complex system, I AM ALS's veterans team
developed a comprehensive toolkit that outlines the available
the available benefits for veterans, including how to access
them. While our community of veterans with ALS are incredibly
grateful for the VA benefits available to them, this toolkit
underscores the complex nature of the benefit structure, which
often leads to veterans and their families diverting valuable
time and energy to navigate and navigating instead of being
able to focus on their health.
Lack of knowledge of the VA system can result in
frustration and delays in service. Because ALS can progress
rapidly, delays need to be avoided at all costs. Congress
recognized this when you all work together in a bipartisan
manner and pass the ALS waiver, eliminating the Social Security
Disability Insurance (SSDI) waiting period in 2020. Our
veterans with ALS and their families deserve the same
recognition when accessing benefits, including home health
care. While the VA spinal cord injuries and disorder centers
are equipped to address the needs of veterans with static
spinal cord injuries, they often struggle to meet the complex
requirements of ALS care. ALS demands a multidisciplinary
approach and specialized equipment that many SCI/D centers
lack. Geographical barriers of the centers compound the
challenges faced by veterans with ALS, especially those not
living in certain urban areas.
Based on the needs of our ALS veteran community, I AM ALS
is asking for an increase in this expenditure cap for
noninstitutional care from 65 percent to 100 percent of the
cost of the closest VA community living center through the
Elizabeth Dole Home Care Act, which is included in the Senator
Elizabeth Dole 21st Century Veterans Healthcare and Benefits
Improvement Act. By raising the cap to 100 percent, veterans
with ALS and their caregivers will be able to access healthcare
in the comfort of their homes. This will enhance the quality of
life for veterans with ALS and alleviate the burden on their
families and caregivers.
I AM ALS and our veteran community also appreciate that the
Elizabeth Dole Home Care Act acknowledges the crucial role of
caregivers, often family, in managing the daily needs of
veterans with ALS. The act offers resources, training, and
financial assistance to caregivers, easing their emotional and
financial burdens and enabling them to provide improved care
and support to our veterans.
I am going to take a moment to share with you the impact of
this legislation could have had on our Navy veteran Garrett.
Garrett served as part of the Seabees, a Navy construction
battalion, with tours in Iraq and Afghanistan. Garrett's battle
with ALS epitomizes the challenges many veterans face,
especially when trying to remain in their homes as the disease
progresses. When Garrett was first diagnosed, he and his wife
attempted to manage his care at home with most of his care
falling on his spouse to avoid reaching the 65 percent cap.
However, despite their efforts to navigate the system, Garrett
was trapped in a cycle of bureaucratic red tape. Garrett
eventually required more assistance, surpassed the home cap,
and was put in an institution. Garrett elected to remove his
trach, ending his life early rather than being isolated in an
institution. Garrett simply wanted to be at home. At the end of
his life, Garrett felt hopeless and out of options. His
heartbreaking decision to end his life because of the complex
system not providing the best support for his final battle
shows the urgency of passing this legislation, and Garrett is
not an outlier. Unfortunately, I can tell you about other
veterans who have had the same circumstance. Through the
Elizabeth Dole Home Care Act, you can improve the quality of
life for veterans living with ALS and their caregivers as it
provides them with flexibility and how they receive care.
I will end, I know I hit my time. I do not want to go over.
[The Prepared Statement Of Sonya Sotak Appears In The
Appendix]
The Chairman. Thank you, Ms. Sotak.
Now we recognize Dr. Jenny Kiratli, representing the
American Federation of Government Employees. Dr. Kiratli is
also the director of spinal cord injury clinical research for
the VA Palo Alto healthcare system.
Doctor, you are recognized for 5 minutes to deliver your
testimony.
STATEMENT OF JENNY KIRATLI
Dr. Kiratli. Chairman Bost and Ranking Member Takano and
members of the House Committee of Veterans' Affairs, thank you
for inviting the American Federation of Government Employees,
AFGE, to participate in today's committee hearing on meeting
the needs of spinal cord injury and disorders veteran
community.
You have just introduced me, so I will skip that. Well,
actually, I am a member of the AFGE since 2009. AFGE's National
Veterans Affairs Council represents more than 302,000 AFGE VA
employees. My role at VA as a research health scientist in the
SCI/D center at VA Palo Alto since 1991 with more than 30 years
of experience conducting research on clinical issues affecting
people with spinal cord injury. In addition, I am on the
faculty of the SCI Medicine Clinical Fellowship program and a
member of our SCI/D Center Leadership Council.
As you have been hearing about re-ed rate, the VA Palo Alto
SCI/D center is one of the 25 VA SCI/D centers that offer
lifelong, comprehensive, integrated, coordinated care,
including primary care, rehab, emergency care, acute medical
and surgical care, mental health care, and home care aimed at
supporting the veteran as a whole person with services that
reintegrate veterans in the community. Care is also delivered
via telehealth, which VA Palo Alto pioneered in 2000 and has
expanded tremendously to enhance access to VA services
remotely. SCI/D providers include physicians, nurses,
psychologists, social workers, physical therapists,
occupational therapists, recreation therapists who coordinate
care with many disciplines such as pharmacy, radiology,
urology, orthopedics, plastic surgery, and many other clinical
services. The expertise of the interdisciplinary care team and
breadth of services available makes the VA SCI/D network based
on a hub and spokes model, the most comprehensive healthcare
system for people living with SCI/D in the U.S.
Primary care physicians need special training to serve the
specific needs of this patient population, as they must be able
to diagnose and treat an array of problems that may present
differently, such as bone fractures and infections. They also
must be trained to recommend appropriate preventive care at
screenings and manage comorbidities such as metabolic and
muscular disorders in collaboration with other specialists.
Most physicians in the VA SCI/D centers pursue an additional
year of specialty training through SCI medicine fellowship
programs, and VA plays an important role in these training
programs in collaboration with academic affiliates. However,
more needs to be done to encourage young clinicians to enter
the field of SCI medicine. Of the approximately 31, 32
positions in SCI clinical fellowships, usually fewer than 20
positions are filled in any given year.
Another unique aspect of the VA system is the large and
very active research enterprise which I am part of. Clinical
research conducted at the VA Palo Alto SCI/D center and other
VA centers can drive improvements in care delivery that also
may benefit nonveterans living with spinal cord injury and
disorders and contribute to best practices. One of my current
projects is a collaboration with the Minneapolis VA to evaluate
a novel wheelchair that provides mobility while staying. This
adaptation will allow greater time in an upright position and
thus reduce the risk for pressure injuries, improve blood flow
and bladder and bowel function, reduce spasticity and pain, as
well as enhance functional capabilities of the user.
VA Palo Alto also was involved in the multisite VA research
to explore the effect on quality of life with exoskeleton-
assisted ambulation, as well as a project a few years ago to
implement and evaluate a model of vocational rehab to return
individuals with SCI/D to employment. Other recent projects
that I have been involved with include exploration of video
gaming as a mode to elicit upper extremity muscle activation
and a current study to improve evaluation of fracture risk by
determining a reliable method to measure bone loss at the knee,
a common fracture site.
Through its research in clinical care initiatives, VA is at
the forefront of improving clinical outcomes and quality of
life for veterans and all people living with spinal cord
injuries and disorders. However, more can be done to strengthen
the VA SCI/D system. There is a great need, as we have been
hearing, for increased staffing for SCI/D services. Staffing
requirements for SCI/D centers should reflect the high acuity
and complexity of care needed, which often require specialized
certification and advanced training. The high acuity of care
creates burnout, and younger clinical staff often leave just as
they have gained sufficient skills to perform all their duties.
Additional retention incentives are needed to address vacancies
and turnover, with specialty pay as a high priority.
In summary, the VA's SCI/D model provides uniquely
comprehensive and integrated services delivered by highly
knowledgeable teams of specialists that do not exist in the
private sector. While the mission act increased access to non-
VA facilities, use of VA and none non-VA care has the potential
to increase unintended duplication of services, costs, and
fragmentation of care. The risk of inadequate care is a great
concern for veterans with SCI/D because of the need for
specialized expertise.
In addition, non-VA providers lack access to VA resources
such as medical equipment and a wide array of adaptive products
often created for each individual for his or her specific
needs. Care should be taken to ensure that increasing
privatization of VA services does not upend the VA's
specialized SCI care model that provides an array of integrated
services and supports research used to develop best practices
for all people living with spinal cord injuries and disorders.
Thank you very much for this opportunity to talk about it.
[The Prepared Statement Of Jenny Kiratli Appears In The
Appendix]
The Chairman. Doctor, thank you very much for your
testimony.
We will now go to questioning and I recognize myself for 5
minutes.
Mr. Blake, in PVA's opinion, what is it--why is it
necessary for Congress to pass H.R. 8371, the Senator Elizabeth
Dole 21st Century Veterans Healthcare and Benefits Improvement
Act, to continue improving services for your membership?
Mr. Blake. Thank you Mr. Chairman, for the question. A lot
of our members rely on home care services, home-based services.
The Veteran-Directed Care program is a very popular program for
our members where it is available. The Elizabeth Dole Act would
make those opportunities much more available. It would
eliminate the 65 percent cap. It would allow our members to be
at home where they want to be and receive the care that they
need and not end up in simply a facility and would just improve
their independence and opportunity.
I think if the bill does not get passed, then our members
will continue to struggle along or we are going to end up in a
situation like the lady from I AM ALS mentioned. Those are
totally unacceptable circumstances. That should never happen
simply because of some arbitrary cap or some limitation on home
care services that are available.
The Chairman. Thank you. Ms. Sotak, can you explain why VA
must ensure that accessibility and safe contracted exam
facilities are available right away for veterans with ALS?
Ms. Sotak. Sure. Thank you for the question. ALS progresses
quickly, not for everybody, but for many. Some veterans have
limited mobility at the time of their diagnosis. For that, we
believe that contracted exam facilities must be accessible. I
think we heard earlier testimony saying that is sometimes very
often a challenge. We need to make sure that they get in
quickly before their disease progresses more and we are able to
hopefully mitigate the rapid progression of that disease.
The Chairman. Thank you. Mr. Blake, VA told the committee
staff that they were operating at a 9 percent vacancy rate for
the clinic staff. I think in your testimony you said that you
probably do not believe that. What do you believe it actually
is?
Mr. Blake. Well, let me correct that. I do not believe that
that is not true. We simply think it is not true. We survey the
system of care every month for its bed and staffing. According
to our own medical services records and our team that surveys
that system, we believe that vacancy rate is closer to 30
percent, not 9 percent.
The Chairman. Do you think that the VA has the staff needed
to safely care for the groups, for this group of veterans?
Mr. Blake. Well, I could just simply say no. That would be
too easy. The answer is no.
The Chairman. Yes.
Mr. Blake. Clearly it is not, because the system is
actually being drawn down, it is not being expanded at all.
The Chairman. Mr. Thomas, can you tell me why it is
important to have competent, properly trained clinical staff
when you are being treated as SCI/D veterans?
Mr. Thomas. Thank you for that question, Mr. Chairman. I
can simply say that, you know, our lives, my life, the life of
our members are in their hand. We really need them to be able
to diagnose us when we come in because the only thing that we
know something is going on. We cannot feel, we cannot tell
exactly what it is. We need to rely on these doctors and nurses
to tell us what is going on and not just simply provide us with
some medication to say, I will see you next time. Check back
with me in a week.
The Chairman. I think you said in your opening statement
that, you know, we know VA wants to provide this. We have just
got to make sure that we do the oversight to make sure that it
is doing it at the top level that you all deserve. We want to
continue to work to do that.
With that, I am going to turn it over to Mr. Takano for his
questions. Recognized for 5 minutes.
Mr. Takano. Thank you, Mr. Chairman. I want to start with
Dr. Kiratli. Dr. Kiratli, can you expand on the training and
continuing professional education that clinicians have to
undergo to be able to provide appropriate care to SCI/D
veterans? We just have been talking about the importance of
highly trained people to take care of this SCI/D population.
Can you expand on the training that is necessary?
Dr. Kiratli. Thank you for that question. Yes, I am glad
to. We have one of the clinical fellowship training programs at
our facility in Palo Alto, and it is a year-long intensive
program for physicians who want to have a subspecialty in
spinal cord injury medicine. They become board-certified. It
includes exposure to inpatient, outpatient, all sorts of
additional specialty trainings that can be provided. We partner
with--our program at Palo Alto is actually under Stanford
University, and we partner with the community SCI/D center
nearby. Most of the programs, many of the programs involve VA,
but not all. When residents choose programs, often they value
being able to be at a VA to gain that training, the training
opportunities to work with veterans in the system for the high
level of specialty training that they can get.
Mr. Takano. Well, thank you. Does VA cover all the costs of
the ongoing training?
Dr. Kiratli. No, not that I know of.
Mr. Takano. They do not. They do not cover the ongoing
costs of continuing education they need to do?
Dr. Kiratli. No, the various professionals have
requirements for ongoing training. For instance, physicians
have to recertify board training. We have a variety of other
specialty certifications, such as wound training, high level
seating training. I think there is some funds available, but
not--it certainly does not cover all of it. There is a limited
amount available for conference attendance.
Mr. Takano. It is fair to say that it takes thoughtful
investment in VA's workforce in order to provide the high level
of care that SCI/D veterans require and deserve. Would you say
that is right?
Dr. Kiratli. Absolutely. Well said.
Mr. Takano. My colleague Julia Brownley has an important
bill, the Department of Veterans Affairs Continuing
Professional Education (VA CPE) Modernization Act, H.R. 543. We
have been stymied in advancing this bill because of its cost,
estimated by the Congressional Budget Office (CBO) to be about
$3.3 billion in combined discretionary and mandatory spending
over 10 years. This is addressing the cost of training SCI/D
employees. However, I think this would be a very worthwhile
investment. This legislation would provide stipends of up to
$2,000 per year for VA clinicians continuing professional
education expenses. What would this mean for employees for VA's
SCI/D system of care; It would mean a lot, would it not?
Dr. Kiratli. That would be wonderful.
Mr. Takano. Well, I would like to change to Mr. Thomas. Mr.
Thomas, in your testimony, you highlighted how VA's SCI/D
system of care is uniquely positioned to meet VA's PVA members,
your members. Why do you think it is so important to ensure
that VA is able to continue to meet the needs of SCI/D
veterans?
Mr. Thomas. Thank you for that question. I believe that
being able to meet the needs of all of my members, myself to be
included, is that it is very important because, you know,
outside in the community, as I stated in my oral statement,
that, you know, the doctors do not know. They are unsure of
what goes on. The specialized training that is provided for VA
clinicians and everything, it is important to us to make sure,
again, that we can be diagnosed correctly. They know what is
going on.
A prime example is if an individual comes up with autonomic
dysreflexia and the individual doctor does not know how to
treat that, it can become very severe to our members and to
myself as well. Having those specialized care, having a
specialized care system available to us means a lot.
Mr. Takano. Our current investments in VA infrastructure
and direct care--direct care, not Community Care--direct care
for veterans with SCI/D, are they sufficient?
Mr. Thomas. I would turn that over to our Chief Executive
Officer (CEO) Blake to answer that question.
Mr. Blake. I will answer it like the other question. No.
Mr. Takano. Thank you. Well, I agree with both of you.
Congress needs to make more considered effort to balance the
amount of funding going out of VA to private sector providers
rather than into VA in the form of investments in the direct
care workforce and improvements in medical care facilities.
Would you agree with what I just said?
Mr. Blake. Yes.
Mr. Thomas. Yes.
Mr. Takano. Well, I am glad we agree on that premise. That
is why we must continue to prioritize efforts that invest in
VA. I believe investments in VA are investments in veterans,
especially veterans who truly depend on the specialized care
that VA can offer. We need to build on that offering and expand
it, as well as other benefits.
In your testimony, you mentioned the importance of enacting
legislation like the Autonomy for All Disabled Veterans Act,
which would increase grants for veterans to make structural
improvements to their homes and the Rural Veterans
Transportation to Care Act, which would provide innovative
transportation options for veterans traveling to medical
appointments. I agree that these should be priorities for
Congress and that we should ensure that we advance these kind
of bills.
Now, I would like to go back for a moment to Dr. Kiratli.
What kind of feedback do you hear from physician fellows and
other providers about training they have received at VA? What
do they like about practicing at VA versus in the private
sector?
Dr. Kiratli. Thank you for that question. It is an
excellent question. The constant feedback we get is how the
clinicians are able to practice medicine as they have been
taught. They have access to the specialty services, they have
access to resources, and they do not have to curtail or
prioritize care based on what might be available to support it.
It really allows them to practice to the fullest extent and the
best interests in the health and well-being of the patient.
Mr. Takano. Well, thank you. I yield back. I am sorry, I
went over my time.
The Chairman. Not a problem. General Bergman, you are
recognized for 5 minutes.
Mr. Bergman. Thank you, Chairman Bost, for holding this
hearing and giving us the opportunity to focus on the needs of
our paralyzed veterans. As has been made clear through the
testimony today, there are a wide range of reforms and
improvements needed at VA to ensure the best possible care for
these veterans. I appreciate being able to hear our witnesses'
support for bills like the Elizabeth Dole Home Care Act.
My focus today will be on VA's annual health assessments
for spinal cord injured and disabled, or SCI/D, veterans, as
well as access to assistive devices to promote mobility and
independence. As a note, when you were talking, Doctor, you
talked about inactive versus active care, and I would suggest
to you that things like an assistive wheelchair to stand and
all that is outstanding, it enables that patient. I also
believe that on the active side, things like the exoskeleton
probably promotes more active care. I will leave it to the
scientists to decide that.
Mr. Thomas, great to see you again, as always. Last time I
think we talked was over on the Senate side. Could you please
describe the benefit of these annual preventative health
assessments for SCI/D veterans?
Mr. Thomas. The benefit to having an annual exam would be
that you could stay ahead of any issue that may be coming up,
and the doctors are aware of the smallest thing that the
individual has not came to that realization that is going on
and happening with them. For me, I did not know that I was
coming down with type 2 diabetes without going to this annual
exam. Having doing that, it gets me to be on top of that and
find a way to try and not be too diabetic, if I could say that,
if that is a real way. It prevents everything. To me, medicine
is preventive care anyway.
Mr. Bergman. Basically, what I am interpreting you to say
that VA should, wherever possible, be doing more to ensure more
paralyzed veterans nationwide are made aware of and then,
therefore, are able to receive these assessments. I assume a
simple yes would probably be----
Mr. Thomas. You are absolutely correct, yes.
Mr. Bergman. Roger that. Okay. Regarding assistive devices,
do you feel there are improvements that can be made to ensure
paralyzed veterans are able to be assessed for and provided
with devices that they are clinically eligible to receive based
upon the assessment of the individual veteran?
Mr. Thomas. I would also say yes to that. If there is any
new and innovative technology that comes out, I feel that they
should always be on top of that so that they can increase our
mobility access.
Mr. Bergman. Perfect. You know, as veterans, we know what
we have been subject to some interesting new technologies over
the course of our careers, and let us keep it to the good ones
and advance capabilities and a better life for others.
While the VA has procedures in place on paper to provide
annual assessments for SCI/D veterans and provide them with
assistive devices, the reality for many paralyzed veterans has
shown that there is more that needs to be done. I am grateful
for PVA's support of my bill, H.R. 6373, the Veterans Spinal
Trauma Access to New Devices, or Veterans STAND Act, which I
introduced along with Chairman Bost, Health Subcommittee
Ranking Member Brownley, and Congresswoman Debbie Dingle. This
bill will codify the VA's obligation to offer annual
examinations for SCI/D veterans, take steps to improve outreach
for those who are eligible, and ensure paralyzed veterans are
able to be assessed for and provided with assistive devices.
As I said, there is still a lot of work to be done on
behalf of our paralyzed veterans. I hope this committee will
advance the Veterans STAND Act so we can make the progress
necessary in those efforts.
With that, I yield back.
Mr. Luttrell. [Presiding.] Thank you, General.
Ranking Member you are recognized for closing remarks.
Mr. Takano. Thank you, Mr. Chairman. Well, Chairman Bost
raised concerns at our budget hearing in April about
significant year-to-year increases in VA's overall budget. I
would love to work with the chairman to address this
unsustainable trajectory, as it is pretty clear that community
care is placing the biggest strain on VA's budget. The chairman
and I seem to have fundamental philosophical differences about
whether community care should be funded at the expense of other
veterans policy priorities. H.R. 8371, the veterans package,
would throw another $1 billion at community care in the short
term and at least $3 billion if we extend temporary authorities
beyond the sunset dates included in the bill. I am sorry, I
just cannot in good conscience throw more good money after bad
and further expand community care eligibility, especially not
when VA is already proposing to transfer as much as $10 billion
from direct care and VA facility infrastructure to community
care in Fiscal Year 2025.
PVA members are among the most medically vulnerable
veterans VA serves, and they will suffer the most if Congress
does not properly fund the VA direct care system by investing
in VA's workforce and medical facility infrastructure. Now, it
is up to the chairman to put the bill on the floor that can
pass, and I have been very clear about my concerns. We are in
agreement on about 95 percent of the provisions in H.R. 8371,
including those taken from H.R. 542, the original Elizabeth
Dole Home Care Act, which passed the House more than 6 months
ago. However, if we want to act quickly, the Senate should pass
Congresswoman Brownley's bill right now. Then we can actually
spend time on the provisions that need more work and that have
received very little progress, including getting updated
stakeholder input and more information on the true cost of
provisions that are going to have lasting impacts on VA's
ability to do deliver care.
Thank you Mr. Chairman, and I yield back.
The Chairman. Thank you Mr. Takano. I would like to thank
the witnesses for coming today. I would like to thank the
veterans and the veterans' families that are in the audience
for your service and everything that you provided for the great
country that we live in. We would not be able to do our work in
this committee without each and every one of you. I want to say
again that many of the issues raised today will be addressed
with the passage of H.R. 8371, the Dole Act.
I ask unanimous consent that all members shall have 5
legislative days in which to revise and extend their remarks
and include any extraneous material. Hearing no objections, so
ordered. The hearing is now adjourned.
[Whereupon, at 12:39 p.m., the committee was adjourned.]
=======================================================================
A P P E N D I X
=======================================================================
Prepared Statement of Witnesses
----------
Prepared Statement of Erica Scavella
Good afternoon, Chairman Bost, Ranking Member Takano, and Committee
Members. Thank you for the opportunity to testify before you today to
discuss SCI/D, which present unique challenges and complexities
requiring specialized care and support. At VA, we are dedicated to
addressing the diverse needs of Veterans with SCI/D, ensuring access to
rehabilitation services; specialty benefits; and services, and
assistive technologies. Joining me today is Jeffrey London, Executive
Director for the Medical Disability Examination Office, with the
Veterans Benefits Administration (VBA).
Overview of Care
VA's SCI/D System of Care is the largest and most comprehensive
network in the U.S. dedicated to providing exceptional care for
individuals with SCI/D, and it is the preferred choice for most
Veterans. Its objective is to enhance the health, well-being,
functionality, and quality of life for Veterans through a coordinated
system of care. The system operates on a ``Hub-and-Spoke'' model, with
25 regional SCI/D Centers (Hubs) offering comprehensive care, while
primary care services are delivered at VA medical centers (VAMC)
without SCI/D Centers (Spokes) by SCI/D Patient Aligned Care Teams
(PACT).
The SCI/D Centers cater to Veterans with SCI/D, as well as those
with motor neuron diseases and multiple sclerosis with spinal cord
involvement, offering acute/sustaining and long-term care beds.
Interdisciplinary teams of highly trained SCI/D clinicians provide a
full continuum of services through the SCI/D System of Care, including
acute rehabilitation, medical and surgical treatment, primary and
preventative care, prescribed durable medical equipment, prosthetics/
rehabilitative devices, respite care, and end-of-life care.
Mental health services are provided or coordinated throughout the
SCI/D System of Care as part of the overall integrated care team plan.
Annual evaluations ensure ongoing assessments of Veterans' needs,
including psychological, social, and vocational assessments. SCI/D-
trained psychologists and social workers are embedded into the care
teams and serve as excellent resources and mental health providers for
enrolled Veterans. When needed, these SCI/D-trained psychologists and
social workers make additional mental health referrals, which are
facilitated by the SCI/D Center or PACT. Peer counseling services and
programs are also offered directly at the SCI/D Center, and through
Veterans Service Organizations (VSO) and community-based programs.
These help Veterans adjust to new impairments, understand the
rehabilitation process, develop social skills, and transition to
community living. Additionally, VHA offers comprehensive pain treatment
options tailored to the unique needs of SCI/D Veterans, ensuring they
receive the highest quality of care and support.
Mobility Interventions and Walking Aids
The prescriptive use of mobility interventions and walking aids is
individualized to the Veteran and often specific to the setting where
the Veteran is seen. Evaluations typically include reviews of
pathology, impairments, functional limitations, and risk factors. If
deemed medically appropriate, the inclusion of mobility devices and
technologies is matched based on the individual Veteran's functional
goals, focusing on enhancing mobility, independence, and overall
quality of life. These can include walking assistive devices, bracing
supports, prostheses, orthotics, shoe modifications, functional
electrical stimulation devices, powered exoskeletons, body-weight
support treadmills, and virtual reality gait training.
VA has implemented rigorous quality control measures and continues
to advance prosthetic technology to deliver the highest standard of
care to Veterans. This approach aims to empower Veterans to live their
lives to the fullest, despite the challenges their SCI/D presents. In
line with this goal, the Office of Advanced Manufacturing is developing
technologies to improve the efficiency and effectiveness of prosthetic,
orthopedic, and assistive devices. The resulting 3D-printed devices can
increase a Veteran's quality of life, maintain the Veteran's
independence, and reduce caregiver burnout.
Long-Term Care Options
VHA recognizes that SCI/Ds are not limited to the geriatric
population and that Veterans with SCI/D have complex and personalized
needs. To address these needs, VA offers a comprehensive SCI/D System
of Care that focuses on providing Veteran-centric care and support in
the least restrictive environment possible. VA offers a range of non-
institutional and home-based primary care options to eligible Veterans
based on their clinical needs, regardless of age, including medical
foster homes, Veteran-directed care, bowel and bladder care, SCI/D home
care, home health aide care, skilled home health care, community or VA-
provided adult day health care, respite care, and telehealth.
Additionally, many Veterans in the SCI/D System of Care receive support
through the Caregiver Support Program, which includes the General
Caregiver Support Services and the Program of Comprehensive Assistance
for Family Caregivers. For Veterans who require institutional care,
available options include assisted living facilities, VA Community
Living Centers, community nursing homes, State Veterans Homes, and VA
SCI/D Long Term Care Centers.
Patient Safety Practices in Emergency Departments
VA emergency departments are required to offer a medical screening
evaluation to all Veterans, including those with SCI/D, to determine if
an emergency medical condition exists. This is the general expectation
of emergency medical care, and our policies require a posture of
continuous readiness to initially stabilize almost any medical
emergency. We can then call upon community providers if there are
ongoing clinical needs beyond what would typically be expected in a VA
emergency care setting, ensuring integrated care for the Veteran. While
there are emergent disease processes more prevalent in the SCI/D
population, including sepsis and autonomic dysreflexia, the role of the
emergency department in providing emergency stabilizing treatment would
apply equally.
If deemed stable for discharge after an episode of emergent care,
there would typically be coordination or follow up with the Veteran's
primary or specialty care team to ensure appropriate care. Veterans
receive specific information and education when discharged from the
emergency department. This communication often involves caregivers--
with the Veteran's permission--to provide them an opportunity to ask
questions and gain an understanding of the necessary next steps and
safety precautions in the Veteran's care journey.
All clinically active emergency department providers undergo
ongoing professional practice evaluation to ensure an appropriate
standard of care. This is in addition to existing quality controls
within VHA to ensure high-quality care, including formal peer review
and patient safety reporting. Additional specialized education is
available through VA's Talent Management System and VA Library
resources. Specialized training specific to SCI/D is not mandated for
VHA emergency care clinical staff, as recognition and treatment of
unstable emergency conditions would be a pre-existing standard across
all clinical presentations.
Staff and Provider Training
Clinician training for providers, nurses, and interdisciplinary
teams involved in caring for individuals with SCI/D is facilitated
through various channels.\1\ SCI/D Centers offer local and regional
training, while the SCI/D National Program Office provides national-
level training opportunities. These programs include monthly expert
learning series, continuing education credits, and VA-professional
community networking sessions. Additionally, annual training is
provided for SCI/D PACTs located throughout the country and PACTs are
also invited to annual leadership summits with SCI/D Centers. The
primary objective of these training channels is to stay updated on best
practices and ensure we deliver optimal care.
---------------------------------------------------------------------------
\1\ Training requirements for the SCI/D System of Care are
described in VHA Directive 1176(2 ), Spinal Cord Injuries and Disorders
System of Care (Sept. 30, 2019; amended Feb 7, 2020).
---------------------------------------------------------------------------
Addressing Transportation Concerns
VA recognizes that transportation can pose a significant barrier
for Veterans with SCI/D and, as a result, VA provides various
assistance options. Eligible Veterans can receive beneficiary travel
(BT) benefits for regular and special mode transportation, such as
ambulances and wheelchair-accessible vehicles. In 2016, Congress
expanded BT eligibility to include Veterans with SCI/D, among other
populations, when their travel is connected to care provided through a
VA special disabilities rehabilitation program if that care is provided
on an inpatient basis or during a period in which VA provides the
Veteran temporary lodging at a VA facility to make the care more
accessible. Additionally, VA operates the Veterans Transportation
Program, offering door-to-door transportation to appointments,
including wheelchair service, regardless of BT eligibility. To support
Veterans in rural areas, VA oversees the Highly Rural Transportation
Grant Program in 13 states, where VA provides funding to State Veterans
Service Agencies or VSOs coordinating transportation in highly rural
counties.
Construction and Facilities Management
VA is committed to ensuring accessibility across all aspects of its
medical facilities, particularly in older facilities. This includes
targeted upgrades, renovations, and integrating advanced assistive
technologies to create modern, inclusive spaces that cater to the
diverse needs of Veterans. VA has also pioneered the deployment of
dedicated mobile units equipped with state-of-the-art equipment and
resources, which serve as vital extensions of the health care network,
reaching Veterans in remote or underserved areas and providing
essential services and support. While not specific to SCI/D care, the
Mobile Prosthetic and Orthotic Care program, supported by the VHA
Innovators Network, aims to increase access to care for Veterans in
rural areas. The program, already adopted in 10 VAMCs and set to roll
out in 5 new areas in 2024, has improved the experience for Veterans
who previously had to travel long distances for VA appointments.
VA's commitment to enhancing accessibility extends beyond physical
infrastructure to a holistic approach to care. The organization has
taken proactive steps to address the unique needs of women Veterans,
implementing specialized facilities that ensure privacy, comfort, and
tailored care. These spaces serve as safe havens for women Veterans to
access the services and support they need in a compassionate and
supportive environment that prioritizes their well-being and dignity.
As part of ongoing efforts to prioritize the health and safety of
all Veterans, VA is also dedicated to reducing infection transmission
rates within its facilities. Through rigorous infection control
protocols, regular monitoring, and continuous staff training, VA is
working tirelessly to create a safe and sterile environment that
minimizes the risk of infections for patients, including those with
SCI/D.
Overview of Benefits and Services
Spinal cord injuries are a significant cause of disability, with
profound and, in many cases, devastating consequences. VBA's foremost
concern is ensuring that the most catastrophically disabled Veterans
receive the benefits they deserve and have earned through their
military service. This includes disability compensation, employment and
independent living training, and support through VA's Veteran Readiness
and Employment (VR&E) program, housing benefits, and the Specially
Adapted Housing Program.
Contract Examinations
As part of the disability compensation process, VBA oversees
medical disability exam (MDE) contracts and related ancillary support
and oversight contracts. VBA provides oversight of the exam contracts
by setting metrics expectations for the Veteran experience, quality,
timeliness, and production; overseeing ancillary contracts to verify
examiners' credentials; and providing financial and data audits, to
include invoice validation and beneficiary travel.
VBA conducts frequent in-person site visits and administrative site
visits (virtual desk reviews) to ensure facilities are safe, clean, and
accessible. In-person site visits allow VBA to visually inspect vendor
examination locations for compliance with VA standards. In addition to
in-person site visits, VBA conducts administrative site reviews
(virtual desk reviews) to supplement onsite facility inspections and
increase overall oversight of all locations where Veterans obtain
examinations. Post-site visit reports note best practices and items
that require vendor actions. All action items are tracked until
completed.
In Fiscal Year (FY) 2023, VBA conducted 288 site visits and has
already conducted 288 site visits in Fiscal Year 2024, with plans to
complete at least another 112 site visits by the end of the fiscal
year. To improve oversight, VBA also conducted a series of joint site
visits with all MDE contract vendors to ensure consistency in site
inspections and MDE vendor compliance.
In May 2024, the Office of Inspector General (OIG) issued a report
titled ``Better Oversight Needed of Accessibility, Safety, and
Cleanliness at Contract Facilities Offering VA Disability Exams.''
Contract facilities are required to comply with the Americans with
Disabilities Act and Occupational Safety and Health Administration
standards to ensure every facility where exams are performed is
accessible, safe, and clean. VBA takes Veterans' safety as its utmost
priority and continues to work diligently to enhance Veteran safety and
the overall Veteran experience. OIG made nine recommendations, which
VBA is acting on, including updating contract requirements and standard
operating procedures, and implementing improved customer feedback
mechanisms. VBA is targeting to complete these actions by the end of
Fiscal Year 2024.
Increasing Examination Access
VBA continues to work with MDE vendors to ensure all Veterans,
including those with SCI/D, have access to VA exams by using modalities
such as acceptable clinical evidence (ACE) exams and telehealth
appointments that limit travel for in-person exams. MDE vendors use
traveling providers, claims clinics, and per-diem or rented locations
to assist Veteran populations that require additional support. Vendors
have mobile units deployed throughout the country and are equipped to
complete most exam types, as well as diagnostic testing. The units are
accessible, with wheelchair lifts and ramps, and are fully self-
contained with power supply and internet connectivity. Vendors continue
to expand their mobile unit fleets and collectively have 28 operational
individual units. For Veterans with SCI/D who are homebound or have
transportation barriers, traveling providers, mobile units, and non-in-
person examinations allow greater access. They reduce wait times
without degrading the quality of the exam. In Fiscal Year 2024, through
April 2024, vendors have completed over 1.9 million appointments
consisting of over 200,000 (11.9 percent) ACE exams and over 160,000
(8.2 percent) telehealth appointments.
In addition to increasing exam modality options, during the
examination scheduling process, MDE vendors are required to include
specific language in appointment notification letters regarding
accessibility needs. VBA is also partnering with VA's Veterans
Experience Office (VEO) to improve the scheduling process and increase
Veterans' understanding of the examination process to build clarity,
predictability, and flexibility to meet Veteran needs.
Customer Satisfaction and Feedback
In April 2024, VBA implemented improvements to the Customer
Satisfaction survey process. A new customer service contract vendor
mails survey cards to Veterans to improve process integrity. Before
April 2024, MDE vendors were responsible for releasing survey cards
directly to Veterans. VBA also enhanced the actual customer
satisfaction survey by incorporating a VA trust question, allowing VA
to gain better insights into Veterans' confidence in the contract
examination process, like other Veteran Experience surveys across the
VA enterprise. VA also incorporated a quick-response code onto the
survey, reducing the Veterans' burden of responding by allowing them
immediate access to their survey by using a smartphone or computer.
VBA takes feedback from Veterans and stakeholders seriously. As an
example, based on a suggestion from Paralyzed Veterans of America, VBA
made interim updates and clarified existing guidance regarding the
Remaining Effective Function of the Extremities sections on the
Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis, Central
Nervous System and Neuromuscular Diseases, and Peripheral Nerves
Conditions Disability Benefits Questionnaires (DBQ). Additionally, in
May 2024, VBA attended an ALS workshop in Seattle, Washington, which
VHA hosted. VEO led this workshop and received a list of 29 suggested
revisions to the ALS DBQ. VBA is evaluating these requests through its
joint VBA-VHA DBQ Change Control Group.
VR&E
The mission of VA's VR&E program is to assist qualified Service
members and Veterans with service-connected disabilities prepare for,
obtain, and maintain suitable employment or maintain a life of
independence. VR&E achieves this mission by providing comprehensive
vocational counseling services to transitioning Service members and
Veterans to ensure goals are suitable and attained.
During Fiscal Year 2023, VA provided VR&E services to 131,179
Veterans and Service members, and 17,135 Veterans successfully
completed their VR&E program. During Fiscal Year 2023, VBA paid over
$1.6 billion in VR&E benefits. As of May 1, 2024, VR&E has 151,769
Veteran participants, with 90,380 enrolled in Long-Term Services, which
helps program participants obtain the education and training they need
to find work in a different field that better suits their current
abilities and interests.
VR&E assists Veterans with SCI/D, and any other Veteran who meets
the eligibility and entitlement criteria. A Vocational Rehabilitation
Counselor (VRC) works with the individual to develop a plan of action
that includes structured, individualized services ranging from
education or necessary training to find work in a suitable field to
services that assist with living as independently as possible if
returning to work is not an option at the time the plan is developed.
VR&E Independent Living Services
The VRC conducts an assessment to determine if achieving a
vocational goal is currently reasonably feasible. To qualify for
independent living (IL) services, the following requirements must be
met:
Service-connected disability of 20 percent or more,
Serious employment handicap resulting in substantial part
from the service-connected disability(ies),
Inability to achieve a vocational goal,
Limitations in activities of daily life impacting the
individual's level of independence, and
Reasonable likelihood that the gains in independence will
continue after completing the program of IL services.
The VRC works with the individual to conduct a preliminary IL
assessment to determine if there are any impairments in activities of
daily living. Areas such as housing, emotional, spiritual, leisure, and
avocational needs are discussed to ensure all aspects of the
individual's needs are considered.
If the preliminary IL assessment confirms impairments in activities
of daily living, the VRC must coordinate a comprehensive evaluation. A
comprehensive in-home evaluation delves deeper into the preliminary
assessment findings and any other areas of need, particularly potential
barriers to living independently.
The VRC works with the Veteran to develop an individualized
independent living plan, enabling the individual to live independently
and participate in family and community life to the maximum extent
possible. IL services may increase the Veteran's potential to return to
work by providing services designed to lessen or accommodate the
effects of the disabilities. Veterans may receive:
Assistive technology/modifications,
Referrals for IL skills training,
Referrals to community-based support services,
Case management services,
Coordination assistance with VA and non-VA service
providers, and
Support of an avocational activity.
VA Specially Adapted Housing (SAH) Program
This year marks the 76th anniversary of the VA SAH grant program,
which provides essential financial support for home adaptations, and
addresses the unique accessibility needs of eligible Service members
and Veterans with specific severe, service-connected disabilities,
including SCI/D. The SAH program assists Service members and Veterans
in constructing an adapted home, purchasing a home with adapted
features, or adapting their own home. These projects, funded through
this critical benefit, make Veterans' homes more accessible by removing
barriers for those with qualifying disabilities. Since the program's
inception in 1948, VA has administered over 52,000 SAH grants to
eligible Service members and Veterans, totaling over $2.1 billion. For
Fiscal Year 2024, through May 2024, VA has approved 1,507 SAH grants
totaling $94.3 million.
With the enactment of P.L. 115-177 in June 2018, the funding and
construction activities for home adaptations made necessary by VR&E
rehabilitation program transitioned to VA's Loan Guaranty Service (LGY)
SAH program. The VR&E and LGY SAH programs have worked together to
develop the qualifying factors for the grant process, including the use
of licensed contractors, permits, technical drawings, and compliance
inspections. Generally, VA may provide home adaptations up to $107,357
as part of an approved VR&E rehabilitation program for individuals who
are unable to work due to service-connected disabilities or who require
home adaptations to achieve a vocational goal. The amount can change,
based on inflationary adjustments.
Other types of grants administered under the SAH program include
the section 2101(a) grant (sometimes referred to as Specially Adapted
Housing) and the section 2101(b) grant (sometimes called Special Home
Adaptation). Also, the Temporary Residence Adaptation allows eligible
individuals to adapt a family member's home where the Veteran or
Service member is temporarily residing. The physical criteria for
eligibility are defined by statute and, depending on the type of grant,
include loss of use of extremities or blindness. Based on the type and
level of a Veteran's service-connected disability, Veterans may be
eligible for up to $117,014 in assistance under a section 2101(a) grant
or $23,444 under a section 2101(b) grant. These amounts represent the
maximum grant amounts in Fiscal Year 2024, which change annually based
on an industry cost-of-construction index.
Conclusion
Chairman Bost, Ranking Member Takano, this concludes my testimony.
Thank you once again for the opportunity to update you on VA's holistic
approach, encompassing innovative technologies, specialized care, and
unwavering support, to ensure Veterans with SCI/D receive the highest
quality of care and services possible. Our commitment to ensuring that
all Veterans receive the care, support, and respect they deserve
remains unwavering. My colleagues and I are prepared to answer any
questions.
Prepared Statement of Steve Bracci
Chairman Bost, Ranking Member Takano, and members of the Committee,
thank you for the opportunity to testify on the independent oversight
conducted by the Office of Inspector General (OIG). The OIG is
committed to conducting work that results in clear findings and
practical recommendations to help the Veterans Benefits Administration
(VBA) promptly and accurately provide veterans, their families,
survivors, and caregivers with the benefits and services they have
earned.
As of March 31, 2024, more than 5.8 million veterans were receiving
disability compensation benefits.\1\ Given the significant hardships
veterans may face when the disability compensation benefit program does
not work as intended, the OIG remains vigilant in its oversight of
various aspects of the program. This written statement focuses on
improvements that VBA can make in its oversight of the vendors
providing medical exams for veterans' disability benefits claims.
---------------------------------------------------------------------------
\1\ VA, ``VA Benefits & Health Care Utilization,'' https://
www.va.gov/vetdata/docs/pocketcards/pocketcard.pdf, accessed June 3,
2024.
---------------------------------------------------------------------------
When a veteran files a claim, VBA staff may request medical exams
to assess the disability before deciding and rating the claim. These
exams, most of which are provided by contracted medical professionals,
represent a multibillion-dollar investment of taxpayer dollars by VBA
since 2017. Exams are typically conducted at the medical examiner's
place of business, and those facilities must be accessible, safe, and
clean according to contract requirements.\2\ The contracts also mandate
that the vendors inspect all facilities where exams are conducted to
ensure compliance with the Americans with Disabilities Act (ADA) and
Occupational Safety and Health Administration (OSHA) standards.\3\
---------------------------------------------------------------------------
\2\ Medical Disability Examination Contracts, Section 5.1 Place of
Performance.
\3\ Americans with Disabilities Act of 1990, 42 U.S.C. Sec. 12101
et seq.; Occupational Safety and Health Act of 1970, 29 U.S.C. Sec.
651 et seq.; Medical Exam Contract, Section 8.5 Deliverable Tasks Nov
28, 2018.
---------------------------------------------------------------------------
Starting in 2022, the OIG assessed concerns raised by veterans
through customer satisfaction surveys that VA requires be provided to
veterans after a disability exam. The OIG review focused on veterans'
feedback regarding the accessibility, safety, and cleanliness of the
contract exam facilities. The team inspected 135 facilities for
compliance with contractual and legal requirements and reviewed key
aspects of VBA's oversight of exam vendors. During the review, the OIG
team identified one or more ADA and OSHA deficiencies at 114 (about 84
percent) of the exam facilities. This testimony highlights the finding
and recommendations detailed in the resulting May 2024 report.\4\ The
report focused on three issues related to (1) the lack of oversight
over the contract exam facilities, (2) the prevalence of noncompliance
with ADA and OSHA standards, and (3) the impact on veterans with
mobility issues.
---------------------------------------------------------------------------
\4\ VA OIG, Better Oversight Needed of Accessibility, Safety, and
Cleanliness at Contract Facilities Offering VA Disability Exams, May 8,
2024.
---------------------------------------------------------------------------
The numerous deficiencies at these locations created needless
burdens for veterans, especially those with spinal cord injuries and
disorders and those using wheelchairs. Proactive monitoring of
contractors' facilities is essential to ensure compliance with laws and
regulations for accommodating individuals with disabilities and
maintaining an accessible, safe, and clean environment for all veterans
seeking exams. VBA has made some progress on remediating these issues.
However, additional monitoring is needed to ensure full compliance.
BACKGROUND
Regardless of whether a veteran is seen at a VA medical center or
contract exam facility in the community, all exam facilities must
comply with ADA and OSHA standards.\5\ The ADA ensures people with
disabilities have the same access, opportunities, and rights as
everyone else.\6\ In particular, the act mandates that publicly
accessible buildings have features to help people using wheelchairs,
walkers, or crutches to maneuver safely. OSHA sets and enforces
standards and guidance requiring businesses to maintain clean and
sanitary workplaces. It also conducts inspections to maintain safe
working conditions. Notably, exit routes must be free, unobstructed,
and properly labeled.\7\ They also must be reasonably straight and have
smooth, solid, and substantially level walkways.
---------------------------------------------------------------------------
\5\ MDE contracts sec. 8.5, ``Deliverable Tasks,'' November 28,
2018; Americans with Disabilities Act of 1990, 42 U.S.C. Sec. 12101 et
seq. (1990); Occupational Safety and Health Act of 1970, 29 U.S.C.
Sec. 651 et seq. (1970).
\6\ The OIG's review focused on the ADA's Title III, which applies
to businesses serving the public. ``Introduction to the Americans with
Disabilities Act'' (web page), accessed November 8, 2023, https://
www.ada.gov/topics/intro-to-ada/#businesses-that-are-open-to-the-
public; Title III regulations.
\7\ ``United States Department of Labor, Occupational Safety and
Health Administration: Maintenance, safeguards, and operational
features for exit routes. standard 1910.37(a)(3)'' (web page), accessed
October 23, 2023, https://www.osha.gov/laws-regs/regulations/
standardnumber/1910/1910.37.
---------------------------------------------------------------------------
VBA created the Medical Disability Examination Office (MDEO) to
oversee contract exams. VBA staff request disability exams from one of
the contract exam vendors when the veteran's nearest VA medical center
has reached or exceeded its maximum capacity for conducting these
exams.\8\ According to MDEO, during the OIG's review period from
January 1 through December 31, 2022, three contract vendors performed
about 88 percent of all exams and a fourth vendor was added.\9\
---------------------------------------------------------------------------
\8\ VA Manual 21-1, ``Mandatory Use of the ERRA Tool,'' updated May
31, 2022, sec. IV.i.2.A in Adjudication Procedures Manual, topic 1c.
\9\ The OIG team conducted inspections at facilities from each of
the four vendors. The fourth vendor was added in June 2022; however,
that vendor did not complete exams until December 2022.
THE MDEO MUST IMPROVE ITS OVERSIGHT OF CONTRACTORS' DISABILITY EXAM
---------------------------------------------------------------------------
FACILITIES TO ENSURE ACCESSIBILITY AND SAFETY MANDATES ARE MET
The vendors' contracts require them to inspect all their facilities
or subcontracted facilities for compliance with ADA and OSHA
standards.\10\ Yet when the OIG team conducted a complete inspection of
99 facilities, and partial inspections for an additional 36, more than
80 percent of them had one or more ADA and OSHA deficiencies.\11\ These
deficiencies reflect problems related to accessibility, cleanliness, or
safety, which, in a number of cases, made it difficult to accommodate
some veterans who needed exams.
---------------------------------------------------------------------------
\10\ The applicable 1991 and 2010 building standards (whichever is
applicable to the site); Americans with Disabilities Act of 1990 (web
page); https://www.ada.gov/law-and-regs/design-standards/1991-design-
standards/ and ``2010 ADA Standards for Accessible Design'' (web page);
29 C.F.R. Part 1910, https://www.ada.gov/law-and-regs/design-standards/
2010-stds/, accessed April 19, 2024.
\11\ Partial inspections generally consisted of examining only
facilities' exteriors. This was due to reasons such as the team finding
facilities closed that had unclear operating hours or operational
status, or the interior being inaccessible because exam rooms were
continuously occupied, and the review team did not want to prolong
veteran exam wait times.
---------------------------------------------------------------------------
The deficiencies went largely undetected by VBA because MDEO did
not provide sufficient oversight to assess the accuracy of vendors'
self-certification of ADA and OSHA compliance. The original vendor
contracts required MDEO to conduct site visits both randomly and in
response to complaints at exam facilities to assess compliance.
However, MDEO modified the contracts in September 2021 to state MDEO
``may'' conduct both random and complaint-based site visits at contract
facilities at VBA's discretion. In Fiscal Year 2022 (October 1, 2022-
September 30, 2023), MDEO conducted visits at 76 randomly selected
sites but did not visit any sites in response to complaints. An MDEO
assistant director said sites are selected based on their proximity to
exam vendors' headquarters.
The OIG team's finding was supported by the following four
determinations:
MDEO Depended on Vendors for Contract Facility Information
As of the report's publication, MDEO did not have independent
access to a current inventory of all contract facilities used to
perform disability exams, instead relying on vendors to provide this
information. This reliance has limited its ability to conduct site
visits. Depending on vendor-provided lists that can be incomplete or
weighted toward more compliant facilities affects MDEO's capability to
oversee its vendors. If facilities are overlooked, compliance issues
may not be found and addressed.
MDEO reported that the ``vendor is responsible for developing and
recruiting a provider network and therefore, a complete list of all
providers they are contracted with would be considered proprietary
information that they do not wish us to disclose to their
competitors.'' The OIG contends that VA routinely receives proprietary
information from contractors and that necessary controls can be
instituted to limit access to those VA personnel who need the
information. Particularly where oversight of veteran safety and
contract exams are at issue, VA must have accurate information.
Concerningly, two of the four vendors could not provide a
definitive number of facilities where their subcontractors conduct
exams. One vendor reasoned that facility numbers are fluid and contract
facilities are added and removed continually. Another vendor stated
that when MDEO requests a list of exam facilities, the vendor provides
10 locations in the geographic area of the facilities where most
veterans are likely to be seen. Another vendor reported that it would
provide addresses and hours of operation for the facilities in an area
upon request from MDEO.
An MDEO chief said site visits are generally within commuting
distance of each vendor's headquarters. An assistant director claimed
that staff plan to expand site visits throughout the country. Another
assistant director also noted it was difficult to provide an exact
number of contract facilities, as some examiners practice at more than
one location, multiple examiners practice at the same locations, and
some examiners have short-term leases. MDEO's executive director said
it is working on maintaining its own list and information on contract
exam facilities, so staff can conduct site visits and desk audits.\12\
---------------------------------------------------------------------------
\12\ Per MDEO, desk audits would include virtual inspections of
contract exam facilities through photographs, internet images, and any
available information to validate facility compliance.
---------------------------------------------------------------------------
Recommendation
MDEO was asked to submit a plan and documentation of progress to
the OIG on implementing VBA's maintenance of an independent, updated
list of contract facilities. VBA concurred with maintaining a list of
facilities but stated it was unable to independently verify all of a
vendor's active subcontracts.
This recommendation, and the other eight discussed below, remain
open (not fully implemented) at this time. In accordance with the OIG's
routine follow-up process, the first request for an update on all the
recommendations is on August 9, 2024.\13\ The OIG will monitor VBA's
progress on its implementation of all recommendations.
---------------------------------------------------------------------------
\13\ At quarterly intervals commencing 90 calendar days from the
report issue date, the OIG sends a follow-up status request to the
action office asking for an implementation status report. The follow-up
staff provides VBA 30 calendar days to respond. Nothing precludes VA
from submitting information before target dates or scheduled follow up.
MDEO Assigned Exam Vendors the Task of Distributing
---------------------------------------------------------------------------
Satisfaction Surveys Rating Their Own Performance
VBA contracts with a separate survey vendor to work with the four
exam vendors to obtain veteran contact and appointment information to
provide all veterans with a paper survey card regarding their exam
experience, as well as access to other methods such as email or text.
However, the survey vendor reported it distributed the blank
customer satisfaction survey forms to the exam vendors, which then
mailed them to individual veterans. MDEO confirmed the practice was
consistent with its guidance. Consequently, the survey vendor could not
monitor how, or if, the customer satisfaction surveys were properly
distributed and whether every veteran examined received one. As a
result, MDEO lacks assurance it is receiving the full picture of
veterans' experiences. MDEO needs the survey vendor or other
distributor with no vested interest in the results to be responsible
for mailing the surveys to veterans. Additionally, because the survey
vendor's performance was tied to the survey response rate, MDEO cannot
fairly evaluate its performance.
Per its contract, the survey vendor is expected to meet a minimum
response rate of 15-20 percent. In 2022, MDEO reported that the overall
response rate to the customer satisfaction survey was about 11 percent.
VBA's response to this report noted that in October 2023, a new
customer satisfaction survey vendor was onboarded.\14\
---------------------------------------------------------------------------
\14\ The rate equals the number of unique responses divided by the
number of appointments completed.
---------------------------------------------------------------------------
Recommendation
VBA concurred with the report's second recommendation to comply
with the requirements of the customer satisfaction survey contract by
routing exam comment cards directly between the survey vendor and the
veteran examined.
MDEO Lacked Formal Standard Operating Procedures and Training
for Site Visits to Assess Safety and Accessibility Compliance
MDEO lacked formal, written, standard operating procedures
outlining the responsibilities, tasks, and processes for staff
conducting exam facility site visits. According to VBA's contracts with
exam vendors, the standard of review for a site visit is based on ADA,
the Joint Commission on Accreditation of Healthcare Organizations,
OSHA, and any applicable State or local standards.\15\ VBA does not
provide its staff with training on ADA or OSHA compliance. Staff use a
checklist with a series of yes/no questions and a space for related
comments. These questions are not specific enough to effectively
address whether the contractual standards have been met. This was
particularly true for questions regarding building and exam room
accessibility for veterans using wheelchairs.
---------------------------------------------------------------------------
\15\ The OIG did not evaluate whether exam vendors met the Joint
Commission's standards for clinical operations.
---------------------------------------------------------------------------
Some MDEO employees said they based their site visit checklist
responses on simple visual observation, rather than addressing
established criteria. When MDEO staff and managers were asked about
specific ADA and OSHA requirements, several reported not knowing the
specific criteria. For example, parking lots require a minimum
percentage of disabled parking spaces, and there are minimum dimensions
for wheelchair turning radius, wheelchair ramp slope, and doorframe
widths.
Formal training plays an important role in helping staff acquire
knowledge, develop skills, and improve performance, especially when
employees have different roles and tasks. An MDEO assistant director
stated that most training is done on the job for the practical purpose
of inspecting facilities; however, MDEO is not opposed to formal
training. The MDEO executive director said staff are working on a
formal training program and standard operating procedures, and a
dedicated team was created to be responsible for providing external
training to exam vendors and MDEO staff.
Recommendations
VBA concurred with the report's third recommendation to develop and
implement formal standard operating procedures for the contract exam
facility site visits detailing roles, responsibilities, objectives, and
monitoring. It concurred in principle with the fourth recommendation
for MDEO to update the site visit checklist to include a focus on
specific ADA and OSHA criteria required by exam vendor contracts. VBA
also concurred in principle with recommendation 5 to complete a
standardized training plan for site visit staff to include ADA and OSHA
compliance.
MDEO Did Not Verify Vendor Compliance with ADA and OSHA
Requirements
Exam vendors are required to self-certify annually that they meet
all ADA and OSHA requirements for accessibility, safety, and
cleanliness, and certify all new facilities in the quarter after they
are added. The contracts allow VBA to suspend any facilities for which
MDEO has identified concerns regarding health and safety. However, exam
vendors generally relied on subcontractors to self-certify, and MDEO
did not validate the self-certifications. One MDEO leader said exam
vendors should be able to inspect every facility to ensure compliance,
while another reported being unaware of any instance in which action
was taken for noncompliance. Further, one of its employees confirmed
that tracking individual facilities would not be possible because staff
do not receive a list of each facility being self-certified; they
received regional certification from the vendor. The vendor's self-
certification process was not comprehensive or reliable because there
was no validation, likely contributing to the unresolved ADA and OSHA
facility deficiencies.
Veterans can submit complaints about contract exams through avenues
such as the OIG hotline, VA regional offices, the White House hotline,
veterans service officers, and MDEO. Exam vendors also submit incident
reports to MDEO.\16\ However, MDEO was not conducting complaint-based
reviews even when survey responses identified deficiencies. The OIG
found that MDEO should review all sources to determine if a complaint-
based site visit is warranted.
---------------------------------------------------------------------------
\16\ An incident report is required in instances of physical
distress, violent or threatening behavior from the veteran, or natural
disaster.
---------------------------------------------------------------------------
The OIG's report describes two incidents in which veterans were
unable to be examined because a contract facility could not accommodate
a wheelchair. In one incident, the veteran was injured being
transferred from a wheelchair into an audio booth with inadequate space
to maneuver a wheelchair.
Recommendations
VBA concurred with the sixth recommendation to conduct complaint-
based contract facility inspections, and with recommendation 7 to
enforce contractual requirements for vendors to conduct inspections and
recertify all facilities for ADA and OSHA compliance. Although VBA
requested the latter recommendation's closure, the OIG will only do so
after monitoring MDEO's contract enforcement.
THE OIG FOUND ADA AND OSHA DEFICIENCIES THAT MAKE EXAM FACILITIES
DIFFICULT TO ACCESS AND UNABLE TO ACCOMMODATE SOME VETERANS
Some veterans said their exams were canceled as contract facilities
did not comply with ADA or OSHA requirements and could not accommodate
their mobility or sensory issues. For example, accessible medical
equipment should include adjustable-height exam tables and chairs,
wheelchair-accessible scales, adjustable-height radiologic equipment,
portable floor and overhead track lifts, and gurneys and
stretchers.\17\ The OIG review team also found numerous facilities
lacking adjustable exam tables.
---------------------------------------------------------------------------
\17\ ``Access to Medical Care for Individuals with Mobility
Disabilities'' (web page), accessed November 13, 2023, https://
www.ada.gov/resources/medical-care-mobility/.
---------------------------------------------------------------------------
Examples of survey responses from veterans highlight accessibility,
safety, and cleanliness concerns at contract exam facilities:
``Wheelchair access is too sleep [sic] for handicap with
wheelchair.''
``Not handicap accessible very hard getting a wheelchair
in and out of the main entrance door.''
``No ramp for wheelchair.''
``The doorway entering the building has a 2-3 inch
threshold that a wheelchair or scooter has to be lifted over.''
``Handicap ramp not wheelchair friendly.''
``Wasn't able to complete exam due to not being able to
get into the exam booth.''
``Getting in and out of the sound booth was difficult
because the wheelchair is too large for the booth. Very unsafe.''
``Office was dirty with bugs crawling on the floor.''
The OIG team developed a site visit protocol that enhanced the MDEO
approach by including ADA and OSHA compliance criteria to be used for
135 sites. This protocol consisted of questions related to seven areas
of concern: (1) the facility location, (2) safety and protective
equipment, (3) exam rooms, (4) general medical clinical equipment and
supplies, (5) audiology clinical equipment and supplies, (6)
ophthalmology or dental clinical equipment and supplies, and (7)
protections for vulnerable veterans.
Using this protocol, the team first inspected 87 randomly selected
facilities (62 complete and 25 partial inspections) that performed
disability exams nationwide from January 1 through December 31, 2022.
The OIG found that
45 facilities had at least one accessibility
deficiency,\18\
---------------------------------------------------------------------------
\18\ Accessibility deficiencies included a steep ramp or curb, lack
of ramps, narrow doorways, an elevated audio booth with no ramp, no
adjustable exam tables, and improper door hardware.
36 facilities had at least one safety deficiency,\19\
---------------------------------------------------------------------------
\19\ Safety deficiencies included expired fire extinguishers,
partially blocked exits, and tripping hazards.
eight facilities had at least one cleanliness deficiency,
---------------------------------------------------------------------------
and \20\
\20\ Cleanliness deficiencies included bugs in fire alarms, stained
carpets, inappropriate waste disposal, and no available hand sanitation
equipment in designated areas.
15 facilities had no deficiencies.\21\
---------------------------------------------------------------------------
\21\ Facilities with no deficiencies were based on results from
the 62 complete inspections only. Some facilities had more than one
type of deficiency; therefore, numbers may not sum to the total number
of sites.
The team then inspected 48 newly added facilities (37 complete and
11 partial inspections) from the four vendors chosen both randomly and
based on veteran complaints. The facilities were added between January
1 and March 31, 2023, allowing the OIG review team to ascertain whether
---------------------------------------------------------------------------
newly added facilities complied with ADA and OSHA standards.
The team identified
28 facilities with at least one accessibility deficiency,
23 facilities with at least one safety deficiency,
one facility with at least one cleanliness deficiency,
and
six facilities with no deficiencies.\22\
---------------------------------------------------------------------------
\22\ Facilities with no deficiencies were based on results from the
37 complete inspections only.
---------------------------------------------------------------------------
Examples of ADA and OSHA Deficiencies
ADA accessibility deficiencies included issues with handicap
parking, wheelchair ramps, accessible entrances, bathrooms, exam rooms,
medical equipment, and audio booths. For example, the team found the
entrance threshold at a facility in California was too high. Facilities
in Texas, Wisconsin, and Missouri all had audio booth accessibility
deficiencies, ranging from insufficient wheelchair turning radius to
higher-than-allowed door thresholds or no permanent or temporary
wheelchair ramp access.
Examples of safety deficiencies included blocked stairways,
noncompliant handrails, expired or inaccessible fire extinguishers, and
blocked exit routes. No materials or equipment may be placed, either
permanently or temporarily, in the exit route. Additionally, the exit
route must have a smooth, solid, and substantially level walkway. At a
facility in Texas, the OIG found a fire extinguisher that was stored in
a cabinet under a sink, also with the last evidence of inspection being
June 2017. The review team also identified eight facilities from the
initial inspection of 12 states with at least one cleanliness
deficiency. Some deficiencies included common area cleanliness, lack of
personal protective equipment and single-use medical supplies, and lack
of available hand sanitation equipment in designated areas.
EXAMS SCHEDULED AT FACILITIES WITH ADA AND OSHA DEFICIENCIES MAY CREATE
DIFFICULTIES FOR VETERANS WITH MOBILITY ISSUES
MDEO told the OIG that vendors are not allowed to cancel an exam
specifically because a facility was not ADA-compliant, noting that
vendors would need to reschedule appointments if a room, booth, or exam
table was not accessible at the time of the scheduled exam for someone
who uses a wheelchair. Concerningly, one vendor could not confirm if
its scheduling unit asked veterans if they needed accommodations at the
time the appointment was set up.
The OIG's inspection confirmed ADA deficiencies may make it unable
to accommodate veterans with mobility issues. Rescheduling these exams
after veterans have needlessly gone to a facility takes time and may
entail traveling long distances. Rescheduling may also delay their
disability benefit claims from being processed. The OIG determined MDEO
had not been holding vendors accountable to ensure exam facilities are
accessible, safe, and clean for veterans attending exams.
Recommendations
VBA concurred in principle with the report's eighth recommendation
to analyze all veteran complaints related to facilities received
through all entities and perform complaint-based site visits or create
action plans, as necessary. It also concurred with the final
recommendation for MDEO to develop a plan with its vendors to determine
if each veteran requires accessibility arrangements before scheduling
an exam.
CONCLUSION
A critical foundation of accountability for any program is
effective oversight to detect and resolve issues. This is crucial for
medical exams given how critical they are to ensuring veterans receive
accurate and timely disability benefits claims decisions. Additionally,
the need for VBA to conduct thorough oversight is essential given the
billions of taxpayer dollars paid to contractors. The OIG recognizes
the challenges with doing so when most of these exams are conducted
outside of VA facilities by nongovernmental personnel. As a VBA leader
noted, however, while VA does not own contractor exam facilities, they
represent the face of VA for veterans applying for benefits.
The deficiencies identified by the OIG persisted because MDEO's
oversight was ineffective at detecting and correcting them,
particularly in failing to consistently conduct site visits in response
to veterans' complaints. VBA and its vendors must continue to take
swift corrective action to ensure veterans with spinal cord injuries
and disabilities, as well as others requiring accommodations, have
prompt access to suitable exams that will help determine their
disability benefits. Mr. Chairman, this concludes my statement. I would
be happy to answer any questions you or members of the subcommittee may
have.
Prepared Statement of Robert Thomas
[GRAPHIC] [TIFF OMITTED] T6243.001
[GRAPHIC] [TIFF OMITTED] T6243.002
[GRAPHIC] [TIFF OMITTED] T6243.003
[GRAPHIC] [TIFF OMITTED] T6243.004
[GRAPHIC] [TIFF OMITTED] T6243.005
[GRAPHIC] [TIFF OMITTED] T6243.006
Prepared Statement of Carl Blake
[GRAPHIC] [TIFF OMITTED] T6243.007
[GRAPHIC] [TIFF OMITTED] T6243.008
[GRAPHIC] [TIFF OMITTED] T6243.009
[GRAPHIC] [TIFF OMITTED] T6243.010
[GRAPHIC] [TIFF OMITTED] T6243.011
[GRAPHIC] [TIFF OMITTED] T6243.012
[GRAPHIC] [TIFF OMITTED] T6243.013
[GRAPHIC] [TIFF OMITTED] T6243.014
[GRAPHIC] [TIFF OMITTED] T6243.015
[GRAPHIC] [TIFF OMITTED] T6243.016
[GRAPHIC] [TIFF OMITTED] T6243.017
[GRAPHIC] [TIFF OMITTED] T6243.018
[GRAPHIC] [TIFF OMITTED] T6243.019
Prepared Statement of Sonya Sotak
Chairman Bost, Ranking member Takano and members of the committee,
it is my honor to be invited to testify today on behalf of I AM ALS and
representing approximately 6,000 veterans living with ALS in the United
States. My name is Sonya Sotak and I am the Chief Government Affairs
Officer for I AM ALS. I AM ALS is a small but mighty non-profit
organization for people living with ALS. Our organization is a patient-
centric driven organization, and many of our activities and policy
efforts are driven by and collaborated with the actual community. We
were established in 2017 by Brian Wallach and his wife, Sandra, after
Brian was diagnosed with ALS at the age of 37 on the same day they
brought their second daughter home from the hospital. Since then, I AM
ALS has been privileged to partner with many of you here today to help
move significant pieces of legislation through Congress to support
people with ALS. First, the ALS Disability Insurance Access Act, which
passed with unanimous support in the House of Representatives in 2020;
next, we worked with many of you to get the ACT for ALS passed in 2021,
again, with overwhelming bipartisan support. Also, many of you on both
sides of the aisle have helped the community increase funding for the
ALS research program at the Department of Defense. For the last 2
years, I AM ALS and the entire community of ALS organizations have
urged Congress to double this funding since the incidence of ALS among
veterans is at least two times that of the general population.
We also know that the Department of Defense ALS research program is
receiving more than double the amount of quality research proposals
that need grant support--proposals that they cannot approve at the
current funding amount--and represent strong science that otherwise
might be able to address the needs of veterans with ALS. We know that
the proposed Fiscal Year 2025 funding measure remains at $40 million
but we continue to urge Congress to find a way to increase resources
for this program for Fiscal Year 2025 and invest in research that can
address this horrible disease and help the 1 in 6 people with ALS who
are veterans.
We thank each of you and all of Congress for these important
accomplishments and truly appreciate the bipartisanship effort that it
took to achieve each of these advancements and the willingness for
everyone to work together to pass legislation improving the lives of
people, including thousands of veterans living with ALS.
As I mentioned, our organization is driven by community members
affected by ALS themselves, thousands of volunteers taking action. Our
veterans team created by incredible veterans and caregivers for
veterans living with ALS is one of our most powerful and impactful
committees. These veterans with ALS and their loved ones identify
barriers, create tools and toolkits, and advocate to ensure that the VA
benefit and health care system is easier to navigate and provides
better and more accessible services. Sadly, we know all too well that
this advocacy is needed to ensure basic, supportive care for veterans
with ALS. As an example, our toolkit helps veterans identify and
receive existing veteran benefits once they are diagnosed with ALS.
This basic guide is over 45 pages long--that is how complex the system
is for our veterans at a time when they are already overwhelmed and
should be focusing on maximizing life with family rather than
navigating a complex, bureaucratic healthcare system. Lack of knowledge
of the VA system can result in frustration and delays in service.
Because ALS can progress rapidly, delays need to be avoided at all
costs. Congress recognized this when you passed the ALS waiver
eliminating the SSDI waiting period. Our veterans with ALS and their
families deserve the same recognition when accessing benefits. We urge
you to work to ensure that all the veterans not yet diagnosed will be
taken care of and hopefully enter a VA system that provides stronger
and better access to health care and support services than they have
had while enduring ALS.
As the Chairman and committee members know, ALS is recognized as a
one hundred percent service related disease. Statistics vary but we
know at a minimum members of our military are two times more likely
than civilians to develop ALS. This stat skyrockets to ten-times when
examining post-9/11 Airforce veterans. We also have seen data that
estimates approximately 5000-6000 of the 30,000 people with ALS in the
United States are veterans or again, about 16 percent. I say
approximately because the world of ALS lacks solid data for many
reasons but one key reason is the significant delay and complexity in
diagnosing ALS. The prevalence of misdiagnosis is incredibly high and
many people may never receive the right diagnosis or receive their
diagnosis too late for being factored into national data. We also have
a national system that does not compel data collection and is based on
self reporting. This is such a complex topic it's worthy of its own
hearing another day up here.
Before I dive into access to home health care that is critical for
our veterans with ALS I want to set the table with some critical facts.
First, I want to be sure that the committee and everyone here today
knows that ALS, or Lou Gehrig's disease as it is often known, is 100
percent fatal.
Nobody survives ALS and most die within 2-5 years after being
diagnosed. When people finally receive a diagnosis they are told to go
home--get their affairs in order and prepare to die. So every one of
our veterans that develop ALS will die from it no matter how hard they
fight or how strong their valor. Every single veteran will lose their
battle with ALS.
ALS is a neurodegenerative disease that affects nerve cells in the
brain and spinal cord. ALS is a wicked, cruel disease that slowly
paralyzes a person, taking away their capacity to be self sufficient
and eventually losing their ability to breath.
ALS was determined to be a one hundred percent service connected
disease by the Department of Veteran Affairs on September 23, 2008.
Following that decision it has been a tough and multifaceted journey
for a multitude of reasons within the VA to provide the necessary,
appropriate and equitable support for Veterans with ALS. The VA issued
the VHA directive 1101.07 the ALS system of care in August 2021. The
intent of this directive is to ensure that all care, services and
access to equipment is known to veterans and their families including
the responsible parties for ensuring access. Too often while managing
ALS, many of our veterans and their families have to take significant
time to advocate for themselves and often it is to explain to the VA
what their VA benefits actually are as a veteran with ALS.
The VA's Spinal cord injuries and disorders (SCI/D) centers are
designed to provide comprehensive care for veterans with spinal cord
injuries and related injuries. However, these centers often face
challenges fully meeting the needs of veterans with ALS due to the
multifaceted nature of ALS. Part of the challenge is the SCI/D's are
set up for your typical spinal cord injury which are often a static
disease while ALS is a progressive & increasingly complicated
debilitating disease.
Specialized care: ALS requires specialized neurological and
respiratory care that is often not fully available at SCI/D centers.
For instance, expertise in managing progressive muscle weakness and
continued respiratory failure is something lacking at these centers.
ALS requires multidisciplinary care with a coordinated approach by a
team of health care professionals from a variety of disciplines to
manage the complex needs of a Veteran with ALS. The goals are to
improve the quality of life, slow the disease progression and provide
much needed psychological and social support. This is too often not
possible and simply not how the SCI/d's are set up and they often lack
the staffing capacity and training for meeting the needs of our
veterans with ALS. Expertise is often lacking for managing progressive
muscle weakness and repository failure at the centers.
Advanced respiratory Support : Veterans with ALS often need
advanced respiratory support, including non-invasive ventilation or
mechanical ventilation which is often not the focus of SCI/D centers.
Comprehensive team : As I outlined earlier, the SCI/D centers do
not have all the specialists available for ALS veterans or do not have
the same level of coordination and collaboration as some ALS clinics or
even what is available through accessing care in a veterans home
setting.
SCI/Ds often have Insufficient focus on ALS specific interventions
including:
Assistive technology:
Veterans with ALS often need specific assistive technologies such
as augmentative and alternative communication devices which may not be
readily available or supported in the centers.
Adaptive equipment
Too often the centers focus on spinal cord injury specific
equipment and not the evolving and very demanding and intricate needs
of ALS veterans.
Psychological and social support gaps
The specialties counseling and training needs for managing the
extensive emotional and psychological support needed by ALS veterans
and their families as a result of the rapid progression and terminal
nature of the disease is often found to be lacking at the centers.
Palliative and end of life care
Many of the SCI centers do not have integrated palliative care
services tailored to the specific needs of ALS veterans. ALS support
requires significant palliative care and end of life planning which has
a unique perspective and approach for managing ALS symptoms and quality
of life.
Another key challenge is the location of the 25 centers. Many of
them are simply not near many of our veterans living with ALS and not
easily accessible for the veterans scattered around the country
managing the very debilitating disease of ALS.
I AM ALS and our veterans community believe an important component
of their ALS care is being able to remain in their home. For this
reason, I AM ALS fully supports the Senator Elizabeth Dole 21st Century
Veterans Healthcare and Benefits Improvement Act. While this
comprehensive bill contains many important measures, I would like to
focus on the pieces that are most important for veterans with ALS--The
Elizabeth Dole Home Care Act contained in this comprehensive package is
significant for veterans with ALS for several reasons:
Most significant for our community of veterans with ALS is that the
legislation increases the expenditure cap for non-institutional care
from 65 percent to 100 percent of the cost of the closest VA Community
Living Center (CLC). This would allow the most vulnerable veterans and
caregivers the support they need to stay in their homes, often leading
to better outcomes for veteran families, especially veteran families
grappling with ASL.
The removal of the cap would help families care for their 100
percent service-disabled veterans with ALS. Because of the mandated
cap, families constantly have to fight with the VA to get the
appropriate support in their home so their veteran can continue to
enjoy being near family rather than being sent away to a facility which
is often hours away from the much needed support system of family and
friends. For many veterans remaining in their home with friends and
family during their hardest battle managing ALS is paramount. Staying
in their home with loved ones improves their quality of life but it can
also help reduce medical complications.
Let me share the story of Navy veteran Garrett who served as part
of the Seabees, a construction battalion with tours in Iraq and
Afghanistan. Garrett's journey with ALS was challenging and started
with him being forced to make the longer journey to Milwaukee because
they had the VA ALS clinic even though the Iron Mountain VA was much
closer to his home. As the disease progressed, and these road trips
were no longer feasible Garret had to start a Go Fund Me campaign to
try and offset the additional home health care he needed that wasn't
provided by the VA. Eventually, he did hit the cap. It was far more
complicated--his wife was overwhelmed with managing his care alone for
so many hours to prevent hitting the 65 percent cap, while also being a
single parent for their three young children. Then, Garret had to get a
trach. After all this chaos, Garrett hit the cap and had to go to an
institution. Garret tried his best to maneuver the system so he could
get back home with medical support from home care. Unfortunately, the
current structure would not afford him that final return home and
Garrett made the decision to remove his trachea and end his own life
rather than spend his days alone in the center far from his family and
without the daily support from friends, family and his kids. Garrett is
not the only veteran that we know that chose to end their life early
rather than endure being in a VA institution that failed to meet their
medical needs and lacked an appreciation for the care they needed as a
veteran with ALS. Even one veteran is one veteran too many to be
isolated from friends and family because of the distance from their
communities and family when forced to leave their homes for care
because of a cap limiting their access to support in their home .
Comprehensive care for veterans with ALS. As I shared earlier--ALS
is a neurodegenerative condition and as the disease progresses,
veterans with ALS require extensive and specialized care. The Elizabeth
Dole Home Care Act ensures that our Nation's veterans receive
comprehensive home-based care tailored to their complex needs, improves
their quality of life and allows them to remain in a familiar and
comfortable environment with their families, friends or loved ones.
Also included in the Elizabeth Dole Home Care Act is the Veteran
Directed, Home-Based Primary Care and the Homemaker Home Health Aide
programs that support the care and quality of life of veterans and
caregivers, especially at home and can serve as a lifeline for veterans
and caregivers in need. This program, a joint offering from the VA and
U.S. Department of Health and Human Services (HHS), offers veterans and
caregivers greater choice and control over their care and services by
allowing participants to utilize friends and family members to provide
unskilled care including transportation support and other services to
support the veteran in their home. Veterans and caregivers can
supervise their own employees and hire additional support during the
hours that are needed rather than being subject to agency hours and
restrictions. In addition, this program has been especially helpful to
those who struggle to find appropriate care in their homes either due
to contracted agency employee absences or the general dearth of HHA
providers around the country.
Support for Caregivers.
The Elizabeth Dole Act recognizes the important role of caregivers,
often family members, in managing the daily needs of veterans with ALS.
By providing resources, training and financial support to caregivers,
the Act helps reduce the emotional and financial burdens and allows
them to provide better care and support for our veterans. Being a
caregiver is hard work; being a caregiver for a person with ALS is
beyond daunting and incredibly exhausting.
Access to Medical Services.
The medical needs for veterans with ALS are complex and frequent
including physical therapy, respiratory care and many other specialized
treatments. The Elizabeth Dole Act facilitates access to these
necessary treatments at home, reducing the need for hospital visits or
visits to SCI/D centers that often lack the personnel and speciality
training needed for minimizing the risks for people with ALS, including
infections, complications and sadly, but very frequently medical
professionals who simply are not familiar with ALS and unintentionally
create more complications when they treat our veterans with ALS.
Quality of Life
Helps maintain a sense of independence and dignity for veterans
while ensuring they receive the medical attention and daily assistance
they need while remaining in a safe and comfortable home environment
with advocates around them to ensure their needs are being met.
Economic benefits
Home based care is more cost effective than institutional care. By
raising the cap to 100 percent and supporting veterans with ALS
receiving home care the EDHCA helps manage health care costs more
efficiently while allowing veterans to receive high quality
personalized care.
I AM ALS is so pleased that the Elizabeth Dole Home care Act is
bringing greater awareness of the challenges and needs of veterans
living with ALS especially those that need more support than the
current SCI centers can provide. This bipartisan legislation advocates
for and demands higher quality care including respect and dignity of
care in their homes with loving friends and family. This legislation
will ensure that our Nation's veterans with ALS receive the respect and
care they certainly deserve after their service to our country.
I would be remiss if I didn't take the honor and privilege of
engaging with Chairman Bost, Ranking Member Takano and the entire
committee without mentioning other key priorities for veterans with ALS
that we hope you will support and guide through Congress quickly for
our veterans with ALS.
As I mentioned earlier, I AM ALS supports doubling the funding for
CDMRP ALS Research at the Department of Defense. Multiple studies have
reported that Veterans are significantly more likely to be diagnosed
with ALS than those who did not serve in the U.S. military. While the
specific cause of this increased risk is unknown, the correlation
between military service and ALS is well-established so we encourage a
significant investment in researching this disease and finding a way to
treat ALS for the thousands of veterans that will develop this horrific
disease. We know that the additional research projects exist and are
simply not being funded because of the lack of resources being
allocated. We urge you to increase the funding to $80 million for
Fiscal Year 2025.
I AM ALS also urges Congress to pass the Justice for ALS Veterans.
This bipartisan legislation would fix the unfair policy that denies
benefits to the surviving spouses of veterans who died from ALS by
providing the surviving spouse with the DIC kicker without meeting the
8 years of disability requirement. Unfortunately, because most people
with ALS, a recognized service-connected disease, live fewer than 8
years from diagnosis, the surviving spouses of veterans with ALS have
been unfairly denied this benefit. The same spouses who may have quit
their jobs to take care of their loved ones who progressively lost
muscle control, became paralyzed and relied heavily on their caregiver
to stay alive.
Closing
I AM ALS is incredibly appreciative for all that Congress has done
for the ALS community in a bipartisan, collegial manner, but the ALS
community needs Congress to do even more for this 100 percent fatal
disease with no real treatment options. And we need you to do more with
a specific focus on our veterans with ALS. We should not allow a system
of care to continue that sees more veterans like Garrett decide that
ending their lives is preferred to enduring a VA institution that fails
them that doesn't provide the support and medical care they need, and
certainly doesn't have the staff available or trained to meet their
complex medical needs despite their sacrifices and commitment to our
Nation through their military service. I AM ALS encourages the
Committee and Congress to continue working together without politics
and to help move important measures forward including the Elizabeth
Dole Home Care Act as part of the Elizabeth Dole 21st Century Veterans
healthcare and Benefits Improvement Act. Our veterans with ALS who have
sacrificed for our country and selflessly served our Nation deserve to
have access to home based care. They need all of you to keep working
together to support them and support their families as they are in
their final battle against a wicked, cruel disease.
Thank you for your time and know that the ALS community appreciates
your efforts and continued work together in Congress for people with
ALS, especially our veterans. For this reason we urge you to work
together to get the Elizabeth Dole 21st Century Veterans Healthcare and
Benefits Improvement Act passed this year on suspension so critical
services are made available for veterans with ALS.
Prepared Statement of Jenny Kiratli
Chairman Bost and Ranking Member Takano, and Members of the House
Committee on Veterans' Affairs:
Thank you for inviting the American Federation of Government
Employees (AFGE) to participate in today's Committee hearing, ``A Call
to Action: Meeting the Needs of the Spinal Cord Injury and Disorders
(SCI/D) Veteran Community.''
I am Dr. Jenny Kiratli, and I have been a member of AFGE since 2009
and a research health scientist in the Spinal Cord Injury and Disorders
(SCI/D) Center, VA Palo Alto Health Care System (VAPAHCS) since 1991.
AFGE's National Veterans Affairs Council represents more than 302,000
AFGE VA employees across the Veterans' Health Administration (VHA),
Veterans Benefits Administration (VBA), and the National Cemetery
Administration (NCA). I have more than 30 years of experience
conducting research on clinical issues affecting people with SCI
including musculoskeletal conditions, bone and body composition; and
nutrition, activity, and exercise interventions--with a focus on
extending therapies into the home to facilitate wellness. I am Director
of the VA Advanced Fellowship Program in SCI Research and Associate
Research Director for the SCI Medicine Clinical Fellowship Program. I
am dedicated to mentoring junior investigators and fostering
partnerships with veterans and other stakeholders and colleagues to
conduct research that can be implemented into best practice.
The Spinal Cord Injury and Disorders (SCI/D) Center, VA Palo Alto
Health Care System (VAPAHCS) is one of 25 Spinal Cord Injury and
Disorders Centers located around the country. These centers offer
lifelong, comprehensive, integrated, coordinated care that includes
primary care, rehabilitation, emergency care, acute medical and
surgical care, mental health care, and home care. The Palo Alto VA also
has dietitians, respiratory therapists and orthotists & prosthetists on
staff. Our services are aimed at supporting the veteran as a whole
person including services that reintegrate veterans into the community
and provide respite care and family education. Our facility has also
pioneered telehealth services, which we launched in 2000. The expertise
of the interdisciplinary care team and breadth of the services makes
the VA SCI/D network the most comprehensive SCI/D care delivery system
in the U.S.
The VA's system of care for SCI/D uses a hub and spokes model. The
25 SCID centers are the hub facilities staffed with clinicians
including therapists and psychologists trained to provide specialized
care to people with a spinal cord injury or disorders. These hub
facilities coordinate with approximately 120 designated medical
``spokes'' facilities that do not have their own SCI/D center. The hub
and spokes model expands the reach of the SCI/D program ensuring that
veterans not located near an SCI/D center have access to comprehensive
primary and specialized care tailored to the unique needs of
individuals with spinal cord injuries and disorders. Primary care
physicians need special training to serve SCI/D patients' specific
needs. For example, primary care physicians treating the SCI/D
population must be able to diagnose and treat an array of problems that
may present differently in patients with spinal cord injuries such as
bone breaks and infections. They must also be trained to recommend
appropriate preventive care screenings and manage comorbidities common
to SCI/D patients such as metabolic disease, endocrine disease, and
musculoskeletal disorders. Most physicians in the SCI/D Centers pursue
an additional year of focused training in SCI Medicine through
fellowship programs.
Veterans comprise more than a quarter of the SCI/D population in
the U.S.\1\ The Palo Alto SCI/D system serves approximately 1,000 of
the 18,000 veterans that receive SCI/D services across the VA system.
Our center serves veterans and active-duty military personnel. While
those with service-connected injuries are eligible for enhanced
services, VA SCI/D centers serve veterans and active-duty military
personnel with nonservice related spinal cord injuries and disorders.
---------------------------------------------------------------------------
\1\ Cai S, Bakerjian D, Bang H, Mahajan SM, Ota D, Kiratli J. Data
acquisition process for VA and non-VA emergency department and hospital
utilization by veterans with spinal cord injury and disorders in
California using VA and State data. J Spinal Cord Med. 2022
Mar;45(2):254-261. doi: 10.1080/10790268.2020.1773028. Epub 2020 Jun
16. PMID: 32543354; PMCID: PMC8986188.
---------------------------------------------------------------------------
Clinical research conducted at Palto Alto SCI/D center can drive
improvements in care delivery that can also benefit non-veterans living
with spinal cord injuries and disorders. VA Palo Alto's Spinal Cord
(SCI/D) Center conducts significant clinical research aimed at
developing best practices for care for veterans with SCI/D. In my role
as director of clinical research, one of my current studies aims to
improve the assessment of bone health of veterans living with SCI/D.
Prior to this work, there has been no standardized method for measuring
bone health at the knee, a common fracture site for those with SCI/D.
This study will help inform evaluation of bone health for all veterans.
Adaptive gaming is another area where VA is plugging a research gap
that existed for the SCI/D population. Adaptive gaming as a therapeutic
tool had been studied within the stroke population, but specific
research was needed on muscle activation of upper limb muscles in
people with spinal cord injuries to determine whether video gaming
improved upper limb motor performance, balance, coordination, and
cardiovascular status. The project I led found that selected Wii games
were able to elicit upper extremity muscle activation and elevated
heart rates for individuals with SCI that may be used to target
therapeutic outcomes.
VA further serves the general SCI/D population by pioneering
modifications to existing technologies to adapt them for the SCI/D
population. For example, a modification to standing wheelchairs
pioneered by a team from the Minneapolis VA Health Care System allows
people to move while in standing positions. Early models of standing
wheelchairs allowed people to stand but not to move in the standing
position. VA physicians worked with biomedical engineers to add a chain
drive system to the chair that allows users to push their chairs from a
standing position. The Palo Alto VA collaborates with the Minneapolis
VA to research the use of this adaptation to maximize the use of the
technology for the SCI/D population. All VA research is ultimately
shared with non-VA SCI facilities through published research and
conferences, contributing to the overall benefit of the larger, non-VA
SCI/D population.
VA also plays an important role in training SCI/D professionals
collaborating with academic programs to provide clinical training. VA
has an advanced fellowship training in SCI medicine. More needs to be
done to encourage young clinicians to enter the field. Of the 31
positions for the SCI clinical training program only usually fewer than
20 positions are filled.
We also participated in a multi-site VA study to establish,
implement and test a model for vocational rehabilitation that greatly
enhances opportunities for veterans with SCI/D to return to work and
contribute to the workforce in meaningful ways by partnering with
potential employers to understand the needs of each individual and
develop jobs that meet their needs.
The VA is at the forefront of improving clinical outcomes and
quality of life for veterans and all people living with spinal cord
injuries and disorders. However, more can be done to strengthen the
VA's SCI/D system. While the hub and spokes model greatly expands
access to VA's SCI/D services, there are gaps in care, particularly for
veterans in rural areas where more spoke facilities are needed.
There is a great need for increased staffing for SCI/D services.
Individuals with SCI have challenging and complex health care needs
requiring significant support. They live with many secondary
complications that require vigilance to prevent functional decline and
premature death. Individuals with SCI are two to five times more likely
to die a prematurely.\2\ SCI is also associated with higher rates of
mental illness, with one in five suffering from depression,
significantly higher rates of anxiety, posttraumatic stress disorder,
and death by suicide. \3\ Staffing requirements for SCI/D centers
should be updated to reflect the higher acuity of the SCI/D population.
Because of the complexity of SCI/D care, it requires specialized
certification and training. The high acuity of care creates burnout and
younger clinical staff often leave just when they have gained
sufficient skills to perform all their duties. It is difficult to use
temporary staff, such as floating nurses, to deal with short staffing
in SCI/D centers because specialized training is required. As a result,
SCI nurses can be moved elsewhere to deal with staffing shortages, but
non-SCI nurses cannot easily fill in on SCI unit. Additional retention
incentives are needed to address vacancies and turnover.
---------------------------------------------------------------------------
\2\ Touchett, H., Apodaca, C., Siddiqui, S. et al. Current
Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury
(TeleSCI). Curr Phys Med Rehabil Rep 10, 77-88 (2022). https://doi.org/
10.1007/s40141-022-00348-5
\3\ Touchett, H., Apodaca, C., Siddiqui, S. et al. Current
Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury
(TeleSCI). Curr Phys Med Rehabil Rep 10, 77-88 (2022). https://doi.org/
10.1007/s40141-022-00348-5
---------------------------------------------------------------------------
The Mission Act increased access to non-VA facilities. Research
suggests that use of VA and non-VA care has the potential to cause
unintended duplication of services, costs and fragmentation of care.\4\
But the potential for inadequate care is a greater concern for veterans
with SCI/D. The VA's SCI/D model provides uniquely comprehensive and
integrated services delivered by highly knowledgeable teams of
specialists that do not exist in the private sector. In addition, non-
VA providers lack access to VA resources such as medical equipment and
a wide array of adaptive products, often created for each individual
veteran to meet his or her specific needs. Further, non-specialists
often do not recognize serious disorders (e.g., a bone fracture)
because of an absence of the normal symptoms. Care should be taken to
ensure that increasing privatization of VA services does not upend the
VA's specialized SCI/D care model that provides veterans living with
spinal cord injury and disorders an array of integrated services and
provides research used to develop best practices for all people living
with spinal cord injuries and disorders.
---------------------------------------------------------------------------
\4\ Hatch MN, Etingen B, Raad J, Siddiqui S, Stroupe KT, Smith BM.
Dual utilization of Medicare and VA outpatient care among Veterans with
spinal cord injuries and disorders. J Spinal Cord Med. 2023
Sep;46(5):716-724. doi: 10.1080/10790268.2022.2027321. Epub 2022 Feb 2.
PMID: 35108176; PMCID: PMC10446768.
Statements for the Record
----------
Prepared Statement of MitoSense, Inc.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Christopher and Dana Reeve Foundation
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Neuralink
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[all]