[Senate Hearing 107-760]
[From the U.S. Government Printing Office]
S. Hrg. 107-760
NOMINATIONS OF ROBERT H. ROSWELL, M.D., TO BE UNDER SECRETARY FOR
HEALTH, DEPARTMENT OF VETERANS AFFAIRS AND DANIEL L. COOPER, TO BE THE
UNDER SECRETARY FOR VETERANS BENEFITS, DEPARTMENT OF VETERANS AFFAIRS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
MARCH 14, 2002
__________
Printed for the use of the Committee on Veterans' Affairs
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82-807 WASHINGTON : 2002
_____________________________________________________________________________
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COMMITTEE ON VETERANS' AFFAIRS
JOHN D. ROCKEFELLER IV, West Virginia, Chairman
BOB GRAHAM, Florida ARLEN SPECTER, Pennsylvania
JAMES M. JEFFORDS (I), Vermont STROM THURMOND, South Carolina
DANIEL K. AKAKA, Hawaii FRANK H. MURKOWSKI, Alaska
PAUL WELLSTONE, Minnesota BEN NIGHTHORSE CAMPBELL, Colorado
PATTY MURRAY, Washington LARRY E. CRAIG, Idaho
ZELL MILLER, Georgia TIM HUTCHINSON, Arkansas
E. BENJAMIN NELSON, Nebraska KAY BAILEY HUTCHISON, Texas
William E. Brew, Chief Counsel
William F. Tuerk, Minority Chief Counsel and Staff Director
(ii)
C O N T E N T S
----------
March 14, 2002
SENATORS
Page
Graham, Hon. Bob, U.S. Senator from Florida...................... 1
Prepared statement........................................... 2
Nelson, Hon. Bill, U.S. Senator from Florida..................... 3
WITNESSES
Cooper, Daniel L., nominated to be the Under Secretary for
Veterans Benefits, Department of Veterans Affairs.............. 35
Prepared statement........................................... 36
Letter from Amy L. Comstock, Director, United States Office
of Government Ethics, dated February 15, 2002.............. 37
Questionnaire for Presidential nominees...................... 38
Response to prehearing questions submitted by Hon. John D.
Rockefeller IV to Daniel L. Cooper......................... 40
Response to written questions submitted by:
Hon. John D. Rockefeller................................. 46
Hon. Bob Graham.......................................... 53
Hon. Arlen Specter....................................... 54
Hon. Larry E. Craig...................................... 61
Hon. Kay Bailey Hutchison................................ 61
Roswell, Robert H., M.D., nominated to be Under Secretary for
Health, Department of Veterans Affairs......................... 5
Prepared statement........................................... 6
Letter from Amy L. Comstock, Director, United States Office
of Government Ethics, dated February 8, 2002............... 7
Questionnaire for Presidential nominees...................... 7
Response to written pre-hearing questions submitted by Hon.
John D. Rockefeller........................................ 10
Response to written questions submitted by:
Hon. John D. Rockefeller IV.............................. 24
Hon. Bob Graham.......................................... 28
Hon. Arlen Specter....................................... 30
Hon. Ben Nighthorse Campbell............................. 33
Hon. Larry E. Craig...................................... 33
Hon. Kay Bailey Hutchison................................ 34
APPENDIX
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado,
prepared statement............................................. 78
Craig, Hon. Larry E., U.S. Senator from Idaho, prepared statement 78
Specter, Hon. Arlen, U.S. Senator from Pennsylvania, prepared
statement...................................................... 77
(iii)
NOMINATIONS OF ROBERT H. ROSWELL, M.D., TO BE UNDER SECRETARY FOR
HEALTH, DEPARTMENT OF VETERANS AFFAIRS AND DANIEL L. COOPER, TO BE THE
UNDER SECRETARY FOR VETERANS BENEFITS, DEPARTMENT OF VETERANS AFFAIRS
----------
THURSDAY, MARCH 14, 2002
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The committee met, pursuant to notice, at 2:26 p.m., in
room 418, Russell Senate Office Building, Hon. John D.
Rockefeller IV (chairman of the committee) presiding.
Present: Senators Rockefeller, Graham, and Nelson of
Nebraska.
Chairman Rockefeller. Good afternoon.
Would it be more efficient if we allowed Senators Graham
and Nelson to go ahead and do the introductions now? Then we
can make our opening statements.
Senator Nelson of Florida. That would be great.
Chairman Rockefeller. Then that is what I think we should
do, if that is all right with you, Senator.
STATEMENT OF HON. BOB GRAHAM, U.S. SENATOR FROM FLORIDA
Senator Graham. Mr. Chairman, I appreciate your courtesy to
my colleague and myself. We are here on behalf of the
nomination of Dr. Robert Roswell to be Under Secretary for
Veterans Health.
I have had the good fortune of knowing Dr. Roswell for a
number of years and have observed at close range the
outstanding service that he has provided to the VISN, which
includes Florida, Southern Georgia, Puerto Rico, and the Virgin
Islands. It doesn't quite make it to West Virginia----
Chairman Rockefeller. My life is filled with
disappointments and I am certain that has been one of Dr.
Roswell's. But now, if confirmed in his new position, he will
finally get to West Virginia.
Senator Graham. In his position at VISN 8, which is
referred to as the VA Sunshine Health Care Network, a very
appropriate title, he has had health care responsibility for
over 410,000 veterans. It is the largest VISN in the country.
His philosophy has been always do what is right for the
veteran. He has been very oriented toward service to the
veteran.
In his 6 years in leadership in VISN 8 he has accomplished
a number of outstanding gains for the benefit of veterans. I
will just mention a few of them. He has seen first a tremendous
growth and expansion within the VISN. He also has been able to
meet this growth and expansion in a very cost-effective way.
Of the 22 VISN's, VISN 8 ranks second in terms of its
efficiency in the use of VA funds for health care services.
He also has seen a large increase in the number of users.
There has been a 17-percent increase in the number of veterans
in VISN 8. He has, in addition to his duties in VISN 8, has
served as the Executive Director of the Persian Gulf Veterans
Coordinating Board from 1994 to 1999.
In that capacity he coordinated Persian Gulf veterans and
activities as they related to medical care and research and
disability compensation on a national basis between the
Department of Defense, Health and Human Services, and the
Veterans Administration.
Mr. Chairman, I would like to file the balance of my
statement in full in the record, but just conclude by saying
that Dr. Roswell's qualifications in my judgment make him an
ideal candidate for this important position. He is admired and
eminently qualified to serve as the Under Secretary of Health
for the VA.
I appreciate this committee's expedited consideration of
Dr. Roswell's nomination and I look forward to working with you
to fill this important current vacancy in the Department of
Veterans Affairs.
[The prepared statement of Senator Graham follows:]
Prepared Statement of Hon. Bob Graham, U.S. Senator From Florida
Mr. Chairman, thank you for scheduling this hearing. I
would also like to thank the committee for its attention to the
nominee--a man who has devoted his career to serving our
nation's Veterans.
It is my pleasure to welcome and introduce Dr. Robert
Roswell. My colleague and good friend, Senator Nelson will also
be giving some remarks and in an effort not to be repetitive,
my remarks will concentrate on his professional experience and
numerous accomplishments.
I have known Dr. Roswell since 1995, when he was appointed
as Network Director of the VA Sunshine Healthcare Network (VISN
8). As director, he has oversight for the healthcare operation
of the largest Veterans Network in the Department of Veterans
Affairs. The Network provides health care to over 410,000
veterans throughout Florida, Puerto Rico, southern Georgia and
the U.S. Virgin Islands.
In addition to his duties as Network Director of VISN 8,
Dr. Roswell also served as Executive Director of the Persian
Gulf Veterans Coordinating Board from 1994 to 1999. In this
capacity, he coordinated Persian Gulf veterans programs and
activities related to medical care, research and disability
compensation between the DoD, Health and Human Services, and
Veterans Affairs.
Dr. Roswell has also remained directly engaged in medicine.
He serves as a Colonel in the Medical Corps, U.S. Army Reserve
and during his tenure as Network Director was also Commander of
the Army's 73rd Field Hospital, St. Petersburg, FL.
Dr. Roswell's philosophy for providing care to our Nation's
veterans is summed up in a simple phrase; ``Always do what is
right for the veteran.'' What he has accomplished over the past
six years for VISN 8 clearly indicates that both providing the
highest quality of care in a cost effective way, and
maintaining patient satisfaction has been his utmost priority.
Under his leadership, VISN 8 has seen tremendous growth and
expansion. Additionally, VISN 8's cost per veteran continues to
decline and it is consistently one of the most cost efficient
VISNs, ranking second out of the 22 VISNs. Veterans in VISN 8
have been well served as a result of Dr. Roswell's efforts as
Network Director.
One of the major challenges facing the Veterans
Administration is timely access to quality health care. All of
the VISN's have seen a huge increase in new users, Florida
handling the largest number of new users, receiving over 17% of
all new enrollees in 2001. As Florida's VISN Director, Dr.
Roswell is well aware of this challenge and is committed to
work to improve the delivery of health care.
Dr. Roswell has had a distinguished career in the
Department of Veterans Affairs and has been recognized at the
national level. Some of the awards he has received include: the
VA Secretary's Commendation, Department of Veterans Affairs
Superior Performance Awards, VA's Meritorious Service Award,
the AMSUS John D. Chase Award for Physician Executive
Excellence. He has also been recognized by the Senior
Executives Association Professional Development League with an
Executive Achievement Award.
Mr. Chairman, Dr. Roswell's qualifications make him the
ideal candidate for this important position. Dr. Roswell is an
admired and eminently qualified candidate to serve as
Undersecretary of Health for the VA.
I appreciate the Committee's consideration of Dr. Roswell's
nomination and look forward to working with you to fill this
important vacancy in the Department of Veterans Affairs.
Chairman Rockefeller. Thank you, Senator Graham.
Senator Nelson.
STATEMENT OF HON. BILL NELSON, U.S. SENATOR FROM FLORIDA
Senator Nelson of Florida. Thank you, Mr. Chairman. I would
echo the comments of my colleague. We are very fortunate to
have such a professional from the State of Florida.
I would just add that he also has the personal touch. As I
was looking into his background I noticed the commentary from
one 100 percent disabled veteran who had gone through major
surgery at one of our VA hospitals. His comment was that the
good doctor took the time to call after the surgery to see how
he was. It is that kind of caring and compassion, that personal
touch, that is so needed as we confront not only the problems
and challenges of veterans, but seeing that they get the
deserved recognition and due that they are owed by this
country.
That is why I am here on behalf of Dr. Bob Roswell.
Chairman Rockefeller. Well, thank you, Senator, very much.
I appreciate your presence. We are honored.
We will now go ahead with our statements. We need to swear
both of you in, then have your statements, and then we will
have questions.
As has been made clear, we are meeting in formal session to
consider the nominations of Daniel L. Cooper to be Under
Secretary for Benefits and also Dr. Robert Roswell to be Under
Secretary for Health. These are two monumental positions. It is
very unusual to be confirming two people that have so much
responsibility between them.
To occupy those two positions means that you will be
affecting the VA's future, or you will not. But you have the
opportunity to do that. If confirmed, your actions will shape
the delivery of health care and benefits and probably because
of where we are right now in our country, for decades to come.
Both of you have shown your commitment to this Nation
through your distinguished careers, so I know that I don't have
to impress upon you the importance of the leadership roles for
which both of you are up for confirmation.
We look to both of you to find the path which has always
been out there for VA but which has never been fully, in my
judgment, realized.
Dr. Roswell, if you are confirmed you will take over the
reins of the VA health care system at a very, very difficult
time. You will have many conversations with me about long-term
care and the fact that it has not happened.
Clinics and hospitals have long waiting lists. Providers
are overworked. Nurses are in short supply and will become more
so. Veterans, at least many of them, are frustrated. Members of
the VA Appropriations Subcommittee are frustrated, as well, and
blame this committee and the VA Committee on the House side for
the budget problems.
I for one do not apologize for the new benefits that we
have enacted. I don't like having Appropriations trying to
overtake our responsibility, and I will fight to preserve the
integrity of this committee.
We have expanded the benefits package. We have improved the
system, and it is those very changes that have caused many
veterans to seek VA care for the first time. So, there is good
news. There are more veterans coming, not less.
Instead of pointing fingers and engaging in an effort to
avoid the challenges we all face, I for one, and I know every
member of this committee--all of us pledge to work with our
colleagues to make sure that sufficient funds are directed to
the VA. We have to do our part.
If you are confirmed, it will fall on your shoulders, Dr.
Roswell, to manage the health care system. On the benefits
side, it may be fair to say that I have never seen the system
in as difficult a situation as it is today.
While the VA has a tremendously dedicated work force that
cares deeply for the veterans that it serves. It has been
hampered by an institutional inertia.
There is a group in any agency, particular one which is as
large as the VA, which just doesn't want to see things change.
The question is: How do you make change. That will be your
great challenge.
You have the consequences of an aging work force, an ever-
increasing level of work, the demands of the veterans, the
complexity imposed by changes in laws that we make.
So, Mr. Cooper, if confirmed, one of the difficulties you
will face will be implementing the plan set forth by the task
force that you chair. I don't know whether the direction
proposed by the task force is better than the one the VA has
been pursuing, but I do know that any significant change could
be very difficult to carry out.
I also know, historically, that VA has a tendency to
propose great plans and then somehow the status quo continues.
VA in not unique in that. So, I urge you to resist the
tremendous pressures from all around, and sometimes even for
those of us in the Congress, to only focusing on reducing the
backlog or the number of days it takes to process an original
claim.
Please don't lose sight of the big picture. No part of the
system can be ignored. I will say that to both of you: All
parts are important. Above all, there must be accuracy in
decisionmaking and confidence veterans must have in the quality
of those decisions.
Cutting corners, even the mere perception of cutting
corners, will lead to appeals. These will not only burden the
VA, but they are enormously detrimental to the veterans who
await the outcome of those appeals.
I am not aware of the order of arrival, so I will call on
Senator Graham.
Senator Graham. Mr. Chairman, I have no opening statement.
Chairman Rockefeller. Senator Nelson.
Senator Nelson of Nebraska. Well, my opening statement is
more of a question. After the chairman's description of the
jobs, my question is: Do you still want the jobs?
Chairman Rockefeller. Yes, they do.
Senator Nelson of Nebraska. I will forego an opening
statement. Thank you.
Chairman Rockefeller. OK. Let me say for the record that
both nominees have completed the committee questionnaire for
Presidential nominees. They have responded to my pre-hearing
questions, all of which will appear in the hearing record.
Also included will be a letter from the Office of
Government Ethics acknowledging that each is in compliance with
laws and regulations governing conflicts of interest.
As chairman of the committee, I will review both nominee's
FBI records and then we will seek committee action of their
nominations. Senator Specter, of course, will join me in doing
that.
So, I would ask you now, if you would stand and raise your
right hand so that I can administer the required oath.
Do you both swear and affirm that the testimony that you
will give at this hearing and any written answers or statements
you provide in connection with this hearing will be the truth,
the whole truth and nothing but the truth?
Dr. Roswell. I do.
Mr. Cooper. I do.
Chairman Rockefeller. Please be seated. We are very
interested in what you have to say.
STATEMENT OF ROBERT H. ROSWELL, M.D., NOMINATED TO BE UNDER
SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS
Dr. Roswell. Mr. Chairman and committee members, especially
Senator Graham who I thank for that very gracious introduction,
it is my distinct honor and pleasure to appear before you today
to discuss the future of VA health care.
Under the visionary and capable leadership of Dr. Ken Kizer
and Dr. Tom Garthwaite the Veterans Health Administration has
undergone a remarkable transformation. Health care delivery has
been shifted from costly inpatient settings to an outpatient
based primary care delivery model focused on prevention and
health maintenance.
Quality has risen from questionable to exceptional and for
the first time in many years we face a burgeoning demand for
care that threatens to exceed the finite resources within VA.
I believe that it is important to continue this
transformation, safeguarding the quality of the care that is at
the vary heart of the system, while continuing to move the
focus of care from the hospital to the outpatient clinic to the
community and into the homes of veterans. But in so doing, we
must also plan for the future needs of veterans and enhance our
ability to respond to a growing demand for VA care.
We must move quickly to assure that the long-term care and
end-of-life needs of World War II veterans will be met in ways
that provide the care and dignity these veterans have earned by
their service and the functional independent and emotional
support they so desperately seek.
We must learn from our experience in treating Vietnam and
Gulf War veterans and recognize that whenever we send men and
women into harm's way there will be health care consequences
that VA must be prepared to face.
Although the exposures our military may face and the
illnesses that they develop may vary, the risk is certain and
VA is uniquely situated to respond to these needs.
We must also improve the capture and utilization of all
resources available to support the veterans health care system,
including medical care cost recovery from private insurance
companies and we must enhance our business expertise in order
to strengthen our efforts to meet the growing demand for VA
care.
Much of VA's progress over the last few years can be traced
to VHA's reorganization into 21 VISN's or regions around the
country. This coupled with the introduction of a performance
measurement system has greatly transformed VA. However, the
time has come to minimize variation across the 21 Veterans
Integrations Service Networks within VHA and maximize our
performance across the entire system.
I deeply believe that this can be accomplished by the
introduction of a comprehensive strategic planning process with
involvement with all key stakeholders, careful alignment of
performance measurement systems with VA's strategic goals and a
cross-cutting management and oversight system for key
functional areas across all of the networks.
Mr. Chairman, if confirmed I look forward to continuing a
productive dialog with you and the committee members to assure
a vital and responsive health care system for generations of
veterans yet to come.
Thank you.
[The prepared statement of Dr. Roswell follows:]
Prepared Statement of Robert H. Roswell, M.D., Nominated To Be Under
Secretary for Health, Department of Veterans Affairs
Mr. Chairman and Members of the Committee:
I am pleased to appear before you today as President Bush's nominee
to lead the Veterans Health Administration. For the past twenty years I
have devoted my professional life to serving the needs of veterans in a
variety of capacities, and I am honored to be considered by you for
this position.
Over the past six years, under the visionary and capable leadership
of Dr. Ken Kizer and Dr. Thomas Garthwaite, the Veterans Health
Administration has undergone a remarkable transformation. Healthcare
delivery has been shifted from costly inpatient settings to an
outpatient-based primary care delivery model focused on prevention and
health maintenance. Quality has risen from questionable to industry
leading in many respects; and for the first time in many years we face
a burgeoning demand for care that threatens to exceed finite resources
within VHA.
I believe that it is important to continue this transformation,
safeguarding the quality of care that is at the very heart of the
system, while continuing to move the locus of care from the hospital to
the outpatient clinic, to the community, and into the homes of
veterans. But we must also plan for the future needs of veterans and
enhance our ability to respond to a growing demand for VA care.
We must move quickly to assure that the long-term care and end-of-
life needs of World War II veterans will be met in ways that provide
the care and dignity these veterans have earned, and the functional
independence and emotional support they seek. And we must find ways to
meet these needs without irrevocably committing our physical
infrastructure in a manner ill suited for the needs of those veterans
who will come behind them.
I believe we must learn from our experience in treating Vietnam and
Gulf War veterans, and recognize that whenever we send men and women
into harm's way, there will be healthcare consequences that VA must be
prepared to face. Although the exposures our military may face, and the
illnesses they will develop may vary, the risk is certain and VA is
uniquely situated to respond to their needs.
We must also improve the capture and utilization of all resources
available to support the veterans healthcare system. Many of our
patients have earned benefits from all three of our country's federal
healthcare programs, yet sadly they still face substantial out-of-
pocket expense to obtain the care they need. We must improve cost
recovery efforts and enhance our business acumen to facilitate our
efforts to meet a growing demand for VA care.
Much of VA's remarkable transformation over the last few years is
rooted in the network structure put in place in 1996. This
reorganization, coupled with the introduction of a performance
measurement system, has led to substantial change across what some have
characterized as 22 ``innovation laboratories''. However, others have
expressed concerns over the regional variations in programs and
services. The time has come to maximize performance and minimize
variation across the 21 Veterans Integrated Service Networks within the
Veterans Health Administration.
I believe this can be accomplished by the introduction of a
comprehensive strategic planning process with involvement of all key
stakeholders, careful alignment of the performance measurement system
with VA strategic goals, and a cross-cutting management and oversight
system for key functional areas across all networks.
Mr. Chairman, if confirmed, I look forward to a continuing and
productive dialogue with you and Committee members, as well as other
members of Congress as we work to assure a vital and responsive
healthcare system for generations of veterans yet to come.
______
United States Office of Government Ethics,
Washington, DC, February 8, 2002.
Hon. John D. Rockefeller IV,
Chairman, Committee on Veterans' Affairs,
U.S. Senate,
Washington, DC.
Dear Mr. Chairman: In accordance with the Ethics in Government Act
of 1978, I enclose a copy of the financial disclosure report filed by
Robert H. Roswell, who has been nominated by President Bush for the
position of Under Secretary for Health, Department of Veterans Affairs.
We have reviewed the report and have also obtained advice from the
Department of Veterans Affairs concerning any possible conflict in
light of its functions and the nominee's proposed duties. Also enclosed
is a letter December 21, 2001, from the Department's ethics official,
outlining the steps Dr. Roswell will take to avoid conflicts of
interest. Unless a specific date has been agreed to, the nominee must
fully comply within three months of his confirmation date with the
actions he agreed to take in his ethics agreement.
Based thereon, we believe that Dr. Roswell is in compliance with
applicable laws and regulations governing conflicts of interest.
Sincerely,
Amy L. Comstock,
Director.
______
Questionnaire for Presidential Nominees
part i: all the information in this part will be made public
1. Name: Robert Roswell.
2. Address: 13528 Oak Run Court, Seminole, FL 33776.
3. Position to which nominated: VA Under Secretary for Health.
4. Date of Nomination: February 6, 2002.
5. Date of birth: August 13, 1949.
6. Place of birth: Bartlesville, OK.
7. Marital status: Married.
8. Full name of spouse: Cheryl Anne Roswell.
9. Names and ages of children: Sara Elizabeth Roswell, 13;
Alexander Robert Roswell, 11; Ashley Rene Roswell, 8.
10. Education: Institution (including city, state), dates attended,
degrees received, dates of degrees:
Oklahoma State Univ, Stillwater OK; 1967-1971; BS; 1971.
Univ of Oklahoma, Oklahoma City, OK; 1971-1975; M.D.; 1975.
Univ of Oklahoma Health Sciences Center; 1976-1978; Internal
Medicine Residency.
Univ of Oklahoma Health Sciences Center; 1980-1982; Endocrinology
Fellowship.
11. Honors and awards: List all scholarships, fellowships, honorary
degrees, military medals, honorary society memberships, and any other
special recognitions for outstanding service or achievement:
John D. Chase Award for Physician Executive Excellence, AMSUS,
1999.
Army Meritorious Service Medal, 2000.
Senior Executives' Association Professional Development Leagues
Executive Excellence Award for Executive Achievement finalist.
Department Appreciation Award, Disabled American Veterans, 1999.
Vice President Al Gore's National Partnership for Reinventing
Government Hammer Award, 2001.
12. Memberships: List all memberships and offices held in
professional, fraternal, business, scholarly, civic, charitable, and
other organizations for the last 5 years and other prior memberships or
offices you consider relevant:
Assoc. of Military Surgeons of U.S.; Member; Current.
Persian Gulf Veterans Coordinating Board; Executive Director; 1994-
1999.
Dept. of Environmental & Occupational Health, Univ. of South
Florida, Tampa, FL; Professor; 1998-present.
American College of Physician Executives; Member; Current.
American Board of Internal Medicine; Diplomate; 1978.
National Board of Medical Examiners; Diplomate; 1976.
Alpha Omega Alpha Honor Medical Society; 1975.
13. Employment Record: List all employment (except military
service) since your twenty-first birthday, including the title or
description of job, name of employer, location of work, and inclusive
dates of employment:
Network Director, Veterans Integrated Service Network #8, Dept, of
Veterans Affairs, Bay Pines, FL (1995-Present).
Chief of Staff, Veterans Affairs Medical Center, Birmingham, AL
(1993-1995).
Associate Deputy Chief Medical Director for Clinical Programs,
Dept. of Veterans Affairs, Central Office, Washington, D. C. (1991-
1993).
Chief of Staff, Veterans Affairs Medical Center, Oklahoma City, OK
(1989-1991).
Acting Chief of Staff, Veterans Administration Medical Center,
Dallas, TX (1988).
Acting Assoc. Chief of Staff for Ambulatory Care; Chief General
Medicine Section, Veterans Administration Medical Center, Dallas, TX
(1985-1986).
Associate Chief of Staff for Education; Senior Staff Physician,
Endocrinology Section; Veterans Administration Medical Center, Dallas,
TX (1984-1988).
Staff Physician, Oklahoma Memorial Hospital, Oklahoma City, OK
(1982-1984).
Staff Physician, Martin Army Hospital, Fort Benning, Georgia (1978-
1980).
14. Military Service: List all military service (including reserve
components and National Guard or Air National Guard), with inclusive
dates of service, rank, permanent duty stations and units of
assignment, titles, descriptions of assignments, and type of discharge:
Colonel, US Army Reserve, Office of Domestic Healthcare Policy,
Office of the Army Surgeon General (2002).
Colonel, Medical Corps, U.S. Army Reserve, Commander, 73rd Field
Hospital, St. Petersburg, FL (1997-2000).
Colonel, Medical Corps, U.S. Army Reserve, 73rd Field Hospital, St.
Petersburg, FL (1996-1997).
Colonel, Medical Corps, U.S. Army Reserve, 3345th U.S. Army
Hospital, Birmingham, AL (1992-1996).
Lieutenant Colonel, Medical Corps, U.S. Army Reserve, Division
Surgeon, 95th Division (Training), Midwest City, OK (1989-1991).
Lieutenant Colonel, Medical Corps, U.S. Army Reserve, Preventive
Medicine Officer, 807th Medical Brigade, Seagoville, TX (1987-1989).
Major, Medical Corps, U.S. Army Reserve, Preventive Medicine
Officer, 807th Medical Brigade, Seagoville, TX (1985-1987).
Major, Medical Corps, U.S. Army Reserve, 94th General Hospital,
Dallas, TX (1984-1985).
Captain, Medical Corps, U.S. Army Reserve, 44th Evacuation
Hospital, Oklahoma City, OK (1980-1984).
Captain, Medical Corps, Martin Army Hospital, Ft. Benning, GA
(Active Duty 1978-1980).
15. Government experience: List any advisory, consultative,
honorary, or other part-time service or positions with Federal, State,
or local governments other than listed above:
None except as previously noted.
16. Published writings: List titles, publishers, and dates of
books, articles, reports or other published materials you have written:
Roswell, R., Mullins, M., Weaver, T., Law, D., Mullins, D., Koenig,
K., Boatright, C., Teeter, D., and Gray, E., Weapons of Mass
Destruction: An Educational and Experiential Training Model for
Healthcare Professionals. Presented at the Association of Military
Surgeons of the U.S., Annual Meeting, 2000, Las Vegas, NV.
Roswell, R.H., Van Diepen, L.R., Jones, J.K., and Hicks, W.E.,
Adverse Drug Reactions Definitions, Diagnosis, and Management, 2001
Lancet 357;561.
Hyams, K. C., and Roswell, R.H., Resolving the Gulf War Syndrome
Question, 1998 American Journal of Epidemiology 148;329-349.
Hyams, K. C., Wignall, F. S., and Roswell, R., War Syndromes and
Their Evaluation: From the U.S. Civil War to the Persian Gulf War. 1996
Annals of Internal Medicine 125; 398-40.
Beach, P., Blank, R.R., Gerrity, T., Hyams, K.C., Mather, S.,
Mazzuchi, J.F., Murphy, F., Roswell. R., and Sphar, R.L., Coordinating
Federal Efforts on Persian Gulf War Veterans, 1995 Federal Practioner
12:No. 12:9-15.
17. Political affiliations and activities
(a) List all memberships and offices held in and financial
contributions and services rendered to any political party or election
committee during the last 10 years: None.
(b) List all elective public offices for which you have been a
candidate and the month and year of each election involved: None.
18. Future employment relationships
(a) State whether you will sever all connections with your present
employer, business firm, association, or organization if you are
confirmed by the Senate: Currently, I am a VA career employee.
(b) State whether you have any plans after completing Government
service to resume employment, affiliation, or practice with your
previous employer, business firm, association or organization: N/A.
(c) What commitments, if any, have been made to you for employment
after you leave Federal service? None.
(d) (If appointed for a term of specified duration) Do you intend
to serve the full term for which you have been appointed? Yes.
(e) (If appointed for indefinite period) Do you intend to serve
until the next Presidential election? N/A.
19. Potential Conflicts of Interest
(a) Describe any financial arrangements, deferred compensation
agreements, or other continuing financial, business, or professional
dealings which you have with business associates, clients, or customers
who will be affected by policies which you will influence in the
position to which you have been nominated: None.
(b) List any investments, obligations, liabilities, or other
financial relationships which constitute potential conflicts of
interest with the position to which you have been nominated:
See attached schedule of listed securities.*
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* Note: The information referred to has been retained in the
committee's files.
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(c) Describe any business relationship, dealing, or financial
transaction which you have had during the last 5 years, whether for
yourself, on behalf of a client, or acting as an agent, that
constitutes as potential conflict of interest with the position to
which you have been nominated: None.
(d) Describe any lobbying activity during the past 10 years in
which you have engaged for the purpose of directly or indirectly
influencing the passage, defeat, or modification of any Federal
legislation or for the purpose of affecting the administration and
execution of Federal law or policy: None.
(e) Explain how you will resolve any potential conflicts of
interest that may be disclosed by your responses to the above items.
(Please provide a copy of any trust or other agreements involved.)
In consultation with the Office of Government Ethics, I will recuse
myself from any procurement decision involving any of the companies in
which I hold an equity position.
20. Testifying before the Congress
(a) Do you agree to appear and testify before any duly constituted
committee of the Congress upon the request of such committee? Yes.
(b) Do you agree to provide such information as is requested by
such a committee? Yes.
______
Response to Written Pre-Hearing Questions Submitted by Hon. John D.
Rockefeller IV to Robert H. Roswell, M.D.
Question 1a. Dr. Roswell, I have a series of questions relating to
the current network structure. As a current VISN director and nominee
for Under Secretary, you are uniquely situated to know how the current
structure works for the network director and how you believe it should
work from the perspective of Headquarters.
The Committee has seen problems with how specific programs--for
example mental health services--are carried out locally, both in terms
of network directors receiving guidance and Headquarters' consultants
having even basic information as to the status of their respective
programs. Such lack of control and oversight has been noticed in the
areas of quality management, long-term care, mental health services,
the maintenance of capacity, and on and on.
What do you believe is the appropriate role of HQ consultants in
overseeing operations of their respective programs and do you believe
this is occurring now?
Answer. I believe HQ consultants' primary roles are for program and
policy development and for providing national level oversight of VHA's
performance in their program areas. I expect HQ consultants to be
advocates for their programs and to be part of the national leadership
team that guides VHA activities. I believe HQ consultants are generally
performing these functions, but will assure that expectations are
clear, and over time I will review the consultants' performance in
these areas.
Question 1b. In your view is it possible for the Under Secretary
and those in Headquarters to actually manage the overall VA system?
Answer. I believe the best results are achieved when both field and
Headquarters managers work together to establish goals and strategies
for achieving the highest possible quality of health care services for
our patients. VHA's achievements over the past few years could not have
been accomplished with a top-down management structure and philosophy.
VHA's Performance Measurement System provides both managerial direction
and results tracking for field personnel; however this system must be
carefully aligned with VA strategic goals for optimal results.
Question 1c. If confirmed, what changes would you propose so as to
attempt to ensure that all aspects of VA health care management are
covered?
Answer. I currently have no plans to change the management
structure. I will work to assure that VHA's senior managers effectively
carry out their responsibilities. This will be achieved, in part, by
the introduction of a comprehensive strategic planning process, careful
alignment of the VHA Performance Measurement System with strategic
goals, and the use of crosscutting committees to maximize performance
and reduce variance across all VISNs. If I find that changes are needed
to improve VHA performance, I will not hesitate to propose those
changes to the Secretary.
Question 1d. Please describe the operations of VISN 8 and how you
interact with Headquarters, especially which offices you work with on a
daily basis; which offices you turn to for guidance; and how you
interact with other networks.
Answer. VISN 8 has frequent contact with all offices in VA
headquarters (HQ). The most frequent contact is through the Office of
the Assistant Deputy Under Secretary for Health, which maintains formal
liaison in support of VISN offices.
VISN 8 frequently has contact and interaction with other Networks
where organizational boundaries overlap state and congressional lines;
where there is interaction to identify and advise on best practices;
and for the purposes of external reviews, education, National
Leadership Board, and patient transfers, among others. All VISN Chief
Medical Officers work as a team and have a very collegial relationship
with Clinical Programs in VA HQ. Consultations occur frequently and
notification of program changes is done consistently. From a planning
perspective, VISN 8 staff have regular exchanges with the VHA Offices
of Policy and Planning, Capital Assets, Financial, IT, and HR offices,
as well as with their network counterparts.
Question 1e. If you are confirmed, what changes, if any, would you
recommend to the Secretary regarding the current VISN structure?
Answer. I currently do not have plans to change the VISN structure.
However, I would consider changes if significant improvement in health
care delivery or cost effectiveness would result.
Question 1f. The General Account Office estimates that as much as
one of every four medical care dollars is spent on building operation
and maintenance.
What does your experience in VISN 8 tell you about VA's
infrastructure maintenance costs?
Answer. Many of VISN 8's VA owned buildings are now exceeding 30
years in age, resulting in the need for significant infrastructure
repair and improvements that surpass available funding. Through the
recently completed VISN 8 Facility Condition Assessment, the most
critical infrastructure problems have been identified and are being
addressed first with available funding. The less critical are being
done over time as resources become available.
VISN 8 is presently undertaking a $20 million Energy Savings
Performance Contract that will, when completed, save about $2 million
annually and reduce associated maintenance and repair costs. To further
reduce indirect operational and maintenance costs, we have done some
streamlining of facility and environmental management services between
and within our medical centers.
Question 1g. What do you know about the experience in other
networks?
Answer. While I cannot speak from first-hand knowledge of other
networks, it is my impression that similar situations exist nation-
wide.
I am advised that building maintenance and operating costs are
generally lower than one in four dollars (25 percent). They are more in
the range of one in six to one in eight dollars (12-16 percent). In
follow-up meetings with GAO, it was determined that GAO had included
all costs of capital operation, which, in their definition, was
everything that was not direct patient care. Thus, hospital
administrators, IT, medical library, and numerous other functions were
applied to the building maintenance and operating costs.
Question 1h. How do VA's costs compare to the infrastructure costs
in the non-VA sector?
Answer. I am advised that this issue has been reviewed in Phase I
of CARES and by VA's Office of Budget. It has been found that VA's
annual appropriations to cover infrastructure costs are between 30 and
50 percent less than the funds obtained for the same purpose in the
non-VA sector.
Question 2. If confirmed, your term would run until 2006. Please
describe your vision for the VA health care system by that year--
specifically describe the mix of services that you believe enrolled
veterans will receive, the makeup of staff providing these services,
and a description of the VA facilities involved.
Answer. I believe that the VHA system will continue to change over
time to adjust to changing patient demographics and health care needs.
The veterans seeking VA care will be older, have more problems, and, in
many cases, need expensive and/or specialized care, such as veterans
with spinal cord injury. Our acute care facilities will continue to
serve as the cornerstone of the VA healthcare system, but I believe we
will see more care shifted from an institutional setting to an
outpatient or home setting. VA will continue to need to focus on
quality, access, and timeliness of care, as well as on patient safety
and satisfaction. And certainly, VHA must concentrate medical research
and education on issues specific to veterans and to military service.
Question 3. The FY 2003 budget request contains a proposal to enact
a $1,500 deductible for Priority 7 veterans. VISN 8--specifically
Florida--has more Priority 7 veterans than any other state. Given VA's
assumption that the proposal will suppress demand and that veterans
will, in fact, leave the VA health care system, what is your view of
the deductible?
Answer. I am aware that the proposal was submitted as a part of the
FY 2003 budget as an option for dealing with burgeoning demand for
services within a fixed budget. VISN 8 is experiencing these pressures,
as are many other VISNs. I believe that the Secretary expressed the
dilemma that we face in your February 14 budget hearing. We do not want
to exclude any group of veterans from the VA system; however, we must
also assure that we maintain high quality services for all of the
veterans that we serve. I am obliged to support the President's budget,
but realize these competing goals could be served in a variety of ways.
Clearly, I support the underlying principles of the proposal--to assure
that we maintain the quality and accessibility to care for all of the
veterans that we serve.
Question 4a. I am deeply concerned about VA's present approach to
caring for veterans suffering from PTSD and other mental health
disorders.
Please describe the priority that you believe VA should place on
providing care to veterans with PTSD, and how you would ensure that
priority is manifested in budget requests and programmatic planning?
Answer. The VA system of specialized PTSD clinical services is a
vital resource not only for treating veterans who are currently our
patients, but also for preparing for the consequences of future
military deployments, for managing disasters at the local and national
levels, and for training new generations of clinicians. I will work
with the Mental Health Strategic Health Care Group, Readjustment
Counseling Service, and the Under Secretary's Special Committee on PTSD
to ensure that PTSD maintains its priority within budgetary and
programmatic planning processes.
Question 4b. From your experience in VISN 8, what is your
assessment of the unmet treatment needs among veterans with PTSD? What
information to you have on this issue in other networks?
Answer. In 1999, Pub. L. 106-117, The Veterans Millennium Health
Care and Benefits Act, required that $15 million be provided to enhance
specialized treatment capacity for both substance use disorders and
PTSD. Similar to other networks, VISN 8 conducted a needs assessment to
identify gaps in its current services to PTSD veterans and received
funding to enhance its PTSD services. I am aware that many other VISNs
received funding from this initiative; however, I have not thoroughly
reviewed other networks' PTSD programs and needs.
Question 4c. Based on your experience in VISN 8, please give your
assessment of the Readjustment Counseling Service and the relationship
to VA medical centers. Also please describe the relationship today--in
VISN 8, and to the extent you can, nationally--between the mental
health departments at VA Medical Centers and the Vet Centers.
Answer. The Readjustment Counseling Service (RCS) provides a model
for providing treatment and establishing effective therapeutic
relationships with veterans who often have great difficulty in trusting
traditional institutions. In VISN 8, the Vet Centers and the Medical
Centers have developed excellent cooperative relationships. RCS is part
of our VISN 8 Mental Health Workgroup, and is involved in these
decisions. Patients flow from one setting to the other, with staff from
each feeling part of the same organization. This is an ideal
relationship as it fosters a continuum of care, placing the focus of
attention on the veteran. It needs to be disseminated throughout our
organization.
Question 5a. As you know, in 1997, VA implemented the Veterans
Equitable Resource Allocation (VERA) methodology to manage how funds
are provided throughout the system.
In April 1997, just prior to VA's implementation of VERA, you
testified before the House Veterans' Affairs Committee's Subcommittee
on Health that you felt this model was ``particularly well-suited to
meet today's veterans healthcare needs because the plan will distribute
federal dollars in a capitation-like manner.'' In 1999, VISN 8 required
supplemental funding from the reserve to cover shortfalls and unmet
needs. For FY 2002, nearly $300 million has been redirected to networks
to cover similar shortfalls. Given the tremendous fiscal pressure faced
by certain networks, are you still satisfied that this system is a fair
way to allocate funds?
Answer. The supplemental funding received by VISN 8 in 1999 was
directed primarily for repairs necessitated by catastrophic hurricane
damage, something that cannot be incorporated into an allocation model.
I believe that VERA still is a good system; some refinements are still
needed, but, in general, it does accomplish what it was designed to do.
VERA has undergone extensive scrutiny to assess whether the model
is meeting its goal of equitable and effective resource distribution. A
Price WaterhouseCoopers LLP study (1998) and two General Accounting
Office (GAO) reviews (1997 and 1998) viewed the progression of VERA in
positive terms and as meeting the intent of Congress. Nonetheless, VERA
continues to be a work in progress. Several VERA workgroups, comprising
VHA field-based and Headquarters staff, provide ongoing evaluation of
the VERA methodology and input on policy issues to improve VERA.
Question 5b. What is your view of using special purpose funding to
emphasize key priorities, and specifically what is your view of the FY
2000 VHA increase for substance abuse and PTSD programs?
Answer. The use of specific (special) purpose funding for certain
initiatives isolates those dollars for just the intended purposes.
Monitoring of those dollars has been an issue that we are studying.
Finding out if sufficient resources were provided, or determining the
cost of a certain diseases, may be easier to ascertain if dollars are
not co-mingled with other dollars, although some have argued fencing
dollars in this manner may discourage the most effective utilization of
the funds. Another tracking mechanism that is being carefully evaluated
in this regard is the DSS system, which can yield very detailed cost
and expenditure information.
Special allocations such as the VHA FY 2000 increases for PTSD and
Substance Abuse are appropriate mechanisms that permit more directed
assignment of resources to meet significant veteran needs.
Question 5c. In your view, does VERA sufficiently allow VA managers
to sustain programs for high cost patients and patients in need of
specialized services?
Answer. Yes. However, VHA is actively evaluating how to improve
VERA's case-mix adjustment and other cost factors. VERA is not a static
model; rather, it is reviewed and refined on an ongoing basis through
internal workgroups and external studies. VHA is currently evaluating a
revised VERA case-mix adjustment, and a mechanism to offset the cost of
networks' highest complex care patients.
Question 5d. In October 1998, VA contracted with Price Waterhouse
to evaluate VERA. The contractor recommended a series of
modifications--most notably that VA implement a transfer pricing
system. This was to be tested and implemented last year. What is your
view on this recommendation?
Answer. Other than the use of pro-rated patients (PRPs), transfer
pricing was never implemented. It was found that the costs of
implementing a transfer pricing system far out-weighed the potential
benefits. In addition, there was no clinical evidence that transfer
pricing improved the coordination of clinical care for patients that
receive care in more than one network. At this time, I plan to maintain
the VERA PRP methodology for funding care across networks, and will
encourage networks to conduct whatever intra-network transfer pricing
funding distributions they deem necessary to meet local patient care
needs.
Question 5e. A 2001 RAND Study suggested that changes be made to
the VERA methodology on case-mix refinement and that there be a
geographic price adjustment for contract labor and non-labor costs.
What is your view of this recommendation?
Answer. VISN and facility directors have frequently reported
difficulty in managing the cost of contract services, particularly in
rural areas where the choice of providers is relatively limited. I
concur with VHA's decision in the FY 2002 VERA methodology to better
account for local cost of living factors associated with procuring
contract labor and non-labor contracted goods such as energy-related
products, utilities, and provisions. The existing VERA labor adjustment
methodology is now applied to the cost of contracted labor and non-
labor contracted goods. This refinement to VERA will account for
expenses caused by geographic cost factors beyond a network's immediate
control.
In its Phase I VERA study, RAND identified a number of issues that
it will address in Phase II by conducting a quantitative analysis.
These issues include improved case-mix adjustment, geographic
differences in prices paid for non-labor inputs and contract labor
costs, the impact of teaching and research hospital affiliations, and
the impact of the facilities' physical plants. VHA now looks forward to
receiving RAND's additional input and recommendations, particularly on
case mix and geographic price adjustments.
Question 6a. As you may know, I am deeply concerned about issues
relating to long-term care services and delivery in VA.
Based on estimates, the number of veterans age 85 and older will
dramatically increase--from 154,000 in 1990 to 1.3 million in 2010. If
confirmed, what changes would you seek to implement to allow VHA to
respond to the impact of this looming change?
Answer. If confirmed, I will continue to move VA toward a patient-
centered continuum of care that can meet the special care needs of an
aging veteran population. In responding to the needs of the over age 85
veterans, we will move forward to improve access to preventive, acute
and long-term care (LTC) services, with the goal of maintaining
functional abilities of these veterans so they can remain in their
homes and communities for as long as possible. VA has made considerable
progress toward organizing a geriatrics and LTC system that can respond
to shifts in demand and to changes in local healthcare market
characteristics, and provide seamless care. We have launched major
national initiatives to improve end-of-life care and pain management
for veteran patients. I fully support expansion of home and community
based care, innovative public/private partnerships for LTC, and
performance improvement goals for assuring the continued quality of
geriatrics and extended care services. Preliminary results with this
approach in VISN 8 have shown a higher level of patient satisfaction
and lower hospitalization rates, with a dramatic reduction in the
overall cost of care. In addition, I would accelerate the training of
our professional staff in the nuances of care for the elderly.
Question 6b. Please share what guidance you have received as a VISN
director on the law which requires non-institutional long-term care
services be made a part of the standard benefit package. What was your
response to that guidance? What contact have you had with other network
directors on the benefit expansion?
Answer. As a VISN Director, I received periodic status reports on
the implementation of the long-term care provisions of the Millennium
Act and directives issued from Under Secretary for Health related to
the implementation. The Directive on Non-Institutional Extended Care
within VHA was issued in October 2001. Prior to that time, the VISN 8
Extended Care Workgroup utilized the law and VHA regulations and
existing directives to develop a LTC plan for this network. The
policies they developed were approved by VISN leadership and
implemented VISN-wide. The Community Care Coordination Service was a
clinical and financial commitment made by VISN 8 to respond to both the
rapid growth and need to provide more non-institutional care. The
results of expanding non-institutional care have been the following:
improved functional status,
reduced premature institutionalization,
decreased nursing home placements (by 64%),
comparable group increased placements (by 106%), and
veteran satisfaction with alternative approach exceeding
90%.
Question 6c. How will you encourage cooperation with others (state
homes, affiliates, and community providers) to offer veterans the very
best long-term care in the most cost effective manner?
Answer. For FY 2002, VHA has a Budget Performance Measure calling
for an ambitious 34% increase in the number of veterans receiving home
and community-based care compared to FY 2001. We plan continued
increases each year to a goal of 34,500 average daily census in FY
2006. To achieve these goals, we will expand both the services VA
provides directly and those we purchase from affiliates and community
partners. We will meet most of the new need for long-term care through
non-institutional care as home health care, adult day health care,
respite, and homemaker/home health aide services. Since some long-term
care must be provided in an institution, we will maintain our current
VA nursing homes, utilize the ongoing expansion of state homes, and
meet remaining need by purchasing care through the Contract Nursing
Home program. In addition, we will enhance the efficiency of long-term
care through creative use of existing resources, including the
provision of Adult Day Health Care at state home facilities.
Question 6d. Some outside experts have argued that VA long-term
care is often under-funded relative to non-VA long-term care. What is
your view of this?
Answer. There have been no major shifts in the funding of Long-Term
Care services either within VA or in large state or other federal
health care systems. The President's Budget for FY 2003 shows VA
spending 12.9 percent of its total health care funds on LTC services.
This is a decline of less than one percent over the last five years.
VA's experience in LTC funding mirrors most State Medicaid Programs.
What appears to be lacking is full implementation of an aggressive
home- and community-based care strategy. The FY 2003 budget suggests
such an approach, and its adoption would move VA towards an appropriate
position of leadership in LTC service delivery. As VA grows, its home
care programs, nursing home care expenditures will need to stabilize.
VA should examine the feasibility of targeted trade-offs between and
among nursing home and home care and outpatient services.
Question 6e. What are your views about VA-community joint ventures,
such as Alzheimer's disease facilities?
Answer. I strongly support the concept of VA-community joint
ventures as a way of leveraging resources and enhancing the quality,
availability, and cost-effectiveness of services. VA is developing a
variety of joint projects through its enhanced-use lease (EUL)
authority, and we have actively encouraged the use of EUL for services
such as assisted living, which VA has limited or no authority to
provide. Additionally, we expect to learn a great deal more about the
best ways to combine VA and community services as a result of the pilot
programs relating to long-term care and assisted living that are
currently underway as part of the Veterans Millennium Health Care and
Benefits Act.
Joint ventures will help expand our capacity for serving veterans
with Alzheimer's disease, as well as other disorders. For example, VA
is currently participating in ``Chronic Care Networks for Alzheimer's
Disease,'' a national demonstration project co-sponsored by the
national Alzheimer's Association and the National Chronic Care
Consortium (NCCC), in which VA's Network 2 (Upstate New York) and seven
other NCCC members are working in partnership with Alzheimer's
Association local chapters to design, implement, and evaluate a model
of coordinated acute, primary, and long-term care for persons with
dementia. Results will be used to disseminate new collaborative models
of chronic care to all VA networks, as well as for geriatric care
throughout the country.
VA facilities planning enhanced-use lease projects or other joint
ventures should also consider the special needs of veterans in the
early or later stages of dementia. For example, a ``Veterans Village''
type of retirement and continuing care community would ideally include
varying levels of services for veterans with dementia as well as those
with other disorders. Given that there are many unresolved questions
about ``best'' care for persons with dementia, careful evaluation of
new joint venture programs for dementia care will be very important.
Question 7a. In recent years, VA's quality management program has
seen some significant improvements. What priority will you give to
Quality Management in the Veterans Health Administration?
Answer. Supporting quality and quality management activities will
be one of my highest priorities. Quality management is an essential
element in a national health care system committed to excellence. It
must be embedded in our core processes through a comprehensive
performance management system that aligns VHA's vision and mission with
quantifiable strategic goals, defines measures to track progress in
meeting those goals, holds management accountable through performance
agreements for results achieved, and advances quality within the
context of patient-centered care across the continuum of care. I will
continue to look to system-wide approaches that integrate quality
management strategies across traditional organizational lines.
Question 7b. If confirmed, will you increase support for the VHA
Quality Management Program, not only in established VA medical centers,
but also in the many newly established Community Based Outpatient
Clinics, whether operated by VA or by contractors?
Answer. All Veterans should have access to a single standard of
care regardless of the site of care. VHA promotes quality management
through a variety of mechanisms across the system, including
development of clinical practice guidelines, evaluation of performance
measures directly related to VHA's strategic goals, monitoring the
external accreditation of facilities, and monitoring and improving the
credentialing and privileging process, among other initiatives. I fully
support oversight of quality, access, and safety system-wide in all
settings and encourage quality measurement programs that provide valid,
reliable data for a comparison of performance at the Network, facility
and CBOC levels. This approach provides the necessary strategic
information on which actions can be taken immediately to improve the
quality of care.
Question 7c. In your view should VHA continue its support of, and
involvement in, the National Practitioner Data Bank and VETPRO
programs? Should the level of support and involvement be increased?
Answer. I believe that VA should continue to participate in the
National Practitioner Data Bank (NPDB). VA queries the NPDB and obtains
available information concerning physicians, dentists, and other health
care practitioners who provide or seek to provide health care services
at VA facilities as members of the medical staff. VA reports to the
NPDB on physicians who fail to meet Nationally recognized standards of
care.
I believe that VA should continue to support VetPro to ensure
consistency of the credentialing process and to support high quality
and safe patient care. VetPro provides VA with the ability to maintain
a common, valid, and reliable electronic data bank of health care
provider credentials. VetPro credentialing results in greater safety
and security for patients, greater efficiency for clinicians and health
systems, and facilitates cross-utilization of medical personnel between
facilities and Networks.
Question 8. The relationship between VA medical centers and medical
schools has endured for more than 50 years. I am concerned about the
viability of the relationship, however, especially in light of a recent
CARES decision. Please share your philosophy regarding the overall
value of academic affiliations, including the role affiliates play in
staffing VA facilities and how you believe they should be involved in
the CARES process.
Answer. I value the role these affiliations play in assuring
excellent care for our nation's veterans. As VA goes forward with
CARES, I believe we need to actively involve our affiliates throughout
the process to find innovative solutions to the changing health care
environment.
Question 9. How will you encourage the non-veteran health care
system to better understand the VA health care system?
Answer. The Veterans Health Administration has developed a
comprehensive communications plan that targets each of VA's stakeholder
groups and audiences--both internal and external. The plan is designed
to sharpen and focus VHA's messages, improve the flow of information,
and foster awareness and understanding of our programs and activities.
Its primary objective is to draw deserved attention to the quality of
our health care; our achievements in medical research; the value of
VHA's partnerships with medical schools and how those affiliations
educate our nation's health care professionals and affect the quality
of everyone's health care; and the critical role VHA plays in homeland
security.
Question 10a. There has been a push, mostly from within VA, to
encourage more cooperation and sharing agreements between the VA and
the Department of Defense (DoD). What areas do you see as having the
most potential for new sharing arrangements?
Answer. The areas that have the most potential for new sharing
include:
joint procurement of medical/surgical supplies, high tech
medical equipment, and commodities;
collaboration in information management/information
technology (IM/IT), particularly in developing standardized,
interchangeable electronic medical records to support health care
delivery and common standards for IT architecture, data,
communications, security and systems;
implementation of a joint protocol for a common physical
examination for both discharges and disability compensation evaluation;
coordination of efforts to enhance homeland defense and
respond to the medical needs of victims of terrorist activities;
medical and educational support for military reservists
and members of the National Guard;
collaboration to make the TRICARE co-payment structure an
incentive for beneficiaries to obtain health care from VA; and
a coordinated and collaborative process for planning
health care facility construction.
Question 10b. What would you do to bring DoD to the table to bring
about more sharing successes.
Answer. I would continue the efforts of the reinvigorated VA/DoD
Executive Council. I would push it to be more of a deliberative,
decision-making body with specific timelines for actionable issues. My
initial focus will be on the nature of the relationship between VA and
DoD and assuring that there are appropriate incentives for TRICARE
beneficiaries to seek care at VA.
I support the efforts of the President's Task Force to Improve
Health Care Delivery of Our Nation's Veterans, as well as the
Departmental level Executive Council that has recently formed. I
believe that we need better data collection of on going activities. We
need to look for new models of collaboration and sharing. With my
background in the Reserves, I feel I have sufficient knowledge of both
systems to move the relationship forward in a positive manner.
Question 11. A Medicare+Choice subvention pilot raised costs for
DoD. Given your health care financing experience and knowledge of VA,
do you believe that VA could gain revenue by implementing a similar
subvention pilot?
Answer. As stated in a recent GAO report on the DoD subvention
demonstration, one of the biggest challenges for DoD was to maintain
costs while managing the care given to the Senior Prime beneficiaries.
Historically, DoD's health care delivery system was not as well
positioned to provide care to the elderly population as the VA health
care delivery system. Additionally, when the retiree's care was
referred to providers in the civilian network, the local military
treatment facilities (MTF) had no direct financial incentive to manage
the care, since DoD, not the MTF, provided the funds. Also, incentives
lacked for the managed care support contractors to limit utilization in
the demonstration. These contractors authorized network services, but
bore no risk for the costs of enrollees' care.
If VA were to undertake a subvention pilot similar to the
demonstration DoD undertook, we would need to change some of the
operating principles to address problem areas that DoD encountered. I
could not predict the revenue gains or losses for VA, but I believe
that VA has a better handle on health care utilization management and
therefore managing our costs.
Question 12. On the issue of medical record privacy, please share
your thoughts about the widespread access to medical records within VA.
How do you understand the HIPAA regulations will affect VA's current
process relating to access to medical records?
Answer. VHA's privacy and information security programs emphasize
training of all users, and all new employees receive Privacy Act
training. VHA policy in accordance with the Privacy Act, requires local
safeguards be established concerning patient record security and
confidentiality. These safeguards include, but are not limited to, the
following:
limiting access to patient record file areas to authorized
personnel;
controlling records which are removed from the facility
for any reason;
locking patient record file areas and other areas where
patient records are temporarily stored (patient record review areas,
quality assurance areas, release of information areas, etc.) when
responsible personnel are not present to ensure the security of the
area;
physically locating patient records in the treatment areas
so that they are not accessible to unauthorized individuals, such as
visitors;
ensuring that the use of computer access codes meet all
laws and regulations;
appropriately labeling ``sensitive'' records in the
computer;
restricting release of information activities to personnel
who are assigned that responsibility;
taking precautions to ensure that patient records on
computer screens cannot be seen by those who do not have a legitimate
need-to-know;
protecting records from potential physical damage by fire,
water, animals or insects; and
having an adequate disaster recovery plan for both hard
copy and computer records.
Question 13a. The Administration's FY 2003 budget request relies
heavily on copayments from veterans and collections from third party
insurance. VA is estimating $1.5 billion in collections for FY 2003,
doubling the amount from FY 2001. What changes to the MCCF program do
you envision to improve third party collections?
Answer. In his testimony before this Committee, Secretary Principi
outlined the broad parameters of the improvements contemplated for the
Department's billing and collection efforts for third party payers. The
bases of those improvements are derived from the Revenue Improvement
Plan that was developed in collaboration with an external contractor.
Twenty-four actions were identified that would yield significant
enhancements to our ability to collect revenue. Management policies,
management practices and procedures, information technology, human
resources, and refocusing corporate culture are all being subjected to
review and improvement. Although some of these require time in order to
reap full benefit, VHA has already noticed significant increases in
revenue. During October 2001 and January 2002, collections exceeded $80
million.
In summary, VHA envisions three broad-sweeping activities that will
have a profound impact upon the MCCF program.
1) Electronic Data Interchange (EDI) effort. EDI will enable VA
nationally to transmit data through a clearinghouse to third-party
payers. This should result in more timely payments by ensuring that
bills are transmitted electronically to the payer. I am pleased to
state that we are actively working toward this conversion and have
already implemented many changes to our processes and systems to
increase electronic processing of claims.
2) Centralization and/or consolidation of like functions in the
revenue process. Centralizing similar functions may produce greater
efficiencies and economies of scale. Several organizations within VHA
already have either centralized their revenue operations or
consolidated their billing and collection efforts.
3) Outsourcing and contracting out revenue-related functions.
Question 13b. VA can not charge a copayment that is more than the
cost of a prescription. To justify the recently announced $7
prescription copayment amount, VA included a myriad of administrative
costs. Do you feel that this charge is appropriate for over-the-counter
medications such as aspirins, vitamins, and cough syrup?
Answer. The medication co-payment is assessed to certain veterans
for medication received for a non-service-connected condition, and
over-the-counter medications are subject to the $7 co-payment. Although
this may appear to be a high price for these items, Pharmacy staff do
perform the administrative functions involved in dispensing these
medications. However, Public Law 106-117, which gave us discretionary
authority to set pharmacy co-payments, also provided that a higher
medication co-payment could be charged for medications described as
``quality of life'' drugs. I will encourage continuing discussions
within VHA on the possibility of implementing a tiered medication co-
payment system, whereby a lower tier is established for over-the-
counter items and low cost medication.
Question 13c. If confirmed, would you recommend that the $7
copayment amount be increased in the future?
Answer. I am advised that VHA would propose increases periodically
based on the Prescription Drug Component of the Medical Consumer Price
Index.
Question 13d. What is your view of contracting out portions of the
MCCF collection effort? What was your experience as a network director
in contracting out revenue generating functions?
Answer. The following revenue functions were contracted out during
my tenure in VISN 8:
Coding--Due to the difficulty in recruiting and retaining qualified
coding staff, several facilities contracted portions of the coding
function to outside vendors. This allowed VISN 8 to successfully
increase collections over the last few years.
Billing and Accounts Receivable--We have had experiences in VISN 8
facilities in contracting out portions of billing and accounts
receivable activities. At our San Juan facility, an outside vendor
works in conjunction with hospital staff to prepare bills and collect
accounts. Due to the combined effort of the contractor and VA
oversight, the San Juan facility experienced increased collections of
$1.4 million (FY 2001 vs. FY 2000).
Pre-Registration--Several facilities have used contract staff to
pre-register patients prior to appointments in order to update
demographic and insurance information. The pre-registration effort has
improved insurance identification through use of periodic updates via
telephone prior to the appointment date.
From these experiences, it is my belief that contracting out
portions of the MCCF collections functions can, in many circumstances,
play a beneficial role in our overall efforts to improve revenue
collections. I know that other networks have also had positive
experiences in this area. I believe that VA, as a whole, should pursue
this avenue where it proves effective and returns value for cost.
Question 13e. Please provide information about the collections
activities in VISN 8, including any successes you achieved and the type
of information and guidance you received from Headquarters on your
collections effort.
Answer. VISN 8 led the nation in cumulative collections in FY2001
with a total of $65.3 million dollars collected, increased collections
from FY 2000 by $22 million, and achieved 140 percent of MCCF Revenue
Goal for FY 2001. In FY 2002, VISN 8 has collected $26.4 million
through January, which is the highest cumulative total of any VISN and
9 percent of the entire VHA collections total.
VISN 8 has established a VISN wide Network Revenue Team, which
meets on a regular basis to discuss issues and share best practices. In
addition, each medical center has organized a local revenue team to
address issues related to insurance, billing, coding and documentation.
In concert with senior managers, VISN 8 implemented several best
practices for identifying insurance including: pre-registration, VISTA
insurance reminders, and veteran insurance inquiry at each visit, and
insurance tracking statistics. VISN 8 also implemented a pharmacy co-
payment call center, which handles co-payment inquiries from veterans
located throughout the state of Florida. The call center has improved
customer satisfaction, streamlined process and freed up MCCF staff in
medical centers to concentrate on billing and collection activities.
The network also developed a participating provider agreement with a
major insurer, which allowed it to improve payment rates and timeliness
of payments.
Question 14. Do you believe that the VistA system is still able to
meet the clinical and administrative needs of VHA?
Answer. VistA was originally built to support individual medical
center/inpatient care models. In VistA, our clinicians have available a
powerful set of tools that improve their ability to provide excellent
patient care. At the same time, however, it is an aging system. The
software has undergone numerous modifications as VA evolved to an
outpatient-centric system of care. It is also built on older
technology. Thus, it is a system that is fragile to maintain and
cumbersome to enhance.
Through the HealtheVet strategy, VA will ensure that VistA remains
a high performance system, and that we meet new requirements of our
future health care system. At this time, I believe HealtheVet is a
sound strategy to successfully accomplish these goals.
Question 15. The Committee understands that several clinics,
including some in Florida, have stopped seeing new patients. Please
provide detail on any such changes in VISN 8 and any information you
have about other networks.
Answer. In VISN 8, nine of 44 clinics currently exceed maximum
capacity (based on average panel size for primary care providers) and
cannot serve additional veterans at this time. These clinics include
Viera, Brooksville, Zephyrhills, Lakeland, Kissimmee, and Sanford under
Tampa VAMC; and Delray Beach, Stuart, and Boca Raton under West Palm
Beach VAMC. New veteran applicants seeking care at these sites are
being redirected to the parent medical center for care.
Other clinics in VISN 8 are assigning new patients as clinic slots
become available. Waits by new enrollees can be as long as 6 months to
a year when their medical need is not urgent. However, patients
requiring urgent care are seen immediately.
Question 16. How many of the VISN 8 CBOCs offer mental health
services? Please also describe how you manage these clinics, for
example, the process you use to evaluate and renew contracts for CBOC
providers?
Answer. VISN 8 has 10 large multi-specialty clinics and 34 primary
care CBOCs. All 10 multi-specialty clinics and 9 of the 34 CBOCs
currently provide Mental Health services on site. VISN 8 Plans call for
mental health resources either through staff on site or through a tele-
psychiatry pilot at 17 additional CBOCs in the near future. For the
remaining CBOCs, tele-psychiatry will likely be utilized if the tele-
psychiatry pilot proves successful. The tele-psychiatry pilot will
primarily be conducted at contract CBOCs, none of which currently have
mental health services on site.
Of over 630 clinics nation-wide, approximately 34 percent are
contracted. In VISN 8, 13 of 44 clinics (30 percent) are contracted.
Quality of care indicators, patient satisfaction surveys, workload
productivity, and cost-effectiveness are evaluated on a regular basis
at all VISN 8 clinics. Using a set of quality measures and other
parameters, a special study by the VISN 8 Measurement Support Team is
also underway to compare quality of care and cost-effectiveness at
contracted versus VA-staffed CBOCs.
In addition, a VISN 8 CBOC Taskforce is developing a uniform
process across the VISN for monitoring and managing CBOC contracts. The
Taskforce has reviewed all of the current CBOC contracts and has
developed a template of items that should be included in all contracts
VISN-wide. Taskforce members will ensure that all contracts, upon
renewal, will be revised by fully addressing each of these factors.
Question 17a. Non-physicians providers are critical to the VA
health care system.
Please describe what you see as the future role within VA for non-
physician providers, such as physician assistants and advanced nurse
practitioners.
Answer. Properly credentialed and licensed non-physician providers
will continue to serve an important role in VHA in a variety of
practice settings. Their roles may include:
performing history and physical examinations;
ordering and interpreting diagnostic studies;
diagnosing and treating illness;
educating patients and prescribing medications, and
providing health promotion and disease prevention
services.
Question 17b. For years, VA physicians assistants have not been
required to retain State licenses to practice and prescribe medications
within the VA health care system. The directive outlining the
requirement that they have certification in lieu of state licensure
expired last year, and PAs currently are operating under an interim
guidance directive. VA is reviewing whether or not state licensure
should be required. What is your view of how this issue should be
resolved?
Answer. The current interim directive stipulates that an individual
must hold a state license that allows prescriptive privileges in order
to write prescriptions. In the case of physician assistants, a state
license, registration, or certification may be accepted, since some
states certify or register rather than license physician assistants. I
understand that a revision to VA regulations is under development that
would permit non-physician providers to write prescriptions only if the
state where the provider is licensed permits the provider to prescribe.
I believe that this is an appropriate way to ensure the quality of care
to our patients. However, we must evaluate any untoward effects that
the implementation of this new regulation would have on our workforce
and the patients they serve.
Question 18. Please describe any recruitment and retention problems
involving health care personnel you have seen in VISN 8 health care
facilities. What would you suggest to respond to these difficulties?
Answer. VISN 8, like many networks, has experienced recent
difficulties in recruiting nurses, particularly in critical care areas
and for evening and night shifts on inpatient units. High seasonal
demand for care leading to a higher average daily inpatient census has
exacerbated this problem during the winter months. We have also
experienced difficulties in recruiting scarce specialty physicians.
There is no simple answer to these recruitment difficulties. Rather the
answer lies in a series of actions that will enhance VA's perception as
an employer of choice, expand employee benefits, increase flexibility
in personnel actions related to hiring and part time employment, and
improving both nurse and physician pay comparability to their non-VA
counterparts.
Question 19. In the past, VA has had increasing difficulty
recruiting and retaining an adequate number of high quality nurses.
Please describe what you see as the current role of nurses in the VA
health care system, and how that might change, if at all, over the next
20 years.
Answer. The Department of Veterans Affairs offers veterans one of
the largest, most comprehensive health care systems in the country.
Within this context, nurses are vital contributors in the delivery of
healthcare to veterans. VA nurses are engaged in clinical practice,
administration, research, and education. Their practice settings
embrace all aspects of the continuum of care within the Veterans Health
Administration ranging from in-patient settings to primary and home-
based care to specialty clinics.
Over the next 20 years, VA nursing practice will certainly reflect
such change in response to patient care demands. Technological advances
in health care treatment and equipment, evolving health care trends,
modifications in delivery settings, and consumer expectations will
require nurses to constantly adapt to change. The expanded roles of
nurse practitioners and clinical nurse specialists will continue to
increase with nurses assuming greater responsibilities for the
provision of primary care and the management of chronic conditions.
Moreover, VA nurse involvement in home-based and community care will
increase as families become more involved as non-traditional
caregivers.
Question 20a. VA research not only makes a major contribution to
our national effort to combat disease, but also serves to maintain a
high quality of care for veterans through its impact on physician
recruitment and retention.
In your view, what should be the goals of VA's research program?
Answer. In my view, the purpose of VA research program is to
discover knowledge and create innovations that advance the health and
care of veterans and the nation. I am advised that specific VA research
goals include:
Sustain a superior environment of inquiry conducive to the
highest quality research, education, and patient care.
Effectively integrate basic, clinical, and applied
research to best meet veterans' health care needs.
Effectively transfer research results to advance veterans'
healthcare.
Capitalize on VHA's value as a national research asset.
Lead and manage an effective and efficient research
enterprise.
Increase awareness and understanding of the value of VHA's
research contributions.
Question 20b. What are your views on the importance of VA research
compared to funding for services?
Answer. They are integrally linked; both are important. Investment
in research ensures that we continue to build the knowledge base
essential for ensuring high quality, efficient health care services,
particularly in areas important to our nation's veterans. Research
helps VA reduce health care costs, improve the quality of our care, and
point the way toward improved access for all veterans to the service we
provide.
Question 20c. What can be done to combat the chronic under funding
of the VA research program?
Answer. I believe that VA needs to continue and, if possible,
enhance the value of VA research and continue to leverage VA
appropriated research funds by partnering with other sponsors of
research including the National Institutes of Health, the Department of
Defense, and private industry.
Question 20d. How do you think VA should allocate its limited
research funds among the general areas of basic, applied clinical, and
health services research?
Answer. The full spectrum of research is important, and the
divisions articulated imply a false separation. For example, much of
health services research also is applied clinical research. Similarly,
much applied clinical research cannot proceed unless the underlying
basic research has been conducted. Funds should be allocated on the
basis of relevance to the high priority healthcare needs of veterans,
scientific opportunity, and rigorous merit review.
Question 20e. Do you support adding a provision to the law which
would authorize strengthen Federal Tort Claims Act coverage for the
employees of VA-affiliated nonprofit research and education
corporations?
Answer. I have not had the opportunity to fully review this
question, but believe that it is an important one. The nonprofit
research corporations add significantly to VA's ability to fulfill its
research and education missions, and I believe we should fully support
these activities towards these goals. I will undertake a review and
provide the results to the Committee.
Question 20f. Recognizing that designating time for clinician
investigators to conduct research and providing them with adequate
infrastructure are continuing problems in VA, would you support
addressing this by administering investigator salaries and facilities
operation costs centrally, in a manner similar to that used by NIH, to
ensure that VA-funded investigators have adequate time and resources to
conduct research?
Answer. The VA indirect costs associated with research are
currently distributed using a research adjustment to the VERA model. At
this time, I do not believe that further centralization of these funds
is needed.
Question 21. What does your experience tell you with regard to
women veterans' access to VA health care services, notably mental
health services? What changes, if any, would you propose in this area
if confirmed as Under Secretary?
Answer. Women veterans represent a rapidly growing portion of the
veterans we serve. I am proud of the efforts of our organization to
provide services tailored to their needs. I am particularly pleased
with the efforts of the mental health professionals in VISN 8 who have
assigned staff to specifically support such programs. This has required
the cooperative efforts of Vet Centers, PCT teams, and specialized
sexual trauma units. Efforts such as these need to be encouraged.
Experienced providers tell us that when mental health services for
women are co-located with the physical health services, both providers
and patients are more comfortable with the care. Several facilities
around the nation have taken this approach, and where it is successful,
it is considered a Best Practice model. A VA program for intensive
treatment of sexual trauma has been developed at the Bay Pines VAMC in
Florida, which sponsors short training programs for VA providers across
the country. This could be a model for treating some of the other
disorders primarily affecting women, and training VA clinicians to
provide this care.
Question 22a. A major concern of mine and others on the Committee
is the question of the exposure of military personnel to potentially
harmful substances during their service--especially in times of war.
In your view, what is VA's role in attempting to ensure that men
and women who serve in our nation's military are protected from toxic
exposures which might ultimately harm them? What do you envision to be
VA's role in monitoring to ensure that servicemembers are protected?
Answer. VA has a strong interest in following the health of
veterans who have separated from military service, and whose health may
have been affected by their military experience. As the lead federal
agency on Gulf War related research, VA has been responsible for
coordinating federally sponsored epidemiological and other relevant
scientific studies. As a whole, the research program has focused upon
specific questions related to the Gulf War. However, there is an
appreciation that the issues involved extend beyond this cohort of
veterans and include a broad range of health effects that may be
associated with all military deployments. The lessons learned from this
integrated Gulf War research program will provide insights into
anticipating, diagnosing, and treating the health needs of future
returning veterans and their families, including veterans from our
current war on terrorism.
Question 22b. What efforts are being made in VISN 8 to ensure that
Gulf War veterans, still suffering from undiagnosed illnesses, are
receiving the specialized care they need at their local VA medical
centers? What information do you have about other networks and what
guidance on this subject have you received from Headquarters?
Answer. VISN 8 has used serial SF36V evaluations to assess the
status of the mental and physical health of Gulf War veterans
throughout the network, and to track changes in their status over time.
The network also established an innovative interdisciplinary treatment
program for Gulf War veterans at the James A. Haley VA Medical Center
in Tampa. This program serves as a referral center for Gulf War
veterans across the entire network.
VA has several programs that focus upon those veterans with
undiagnosed war-related illnesses. Based upon our experience with
veterans from previous conflicts, we now appreciate that combat
casualties do not always result in obvious wounds, and that some
veterans from all conflicts or peace-keeping missions will inevitably
return with difficult to diagnose yet nevertheless debilitating health
problems. We have seen that Gulf War veterans as a group report a
variety of chronic and ill-defined symptoms including fatigue,
neurocognitive and musculoskeletal problems, at rates that are
significantly greater than for their non-deployed peers. This has
required that we develop new ways of responding to the health needs of
these veterans.
In response to the clinical needs of Gulf War veterans with
difficult to diagnose yet sometimes debilitating symptoms, VA, in
collaboration with DoD, are developing new Clinical Practice Guidelines
for Post-Deployment Health and for two symptom-based illnesses, Chronic
Fatigue Syndrome and Fibromyalgia. These new Guidelines, which the
Institute of Medicine has highly recommended, will give VA primary care
providers the tools they need to diagnose and treat veterans with such
illnesses.
VA also has developed an independent study guide ``A Guide to Gulf
War Veterans' Health,'' to ensure that all Gulf War veterans coming to
VA facilities will encounter health care providers who are
knowledgeable and sensitive to their health care concerns. All our
health care providers are encouraged to take advantage of this
training.
Question 22c. Are ill Gulf War veterans in VISN 8 being followed by
a designated physician who is kept informed of the latest information
pertaining to Gulf War illnesses and can coordinate the veteran's
medical care? What information do you have about other networks and
what guidance on this subject have you received from Headquarters?
Answer. All VA Medical Centers, including those in VISN 8, operate
VA Gulf War Health Examination Registry programs. These programs
involve both a registry physician and registry coordinator. VA
established this registry in response to the immediate health concerns
of returning Gulf War veterans. Modeled after the VA Agent Orange
Registry program for Vietnam veterans, the Gulf War Veterans' Health
Examination Registry incorporates data on symptoms, diagnoses, and
reported hazardous exposures of Gulf War veterans who come to VA for
this systematic clinical examination. Registry physicians can make
referrals to other health care specialists, as needed.
VA operates several programs to keep primary care providers and the
registry staff informed about the latest information on Gulf War
illnesses. These include self-study guides on Gulf War health issues;
quarterly conference calls to update all registry staff on Gulf War
health issues; regular mail-outs of new publications and other
documents; and, a VA Gulf War web site that includes reports on a wide
range of Gulf War health issues.
Question 22d. Is there still a Gulf War coordinator within each
VAMC within VISN 8, and, if so, what is their current role? What
information do you have about other networks and what guidance on this
subject have you received from Headquarters?
Answer. Every Medical Center in VISN 8 has a designated Gulf War
physician coordinator, whose duties include assuring that the
comprehensive healthcare needs of Gulf War veterans are fully met.
Generally, all VAMCs in all VISNs have Gulf War Registry Physicians and
Coordinators. In a few cases, following reorganization of a VA
facility, the registry coordinator is located at the primary or main
hospital and coordinates activities for satellite facilities. The roles
of the physicians and coordinators are to coordinate Registry
Examination appointments, conduct the Registry Examination, make
referrals to other specialists as needed, communicate results to the
patient, and to report the results of the registry examination to VA
Central Office.
Question 23. Recently, we received reports about financial
mismanagement involving the Tampa-Hillsborough Action Plan--a
community-based homeless program that received grant money through the
Grant and Per Diem program. What steps do you think need to be taken in
order to ensure better oversight of such program recipients,
particularly in light of the fact that the program's authorization was
just increased?
Answer. First, I would like to acknowledge the success of VA's
Homeless Providers Grant and Per Diem (GPD) program. The GPD Program
has quickly expanded from a small capital funds competitive grant
program in 1994 to a nationally recognized community-based VA funded
initiative operating in partnership with non-VA agencies providing more
than 2,500 transitional housing beds throughout the country. Over 5,000
homeless veterans received services under the GPD during the last
fiscal year.
By the end of FY 2001, VA had provided more than $63 million in
grants to non-profit or state and local government agencies to assist
in the creation of over 100 supportive housing programs or service
centers around the country. In addition, VA had distributed more than
$45 million to medical centers to provide per diem payments to assist
these organizations in defraying the costs of programs operations. It
is expected that within the next five years the number of programs and
community-based transitional housing beds will double.
With the increasing emphasis on and need for the utilization of
medical center staff for the development and oversight of community
providers offering services for homeless veterans under the GPD
program, comes the need for enhancement of and increased delineation of
tasks for those VA staff in liaison roles.
The Secretary's office in consultation with the Director, VA
Homeless Programs and Associate Chief Consultant, Health Care for
Homeless Veterans Programs has developed a nation-wide Action plan to:
1) increase assurances that veterans in GPD funded community-based
project sites are receiving quality services; and 2) enhance safeguards
to prevent conflict of interest between VA employees and the GPD funded
community provider organizations. The steps in this action plan are
currently being implemented and should be fully incorporated into
Grant/Per Diem Program management process by the end of the year. I
will support these efforts and I will also ensure that these action
steps--designed to increase VA's abilities to provide oversight of GPD
community programs--are carried out to the fullest extent.
Question 24a. It is my sense that VISN 8 has done a very good job
in preparing for the potential medical consequences of a terrorist
attack. Given your experiences there in encouraging medical readiness
for deliberate and natural disasters, especially in building strong
regional partnerships, how do you think you might foster a similar
degree of preparedness throughout the VA healthcare system? What
information do you have about other networks and what guidance on this
subject have you received from Headquarters?
Answer. I will continue to urge preparedness by issuing specific
guidance to VISNs and VAMCs. I will also continue to apply the
expertise of VHA's Emergency Management Strategic Healthcare Group
(EMSHG) and its field based Emergency Managers, as well as guidance
from the EMSHG Technical Advisory Committee. It is critical that we
support our system by providing them the tools, i.e. the most current
information on emergency management, weapons of mass destruction (WMD)
and related subjects and urge their involvement in education, training,
and exercises with community partners. I will also urge participation
in national videoconferences, training, and other initiatives that we
can provide from VACO.
Some VISNs already have appointed task forces to address medical
readiness. Some have highly trained teams and equipment. Examples of
current initiatives include VISN 8's Hazmat team and decontamination
system, Emergency Medical Response Teams (EMRTs) in VISNs 4 and 7, and
Hazmat teams and decontamination facilities in Washington DC,
Indianapolis, and Little Rock. Last year, 40 VAMCs hosted the Hospital
Domestic Preparedness training presented by the US Army Soldier and
Biological and Chemical Command (SBCCOM). VHA has just completed a
survey of all VAMCs and their preparedness for WMD. I plan to review
the results and determine where we still need to enhance readiness. I
also plan to have all VISN and VAMC contingency plans reviewed to
ensure consistency throughout the system.
We have received ongoing guidance in Emergency Management, VA
Contingency, VA/DOD Contingency, and the Federal Response Plan from
EMSHG--long before 9-11. Additionally, VHA has just completed
development of an Emergency Management Guidebook. The Guidebook
incorporates many directives and plans and aligns with the new
emergency management standards of the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO). It also integrates ``Comprehensive
Emergency Management,'' a concept that I fully support and that views
``disaster'' from an all-hazards perspective. By using this approach,
we can plan for all events in the same way, saving time and resources.
Question 24b. Not only must VA equip its facilities and train its
staff to protect themselves and their patients during disasters, but VA
medical centers must also be prepared to fulfill obligations to non-
veterans under VA's Fourth Mission and the Federal Response Plan. Do
you believe that VA medical staff can meet these challenges without
overburdening an already strained system? How would you propose to
balance the need to maintain VA's medical infrastructure for use during
conflicts and disasters with the pressures to eliminate staff and beds?
Answer. Care of Veterans is first and foremost and we will not
commit resources outside our system that degrades care of Veterans in
any way. Historically, VA has heeded the call for disasters and
national crises and will continue to do so. VA has the largest and most
comprehensive integrated health care system in the country. The
temporary deployment of personnel and resources, therefore, would not
have the impact on VA that it might have on other, non-integrated
systems. VISNs and VAMCs have well designed contingency plans and have
planned for contingencies that would require personnel losses though
military deployments or for VA/DoD Contingencies, and that may,
therefore, require us to call back retirees and volunteers to back-fill
staff and transfer patients among facilities. More importantly, we
consistently train, exercise, and evaluate contingency plans in order
to recognize where shortfalls may occur.
Question 24c. I understand that the new Office of Operations,
Security, and Preparedness is still being developed. How would you
envision its role in influencing medical preparedness strategies and
how would you, if confirmed, work with that office as the Under
Secretary for Health?
Answer. I understand that the new Office of Operations, Security,
and Preparedness will have oversight for all VA. Its roles will include
the evaluation of programs and the issuance of guidance for the
Department. It will also represent VA at high level meetings with the
new Homeland Security Office and with other department/agency leaders,
addressing issues that may include, but go well beyond, health care
concerns. I plan to have a positive and effective relationship with the
new Office. I plan to communicate routinely with them about VHA's
specific requirements and issues. We all have veterans' best interests
as our primary concern and will approach the challenges of Homeland
Security as a team.
Question 24d. VA can claim resources--including experts in treating
post-traumatic stress disorder and local partnerships throughout the
Nation--that place it in a unique position to meet the needs of
communities overwhelmed during natural or deliberate disasters.
Historically, VA's assets have not always been used efficiently during
public health crises. How do you propose integrating VA more
effectively into the Federal health and medical services planning
effort?
Answer. The use of VA assets during public health crises has
improved over the past few years, as the Federal Response community has
come to realize VA's vast and tremendous resources and expertise. VA
assists HHS and CDC in managing pharmaceutical caches and provides
training to personnel in hospitals enrolled in the National Disaster
Medical System. We have supported every major Presidentially declared
disaster beginning with Hurricane Andrew, have provided support for
many special events deemed ``high risk'' by the National Security
Council, and have coordinated and delivered many interagency education,
training and exercise programs. The area where we need to improve is in
having a ``seat at the table'' with the decision-making bodies. It is
critical that VA has an opportunity to be involved throughout the
planning process at the highest level. I plan for VHA to be
aggressively involved with relevant decision-making groups, e.g. the
NDMS Senior Policy Group. I will consistently communicate and interact
with those making the decisions that impact VA and the veterans we
serve.
Question 25. GAO has encouraged expedited implementation of the
cook-chill food preparation systems at VA Medical Centers. Do the
facilities in VISN 8 have such system. In your view, are there any
quality issues related to this type of advanced food preparation?
Answer. GAO recommended that consolidated advanced food production
systems (known as cook/chill) be one of the service delivery options
that VA facilities consider for improved efficiency, cost savings, and
quality patient food service. VHA recommended that VISNs and VAMCs
conduct feasibility studies prior to implementing this option in order
to address issues of patient satisfaction, cost effectiveness, and cost
savings. Several facilities in VISN 8 have consolidated advanced food
production and delivery systems, including Tampa, West Palm Beach/
Miami, and Bay Pines. The food service operation in Tampa was
recognized with a VA Deputy Secretary's Scissors Award for its improved
efficiencies, cost savings, and customer satisfaction.
Quality issues certainly can arise in this system as with any
system of food production and service. Following are potential positive
and negative issues impacting the ``cook-chill'' system.
positive
Greatly enhanced food temperatures for hot and cold
temperature retention.
Greater food safety measures relative to food handling and
time/temperature control.
Greater control of food costs and yield related to Food
Production changes.
Reduced labor requirements in Food Production and service
due to ability to cook product in advance and store it for future
service, which compresses work schedules.
Potential for outside revenue streams for food product.
negative
Menu selection can be more restrictive since certain food
products do not hold proper texture and appearance when prepared in a
cook-Chill system.
System design requirements for hot and cold side of the
meal tray limits size of trays. This in turn limits the number of items
that can be provided on each side.
Human error factors such as putting the tray into the
retherm cart backwards where the hot side is chilled and the cold side
is heated. This generally impacts on timeliness of meal delivery, as
the patient waits until a new tray is made.
______
Response to Written Post-Hearing Questions Submitted by Hon. John D.
Rockefeller IV to Robert Roswell, M.D.
Question 1a. At some facilities, physicians are being asked to
spend less time with each patient in order to see more patient visits
and reduce waiting times. Doctors and other direct care providers are
also being asked to increase their total patient caseload. How will you
balance the need for VA to reduce wait times for appointments with the
needs of doctors and care providers to spend adequate times with their
patients?
Answer. VHA has recently adopted a set of standards that will be
employed to uniformly measure the number of patients managed within
each provider's panel. These standards will allow us to determine those
factors associated with a need to spend more time with individual
patients, and develop more consistent standards for an optimal provider
panel size that balances efficiency with patient needs.
Question 1b. What process will set up to ensure that care providers
will have input on caseload sizes and length of patient visits?
Answer. I will rely upon advice and counsel from both the VA Chief
Consultant for Ambulatory Care and field advisory groups when
formulating any policy guidance related to establishing provider panel
sizes.
Question 2. In a Tampa Tribune article dated February 26, 2002, you
are quoted as saying that the VA needs legislative changes to make
physician pay more competitive. If you are confirmed, can we expect
such a legislative proposal?
Answer. I understand that VA has made recommendations to OPM and
OMB concerning the need to increase VA physicians' special pay. I also
understand that based on these recommendations, OMB will soon forward a
legislative proposal to make certain adjustments in VA physician
special pay. Although, I am not aware of the exact nature of the
recommended changes, I would likely support this legislative proposal.
Question 3. Many VA facilities are considering contracting out fire
fighting and prevention to local communities. Even in non-disaster
situations, fires at hospitals--which house radioactive materials and
many toxic chemicals--are critical and crisis events. By law the
Department of Defense is prohibited from contracting out fire
prevention just because of the need to maintain in-house first
responder capacity in times of natural or deliberate disasters. Will
you recommend that VA reconsider its plans to further cutback on VA's
in-house fire prevention and hazmat capacities?
Answer. Each decision to eliminate an in-house VA fire department
and transfer the fire suppression services to a local community is done
with considerable review. We will continue to evaluate each new plan
from individual VHA health care facilities when they consider obtaining
fire suppression services from the local community. There is no agency
mandate for VHA health care facilities to eliminate their in-house fire
departments. It is always a local decision. However, the local fire
suppression services must meet our minimum criteria before the VA
facility phases out their in-house fire department. The closure of 12
of our in-house fire departments over the past 15 years occurred as a
result of the community fire departments eventually meeting our fire
suppression criteria. Protection is provided by community fire
departments for the vast bulk of our health care facilities with only
24 of 172 locations currently provided with in-house VA fire
departments. VA has never contracted out with private firms for fire
suppression services. A few of our facilities contract with the local
communities when the VA facility is not entitled to receive the fire
suppression services for free. Our standard protocol when closing an
in-house fire department is to offer all fire fighters other positions
at the facility, including some fire prevention specialist positions.
All of our facilities with radioactive materials must comply with
National Fire Protection Association Standard No. 801, Standard for
Fire Protection for Facilities Handling Radioactive Materials along
with other pertinent requirements. As a health care provider subject to
numerous safety oversights, our facilities are well equipped and
trained to address incidents involving hazardous materials, including
those where fire suppression services are provided by the local
community fire department. VA health care facilities work extremely
closely with local communities in coordinating responses to hazardous
material incidents and planning for incidents with weapons of mass
destruction. The hazmat capability of our health care facilities has
expanded dramatically over the past few years and especially since 9/
11. Much of this effort has been due to increased Joint Commission on
Accreditation of Healthcare Organizations emphasis on emergency
management. Those facilities with an in-house VA fire department use
our own fire fighters as first responders in coordination with other
local fire and emergency forces.
Question 4. How does conversion to cook/chill affect VA's ability
to provide food and shelter in mass disasters?
Answer. From my personal experience with cook/chill systems in VISN
8, I believe that conversion to this process would enhance disaster
capability through the increased capacity and flexibility in
preparation afforded by this approach. Emergency/disaster feeding
programs are an integral part of VA's healthcare emergency preparedness
plans at local VA facilities. Generally, VA emergency plans include
provision for several days of food and supplies and a menu with limited
requirements for preparation and service.
Question 5a. As you know, I am quite interested in new quality
management initiatives that are able to demonstrate good results. Last
year, VA physicians at the Tampa VA evaluated a diabetes software
management tool that helped guide physicians in the care of veterans
with diabetes. The group of diabetic veterans that used the software
had enhanced medical care for each of the six clinical diabetes
variables measured. Further, the study extrapolated the 38 veterans who
tested this software may have saved the VA almost $800,000 in deferred
medical interventions. Considering the success of this study, if
confirmed, what will you be doing to bring this kind of software to all
medical centers, so that patients throughout the system can benefit?
Answer. The software system evaluated at the Tampa VA is one of
several efforts to automate clinical practice guidelines. Practice
guidelines such as this have been shown to enhance both the quality and
efficiency of care provided to patients. Moreover, when guidelines are
automated and integrated into an electronic medical records system,
their access and utilization by clinicians is greatly enhanced, further
increasing these desirable outcomes. I strongly support efforts to
integrate clinical practice guidelines into VA's Computerized Patient
Record System and will work to assure continued progress towards this
goal.
Question 5b. There are indications that veterans may be at an
increased risk for hepatitis C. Please share your assessment of the
status of VHA's hepatitis C programs and note any changes you would
make.
Answer. VA is the largest single provider of hepatitis C screening,
testing and treatment in the nation. In 1998 VA recognized the need for
a concerted, organization response to the problem of hepatitis C
infection. The essential components of that response are:
Identification of those at risk through organized
screening activities
Testing for infection in those with risk factors
Education and counseling for those with and at risk for
hepatitis C
Education and skill building for providers for care for
patients with or at risk for hepatitis C
Offering the best available therapies for those infected
Supporting research to improve knowledge about hepatitis
C, particularly among veterans.
These are the elements of a comprehensive public health approach.
As a result, VA has emerged as a national leader in hepatitis C. During
the past three fiscal years (FY 1999-2001), over 1.7 million veterans
have been screened for risk factors associated with hepatitis C, over
800,000 blood tests were performed, and over 109,000 veterans had a
positive blood test. All FDA-approved therapies for hepatitis C are on
the national VA formulary. VA has the only published treatment
recommendations that incorporate newest therapeutic advances. Strategic
partnerships have been forged with veterans organizations, the
pharmaceutical industry, and with other federal agencies. VHA has
established a specific program office for hepatitis C and has funded
four field-based sites to serve as resources for developing best
practice models in screening and testing, education, prevention, and
clinical care delivery. Thus, VA is meeting the challenge of hepatitis
C with a comprehensive public health approach that has been extremely
successful.
Screening at risk veterans for hepatitis C has also been
incorporated into VA's performance measurement system, and I understand
that we are currently very close to our goal of screening 80% of all
patients at risk for this disease. I will continue to monitor our
progress and re-evaluate the target goal of 80%.
Question 5c. I understand VHA has worked with veterans
organizations and other advocacy organizations to educate and inform as
many veterans as possible about hepatitis C. Please tell the Committee
about these activities and what other activities you envision to better
inform veterans about hepatitis C so those who may be at risk can be
screened or tested.
Answer. VA has developed effective partnerships with a number of
veterans service organizations (VSO's), advocacy groups for veterans
with hepatitis C, and other public service organizations to increase
awareness of hepatitis C. In addition, VA has developed, initially
through the Centers of Excellence program, and now through the
Hepatitis C Resource Center program, a wide variety of educational
materials in a variety of formats including, print, video, and
internet-based communication tools. Collaboration with the American
Liver Foundation (ALF) produced educational brochures that will be
distributed to over 3 million veterans. If confirmed I will actively
support the continuation and enhancement of these programs.
The greatest challenge at this time is to reach veterans in remote
areas, those without regular medical care, and those who may not be
aware of VA services for hepatitis C. Through the Vet Center program
and the Hepatitis C Community Advisory Board, made up of veterans from
across the country, we have heard repeatedly of the need to incorporate
veterans groups in these outreach efforts. I anticipate that we will
increase our outreach efforts through the Vet Centers, domiciliary
units, homeless veterans programs, and through innovative education
programs with ALF, Vietnam Veterans of America, American Legion,
Veterans Aimed Toward Awareness and other organizations to make sure
that the information is available at the right time and in the right
place.
Question 5d. I understand the American Liver Foundation has offered
to partner with VHA to provide home specimen collection and telephone
counseling to veterans who may not want to come to a VA facility for
hepatitis C testing. Please share with the Committee your perspective
on this proposal.
Answer. I believe that all veterans offered hepatitis C testing
should be provided with appropriate counseling concerning the
implications of the testing and the results. I also believe that the
results from any veteran tested for hepatitis C through a VA program
should be recorded in the veteran's patient record.
I am somewhat familiar with the American Liver Foundation (ALF)
proposal and support the general concept. VA has developed an effective
partnership with the ALF and has worked with that organization on a
hepatitis C education program that will result in delivering over 3
million informational brochures into the hands of veterans.
I understand that the ALF proposal for telephone counseling and
home specimen collection for veterans who were not receiving care at VA
facilities was carefully reviewed by VA's hepatitis C program office.
VA concluded that the proposal could not be accepted due to concerns
about the adequacy of telephone counseling provided by non-VA employees
without medical training. There were also serious concerns about the
ability to provide adequate follow up for those who tested positive if
they were not enrolled in or not eligible for VA care. VA has informed
the ALF of this decision and has offered to work with ALF on
alternative proposals to improve awareness of hepatitis C and to
encourage those at risk to be tested. Discussions between the hepatitis
C program office and the ALF are continuing and VA looks forward to
continuing this successful partnership.
Question 6. The number of inpatient mental health programs have
been drastically reduced; some argue that units have been closed
without a corresponding increase in supportive outpatient programs.
What is your view of this change and, based on your view, what guidance
will you disseminate to the field ensuring that an adequate capacity
remains?
Answer. Improved treatment approaches and more effective
medications have reduced our reliance upon inpatient programs to manage
serious mental illnesses. However, veterans lacking adequate social
support systems, including homeless veterans, may not be appropriate
candidates for non-institutional programs. I will work to see that
residential beds are available for this group of veterans, and I will
work closely with the Secretary's Special Advisory Committee on Serious
Mental Illness to assure that a full range of needed mental health
services are available to all veterans.
Question 7. Increasingly it seems that under the current network
structure, network directors have tremendous autonomy. You have
expressed your intention to heighten their responsibilities, such as
requiring one or two network directors to monitor certain services,
like mental health. Please share your thoughts on why Headquarters'
Consultants could not instead be drawn upon to make sure best practices
are found and developed across the system. Are you confident that
network directors have the impartiality and the program knowledge to
make decisions for the entire system?
Answer. My plan to reorganize the National Leadership Board into
crosscutting committees responsible for key functional areas across all
VISNs will place a Network Director and a Headquarters Consultant or
Chief Officer as Co-chairs, of each committee. In this manner, the
field operational experience of the Network Director will be augmented
by the program knowledge and expertise of the Headquarters program
official. This utilization of network directors in national program
areas in partnership with Headquarters program officials will bring
greater shared leadership and accountability to the system. I believe
this will assist VHA in balancing multiple interests, policies, and
operational needs, and in making difficult choices where required.
Question 8. While non-physician extenders are critical to VA, there
currently seems to be a problem with the licensing of Physician
Assistants. For years PAs received national certification in lieu of
state licenses--which are difficult to obtain for PAs who move around
the system so frequently. You stated in your prehearing questions that
you believe VA should reverse that long-standing policy and require
state licensure. Please explain your position, notably why national
certification is no longer an acceptable standard.
Answer. I stated that I believe requiring licensure is an
``appropriate way to ensure the quality of care to our patients.
However, we must evaluate any untoward effects that the implementation
of this new regulation would have on our workforce and the patients
they serve.'' I agree that current state licensing procedures may make
it difficult for some PAs to obtain a license that accurately reflects
the nature and scope of their VA practice. This may result in an
``untoward effect'' that was mentioned in my statement. If this proves
to be the case, I would support a waiver mechanism for the PA's
affected.
Question 9. The recent decision under CARES in Chicago illustrates
that the plan is to reduce hospital presence in some areas and redirect
those resources elsewhere. This ultimately will lead to reductions in
training opportunities for medical residents, as was the case with
Northwestern University. Given this decision, how will VA maintain its
long-standing and valuable emphasis on teaching?
Answer. The first deployment of the CARES process in VISN 12 is
still underway. I am informed that both VHA and Northwestern University
continue to work together to plan ways to provide the highest quality
of health care for veterans while at the same time maintaining the
academic mission of VHA and Northwestern University. All parties are
actively seeking creative solutions that will strengthen educational
opportunities.
My understanding of the VISN 12 CARES recommendations is that
Northwestern will be encouraged to place residents funded through VA at
either the outpatient facility to be located at the former Lakeside
location or at the renovated Westside location.
VHA recognizes that we must consider many aspects of the academic
environment when considering changes in health care delivery. These
areas include residency program needs, faculty development,
departmental needs, medical student needs, workforce constraints, and
accreditation requirements. I strongly support our affiliations with
over 100 medical schools and believe we must take a more aggressive
approach to involving them in the formulation and evaluation of future
CARES service delivery options. The regular participation of these
important stakeholders will be actively encouraged.
______
Response to Written Post-Hearing Questions Submitted by Hon. Bob Graham
to Robert Roswell, M.D.
Question 1. What is your view of the CARES system? If this isn't
the best method of getting value for VA's health dollar--what is? How
do we ensure health care dollars are spent for health, rather than
maintenance of facilities?
Answer. In 1999, GAO concluded that VHA could significantly reduce
the funds used to operate and maintain its capital infrastructure by
developing and implementing market-based plans for restructuring
assets. Therefore, VA established the Capital Asset Realignment for
Enhanced Services (CARES) program to objectively assess veterans'
health care needs within each Network and propose the most effective
alignment of assets and related resources to meet the future health
care needs of veterans. Such a comprehensive evaluation of a large
health care delivery system had never been undertaken before. The
Secretary of Veterans Affairs recently announced his decision about the
final options for the pilot Phase I conducted in VISN 12. Projected
savings throughout VISN 12 over the next 20 years are estimated to be
$725 million, which are savings that will be redirected within the VISN
for new/expanded health care programs.
Plans are being developed to perform the remaining CARES studies in
20 VISNs simultaneously in Phase II. VA expects that these studies will
be completed, reviewed by an external Commission, and that final
decisions will be made by the Secretary within the next two years. I
believe we have a method through the CARES process to ensure that we
are redirecting resources where they are most needed and are improving
the quality of and access to VA care.
Question 2. Due to Florida's growing veteran population, the wait
in VISN 8 for a first time physician visit is often over one year. How
do you plan to shorten the waiting period nationwide?
Answer. Lengthy waiting times for new enrollees in Florida and
elsewhere in the country are clearly related to a growth in the demand
for VA care that has exceeded currently available resources. Although a
completely satisfactory resolution of this problem will require
additional funds, there is much VA is currently doing to address the
issue. Primary care provider panel sizes are being carefully evaluated
with a goal to increase the number of veterans to whom each clinician
is able to provide care. Waiting times have been significantly
shortened in many areas through a program known as Advanced Access that
re-engineers the scheduling process allowing patients greatly increased
access to their providers. Extensive management efficiency efforts are
underway that will allow existing dollars to be re-directed to address
this problem. I will support these and similar programs, while seeking
new and innovative approaches to continue to reduce waiting times.
Question 3. Some VISNs have a lower volume of patients than others,
and thus, lower funding. Yet due to travel or retirement, the veteran
population is quite mobile and often needs treatments or physician
visits away from their primary VISN region. This is especially
prevalent in Florida when the senior, and consequently, the veteran
populations grow considerably during the winter months, yet funding
remains stable throughout the year. Do you envision ways to unify the
distribution of money and care per patient throughout the VA system,
rather than directly to the VISN?
Answer. The current VERA model used to distribute funds to each of
the VISNs has a mechanism to direct dollars to multiple networks when
an individual veteran receives care in more than one network during a
fiscal year. This process, involving pro-rated patients, is one of
several aspects of the VERA process currently under review to determine
if further improvements to the model are needed.
Question 4. What is your view as to the adequacy of the VA's
response to the high prevalence of hepatitis C among veterans?
Answer. VA is the largest single provider of hepatitis C screening,
testing and treatment in the nation. In 1998 VA recognized the need for
a concerted, organization response to the problem of hepatitis C
infection. The essential components of that response are:
Identification of those at risk through organized
screening activities
Testing for infection in those with risk factors
Education and counseling for those with and at risk for
hepatitis C
Education and skill building for providers for care for
patients with or at risk for hepatitis C
Offering the best available therapies for those infected
Supporting research to improve knowledge about hepatitis
C, particularly among veterans.
These are the elements of a comprehensive public health approach.
As a result, VA has emerged as a national leader in hepatitis C. During
the past three fiscal years (FY 1999-2001), over 1.7 million veterans
have been screened for risk factors associated with hepatitis C, over
800,000 blood tests were performed, and over 109,000 veterans had a
positive blood test. All FDA-approved therapies for hepatitis C are on
the national VA formulary. VA has the only published treatment
recommendations that incorporate newest therapeutic advances. Strategic
partnerships have been forged with veterans organizations, the
pharmaceutical industry, and with other federal agencies. VHA has
established a specific program office for hepatitis C and has funded
four field-based sites to serve as resources for developing best
practice models in screening and testing, education, prevention, and
clinical care delivery. Thus, VA is meeting the challenge of hepatitis
C with a comprehensive public health approach that has been extremely
successful.
Screening at risk veterans for hepatitis C has also been
incorporated into VA's performance measurement system, and I understand
that we are currently very close to our goal of screening 80% of all
patients at risk for this disease. I will continue to monitor our
progress and re-evaluate the target goal of 80%.
Question 5. In view of the VA's failure to spend appropriate finds
for this purpose, do you believe VA management should ``fence'' these
funds as they have for prosthetic and sensory aids in the past?
Answer. In general I oppose ``fenced'' funds because they can limit
the best utilization of dollars and may lead to unspent dollars at the
end of a fiscal year.
VA's failure to effectively utilize funds appropriated for
hepatitis C care resulted from projections based on a set of
assumptions and estimates that were untested at the time. The cost
projections forecast by these models were higher than the actual costs
recorded in each of several fiscal years. Current cost estimates have
been adjusted accordingly, and VA is taking positive steps to measure
hepatitis C-related costs and workload more accurately through the
development of a national hepatitis C case registry and other automated
systems. I believe that we can have a more positive effect on care
through the adoption of performance measures, the provision of useful
and timely data, and the quality management initiatives of the
hepatitis C program office. I am confident that such an approach can be
adapted to track hepatitis C care without limiting the best utilization
of these funds.
Question 6. I believe that you are aware that the American Liver
Foundation proposed a significant outreach program that included as a
component the use of an FDA-approved home test kit. Are you familiar
with this proposed, and what is your view with regard to its merits?
Answer. I am somewhat familiar with the American Liver Foundation
(ALF) proposal and support the general concept. VA has developed an
effective partnership with the ALF and has worked with that
organization on a hepatitis C education program that will result in
delivering over 3 million informational brochures into the hands of
veterans.
I understand that the ALF proposal for telephone counseling and
home specimen collection for veterans who were not receiving care at VA
facilities was carefully reviewed by VA's hepatitis C program office.
VA concluded that the proposal could not be accepted due to concerns
about the adequacy of telephone counseling provided by non-VA employees
without medical training. There were also serious concerns about the
ability to provide adequate follow up for those who tested positive if
they were not enrolled in or not eligible for VA care. VA has informed
the ALF of this decision and has offered to work with ALF on
alternative proposals to improve awareness of hepatitis C and to
encourage those at risk to be tested. Discussions between the hepatitis
C program office and the ALF are continuing and VA looks forward to
continuing this successful partnership.
______
Response to Written Post-Hearing Questions Submitted by Hon. Arlen
Specter to Robert Roswell, M.D.
insurance reimbursements
Question 1. As you may have heard, during the Budget hearing on
February 14 of this year. I suggested to Secretary Principi that he
begin disciplining--even firing--physicians and other clinicians who do
not properly document their work. If you are confirmed, do you believe
that you can take the necessary steps, including severe discipline
against your fellow physicians, should this obvious documentation
problem continue?
Answer. Physician documentation is one of many critical steps in
the revenue cycle where improvements must be made to enhance VA's
collections from private insurance companies. I believe we must provide
needed education and training for all clinical staff, incorporate
certified coders into the patient care areas of our medical centers and
clinics, and develop performance monitoring mechanisms that will
provide physician-specific performance data. These actions will
facilitate the documentation process and allow us to identify under-
performing physicians.
To the extent a specific provider does not comply with requirements
following necessary education/training and feedback from monitoring
efforts, I support specific management actions that would include
validating understanding of requirement and determining willfulness of
noncompliance. I am prepared to take disciplinary action against
physicians identified in this manner who fail or refuse to correct
their documentation performance.
Question 2. In that same February 14 hearings I asked Secretary
Principi to report back to me on his plan for ensuring that physicians
are held accountable for proper documentation of medical procedures.
His response stated that he believes new performance goals and pay
incentives are necessary to modify physician behavior. Do you agree? Do
you think new performance goals and pay incentives are the ``most
effective'' tools to use in encouraging physician attention to proper
medical documentation? Do you believe that there are steps--other than
those identified by Secretary Principi--that need to be taken to
improve documentation by clinicians? If so, please describe the steps
you would recommend.
Answer. I agree with Secretary Principi that performance goals and
pay incentives are effective means to change physician behaviors.
However, another highly effective way to alter clinical behaviors is
providing physicians with feedback on individual performance.
Therefore, we must develop monitoring mechanisms that provide
physician-specific data. This information, coupled with proper
education and training, compliance monitoring, and the placement of
certified coders in patient care areas should greatly enhance physician
documentation performance. These steps will also allow us to accurately
identify high performing physicians for pay incentive purposes, and low
performing physicians for remedial purposes. To the extent the proper
information and tools are available to all staff involved in the
billing process, formal disciplinary action should be an action of last
resort.
Question 3. VA's Inspector General issued a report at the end of
February that said that VA would have collected over $500 million more
in third-party receipts had VA implemented and followed previous IG
recommendations. Do you agree with the IG's assessment? If you are
confirmed, will you implement all of the recommendations made by the IG
in this most recent report?
Answer. The revenue cycle is an extremely complex process that
involves numerous steps. Maximum performance can only be obtained with
a strong leadership commitment and a comprehensive analysis of each
step of the cycle with careful attention to improvement opportunities.
Although I am not familiar with how the IG calculated lost revenues, I
agree that the VA collection potential is significantly greater than
current receipts. If confirmed, improvement across the entire revenue
cycle will be one of my highest priorities. I will carefully examine
each of the IG's recommendations, along with other recommendations
contained within the VA Revenue Cycle Improvement Plan, and will
consult with industry experts to assure that our efforts to improve the
process leave no opportunity untouched.
Question 4. The same IG report noted that VA timeliness in
preparing and sending out bills to insurance companies is getting
worse--not better. The IG stated that, in the private sector, the
average time to send a bill for reimbursement is 10 days, whereas, in
VA, the time is approximately 95 days. What steps can you rake
immediately to at least reverse the direction of this statistic and
bring the times closer to those in the private sector?
Answer. VHA is nearing completion of an Electronic Data Interchange
(ED[) that will allow bills to be transmitted directly to third-party
insurers, thereby greatly reducing the billing lag time. If confirmed,
I will assure that this software is distributed and implemented as
quickly as possible throughout all VHA facilities.
budget issues
Question 5. Secretary Principi has stated, in effect, that VA is a
victim of it's own success and that it is now being overrun by patient
demand. The Secretary recommended that Congress charge a $1500
deductible to veterans making just over $24,000 annually to retard
demand. Do you believe that there are other alternatives to the $1500
deductible proposal that the Committee should consider to help VA
manage increased patient demand? Was your experience with increases in
patient population in Network 8 over the past several years similar to
the experience Secretary Principi relayed to the Committee?
Answer. Over the past several years, the number of veterans
receiving care through VISN 8 facilities has grown by an astounding 80
percent. During this same time period the VISN 8 budget has grown by
only 40 percent. Obviously, this growth cannot continue without a
substantial increase in funds, if we are to maintain our current high
standards of quality and access to care. For this reason Secretary
Principi has proposed a $1500 deductible for priority seven veterans,
although he has stated that he is willing to consider other
alternatives. Unfortunately, the alternatives to imposition of the
deductible are few. We must either limit enrollment, or reduce the
level of services provided to enrolled veterans, or supplement the
current medical care budget with additional funds from either
appropriated or non-appropriated sources, such as Medicare.
Question 6. In recent testimony before the Senate VA-HUD
Appropriations Subcommittee, Secretary Principi stated that VA's
financial difficulties were due, in large part, to ``unfunded
mandates'' imposed by Congress on VA. As a network director, did you
find that your budget was severely hampered by having to absorb
``unfunded mandates'' from Congress? What are some examples of the
unfunded mandates Secretary Principi spoke of in his testimony last
week?
Answer. A number of factors including increased workloads and
unfunded mandates have made it difficult to meet patient needs and
expectations in VISN 8. As a Network Director, some of the programs
that have been mandated in recent years without specifically identified
funds include a requirement to increase staffed nursing home care unit
beds, a requirement to provide mental health services in community
based primary care outpatient clinics, a requirement to enhance opioid-
replacement programs, a requirement to provide life-long nursing home
care to veterans with 70 percent or greater service-connected
disabilities, a requirement to provide home and community care services
to all enrolled veterans in need of such care, and, specific to VISN 8,
a requirement to provide community-based contract hospital care to
veterans residing in East Central Florida.
Question 7. Following enactment of so-called Eligibility Reform
legislation, VA began a significant effort to recruit new patients into
the system. VA opened hundreds of outpatient clinics, and made the
decision to accept all categories of enrollees (1-7). How many patients
were enrolled for VA health care when you assumed the position as
director of VISN 8? How many are enrolled today? Isn't it fair to say
that the increase in VISN 8--and VA-wide--enrollment is a direct result
of these extensive outreach and patient-enrollment efforts?
Answer. When I became the VISN 8 Director in early 1996, there were
approximately 225,000 veterans receiving care from VISN 8 facilities.
Today that number has risen to over 410,000. This tremendous increase
in users has certainly been facilitated by the opening of a number of
community based outpatient clinics, coupled with a national enrollment
policy allowing all veterans to receive VA care. However, I believe
there are several other factors contributing to this growth. These
include the general economic conditions within the United States, the
failure of a number of Medicare HMOs, lack of a Medicare prescription
drug benefit, and a growing recognition that VA now provides extremely
high quality medical care. Additional factors that may be specific to
VISN 8 and Florida include a historical inability to provide care to
lower priority veterans, creating a very large suppressed demand for
care; and the large number of veterans who continue to relocate to
Florida.
Question 8. The ``VERA system'' of resource allocation has run a
painful course for a few of the networks in the northeast. Some, like
Network 4 (Pennsylvania) have become extremely efficient operations and
have absorbed significant financial stress without running a deficit.
Others--such as Network 3 (New York City) have repeatedly exceeded
their allocated budgets--and have been ``bailed out'' with supplemental
funding at the expense of other networks. What will you do to assure
that efficient, successful networks do not continue to subsidize the
inefficient and unsuccessful practices of other networks?
Answer. Supplemental funds may be required by a VISN for a number
of reasons, including catastrophic events, irregularities within the
VERA system that fail to adjust for regional variations in labor and
contract costs, aging facilities that are more expensive to maintain,
and the presence of high cost programs that may not exist in other
networks, as well as management inefficiencies. If confirmed, I will
continue to evaluate the VERA allocation model and adjust it as
necessary to correct these deficiencies. I will also take aggressive
steps to reduce management inefficiencies in all VISNs through a
revised performance measurement system, the use of budget execution and
financial management monitors, and the creation of a finance committee
within the VHA National Leadership Board, charged to improve management
efficiencies across all of the 21 networks.
national emergency preparedness
Question 9. In his testimony before this Committee on February 14,
2002, Secretary Principi stated that VA should play a more significant
role in the nation's domestic preparedness efforts. Do you agree with
the Secretary's view?
Answer. I strongly support the Secretary's position on the role of
the VA in domestic preparedness efforts. I believe there is no better-
situated integrated healthcare system to provide emergent care in the
event of a domestic terrorist action than the VA. In addition to over
800 locations of care throughout the nation, VHA employs a workforce of
over 185,000 including more than 12,000 physicians. A vast
communications network, which includes a comprehensive electronic
medical record system, and a digital satellite network connect this
extensive network of facilities and clinicians. Collectively, these
features virtually assure that VA care will be available in a time of
need, and the necessary education, training, and communications to
assure both preparation and response can be readily provided.
Question 10. What actions do you believe VA should take to prepare
itself better--and to prepare the Nation better--to respond to a large-
scale disaster like that which occurred in New York, Pennsylvania, and
Virginia in September? How much money does VA need to prepare itself,
and others in our Nation's communities, to respond to a large-scale
disaster? And how much are you devoting to that process now?
Answer. VA must first prepare itself to ensure continued care for
VA patients, viability of facilities, and protection of staff. In this
regard we are implementing a program of education, training,
decontamination capability, and supplementing pharmaceutical
inventories with special caches. Secondly, VA has determined a need for
a more resourced and focused approach to coordinate and execute its
mission to respond as a key support agency during national emergencies,
To this end, VA is developing a new office of Operations, Security, and
Preparedness, which will report to the Deputy Secretary and work
closely with the Office of Homeland Security. Finally, VA must
strengthen relationships with the many communities in which we reside,
through mutual support and the maintenance of a high degree of
readiness. We are doing this through our network of Area Emergency
Managers in every VISN.
In the current Fiscal Year (FY2002) we have devoted $22M to the VA
pharmaceutical caches, $156,266 to the initiatives of the Emergency
Management Strategic Healthcare Group (EMSHG), $146,000 to Continuity
of Operations (COOP), and slightly more than $22M to Critical
Infrastructure Protection (CIP). Required additional resources are
ongoing and evolutionary as VA progresses in identifying and
quantifying requirements. I am not able to predict what these costs
would total, but I will actively pursue this agenda if confirmed.
______
Response to Written Post-Hearing Questions Submitted by Hon. Ben
Nighthorse Campbell to Robert Roswell, M.D.
Question 1. As you are aware, I have been very supportive of an
innovative proposal which, if implemented, will provide veterans in
Colorado and the nation with state of the art health care facilities at
the site of the former Fitzsimons Army Medical Center. I have two
questions: Would you comment generally on your attitude about seeking
new and creative ways to align with other organizations to deliver high
quality health care to America's veterans? And, will you, if confirmed,
work to bring this precedent-setting project to fruition?
Answer. I am very interested in working to enhance the efficient
delivery of high quality healthcare service to veterans in new and
innovative ways, including partnering with other healthcare providers
and institutions. During my tenure in Florida, I was able to establish
innovative programs to enhance veterans care through arrangements with
Florida State Veterans Homes, the U.S. Navy, private community
healthcare facilities, and several of our affiliated medical schools. I
am familiar with the proposal to enhance veterans' care at the former
Fitzsimons location, and I understand that numerous meetings have been
held with veterans service organization representatives and employee
union representatives to discuss the potential options and progress in
making a definitive recommendation to the Secretary. A consultants
report outlining the costs and benefits of several potential options
for the VA Denver facility is due in mid-April. The recommended course
of action will then be determined. If confirmed, will actively explore
ways this project could be brought to completion.
Question 2. The VA is already experiencing a doctor and nurse
shortage. According to some of the vets in Colorado, it takes six
months to get a regular medial appointment and for veterans with spinal
cord injuries and multiple sclerosis, there is an 18 month waiting
period for an annual checkup! What plans would you put in place to
address this personnel shortage?
Answer. We are currently experiencing a national shortage of nurses
and physicians in certain specialty areas. I believe VA's efforts to
recruit and retain needed clinicians during this shortage must be
multi-faceted. We do not have the flexibility to respond as quickly to
competition in the job market as do private sector entities. Therefore,
we must explore financial incentives including recruitment bonuses,
enhanced salary rates, an expanded special pay authority for
physicians, and loan and tuition reimbursement programs. However,
success in this area will also depend on creating a rewarding and
stimulating setting where clinicians are able to achieve their full
practice potential aided by the latest innovations in technology and
health care delivery. We must also continue to support our research
programs and academic affiliations that have consistently helped VA
recruit and retain outstanding clinicians.
Question 3. As our veterans' population ages, long term care will
become a more and more important part of VA services. How would you, if
confirmed, address the increased needs for long term care? Are you in a
favor of a voucher system?
Answer. If confirmed, I will actively work to develop a full
continuum of long-term care and end of life services. In addition to
existing VA, State Home, and contract nursing home beds, I will work to
expand community and home care programs and services as I have done in
VISN 8. We have shown that by using interactive technology to
coordinate care and monitor veterans in the home environment, we are
able to significantly reduce hospitalizations, emergency room visits,
and prescription drug requirements, while improving patient
satisfaction with the care they receive. This approach not only reduces
the need for institutional long-term care, but provides veterans with a
more rewarding quality of life and greater functional independence.
Because I believe that VA is positioned to provide a higher quality of
long-term care at lower cost than non-VA providers, I do not favor a
voucher system.
______
Response to Written Post-Hearing Questions Submitted by Hon. Larry E.
Craig to Robert Roswell, M.D.
Question 1. In your opening statement you talk about the need to
maximize performance and to minimize variation across the 21 VISNs via
a strategic planning process. How long do you anticipate this process
taking?
Answer. My plan to improve performance and reduce variance across
the current 21 VISNs involves a restructuring of the National
Leadership Board, which consists of all VISN Directors and Chief
Officers from VA Central Office. By reorganizing the board into
crosscutting committees with responsibilities for key functional areas
across all VISNs, our most senior executives will become responsible
for performance results across the entire system instead of just within
their own network. The plan also calls for a comprehensive strategic
planning process and alignment of performance measures to reflect the
highest VHA priorities identified through the planning process.
Performance contracts with individual VISN Directors will reflect both
network priorities and system priorities addressed through the
crosscutting committees. The implementation plan for this
reorganization is nearly complete and I expect to have it in place
within 60 days after my confirmation.
______
Response to Written Post-Hearing Questions Submitted by Hon. Kay Bailey
Hutchison to Robert Roswell, M.D.
gulf war illness
Question 1. Were you involved in conceiving the stress theory of
Gulf War syndrome? What was the basis for it? Do you still believe that
stress plays a major role in the illnesses? Should treatments for
stress be a main part of treating Gulf War veterans?
Answer. I was not involved in either the formulation or
promulgation of a hypothesis that Gulf War illnesses were a result of
combat stress. In fact, I coauthored a paper that contrasted the
symptoms of Gulf War illnesses with those typically associated with
stress. However, I do believe that stress can co-exist and even
aggravate any chronic debilitating illness, including those seen in
veterans of the Gulf War. I have also been personally involved in the
care of a number of veterans who experienced PTSD symptoms in addition
to Gulf War illnesses. Therefore, I believe that stress management or
treatment should be an available treatment modality in any
comprehensive approach to managing the health of Gulf War veterans.
Question 2. What was your role on the PGVCB (Persian Gulf Veteran
Coordination Board)? Why has the research funded by PGVCB failed to
show important causes for Gulf War syndrome?
Answer. I served as the Executive Director of the Persian Gulf
Veterans Coordinating Board (PGVCB), whose membership was limited to
the Secretaries of Defense, Health and Human Services, and Veterans
Affairs. In this role, I was responsible for coordinating the
activities of the support staff assigned to the board. Research was
never funded directly by the Board, although the Board undertook
activities to coordinate and compile research activities funded by the
three participating Cabinet Agencies.
Question 3. What research experience have you had? How many
research papers (not editorials and commentaries) have you published?
Do you feel that you understand the research process well enough to
lead the VA research program?
Answer. My personal research experience as a funded investigator is
limited to the earlier part of my VA career and I have published only
approximately a dozen ``research papers''. However, as a member of the
faculty of four medical schools, including the University of Texas at
Southwestern, and as an experienced clinical administrator, I have
extensive experience in oversight and support of research programs. I
have also served on national boards and committees with research
oversight responsibility and have been invited to serve as a reviewer
for a number of journals that publish research papers. This breadth of
experience has given me a thorough understanding of the research
process, which I believe makes me well qualified to provide
administrative oversight for the VA research program.
Question 4. Why did PGVCB never fund creative research approaches
that ultimately proved successful, such as the UT Southwestern work?
Would you now be more supportive of researchers who are making positive
contributions?
Answer. As mentioned above, no research was directly funded by the
PGVCB. However, my experience with the Board has taught me that we must
carefully consider both traditional and non-traditional approaches to
the diagnosis and management of what are still poorly understood
disease processes observed in veterans of the Gulf War. Accordingly, I
would support such investigative efforts when peer review has validated
the merit of the scientific principles employed in the proposed
studies.
Question 5. Currently, one of the big problems in research on Gulf
War syndrome is obtaining honest, accurate statistical analyses of the
existing DoD and VA databases. We are told that they are too fragmented
t put the complete picture together to show how many are sick, and why.
Would you be in favor of creating a master computer database by
combining all the DoD and VA databases and letting impartial analysts
analyze it?
Answer. I am very much in favor of sharing and, where possible,
combining information from both VA and DoD databases. This was a key
principle upon which the PGVCB was established and I still strongly
support this premise. There are some significant differences between
the two registries that create technical challenges when this type of
merger has been attempted. However, if confirmed, I would work to
increase access to the combined registries by qualified scientific
scholars.
Question 6. The President's FY'03 VA budget submission does not
contain a request fro peer-reviewed medical research for Gulf War
Illness. Do you think research of any value could be conducted if even
a few million dollars funds were available? Would you support
Congressional efforts to add money specifically for that purpose?
Answer. Although the President's FY'03 budget request does not
specifically seek funds for Gulf War Illnesses, I believe the level of
the request for VA intramural research should be sufficient to allow
funding of meritorious work in this area. However, I am generally
opposed to fencing funding for a specific purpose, because such efforts
cannot assure the scientific merit of the work that receives funding. I
believe that competitive peer review of requests for research funding
adds value and scientific rigor to the work that ultimately results.
dva/dod cooperation
Question 7. I am convinced that the missions of our DoD and VA
hospitals can be best achieved with enhanced cooperation and
integration between the two systems. Dr. Roswell, would you please tell
me your vision for accomplishing this?
Answer. I fully agree that enhanced cooperation and sharing between
DoD and VA will benefit both healthcare systems and the patients they
serve. If confirmed, I will pursue this initiative through my full
support of the activities of the Presidential Task Force on VA and DoD
Sharing. In addition, I will actively support and participate in the
recently revitalized Health Executive Council between the two
Departments. I will also draw upon my personal experiences on both
active military duty and in the military reserves to support this
effort.
dallas mental health facility
Question 8. I am very concerned over the deteriorating state of the
Dallas VA Mental Health facilities. In spite of being regarded as a
high priority project for years, recent changes in the VA's process for
evaluating construction projects has once again left this critical
facility high and dry. Can you give me your vision for improving the
condition of the VA's critical treatment facilities?
Answer. Although, I cannot speak directly to the status of the
Dallas Mental Health facilities, I will fully investigate this concern
if confirmed. However, VA currently operates an extensive number of
facilities where advanced age and insufficient renovation and
modernization funding over a period of years has rendered them ill-
suited for the delivery of today's healthcare services. I fully support
Secretary Principi's efforts to carefully evaluate VA's capital assets
and study how they can best be used to meet the current and future
needs of America's veterans. I believe this effort, when complete, will
provide VA with a blueprint to determine how available construction
dollars can best be utilized to modernize facilities such as those in
Dallas.
Chairman Rockefeller. Thank you, Dr. Roswell.
Mr. Cooper.
STATEMENT OF DANIEL L. COOPER, NOMINATED TO BE THE UNDER
SECRETARY FOR VETERANS BENEFITS, DEPARTMENT OF VETERANS AFFAIRS
Mr. Cooper. Mr. Chairman, I am deeply honored to be here
today before this committee as a nominee for this particular
position, which I consider extremely important to our veterans.
In mid-April of 2001 the Secretary of Veterans Affairs,
Anthony Principi, asked that I chair a study focused on methods
to improve the veterans' benefits claims processes. We did
that. We had 12 people on that committee 12 very knowledgeable
people from various facets of VBA. In October our Task Force
reported out to the Secretary and subsequently reported to
congressional committees over here.
If I were to presume to tell you what should be done, I
would point to this particular Task Force report. It lays out a
plan. It lays out things that need to be done. It has 34
recommendations and 66 actions, all of which impact how we do
business.
The report is serving now, and will continue to serve, as a
blueprint for action and it is being implemented. The Secretary
looked at it very carefully about 2 months after we reported
out. He made decisions on what he wanted us to do and, with
some minor modifications, he accepted the Task Force report.
During my short involvement in VA I obviously was deeply
immersed in the Compensation and Pension claims process.
However, I want to assure you that I am fully aware of the
other very important programs that we have Education, Loan
Guaranty, Insurance and Vocational Rehabilitation.
I respectfully request that my full statement be entered
into the record and I stand by to answer your questions.
Chairman Rockefeller. Thank you, sir, very much.
[The prepared statement of Mr. Cooper follows:]
Prepared Statement of Daniel L. Cooper, Nominated To Be the Under
Secretary for Veterans Benefits, Department of Veterans Affairs
Mr. Chairman, I am honored to appear before your committee as the
nominee for Under Secretary for Veterans Benefits, Department of
Veterans Affairs.
In January 1991, I completed a 33\1/2\-year career in the United
States Navy primarily with the submarine force. Since retirement, I
have been involved in industry, participating in several submarine
studies, advising for two University Laboratories and serving as a
board director for the USAA and later for EXELON Corporation.
In mid-April 2001, the Secretary of Veterans Affairs, Anthony J.
Principi, asked that I chair a study focused on methods to improve the
veterans' claims processes in the Veterans Benefit Administration. He
desired that the entire range of available Secretarial authority, which
could address the backlog problem, be reviewed and appropriate action
be recommended. He chartered the Task Force to focus on those changes
that he could execute quickly--those actions that he could require
immediately in order to precipitate a dramatic and immediate impact to
mitigate the claims backlog problem. In October, our Task Force
reported to the Secretary and subsequently to Congressional staff and
the VSO community.
If I were to presume to tell you what needs to be done, I would
start with our Task Force report. The report is serving now, and will
continue to serve as the blueprint for action. The recommendations have
been fully reviewed by the Secretary and ordered implemented with minor
modification. Finally, the acting Under Secretary and the acting Deputy
have moved expeditiously to implement the recommendations.
I assure you that the philosophy expressed in the first several
pages of the Claims Processing Task Force Report is one I strongly
espouse. It emphasizes accountability, integrity and professionalism.
Those principles are sacrosanct and I know of no other way to operate.
Some people who have reviewed the Task Force Report have implied
that, with the dual emphasis of reducing the backlog and decreasing the
time delays, we had somehow denigrated ``quality''. I desire to
disabuse anyone of such a notion. The entire report speaks to quality.
The quality of response and service to veterans is predicated on a
timely, accurate, well stated and consistence process. Every
recommendation made by our study--be it the ``triaging'' of claims, the
quest for improved medical exam processes, or the BVA processing of
appeals and remands--is based on being consistent, improving quality
and providing timely decisions.
Further, I want to assure you I have sampled enough of the VBA
organization, both in headquarters and in the field, to be convinced
that there is a strong cadre of superb, dedicated, and enthusiastic
people in the Veterans Benefit Administration.
During my short involvement with VA, I have been immersed in the
Compensation and Pension programs. However, I am becoming more familiar
with the four other very important programs overseen by VBA: Education,
Loan Guaranty, Vocational Rehabilitation and Employment and Insurance.
The VA Education Program has been a major contributor to the
success of the United States since WW II. The GI BILL and its
successors have educated more than 21 million beneficiaries since 1944.
The goals in Education must be to reduce the claims backlog in this
program and to improve the timeliness of response. A priority must be
to implement properly the recent legislation expanding education
benefits in the areas of ``hi-tech'' courses and in benefits
transferability.
Vocational Rehabilitation provides services and assistance to
enable veterans with service-connected disabilities to obtain and
maintain suitable employment. Over 10,000 veterans achieved
rehabilitation status last year. VocRehab must continue to enhance
services to our most seriously disabled veterans and to achieve
employment as an outcome during periods of economic uncertainty.
The Loan Guaranty Program guaranteed over 250,000 loans in FY 2001.
This program continues to offer ``no downpayment'' home loans to
veterans and to provide an attractive option to veteran buyers. I have
been made aware of the challenge in the program to successfully execute
the field restructuring effort that is underway. This includes
consolidating the Construction and Valuation function from 45 offices
to 9, completing the A-76 cost comparison study of the property
management function and implementing its outcome, and finishing the
comprehensive redesign of the Loan Administration function. Each of
these is vital to our veteran population; knowledgeable oversight is
mandatory.
Recently, I had the opportunity to visit the Insurance Service in
Philadelphia and learn of the tremendous success of this program.
Obviously I would do all I could to support their continued success.
Finally, let me assure you that my intention, if confirmed, is to
identify the best personnel I can for advice and implementation, and to
visit Regional Offices in a methodical but comprehensive manner. I
desire to leave no doubt in the mind of every VBA employee, of both the
gravity of the ``backlog'' problem and the direction in which VBA must
go to attack it. If it becomes necessary to make ``mid-course changes''
(in the process or in the plan) the emphasis will always be to do what
is best to serve the veteran. And every action must be taken to ensure
all the programs are given the priority necessary to be successful.
I can not emphasize too strongly the importance of working closely
with the Veterans Service Organizations. We had VSO representation on
our Task force and the both the TF and I, personally, met with various
VSO representatives. I have also met with VSO representatives when I
have visited Regional Offices, and would continue to do so if I were to
be confirmed. A professional partnership must be maintained and
strengthened as we move forward in the difficult job ahead.
I look forward to working with Congress, your committee and your
staff to serve our veteran population the very best way possible.
______
United States Office of Government Ethics,
Washington, DC, February 15, 2002.
Hon. John D. Rockefeller IV,
Chairman, Committee on Veterans' Affairs,
U.S. Senate,
Washington, DC.
Dear Mr. Chairman: In accordance with the Ethics in Government Act
of 1978, I enclose a copy of the financial disclosure report filed by
Daniel L. Cooper, who has been nominated by President Bush for the
position of Under Secretary for Benefits, Department of Veterans
Affairs.
We have reviewed the report and have also obtained advice from the
Department of Veterans Affairs concerning any possible conflict in
light of its functions and the nominee's proposed duties. Also enclosed
is a letter dated February 6, 2002, from the agency ethics official,
outlining the steps which Mr. Cooper will take to avoid conflicts of
interest. Unless a specific date has been agreed to, the nominee must
fully comply within three months of his confirmation date with the
actions he agreed to take in his ethics agreement.
Based thereon, we believe that Mr. Cooper is in compliance with
applicable laws and regulations governing conflicts of interest.
Sincerely,
Amy L. Comstock,
Director.
______
Questionnaire for Presidential Nominees
part i: all the information in this part will be made public
1. Name: Daniel Leander Cooper.
2. Address: 121 Leisure Court, Wyomissing, PA 19610.
3. Position to which nominated: Under Secretary for Benefits,
Department of Veterans Affairs.
4. Date of nomination:
5. Date of birth: May 21, 1934.
6. Place of birth: East Liverpool, OH.
7. Marital status: Married.
8. Full name of spouse: Betty Jane Ogilvie Cooper.
9. Names and ages of children: Amy Louise Hughes and Cynthia Jane
Rose.
10. Education: Institution (including city, state), dates attended,
degrees received, dates of degrees:
East Liverpool H.S., East Liverpool, OH; Aug 48-Jun 52; HS; 6/52.
Washington & Jefferson College, Washington, PA; Aug 52-Jun 53;
None; NA.
US Naval Academy, Annapolis, MD; Jul 53-Jun 57; BS; 6/57.
Harvard University, Littauer School of Public Administration,
Cambridge, MA; Aug 62-Aug 63; MPA; 6/63.
11. Honors and awards: List all scholarships, fellowships, honorary
degrees, military medals, honorary society memberships, and any other
special recognitions for outstanding service or achievement:
Distinguished Service Medals (3); Legion of Merit (2); and
Meritorious Service Medal (4).
12. Memberships: List all memberships and offices held in
professional, fraternal, business, scholarly, civic, charitable, and
other organizations for the last 5 years and other prior memberships or
offices you consider relevant:
Naval Submarine League; President; 6/97-6/01.
Boys Scouts (Hawk Mt. Council); Executive Board; 6/92-Present.
YMCA of Rdg & Berks Co.; Board of Directors; 8/94-Present.
Torch Club of Reading; None; 1996-2/02.
National Defense Industrial Association; None; 1995-2/02.
World Affairs Council of Rdg, PA; Board of Directors; 1997-2/02.
Rotary; None; 1995-Present.
Navy League; None; 1991-Present.
13. Employment Record: List all employment (except military
service) since your twenty-first birthday, including the title or
description of job, name of employer, location of work, and inclusive
dates of employment:
Special Asst to CEO Alex Smith; Gilbert Assoc.; Reading, PA; 3/91-
1/92.
VP & GM, Nuclear Services; Gilbert & Commonwealth; Rdg, PA; 11/92-
8/94.
Consultant--Primarily studies on Navy Submarines; 8/94-1/02.
Board Member:
Navy Federal Credit Union; 1982-1988.
USAA; 1988-1998.
PECO Utility; 1999-2000.
Exelon Utility; 2001-Present.
META 4; 1999-2001.
HJW Inc; 1999-2001.
14. Military Service: List all military service (including reserve
components and National Guard or Air National Guard), with inclusive
dates of service, rank, permanent duty stations and units of
assignment, titles, descriptions of assignments, and type of discharge:
US Navy from graduation from the Naval Academy as an Ensign to
retirement as Vice Admiral in 1991. Primarily on submarine, budgetting
and programming Billets.
06/57-12/58; Ensign; USS Chilton (APA 38); Junior Officer.
12/58-06/59; JG; Sub School (NLON); Student.
06/59-06/62; LT; USS Trigger (SS564); Junior Officer.
08/62-08/63; LT; Harvard; Student.
09/63-07/64; Nuclear Power School; Student.
08/64-12/64; Bettis Atomic Lab; Student.
12/64-12/65; LCDR; Haddo (SSN 604); OPS Officer.
01/66-06/66; DAM Neck (XO School); Student.
07/66-07/68; USS Simon Bolivar (SSBN642); XO.
07/68-12/70; CDR; Aide to VCNO--Washington; Aide.
01/71-12/71; Various ships and school; Student.
01/72-03/74; USS Puffer (SSN 652); Command.
03/74-06/74; Puget Sound Shipyard; CSP REP.
06/74-06/76; CAPT; Assistant Secretary of Navy; Executive Asst.
Commander.
07/76-07/79; Submarine Squadron Ten.
08/79-06/80; RADM; OP Nav--Trident Coordinator.
06/80-06/83; Controller Naval Sea Systems Command.
06/83-10/85; Director, Navy Budgets and Reports.
10/85-08/86; VADM; Director, Navy Program Planning.
08/86-08/88; Commander, Submarine Force; US Atlantic Fleet.
09/88-01/91; Assistant CNO for Undersea Warfare.
15. Government experience: List any advisory, consultative,
honorary, or other part-time service or positions with Federal, State,
or local governments other than listed above:
April 01-Oct 01; Chairman, Sec VA Task Force on Claims Processing.
Since Oct 01; Implementation Oversight Consultant.
Spring 1995-Fall 2000 served as member of Naval Research Advisory
Committee (NRAC) which studied subjects of interest to Navy Research.
16. Published writings: List titles, publishers, and dates of
books, articles, reports or other published materials you have written:
None.
17. Political affiliations and activities
(a) List all memberships and offices held in and financial
contributions and services rendered to any political party or election
committee during the last 10 years: No offices. Member of Republican
Party.
(b) List all elective public offices for which you have been a
candidate and the month and year of each election involved: None.
18. Future employment relationships
(a) State whether you will sever all connections with your present
employer, business firm, association, or organization if you are
confirmed by the Senate: Yes.
(b) State whether you have any plans after completing Government
service to resume employment, affiliation, or practice with your
previous employer, business firm, association or organization: No.
(c) What commitments, if any, have been made to you for employment
after you leave Federal service? None.
(d) (If appointed for a term of specified duration) Do you intend
to serve the full term for which you have been appointed? Yes.
(e) (If appointed for indefinite period) Do you intend to serve
until the next Presidential election? N/A.
19. Potential Conflicts of Interest
(a) Describe any financial arrangements, deferred compensation
agreements, or other continuing financial, business, or professional
dealings which you have with business associates, clients, or customers
who will be affected by policies which you will influence in the
position to which you have been nominated:
Have a normal blanket agreement with Exelon which states whenever a
Director departs he or she will receive deferred compensation
previously earned, distributed as agreed at least four months prior to
separation.
(b) List any investments, obligations, liabilities, or other
financial relationships which constitute potential conflicts of
interest with the position to which you have been nominated: None.
(c) Describe any business relationship, dealing, or financial
transaction which you have had during the last 5 years, whether for
yourself, on behalf of a client, or acting as an agent, that
constitutes as potential conflict of interest with the position to
which you have been nominated: None.
(d) Describe any lobbying activity during the past 10 years in
which you have engaged for the purpose of directly or indirectly
influencing the passage, defeat, or modification of any Federal
legislation or for the purpose of affecting the administration and
execution of Federal law or policy: None.
(e) Explain how you will resolve any potential conflicts of
interest that may be disclosed by your responses to the above items.
(Please provide a copy of any trust or other agreements involved.)
I will resign from Exelon, have severed all other potentially
conflicting arrangements.
20. Testifying before the Congress
(a) Do you agree to appear and testify before any duly constituted
committee of the Congress upon the request of such committee? Yes.
(b) Do you agree to provide such information as is requested by
such a committee? Yes.
______
Response to Prehearing Questions Submitted by Hon. John D. Rockefeller
IV to Daniel L. Cooper
Question 1. If confirmed, you will assume the position of Under
Secretary for Benefits at an extremely crucial time. Please describe in
order of importance, what you see as the major problems facing VBA and
briefly outline your plans for addressing each, with milestones that
you expect to reach.
Answer. For the past eleven months I have served as the Chairman of
the Claims Processing Task Force and have been deeply engaged in the
analysis of VBA's management of the claims process and in the
subsequent development and implementation of the Task Force
recommendations. That experience has given me an understanding of the
issues and problems facing VBA and their potential solutions, at least
within the Compensation and Pension Program. It is clear that the top
priority, as expressed so often to me by the Secretary, is to reduce
the claims backlog, including appeals, while maintaining rigorous
quality standards. With the decline in the backlog and as old cases are
removed from the inventory, VBA will begin to improve its processing
timeliness. Our plan has been well documented in the Task Force Report,
which contains 34 recommendations with 66 actionable tasks. Appropriate
milestones have been established for each task and implementation is
being tracked in VBA's Project Management System. Seven of the 66 tasks
have been completed and another 13 are scheduled for completion within
the next 6 months. The challenge for me will be to maintain the
momentum that the Acting Under Secretary has created in quickly moving
forward with the implementation of the Task force recommendations and,
at the same time, immerse myself in the issues facing VBA's four other
programs.
I have been made aware of the challenge in the Loan Guaranty
Program to successfully execute the field restructuring effort that is
underway. This includes consolidating the Construction and Valuation
function from 45 offices to 9; completing the A-76 cost comparison
study of the Property Management function and implementing its outcome;
and finishing the comprehensive redesign of the Loan Administration
function. VBA has recently been successful in completing similar
initiatives in this program and, if confirmed, I expect to be
successful with these.
In Education, like in the C&P Program, I believe the main focus
must remain on reducing the claims backlog and providing timely
service. The other priority is implementation of the recent legislation
that expanded education benefits in the areas of ``hi-tech'' courses
and benefits transferability. In the Vocational Rehabilitation and
Employment Program, VBA must continue to focus on enhancing services to
the most seriously disabled veterans and achieving employment as an
outcome during periods of economic shifts.
Recently I had the opportunity to visit the Insurance Service in
Philadelphia and learn of the tremendous success of this program.
Obviously, I would do all I could to support their continued success.
Question 2. What is your opinion of having outbased decision-making
teams from regional offices stationed at military facilities, VA
medical centers, or dispersed throughout their jurisdiction for access
by geographically dispersed veterans? If you support this endeavor,
what kind of resources would be needed to support its continued success
(e.g. technology, training, support from the VSO community, and the
like)?
Answer. The Claims Processing Task Force was advised that the
Benefits Delivery at Discharge (BDD) program is active at 128 military
sites, with outbased claims processing teams at 38 of these sites. The
Task Force concluded that the BDD initiative is a highly successful and
absolutely necessary outreach program for serving new veterans. The
medical examination protocols used at these sites allow VBA to evaluate
the disabilities claimed without requiring additional examinations
after separation. As a result of the services provided by the VBA staff
at the separation sites, a complete ``ready-to-rate'' claim is
forwarded to the regional offices or processed to completion at the
separation site. Most of these claims are processed within 30 days of
the service members' separation from the service.
The Task Force was also informed that only a very limited number of
regional offices have a Rating Veterans Services Representative (RVSR)
presence at VA medical centers. In those cases where they are stationed
at a VAMC, the RVSRs serve in a liaison role. The RVSR assists the
medical center by ensuring the examinations are completed timely and
that the examination reports are sufficient for rating purposes.
There can be no doubt that initiatives such as the Benefits
Delivery at Discharge program and placement of RVSRs at medical centers
add significant value to customer service and the delivery of quality
decisions, the current claims inventory and the need for all FTE
possible to attack it do not permit the dedication of further
additional staffing to outbased locations at this time. The Task Force
recommended that VBA develop specific criteria to determine when
staffing levels are adequate to support expansion to additional
outbased sites.
Question 3. VBA's efforts to go paperless seem to have shifted from
a whole Compensation and Pension (C&P) approach to just being used for
pension consolidation. What was the basis for the shift and do you
support this more limited approach? The Washington Regional Office
(WRO) has been a test site for the paperless office. How will these
changes impact the WRO?
Answer. The Virtual VA deployment strategy for the processing of
disability compensation claims has been postponed as the direct result
of the recommendations of the Claims Processing Task Force regarding
new technology implementation in regional offices. The new short-term
(two-year) focus of the Virtual VA prototype is to support the Pension
Maintenance Consolidation initiative. Initially, the program is being
deployed to the Philadelphia Maintenance Center. One regional office
(currently expected to be the Baltimore Regional Office) will receive
scanning capabilities to test the feasibility of scanning records at a
local regional office for transfer to and storage at a Pension
Maintenance Center.
The timeline for the long-term goals for Virtual VA will be
dependent upon the success of inventory reduction, cooperative
technology planning with the VA Chief Information Officer, and
continued funding.
I am told that the Washington Regional Office was the test site for
the original Highway I prototype for this project. However, to minimize
impact on their workload and achievement of their goals, VBA's
Compensation & Pension Service built a Systems Development Laboratory
in the Fall of 1999. While this Systems Development Laboratory
presently shares office space at the Washington Regional Office, C&P
Service hired and dedicated separate C&P Service resources to work on
Virtual VA. Consequently, there will be no impact on the operations of
the Washington Regional Office.
Question 4. I have serious concerns about the adequacy of training
of VBA adjudicators. The Task Force report noted that there were
initial suspicions that the new centralized training programs for VSRs
and RVSRs had been planned quickly and executed poorly, but after
closer examination the task force members were encouraged by the
results. Nonetheless, you note that VBA still has no fully integrated
training plan. Can you explain why you were encouraged by those
findings, and list the ways in which you would improve training of
adjudicators.
Answer. Over the past several years with the financial support of
the Congress, VBA has acquired some very valuable training resources
both in terms of the professional training staff in Orlando and its
infrastructure assets for the delivery of training. These assets
include VA's satellite network, its Training Academy in Baltimore, and
its video conferencing system. Our Task Force was impressed with the
computer-based training modules that have been developed for the Rating
Veteran Service Representatives (RVSRs) and Veterans Service
Representatives (VSRs) and were used last year in the centralized
training efforts to support VBA's hiring initiative. The Task Force,
however, did identify several significant improvement opportunities.
These opportunities included development of certification programs for
instructors and journey level positions; targeted training for each
grade level in the VSR and RVSR job series; and greater use of the
Baltimore Academy and Orlando Instructional Systems Design assets. We
also saw a need for organizational changes that will facilitate the
integration of the training plan throughout VBA. A VBA task team was
formed to develop an implementation plan for the Task Force's
recommendations.
Question 5. What changes do you anticipate making to the way
quality is measured at VBA?
Answer. The VA Claims Processing Task Force recommended redefining
claims processing errors. Correcting substantive errors and taking
steps to prevent future mistakes requires that serious material defects
be identified and measured apart from the procedural defects. VBA has
already modified the quality assurance review process (STAR) to
implement this recommendation. Beginning with reviews of work completed
in FY 2002, the accuracy rate will be captured based on the following
review categories: addressing all issues, VCAA-compliant claims
development, correct decisions, and correct payment dates. This core
accuracy measurement will be labeled ``benefit entitlement.'' It will
be recorded on VBA's balanced scorecard and will be the official
accuracy rate for compensation and pension claims processing.
Question 6. What is your general philosophy regarding the use and
effectiveness of decentralized pilot programs and test stations? Please
describe what strategies you would implement to coordinate and monitor
all of the pilot programs at regional offices.
Answer. If by ``decentralized pilot programs'' you are referring to
independently and locally developed information technology or process
change initiatives, I do not support that approach to change
management. Although I strongly encourage innovative ideas and
suggestions for change, those ideas need to be centrally assessed and
controlled. This centralized control is necessary to ensure that VBA
has consistent policies and procedures for serving veterans throughout
the country. I do believe that after an initiative is approved at the
headquarters level, new processes and technology initiatives must be
thoroughly tested and piloted at Alpha and Beta sites in the field. In
establishing these tests and pilots, VBA needs to clearly identify and
measure the criteria that will be used to determine whether the
initiatives will achieve the performance goals that they were designed
to meet before they are deployed nationally. The Claims Processing Task
Force specifically addressed the need for a formal ``change management
process'' within VBA (Recommendation S-14).
Question 7. Inadequate, incomplete or untimely C&P examinations
have been blamed for many of the delays in the claims adjudication
process. They are one of the main reasons for BVA remands. What is the
status of the VBA pilot program to contract with non-VA physicians to
conduct C&P exams?
Answer. I have been advised that the VA Contract Medical Disability
Examination Pilot is currently in its third option year with QTC
Medical Services, Inc. The fourth option year, which is the final
option year in the contract, will be exercised on May 1, 2002. The
Compensation and Pension Service has drafted a statement of work (SOW)
for another five-year period (base plus four option years), but has
also added that additional option years may be added based on good
performance. During our deliberations, the members of the Task Force
heard no derogatory comments about the QTC examination deliverables.
Question 8. What are your plans for increasing the exchange of
information between VBA and its partner agencies, such as the
Department of Defense and Social Security Administration, for use in
VBA eligibility determinations? Also how specifically can VA and DoD
improve their hand off of servicemembers leaving the service with a
disability?
Answer. I have learned that VBA has a successful agreement with the
Social Security Administration (SSA) which allows for joint on-line
access to respective databases. The Pension Maintenance Centers provide
a current example of the success of this initiative. Employees at these
sites are currently using direct access to SSA income information to
improve the timeliness of pension claims processing.
As to data exchanges, I believe that every effort should be made to
fully leverage the data and technology capabilities of DOD to enhance
delivery of services to veterans
I have been advised that there are significant opportunities to
improve the current data and information exchange processes between VBA
and DOD and that improvement efforts are under way.
For example, I am aware that VBA has entered into an interagency
agreement with the DOD Defense Manpower Data Center to establish an
electronic exchange of VBA defined demographic and military history
data from the Defense Enrollment and Eligibility Reporting System
(DEERS). I have also been told that a joint effort is now underway with
the DOD to develop an interface which would allow on-line access to
imaged documents contained in service member's personnel files, to
include DD 214s. I am also aware that the Acting Under Secretary for
Benefits has initiated dialogue with the Assistant Secretary of Defense
for Force Management Policy to create a VA/DOD Joint Benefits Council
and that expanded and improved information sharing is the first
targeted improvement objective.
As Under Secretary for Benefits, I will continue to support these
efforts to ensure that veterans receive the services and benefits they
have earned in a timely and responsive manner
Question 9. What is your understanding of the relationship between
the VBA and the Board of Veterans' Appeals? How is the implementation
of the Board's development of evidence affecting VBA? How closely do
the two organizations interact on common outcomes, such as the
implementation of decisions from the U.S. Court of Appeals for Veterans
Claims?
Answer. VBA and BVA are currently working very closely to ensure
successful implementation of the Task Force recommendation advocating
that BVA develop for ``additional information'' rather than remanding
appeals back to regional offices. Regional offices support this
initiative because development of evidence by BVA will decrease the
amount of time they spend on performing such work. But more important,
it can dramatically shorten the length of time to consider an appeal.
Our Task Force was briefed on the cross-organizational process that
the Secretary established to analyze and disseminate Court decisions.
It involves the Office of General Counsel (OGC), the Board of Veterans'
Appeals (BVA), and the Compensation and Pension (C&P) Service. The
Appellate Litigation Group of the OGC distributes the Court's Orders
and decisions to the BVA, OGC, and the Judicial Review Staff of the C&P
Service on a daily basis. The principals of those activities regularly
discuss the decisions and their impact on operations throughout VBA.
This group leads the effort to interpret the Court's rulings,
disseminate information and monitor compliance with the Court's
rulings. In addition, BVA and the C&P Service produce timely written
assessments of the Court's case law and disseminate these assessments
to all VBA decision makers.
Question 10. Some veterans service organizations have suggested
that there should be more accountability for VBA decisionmakers. The
Task Force you chaired also stresses the need for accountability. The
VSOs suggest tracking decisions by adjudicators that are overturned by
BVA and hearing officers, or remanded by BVA. Such statistics could be
used to determine when additional training is needed or to determine a
basis for merit bonuses. What are your views on this method of quality
control?
Answer. Decisionmakers should be held accountable for the quality
of their work. But in holding decisionmakers accountable, we must
ensure that a fair system is in place to accurately judge the quality
of the decisions made.
BVA remand and allowance rates are not necessarily good indicators
of the quality of decisions made at the regional office level. First,
BVA has de novo review authority, allowing them to overturn regional
office decisions based on judgment variance. Second, appellants can
submit new evidence to BVA after the appeal has been certified to BVA.
Finally, changes in the laws or regulations (e.g., enactment of the
Veterans Claims Assistance Act) or a Court decision, during the appeal
period, can result in BVA overturning a regional office decision or
remanding a case back to the regional office.
VBA tracks quality nationally by using a review process called
Systematic Technical Accuracy Review (STAR) to evaluate decisions made
at each regional office and to determine national training needs. Local
quality reviews, based on STAR protocol, are used to evaluate the
quality of work performed by individual decisionmakers. The data from
these local reviews will be used by regional offices to determine where
training needs exist and to evaluate the performance of decisionmakers.
Question 11. One of the Task Force's chief recommendations is that
successful offices should receive priority for increases in FTE and
funding, while offices that experience chronic problems should be, in
essence, denied further resources. This philosophy rewards achievement,
but also reinforces failure by making no provision for rehabilitating
offices that fail to meet expectations. Do you believe that this will
result in an improved experience for veterans in the long run? Are
there steps that could be taken to aid under-performing offices in
order to maintain VBA's regional presence consistently?
Answer. The Claims Processing Task Force recommended that VBA
allocate new staffing resources to high-performing and high-quality
regional offices. This recommendation was made in the context of the
apparent random hiring that occurred during FY 2000 and 2001. The Task
Force report specifically identified the need to have an integrated and
well-understood hiring strategy based on workload, efficiency, and
demonstrated need. The focus of the recommendation is to have a
cohesive strategy for getting resources to the stations that can most
effectively address our national workload challenges.
The FY 2002 model also allocated resources to support the
accomplishment of the Secretary's priorities, which resulted in
staffing allocations for VBA's Tiger Team, the Resource Centers, and
the Pension Maintenance Centers. All of these initiatives provide
additional support to offices experiencing workload difficulties. These
types of initiatives will continue to provide support for veterans
living in regional office jurisdictions that have historically
performed poorly.
I have been advised that there are several other initiatives under
way aimed at providing support to some of the lower-performing
stations. These include two-week ``Help Teams'' and support from the
Satellite Rating Activity at the Huntington Regional Office, which
works a total of 350 cases per month for other offices.
The Claims Processing Task Force also recommended that VBA hold
senior executives accountable for performance. New performance
standards for directors emphasize quantifiable performance measures. As
part of this emphasis on accountability, VBA will focus on performance
management and look at the underlying causes of poor performance in
some regional offices. This will be accomplished by reducing the span
of control through the implementation of four Area offices and by
increasing oversight through site surveys and on-site reviews. The
focus will be on identifying and correcting poor performance so
veterans receive the same level of service at all VBA regional offices.
Question 12. The Task Force that you chaired recommended in its
report that VA should reorganize and clarify the Compensation and
Pension program regulations and manuals. What is your strategy to
implement these changes?
Answer. VBA is supporting a Department-level initiative to
reorganize and clarify the basic eligibility regulations contained in
38 CFR, Part 3. A group of fifteen employees from the C&P Service, the
Office of the General Counsel, and the Board of Veterans' Appeals will
be included in the initiative. Besides reorganizing and rewriting the
Part 3 regulations for clarity, the project will also identify
substantive rules contained in manuals or other directives that should
be included in the regulations.
When the project is completed in February 2004, the Part 3
regulations will be completely reorganized and rewritten for clarity
and consistency, as well as congruence with the authorizing statutes.
The regulations will also be strengthened to better reflect the pro-
veteran, non-adversarial intent of the laws that has been the hallmark
of all veterans' laws since their inception.
I will be attentive to the manner in which directives are issued by
VBA. I will work to assure clarity and consistency and to reduce the
volume of releases that contribute to confusion by our field employees.
Question 13. The Task Force also recommended several measures that
they believed would speed up the appeals process. For example, it
advocated development of remands in BVA rather than at the RO level.
How do you plan to accomplish this without adding to the appeals
backlog?
Answer. The implementation of the Task Force recommendation to
require BVA to develop for evidence rather than remanding appeals back
to Regional Offices will assist in reducing the appeals backlog. The
implementation of this initiative will also result in the expeditious
processing of appeals.
To negate any adverse workload impact at BVA, a fully staffed
development team was hired to perform this function. With full support
from both BVA and VBA, this development team has received comprehensive
training. The daily communication and the sharing of ideas between
representatives of BVA and VBA are largely responsible for the positive
steps made in achieving the goals established by this Task Force
recommendation.
Question 14. The Task Force's instructions from the Secretary
restricted recommendations to matters that would not require a change
in law. What changes in law would be needed to address VBA's problems?
Answer. Because the focus of the Task Force was to work within the
framework of the existing law, we did not devote any time to
considering proposed changes to existing Compensation and Pension law.
As a general principle, I believe regular review of veterans programs
by Congress is valuable in determining if they are functioning as
intended and whether or not statutory changes are warranted. I am aware
that a formal program evaluation of the Dependency and Indemnity
Compensation Program was completed last year and that an evaluation of
the Pension Program is currently underway. I am also advised that a
thorough program evaluation of the Disability Compensation program is
scheduled for 2004. In this connection, I understand in 1999 and 2000
that VBA convened stakeholder meetings which included representatives
from veteran service organizations, congressional staff, OMB and the
Department to discuss disability compensation program outcomes goals
and measures. These discussions and evaluations should provide valuable
information for Congress to consider.
Question 15. I know that in preparation for the Task Force's
report, you consulted prior analyses of the claims processing system.
What are your views of the report of the Congressionally-chartered
Adjudication Commission, chaired by Mr. S. W. ``Mel'' Melidosian? And
have you spoken with him or others responsible for that effort?
Answer. The Task Force not only reviewed the previous reports on
claims processing prepared by the National Academy of Public
Administration (NAPA) and the Veterans Claims Adjudication Commission
(VCAC), we also received briefings from Milton Socolar, the Panel Chair
for the NAPA study, and Mel Melidosian, the Chairman of the VCAC. We
also had the opportunity to hear from Darryl Kehrer on the House Staff,
who was the Executive Director for the VCAC. Our Task Force was
impressed with the reports and findings of these earlier study groups
and learned a great deal from their experience. Mr. Melidosian also
attended several of the Task Force's open hearings and offered comments
during those hearings. Although I have not personally met with him, I
intend to request a meeting with him, if confirmed.
There were four major concerns regarding the administration of VA
benefits addressed by the Melidosian Commission: the lack of finality
in the claims process, claims processing problems, the system for
administrative appeals processing, and inadequate strategic management.
Some of the issues the Commission covered fell outside the scope of our
Task Force as they involved legislative changes (e.g., the lack of
finality in the claims process and lump sum payments to veterans with
minimal disabilities). Other issues, such as expanding the role of the
Hearing Officers and acquiring actuarial expertise, have already been
adopted by VA. It is my understanding that much of the data analysis
conducted by the Commission has been captured and expanded in VBA's
current Annual Report, which was a direct outgrowth of the Commission
Report. There were other concerns and recommendations that the Claims
Processing Task Force embraced and addressed in our own report, such as
the need for greater partnerships with veterans and their
representatives in the Veteran Service Officer Community at the county,
state and national levels. We also endorsed the call for better
strategic management and made recommendations to strengthen VBA's data
analysis capability.
Question 16. VA has finally moved to add several cancers to the
list of diseases presumptively connected to exposure to ionizing
radiation. However, veterans must still contend with the dose-
reconstruction process to establish exposure levels, a process that
many veterans and scientists believe may lack validity.
a) An Institute of Medicine committee is currently reviewing the
accuracy of the dose-reconstruction method in use, but that doesn't
address the question of whether veterans should have to prove
individual exposure. In your view, is the dose-reconstruction method a
necessary tool for determining whether veterans should be eligible to
receive compensation for radiation-related diseases?
b) In 1991, Congress enacted legislation charging VA to contract
with the National Academy of Sciences to periodically review the
scientific literature to determine associations between health
conditions and exposure to herbicides like Agent Orange. The NAS
reports are intended to advise the Secretary in determining what
conditions warrant presumptive service connection. In 1998 Congress
mirrored this bill, providing a similar process for Gulf War veterans.
However, veterans exposed to ionizing radiation have experienced a more
piecemeal approach to compensation. In your view, is there value in
crafting authority for atomic veterans similar to Agent Orange and Gulf
War legislation?
Answer. These are important issues that I would like to study
further before taking a position. When I have reached a conclusion, I
would be pleased to share my position with you.
Question 17. Recent scientific research suggests that former World
War II and Korean prisoners of war may be at an increased risk of dying
of chronic heart disease or cirrhosis when compared to fellow veterans.
If confirmed, how would you follow up on these findings, and would you
consider recommending service connection for chronic heart disease and
liver disease for former POW's?
Answer. I have been advised that the Veterans Health Administration
has convened an Expert Panel on POW Presumptions. It consists of
medical experts who are reviewing the medical literature in order to
address the possible relationship of a number of conditions, including
cardiovascular and liver diseases, to the prisoner of war experience.
The Panel is expected to deliver its report this spring. After VBA and
VHA review this report, VBA will consider the issue of whether or not
heart and liver diseases, or specific types of these diseases, should
be presumptive conditions for former prisoners of war and appropriate
recommendation will be made to the Secretary.
I am keenly aware of the sacrifices made by POWs and their
families. Clearly the unique hardships associated with their captivity
warrant special consideration and I will carefully evaluate any
findings.
Question 18. VA and the Department of Labor support a shift of
veterans' employment and training services to VA. Do you support the
shift? If this were to occur, how would you ensure that veterans have
access to outside job placement resources?
Answer. Yes, I support the proposed transfer of the Veterans
Employment and Training Service from the Department of Labor to VA. I
realize that there are many details to be determined for full
integration of VA's and DOL's missions to provide job placement
services to veterans. I believe that utilization of competitive,
performance-based grants that leverage existing and emerging
technologies in the market place is a key strategy to ensuring we meet
the employment needs of veterans, particularly disabled veterans. Also,
strong outcome and performance measures, which I am told have not
historically been in place, need to be established so that VA can
ensure veterans receive the highest level of services.
Question 19. VA recently decided to focus more on employment in the
Vocational Rehabilitation & Employment Program. How do you assess VBA's
current efforts concerning employment of disabled veterans? How do you
plan to ensure that disabled veterans are affirmatively hired and
promoted as required under Title 38? How would the addition of VETS to
VBA's services affect the needed emphasis on the special job placement
needs of disabled veterans?
Answer. I have been advised that over the last few years VR&E has
engaged in a number of strategies that embraced its renewed focus on
employment. While these strategies have yielded substantial improvement
in VR&E's rehabilitation rate in the past three years, improvements
still need to be made. I will support efforts to further reduce the
drop-out rate and ensure sustained employment and career advancement
for disabled veterans. I am told that VBA is pursuing a strategy that
uses a new Employment Specialist position to enhance communications
with employers. This concept offers promise to improve the
rehabilitation rate and I will explore it further, if confirmed.
If the decision is made to add VETS to VBA, I think VA will have
the opportunity to consider new ways to effectively meet the employment
needs of veterans. This should be done in a manner that integrates and
complements the other parts of VA's mission, especially those that
address the needs of disabled veterans. I look forward to working with
the Secretary to ensure the transition is accomplished in a way that
improves employment services to disabled veterans and increases job
opportunities for all veterans.
Question 20. GAO has reported that serious computer security
problems persist within the VA health care system, endangering the
privacy of veterans' medical records. Many of the problems came down to
access--too many personnel could access private information, due to
problems with both physical and network security. Given that both VA
health care and benefits providers must soon comply with new, more
stringent federal health privacy regulations, how will you ensure that
VBA shares in a truly integrated department wide information security
management strategy that meets the new standards?
Answer. I have been informed that, in order to enhance information
security in general, VBA is working very closely with the VA Office of
Cyber Security (OCS), which was established in the past year and
reports to the VA Chief Information Officer. I will make sure that VBA
continues to coordinate all security matters with the OCS. I will also
require that VBA's Security Infrastructure Protection Office and Chief
Information Officer work daily with their counterparts to ensure that
VBA is being responsive to all security matters/concerns and complies
with all Congressional mandates and federal guidelines.
Additionally, a joint VBA and VHA work group has been established
and is charged with developing recommendations to ensure only
appropriate access to veterans' health records. I will ensure that VBA
continues to participate in this effort, including the implementation
of measures approved by the Secretary.
Question 21. How will you improve VBA's efforts to meet VA's ``One-
VA'' enterprise solution vision? As legacy systems migrate towards new
technology solutions, staff needs to be educated and flexible. How will
you support these requirements?
Answer. VBA has participated extensively in the VA Enterprise
Architecture, which builds on the interdependencies and
interrelationships among the administrations. If confirmed, I will
require VBA to continue supporting the development of this initiative.
Part of this will include a migration strategy toward technology
solutions to support the claims process.
This migration strategy will include the identification of the
information technology (IT) work force of the future. The Assistant
Secretary for Information and Technology has begun the development of
an IT workforce initiative, designed to match the work force of the
future with the envisioned or ``end state'' VA technology. VBA will
continue to contribute to and benefit from this effort that is already
underway.
______
Response to Written Post-Hearing Questions Submitted by Hon. John D.
Rockefeller IV to Daniel L. Cooper
Question 1. If confirmed, do you intend to continue any of VBA's
Business Process Reengineering initiatives? If not, what measure would
you implement?
Answer. There are several initiatives that VBA implemented as part
of its broad business process reengineering plan that I believe have
had a positive impact on the service provided to veterans and should
continue. One of the many documents that the Task Force reviewed was
the semi annual report on the status of VBA's BPR initiatives. Many of
the initiatives covered in this report--which include the Benefits
Delivery at Discharge Program, the establishment of the Decision Review
Officer position, the TRIP initiative (Training, Responsibility,
Involvement, and Preparation of Claims), the Contract Medical
Examination Pilot, the technology initiatives implemented to improve
phone service, and the certification program for Veterans Service
Representatives--were endorsed in one form or another by the Claims
Processing Task Force.
The Task Force did have a different view of the extent to which
case management should be applied in the claims process. The Task Force
recognized the importance of providing certain claimants with ``status
updates'' regarding their claims. The Task Force did not believe that
all claims required case management, but that the process should be
applied in cases that involved claims submitted by Ex-POW's, terminally
ill veterans, homeless or financially distressed claimants, or those
filed by veterans who are claiming a disability as a result of sexual
trauma.
Question 2. How will the shift from an ``assembly-line'' approach
to claims processing to a ``working group'' approach affect the
development of Training Performance Support System (TPSS) modules?
Answer. No changes will be required in the training modules that
have been developed for the Rating Veterans Service Representatives
since they will be part of one of the self-contained specialized work
teams. There will have to be some changes in the recently developed
Veterans Service Representative training modules in terms of the
sequencing and grouping of some of the skill sets required for the
various teams. I have been advised by the Compensation and Pension
Training Staff that this should not be a difficult task. It is likely
that the ``working group'' approach will allow for a more focused
design of the TPSS modules and the job/training aids for VSRs.
Question 3. Do you have any plans for reorganizing VBA, either in
VA Central Office or in the field? Please include your views on the
potential consolidation or merger of processing functions.
Answer. The VA Claims Processing Task Force recommended to the
Secretary that VBA eliminate the Service Delivery Network
organizational structure and establish an appropriate number of Area
Offices in the field (at least four) with line authority over the
Regional Offices.
The Secretary approved the proposal to have four Area Directors,
with 12 to 16 Regional Offices in each Area. The Area Directors would
report to an Associate Deputy Under Secretary for Field Operations.
Functional requirements, tables of organizations, and position
descriptions are now being finalized. Service Delivery Networks (SDNs)
have been eliminated as entities.
VBA has already acted on the Task Force's recommendation to
consolidate the pension maintenance functions into three centers that
are located in the Regional Offices in Milwaukee, Philadelphia, and St.
Paul.
VBA is considering a reorganization plan for Central Office based
on the recommendations of the Task Force.
Question 4. The Task Force report recommends that VA perform a
study to determine the best location for specialized operations. Some
of the factors to be considered include the ability to recruit a
skilled workforce, proximity to vet population centers, availability of
space, as well as quality and timeliness of work consistently produced.
If you are confirmed, will such a study be performed? Also except for
an analysis of quality and timeliness of work, wasn't this the approach
the Task Force criticized VBA for using when it hired extra-budgeted
staff in the last two years?
Answer. If confirmed, I would not plan to initiate any new studies
to establish specialized operations until VBA's workload situation is
stabilized. One of the findings of the Task Force was that change, even
a positive one, comes with a cost. The cost is incurred by the
temporary loss in productivity as employees are pulled off line to
assist with training, developing new procedures, and implementing the
new operational units. As VBA begins to reduce the backlogs, we will
look for more opportunities to establish specialized operations similar
to the Pension Maintenance Centers that were recommended by the Claims
Processing Task Force. Several of these opportunities are listed in a
chart that accompanies the recommendation on developing specialized
Regional Offices (S-9).
The staffing allocation methodology that was apparently used
previously considered only the ability to recruit plus the availability
of space and proximity to veteran population centers. The allocation
methodology recommended by the Task Force focuses on performance.
Quality and timeliness are two of the critical performance measures
that VBA must consider in making staffing decisions. Another critical
performance measure is productivity, which was discussed in the Task
Force's recommendation (S-10) concerning staffing resource allocation.
Question 5. The Task Force noted that there are several ``super-
sized'' regional offices and found that the method of resourcing and
organizing should not be different whether it is a very small or very
large office. It seems to me that some of the super-sized ROs or those
located in big cities are often the poor performers. Don't you agree
that these offices face distinct challenges, that places such as the
Huntington Regional Office, which has a very stable workforce, don't
face? Also, how do you plan to address the distinct needs of the very
small offices that only have one person performing a function, that
undergo hardship if that person resigns or retires?
Answer. The performance data that I have reviewed does not indicate
that size of an office necessarily determines whether or not that
office is successful. Several of VBA's larger offices are, in fact,
performing well. For example, the Houston and Winston-Salem VAROs have
exceeded their production goals. Houston has produced 114% of its
target and Winston Salem has produced 109% of its target. Both offices
are also processing cases in less time than the national average. The
Cleveland Office was selected as the site of the Tiger Team because it
has traditionally been a high performing office. At the same time,
there are several smaller stations that have sub-par performance levels
that need to be improved.
While the cost of living and other economic factors can have an
impact on the ability of a station in a large city to recruit a highly
qualified work force, I believe the critical factor in the success of
any office, large or small, often comes down to the leadership and
management skills of the Director and his or her management team.
The key to dealing with one-of-a-kind positions, whether they exist
in a large or small office, is to ensure that you have an effective
cross-training plan in place so an alternate can step in temporarily to
fill a vacancy until a permanent replacement can be found. Regional
offices also need to have a succession plan in place so that losses are
anticipated and replacements are hired and trained before the vacancies
occur. One of the critical functions that the headquarters elements
must provide is training programs that regional offices can use to
develop the skills of every position in the organization. The Claims
Processing Task Force recommended that VBA establish a training plan
for each employee consistent with the requirements of their job series.
I intend to ensure that this recommendation is implemented.
Question 6a. To follow up on your response to my prehearing
question #9, regarding the Board of Veterans' Appeals greater
involvement in the claims process:
What specific changes in VBA have resulted from the Board's
development of evidence, such as the process for dealing with remanded
claims and the increase in production associated with remanded work?
Answer. Since February 25, 2002, BVA has begun to develop over 600
appeals instead of remanding them to field offices. In addition, VBA
requires field offices to certify to BVA a defined number of appeals
each month.
Question 6b. Since the Board is now developing evidence rather than
remanding cases for further development, how will you ensure a feedback
loop to regional offices to notify them of any errors in the underlying
decision?
Answer. BVA and VBA have a joint tracking system that identifies
cases that the Board retains for development and the reasons these
cases required additional development. The number of such cases is
tracked for each office, and a monthly report provides for feedback and
monitoring by C&P Service and the Office of Field Operations.
Question 6c. What action will you take so as to maintain a sense of
ownership by regional office adjudicators?
Answer. Egregious cases will be returned to Regional Offices.
Instead of a remand rate alone, offices will be provided information on
their combined remand plus BVA development rate.
Question 6d. What responsibilities, if any, will the regional
offices have in either notifying the veteran or responding to inquiries
concerning any development being conducted by the Board? What system
will be in place to coordinate on these responsibilities with the
Board?
Answer. The Veterans Appeals Control and Locator System (VACOLS) is
shared by both BVA and the Regional Offices. The Board will notify the
veteran of actions they are taking, but Regional Office personnel will
have access to all pertinent information regarding the appeal and will
therefore be able to answer questions.
Question 6e. It is my understanding, that during the past few
months regional offices have not worked on appeals. What is the current
policy regarding VBA employees working on appeals? What steps would you
take to ensure that efforts to maintain a balance in working on claims
at all stages?
Answer. On February 20, 2002, VBA issued a letter to all Regional
Offices that provided each station with specific production targets for
appeals. VBA has provided overtime funds that may only be used to work
appeals during designated periods. The Directors' performance plan also
includes goals for reducing the number of pending appeals and for
improving the processing time for remands.
I believe the actions that VBA has recently taken will ensure that
an appropriate balance is maintained between working claims and
processing appeals. VBA and ultimately veterans will also benefit from
recently implemented recommendations of the Task Force related to
appeals processing. The Board of Veterans' Appeals can now develop for
additional evidence, when necessary, rather than remanding cases to the
Regional Offices. This initiative will free up resources in the field
offices to work appeals and ratings and will result in more timely
decisions for veterans.
Question 6f. The Task Force recommended that VBA stop new IT
initiatives until there is a formal mechanism in place to evaluate and
oversee technology projects. While I agree that a more organized and
strategic approach is needed, I believe that VBA could improve its
processes by taking advantage of innovative technology as it becomes
available. Will you create an environment that is open to technological
advancement? Will your administration actively seek technology
demonstrations and recommendations from private sector and government
partners?
Answer. It is my belief that VBA must be open to advances in both
technology and business processes. To accomplish this, VBA will
continue to work closely with the Department in the continued
development and implementation of the VA Enterprise Architecture
initiative. The main purpose of this initiative is to align the
business and technology processes. Within this initiative, both VBA and
VA will ensure that information technology and business processes are
linked together and that they are working together as effectively as
possible. An important part of this process will be to ensure that the
best technology and business processes from both the private and
government sectors are identified and successfully applied wherever
appropriate within VBA.
Question 7. As you explained in your answer to prehearing question
#3, the Virtual VA timeline has been put on hold as a result of the
Task Force recommendations. You stated in your answers that the
timeline for the long-term Virtual VA goals will be dependent on
inventory reduction, funding and cooperative planning with the VA CIO.
Please be more specific as to a timeline. Also, will you support the
paperless office and other technology initiatives to create more
efficient C&P processing, once IT decisions are centralized?
Answer. The immediate plan is for Virtual VA to support our Pension
Maintenance Consolidation effort. Plans include deployment to the
Philadelphia Pension Center during FY02 and to the Milwaukee and St.
Paul Centers during FY03. As you state, reduction of the claims
backlog, including appeals, is the top priority. Timelines for
deployment beyond the pension sites will be dependent on VBA's success
in reducing the backlog. Future deployment dates have not yet been
determined and require further development.
I strongly support the use of technology to assist in creating
efficiencies in C&P claims processing with the ultimate goal of
providing high quality service to veterans. Recently developed tools
and applications are furnishing valuable information about our pending
workload. This information is used to help manage claims through the
various stages, identify potential areas of weakness or processing
delays, target cases for expedited processing, and provide on-line
claims status to assist in answering telephone inquiries. Information
Technology applications under development will focus on facilitating
the work of the decision-makers and provide important information for
the organization. Technology is vital to support our management of
today's challenges and will increase in importance. However, technology
will not replace real people helping veterans--it will merely help
these dedicated people do it better.
Question 8. The Task Force Report questioned the viability of
VETSNET based on old technology and a concern over whether it is the
best long-term solution for VBA's payment system. However, in January,
VBA determined that VETSNET is a necessary stepping stone to migrating
to new technologies. Do you agree? What outside sources, if any, were
consulted in making this determination? How long will it take for your
administration to implement VETSNET to a point where it can make an
impact on the claims process?
Answer. I agree that VETSNET is an important stepping stone for VBA
in the migration from the legacy Benefits Delivery Network to new
technology. In making this determination, VBA considered the outcome of
a recent independent audit by Abacus Technology Corporation, as well as
the assessment of the VA Assistant Secretary for Information and
Technology and the report of VBA's IT Task Team. As far as gauging the
time when VETSNET can make a favorable impact on the claims process, we
believe that this is already occurring in some locations. For example,
some locations using Rating Board Automation (RBA) 2000 (one of the
VETSNET applications) have experienced an increase in production.
However, because of perceptions that the introduction of new
applications may adversely affect workload, we have decided to develop
a systematic field strategy that will include conducting an ``impact
analysis'' prior to the roll out of each application. We will use this
strategy to develop an acceptable implementation time frame designed to
maintain the highest overall production while still allowing the
introduction of modern technology, including the completion of VETSNET.
Question 9. In response to pre-hearing question #8, you discussed
the opportunities to improve the exchange of information between VA and
DOD. Currently, the barriers to making a seamless transition from
active duty servicemember to veteran seeking VA benefits range from
incompatible technology to limited knowledge of eligibility to process
differences between VA and DOD. What management strategies do you plan
to implement to remove these obstacles?
Answer. The recently established VA/DOD Joint Benefits Council,
discussed in my response to the pre-hearing question noted above, holds
great promise as a forum for addressing the many areas of common
interest and overlap that will ultimately enhance our ability to more
effectively partner with DOD to improve service delivery. I intend to
fully support the council by appointing knowledgeable VBA
representation and as necessary, becoming personally involved in
matters impacting our ability to overcome inter-operational obstacles.
At this point, preliminary Benefits Council discussions have
identified three ``top tier'' collaboration objectives: data and
information sharing; improved records access and refinement; and
formalization of transition procedures and protocols. Specific to data
and information sharing, the Council has discussed the establishment of
an information management coordinating body to focus on the execution
of existing interagency agreements and development of policy and
procedures to ensure a business-driven exchange of critical service
member and veteran data to support both tactical service delivery and
strategic planning.
An essential element of timely benefits decisions is timely access
to documentary evidence contained in military records stored at DOD-
operated facilities. As discussed with the Assistant Secretary for
Force Management Policy, it is my understanding that VA has agreed to
consider various options including expanded co-location of VA staff at
DOD records centers, as well as enhanced utilization of emerging
technologies to improve records retrieval and thus benefit
determination decisions.
Cooperative initiatives such as Benefits Delivery at Discharge
(BDD) and the establishment of a joint VA/DOD separation examination
process have proven very successful. Building on that success, I will
support the further development of complementary procedures and
protocols for separation, retirement and disability examinations and
evaluations.
Question 10. There have been several high profile incidents in the
last few years of employee fraud at the VA Regional Offices. Please
describe your views on how employee theft should be addressed within
VBA. What steps would you take to monitor regional offices?
Answer. VBA has taken a number of actions to minimize the
possibility of employee fraud. I would continue to implement the
procedural and systematic changes necessary to improve VBA's internal
controls. Most important will be the increased accountability of
managers to ensure that proper procedures are followed. The VA Claims
Processing Task Force found that ``accountability--is the most serious
deficiency in the VBA organization.''
Based on the recommendations of the Task Force, VBA is enforcing
more accountability for managers, particularly in the areas of internal
controls. For example, Directors' performance standards were revised
for FY 2002. A number of specific performance expectations were added
or strengthened. The performance element of Program Integrity, which
covers areas such as Office of Inspector General (OIG) findings, is a
critical element.
As of August 2001, Directors or their Assistant Directors are
required to personally review all Compensation and Pension payments
over $25,000. They receive notification by email on a bi-weekly basis
and must complete and return the review within 15 days. Any
deficiencies found are reported to VBA's Office of Program Integrity.
The OIG recently visited all regional offices to conduct a review
of large one-time payments for the period January 1996 through August
2001. The areas of review included the security of employee folders and
employee access to sensitive files. OIG examined several IT security
areas, identifying deficiencies that required corrective action.
Regional Offices are currently making those corrections. Additionally,
VBA requires special analyses of these deficiencies to include why they
were found and details of the corrective actions being taken to prevent
future discrepancies.
To identify ``suspect'' claims below the $25,000 threshold, VBA
recently completed a data mining Pilot utilizing proven commercial
technology and applying statistical analysis techniques to the C&P
benefits payment process. Currently, VBA is evaluating available Data
Mining technology.
Finally, VBA is enlarging and expanding its Office of Program
Integrity. This office will be responsible for working with field
stations, VBA program offices, and other VA organizations, such as the
OIG. I support the recent VBA efforts to strengthen program integrity.
I will work to expand and improve the VBA internal controls systems, to
resource those efforts fully, and to steadily diminish risk of fraud
and mispayment in our delivery systems.
Question 11. One of the quickly implemented recommendations of the
Task Force was to make a special effort to address the oldest claims
and claims of older veterans. What is the status of this project and
what changes, if any, do you intend to make?
Answer. A Tiger Team has been established in Cleveland to expedite
resolution of VBA claims pending over one year, especially for veterans
age 70 and over. The Tiger Team became operational in November 2001.
Concurrent with this, the Tiger Team Director operationally controls
the resources of the nine Resource Centers (RCs) located throughout
VBA. The RCs' claims processing activities under the Tiger Team
initiative began October 1, 2001.
The Tiger Team is responsible for developing needed evidence,
preparing rating decisions, and processing award actions. The RCs
prepare rating decisions and process award actions.
Under the Tiger Team initiative, special arrangements have been
formalized with the National Personnel Records Center to retrieve
military records. These arrangements have caused NPRC's productive
output to double and information to the Tiger Team is routinely
provided within two days. Also, special arrangements have been made
with the United States Armed Services Center for the Research of Unit
Records (CURR) and the Defense Threat Reduction Agency to secure needed
evidence in an expeditious manner for Tiger Team claims.
The Tiger Team's goal is to complete no less than 1,328 claims per
month. The RCs are to complete no less than a combined 2,158 per month
through end of March. The RCs' goal increases by 50% for the month of
April.
To date, the Tiger Team and RCs have met all monthly goals since
implementation. Through the end of February, the Tiger Team has
completed 5,710 claims and the RCs have completed approximately 11,886
claims. The combined productive output of the total initiative through
February is nearly 18,000 claims.
Question 12a. VBA has recently assigned production quotas, which
will require some regional offices to almost double their production
for the month of August 2002 as compared with October 2001.
Specifically, how will these goals be reached? Will you continue or
institute a practice of diverting staff from training, supervision, and
management to process claims? If so, what will be the impact of that
practice for the long-run success of regional offices?
Answer. VBA has begun to reap the benefits of its long term
investment in hiring and training a cadre of over 1000 new claims
processing personnel (Veterans Service Representatives and Rating
Veterans Service Representatives) over the past two years. As these
employees become more experienced, VBA's production output has
increased significantly. In January 2002, VBA completed more than
62,000 rating cases, the most productive month in nearly four years.
This production was continued in February, when almost 63,000 rating
claims were decided despite the fact that February had only 19
workdays. This has been accomplished without diverting staff from
training, supervision and management to process claims. It is my
understanding that VBA did not consider Decision Review Officers,
supervisors or managers in establishing rating output targets for
regional offices. Output targets are based on the numbers of RVSRs in
each regional office and the RVSRs' experience levels.
I expect VBA's productive capacity to continue to increase as we
implement the Task Force recommendations. Included among those
recommendations already having a significant impact are: establishment
of the Pension Maintenance Centers; formation of the Tiger Team in
Cleveland; and creation of the Board of Veterans' Appeals Development
Unit. As a result of these recommendations, regional offices are able
to focus additional resources on the claims backlogs. Implementation of
specialized processing teams in the Veterans Service Centers, although
still in the early stages of testing at four regional offices, is also
showing very promising results. Many more of the Task Force
recommendations will be implemented in the coming months.
Question 12b. Is the classification of work measurement by end
product codes using ``one to seven issues'' and ``seven and above
issues'' a meaningful measurement tool in light of the trend toward
claims with dozens of issues?
Answer. The work measurement system as I currently understand it
provides a meaningful tool for assessing resource utilization. It
discriminates based on two main factors: (1) the type of issue claimed,
i.e., compensation or pension; and (2) for original compensation or
pension claims, if there are more than seven issues claimed. As such,
the work measurement system is an effective tool. I do believe it could
be improved, however. I foresee enhancements that would track issues
rather than claims. This will provide finer distinctions and enhanced
predictive capacity. Work on this concept must be deferred, though,
while VBA stabilizes processing and the pending inventory.
Question 13. For years, this committee has wrestled with the
potential long-term consequences of battlefield exposures, ranging from
Agent Orange in Vietnam to the environmental hazards of the Gulf War
that we still don't completely understand. With each new conflict and
new finding, VA, veterans, and Congress seem to react as though this is
a new issue. It seems to me that VA--together with DOD--could work
together to develop a better strategy for anticipating post-exposure
compensation and health issued. Do you agree and, if so, how would you
go about this?
Answer. I agree that VA should attempt to anticipate the
compensation and health care needs of today's service members, who will
be tomorrow's veterans. In this regard, the Veterans Benefits
Administration included a chapter entitled, ``The Future--Forecasting
Program Liabilities,'' in its last VBA Annual Benefits Report. If
confirmed as Under Secretary, I would ensure that such efforts
continue, and I would expand them as necessary.
I also agree that coordination between VA and the Department of
Defense (DOD) can help us achieve this goal. Earlier this year, VA and
DOD formed joint Executive and Health Benefits Councils. This is part
of a long-term commitment by the two departments to build a more
collaborative relationship. The two panels will work together to
improve coordination between the departments in such areas as health
care services, benefits delivery, information sharing and capital asset
coordination.
Question 14. In your responses to the prehearing question #1, you
listed eliminating claims backlog in education and implementing
expanded education benefits as one of your top priorities for improving
VBA. However, your answer does not discuss your plans for changing the
status quo in education claims administration. Please clarify your
plans.
Answer. Timeliness of education claims processing has been
improving during the first five months of fiscal year 2002. When
compared to the same period last year, the pending claims inventory in
education is lower.
VBA has taken the following steps to change the status quo in
education claims administration:
100 new claims examiners were trained and are gaining
experience, resulting in improved timeliness of claims processing.
Seasonal employees and Education Liaison Representatives
answer calls to help reduce the number of callers who can't complete
their calls. Seasonal employees are most beneficial during peak
workload periods (August-October and January-February).
Web Automated Verification of Enrollment (WAVE) became
available to claimants in late FY 2001. WAVE allows MGIB beneficiaries
to verify their continued enrollment each month over the Internet
instead of mailing the verification form. This improves communication
with claimants and speeds release of monthly payments. Although
installed too late in the fiscal year to have a significant effect, it
will reduce paperwork in the regional processing offices and speed the
benefit payment process.
Electronic Funds Transfer (direct deposit) was expanded to
the MGIB-SIR (chapter 1606) program, making funds available to these
claimants 3 to 5 days earlier than if a check were mailed.
Continued improvements in Enrollment Certification
Automated Processing (ECAP), allowing more cases to be processed
without human intervention. ECAP is a proof-of-concept prototype that
uses 4(expert'' or rules-based systems to process claims in a totally
automated environment. At this point, only 3-4 percent of all incoming
work is completely processed in this way. A more sophisticated rules-
based application will allow many more claims to be completed without
human intervention.
VBA is developing a system to enhance customer service
delivery by integrating people, processes, and technology to manage
veteran interactions through all means of communication. This will
result in improved access to information over the Internet as well as
improved telephone service.
Question 15. The Loan Guaranty Service Foreclosure Avoidance
Through Servicing (FATS) ratio demonstrates what foreclosures VA has
prevented for veterans who work with VA and their lenders often to
restructure the terms of the loan to accommodate veterans' current
financial situation. However, the FATS ratio is a lagging indicator. As
a matter of fact, your Task Force's report alluded to an almost one-
year lag in the FATS ratio. Would it be possible to formulate a leading
indicator that would enable VA to anticipate changes in the number of
foreclosures it will face in the near future to adapt more quickly and
improve service to veterans?
Answer. The FATS ratio is a performance measure designed to assess
the effectiveness of VA efforts in assisting veterans in avoiding
foreclosure. It is maintained on a cumulative fiscal year basis,
measuring total performance over the course of the year. It is not
intended to be used as a predictor of changes in the number of
foreclosures. Since some of the alternatives to foreclosure included in
the FATS ratio may take a while for successful completion, such as
extended repayment plans, it may sometimes measure the success of
efforts initiated many months earlier. However, we believe it is more
appropriate to measure successful VA interventions than simply all
cases in which VA may have arranged extended repayment plans that
veterans were unable to maintain.
In fact, our Claims Processing Task Force limited its report to the
Compensation and Pension Program. It did not discuss Loan Guaranty or
the other three programs.
______
Response to Written Post-Hearing Questions Submitted by Hon. Bob Graham
to Daniel L. Cooper
Question 1. The St. Petersburg VA Regional Office in February has
the highest number benefit claims of pending claims--over 2,000 more
claims pending than any other regional office. Although all of VBA's
(Veterans Benefits Administration) regional offices have experienced
problems processing benefits claims, but these problems are the most
prevalent in Florida's single VBA office. Last month, on average, it
took the St. Petersburg Regional Office over 228 days to complete a
benefit claim. This is unacceptable! How do you plan to reduce this
backlog? Does Florida need another Regional Office?
Answer. Reducing the backlog of claims will be my top priority, if
I am confirmed. The primary reason for the establishment of the Claims
Processing Task Force was to develop specific recommendations that
would meet this objective. My plan for reducing the backlog is well
documented in the Task Force Report, which included 34 recommendations
and 66 actionable tasks. Several of those recommendations have already
been implemented and I intend to ensure the remainder are also fully
implemented.
I was pleased to note that nationally the pending rating workload
dropped by approximately 4,200 cases this past week. St. Petersburg's
pending rating workload dropped by 664 cases. As VBA's newer employees
become more experienced and, consequently, more productive, VBA expects
the pending backlog to continue to decline. The Secretary has given VBA
a goal to reduce the pending inventory to 315,000 claims by the end of
this year. I intend to aggressively pursue that goal.
The national average for the number of days it took to complete the
claims that were processed in February was 230.6 days. The average
number of days for St. Petersburg was slightly better at 230 days. I
agree that this represents an unacceptable time frame for a veteran to
wait for a decision. As VBA reduces its backlog of cases, including the
older cases that have been in the pipeline, the average days to
complete a case will improve.
In terms of the national inventory of pending claims, St.
Petersburg actually has a lower pending balance than could be expected
based on its share of claims receipts. The St. Petersburg office
normally receives 7% of the national workload. However, the rating
claims inventory for St. Petersburg is currently about 24,000 claims,
or 5.8% of the nationwide inventory.
I understand that there have been discussions about the need for a
second regional office in St. Petersburg, and I would be pleased to
continue those discussions with you and your staff, if I am confirmed.
I would note that establishing a new office does not represent a short
term solution to the current backlog situation. It would take several
years to hire and train an experienced staff before a new office would
have an appreciable effect on VBA's ability to meet the needs of
veterans in Florida.
Question 2. You have indicated that you are committed to ``feeding
the success and starving the failure'' of Regional Offices (RO) of the
VBA by transferring cases out of low performing offices to higher
performing offices. How do you propose to prevent cases from failing
through the cracks during transfer? Further, what do you suggest to
remedy the failing offices themselves, besides lower their case work?
Answer. It is my understanding that VBA has been transferring cases
(``brokering'') among offices for several years to take advantage of
available production capacity at one office or another to process work
or correspondingly offset the lack of capacity at an office. Automated
systems are in place within the Benefits Delivery Network to maintain
control over the case as it moves from one location to another within
the office itself or to another VA facility. To the best of my
knowledge, these systems, if used appropriately, prevent cases from
``failing through the cracks.''
As a result of the Task Force's recommendations on accountability,
VBA has established specific performance requirements for every
Director that are focused on his or her station's performance.
If a station fails to meet its service delivery goals, the Director
is required to provide mitigating reasons why the goal was not met and
identify actions that are being taken to improve performance.
``Wellness'' plans have already been requested of some station
Directors who have, thus far, failed to achieve the goals specified in
the performance plan. The ``wellness'' plan involves detailed analyses
of the current situation, identification of causes for the non-
performance, and development and implementation of countermeasures. In
addition to the station's self analysis, the Compensation and Pension
Service should provide ``help teams'' to stations experiencing workload
and performance difficulties to identify problem areas and improvement
opportunities. Similarly, four Area Directors will be established in
the field to play a strong role in working with poorly performing
stations to identify ways that they can improve. If all of those
measures fail, VBA will continue to transfer work to high performing
stations so that every veteran is provided similar levels of service,
no matter where he or she resides in the country.
Question 3. Describe how you envision increased specialization
within RO's would increase efficiency.
Answer. The Task Force believed that the vast majority of Regional
Office employees are executing an extremely difficult and complex task
to the best of their abilities. According to the training module
developer in Orlando, FL, the VSR position in the current model of
claims processing must understand and be capable of performing over
10,900 separate tasks on any given day. Separating the VSRs into
distinct functional areas will significantly reduce the number of
separate tasks performed on any given day and will allow for greater
workload control. Further, concentrating on distinct functional areas,
such as development of claims, awards of benefits, public outreach
etc., will result in development of expertise of the VSRs in the
individual teams. This will lead to higher quality decisions, resulting
in less ``re-work'' thus promoting efficiency and timely claims
processing.
Question 4. What standards are you going to use to consider the
accountability for individual ROs?
Answer. A station's performance will be evaluated on the same
criteria that VBA is using to assess the performance of the Director.
Those standards include:
Achievement of monthly rating production goals;
Improvement in the timeliness of rating decisions;
Reduction in the number of cases pending over six months;
Reduction in the number of pending claims;
Reduction in the number of pending appeals;
Improvement in the timeliness of appellate remands.
The Directors and their stations also have performance standards
for the other VBA programs. These standards are reflected in the
balanced scorecard measures for each of the business lines that have
operational divisions in a Regional Office.
______
Response to Written Post-Hearing Questions Submitted by Hon. Arlen
Specter to Daniel L. Cooper
Question 1. What are the top three problems within the Veterans
Benefits Administration (VBA) that you would like to address? What is
your plan to address those problems?
Answer. Based on my experience as Chairman of the Claims Processing
Task Force, the three most significant problems or issues that must be
addressed are the size of the backlog; the need to maintain high
quality decisions while producing large numbers of claims; and the need
for greater accountability and consistency in Regional Office
operations. A plan for addressing these issues can be found in the
recommendations that were submitted by the Claims Processing Task
Force. The Task Force recommendations have been endorsed by the
Secretary.
The Secretary has made it clear that he wants VBA to reduce the
number of pending claims from its current level of approximately
600,000 claims to 315,000 by the end of the year. To achieve this
target, VBA needs to continue to meet the monthly goals that have been
set for each Regional Office by the Acting Under Secretary for
Benefits. The Task Force report included several recommendations that
should help VBA achieve and sustain higher levels of productivity. For
example, the Task Force recommended that VBA establish specialized
processing teams within each Veterans Service Center which will narrow
the focus of each employee's job and result in more efficiency in the
claims process. These new processing teams are currently being proto-
typed in four Regional Offices. Other recommendations included
consolidating pension maintenance work at three Pension Maintenance
Centers and reestablishing phone units, both of which will allow
Veterans Service Representatives to spend more time processing claims.
Similarly, the Task Force recommendation to have the Board of Veterans'
Appeals develop for additional evidence rather than remanding cases to
the Regional Office will also free up resources in the ROs to spend
more time on new claims.
While VBA has recently made dramatic improvements in the accuracy
of its decisions, I am aware of and share the concern that members of
the Veterans' Affairs Committees have expressed about the need to
maintain quality even with the higher output levels expected of
employees. There are several recommendations in the Task Force Report
designed to help VBA achieve this objective. One involves a change in
the accuracy reviews conducted in the Compensation and Pension Program.
These changes will allow VBA to focus on the critical quality issues in
a decision involving entitlement, the amount of a veteran's award and
the effective date of the award. The C&P Service has increased the
number of cases that it reviews so that it can properly assess the
accuracy rates for each station. The Task Force also identified the
quality of the medical examination process as a critical component of
decision accuracy. We made several recommendations to improve the
examination request process and the examination process itself. I had
the opportunity to visit the Compensation and Pension Examination
Project (CPEP) Office in Nashville. CPEP is a joint VHA/VBA initiative
to address many of the concerns expressed by the Task Force. My
intention would be to fully support this ongoing initiative.
The third issue that needs to be addressed is accountability. Each
regional office must know the processes and results expected, and
headquarters must be completely aware of the status of actions and
processes at each regional office. In order to hold regional offices
and their staffs accountable, VBA must first assure that there is
nationwide consistency in the business processes, the data processing
applications, and the procedures that are being used in the field to
process claims. To achieve this, VBA must issue clear guidance in terms
of how work should be accomplished along with specific and measurable
performance targets. At the same time, VBA needs to establish
appropriate monitoring and inspection systems to ensure and measure
compliance.
Question 2. You have made public your belief that VA cannot now
justify asking for additional resources to fix the claims processing
system. The President's Budget prominently quoted you to that effect.
Do you still hold that view?
Answer. First, I would like to explain that the answer that ``no
resources were needed'' was to specifically address VBA C&P needs at
that time (fall 2001).
VBA did secure funding during FY 2001 to support the hiring and
training of more than 1,000 new employees. The addition of this many
employees in such a short period of time was critical to the
Administration's ability to manage the increased workloads resulting
from the Veterans Claims Assistance Act and the addition of Type 2
Diabetes to the list of Agent Orange presumptive conditions. A hiring
initiative of this magnitude strains VBA's training infrastructure and
places a burden on its core of senior-level field employees.
VBA must now continue to focus on maximizing the impact of this
hiring and ensure employee retention. As these recent hires are
assimilated into the organization and gain experience, I fully expect
these employees to make a significant contribution toward achievement
of the Secretary's claims processing goals. Essentially, this is a
period of stabilization as VBA assesses the recent hiring and training
of the new employees and implementation of the Task Force
recommendations. I would like to refrain from asking for more FTE until
we achieve a more stable situation, which will allow reasoned analysis
of our needs.
Question 3. The President's proposed budget states that, until a
relationship is found between increases in funding for claims
processing and the results achieved with that funding, it is impossible
to determine the optimal amount of funding for veterans' services. How
do you plan to tackle this problem? Do you believe Congress should
withhold further funding increases for claims processing until VA
establishes a link between performance and results?
Answer. VBA has undergone a tremendous amount of change in the last
two years with the hiring and training of 1,000 new employees, the
introduction of new technology and business processes to support claims
processing, the addition of Type 2 Diabetes to the list of Agent Orange
presumptive conditions, and the impact of the Veterans Claims
Assistance Act. With these changes came the very large increase in the
claims backlog and the establishment of the Claims Processing Task
Force.
As I have stated in several forums, VBA is in the process of
implementing the Task Force recommendations, which are designed to
reduce the backlog. Before VA asks for additional funds for staffing,
it is incumbent on the leadership to make an assessment of the impact
all these changes will have on VBA's future productive capacity for
processing claims. That assessment cannot be made until the new
employees are fully trained and until we can determine how the Task
Force recommendations will affect VBA's productivity. VBA has already
increased the number of cases it produces each month by a significant
margin. This increase is due both to the additional work being done by
the recently hired employees as they become more experienced and the
result of the establishment of very clear production targets for each
of the Regional Offices. These standards have been incorporated into
the performance requirements of the Directors.
As VBA rolls out the new specialized teams in the Veterans Service
Centers, I expect to see even greater gains in productivity. By the
time the next budget cycle rolls around, I would expect VBA to be in a
better position to determine its staffing needs based on a sound
assessment of its productive capacity in relation to its future
projected workload.
Question 4a. Secretary Principi has staked the success or failure
of his tenure as Secretary on the improvement of the claims system. He
has established aggressive goals to achieve improvement by the summer
of 2003. Am I correct in assuming that the plan to achieve those goals
is outlined within the VA Claims Processing Task Force report? If so, I
have several questions relative to the Task Force recommendations.
Answer. You are correct that the plan to achieve the Secretary's
goals for the improvement of the claims system is outlined in the
Claims Processing Task Force Report.
Question 4b. The Task Force concluded that accountability was the
single greatest deficiency within VBA. Congressionally-mandated reports
dating back to at least 1996 highlight the same deficiency. It would
seem that although the problem has been well-identified, the will to
remedy the problem has been lacking. If you are confirmed, how will
your efforts to hold individuals accountable differ from past efforts?
What does accountability mean to you?
Answer. Before you can hold a Director or any employee accountable,
you have to first establish clear and measurable performance
expectations. As a result of the Task Force's focus on this issue, VBA
has established performance requirements for every Director that are
tied directly to the Secretary's priorities. Specific service delivery
goals have been set for: monthly rating production, improvements in
processing times, reductions in the number of cases pending over six
months, reductions in the total pending inventory of claims, reductions
in the number of pending appeals, improvements in remand timeliness,
and timeliness standards for putting cases under control in VBA's data
processing systems.
The Directors' performance plan also states that if any of the
service delivery goals are not met, the Director is required to submit
compelling mitigating reasons why the goal was not met and identify
actions that are being taken to improve the performance.
``Wellness'' plans have already been requested of some station
Directors who have, thus far, failed to achieve the goals specified in
the performance plan. The ``wellness'' plan is a detailed analysis of
the current situation, causes for the non-performance, and development
and implementation of countermeasures.
National performance plans have also been developed for the first
time for Rating Veterans Service Representatives and Veterans Service
Representatives. The plans address both production and accuracy
standards. Directors are also expected to establish complementary
performance requirements for all of their managers and supervisors that
support the organization's ability to meet its goals.
Accountability to me means not only being the person considered
``in charge'' or responsible for the actions and results of the group,
but also being knowledgeable of the actions of subordinate groups. In
this case, it means not only directing 57 regional offices, but also
knowing what actions they are taking, what results they are achieving,
and why they may or may not be successful. My intention is to have
direct, frequent, and substantive communications with regional office
directors. There will be little doubt of my expectations and my strong
desire to help them be successful.
Question 4c. The Task Force made a short-term recommendation to
consolidate pension maintenance functions. VA has begun to implement
this recommendation. However, I also see a long-term recommendation to
contract out pension maintenance functions. Why would you have
recommended contracting out pension maintenance before VA has an
opportunity to learn how consolidation within VA is working?
Answer. Task Force recommendation S-9 includes the development of
``a prototype for the competitive sourcing of pension claims processing
with a demonstration contract in FY 2002.'' Action on this part of the
recommendation has been deferred until July 2003. VBA must assess the
impact of the pension maintenance consolidation initiative, which will
not be fully implemented before end of year 2003, before proceeding
with this recommendation. After full implementation of the pension
consolidation initiative, weaknesses that continue in the system can be
identified and analyzed. At that time, VBA will assess the need for
competitive sourcing of pension claims processing.
Question 4d. Your Task Force envisioned increased work
specialization across VA Regional Offices (110s), recommending that
some ROs do more complex rating work while others do less complex
claims maintenance or public outreach work. How will you identify the
ROs which will specialize in each type of work? If, as the Task Force
recommends, underperforming RO's will be targeted to specialize in less
complex work, haven't you predetermined the necessity for some ROs to
fail so that the specialization scheme works? What opportunity will you
give underperforming ROs to turn things around before denying them
resources and assigning them less complex work?
Answer. What I would call ``judicious use of specialization'' can
be an effective technique to increase productivity and help foster
consistent treatment of similar claims. This specialization can be
accomplished at a couple of levels.
At the Regional Office level, the Task Force Report recommends the
establishment of specialized teams within the defined claims processing
functions of Triage, Pre-determination, Rating, Post-determination,
Appeals, and Public Contact. Four stations (Milwaukee, Reno, San Diego,
Roanoke) are now piloting this recommendation. National implementation
will be complete by mid-fall.
VBA has also taken action on the Task Force recommendation to
designate specialized Regional Offices to work specific tasks. Spina
Bifida claims and claims for disabled children of female veterans are
now consolidated in the Denver VARO. On a larger scale, VBA began to
consolidate pension maintenance activities into three centers located
at the Regional Offices in Milwaukee, St. Paul, and Philadelphia. As a
result of another Task Force recommendation, claims for older veterans
that are over one year old and frequently involve complex development
issues are being processed by the Cleveland Tiger Team.
While there are several factors to consider in selecting a site for
specialized activities (including the availability of space and the
ability to recruit), the primary factor will be performance. Stations
that have established track records for high performance will be
considered first in any decision to consolidate or to perform
specialized functions.
As recommended by the Task Force, VBA has revised its resource
allocation model for this fiscal year. The focus of the recommendation
was to have a cohesive strategy for getting resources to the stations
that can most effectively address VA's national workload challenges.
Stations that are not performing up to expectations are being asked
to develop ``wellness plans.'' The ``wellness plan'' provides a
detailed analysis of the current situation, causes for non-performance,
and countermeasures to improve performance. In addition to the
station's self analysis, the Compensation and Pension Service should
provide ``help teams'' to stations experiencing workload and
performance difficulties to identify problem areas and improvement
opportunities. Finally, four Area Directors will be established in the
field to play a strong role in working with poorly performing stations
to identify ways that they can improve. If all of those measures fail,
VBA will continue to transfer work to high performing stations so that
every veteran is provided consistent service levels levels no matter
where he or she resides in the country.
Question 4e. What role do you envision veterans' representatives
playing once you specialize functions among Regional Offices? If a
veteran's claim is sent to a remote Regional Office, how can that
veteran's representative remain involved with the claim?
Answer. Veterans' representatives will continue to play a vital
role in claims processing. VBA is continuing training of the
representatives in the TRIP (Training, Responsibility, Involvement and
Preparation of Claims) Program. Through this program, representatives
are trained and given access to computer applications that provide
information for their clients and that will help them help veterans.
They will have access to this information, regardless of where the
claim is sent for processing. As new computer programs become
available, the veterans' representatives will be trained in use of
these programs in order that they may better assist veterans,
regardless of the location at which the claim is being processed.
Question 4f. The Task Force highlights the inordinate number of
days it takes to establish a computer record on a newly-filed claim.
Why does it take so long? The Task Force goal is to bring the number of
days down to two. How will you accomplish this? How will you account
for time delays resulting from claims being sent from one Regional
Office to another?
Answer. The reason for the delay in getting new claims under
control was simply that the function was not a management priority. It
was one of a multitude of tasks that were assigned to the Veterans
Service Representatives and the relatively small cadre of clerical
staff that exists in each office. The new processing model developed by
the Task Force includes a Triage Team whose primary function will be to
review all of the mail and to get claims under control in two days.
VBA has already taken some initial steps to improve the timeliness
of this process by including a standard in the Directors' performance
plan that requires stations to put 70% of new claims under control
within 7 days. The 70% factor was added to account for the time delays
associated with transferring cases from one jurisdiction to another.
This standard will be dropped to 2 days when the new specialized
processing teams are implemented throughout the country. In addition,
an automated system is being developed that will provide the date that
a claim is received by a second station. The receiving station will
have two days from this date to put the case under control. The new
claims processing model is currently being prototyped in four stations.
VBA expects to deploy the process throughout every Regional Office by
mid-fall.
Question 4g. The Task Force recommends establishing a prototype
site for outsourcing the claims development function. When do you
envision implementing this recommendation? What, in your estimation,
would be the impact on VA employees if you were to outsource this
function?
Answer. The Task Force did recommend a prototype site for
outsourcing claims development. In order for us to make an equitable
comparison between VA and a private contractor, full implementation of
the Pre-Determination Team in the new model will have to be completed.
Further, because of the complexity of the process and the various
regulatory and manual requirements, the Task Force believed that this
outsourcing could not be implemented until the regulatory and manual
re-writes are completed. Any outsourcing action would have to also
determine the impact on VBA employees. This recommendation is a very
low priority and I do not have a thought on a possible time frame for
implementation.
Question 4h. A number of Task Force recommendations touch on
collaborative efforts that need to be conducted with the Board of
Veterans Appeals and the Veterans Health Administration. How will you
ensure that those organizations cooperate with what you're trying to
accomplish?
Answer. BVA and VBA began collaboration on February 25, 2002, with
a team of eight BVA personnel and three VBA personnel. Jointly, they
are developing for evidence on appeals, rather than remanding appeals
back to the field stations to be developed. The VBA personnel also do
ratings and awards on appeals at BVA when a partial grant of benefits
results from a BVA decision.
The Compensation & Pension Examination Project (CPEP) is a VBA and
VHA collaborative project to improve the quality and timeliness of C&P
examinations.
Question 4i. The Task Force report criticizes VA for its
unrealistic assumption that the claims processing workload would remain
static and not be affected by events like future military conflicts and
changes in legislation. Are you aware that the Fiscal Year 2003 budget
request assumes that workload will not be dramatically affected by a
major national security emergency within the next five years? Do you
think this is a reasonable assumption given the present state of world
affairs?
Answer. The assumptions for the FY 2003 budget cycle were
originally formulated in FY 2001. While there may have been some
opportunity during the FY 2003 OMB passback process to make changes to
our assumptions, at that point the military actions in the war on
terrorism did not warrant changes. We will continuously monitor the
situation and advise you if we foresee increases in our resource
requirements as a result of the war. For the FY 2004 budget submission,
our assumptions will include such factors as appropriate.
Question 5. From fiscal year 1997 through fiscal year 2001, VA's
total claims workload declined 19% and VA's rating-related claims
workload declined 6%. However, personnel dedicated to handle the
workload during the same time period increased 30%. In your judgment,
why has performance not improved commensurate with the resources
provided? Do you believe VA is ``turning the corner'' on reducing
backlogs and processing times?
Answer. I am aware that VBA substantially increased its staffing
levels over the past 5 years. However, in 1997 the staffing levels were
at the lowest level since 1990, dropping 14% in just two years, from
1995 to 1997.
The average workload decline from 1997 to 2001 was in the range of
1-2%. Although the data shows a more significant decline in 1998 and
1999, this decline was due to several factors. VBA reduced the release
of several internal control reviews such as dependency questionnaires,
social security number verifications, income verification matches and
eligibility verification reports.
In 1998, VBA began the major realignment of the Adjudication and
Veterans Service Divisions. This realignment involved extensive
training hours. Even
though VBA gained resources during this period, the training hours
dedicated to mentoring these new employees (to include classroom
instruction) augmented an already intense training effort. At that
time, VBA was cognizant that it took an average of 2-3 years for an
employee to reach journey-level status.
VBA was also developing several information technology (IT) tools
that would accelerate the data exchanges, reduce routine data entry and
award generation as well as provide claim status information to service
organizations. These efforts demanded a lot of time from experienced
decision-makers in both rating and authorization.
Finally, VBA was faced with absorbing the impact of the increased
complexity of decisions due to the changes in legislation and Court
decisions, an increase in the number of issues per original claim, and
the fact that prior staffing levels did not allow VBA to absorb those
impacts.
I believe that with the implementation of the recommendations of
the Claims Processing Task Force, VBA has the opportunity to turn the
corner on reducing the presently very high backlog and processing
times. VBA is carefully monitoring the monthly performance and workload
levels to assess the progress. This careful monitoring will allow VBA
to proactively effect change whenever anomalies are identified in the
data or workflow. As recommended by the Task Force, VBA is now focused
on a few IT efforts that will eventually benefit the organization and
the veteran.
Question 6. Your predecessor recommended that the Committee look to
a ``Balanced Scorecard'' to gauge performance. What performance
measures should the Committee look at when evaluating whether the
claims processing system is improving under your leadership?
Answer. VBA continues to use the balanced scorecard as the
composite approach to measuring performance. The first page of this
tool identifies the measures that can be readily used to assess the
level of national performance. The scorecard has been enhanced to
include a ``page 2,'' which identifies more discrete, operational
measures that contribute to performance improvements. Focus on these
operational measures will facilitate identification of processing
vulnerabilities and rapid development of management corrections.
Comparison back to the corporate scorecard measures will validate
management successes.
Question 7. Your predecessor resigned in the aftermath of multi-
million dollar fraud case in which current and former employees stole
money by ``resurrecting'' disability claims of deceased veterans and
having the proceeds sent to themselves. What will you do to prevent--
and detect--other cases like this from occurring? If you are confirmed,
would you do anything different than what is being done now to prevent
fraud?
Answer. VBA has taken a number of actions to minimize the
possibility of employee fraud. I would continue to implement the
procedural and systematic changes necessary to improve VBA's internal
controls. Most important will be the increased accountability of
managers to ensure that proper procedures are followed. The VA Claims
Processing Task Force found that ``accountability--is the most serious
deficiency in the VBA organization.''
Based on the recommendations of the Task Force, VBA is enforcing
more accountability for managers, particularly in the areas of internal
controls. For example, Directors' performance standards were revised
for FY 2002. A number of specific performance expectations were added
or strengthened. The performance element of Program Integrity, which
covers areas such as OIG findings, is a critical element.
As of August 2001, Directors or their Assistant Directors are
required to personally review all Compensation and Pension payments
over $25,000. They receive notification by email on a bi-weekly basis
and must complete and return the review within 15 days. Any
deficiencies found are reported to VBA's Office of Program Integrity.
The Office of the Inspector General (OIG) recently visited all
regional offices to conduct a review of large one-time payments for the
period January 1996 through August 2001. The areas of review included
the security of employee folders and employee access to sensitive
files. OIG examined several IT security areas, identifying deficiencies
that required corrective action. Regional Offices are currently making
those corrections. Additionally, VBA requires special analyses of these
deficiencies to include why they were found and details of the
corrective actions being taken to prevent future discrepancies.
To identify ``suspect'' claims below the $25,000 threshold, VBA
recently completed a data mining Pilot utilizing proven commercial
technology and applying statistical analysis techniques to the C&P
benefits payment process. Currently, VBA is evaluating available Data
Mining technology.
Finally, VBA is enlarging and expanding its Office of Program
Integrity. This office will be responsible for working with field
stations, VBA program offices, and other VA organizations, such as the
OIG. I support the recent VBA efforts to strengthen program integrity.
I intend to work to expand and improve the VBA internal controls
systems, to resource those efforts fully, and to steadily diminish risk
of fraud and mispayment in our delivery systems.
Question 8. Congress has made significant improvements to
Montgomery GI Bill (MGIB) education benefits in recent years. Do you
have a view as to the appropriate level of assistance Congress should
provide as an MGlB benefit? Do you support equalizing, with MGlB
benefits, education benefits afforded to spouses or dependent children
of service members and veterans who die as a result of service-
connected causes?
Answer. Each year the College Board determines the average cost for
a commuter student to attend a public four-year education institution.
Consideration should be given to increasing the VA Education Program
rates to equal this amount each year.
Last year increases were authorized for spouses and dependent
children attending school under the Survivors' and Dependents'
Educational Assistance Program (known as DEA). Action was also taken to
tie future rate adjustments to the Consumer Price Index (CPI). The
current full-time DEA rate is $670 per month. The full-time rate for
IVIGIB claimants with a two-year period of service is $650. For an
IVIGIB claimant with a three-year period of service the full-time rate
is $800 per month. The action that was taken to tie future DEA rate
adjustments to the CPI will insure appropriate adjustments continue.
Therefore, in my view, no further action is necessary.
Question 9. Since Fiscal Year 2001, processing times for MGIB
benefits claims have worsened. What is your plan to improve MGlB
benefit processing times?
Answer. Performance improved significantly during the first five
months of fiscal year 2002, when compared with the first five months of
fiscal year 2001. The following table shows the average processing days
for each month:
----------------------------------------------------------------------------------------------------------------
Supplemental Actions Original Claims
---------------------------------------------------
FY 2001 FY 2002 FY 2001 FY 2002
----------------------------------------------------------------------------------------------------------------
October..................................................... 27.71 23.98 49.73 43.75
November.................................................... 20.88 17.44 55.73 43.58
December.................................................... 21.88 18.37 63.66 39.71
January..................................................... 25.19 17.03 58.78 38.50
February.................................................... 23.50 14.50 50.16 33.90
----------------------------------------------------------------------------------------------------------------
Several actions contributed to this improved performance:
Adequate overtime was authorized earlier in the fall and
was focused on achieving production targets.
Seasonal employees were hired to perform certain tasks
during peak periods, allowing station managers to shift their
experienced staff to claims processing.
In anticipation of an increased workload, VA hired over
100 new employees to handle education claims last year. These new
employees have received training and gained experience, resulting in
increased per capita output and improved timeliness.
I would expect to continue to appropriately target overtime and use
seasonal employees during peak enrollment cycles to effectively manage
the education workload. In addition, enhancements to the Enrollment
Certification Automated Processing system (ECAP) are being developed
that will allow more cases to be processed without human intervention.
ECAP is a proof-of-concept prototype that uses ``expert'' or rules-
based systems to process claims in an automated environment. At this
point, only 3-4 percent of all incoming work is completely processed in
this way. A more sophisticated rules-based application will allow many
more claims to be completed without human intervention.
Question 10. The Federal Housing Administration (FHA) provides some
federal home loan benefits that are not available exclusively to
veteran under VA's home loan program. As a general principle, do you
support enhancing the benefits provided under VA's loan program so that
veterans have loan options at least as attractive as those available to
non-veterans through FHA?
Answer. As a general principle, I favor enhancing VA's home loan
program to give veterans the same options non-veterans have under the
FHA program.
______
Response to Written Post-Hearing Questions Submitted by Hon. Larry E.
Craig to Daniel L. Cooper
Question 1. What are some of your ideas for improving the VA
Education program?
Answer. Each year the College Board determines the average cost for
a commuter student to attend a public four-year education institution.
Consideration should be given to increasing the VA Education Program
rates to equal this average cost each year.
Public Law 107-103 provided for accelerated payments for education
leading to employment in high technology industry starting October 1,
2002. VBA will evaluate the response to this program to see if it
should be expanded to other types of courses as well.
______
Response to Written Post-Hearing Questions Submitted by Hon. Kay Bailey
Hutchison to Daniel L. Cooper
claims processing backlog
Question 1. The report of your task force looking into the VA's
claims process revealed many areas of potential improvement. What is
your vision for implementing these recommendations and what stumbling
blocks do you foresee?
Answer. Implementation of the Task Force report was begun in
earnest last fall when Judge Guy McMichael became acting Under
Secretary for Veterans Benefits and Stanley Sinclair became his acting
Deputy. Both of these men had been participants in the Task Force
deliberations and had strongly supported the Report.
In my opinion, the implementation process they began is the best I
have seen and it far exceeds any implementation done after the previous
several VBA studies completed in the last decade.
Each recommendation has been evaluated, grouped where appropriate,
delayed if considered of low priority or low return, and effectively
planned with timelines developed. Each month reports are made to the
Secretary and Deputy Secretary of Veterans Affairs.
I see no stumbling blocks. There may be some diversions and
accommodations, and every single recommendation may not be implemented
as stated--but every one will be studied and properly judged. Each one
to be implemented will be measured and tracked until completed.
Senator Rockefeller. Senator Graham, I was just suggesting
that I have a whole series of questions. If you and Senator
Nelson want to start off with questions, I would be more than
pleased by that.
Senator Graham. Thank you very much, Mr. Chairman.
Dr. Roswell, to pick up on a comment that Chairman
Rockefeller made in his opening statement relative to the issue
of long-term care. As our veterans population grows older
obviously that will be at heightened demand. From your
experience in a state with a large population of older
veterans, how have you proceeded to try to meet that demand and
what would you now suggest at a national level be the policy at
the VA?
Dr. Roswell. The long-term care needs of America's veterans
are significant. I don't believe those needs can be fully
addressed with a single level or program of care. Certainly, VA
needs to continue its efforts to build its staffed nursing home
care capability. But probably more significantly, VA needs to
seek alternatives to institutional care.
We need to partner with the State Department of Veterans
Affairs to improve and enhance the State veterans home nursing
capability. But we also need to seek home care programs;
programs in the community, adult day health care programs.
In Florida we have a very innovative program with over
1,000 veterans receiving care through interactive technology in
their very home. This has greatly enhanced care. It has
actually reduced nursing home placement by almost 80 percent at
a cost savings of approximately 75 percent for veteran served.
I believe there are many innovative opportunities and will
certainly look forward to working with this committee and the
chairman to try to meet those needs, not only in Florida, but
around the country.
Senator Graham. Doctor, one of the fastest growing areas in
terms of VA health services have been the Priority 7 veterans.
These are non-service connected disabled veterans who have
income levels of $24,000 a year or above. The growth rate in
Priority 7 veterans in terms of accessing health care has been
approximately 30 percent annually for the last 6 years. So, it
is a very rapidly expanding group of veterans.
The President has recommended that there be a $1,500 annual
deductible for the Priority 7 veterans. Others have suggested
closing off enrollment for Priority 7 veterans. What options do
you think we ought to consider for the Priority 7 veteran?
Dr. Roswell. Well, while I am obliged to support the
President's budget----
Senator Graham. I hope we don't have a repetition of the
Corps of Engineers here.
Dr. Roswell. Thank you, sir. I would point to Secretary
Principi's testimony before this committee, that he believes
the $1,500 deductible is one option to defray some of the cost
of care for Priority 7 veterans, but there are other options.
Clearly VA needs to be as efficient as we possibly can in
the use of appropriated resources. To compliment those
appropriated resources, we must do a better job of enhancing
our recovery from private insurance companies where that is
authorized by law.
Having said that, I think we need to examine the health
benefits. It is my belief that many of the Priority 7 veterans
are currently Medicare beneficiaries who are attracted to the
prescription benefit within VA. I believe we need to examine
both the incentives and the economics in order to fully
understand the situation and begin to work toward a solution.
Senator Graham. Your last comment about the attractiveness
of the VA prescription benefit, do you have an idea of how much
of the health care services delivered to Priority 7 veterans
have been in the pharmaceutical area as opposed to other health
care services and products?
Dr. Roswell. I can't give you a specific amount, Senator. I
would be happy to get back with you. We do know that the
average cost for a new Priority 7 veteran, the first year of
care, is less than what we would expect for a typical veteran.
It is on average around $1,000.
Many of the veterans who are Priority 7 veterans who are
new to our system expressly state that they are seeking
prescription benefits through VA's attractive $7 co-payment. I
do believe that is a significant factor in the large number of
Priority 7's now using the VA for care.
Senator Graham. I'll ask one more question.
A number of members of this committee were instrumental in
the establishment of the VERA model which has as its goal to
provide equality of treatment in terms of health care resources
for the veteran, wherever that veteran might live.
Could you give us your assessment of how well the VERA
program is working and are there any areas of refinement that
you would recommend we consider?
Dr. Roswell. I believe that the VERA model has done a
laudable job of what it was intended to do. However, we face a
dynamic veteran population and as the veteran population and
the demand for care evolves so must the VERA model. Each year
the VA has reexamined that VERA model and has made adjustments,
including adjustments this year to refine that model.
Currently VA is evaluating the applicability of the model
to the Priority 7 veterans that you spoke of which previously
have not been funded through the VERA process. We are also
examining the way the model adjusts for case mix in the most
costly patients. I am committed to the concept behind VERA, but
believe we must continue to work and refine the model to make
sure that it continues to meet both current and future
veteran's needs.
Senator Graham. Thank you, Mr. Chairman.
Chairman Rockefeller. Thank you, Senator Graham.
Senator Nelson.
Senator Nelson of Nebraska. Thank you, Mr. Chairman. Dr.
Roswell, I was impressed with your comment and your written
testimony that states regarding VISN's that the time has come
to maximize performance and minimize variation across the
Veterans Integrated Service Networks.
We currently have an issue regarding the merger or
integration of VISN's 13 and 14 and we are scheduling a field
hearing in Nebraska to deal with that, plus raise some
questions about Priority 7 benefits and deductibles. In the
process of doing that, I know that the Secretary has indicated
a desire to come appear at the hearing, but I realistically
understand schedules and I would like to begin by extending
you're an invitation, if it would work with your schedule, to
perhaps join with us at that field hearing.
But my question today goes toward the funding of
legislation for the year 2002. Congress required that the VA
maintain an open access policy for veterans with schizophrenia
who need a typical anti-psychotic medication. As a matter of
fact, the language requires the agency to inform each VISN that
anti-psychotic medicines ought to be chosen based solely upon
the best clinical judgment of VA physicians as opposed to the
process and procedure in place before that excluded certain
kinds of medications and favored other medications quite apart
from what the clinical judgment of the VA had.
I wonder if you might inform the committee. I am interested
in this in an individual way, but the committee probably has an
interest in it as well about what steps VA is taking to ensure
that the open access policy is in fact open and is being
properly implemented.
Do you have monitoring systems that are in place? Can we
get a report? Is there something that you can report to us even
today based on what you may know already?
Dr. Roswell. Well, thank you, Senator. It would be my
distinct privilege and honor to appear at the field hearing
when that is scheduled.
With regard to the prescribing of atypical anti-psychotics,
there is compelling scientific and medical evidence suggesting
that the use of atypical anti-psychotic agents in the
management of chronic mental illness reduce the requirement for
hospitalization.
We have studied this in some detail in Florida and know for
a fact that when there is a higher prescribing rate for
atypical anti-psychotics that we actually reduce
hospitalization and the overall cost of care, not to mention
enhancing the quantity of life for those veterans who suffer
serious mental illness.
That information is available. I think the open access
issue centers around whether an atypical anti-psychotic should
be used. Clearly one should be used when it is indicated.
There is also an issue of cost. Several of these agents
have a similar efficacy. They do essentially the same thing but
they may vary significantly in cost.
With regard to the use of one of the atypical anti-
psychotics in patients who carry a diagnosis of schizophrenia,
by using our current data base we are able to determine that.
The numbers show that a substantial majority of veterans who
have that diagnosis are currently receiving an atypical anti-
psychotic agent.
We would be happy to followup with more specific
information.
Senator Nelson of Nebraska. So, you are tracking to see
whether or not it is open access and then also in the results
that the patients are having as part of the consideration for
continuing to prescribe these kinds of medicines.
Dr. Roswell. Yes, that is possible using the robust nature
of VA's electronic medical record data base. We can track that
and in fact do track that.
Senator Nelson of Nebraska. Thank you. Thank you, Mr.
Chairman.
Chairman Rockefeller. I have a series of questions. I will
start with you, Dr. Roswell.
There is no secret that the health care system as a whole
is experiencing budget shortfalls. The problem is that we are
really under spending limits. We have to live within our means.
You have 27 outpatient clinics in your network.
I find that clinics are an enormous conduit to get veterans
into the VA health care system, which is what I want to see--
not just to keep our hospitals busy but so that they get the
health care which they need.
Committee staff actually called each of these 27 outpatient
clinics in the last several days. They found that only one of
those clinics is now seeing new patients without an extensive
waiting list. I think that says a lot. Veterans want in. These
clinics are speaking to them in very strong ways.
Asking you how many new patients have these clinics brought
into the system, and what kind of effect has that level of
demand had on your corner of VA is probably not an entirely
fair question to ask at this point, but I am going to ask it
anyway. There are some who say that every time you open up a
clinic all you are doing is burdening the system.
You are spending money, which means you have to take it
away from somewhere. I am interested in your thoughts on the
clinics.
Dr. Roswell. Well, Mr. Chairman, I certainly echo your
support for clinics. I believe that providing care in non-
institutional settings across the gamut of health care services
is a very desirable strategy. On my opening remarks I mentioned
that I believe the next major transition in health care will be
taking care more significantly into the home environment. So, I
do support that.
We have had a tremendous growth in demand for care in
Florida and certainly the creation of community based
outpatient clinics has spawned much of that demand, as has the
new eligibility legislation which became effective in October
1998.
Currently, there are over 405,000 veterans receiving care
in Florida compared to about 225,000 receiving care each year
when I went to Florida as the VISN Director in 1996. So, there
has been an 80-percent increase in the total number of veterans
receiving care.
I believe that each and every one of those veterans is
entitled to that care by their military service. As a person
who has dedicated my life to caring for veterans, I have done
everything I can to make that care available. I do think it is
important that we do everything we possibly can, to make that
care as efficient as possible. I believe there are still
opportunities to improve the efficiency of the care we deliver.
We are diligently working to achieve those efficiencies this
year and we will be continuing to do that.
Chairman Rockefeller. Often clinics are just a couple of
people--a couple of rooms in a little building on the corner of
the street. So, achieving efficiencies is difficult. What are
some examples of how you would do that?
Dr. Roswell. Some of the ways clinics can be efficient,
include the way they manage patients and the way they refer
patients to the parent medical center, and the way we use
technology to take expertise to the clinic. For example,
telemedicine can bring psychiatric or mental health care into a
primary care clinic where the only physician may be a primary
care generalist.
I think technologies can reduce the travel time and can
reduce the use of specialty resources by using automated
practice guidelines and clinical reminders that we can place on
the computerized patient records system. We can impart more
knowledge and decision support to the clinician in a remote,
isolated setting.
We can achieve efficiencies in the way we provide
pharmaceuticals utilizing mail-out pharmacies. There are a
variety of ways, even in the community clinic setting that we
can become more efficient.
Chairman Rockefeller. Thank you. Let us look again, Dr.
Roswell, at the situation in St. Petersburg and Beckley, WV.
Now, here is a true story: A West Virginia veteran spends
time in Florida for the winter. While he is there he receives
care at one of these clinics, but after some tests he is told,
``We don't have enough physicians to follow your care on an on-
going basis. You have been placed on a waiting list along with
more than 2,200 other veterans.''
Now, the veteran's doctor in Beckley is told that even
though the veteran is in Florida, it is his problem to care for
him. While this is obviously a budget issue, it is also a
management issue. I don't think that we are doing right by our
veterans. I don't know exactly how to fix a situation like that
and to be honest with you, I can't tell you how common that is.
But if it happens to one of my veterans once in my State, I
am going to make it into an international case before the
Security Council of the United Nations.
How does something like that come about?
Dr. Roswell. I think it is probably not terribly difficult
to explain. A veteran receiving primary care in Beckley, WV
should know their primary care provider. If that veteran plans
to spend a significant amount of time out of State, in Florida,
let us say, during the season, it would be usual and customary
for the veteran to arrange with the primary clinic to provide
the medications needed.
Chairman Rockefeller. In Beckley?
Dr. Roswell. Correct. That is the policy that is advocated
by the pharmacy service here in our VA central office. It is a
policy that is generally adhered to around the system.
Chairman Rockefeller. It is one thing if it is prescribing
prescriptions. I want to understand how the care part works.
Dr. Roswell. That part, is what we try to make available.
We would expect that chronic routine medications be provided by
the primary physician responsible for the veteran's care. But
if there were any type of urgent or emergent need or interval
check that would be required, that should be provided.
We have made a tremendous screening effort with veterans
waiting to receive care throughout the clinic locations that
you alluded to in Florida to identify any urgent or emergent
need for health care and make that available.
But by taking a veteran who needs to be seen or may have an
interval illness that requires supplemental medication, we want
to be able to provide that evaluation, provide that care,
provide the needed medication. But that is not necessarily
tantamount to enrolling that veteran into and assigning him to
a new primary care provider, which would duplicate their
primary care physician in Beckley, West Virginia.
Clearly, we need to have better coordination, though.
Chairman Rockefeller. Because when they said 2,200 people
on a waiting list that wouldn't apply to Beckley. That is kind
of a Florida figure.
Dr. Roswell. The 2,200 sounds like that particular clinic.
In Florida, we have over 30,000 waiting to be assigned to a
primary care provider.
Chairman Rockefeller. Oh, really?
Dr. Roswell. That's correct.
Chairman Rockefeller. Well, then, let me ask about that.
Dr. Roswell. As I said, it is a significant issue. Most of
these veterans are veterans who have newly enrolled in VA. Over
55 percent of them are Priority 7 veterans who are seeking
supplemental benefits to augment the care they currently
receive. We do make sure that they are offered enrollment. We
process the enrollment forms. We screen them for any emergent
need for care. If they need emergent care, we provide that
emergent care. If they need to be seen more quickly than the
waiting list that a particular location allows, we will refer
them to a facility where there are not such lengthy waits which
is usually the case in our metropolitan medical centers.
But assignment to a routine primary care provider
unfortunately can take many, many months, given the current
resource constraints we are struggling with.
Chairman Rockefeller. Describe to me, as you understand it,
those resource contraints with respect to the 30,000 waiting
for care in West Virginia. I assume that figure can be broken
down into those who would require much more attention than
others.
Like a veteran with PTSD. Or a veteran with a spinal cord
problem. What kind of shortage or lack of doctors and nurses
did you face, because of budgetary constraints?
Dr. Roswell. I do understand, I believe, sir. I think the
comprehensive needs of most veterans are being met. The veteran
with the more complex care requirements, the veteran with the
spinal cord disability, the veteran with catastrophic medical
illness would typically fall into a higher priority.
What we find is that the overwhelming majority of those
veterans who chose to use the VA are already receiving care.
When we typically open a new primary care of community-based
outpatient clinic, the new users are generally healthy
veterans, typically Priority 7 who have an alternate provider
who are seeking to augment their current health care with
prescription benefits or care that is more conveniently
provided in their local community.
Many of those veterans don't have the complex conditions,
which is probably why the cost of care is substantially lower
for this group of veterans. The resource constraints we face
are primary care physicians.
As you pointed out earlier, a typical community clinic
might include one primary care physician, one or two advanced
practice nurses and three or four support staff.
There is a finite limit of how many patients a physician
such as that can safely care for. What we are trying to do now
is to maximize the efficiency to increase the number of
veterans a primary care clinic is able to handle, but do that
in a way that doesn't require us to hire additional staff that
our current budget doesn't support.
Chairman Rockefeller. My driving force over the years has
been health care. For the 500th consecutive year, we are trying
to pass a prescription drug benefit. The cost of that ranges
all the way from $190 billion to $850 billion.
I just pray that somehow we can come together and get
something done this year. If we passed a Medicare prescription
drug benefit, what would be the effect on the waiting lines for
appointments?
Dr. Roswell. It would only be speculation on my part.
Clearly there would be an impact. I think the challenges, VA as
a health care system faces today exactly mirror the challenges
this Nation faces in its health care delivery.
We don't have an effective prescription drug benefit for
older Americans. As a Nation we don't provide comprehensive
long-term care and end-of-life care program benefit for older
Americans.
Those are the very same challenges VA is facing. Because VA
is attempting to provide in a comprehensive manner those
prescription benefits and long-term care benefits, increasingly
that makes VA health care more attractive to veterans entitled
to that health care system.
Chairman Rockefeller. You left out mental health, at least
in my judgment.
Dr. Roswell. I would agree with you.
Chairman Rockefeller. This is to Mr. Cooper. Let us suppose
that you are confirmed and complete a full term in your
position. Here is the kind of question I hate being asked, but
whenever I am it makes me think in ways that I otherwise
wouldn't.
In 2006 when your term would be completed, what will you be
able to say or what would you want to be able to say was
accomplished during your tenure in the VA? I want you to think
about that.
Mr. Cooper. What I would hope to be able to say is that the
VBA regional offices were operating essentially in the same
way, using the same processes, using the same IT and coming out
with consistent results.
I think the second part of that, although tied to it, would
be that we had increased, at least in my eyes, the
accountability that everybody within VBA felt for accomplishing
the work that we needed to do.
Chairman Rockefeller. That is a good answer. What are the
impediments for that? You have dedicated people. But you also
have a lack of uniformity in decisionmaking and you have
insatiable and understandable demand for services. Since claims
may be held up for months, in their hearts some veterans feel
like they have been ignored by their country, their service
forgotten. So, you have not only a personnel and succession
issues to get through. You have financial challenges to get
through. You have a technology gap to get through. But you also
have a psychological challenge to overcome. That is hard to do.
It is easy to say that you can go around and go to every
VBA office and boost morale. You see new technology and you
feel great as you walk out thinking the world is going to
change. But it never quite does. It never quite does.
Recognizing that this is the second largest agency in the
U.S. Government, do you see yourself being able to achieve your
goals and to do the kinds of things which would be required to
achieve them. When Secretary Principi was being confirmed, I
used my ``in your face'' line of questioning.
Basically, I was saying, ``Would you be willing to go face
to face with the President of the United States if you felt
that you weren't getting the budget you needed for benefits,
for health care, for all the things in the VA system.'' He
said, yes, he would. I believe him. I believe he would.
So, I am looking for that kind of ``in your face'' attitude
from you with the people that you must work with, you know what
I am saying.
Mr. Cooper. Yes, sir. And I go back to accountability. I
really go back, quite frankly, to my own background in nuclear
submarines because there is no more focused group than the
submarine force as far as how they operate and what they do.
I quite frankly use that as a model because I could go from
one submarine to another and I could tell you how that ship was
operating because they were always operating within certain
parameters.
I knew where things were on the ship and they knew what the
procedures were that they carried out. Was there deviation? Of
course, each ship operated slightly differently. That's my
goal, not that everything is cookie-cutter. But the fact is
there are certain basic things that we have to be doing in
every RO to accomplish the quality, the accuracy, the
timeliness that we need.
If we aren't doing those in every RO, how can I possibly
tell what corrections can be made to the whole system? If
everybody is doing it completely differently, it is difficult
to tell what you can do to help the whole system. So, I would
merely tell you that the primary component of this is
accountability and they have already started making sure that
people realize the things for which they are accountable and
that people are being measured.
Chairman Rockefeller. That was a very good example, to
carry over the intensity of what you find in the life of a
submarine. That is a good answer. That is what I would wish for
you then, that intensity, that command, pressure, coordination,
no room for mistakes, will dominate your thinking on this.
Mr. Cooper. They are still people out there. Everybody is a
people and we have to understand that. The people understand
the guidelines that they are supposed to follow and if they
don't want to or feel that they can't follow those, fine. Then
we will allow them to do something else.
But it is important that everybody understand what the
parameters are within which you have to work because this is so
important. We can't have everybody doing their own thing.
Chairman Rockefeller. How do you say that to them; that if
you don't do this, you know, maybe you have Civil Service
protection, but you are going to be doing something else.
That is a very powerful tool that a manager has and it is
often not exercised because the other place where you would
have that person go already has somebody in it or something of
that sort. I mean that is a powerful concept.
Mr. Cooper. I would say to you that one on one, as you look
them in the eye, you say, look, this is my vote. We aren't
voting today. The vote is in. This is what we are going to do.
Now, that doesn't mean you have cutoff communications. That
doesn't mean you don't listen to other ideas, but when the dye
is cast, then that is what we are going to do. So, quite
frankly, I think you do it by eye in this particular position,
communicate personally with the RO directors.
Again, I go back to the only model I know from my years of
experience in the Navy, namely the submarine. When I was
commander of the submarine force in the Atlantic, every
commanding officer that came through, I talked to him
personally for a specific amount of time. I would go to sea
once a month, on a different ship each time, and I had
communications with them. That, in fact, is the only way I
know.
Quite frankly, I have a letter that will go out to all the
regional office directors that says, here are some of the
things I want you to think about and, by the way, you and I are
going to have some direct communications. I will be sending you
letters and you can feel free to send me letters.
I want them to feel that I am knowledgeable about what they
are doing, and I will help them if they need help, but on the
other hand, I want them to tell me how they can solve their own
problems.
If you don't have that, you can't expect an organization
that will function properly.
Chairman Rockefeller. But if field managers really feel
that you are looking hard at what they are doing and that they
might have to report to you any given night on something that
is happening, it would send a message to every one of them.
That would have a heck of an effect as well as the face-to-face
meetings and letters.
Mr. Cooper. I think that has to be the approach that, if
confirmed, I will take.
Chairman Rockefeller. Yes. Good.
Dr. Roswell, let me say something politely, but I need to
say it firmly: Some of your pre-hearing questions and answers
were a little bit what I would call ``general'' or lacking in
specificity. I understand that because if I were in your
position, and I was replying to a Senate Committee on Veterans'
Affairs, I would tell myself I am going to do this really well.
I might not in the end, but I should aim that way and you
should.
So, you described your vision for the VA health care system
in the year 2006 in fairly general terms; too general for me.
So, I would like to get a little bit more detail about what
gets emphasized, what are your priorities, the size of the
system, and your realistic projections as to what budget
possibilities might do to your vision.
Dr. Roswell. Thank you, Mr. Chairman. I apologize for the
vagueness in the answer. I believe that VA exists and must
exist to meet the specialized needs of veterans. I don't
believe America's veterans, whether today, tomorrow or 100
years from now will ever have the health care they deserve, not
will it be provided in a comprehensive fashion if we don't have
a dedicated system that is structured to meet the specialized
needs, disabilities and problems associated with military
service.
There are classic examples that abound. VA's world class
spinal cord injury care, VA's blind rehabilitation care, VA's
commitment to treating veterans with Post Traumatic Stress
Disorder and other serious mental illness, those are the
components of VA health care that we must safeguard because
that is not care that can ever be vouchered or ever be provided
in a system that is not specifically dedicated to veterans.
Having said that, we need to make the system more
efficient. First of all, we need to preserve the quality that
Ken Kizer and Tom Garthwaite have given us. We need to
safeguard that. But we need to improve the efficiency with
which we manage the system, the efficiency with which we manage
both appropriated and non-appropriated revenues.
Having done that, we need to seek guidance from the
committee on exactly what the mission of VA will be for long-
term care of veterans.
I have very strong personal feelings. I have shared those
briefly with you. I believe that we do have a tremendous
commitment to meet the long-term care and end of life needs of
World War II and Korean era veterans. Those have been our loyal
customers for the last 50 years. They have been our primary
users. They have stood by us during difficult times.
It would be a travesty, a national disgrace, to turn our
backs on them right now. But to be able to meet those long-term
care needs in a way that is consistent with our budget has to
be done so that we don't irrevocably commit resources to a
health care that is ill suited for veterans who will come
behind them.
That is why I believe that long-term care is something that
needs to be addressed in non-institutional settings. That is
not to say I don't believe in a floor on nursing home beds. We
do have to establish a floor. We need that capacity.
But I believe we can do a lot more in long-term care and
end of life care by providing that care in non-institutional
settings which provide greater functional independence to the
veteran, a better quality of life, greater emotional support,
not to mention lower cost, which is important.
Having said that, I think that----
Chairman Rockefeller. May I interrupt on that, though?
Dr. Roswell. Certainly.
Chairman Rockefeller. I would have a different point of
view, and maybe this is just where I come from. I am a great
believer in getting your, what is the phrase, your nose under
the tent. I am now referring to long-term care.
If I start long-term care, we should be so lucky to get OMB
and everybody to agree on regulations; it has only been 3
years, I wouldn't ask the question of affordability.
My reaction would be, instead, we are instead going to
solve the problem and let the Congress and the President stew
in the public and veteran's rage. Long-term care is the one
thing, which we all face and which this country has done
nothing about since Medicaid in the 60's--except what we did
here in this committee nearly 3 years ago for a limited number
of people.
So, argue with me for a second, if you care to. I would
say, let's push the envelope and make the process catch up with
us. Say, we will serve the veterans, because that is my job.
That is what I took an oath for. Let the others figure out how
I am going to get the funding as opposed to you becoming the
budget officer for the VA.
I understand that is an easy thing for me to say.
Dr. Roswell. Mr. Chairman, I do agree with you. Let me
clarify my point. My point is that before we push the envelope,
before we build a better mousetrap for long-term care, and I
believe VA can and will set the standard for the Nation in
providing long-term care and end of life care. I deeply believe
we can do that.
But before we push the envelope and create care delivery
models that set the standard for the nation, not to mention the
standard for veterans' health care, we must be as efficient as
we possibly can with the taxpayer dollars.
So, all I am saying is that we have to maximize the
efficiency of the appropriated resource, use it as wisely as we
can, be the steward for America's taxpayers who have vested
their dollars in us to provide care to America's veterans.
Having done that though, you are absolutely correct, I do
agree with you that we should begin to explore innovation in
long-term care. For example, I believe that we have a pilot in
Florida that will provide quite comprehensive long-term care at
very little cost from the medical care appropriation.
Using VA's enhanced use leasing capability, we can make
property available. We can bring in an assisted living facility
provider who will bear the cost of capital construction to
build an assisted living facility. That ALF provider in Florida
can accept Medicaid block waivers from the State. That coupled
with the aid and attendance veterans are already receiving, is
sufficient to pay the cost of care in an assisted living
facility.
Now, you will argue, and rightly so, that an assisted
living facility doesn't provide the same comprehensive level of
care as nursing home care, and that is correct. But by placing
interactive technologies in an assisted living facility, as we
have already done in Florida, we can provide telemedicine are
to individuals in that situation. We can have an advanced
practice nurse monitoring patients on a daily or even twice
daily basis if needed.
When medical problems develop, when a need for
hospitalization is identified, we can provide that care on a
near immediate basis. We can even do that by co-locating such
facilities next to VA outpatient clinics so that the trip to
the doctor is minimal or non-existent, if VA physicians make
house calls.
That is an example of how we can address long-term care
needs and do it efficiently. We are talking pennies a day for
care like that, versus hundreds of dollars a day in a staffed
institution.
Chairman Rockefeller. So, I can eliminate from my head and
from the record any sense that you will judge what you can do
in terms of consequences of demand.
The driving thing in you is to take care of the needs of as
many veterans as we possibly can.
Dr. Roswell. As you well know, that is the purview of the
authorizers and the appropriators to determine that.
Chairman Rockefeller. No, no, it is, but then it gets
inside the VA and then it takes on a whole life of its own.
Dr. Roswell. Mr. Chairman, as I said, I feel very strongly
that we have to provide that care. I am excited about the
opportunity to develop innovative long-term care models within
the VA. I believe we can do that. I believe that the creation
of such models will include institutional care but will also
rely heavily on non-institutional care, and will create a
comprehensive continuum of long-term care services that
America's veterans will want, and I hope that we will be able
to provide that.
Chairman Rockefeller. I want you to talk about Roswell, not
about Kizer and Garthwaite. I don't want you referring to the
past. I want you referring to you and the future,
That is not commenting on either of them, but that was a
different era. Everything is different, and we have not even
talked--and I am not going to this afternoon--in terms of
preparing the VA hospitals to meet homeland security needs and
all the rest of that.
I am not interested in Kizer or Garthwaite. I am interested
only in Roswell and what you want to do in veterans' health
care. So that the maintenance of what has been done is not a
phrase I welcome.
Do I make my point?
Dr. Roswell. Yes, Mr. Chairman, you do.
Chairman Rockefeller. Mr. Cooper, how has the
implementation of the task force recommendations been different
than you expected and are you facing barriers or time
constraints that you did not expect?
Mr. Cooper. I would say the implementation, as I have seen
it, is not different from what I expected, other than the fact
that I think it has been implemented a little bit faster than I
might have expected.
I would further say to you that one of the things when we
came in to start our report, I asked to see all the previous
reports that had been done over the previous decade to tell how
to do it better in VBA. There are about five of them including
National Academy of Public Administration [NAPA], Mr.
Melidosian's report, and a couple of others.
I then asked to see the specific steps that were taken to
carry out those recommendations and they were not very
complete. A lot of things had not been done. I would say to you
that this report is being executed in about the best manner I
have ever seen a report executed in that it is being followed
very closely. There are about, I believe right now, maybe seven
of those 34 recommendations that they consider done.
The others are ongoing and will take varying amounts of
time. So, my answer to you is that the execution of this report
is much more thorough and more carefully followed and more
fully reported than what I observed had been done in previous
administrations or in previous times when they had received
reports.
I would say to you that the two gentlemen who have been in
charge for the last 4 months, Judge McMichael and Stan
Sinclair, both of whom were on our Task Force study, and very
strong participants in it. I think it is fortuitous that they
were able to go over because they fully agreed with the report
and did everything they could to implement every facet that
they could. For those recommendations they didn't want to do
right that second or they thought not appropriate, they have
started people looking at them very carefully to see how they
will execute them.
I personally think they have done as good a job as anybody
could do with a report like this. It is much easier to write a
report than it is to execute it.
Chairman Rockefeller. I think you are right on that.
Mr. Cooper. Thank you.
Chairman Rockefeller. Dr. Roswell, back to you. This is not
a question but an unburdening on my part. I just want to make
it very clear for the record, that the research program at the
VA is very, very dear to this particular chairman's heart and I
suspect to many around the table, for a lot of reasons.
I think it is critically important to veterans and to the
system which serves veterans. I see the goal of the VA's
research program as providing the best possible care for
veterans.
I think the figure is still 50 percent of doctors-in-
training rotate through VA hospitals, but on the other hand,
the VA Hospital affiliated with Northwestern will be closed. I
think above all, however, and the thing which attracts the best
doctors is research.
I just think research helps to meet so many goals by being
a potent attraction to the best possible folks in medicine that
we possibly can. It also cements affiliations with
universities, which is equally as important.
Along those lines, I think it is absolutely essential that
researchers have the protected time to do their research. I
want to make sure that they do, because if you are a researcher
who is not allowed to do research but is required to do other
things, people are going to find out about it. It won't take
long for the word to get around.
So, the protected time factor is very, very important to
me. Of course, it increases expense. But I think in the long
run, it is enormously cost effective. So, I am going to be
looking to you, Dr. Roswell, to make all of this happen.
I have no worries, do I?
Dr. Roswell. Mr. Chairman, I would like to state for the
record that I began my VA career some 20 years ago as a direct
result of VA's research program. I came to the VA as a young
staff physician seeking research funding through the VA. That
is how I began my research career and my VA career.
I am in total agreement with your commitment to research.
It not only adds value, it improves the care that we provide to
today's veterans, to tomorrow's veterans, and we really do need
to safeguard that program, build that program in such a way
that it continues to make VA health care second to none.
I think that protected time is important. I think the way
we distribute money through the VERA model is important. I
think the way we utilize nonprofit research corporations to
augment and bolster the care we provide through our programs is
very important.
You can count on me to work with you to see those goals
accomplished.
Chairman Rockefeller. Another question, Dr. Roswell, you
indicated in your pre-hearing questions that quality management
activities will be one of your highest priorities. This is very
key for me, too. If not now, could you provide this committee
with a plan, and this gets back to the broadness of your pre-
hearing questions, describing exactly what you will do to make
sure quality improvement is not merely a paper exercise. I ask
that you do that within the next 30 days.
Mr. Cooper, a final question for you: The task force
reviewed many of the previous reports and studies conducted on
the VA, as you would expect. It concurs with many of the
recommended changes from those reports.
But I believe that some of the VBA actions actually
exacerbated the backlog because of too many and too disparate
initiatives. That is an interesting thing to say. On the one
hand, you have to do different things to innovate, if the
changes get too complicated or so innovative you may confuse or
overwhelm people. These two visions are difficult to reconcile.
In some ways you may end up making the process more
inefficient.
What is your view about that?
Mr. Cooper. What you say is absolutely correct in that you
don't want to put in change on top of change on top of change.
It is all part of getting focused as to what you think is the
right way to do it. Although there may be four or five rights
ways to do it, once you decide on the right way you are going,
then that is what you have to do. So, you can't allow changes
to come in from the side just to change.
We felt as we looked at changes that have been made,
particularly in the last 4 years, that they had not been
implemented in a way that you saw how one change affected the
other changes.
Further, we felt that each one of the 57 different RO's
were taking parts of those changes and implementing them to the
degree that they wanted to or did not want to. Some they
limited to 5 percent. In some, a few ran off and did it 100
percent. But there was such a wide disparity in the way those
were implemented that it was difficult to figure out exactly
who was where and why things were not going well.
As I mentioned earlier, we did look at each one of those
previous reports. We did use those as we developed our own
recommendations. Now the point is to make sure that we do not
implement all 34 recommendations simultaneously and we very
carefully stated that.
We put about 20 of those recommendations in a short-term
timeframe. However you are not going to do all 20 in that short
term. We are merely saying that any one of those, or four or
five of those could be done in the first 6 months. But for pity
sakes, you don't want to do all of them at once over the first
6-month period.
We tried to remain very cognizant of that. I would say to
you that the implementation process that they are going through
very carefully takes that into account. It looks to see where
they are today, where they want to get, and then how that is
impacted with other recommendations.
So, again, I would say to you, I think the execution and
implementation of this report, one, is very vital, but two,
right now is being done as well as I could possibly imagine.
Chairman Rockefeller. OK. I would just conclude by saying
that I would suspect that, if the veterans of the United States
were looking in on this, they would look upon you two as the
hope of the VA.
I am not putting the Secretary down because he is the top
person.
This confirmation process is very, very important to me,
and I think very meaningful to the VA and its future.
So, there is a lot riding on you two gentlemen. I am going
to support you both, and I think the committee is going to move
expeditiously to make sure that you get into your positions as
quickly as possible. But I just can't emphasize how important I
think the work each of you will undertake.
So, I thank you both very much for coming. I look forward
to working with you both in the future.
Mr. Cooper. Thank you, Mr. Chairman.
Dr. Roswell. Thank you.
Chairman Rockefeller. The committee is recessed.
[Whereupon, at 3:59 p.m., the committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Arlen Specter, U.S. Senator From
Pennsylvania
Thank you, Mr. Chairman. I join you in welcoming Admiral Cooper and
Dr. Roswell.
I also welcome the family members of both nominees. I know it is a
proud day for both the Roswell and Cooper families; both families
should be proud of the long and distinguished service that each nominee
has already given to the Nation. In my estimation, VA is fortunate--
very fortunate--that the President has asked these two fine men to
serve. And I am pleased to consider their nominations. I look forward
to hearing their testimony.
These are tough jobs that Dr. Roswell and Admiral Cooper propose to
take on. Indeed, I think they are two of the most difficult--and
important--jobs in government. The Under Secretary for Health is in
charge of the Nation's largest integrated health system--a system that
provides care to over 4 million veterans and which employs almost
200,000 people. The Under Secretary for Benefits is charged with
administering over $30 billion per year in compensation, rehabilitation
and readjustment benefits received by over 3 million veterans. Both of
these jobs--obviously--are big jobs. I do admire both of you for
stepping up to take on the challenges these jobs entail.
Admiral Cooper, Secretary Principi told me before he was confirmed
that his number 1 priority would be speeding and streamlining VA's
claims adjudication system. The Secretary has, in effect, staked his
reputation on solving the seemingly intractable problems that have
plagued VA's adjudication system; he has now, in effect, placed his
reputation in your hands. Since your hands have guided an anti-
ballistic missile-equipped nuclear submarine, no one can question
whether they are steady enough. But it is a considerable challenge you
propose to take on, Admiral Cooper. I look forward to questioning you
today--and over the course of the next four years--on how VA claims
processing can be speeded and, simultaneously, improved from a quality
standpoint.
Doctor Roswell, you may have been informed that while the Chairman
and I are strong supporters of needed VA funding, I have made the point
to the Secretary that VA has to do better in billing for--and
collecting--reimbursements owed to VA by insurance companies for VA
treatment of veterans' non-service-connected illnesses and injuries. I
am pleased to learn that the service network that you have headed up
since 1995 is the VA's single most successful collector of insurance
reimbursements. That is good news indeed since what you have done in
Florida needs to be brought to the rest of the VA system. You can count
on the Chairman and me to be among your strongest proponents in the
annual budget fights up here on Capitol Hill. But we will both insist
that VA do better in generating a small fraction of its operating funds
through collections.
One other matter needs to be discussed briefly this morning. I am
told that VA has grown uneasy with Congressional mandates with respect
to long term care and other forms of priority care at VA. I want to
make two points with utter clarity: statutory mandates are mandates. VA
does not have the discretion to ``do what it can'' to meet statutory
mandates--it must meet them. And as for the substance of such mandates,
I want to make clear my commitment to a VA that provides inpatient-
based long term care, and non-institutional long term care services, to
senior veterans in Pennsylvania--and nationally. Such services are, in
my estimation, among the most important services that VA provides to
veterans. If you want to gain--and keep--my support, Dr. Roswell, you
will need to share that commitment to our seniors' needs. Since you
have spend the last six years operating VA's medical care system in
Florida, I believe you have been sensitized to those needs. Please
understand that they are important in other States too.
As I said at the outset, I welcome both of you. I look forward to
working with each of you for a long time.
______
Prepared Statement of Hon. Ben Nighthorse Campbell, U.S. Senator From
Colorado
Thank you, Mr. Chairman. I appreciate your convening today's
hearing which will give us the opportunity to hear testimony from
Robert H. Roswell, nominee to be Under Secretary of Health, and Daniel
L. Cooper, nominee to be Under Secretary for Benefits. I welcome both
witnesses and look forward to their testimony.
I have always supported the VA's efforts to do the absolute best
they can with the money they are provided. This year, however, I am
concerned that the VA health care system is not currently able to meet
the needs of our veterans. Many veterans in Colorado are required to
travel long distances for routine care, and others are required to wait
months for appointments for routine check-ups. We have an obligation to
help our vets get the care they need and deserve.
And, I am supportive of the innovative proposal in Colorado to
relocate the Denver Veterans Affairs Medical Center (DVAMC) to the site
of the former Fitzsimons Army Medical Center. I believe the relocation
can provide state of the art health care facilities for Colorado
veterans and veterans nation-wide. I look forward to hearing Dr.
Roswell's thoughts on addressing these issues.
In addition, I remain concerned about the continued backlog that
continues to hinder the adjudication process of veterans' claims
appeals. I understand some progress has been made in this area. And, I
understand that Admiral Cooper has extensive experience and some
innovative ideas for addressing the problem. I look forward to his
strategies for eliminating the backlog and speeding up the process.
Again, Mr. Chairman, thank you for convening this hearing. I look
forward to the testimony.
______
Prepared Statement of Hon. Larry E. Craig, U.S. Senator From Idaho
Mr. Chairman, it is indeed a pleasure to be here at the
confirmation of Dr. Robert H. Roswell for Under Secretary for Health,
and Admiral Daniel L. Cooper for Under Secretary for Benefits. The
mission of the VA is not only high quality health care, but it also
encompasses educational and housing loans, pensions, and survivors
benefits. Thus, it is imperative for us as custodians of the public's
trust to ensure that those individuals that lead this organization are
worthy of that high calling.
After reviewing the qualifications of the two nominees I can say
that I am impressed with both of them. Dr Roswell's background as a VA
physician, and former director of Veterans Integrated Service Network
(VISN) 8 indicates to me that he understands the intricacies of
managing a large and diverse workforce and patient base, which is a
necessity for an Administration that covers more than 170 medical
centers across the country.
Admiral Cooper, who has served our great nation for 33 years in the
Navy's Nuclear Submarine service, has first hand knowledge of what the
VA is and understands the potential of what the VA can be. It is also
important to note that he has worked with VA Secretary Principi
previously and has his trust, as he was appointed to head the VA Claims
Processing Task Force. I think it only proper that he now have the
opportunity to implement the recommendations his task force has
previously issued.
I look forward to working with both of these capable and astute
administrators when addressing, expanding, and improving the delivery
of services and benefits so that all veterans have equal access to high
quality medical care. In many areas of the country as in Idaho, the
waiting lists are long and only getting longer. I would encourage the
VA to continue exploring under serviced areas. Any time we can provide
local--as opposed to regional--service, the veterans will be grateful
and overall cost reduced. Of course, one of my major concerns is
ensuring funding for primary care is adequate, but we must not forget
to provide all the services and specialty care that many of our
veterans require.
I believe that Dr. Roswell and Admiral Cooper are both excellent
choices to help define our commitment to our nation's veterans, while
recognizing the tough fiscal decisions that must be made. Let us never
forget the important role that our veterans have made insuring our
national security--the United States is a super power and enjoys
success because of the service and--as we have seen recently--the
sacrifices of our veterans, for whom we should be forever grateful.
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