[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON: H.R. 1319; H.R. 1603; H.R. 1904; H.R. 2639;
H.R. 3234; H.R. 3471; H.R. 3549; DRAFT LEGISLATION, THE PROMOTING
RESPONSIBLE OPIOID MANAGEMENT AND INCORPORATING MEDICAL EXPERTISE ACT;
AND, A VA LEGISLATIVE PROPOSAL, THE VA PURCHASED HEALTH CARE
STREAMLINING AND MODERNIZATION ACT
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, NOVEMBER 17, 2015
__________
Serial No. 114-44
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
24-360 WASHINGTON : 2017
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
GUS M. BILIRAKIS, Florida JULIA BROWNLEY, California,
DAVID P. ROE, Tennessee Ranking Member
TIM HUELSKAMP, Kansas MARK TAKANO, California
MIKE COFFMAN, Colorado RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana BETO O'ROURKE, Texas
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Tuesday, November 17, 2015
Page
Legislative Hearing On: H.R. 1319; H.R. 1603; H.R. 1904; H.R.
2639; H.R. 3234; H.R. 3471; H.R. 3549; Draft Legislation, The
Promoting Responsible Opioid Management And Incorporating
Medical Expertise Act; And, A VA Legislative Proposal, The VA
Purchased Health Care Streamlining And Modernization Act....... 1
OPENING STATEMENTS
Dan Benishek, Chairman........................................... 1
Julia Brownley, Ranking Member................................... 2
Prepared Statement........................................... 40
Gus Bilirakis, Member............................................ 3
Prepared Statement........................................... 44
Mike Coffman, Member............................................. 28
Ron Kind, U.S. House of Representatives, 3rd Congressional
District; Wisconsin............................................ 29
John Kline, U.S. House of Representatives, 2nd Congressional
District; Minnesota, Prepared Statement only................... 43
WITNESSES
Honorable Beto O'Rourke, U.S. House of Representatives, 16th
Congressional District; Texas.................................. 5
Honorable Andy Barr, U.S. House of Representatives, 6th
Congressional District; Kentucky............................... 6
Prepared Statement........................................... 40
Honorable Matt Cartwright, U.S. House of Representatives, 17th
Congressional District; Pennsylvania........................... 9
Prepared Statement........................................... 41
Honorable Scott Peters, U.S. House of Representatives, 52nd
Congressional District; California............................. 10
Prepared Statement........................................... 41
Honorable Martha Roby, U.S. House of Representatives, 2nd
Congressional District; Alabama................................ 11
Prepared Statement........................................... 42
Honorable Jackie Walorski, U.S. House of Representatives, 2nd
Congressional District; Indiana................................ 13
Prepared Statement........................................... 42
Adrian Atizado, Deputy National Legislative Director, Disabled
American Veterans.............................................. 17
Prepared Statement........................................... 45
LaRanda D. Holt, Assistant Director for Women and Minority
Veterans Outreach National Veterans Affairs and Rehabilitation
Division, The American Legion.................................. 19
Prepared Statement........................................... 49
Carlos Fuentes, Senior Legislative Associate, National
Legislative Service, Veterans of Foreign Wars of the United
States......................................................... 20
Prepared Statement........................................... 54
Janet Murphy, Acting Deputy Under Secretary for Health for
Operations and Management, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 31
Prepared Statement........................................... 58
Accompanied by:
Elias Hernandez, Chief Officer, Workforce Management and
Consulting, Veterans Health Administration, U.S.
Department of Veterans Affairs
Harold Kudler, Chief Consultant for Mental Health Services,
Veterans Health Administration, U.S. Department of
Veterans Affairs
Susan Blauert, Deputy Assistant General Counsel, Veterans
Health Administration, U.S. Department of Veterans
Affairs
STATEMENTS FOR THE RECORD
American Counseling Association.................................. 72
American Orthotic and Prosthetic Association..................... 74
AMVETS........................................................... 76
Kentucky Department of Veterans Affairs.......................... 79
National Mobility Equipment Dealers Association.................. 80
Paralyzed Veterans of America.................................... 81
Heather Simcakoski............................................... 85
Marvin Simcakoski................................................ 86
Susan Mosley, Prepard Statement only............................. 86
LEGISLATIVE HEARING ON: H.R. 1319; H.R. 1603; H.R. 1904; H.R. 2639;
H.R. 3234; H.R. 3471; H.R. 3549; DRAFT LEGISLATION, THE PROMOTING
RESPONSIBLE OPIOID MANAGEMENT AND INCORPORATING MEDICAL EXPERTISE ACT;
AND, A VA LEGISLATIVE PROPOSAL, THE VA PURCHASED HEALTH CARE
STREAMLINING AND MODERNIZATION ACT
----------
Tuesday, November 17, 2015
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:04 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[Chairman of the Subcommittee] presiding.
Present: Representatives Benishek, Bilirakis, Roe,
Huelskamp, Coffman, Wenstrup, Abraham, Brownley, Ruiz, Kuster,
O'Rourke.
Also Present: Representative Walorski.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Mr. Benishek. The Subcommittee will come to order.
Before we begin, I would like to ask unanimous consent for
our colleagues, Congresswoman Jackie Walorski from Indiana and
Congressman Ron Kind from Wisconsin, to sit on the dais and
participate in today's proceeding. Without objection, so
ordered.
Good morning and thank you all for joining us for today's
legislative hearing.
There are nine bills on our agenda this morning and three
panels of witnesses ahead of us, so I will keep my comments
short in the interest of time.
The bills and legislative proposal that we will discuss
this morning address a number of critical issues facing our
veterans and the Federal agency tasked with caring for them,
the Department of Veterans Affairs.
Those issues include how to help struggling VA medical
facilities, how to increase access to care for wounded warriors
and those who have experienced military sexual trauma, how to
improve the quality of the adaptive equipment provided to
disabled veterans, and how to add fairness to the VA's broken
billing system.
I am particularly interested in our discussion surrounding
Vice Chairman Bilirakis' draft bill, the Promise Act, which
would address the over-reliance of opioid medication amongst
our veterans.
This Subcommittee has been and will continue to be
aggressive in our oversight of VA's pain management programs.
To be sure, chronic pain is complex and difficult to treat and
prescription medication overuse is a national problem that is
not unique to the VA health care system, but far too many of
our veterans are going to VA facilities looking for ways to
cope with their pain and being given nothing more than multiple
prescriptions for high-risk medications.
Some of these same veterans come to the VA already heavily
reliant on a cocktail of medications initiated in treatment
while on Active duty. Tragically, some of these veterans have
lost their lives as a result of simply taking the medication as
prescribed or in some cases have succumbed to the dangers of
having too many high-potency opiates readily and fatally
available.
One of those veterans is Jason Simcakoski who inspired the
Promise Act and its companion bill in the Senate. We are too
late to help Jason or to ease the anguish that his family
including his wife, Heather, and his father, Martin, who have
submitted statements for the record have been left with. But we
can promise to do better for those that come after him and I
believe the Promise Act can help get us there.
The last bill on our agenda today is a draft legislative
proposal from the department that would grant the VA the
authority to enter in provider agreements. This is similar to a
bill H.R. 1369 that the Subcommittee considered in a
legislative hearing earlier this year.
Provider agreement authority may, in fact, be critical to
moving VA forward. We must be careful that we do not take a
short-sighted approach to solving one problem that VA is facing
and as a result create a whole host of others.
When considering whether to allow provider agreements that
are not subject to traditional Federal acquisition regulation
checks and balances, I want to be sure that appropriate
controls are in place to protect our veterans and the taxpayer
dollars that are supporting them.
I am grateful to the sponsors of the bills that are being
considered today and to all of our witnesses from our veteran
service organizations and the VA for being here to share their
views. I look forward to hearing their testimony.
I now yield to the Ranking Member, Ms. Brownley, for an
opening statement.
OPENING STATEMENT OF JULIA BROWNLEY
Ms Brownley. Thank you, Mr. Chairman, and thanks for
calling this hearing today.
It is important for us to, I think, review the legislation
that has been referred to this Subcommittee and it is important
to hear from our colleagues on their priorities and to hear all
views on how to best protect the health of those men and women
who dedicate their lives to protecting this Nation.
I wanted to just highlight three bills today that I am a
co-author on. And the first is Mr. O'Rourke's bill which I
believe will greatly improve and enhance the way we survey our
veterans to get the data that we need to provide good policy
and relationship to how well our veterans are served.
Also, Mr. Peters' bill which I believe again will enhance
the VA's ability to hire more marriage and family therapists to
provide more resources and more professionals that we need for
the mental health of our veterans.
And, finally, Ms. Walorski's bill which would enhance
adaptive technology in our automobiles to make sure that our
veterans who need that will receive automobiles that are rated
and classified.
In support of all three of those bills, I think all the
bills before us are worthy. And I look forward to the testimony
from our witnesses today and their views on how to improve upon
the many bills that we are considering.
So thank you and I yield back the balance of my time.
[The prepared statement of Julia Brownley appears in the
Appendix]
Mr. Benishek. Thanks.
I am honored to be joined this morning by several of my
colleagues to speak in support of their legislation. With us
today is the Honorable Beto O'Rourke from Texas; the Honorable
Andy Barr from Kentucky who is not quite here yet; the
Honorable Matt Cartwright from Pennsylvania; the Honorable
Scott Peters of California; the Honorable Martha Roby from
Alabama; the Honorable Jackie Walorski from Indiana; the
Honorable John Kline from Minnesota who will shortly arrive, I
hope; and the Honorable Gus Bilirakis from Florida.
We are also joined by a veteran constituent of Mr. Barr's,
Ms. Susan Moseley who is apparently going to speak during
Representative Barr's time about her personal experience
accessing care from the VA.
Thank you all for being here this morning and thanks to
Mrs. Moseley for your service.
We will begin with Representative Bilirakis. Mr. Bilirakis,
please explain your legislation. You have five minutes.
OPENING STATEMENT OF GUS BILIRAKIS
Mr. Bilirakis. Thank you very much, Mr. Chairman. Thanks
for holding this hearing and agendaing my bill.
Chairman Benishek and Ranking Member Brownley and
distinguished Members of the House Subcommittee and my
colleagues, thank you for holding this legislative hearing
today.
Today's hearing includes many important pieces of
legislation that will improve the services and care for our
veterans, the care our veterans receive for their dedicated
service to our great Nation.
Among the bills under consideration at today's hearing is
my bill, the Promoting Responsible Opioid Management and
Incorporating Scientific Expertise Act or the Jason Simcakoski
Promise Act.
[The attachment appears in the Appendix]
Mr. Bilirakis. I appreciate the Chairman's leadership to
bringing this important issue before the Committee and for
allowing me to speak today on the Promise Act.
The tragic death of Marine Corps veteran Jason Simcakoski
in the Tomah, Wisconsin VA medical facility prompted the need
for Congressional action.
In August of 2015, nearly one year from Jason's death, the
Office of Inspector General released a report titled Unexpected
Death of a Patient During Treatment with Multiple Medications.
The IG report concluded that Jason's cause of death was due to
mixed drug toxicity with the potential for respiratory
depression and a combination of various medications was a
plausible mechanism of action for a fatal outcome.
Furthermore, the IG also found deficiencies in the informed
consent process, confusion among staff when initiating
cardiopulmonary resuscitation, and the absence of certain
medications available in emergency situations to reverse
effects of possible drug overdose.
I request unanimous consent to submit this IG report, Mr.
Chairman, for the record in today's hearing materials.
Mr. Benishek. Without objection.
[The attachment appears in the Appendix]
Mr. Bilirakis. Thank you.
As the guidelines used by the VA and DoD for opioid
management have not been updated since 2010, it is due time to
ensure those treating our veterans have the necessary resources
and training to effectively treat veterans with chronic pain.
I want to be clear. The intent of this bill is to improve
patient safety, not to restrict access for those who truly need
their prescriptions for their wellness plan. The Promise Act
will increase safety for opioid therapy and pain management by
requiring the VA and DoD to update the clinical practice
guidelines for management of opioid therapy for chronic pain
ensuring VA opioid prescribers have enhanced pain management
and safe opioid prescribing education and training and
encouraging the VA to increase information sharing with State
licensing boards.
We have discussed this in the past, Mr. Chairman.
This bill also promotes needed transparency within the VA
and will further our efforts to hold the VA accountable by
requiring GAO to report on recommendations for improvements and
assess the level of care veterans are receiving.
Additionally, the Promise Act will authorize a program on
integration of complementary and integrated health within the
VA and encourage more outreach and awareness of the patient
advocacy program to educate veterans on their care options.
Our veterans have sacrificed so much for our country and we
have a responsibility to ensure they are receiving the quality
of care they have earned and deserve. We must hold the VA
accountable and encourage quality care for our veterans who
have fought for the freedoms we enjoy on a daily basis.
I want to thank the VSOs for their support and for
appearing today to provide their testimony in today's
legislative hearing. I also want to thank all my colleagues on
this Committee, of course, and the whole House for your co-
sponsorship of this bill.
And I appreciate it very much. Thanks for agendaing the
bill. With this strong list of bipartisan support, we can send
a clear message to the Simcakoski family, our veterans, and
those that have been affected by such tragedies that we are
dedicated to ensuring similar failures will never happen again.
In closing, I am grateful we are here discussing these
important bills. I look forward to having substantive
discussion on how we can improve the lives of our true American
heroes and upholding our sacred vow and promise to our
veterans. I urge my colleagues to support this bill and co-
sponsor the Promise Act.
I yield back, Mr. Chairman. Thank you so much.
[The prepared statement of Gus Bilirakis appears in the
Appendix]
Mr. Benishek. Thank you.
Mr. O'Rourke, you may proceed with your testimony. Thanks.
OPENING STATEMENT OF BETO O'ROURKE
Mr. O'Rourke. Thank you, Mr. Chairman and Madam Ranking
Member, for having this hearing and then allowing me the chance
to discuss the bill that we are proposing, the Ask Veterans
Act.
[The attachment appears in the Appendix]
Mr. O'Rourke. And it is essentially based on experiences
that we have had in the district I represent, El Paso, Texas,
that I think are applicable to all of our districts.
When I was sworn in in 2013, I began to hold regular town
hall meetings and I was struck by the number of veterans who
would attend them to tell me that they could not get in to get
a primary or specialty or mental health care appointment.
That was at direct odds to what I was hearing when I would
follow-up with the VA. The VA in El Paso told me that, you
know, the vast majority of veterans seeking care were seen
within 14 days which at the time was the established basic
minimum wait time for a veteran and yet the complaints
persisted.
And the VA was almost saying, you know, what you are really
dealing with here, Beto, are some cranky, ornery veterans. You
know, some of these folks, you just can't make them happy, but,
you know, you got to take our word for it and here is the data.
We are seeing everybody within the established period of time.
Well, something just didn't add up. And so we commissioned
an objective scientific, third-party survey with a margin of
error under four percent to ask veterans directly what their
experience has been at the VA. And what we saw in the results
confirms what we were told by the veterans which is, they were
waiting far longer than the VA had told us they were waiting.
To give you an idea, on average, this is an average,
veterans in El Paso waited over 80 days for a primary care
appointment, over 70 days for a mental health care appointment.
And what was truly shocking and confirmed stories that I had a
hard time believing when I was told by veterans when we first
took office was that more than one-third of the veterans
surveyed who tried to obtain a mental health care appointment
could not obtain one at all, not in 14 days, not 30 days, not a
year, just not ever.
And that data helped us to apply targeted pressure to the
VA on where they needed to do a better job for veterans in our
community. And to the VA's credit, they were very responsive to
that and they didn't resist the facts as told by the veterans.
They have worked to try to make things better.
We conducted this survey again this year, got similar
results. There were some improvements, but people are waiting
far too long and there is still a crisis in access to mental
health care.
I think we learned after the Phoenix wait time scandal and
my experience in El Paso, and you may have similar experiences
in your districts, that we cannot ask the VA how the VA is
doing and always expect an honest answer. You know, shame on
them the first time this happens. Shame on us if it happens
going forward.
For us to truly hold them accountable, there needs to be an
independent verification of the veterans' experience at each of
the VA medical facilities in each of our districts. And so this
bill would simply require that the VA contract with an
independent third-party to assess true wait times, not the
preferred wait times which I still don't understand how that
works.
But from the moment you, the veteran request an appointment
until that appointment is actually granted and you are actually
seeing your provider, not when it was scheduled, but when you
are seeing the provider, we want to measure that wait time. We
want to measure wait times across primary, specialty, and
mental health care and we want to measure veterans'
satisfaction with the care that they received both at the VA
and care that they received in the community.
This bill also requires that the VA work with veteran
service organizations in each of our communities to make sure
that we are asking the right questions, that we are getting at
concerns that VSOs and veterans have with the quality and
access and timeliness of health care in a given community. And
then the VA must publish these reports publicly on the Web for
everyone to see and to be held accountable.
And so that, in essence, is a very short simple bill. That,
in essence, is what the Ask Veterans Act would do. And with
that, I yield back.
[The prepared statement of Beto O'Rourke appears in the
Appendix]
Mr. Benishek. Thanks. Nice.
Mr. Barr, I am going to yield to you for 30 seconds and
then to Ms. Moseley for four minutes and 30 seconds.
OPENING STATEMENT OF ANDY BARR
Mr. Barr. Thank you, Chairman Benishek and Committee
Members, for allowing me the opportunity to present my
legislation, H.R. 1603, the Military Sexual Assault Victims
Empowerment Act, also referred to as the Military SAVE Act.
[The attachment appears in the Appendix]
Mr. Barr. Two years ago, several veterans visited my
district office to share with me their powerful and heartfelt
stories. They told me about how they had survived military
sexual trauma during their service but now faced with the task
of navigating the bureaucracy at the VA. They explained that
they were unable to access the individual care that they needed
from the VA.
I would like to introduce one of those veterans, Specialist
Susan Moseley of the U.S. Army, who helped inspire me to
introduce the Military SAVE Act. She is a courageous woman, a
survivor of military sexual trauma and I am pleased to
introduce her to the Committee today.
[The statement of Andy Barr appears in the Appendix]
Ms. Moseley. Good afternoon. I am so grateful to be in
front of you all today.
I entered into the military over almost 20 years ago. I
went in like the typical youngster does not knowing what you
want to do with your life. Going through basic training and AIT
for your schooling, I thrived. It was the most amazing
experience I ever had in my life.
Then I showed up to my permanent duty station in El Paso,
Texas at Fort Bliss where I was instructed which unit I would
be going to. There was a female soldier that was there and she
said I am sorry to tell you, but you are going to Foxtrot. I
thought, huh, what does that mean. She said you need to find a
boyfriend. Top is pretty handsy and likes girls like you. I was
taken aback. Really? This is my future?
I spent six months working very diligently to learn my job,
be a good soldier, and represent the people that I was there to
serve. I was in a patriot missile systems battery which we
rotated in and out of Southwest Asia. And I was first assaulted
within six months of arriving at my permanent duty station by
the top ranking enlisted member of our unit, the first sergeant
or Top as many enlisted people call him.
Then I began to avoid him, tried to do everything that I
could to do my job and stay away from him. So then he decided
to move me into being his assistant. So I was in the CQ and my
office was directly across from his. I spent long, long periods
of time in trying to turn it around and instead of him
manipulating me, me manipulate him into how, if I was going to
be assaulted, it was going to be on my terms.
So instead of him raping me at my desk, I would say, okay,
I will give you a little handy J. That was the only way I could
get to the point that I wouldn't be torn down to nothing. My
dignity was lost and I had no idea how I was going to get
through it.
In the military, you are told where to go, what to do, how
to dress, and where to be. The only thing you couldn't or the
only thing that no one could control for me was what I ate. So
I developed an eating disorder. And when I developed that
eating disorder, it was the only sense of power I had.
Once they realized that I had a problem, they sent me to
the Army hospital which decided to send me to a treatment
facility. My commander and Top showed up at the hospital that
day and when I was at the lowest of low knowing that I had no
power and no control over my life, Top whispered in my ear we
are good, right, which meant you are not going to say anything.
I said, yeah, we are fine.
But I knew I had to do something. I am not the kind of
person to sit back and allow someone to violate me and let that
be okay. I knew that my end of service time was coming and
after I came back from treatment, I walked into my commander's
office and I informed him that I wanted to press charges.
I was then sent to CID where I was given a lie detector
test, a lie detector test as a victim. I passed that lie
detector test. And my end of term of service came and I was
leaving to come home to Kentucky when the major in the unit ran
out into the parking lot when I was getting into a vehicle to
leave and called me you lying whore and slut. How dare you say
things to which many people which were in my unit began to join
in with him.
So my exit from the military was being called a whore after
I had been in Southwest Asia and done everything I could to
support and defend the United States of America.
When I came back, my transition coming into out of the
military and into the VA was quite difficult. I went into a
reclusive state that many of us go into where we just avoid
everything. I didn't know what had happened to me had a name to
it. There was something that happened to me and I could go and
I could get help.
The VA did not help with that process for me. I eventually
after about 16 years found a therapist who had been trained in
Bay Pines which is at the VA there who specializes in military
sexual trauma and knew how to treat us.
We were given the opportunity to have great treatment, but
we could only be seen every three weeks by her. And she, on
every Friday gave up her lunch so we could have a group time,
but that was all the VA could offer us. We had those groups
until she left the VA. At that point in time, she agreed to see
some of us at her home.
Many of us that live out of certain areas get travel pay to
come to the VA. But if you went to go see Karen at her home,
you could not receive that travel pay which meant getting and
receiving and maintaining that continuity of care was broken
because people could not go and see her.
The therapists that were introduced to us once Karen left
had little to no training. And when you had been so violated,
so violated to the core, it takes several, several visits
before you can even begin to trust the therapist that is
sitting in front of you.
I was told that I could be seen once a month. How can a new
person I had never known see me once a month and think that I
could overcome and be a more productive member of society? It
just doesn't happen that way. You have to have more access to
care and be able to be treated as needed.
Unfortunately in the not too recent, it was probably about
six months ago, we had a member of our group who committed
suicide. She shot herself in the stomach. She left a note to
her son which said she did it this way so she could die slowly
because she thought that that is what she deserved. After
wearing a uniform, that is what she deserves? That is what she
deserves, to die slowly?
I had many problems at the VA where I have been required to
take off my clothing. That is a very uncomfortable position for
people like me. So I decided I was going to do something about
it and I went to my State Representative who led me to
Congressman Barr. This legislation is so important for us to be
able to go to these specialists that can help us.
In Lexington, Kentucky, it took fee-for-service almost six
months to find me a female doctor to go see for one of my
problems. There are many, many, many things that, many doctor
positions that need to be filled by females. There needs to be
a priority in hiring and a priority in health care for us to be
able to walk in the door and be treated by females.
When I went into the emergency room, I sat for seven hours
and I was told by a female I was lucky there was a female that
was on duty that day. Really? In a whole hospital, there is not
any more than one female that day?
It needs to be a priority that there is a female in every
specialty that is available to every veteran so that no matter
when you have a problem, you can have these problems addressed
so that you can go out and you can do the things that you need
to do to be a good parent.
I can say without a doubt and it probably will choke me up,
but I can truly say that if my daughter hadn't been born, I,
too, probably would have been one of those statistics that
would have not--I just wouldn't be here. And my daughter has
given me the strength to go out.
Still to this day, I struggle with triggers. I have to
every day go out. I have to think about where I am going, who I
am going to be around, what is going to happen, is there an
entry, is there an exit. Everything in my mind is that MST
brain that I have because I have to figure out constantly am I
safe.
I had to stop getting on People Finder--
Mr. Benishek. You have very compelling testimony and I
really appreciate you being here, but--
Ms. Moseley. I understand.
Mr. Benishek [continued]. unfortunately, we have a time
situation where we want to hear from everyone. But thank you
very much--
Ms. Moseley. Thank you.
Mr. Benishek [continued]. for being here, Ms. Moseley.
Mr. Cartwright, you are recognized.
OPENING STATEMENT OF MATT CARTWRIGHT
Mr. Cartwright. Thank you, Mr. Chairman.
Chairman Benishek, Ranking Member Brownley, and the Members
of the Committee, thank you for including today H.R. 1904, the
Wounded Warrior Workforce Enhancement Act, as part of your
hearing today and for the opportunity to speak to the
Subcommittee about this very important piece of legislation.
[The attachment appears in the Appendix]
Mr. Cartwright. I want to say it is an honor for me to
appear before the Veterans' Affairs Committee and its Health
Subcommittee. I also want to express my gratitude to the
American Orthotics and Prosthetics Association as well as to
Senator Durbin as they have been instrumental in focusing
attention on this critical issue facing our Nation's veterans.
The field of orthotics and prosthetics is at a critical
tipping point in terms of the future viability of its workforce
and the ability of those professionals to provide the best
tailored care to our Nation's servicemembers and veterans.
In its testimony, the American Orthotics and Prosthetics
Association stated that there has been an approximately 300
percent increase in the number of veterans with amputations
served by the VA since the year 2000. Unfortunately, currently
only 7,100 practitioners specially training in O&P nationwide
serve more than 80,000 veterans with amputations.
Of those trained practitioners, one in five is either past
retirement age or is eligible to retire in the next five years,
so we have a dwindling workforce we are working with.
However, there are only 13 schools around the country with
master's degree programs in this field with the largest program
supporting fewer than 50 students. And with the growing demand
of amputee treatment outpacing the number of new practitioners
trained to replace an aging workforce, it is clear we must act
now to meet our moral obligation of providing our heroes with
the best health care available.
The Wounded Warrior Workforce Enhancement Act is a cost-
effective approach to assisting universities in creating or
expanding accredited master's degree programs in orthotics and
prosthetics.
Specifically this bill addresses these issues by
authorizing a competitive grant program of $5 million a year
for three years to help colleges and universities develop
master's degree programs focusing on orthotics and prosthetics.
The bill also requires the VA to establish a center of
excellence in prosthetic and orthotic education to provide
evidence-based research on the knowledge, skills, and training
clinical professionals need to care for veterans.
This past week, I actually ran into a professional in
orthotics and he introduced himself as an orthotist. And I
didn't know what that was, but all of the physicians on the
panel already knew what that was. And then I explained this
bill to him and he was very grateful, a gentleman from
Nashville, Tennessee actually.
These prosthetic and orthotic treatments serve soldiers who
suffered limb loss injuries because they put their bodies on
the line for our country and as a result had their lives
forever changed. With Veterans Day just last week, it is a very
good reminder to us all just how much we owe to our wounded
warriors.
Again, I want to express my gratitude, Mr. Chairman
Benishek, Ranking Member Brownley, and Members of this
Committee, for your consideration of this bill today and for
bringing attention to the important issue of providing veterans
with the very best possible prosthetic and orthotic treatment
available.
Thanks so much.
[The prepared statement of Matt Cartwright appears in the
Appendix]
Mr. Benishek. Thank you very much.
Representative Peters, please go ahead.
OPENING STATEMENT OF SCOTT PETERS
Mr. Peters. Thank you, Mr. Chairman.
Good morning, Mr. Chairman, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for inviting me here to
discuss the Marriage and Family Therapist for Veterans Act.
[The attachment appears in the Appendix]
Mr. Peters. So we all know that the veterans, and you
mentioned this before, the VA's challenge to meet the need for
counselors among which are marriage and family therapists or
MFTs. In 2006, Congress enacted legislation that permits the VA
to employ licensed MFTs.
But the problem is that the VA takes a very restrictive
view of which MFTs it can employ. It limits its pool to MFTs
that graduate from a school that has been specifically
accredited by a certain accreditation organization, the
Commission on Accreditation for Marriage and Family Therapy
Education or COAMFTE, a nationwide accreditation.
What it excludes is a number of MFTs who have graduated
from schools that have long relied on established regional
accreditation systems. These systems existed long before the
COAMFTE accreditation was even established.
So, unfortunately, the VA's interpretation, their
limitation to that one accreditation system means that MFTs who
are qualified to practice in their home states can't walk
across the street and apply for a job to work at the local VA
for an MFT opening.
So my bill would simply specify that the VA can hire State
accredited MFTs in addition to the ones that have graduated
from schools that are accredited by COAMFTE.
In Florida, for instance, there is only one school that
meets the VA's qualification standards which excludes a major
portion of graduates from that state. Florida's situation is
similar to California and New York.
At this time, the California licensure and accreditation
process has been established for 15 years with well-trained and
qualified individuals heading into the job market, but because
of this interpretation by the VA, they are not eligible to work
at the VA.
So the bill simply opens up the employment eligibility for
those who have the proper training. It does not require
additional work on the part of the VA. It preserves the VA's
discretion over who they hire. It just enlarges the pool from
which they can select applicants.
So I appreciate the support the bill has already gotten
from Members here and look forward to working with everyone
here to enhance the care our veterans receive. Thank you for
the work you do and thanks for your consideration.
[The prepared statement of Scott Peters appears in the
Appendix]
Mr. Benishek. Thanks.
Representative Roby, please go ahead.
OPENING STATEMENT OF MARTHA ROBY
Ms. Roby. Mr. Chairman, Ranking Member, thank you for your
time today and the other Members of the Subcommittee for your
consideration of H.R. 3234, the Failing VA Medical Center
Recovery Act.
[The attachment appears in the Appendix]
Ms. Roby. As you recall, we have had major problems for an
extended period of time in my district at the Central Alabama
Veterans Healthcare System. We call it CAVHCS. The litany of
scandals captured national headlines, including unacceptable
wait times, the unearthing of thousands of unread x-rays, some
of which detected cancer, I might add, a VA employee caught
taking a drug rehab patient to a crack house and never
disciplined until we publicly exposed it, the CAVHCS director,
James Talton, lying directly to me, a Member of Congress,
retaliation against whistleblowers, and, finally, the
termination of James Talton, the first termination in the
Nation of a director in the wake of the wait list scandal that
has swept the Nation.
I cannot overstate the malfeasance that took place during
his tenure and the lasting harm that he inflicted on our
veterans in Alabama. At the same time, his termination was well
over a year ago. To this day, we still don't have a permanent
director and the hiring of other key staff has been extremely
slow.
While progress has been made, wait times, particularly for
outside care, remain unacceptable. Given the challenges that we
have faced in Alabama and the bureaucratic and cultural hurdles
to turn around a troubled medical center, I have introduced
this bill, the Failing VA Medical Center Recovery Act.
Today the VA lacks the organization, structure, and tools
for swiftly addressing problems at the worst performing medical
centers. Furthermore, there is little direct accountability at
the very top for turning around an especially troubled medical
center.
This legislation focuses on the most dysfunctional medical
centers in the Nation, ones that need major innovation and
oversight at the highest levels of the VA.
These two to seven medical centers are determined by
objective criteria, a composite score derived from the VA's own
SAIL data which measures key health metrics. Similar to how a
State school superintendent would take over the day-to-day
operations of a failing school, this legislation requires the
establishment of highly specialized teams to take over the day-
to-day operations of the worst VA facilities in the Nation,
removing the medical centers from the failed local and regional
VA leadership.
Rapid deployment teams are empowered with enhanced legal
authorities so they have the tools that they need to truly make
a difference on day one. Legal authorities in this bill include
direct hiring authority and the ability to pay up to 125
percent of the prevailing rate to address critical vacancies,
enhance personnel accountability authority for termination and
transfers, simplified contracting authority.
Given the challenging nature of this assignment, members of
the team are eligible for enhanced compensation and receive
favorable consideration for promotion with a two-year tour.
The Office of Accountability and Review is required to
prioritize whistleblower retaliation cases at failing medical
centers, and the Inspector General is required to prioritize
investigations related to failing medical centers.
Upon sustained satisfactory performance for nine months
measured by the SAIL data, these medical centers return to the
operational control of local and regional leadership.
The deployment teams are managed by the Office of Failing
Medical Center Recovery. In the legislation today, this office
is managed by a presidentially appointed Under Secretary who
has a direct line of access to the Secretary of the VA.
However, I recently met with the Under Secretary of Health,
Dr. Shulkin, and I have accepted his recommendation that this
office fall under his direct control in VHA and I am open to
modifying this legislation accordingly. I also welcome his
personal commitment that these failing medical centers will
receive his close supervision.
There are some objections on behalf of the VA and some of
the veterans' organizations. I am happy to address those
objections, but due to my rapidly decreasing amount of time, I
will save that for any questions that you may have.
What is clear here, though, Mr. Chairman, is that the
status quo is not going to cut it. We have to do better on
behalf of our veterans. And I understand any of your concerns
and I appreciate your feedback.
I am willing to work with anyone who truly wants to improve
the VA through this proposal and others, but let me tell you
what I am not going to do. I am not going to wait for a broken
bureaucracy to fix itself, so I would appreciate this
Committee's support on this piece of legislation.
I am happy to answer any questions. Thank you. I yield
back.
[The prepared statement of Martha Roby appears in the
Appendix]
Mr. Benishek. Thank you very much.
Mrs. Walorski, please go ahead.
OPENING STATEMENT OF JACKIE WALORSKI
Mrs. Walorski. Thank you, Mr. Chairman and Ranking Member
Brownley and Members of the Committee. I appreciate being given
the opportunity to discuss H.R. 3471, the Veterans Mobility
Safety Act of 2015.
[The attachment appears in the Appendix]
Mrs. Walorski. And first, I would like to thank Chairman
Benishek and Ranking Member Brownley for your support of co-
sponsoring this legislation.
Automotive mobility plays a vital part in helping our
disabled veterans live a normal life after being wounded on the
battlefield. This legislation ensures these veterans receive
the best adaptive equipment installation and service by
requiring vendors who participate in the Department of Veterans
Affairs' VA Automotive Adaptive Equipment or AAE Program to
meet minimum certification or accreditation standards.
The AAE Program provides eligible disabled veterans with a
new automobile or modification such as wheelchair lifts,
reduced effort steering and braking to existing vehicles in
order to improve their quality of life.
However, the VA does not require any type of certification
or accreditation from vendors to install or sell these
products. Since there are no requirements, VISNs operate based
on their own interpretations of VA procedures which has
resulted in VISNs using inferior vendors in an attempt to
reduce costs.
The modifications we are talking about are highly complex
products which means a lack of quality in service requirements
is putting the veteran and driving public at risk. Two cases in
my home State of Indiana illustrate this danger.
In the first case, the VA had a company install an easy
lock system into a veteran's vehicle. An easy lock system is a
wheelchair docking system that secures a wheelchair to the
vehicle floor. However, the bolt was improperly installed by
the company and kept getting caught on things.
The veteran complained to the VA which sent him back to the
dealer whose solution was to cut off the bolt on the bottom of
the chair in order to give him more room. However, doing so
meant that the wheelchair could not lock into position,
something the veteran didn't realize until his chair moved when
a car cut him off and he slammed on his brakes. Thankfully the
veteran wasn't hurt, but it is an illustration of the needless
danger caused by the lack of standards.
In the other case, a dealer subcontracted an individual to
come to a veteran's home to install a wheelchair lift. However,
that individual never tested the lift. When the wheelchair was
on the lift, it pushed the lift down causing it to catch on and
damage his bumper.
The VA had another dealer take a look at the lift. Their
solution, remove the bumper. Finally, qualified professionals
looked at the vehicle and concluded that the lift wasn't even
compatible with the vehicle and should never have been
installed in the first place.
As a point of comparison, the VA currently requires a
certification to sell a veteran a bottle of oxygen while the
AAE Program uses an outdated handbook that was last updated in
2000. This inconsistency of procedures has put veterans' lives
at risk and resulted in taxpayer dollars being wasted on shoddy
or improperly installed equipment.
My bill H.R. 3471 ensures disabled veterans receive the
best quality, performance, safety, and value by establishing a
minimum set of standards for vendors who want to participate in
the AAE Program.
Specifically, the vendors of adaptive equipment
modification services must be certified by a certification
organization or the manufacturer of the adaptive equipment and
must adhere to the Americans With Disabilities Act of 1990 and
the National Highway Traffic Safety Administration's federal
motor vehicle safety standards.
Individuals performing these modification services must
also be certified by either a certification organization or a
manufacturer or the State.
Lastly, this legislation puts the veteran in charge of what
equipment he gets by giving them the opportunity to make
personal selections of their automobiles or adaptive equipment.
Disabled veterans have given so much for our country and
they deserve the highest standard of mobility services. The
robust, enforceable set of standards that are prescribed in
H.R. 3471 will protect our veterans and the driving public
while responsibly spending taxpayers' funds through the AAE
Program.
I look forward to working with the Members of this
Committee, veteran service organizations, and the VA in
addressing this critical issue for disabled veterans.
And I thank you again, Mr. Chairman and Ranking Member
Brownley, for this opportunity to speak today.
[The prepared statement of Jackie Walorski appears in the
Appendix]
Mr. Benishek. Thanks, Mrs. Walorski.
Mr. Kline was unable to make the hearing this morning.
I am not going to take time right now to ask any questions.
Does anyone have any questions for the panel?
Go ahead.
Mr. Roe. Just one brief question for Ms. Roby.
One of the problems that we have seen in VA is the more
centralized it gets, it doesn't get better. The Veterans Choice
Program is a perfect example of one that we initiated. And the
more you send upstream here to Washington, the worse it seems
to get.
I think the accountability needs to be from here down to
make sure. That was untenable what happened and obviously a
failure of leadership, but I am not sure making it more
bureaucratic and putting it up to people who are in charge that
weren't successful to begin with is going to work.
That is my true question. I understand exactly what you are
saying, but we have just seen something that we intended and
you intended when everybody in this room voted for the Veterans
Choice Act. It didn't turn out like we thought it was going to
and I am afraid they will have the same result here.
I think you have just got to have accountability. We have
people now who are in charge of those VISNs. They need to be
fired if they are not doing the job. And then they need to have
the director fired and that is what needs to happen.
So we look instead of making it more bureaucratic, we need
to hold people accountable and that is what has been lacking at
the VA is accountability.
Ms. Roby. Right. And so I would suggest to you if you look
closely at this bill that it cuts through the layers of
bureaucracy and does apply direct accountability to the Under
Secretary of Health.
These rapid deployment teams come in and they are given the
tools that are necessary to clean house if that is exactly what
needs to happen so they can assess the situation on the ground.
I do a monthly call with my acting VISN 7 director, and I
meet with him when necessary between those calls as well
because of the malfeasance and mismanagement.
And what we found, James Talton, the director that was
fired at CAVHCS, just because he was fired, we haven't seen an
improvement in the culture. This shows that it doesn't lie at
the feet of one person.
Yes, Mr. Talton created a culture there and he needed to be
removed, but there are more bad actors and they are all
pointing fingers at one another. And they are able to hide
behind these layers of bureaucracy that exists in the VA.
So as I used the example of a failing school system in the
State of Alabama and I suspect in some of your states as well,
the school superintendent can come in and take over the day-to-
day operations of a failing system. It is an embarrassment to
everybody involved.
Mr. Roe. But a director can do that now. There is no--
Ms. Roby. What we are finding is that the directors and
others responsible are not being removed.
Mr. Roe [continued]. And, quite frankly, we had the Under
Secretary of Health the last time that is now gone tell us that
everything was hunky-dory at the VA. So I am not sure. I think
you remember that.
So, anyway, I yield back. That was the questions I had.
Mr. Benishek. Mrs. Walorski.
Mrs. Walorski. Ms. Moseley, I want to take a second and I
think many of us involved on this Committee have worked for
years long and hard to take the horrific thing that happened to
you and the kind of environment that you had to tolerate as a
member of the Armed Services fighting for our Nation and we are
working as hard as we can and as fast as we can to eradicate
military sexual assault from this military.
And I just wanted to thank you for what you do and let you
know that we are behind you. And we are working every day to
make sure that we together are going to be able to say that we
eradicated this and it is a safe place to serve.
So I am so sorry for what you have had to endure, but your
bravery coming here today does make a difference and we are
taking steps forward. And you help make that happen, so thank
you.
Ms. Moseley. Thank you.
My hope is that it will help the veterans that are coming
home from the long bouts of war that we have been in so that
they can get better care than I have.
Mrs. Walorski. They absolutely will. Thanks for your
bravery.
Mr. Benishek. Ms. Kuster, you have a question?
Ms. Kuster. Yes. Thank you.
I just want to add to thanking you. This is a bipartisan
issue that we have worked very closely on and will continue to.
And I appreciate you coming forward.
My question for Mr. Barr, and this is just more of a
conundrum that we have on this Committee, is if we use the
option of outside care, which makes a great deal of sense to
me, I am in a rural area, there are times when you can't see
the providers you need, will we run the risk of this issue not
being taken seriously and being front and center going forward
within the VA?
That is my concern. I am afraid that if we turn our
attention away that--I mean, this is something Mrs. Walorski
and I have been working on. We have a large group of people. We
have passed some pieces of legislation. I hesitate to let the
VA off the hook and that is my question.
Mr. Barr. I appreciate my friend and the gentle lady's
question.
And what I have found and discovered is that the simple
introduction of this legislation that would empower victims and
empower survivors of MST to choose their own care, to find that
specialized care that they need actually is the feature, the
reform feature that holds the VA accountable and actually gets
the VA to do those things.
And we have seen it in our own VA right in Central
Kentucky. The fact that we introduced this legislation has
resulted in response from the VA in terms of some hiring
decisions and some reforms internally that have offered new
veterans those services that they need within the VA.
But regardless of those reforms and those improvements that
we have seen, we still see a need for that immediate choice to
ultimately give the veteran the power over his or her care. And
so they can decide the therapist, the psychologist, the care
provider that they deem to be most suitable for their
particular situation.
Ms. Kuster. Great. Thank you very much. And I will look
into working with you on that and I appreciate it.
And then I just wanted to thank Mr. Bilirakis for his bill.
We have an opioid crisis in New Hampshire. I started a
bipartisan taskforce that I encourage folks to join. Mr.
Coffman has been so kind as to schedule a hearing coming up in
December in New Hampshire.
And on this opioid issue within the VA, we have some folks
working in pain management that are doing some cutting-edge
work that I am very excited to share through this hearing
bringing down the prescriptions of opioids and using other
methods of pain management.
And so I just want to thank Mr. Bilirakis. I am going to be
an original co-sponsor of his bill and look forward to working
in a bipartisan way on this issue.
Thank you, Mr. Chair.
Mr. Benishek. Thank you.
Well, if there is no further questions, the first panel is
excused. Thank you.
I would like to welcome the second panel to the witness
table. Joining us on the second panel is Adrian Atizado, the
Deputy National Legislative Director for the Disabled American
Veterans; LaRanda Holt, the Assistant Director for Women and
Minority Veterans Outreach for the National Veterans Affairs
and Rehabilitation Division of The American Legion; and Carlos
Fuentes, the Senior Legislative Associate for the National
Legislative Service of the Veterans of Foreign Wars of the
United States.
Thank you all for being here and for your hard work and
advocacy on behalf of our veterans. So I look forward to
hearing the views of your members.
And let's see. Mr. Atizado, you may begin when you are
ready.
STATEMENT OF ADRIAN ATIZADO
Mr. Atizado. Thank you, Mr. Chairman, Members of the
Subcommittee.
First I would like to thank you for inviting DAV to testify
at this legislative hearing. As you know, our organization is
nearly 1.3 million members. They are wartime service-disabled
veterans.
As an organization, we are dedicated to a single purpose
and that is to empower veterans to lead high-quality lives with
respect and dignity. So DAV is pleased to be here today to
present our views on the bills under consideration by the
Subcommittee. So for the sake of brevity, I will limit my
remarks to three of these bills.
First is H.R. 3549, the VA Billing Accountability Act. As
we mentioned earlier, this bill would provide VA the authority
to waive a required co-payment if the veteran received a VA
notification more than 120 days from date of VA service or more
than 18 months after the date of a non-VA facility service and
that the notification was delayed due to the agency's error and
that the VA would also need to provide information to veterans
on arranging payment plans and applying for waivers.
We support this legislation. We have a resolution passed by
our membership regarding co-payments and ask for swift action
on this bill.
With regards to the draft bill, the Promise Act, DAV
supports this bill based on a number of resolutions adopted by
our membership at our most recent national convention. While VA
has made recent efforts to address over-prescribing, its
existing pain management program appears to be not well
organized. It is also insufficiently staffed.
We believe enactment of this bill would call attention to
the need for VA to better manage and staff this function at
both the national and local levels. DAV also believes this bill
is a good first step toward improving the patient advocacy
program to help veterans and family caregivers better navigate
the VA health care system.
We support the advent of complementary and alternative care
in substitute of VA's use of pharmacological agents and to
better respond to the preferences of younger, mostly younger,
but some aging veterans as well who often do not want
traditional medical management, especially if it involves
prescribing of pain or psychotropic medications.
We appreciate the sponsors introducing this omnibus
proposal and we urge Congress to proceed with its enactment
this year.
Now, the last measure I would like to discuss is VA's
legislative proposal which would give the agency the authority
to enter into agreements for purchasing medical care from
community providers.
Now, according to VA, this proposal will streamline and
speed the business process for purchasing care for an
individual veteran when necessary care cannot be purchased
through existing mechanisms such as contracts or sharing
agreements.
We support the intent of this draft legislation based on
DAV resolution 217. However, we do recommend this measure be
amended to add certain federally recognized providers of
service with whom VA would be able to enter into an agreement
with under the measure.
These providers have served over 3,400 severely ill and
injured veterans of all ages across 31 states, the District of
Columbia, and Puerto Rico. Under this program, veterans are
given the opportunity to determine their own supports and
services. They themselves control it. This allows them to live
independently in the community and stave off having to go into
a nursing home.
However, as with other community providers affected by the
current situation, their arrangement with VA remains uncertain.
This critical program's growth to become available at every VA
medical center has been stymied for lack of VA's authority that
would be provided under this measure.
We urge this Subcommittee pass this measure to relieve the
current unsustainable and untenable situation that is adversely
affecting the lives of ill and injured veterans and their
families.
This concludes my testimony, Mr. Chairman. I would be happy
to answer any questions you or other Subcommittee Members may
have.
[The prepared statement of Adrian Atizado appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony.
Ms. Holt, you may begin your statement.
STATEMENT OF LARANDA D. HOLT
Ms. Holt. Thank you.
Good morning, Chairman Benishek, Ranking Member Brownley,
and Members of the Committee. I am privileged to be here today
and to speak on behalf of The American Legion, our National
Commander, Dale Barnett, and more than two million members in
over 14,000 posts across the country that make up the backbone
of the Nation's largest wartime veteran service organization.
There are several good bills for discussion today and our
full remarks are with you. I would like to focus on one key
bill, H.R. 1603, Military Sexual Assault Victim Empowerment Act
or the Military SAVE Act.
This bill would amend the Veterans Access Choice and
Accountability Act of 2014 which is to improve the private
treatment of veterans who are victims of military sexual
trauma. This bill would make victims of military sexual trauma
potentially eligible for non-VA health care under the Veterans
Choice Program.
Ultimately this is about trying to find the right
treatments and therapies for every veteran. And in the case of
MST, unique circumstances can shape treatment and therapy
needs.
VA should be flexible to ensure these veterans receive the
appropriate care they need in an environment that is conducive
to the veteran's unique circumstances. MST if left untreated
for veterans is a nexus to other mental health conditions such
as PTSD, depression, substance abuse, and suicidal ideations.
In the case of these survivors, ensuring they get the
appropriate therap and treatment can mean the difference
between a survivor continuing their treatment, abandoning
treatment, and feeling further isolated and possibly
escalations in their symptoms.
The American Legion is deeply concerned with the challenges
survivors of MST face and is urging Congress to ensure MST
survivors can receive the right health care at the right place
and at the right time.
In January 2011, The American Legion launched a landmark
women veteran survey which identified challenges women veterans
face when receiving gender-specific health care for treatment
of MST conditions throughout the VA health care facilities.
The American Legion has since fought for better awareness
training in the VA for MST sensitivity, significant increases
in outreach, and to provide more comprehensive care options for
MST survivors to include female therapists, group therapists,
and other options for care for MST accessible to include care
in their community.
As noted in our written testimony, VA is working to improve
their MST programs. However, as we know, changes within the VA
can take time and even the best programs can have different
results from one VA to another. The veterans should not have to
suffer because the health care they need is not available in
their local health care facility.
The American Legion recognizes that the Choice Program was
an emergency measure to make health care accessible to veterans
where VA was struggling to deliver such care. In recognition of
the needs of an integrated system to deliver non-VA health care
when needed, The American Legion believes VA needs to develop a
well-defined and consistent non-VA coordinated program,
policies, procedures that include a patient-centered care
strategy which takes veterans' unique medical injuries and
illness as well as their travel and distance into
consideration.
For survivors of MST who are suffering right now, The
American Legion believes they should have immediate access to
prompt medical treatment either within the VA health care
system or in their local community.
As with an outside VA, The American Legion stresses the
importance of ensuring non-VA health care has quality of care
standards equal to or better than VA quality care standards.
Additionally, the care MST survivors receive must be
coordinated effectively and efficiently to ensure veteran
health care is not adversely impacted.
Most importantly, non-VA health care providers must have
access to VA health care records and to the fullest extent
possible make use of the electronic data information exchange
to share patient health information.
Again, I thank the Committee for their hard work and
consideration for this legislation as well as your dedication
to finding solutions for problems that stand in the way of
delivery of veterans' health care. And I am happy to answer any
questions.
[The prepared statement of LaRanda D. Holt appears in the
Appendix]
Mr. Benishek. Thank you, Ms. Holt.
Mr. Fuentes, please begin.
STATEMENT OF CARLOS FUENTES
Mr. Fuentes. Chairman Benishek, Ranking Member Brownley,
and Members of the Committee, thank you very much for the
opportunity to present the views of the men and women of the
VFW and our auxiliaries. I thank you for the opportunity and
believe that the bills that we are discussing today are aimed
at improving the health care VA provides our Nation's veterans
and I thank you for bringing them forward. I would limit my
remarks to bills we support and have recommendations to
improve.
The VFW supports the Ask Veterans Act, which would survey
veterans to evaluate their views and experiences seeking VA
health care. When the VA access crisis erupted in April, 2014
the VFW turned to our members to gauge their experiences and
evaluate the access issues from their perspectives. The
information we obtained through surveys was invaluable. It
helped us shape our health care policy agenda and develop
recommendations to improve the VA health care system.
Currently, VA conducts a number of surveys to measure
veterans' experiences and evaluate its progress in meeting
strategic goals. However, frequent surveys only sample veterans
who have recently used VA health care and surveys that sample
all veterans are not frequent enough. That is why we urge the
Committee to require the legislation's survey to include a
sample of all veterans, not just recent VA patients.
The VFW supports the Wounded Warrior Workforce Enhancement
Act, which would expand availability of orthotic and prosthetic
care. Orthotists and prosthetists are vital to ensuring VA
provides the prosthetic care and services veterans have earned
and deserved. For this reason we urge the Committee to amend
this legislation by adding a requirement that grant recipients
offer reduced or no cost education to students who enter into a
service agreement with VA similar to service agreements under
other VA health professionals education assistance programs.
The VFW also supports the VA Billing Accountability Act,
which would ensure veterans are promptly notified of their
copayment obligations and would require VA to waive copayments
if it fails to properly notify veterans. Earlier this year,
more than 1,400 veterans were charged more than $500,000 for
five years worth of health care received at the Minneapolis VA
Medical Center. While disheartening, VA charging veterans for
years of copayments is not rare. The VFW continues to hear from
veterans that VA has sent them large bills for care they either
had no idea they were liable for or were unaware they had not
paid. This legislation ensures veterans are not punished for
VA's inability to get its house in order. However, the VFW
recommends that the Subcommittee allow VA to evaluate whether
the 120-day and 18-month requirements for notifying veterans of
copayments obligations are aligned with industry best
practices.
The VFW also supports the Promise Act, would reduce VA's
reliance on pharmacotherapy to treat mental health and complex
pain conditions, expand VA research, education, and delivery of
complementary and alternative medicine, and improve VA internal
audits. Countless veterans have experienced firsthand the
dangerous side effects of pharmacotherapy. High dose pain
medications if incorrectly prescribed have been proven to
render veterans incapable of interacting with their loved ones
and even contemplate suicide. This legislation would reform the
way VA treats complex pain conditions to ensure VA medical
facilities comply with VA's critical practice guidelines for
pain management.
The VFW has consistently heard from veterans that their
patient advocates are ineffective or seek to protect the
medical facility's leadership instead of addressing their
concerns. For this reason we strongly recommend that the
Subcommittee amend this legislation to codify VA's Veterans
Experience Office, established to collect and disseminate best
practices for improving customer service, coordinate community
outreach efforts, and serve as the subject matter experts on
the benefits and services VA provides veterans. The Veterans
Experience Officers should replace patient advocates currently
located at VA medical facilities. That requires that the duties
of Veterans Experience Officers be amended to include ensuring
protections under Title 38 are fully applied and complied with
by VA medical facilities and contracted community care
providers.
Mr. Chairman, this concludes my remarks and I am ready to
answer any questions you and your Members of the Subcommittee
may have. Thank you.
[The prepared statement of Carlos Fuentas appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Fuentes. I appreciate all of
your comments. They are very helpful. I yield myself five
minutes for a few questions that I have. And I guess really
what I want to talk about a little bit is the VA is going to
talk about their VA purchased health care streamlining and
modernization proposal. And I would like to talk to you about
that a little bit before they actually testify and I get to ask
them questions about it. Because you know, we passed this
Choice Act last year which we thought would make it easier for
veterans to get care in the private sector. And basically the
implementation of that was left to the VA and they decided they
cannot do it, we are going to get these third party providers
to do it, and it is going to be so much easier for veterans to
get care in the local community. And yet that really has not
worked as far as I can tell. It has been a difficult
implementation. So now they want to have a unified plan to
getting care in the community instead of different programs and
one community outreach plan, so it is uniform and easier for
everybody. So I was hoping to ask you all if you had any ideas
as to the best way to do that. Because we left it to the VA,
they came up with a plan that has not been that good. So with
that thought in mind, Mr. Atizado, what do you think of a way
to improve patients' access to community care? Do you have any
ideas in that regard? Or what has your group been thinking
about?
Mr. Atizado. I guess I will tackle that question from two
fronts. With regards to this bill that VA has proposed, my
understanding is, and I am sure VA will mention this as well,
provider agreements are a staple when purchasing care in the
communities. At least for VA's side of the house, they have
used this type of arrangement rather than a more cumbersome
contract vehicle, which is what the Choice program actually
requires is a contract as a vehicle to establish the business
arrangements.
With a contract there are a lot more requirements that some
smaller service providers may find not appealing to enter in
with VA. They just, the volume just would not make any business
sense for them to enter into that kind of an agreement, hence a
provider agreement.
But with respect to the Choice program, you know, this was
a pretty rapid response to a burgeoning issue, a crisis. And as
we have noticed, Congress has acted to change the Choice
program at least a couple of times because once it was
implemented we realized, everybody realized, that there were
problems with operationalizing this concept. So with regards to
your central question about what do we have to do to get VA to
be able to purchase care in the community the way we would
like? Well, I can tell you as a patient and as members of our
organization have requested, there are four main areas that
need to be addressed. I do not want to take up all your time.
But I can certainly send you a written response to that.
Mr. Benishek. Well, I appreciate that. You know, I have
been a provider at the VA myself. And I understand lots of
those things that you mentioned here. I just thought I would
try to reach out because this is a problem that we tried to
solve, improving care, but we just have not got the VA to do it
right. And we are just hoping to get continued input as we
struggle to find a way to get community care for our veterans
in a timely fashion. And I would welcome input from all your
groups as we work toward that struggle here and now. So Mr.
Fuentes?
Mr. Fuentes. Mr. Chairman, if I may, I just wanted to kind
of follow-up on what my colleague said here. And also to say
that the Choice program, although it has made a lot of
progress, was intended to be essentially a pilot program to see
what works and what does not. Through our surveys, working with
VA and working with the contractors, we have been able to
identify a lot of issues, right? And I think you have all seen
it through your constituents. And really the next step really
is to reform the delivery model, right? And take the lessons
learned and really take a holistic approach to delivering
health care to veterans that incorporates the best qualities
and capabilities of the private sector and VA and other public
health care providers, right? And making that analysis at the
local level to see what VA is able to provide, what the demand
is, and I think that is what has been lacking for a long period
of time. Is having that demand capacity analysis to really take
a look at what the demand is and who can provide that care, who
is best to provide that care with the most quality and also
accessible. And, you know, we are happy to follow-up. And we
are looking forward to the hearing tomorrow to discuss the plan
and we are hoping to maybe comment on some of the VA's plan in
more detail.
Mr. Benishek. Right. Thank you. Ms. Brownley?
Ms. Brownley. Thank you, Mr. Chairman. I wanted to ask
quickly about Mr. O'Rourke's bill, the Ask Veterans Act. And I
know that the DAV and the American Legion both either do not
have a position or feel, agree, I guess, with the VA that it is
duplicative. And you know, I just wanted to hear why you think
that. From my perspective, it is not because of the surveying
that the VA is doing now, it is sort of comprehensive, it is
sort of national. It does not, I do not think, we have not
really been able to trust the data and it does not drill down I
think deep enough to get the data that we really need on a
regional basis to understand what some of those issues are. So
I am just curious to hear from both of you about it.
Ms. Holt. Yes. The American Legion, as you mentioned we do
not have a position at this time for that. And it is because
they do have this process in place. Now what we can do we can
take that into consideration and maybe bring that back to our
members. Because we do not want to do anything without our over
two million members agreeing. And we really want to know what
it is that their needs are. So I think we just need to do
further research on that. And we can get back with you and
provide you a written, a more written, conductive statement to
provide for you on that topic.
Ms. Brownley. Thank you.
Mr. Atizado. Ms. Brownley, I appreciate you having read our
testimony on it. Our positions on legislation really come from
mandates from our membership. Since we do not have one
specifically on surveys, taking a position on Mr. O'Rourke's
bill would just, it would not be the place based on our
constitution and bylaws. But having said that, we understand
Mr. O'Rourke's situation. We hear it everyday. I hear it
everyday. I see the numbers that VA puts out and I hear those
thousands, there are literally thousands of veterans, or I
should say as VA measures them, appointments that are well
outside what we would think to be timely. Now the concern that
we have with surveying members, or surveying patients, is that
what happens after that? Our testimony talks about getting all
this information and what happens after? What is the action to
be taken? So our recommendation with the bill is if this
Subcommittee passes this bill in its form, notwithstanding what
VA has been trying to do recently. I think they came out with
some, a couple of additional surveys that look to more specific
points of service within a hospital as well as outside in the
community. But what action will be taken after that?
I have looked at the numbers for El Paso, Mr. O'Rourke. And
I can tell you the wait times are higher than average. We are
talking thousands of veterans, not only in completed
appointments, but waiting to have scheduled over 30 days. There
are certain areas of the country that are just far worse off
than others. And as any medical center director or any facility
director can tell you, it is far more complicated than surveys.
But that is a key question to ask. I think one of the
prevailing themes that we have been, that we have come across
throughout this discussion about access to care is where is the
patient's voice in all of this? Where does VA put veterans when
they develop their initiatives or their policies? Where is the
patient in that? Oftentimes we are consulted. They take our
ideas into consideration. But being part of the development I
think would be key. It would go a long way.
Ms. Brownley. Thank you. I wanted to ask quickly another
question on the military sexual assault. So Mr. Fuentes, I
understand that VFW is opposing the bill. They feel as though
MST is better treated within the VA, generally, roughly. So,
you know, if you could respond to that? And what I am really
curious to know for all three organizations on something like
military sexual assault, how do you survey your membership? Do
you, is it a broad brush survey that everybody responds to? Or
are you surveying just, well not necessarily, it is not always,
always women. Sometimes men are assaulted too. But, you know,
how do you get that information from your organization?
Mr. Fuentes. And just to clarify, we do not believe that
MST is best delivered at VA at all times, right? I think our
opposition is that the Choice program, as I said, is going to
end soon. And really what you need to do is take a look at how
to solve the access issue as a whole, and I think MST is also
included in there. And how to, ultimately our belief is that VA
is accountable for the care that is provided to veterans,
regardless if it is a non-VA care provider or VA. It is
providing that holistic approach to medicine that has made VA
the best, one of the best providers in the world, actually.
Now--
Ms. Brownley. My time is running out. So I think we are
going to have to follow-up.
Mr. Fuentes [continued]. Yes. I can follow-up with that.
Ms. Brownley. Okay. Very good. Thank you. I yield back.
Mr. Benishek. Dr. Roe? You are recognized.
Mr. Roe. Thank you, Dr. Benishek. Just a couple of things
that seem simple to me. One is, what is the purpose of the VA?
It is to provide health care for veterans, real simple. I have
literally made thousands of appointments, medical appointments,
to see other specialists. The VA is one of the only
organizations in the world that can make that complicated. It
is really simple to do. The patient comes in and sees Dr. Roe.
They need to see a dermatologist. I know who the dermatologists
are in my community who are quality. I write it. It goes out
front. I send them a note either electronically or by, oh
heaven forbid somebody types it. They make an appointment. They
go see the dermatologist, and I get information back. That
happens millions of times. But only the VA can take something
as simple as an appointment and send it out front, to
Washington, to a third party, to my Lord, and it could make
your head, you could send it up to the space shuttle easier
than getting an appointment.
And so I think we have got to back up and empower veterans.
And I think veterans are going to be able to vote with their
feet. I think if they want, if they feel like they get the best
care somewhere else they should be getting that care wherever
they can get the best care. And I am so frustrated with this
because it should not be that hard, I can tell you having done
it for 30-plus years, to get a patient an appointment. We know
if you cannot get a cardiology appointment you recruit
cardiologists. We know if you cannot get primary care, I am not
saying it is easy, but you know what those things are and this
is not difficult to do. Dr. Benishek has done it, and Dr.
Abraham has done it. Others of us. And Dr. Ruiz, he is not here
now, he has done the same thing. We know how to get those
appointments. And we know there are places, like in treating
PTSD, there is a shortage of providers. We know that. So we
need to concentrate on providing those resources for people.
But I just share my frustration with how the VA has gotten so
bogged down about it being about the VA and not about the
patient. It ought to be about the veteran and how to quickly,
the best way to get that veteran care. Look, if it is to do
with the loss of a limb, probably some of the best in the world
is certainly at Walter Reed. I have been there many times and
looked at that, translated down to the VA. For others it may be
something else. It may be out in the non-VA care. It should be
about getting the quality, quick care for the veteran. We ought
to be figuring, not making the bureaucracy bigger and harder to
do.
But anyway, I just wanted to make those statements. And
certainly I disagree. And you cleared it up, Mr. Fuentes, that
Military Sexual Trauma may be best treated outside the VA for
that particular, it should be where it is best, as this young
woman provided her testimony, what is best for her. It should
not be about the VA, it should be about where is the best care.
Mr. Fuentes. And if I may, Dr. Roe, you know, I completely
agree in terms of, you know, it needs to be where it is best.
Ultimately, what I think has been lost in a lot of this
conversation is that first and foremost it needs to be high
quality care, and accessible is also a part of that. And I
think it is secondary to quality, however. But when it comes to
reformed ideas we are strongly opposed to just simply giving a
veteran a card and going off to the community and fending for
themselves. That is because if you do that what you are doing
is underfunding VA and then giving them an option, or putting
them out there in the private sector that is not prepared or
does not have the actual capacity in all aspects, in every
state and every place.
Mr. Roe. Mr. Fuentes, I disagree with you on that. And we
will just respectfully disagree. Look, I was prepared to see
veterans. I am a veteran. I was prepared to see veterans,
although I did not work at the VA. I could clearly see those
patients. That is what I did for a living, took great care of
people, but put the quality up with anybody. I think you are
going to have the VA compete for those patients to keep them in
there and not trap them in there. I had an old GP tell me one
time that there are three A's of practicing medicine before I
started my practice. It is accessibility, affability, and
ability. People have got to like you. They have got to be able
to get to you. If you cannot get there, the quality does not
count if you cannot get an appointment. And just because the VA
practices medicine does not mean that that quality does not
exist because it does outside the VA and yet we are making it
hard when the patient, the veteran, cannot get in to get the
care in the VA, we are making it almost impossible to get care
outside the VA and we are going to hear more about that
tomorrow.
Mr. Fuentes. And if I may, Dr. Roe, I completely agree with
you that VA is not the best every single place, right? What
needs to happen is analyze who has the best care in what market
and determine what--
Mr. Roe. Yes, I agree with that.
Mr. Fuentes [continued]. where that veteran needs to go to
receive high quality, accessible care.
Mr. Roe. And in a timely--
Mr. Fuentes [continued]. And most of the times we think it
will be VA. But in plenty of times, in a lot of times,
depending on MST, depending on what the service is, it could be
in the private sector. Because there are providers, such as
yourself, in the private sector who are ready and able to care
for veterans and we need to empower them to be able to do so as
well.
Mr. Roe. I yield back.
Mr. Benishek. Thanks. Mr. O'Rourke, you are recognized.
Good? Mr. Takano?
Mr. Takano. Ms. Kuster was in before me.
Mr. Benishek. Oh, okay.
Mr. Takano. I just had one question. Regarding the Failing
VA Medical Center Recovery Act, do you think a new office is
necessary to oversee whether a VA medical facility is doing its
job of treating veterans? And what are your concerns regarding
the medical treatment of veterans should this new office be
created? And it is generally to whoever wants to answer the
question.
Mr. Atizado. I will step in. Thank you for the question,
Congressman Takano. We, as you probably surmised from our
testimony, we do not have a resolution to support the bill, but
we have a number of concerns on the bill. I think one first and
foremost is creating a new bureaucracy within the VA health
care system where the responsibilities for that one new office
really rest with those parts within VA that have the expertise
that deal with that domain. A health care hospital is a very
complex institution. And I understand that the bill wants to
centralize all those under one office. But I hesitate to
consider what would happen if you were to create that, and what
happens to the other parts of VA whose responsibility is right
now to make sure that hospitals that need help, are
underperforming, are actually incentivized to raise up to the
standard that VA expects its facilities to be.
But having said that, there is one part of the bill that I
want to make sure this Committee is aware of and I am thinking
you already are. And it is this dearth of leadership. There
seems to be an environment right now within the VA health care
system that people who would otherwise step forward to take
leadership positions in the VA just are not. I cannot explain
to you why that it is not. VA has had statements before about
how many are acting, how many are vacant, not only in the
facilities at the local level but also at central office, who
we need to make sure that there is a minimum standard that
every facility must meet, whether it is MST or access. Whether
it is recruiting appropriately or having a center of
excellence. That I could not tell you how to possibly address
that situation, but it is hurting facilities which means it is
hurting VA employees, which means it is hurting veterans.
Ms. Holt. And on behalf of the American Legion, the reason
why at this moment or at this time that we are not supporting
this is because we feel that we do not need to establish
another bureaucracy to monitor and track the VA facilities for
poor performance. We believe that that responsibility should
lie solely under the Under Secretary for Health. Now should
Congress make amendments to this we can bring that back to our
members and we would be more than happy to provide a statement
in a later time if that is okay with you.
Mr. Fuentes. Congressman, we agree with the intent of
identifying facilities that need assistance. However, what we
believe is necessary is a compliance mechanism, right? And our
opinion is that the Patient Advocacy Program is supposed to be
that compliance mechanism to ensure that veterans are receiving
the care that they have earned and deserved. However, due to
the fact that they are under the chain of command of their
local medical facility leadership, it prevents them from really
being that advocate for veterans. And we feel that if you
strengthen that program, and like we said, like we recommend
codifying the Veterans Experience Office and having that be a
part of the chain of command--not, I am sorry, separate from
the chain of command will enable VA to really implement that
compliance mechanism that is necessary.
Mr. Takano. Thank you. Mr. Chairman, I yield back.
Mr. Benishek. Thanks, Mr. Takano. Mr. Coffman, you are
recognized.
OPENING STATEMENT OF MIKE COFFMAN
Mr. Coffman. Thank you, Mr. Chairman. As a member of both
the American Legion and the VFW, thank you for being here
today. And certainly in talking about Military Sexual Trauma I
really appreciate the position of the American Legion. I think
that those victims of Military Sexual Trauma ought to be able
to choose the best treatment options available in their
specific case rather than having it dictated to them. And I
would expand that to all mental health care. Because the
biggest cost-driver, I think that we are confronted in
disability care, I mean in disability, is Post-Traumatic Stress
Disorder, or mental health. And so I think it is a very
personal thing, that interaction between a therapist and a
patient. And I really think that individuals ought to be able
to select what is best for them. And I am disappointed with the
VA in terms of having a drug-centric approach in terms of a
modality of treatment. And I think we have had testimony to the
effect in this Committee where in fact we have related suicides
to, say, I think we had one instance where a veteran had moved
and was given a cocktail of psychiatric drugs to counter
symptoms of PTSD, and then moved and could not navigate the
system for a refill. And that is a fairly dramatic thing to
happen, when somebody is suddenly off of these drugs. And at
the end they are given a drug to wake up in the morning, and a
drug to go to sleep at night, and a drug for this and a drug
for that. In my view, that is not a good therapy but I
understand that it is, probably from the VA's point of view it
is more cost effective to do that than the laborious sort of
treatment where psychotherapy is given as an exchange between
two individuals, the therapist and the patient. And so I think
the more options, the better? If a patient is feeling better as
a result of a certain modality of treatment that they are going
through, whatever that modality of treatment is, I just think
it ought to be available. And again, I think it is a very
personal, interpersonal thing. And so I would ask for the VFW
to go back and take a second look at this issue. Because I just
think it is so important for individuals to have options and to
make it their decision when it comes to something so
interpersonal as therapy for MST, for Military Sexual Trauma,
or for Post-Traumatic Stress Disorder. Sure.
Mr. Fuentes. If I may, Congressman? We completely agree
that veterans need to be presented with options. But I think
high quality and accessible options. And ultimately what it
comes down to is providing them the ability to go to providers
that, one, knows how to care for veterans, right? But also
knows the other aspects of comorbidities that are associated
with mental health conditions, right? But ultimately what it
comes down to is reforming the VA culture and the deliver care
model. One of the things that is most frustrating about VA is
that we often, as a patient we also find that a lot of VA
employees are quick to justify why they can say no instead of
getting to yes, right? That is something that needs to change.
But also the delivery of care model, to be able to provide them
those options instead of just sending them off to the private
sector to fend for themselves.
Mr. Coffman. All right, let me tell you, I do not think our
veterans that have returned from war can wait for the VA to
reform itself. There was one veteran, Iraq War veteran, in my
Congressional district who committed suicide. He, the only
thing, what we were able to trace was the fact that he called
VA for an appointment and had not received a response for two
weeks before his death. And so I can tell you as an Army Marine
Corps veteran, our veterans deserve better. And they cannot
wait for this system to improve. They have to have choices and
they deserve to have those choices now. With that, Mr.
Chairman, I yield back.
Mr. Benishek. Thanks, Mr. Coffman. Mr. Kind?
OPENING STATEMENT OF RON KIND
Mr. Kind. Thank you, Mr. Chairman. I want to first of all
think you and Ranking Member Brownley and all the Members of
the Committee for the courtesy for me to be in the dais. I am
not a normal Member of the Veterans Committee, but I do
appreciate the oversight, the work, the attention, the concern
that you have shown with many of the challenges that we face
within the VA system itself, but the VA medical centers.
I am here specifically in regards to legislation that Mr.
Atizado and the DAV has endorsed, the Jason Simcakoski Promise
Act. I have been working very closely with Chairman Bilirakis
as well as Representative Rice of this Committee to introduce
this bill this week. And Mr. Coffman, I could not agree with
you more. I think we have got a major opiate problem within the
VA system, but not limited to the VA system. I think it is
health care systemwide, that is going to require a lot more
care and focus and attention by this Congress in order to make
the changes that are necessary. And that is exactly what the
Promise Act was meant to do.
It is named after a constituent of mine, Jason Simcakoski,
who lost his life under the care and the treatment of the VA
medical center in the center of my Congressional district in
Tomah, Wisconsin. And I have been working very closely with his
wife and his father, Heather and Marvin Simcakoski, to get the
story out. But that family has one concern on their mind, and
that is to work with this Congress, to work with the VA to make
sure that the tragedy that befell their loved one does not
happen again. And that is the whole intent behind the Promise
Act. We have companion legislation already in the Senate on
this. And again, with Chairman Bilirakis' leadership we are
hoping to be able to introduce something. And we appreciate the
DAV's level of input and support that you have given this
legislation.
In a moment I am going to ask you whether the DAV in
looking at the legislation has any further recommendations in
working with us and what you would make. There is one aspect of
it I have been especially focused on. It is based on
legislation I have introduced earlier called the Veterans Pain
Management Improvement Act, that I have introduced with Mr.
Zeldin and Mr. Ribble, which would establish pain management
boards. It comes out of the recommendations that the OIG has
made on a nationwide survey withing the VA system, but also the
particular investigations that came out of Tomah in light of
what took place there. And what it does do is it changes the
delivery of care model, the culture. But probably most
importantly it gives the patients and the family members
themselves a greater say and a greater input in regards to the
treatment regimen. I am convinced that the family members are
the first line of defense when it comes to our veterans. They
are going to know what is working and what is not working, and
we have to make it easier for them to provide that input in
regards to the care and the treatment that the loved one, the
veteran in their family, is receiving. And unfortunately we
have not seen that in many instances.
That Pain Management Board Act is included in the Senate
version. We are still working on whether or not it makes sense
or what type of changes have to be made in regards to the
Promise Act when we introduce it this week. But Mr. Atizado, if
you have anything you want to share in regards to the DAV's
insight on this matter it would be appreciated.
Mr. Atizado. Congressman Kind, thank you for your kind
words, your effort in this area. This is a very sensitive
issue. Most of our members, if not all, are severely injured
with some kind of chronic pain. It is prevalent in our
membership. Our members are quite, feel very strongly about
pain management in the VA. Yes, they are worried, as Mr.
Coffman had mentioned, about overprescribing. But there is also
a growing voice that is worried that they are being
underprescribed. And if they are in fact being underprescribed
they are trying to seek relief with alternative types of care
which while they would like to receive are not, are having a
hard time trying to get for a number of reasons.
I would love to work with you and your staff on that.
Mr. Kind. Yes, I am glad you mentioned that aspect because
it is so important. There are so many more alternative and
complementary forms of care that we ought to be exploring in
much greater detail rather than just loading them up on a
cocktail of drugs all the time. And I have been aghast with the
number of veterans and families who have come into my
Congressional office with literally grocery bags full of
prescription drugs that they are getting from the VA system.
And they cannot in their lifetime take all of that, yet it
keeps being sent to them almost on a weekly basis and they are
overwhelmed with it. So I think we have to be a little
creative.
And one other piece of legislation, if you may, Mr.
Chairman, is I have introduced a Veterans Access to Care Act to
try to deal with the access and waiting line issue that we have
out there. And what this does is expands the definition of
health professional shortage areas for qualified VA medical
centers around the country. It is loan forgiveness, it is
scholarships, it is other incentives in order to get the highly
qualified and trained health care professionals in the VA
system in order to address the shortages. And I know speaking
to Tomah, they have got a critical shortage of primary care,
nurse practitioners. They cannot find a dermatologist. I mean,
all that has to be farmed out if they are lucky enough to do
that. But we are seeing this across the board, these shortage
areas and that. And this legislation that I have introduced
with my colleague Mr. Ribble might be a part of the answer of
creating further incentives to get the trained professionals in
where we need them the most. But I thank you again for your
courtesy in allowing me to participate here today for this
important hearing. I yield back.
Mr. Benishek. Well thanks for being here. I appreciate it.
Are there any other questions? If not, then the panel is
excused. Thank you very much for being here. I very much
appreciate your input.
I would like to now welcome our third and final panel to
the witness table. Joining us from the Department of Veterans
Affairs is Janet Murphy, the Acting Deputy Under Secretary for
Health for Operations and Management. She is joined by Elias
Hernandez, the Chief Officer of Workforce Management and
Consulting; Harold Kudler, the Chief Consultant for Mental
Health Services; and Susan Blauert, the Deputy Assistant
General Counsel. Thank you for being here. Ms. Murphy, you may
begin when you are ready. Thanks.
STATEMENT OF JANET MURPHY
Ms. Murphy. Good morning, Mr. Chairman and Ranking Member
Brownley. Thank you for inviting me here today to present our
views on several bills that would affect the Department of
Veterans Affairs. Joining me today is Dr. Harold Kudler, Chief
Mental Health Consultant; Elias Hernandez, Chief Officer,
Workforce Management and Consulting; and Susan Blauert,
Attorney in the Officer of General Counsel.
First let me begin by thanking the Committee for including
the VA legislative proposal to establish certain agreements for
purchasing medical care for veterans when care within VA
facilities or through contracts or sharing agreements is not
feasibly available. As many of you know, this is VA's top
legislative priority and we certainly appreciate the full
Committee's support and passage of this bill.
H.R. 1319 would require VA to enter into a contract to
conduct annual surveys of veterans at each facility. However,
VHA is already conducting ongoing surveys of over one million
veterans annually through our survey of health experiences of
patients per our SHEP program. VA uses a scientifically
designed survey instrument, the consumer assessment of health
providers and systems, in developing our SHEP survey which
allows us to compare our performance with non-VA hospitals and
health care systems.
H.R. 1603 would allow veterans seeking care for Military
Sexual Trauma to elect to use the Veterans Choice Program and
waive Choice eligibility requirements. While VA fully supports
veterans seeking care for MST where they choose in the
community, if they choose, we are currently able to offer that
option through Choice at this time and the new changes that
Congress has made to the Choice Act make that even more
available for those veterans. I would also say that VA
providers have received evidence-based training and education
about MST related issues which may not be commonly found in the
community.
H.R. 1904 calls for enhancing existing prosthetic orthotic
graduate programs, as well as developing a prosthetic orthotic
research center of excellence. VA currently operates five
research centers of excellence which incorporate our interns
and residents as well as graduate students from affiliated
academic institutions.
VA does not support revising the VA Marriage and Family
Therapy Qualification standards as proposed by H.R. 2639. VA's
current qualification standards for all mental health
professionals require an individual to have graduated from a
program accredited by an approved accrediting body that also
certifies the training program within that specific discipline.
With H.R. 3234 we recognize the intent of the bill is to
improve performance. VA already conducts many of the activities
and requirements outlined in the bill. We utilize strategic
analytics improvement and learning, or SAIL data, to measure,
evaluate, and benchmark quality and efficiency at VAMCs. Based
on SAIL, VA also sends teams of subject matter experts to local
facilities to provide consultative training and to help
facilities and provide follow-up consultation. We continuously
monitor facility performance and provide additional resources
as necessary.
VA is extremely concerned with establishing a new Under
Secretary position to manage and lead this office as it removes
authority currently vested in the Under Secretary for Health.
We believe such an organization would be costly and duplicative
and would not be successful in achieving improved outcomes in
care.
With H.R. 3471, VA does not believe this bill is necessary.
VA does not manufacture nor install adaptive equipment on a
beneficiary's vehicle. Instead VA's role is to prescribe and
pay for adaptive equipment. All safety and compliance issues
are addressed by the National Highway Traffic and Safety
Administration.
VA supports the intent of 3549 to provide the authority to
the Secretary to waive copayment bills generated in error to
prevent undue burden to veterans. However, VA wants to ensure
that any statutory changes do not remove authority to generate
copayment bills that are rightfully owed, but are delayed due
to normal businesses processes. VA estimates a ten-year revenue
loss of about $700 million if copayments are waived after 120
days from the date of service.
We do not have cleared views or costs for Section 103,
Title 3, and Section 501 of the Promise discussion draft.
However we would be glad to provide these views at a later
time.
Thank you, Mr. Chairman and Ranking Member, for the
opportunity to testify before you today. My colleagues and I
would be pleased to respond to any questions that you may have.
[The prepared statement of Janet Murphy appears in the
Appendix]
Mr. Benishek. Thanks for your testimony, Ms. Murphy. I
really appreciate it. How do you explain the difference in the
results of Mr. O'Rourke's survey and the VA survey? I mean,
that is basically the reason here. Is that, you know, we have
sort of come to not trust the VA and the results. So when you
say that you are doing things in a scientific fashion, you
know, that is all well and good. But you are opposed to a third
party doing it? I do not get that.
Ms. Murphy. So currently we do have a third party that does
our survey. So it is directly between the third party under
contract directly with the veterans and we are simply given the
results. So there is no interaction with that survey between us
and the veterans. The contractor does it all.
But I would just say that our results actually are the same
as the Congressman's results. The veterans are not very happy.
And so our results actually align.
I think also we want, in measuring access what we really
want to know is what the veterans think, which is what the
Congressman's survey tells us, and which is what our survey
tells us too. And so in many ways they are very aligned. And I
guess what I would really welcome is the opportunity to sit
down with the Congressman and see where we could, where we
feels we have deficits in our process and where we could align
our process more with what he has in mind. We are always
looking for input. The VSOs and veterans have input on our
current survey. In 2016, we are actually going to expand it to
be able to drill down more to certain specialties, particularly
high volume specialties in mental health and other areas. So
you know, we are constantly improving it. And you know, I would
welcome having a conversation with the Congressman or his staff
on how we could do better.
Mr. Benishek. I guess I have, you heard my question to Mr.
Atizado there, obtaining third party or outside the VA care.
And really it was up to the VA to develop the plan for how to
implement Choice. And they said that they could not do it
internally, and so they got these third party payers. And now
it does not seem to be working too good. So why did we not do
that in the first place? I mean, why did we not do what we are
talking about here in the first place? And I know that somebody
mentioned that, oh, it was a pilot program and we found out
this does not work. Give me your thoughts as to how we can make
this work better, getting care in the community.
Ms. Murphy. So it is true, sir, that we had a pretty short
timeline to get that program up and running. It was really our
first time out of the shoe with a program like that, of that
magnitude and with those requirements. I think as the program
has evolved and as Congress has given us additional authorities
and flexibilities with the program it is getting better.
I would say that I am probably as unhappy with the TPAs as
the veterans are. We are working hard to hold them accountable
to their contractual obligations. We have sent some of them
letters of correction, so that they are required to correct
some of the deficiencies. So I would say it is a work in
progress.
But let me give you an example of something that Congress
has done recently that is going to help us really tremendously.
So the provider agreements that we are asking for legislative
authority for, we already have that under the Choice
legislation. So currently our Choice providers do not provide
home and community care, for example. But with our provider
agreement authority we are now going to be able to set up our
own agreements with those home and community care providers and
we are going to be able to use Choice funding to pay for that
care. That is a terrific opportunity for us to really open up
access to care.
Mr. Benishek. Well I guess I understand that. It is just
that you guys set up this third party administration of the
Choice program providers. Now you are saying that is not
working out, right? I mean, I do not get why we did not do it
right the first time.
Ms. Murphy. I think we tried the best we could, and I think
we are trying to make it work and it is getting better.
Mr. Benishek. Well, I mean I agree that we should have one
way of doing it, and a coordinated way rather than having six
different techniques of getting people into the private sector.
Ms. Murphy. And you have now legislated us and you have
told us that we must find a way to do that, which is going to
be coming forward to you, I think later this month to tell you
what our plan is to do that.
Mr. Benishek. Yes, we are going to do another hearing
tomorrow. All right. Ms. Brownley?
Ms. Brownley. Thank you, Mr. Chairman. I just have two
quick questions. On Ms. Walorski's bill on Veteran Mobility
Safety Act, so you stated that the VA simply pays for the
adaptive equipment, that you are not, you know, building or
constructing the adaptive equipment. So when, you know, she
cited a couple of different examples that veterans have
incurred. And so when something happens to a, you know, it is
adapted improperly, the lift does not work, then what does the
VA do then? The veteran comes back to you and says it is not
working, I paid for it but my car is still not working for me?
Do you just pay again?
Ms. Murphy. No.
Ms. Brownley. That is it?
Ms. Murphy. No, we do not pay again. So I am not familiar
with those two cases. But theoretically, you know, that could
happen anywhere. It could happen under a certification program
or a state certified program as well.
Ms. Brownley. Understood. But what do you do at that point?
Ms. Murphy. Well we would go back and try to help the
veteran get the problem remedied. If it were really serious, I
presume we would report that vendor to the Transportation
Safety folks. You know, I think, you know, we do not have
regulatory authority. You know, we, but we try to resolve the
problem for the veteran if we can. And you know, if we see a
pattern of unsafe installments, I am sure we would be really
quick to report that to the appropriate Federal authorities.
Ms. Brownley. So do you have success in rectifying this for
veterans who have these experiences?
Ms. Murphy. I believe so. And I personally was involved in
a case where we went back to the vendor several times to get
the modification corrected and it was eventually corrected.
Ms. Brownley. So do you have data on that?
Ms. Murphy. I can ask and if we do we can provide that to
you.
Ms. Brownley. Okay. Very good. And on the marriage and
family therapists, so does the, what are the amount of openings
across the country for mental health professionals and
counselors? I do not have the data in front of me but I know
that we struggle with filling all of those positions. I know in
my district, you know, the turnover of that is very, very high.
So you know, it is, I am still struggling with your opposition
to this because I feel like we should be doing everything
possible. We obviously want highly qualified people. But you
know I think that we need to do as much as we possibly can to
make professionals available so that we can fill these
positions. Because it is, I know in my own district it is a big
problem.
Ms. Murphy. So I am going to defer the question to Mr.
Hernandez here. But I would say that marriage and family
therapist is not a classification of employees that we find
difficulty filling. So I think we really feel that the
standards that we have are high standards and we have some
concern about going in a different direction with the
standards. But to your question about openings and vacancies, I
will defer to Mr. Hernandez.
Mr. Hernandez. Thank you, Ms. Murphy. Ranking Member
Brownley, currently we have a total of 51 vacancies, of which
40 of them are already in the recruitment process. So we do not
have a high number of vacancies for--
Ms. Brownley. This is specifically for your definition of
marriage and family therapist. And so what about, you know,
across the board in terms of other counselors and other mental
health professionals?
Mr. Hernandez [continued]. I do not have those numbers in
front of me, Ranking Member. But I do know that for the family
and marriage therapist, you know, we have seven of those
vacancies and for the licensed professional mental health
counselors we have 34 vacancies.
Ms. Brownley. Thank you. I yield back.
Mr. Benishek. Mr. Coffman, you are recognized.
Mr. Coffman. Thank you, Mr. Chairman. And Ms. Murphy, you
characterized the legislation before us today, or being
discussed before us today, on Military Sexual Trauma as that
you already have the authority to do that under the Choice Act
so the issue is already taken care of. That is simply not true.
The way this legislation is written is that it is not
contingent upon distance from a VA facility, nor is it
contingent upon wait time. It makes one eligible from day one
who has an incident of Military Sexual Trauma. So I am just
surprised at your testimony before this Committee. Can you
explain that?
Ms. Murphy. Thank you, sir. Yes, and with the new
authorities that you gave us we no longer have to wait the 30
days if there is a clinically indicated need for the service.
So basically, if a clinician or a physician or a patient feels
they need it today, and that becomes a clinically indicated
date in that service, they are eligible for Choice today. There
is no longer any enrollment constraint. So anybody enrolled at
any time can take advantage of Choice. We also have the undue
burden criteria, where if it is an undue burden for a veteran
to travel a certain distance or to get to a VA facility, they
are also eligible under Choice.
Mr. Coffman. Here is the problem with that. They have to
navigate your bureaucracy to get there, which is so hard to do.
I mean, it is unfriendly to veterans, it is unfair to veterans.
And so what this legislation does is it automatically places
them as eligible. And so despite your testimony, I would
strongly urge my colleagues today to support that legislation.
With that, Mr. Chairman, I yield back.
Mr. Benishek. Thank you, Mr. Coffman. Ms. Kuster? Do you
have any questions? Oh, okay. Mr. Takano?
Mr. Takano. Yes. Ms. Murphy, in his testimony, Mr. Fuentes
mentioned that veterans in extended care facilities are in
danger of losing access to their homes because VA cannot extend
the contract. Can you explain the situation? Would the VA's
proposed legislation help? Or would the bill text need to be
revised to impact those veterans?
Ms. Murphy. So thank you, sir. Are you referring to the
provider agreement legislation?
Mr. Takano. I think so. That is right.
Ms. Murphy. Right. So the way we have used those vehicles
is there are often small nursing homes or community living
centers or home board and care facilities--not board and care.
Sorry, that does not qualify. But home health agencies, aid and
attendance, where we are able to use a vehicle called a
provider agreement rather than a FAR-based contract to procure
those services.
What we have learned as we began to try to find ways to
continue those agreements that we really are being pressed to
use FAR-based contracts. And some of those providers are
dropping out. Because if you are a small family run agency or a
small business, it is very difficult to comply with FAR-based
requirements. Our provider agreements give us another vehicle
that has protections, such as those that are provided to
Medicare providers, and has constraints, but does not have all
the requirements of a FAR-based contract. And thus some of our
smaller providers, our community providers, our one doc shops
we hope will be more willing to stick with us and continue to
serve veterans.
Mr. Takano. Okay. Thank you. You mentioned briefly that the
VA would like to make additional improvements on the draft bill
on care in the community that we are discussing today. Could
you go into a little bit more detail on that?
Ms. Murphy. So I am sorry sir, which bill are you referring
to?
Mr. Takano. The provider agreement.
Ms. Murphy. I am going to turn it over to Susan as our
legal eagle here.
Ms. Blauert. Yes. So Senator Blumenthal introduced S. 2179
and we noted that it more clearly articulated some of the
protections for employment opportunities more so than the draft
bill that the administration introduced in May. So that is, it
is really clarifying those portions.
Mr. Takano. Okay. Great. Well I agree with the intent of
the VA Billing Accountability Act. Veterans deserve to know
what they are expected to pay in a timely manner. I understand
the VA puts a 90-day hold on bills to veterans when other
health insurance is involved. This is to allow VA to collect
from third party payers before billing the veteran. But how
does that compare to the industry standard? Would that initial
hold period make the 120-day timeline unworkable? Would that
period need to also be revised? What billing and processing
improvements would make, would VA need to do to meet the 120-
day limit? If 120 days is not feasible, what limit would be
acceptable to the VA?
Ms. Murphy. So sir, I would point out that you are giving
the private sector 18 months and you are giving us 120 days. So
there is a little bit of imbalance there. I think we would
just, the 120 days is just too fast for normal business
processes. You know, we are relying on the other health
insurance to actually accept our bill, accept it as a clean
claim, pay it timely. We rely on them to have their bill
processing in order. Claims sometimes go back and forth because
they disagree with what we have got on there or they want
additional information. So sometimes it just takes more time.
The other thing that happens is that sometimes our copay
bills are delayed because we have a process of verifying a
veterans' income. And we use the IRS database for that. So
sometimes veterans will appear based on the income that they
have declared not to owe a copay, but when we go through the
IRS verification process which is sometimes out in the future
after people file their taxes, we sometimes find that the IRS
tells us that the income that the veteran has declared is not
accurate and in fact they are now liable for copays. And so we
want to be able to bill those copays for which the veterans are
liable, even though that is well beyond the 120 days. So I
guess what I am saying is that that is too limited a timeframe
for us to work in. It is too small a box for us to be able to
manage this appropriately. And I mean the opportunity for us to
lose revenue that, you know, veterans actually owe. I mean,
obviously if we made a mistake we need to own that. But we also
need a little bit more time to work in.
Mr. Takano. Thank you, Mr. Chairman, I yield back.
Mr. Benishek. Mr. O'Rourke, you are recognized.
Mr. O'Rourke. Thank you, Mr. Chairman. And Ms. Murphy,
first of all thanks for the offer to work with us. Because if
you are already tracking some of this then I agree, or we want
to look at this, but I agree we do not want to duplicate
efforts and spend more money. And we just want to get to an
accurate measure and understanding of veterans' experiences in
their own words or by their own measure. I think that is
important. Where can I find the SHEP survey that you
referenced?
Ms. Murphy. We will send it to you.
Mr. O'Rourke. Where could a veteran in my district find the
SHEP survey?
Ms. Murphy. I think it is on a link. I think the link, I
will send you the link.
Mr. O'Rourke. So I spent the last, and David who is behind
me spent the last 20 minutes searching for SHEP VA survey,
survey of health care experiences of patients, which is what
SHEP stands for, El Paso VA survey, we cannot find it online.
So I do not doubt that it exists. It is not accessible. And I
think that lack of accessibility is connected to a lack of
accountability. Part of the reason we want to do this is we
want the VA, and frankly my office, to be accountable for the
performance of the VA. And I am a big believer in that which is
accurately measured tends to improve. And when people do not
know what those measures are it makes it harder for us to
direct resources or prioritize accordingly. How did you measure
wait times? How were wait times measured or asked for in the
SHEP survey?
Ms. Murphy. They do not ask specifically for wait times.
They ask questions like when you called, did you get an
appointment when you wanted it? Did you have to wait more than
15 minutes past your appointment time? When you called, when
you needed an urgent care appointment, did you get it when you
wanted it?
Mr. O'Rourke. So the SHEP survey does not ask for wait
times? So we have no independent check on what the VA has been
telling us, which was wrong in Phoenix, it was wrong in El
Paso. I think it is actually still wrong today because you do
preferred appointment, which is a concoction that I do not
understand. I understand the veterans requests an appointment
on day one, and I understand he or she is seen at a certain
date thereafter. That, the period between, you know, one and
whenever that date is is the wait time. I do not know why you
do not measure it that way, but our survey does.
So does the SHEP survey measure access to mental health
care?
Ms. Murphy. It asks veterans if they felt they got an
appointment when they needed it or wanted it?
Mr. O'Rourke. Specific to mental health care?
Ms. Murphy. I would have to check. I think it does.
Mr. O'Rourke. Okay. So our survey found that, as I
mentioned earlier, more than one-third of veterans in El Paso
did not have access to mental health care. Could not make an
appointment despite their best efforts to do so. When we
brought that to the VA's attention, and when we hammered the VA
frankly on this huge gap in service, that helped the VA to
prioritize resources where they were most needed. It is not too
hard to connect care denied, frankly, absolutely denied, to the
high rate of veteran suicides. And we have those in El Paso. So
that is where I found this survey to be incredibly useful to
us.
If I understand you correctly, the SHEP survey says were
you happy with your service, were you seen when you wanted to
be seen? It does not give us an independent check or
verification on numbers and data that you give us, which is
what we need and what I think veterans would be far happier
with, and what I as a Member of Congress with oversight
responsibility would be far happier with, than just trusting
you that you are seeing veterans within a certain period of
time that you say they are.
So if the SHEP survey does not do all those things, then I
do not think you have a compelling case against the Ask
Veterans Act. Now I am very happy to take you up on your offer.
I will meet with you. If in fact the SHEP survey does all those
things that today we are not sure about, then let us just
publish it, make sure everybody can see it, and let us hold
everyone responsible accountable. But if not, then I think we
need to have, I would love to have your support on the Ask
Veterans Act.
And lastly, Mr. Chairman and Madam Ranking Member, this is
not rocket science to design these surveys. It is not
incredibly expensive. We spent about $6,000 of our office's
resources to conduct these surveys to get it within a margin of
error under four percent. If we do not pass this legislation,
if the VA does not want to implement it on its own, I would be
very happy to show any office how to do this or at least how we
did it. And it could certainly be improved upon. So with that,
I yield back.
Mr. Benishek. Thank you. Any other questions? Well, thank
you for being here this morning. I appreciate that. The panel
is excused. I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks and include
extraneous material. Without objection, so ordered. I would
like to once again thank all of our witnesses and the audience
members for joining us this morning. The hearing is now
adjourned.
[Whereupon, at 12:10 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Ranking Member Julia Brownley
Thank you, Mr. Chairman, for calling this hearing today. It is
important for us to review the legislation that has been referred to
this subcommittee. It is important to hear from our colleagues on their
priorities and to hear all views on how to best protect the health of
those men and women who dedicate their lives to protecting this nation.
I am pleased so many of our colleagues are attending the hearing
today in support of their legislation. Thank you so much for your
interest in the well-being of the veteran community.
Mr. Chairman, while there are many worthy bills on the agenda
today, I will focus on just a few being considered today.
I am pleased to be a cosponsor of Congressman O'Rourke's bill, H.R.
1319, the Ask Veterans Act. This bill requires the VA to conduct an
annual survey over the next five years to find out if
Veterans are obtaining hospital care and medical services at the
facility in a timely manner; how long it is between the time a veteran
requests an appointment and the date the appointment is scheduled, the
frequency with which scheduled appointments are cancelled, and the
quality of hospital care or medical services received. These reports
will then be posted on the VA's website.
I am also a cosponsor of Congressman Peters' bill, H.R. 2639, the
Marriage and Family Therapists for Veterans Act. This bill revises the
eligibility criteria for appointment to a marriage and family therapist
position with the Veterans Health Administration to require a person to
hold a master's degree in marriage and family therapy, or a comparable
degree in mental health, from an appropriately accredited institution
and to have passed the Association of Marital and Family Therapy
regulatory board examination in marital and family therapy or have a
marriage and family therapy license given by a state board that
oversees this issue. We need to know that our men and women coming to
the VA are getting the proper therapy when they come to the VA for
treatment.
I am also delighted that we are considering H.R. 3471, the Veterans
Mobility Safety Act of 2015. This bill directs the VA to ensure that an
eligible disabled veteran provided an automobile or other conveyance is
given the opportunity to make personal selections relating to the
automobile or other conveyance. It also included the minimum standards
of safety and quality for adaptive equipment. I am pleased to be a
cosponsor of this legislation.
Mr. Chairman, I look forward to the testimony from our witnesses
today and their views on how to improve upon the many bills that we are
considering.
Thank you and I yield back the balance of my time.
Prepared Statement of Honorable Andy Barr
Thank you Chairman Benishek and Committee Members for
allowing me the opportunity to present my legislation, H.R. 1603, the
Military Sexual Assault Victims Empowerment Act also referred to as the
Military SAVE Act.
Two years ago, several veterans who were survivors of
military sexual trauma but were not receiving the proper individual
care they needed from the VA, visited my district office to share with
me their powerful and heartfelt stories.
I would like to introduce one of those individuals who
helped inspire the creation of the Military SAVE Act - a courageous
woman and survivor of military sexual assault, Ms. Susan Moseley.
I would like to yield the balance of my time to Ms.
Mosley.
Prepared Statement of Honorable Matt Cartwright
Chairman Benishek, Ranking Member Brownlee, and Members of the
Committee, thank you for including H.R. 1904, the Wounded Warrior
Workforce Enhancement Act, as part of the hearing today and for the
opportunity to speak to the Committee about this very important piece
of legislation.
Additionally, I would like to thank the American Orthotics and
Prosthetics Association as well as Senator Durbin as they have been
instrumental in focusing attention on this critical issue facing our
nation's veterans.
The field of orthotics and prosthetics is at a critical tipping
point in terms of the future viability of its workforce and the ability
of those professionals to provide the best-tailored care to our
nation's service members and veterans.
In its testimony, the American Orthotics and Prosthetics
Association stated that there has an approximately 300% increase in the
number of veterans with amputations served by the VA since the year
2000.
Unfortunately currently only 7100 practitioners specially trained
in O&P nationwide serve more than 80,000 vets with amputations. Of
those trained practitioners, one in five is either past retirement age
or eligible to retire in the next five years.
However, there are only 13 schools around the country with master's
degree programs in this field with the largest program supporting less
than 50 students.
With the growing demand of amputee treatment outpacing the number
of new practitioners trained to replace an aging workforce, it is clear
that we must act now to meet our moral obligation of providing our
heroes with the best health care available.
The Wounded Warrior Workforce Enhancement Act is a cost-effective
approach to assisting universities in creating or expanding accredited
master's degree programs in orthotics and prosthetics.
Specifically, the bill addresses these issues by authorizing a
competitive grant of program of $5 million per year for 3 years to help
colleges and universities develop master's degree programs focusing on
orthotics and prosthetics.
The bill also requires the VA to establish a Center of Excellence
in Prosthetic and Orthotic Education to provide evidence-based research
on the knowledge, skills, and training clinical professionals need to
care for veterans.
These prosthetic and orthotic treatments serve soldiers who
suffered limb loss injuries because they put their bodies on the line
for our country, and as a result, have their lives forever changed.
With Veterans Day just last week, it is a very good reminder just how
much we owe our wounded warriors.
Thank you again Chairman Benishek, Ranking Member Brownlee, and
Members of the Committee for your consideration of this bill today and
for bringing attention to the important issue of providing veterans
with the best possible prosthetic and orthotic treatment possible.
Prepared Statement of Honorable Scott Peters
Thank you to Chairman Benishek, Ranking Member Brownley and members
of the subcommittee, for agreeing to hear H.R. 2639, the Marriage and
Family Therapists for Veterans Act. This subcommittee works tirelessly
to provide veterans the care they deserve, and this bill can help
achieve that goal for which we all strive.
My bill is short and simple. It will modify the current US Code to
allow well trained Marriage and Family Therapists (MFTs) the
opportunity to provide mental health services to veterans, and their
families, through the VA.
The current standards make it impossible for many MFTs to work at
the VA despite being licensed in the state they operate, due to non-
alignment with federal hiring requirements. Some of the most affected
applicants are those in California, Florida, and New York. My bill will
open the VA application process to those who are qualified through
regionally accredited programs and established regulatory board
examinations. Furthermore, this bill allows the VA to maintain its
authority to make the final decisions on who is hired. Fixing this
problem will help foster competition in hiring practices at the VA and
America's veterans will be the greatest benefactor.
My intent is that the VA will recognize MFT's who have the
qualifications outlined in this bill are able to apply for jobs and be
hired at the VA to increase the mental health care that is available. I
look forward to working with the committee to enhance the care our
veterans receive and appreciate the consideration.
Prepared Statement of Honorable Martha Roby
Mr. Chairman,
Thank you for your time today and consideration of HR 3234, the
Failing VA Medical Center Recovery Act.
As you recall, we have had major problems for an extended period of
time in my district at the Central Alabama Veterans Healthcare System
(CAVHCS). The litany of scandals captured national headlines:
unacceptable wait times
the unearthing of thousands of unread Xrays (some of
which detected cancer I might add)
an employee of the VA taking a patient to a crack house
CAVHCS Director James Talton lying directly to me, a
Member of Congress
retaliation against whistleblowers
and finally the termination of James Talton, the first
termination in the nation of a Director in the wake of the wait list
scandal that swept the nation
I cannot understate the malfeasance that took place during the
tenure of James Talton and the lasting harm he inflicted on Veterans in
Alabama. At the same time, his termination was well over a year ago. To
this day, we still do not have a permanent Director, and the hiring of
other key staff has been extremely slow. While progress has been made -
wait times, particularly for outside care - remain unacceptable. Given
the challenges we have faced in Alabama and the bureaucratic and
cultural hurdles to turn around a troubled medical center, I have
introduced the Failing VA Medical Center Recovery Act.
Today the VA lacks the organization structure and systemic tools
for swiftly addressing problems at the worst performing medical
centers. Furthermore, there is little direct accountability at the very
top for turning around an especially troubled medical center. The
legislation focuses on the medical centers facing the most
dysfunctional medical centers in the nation, ones that need major
intervention and oversight at the highest levels of the VA. These 2-7
medical centers are determined by objective criteria, a composite score
derived from the VA's own SAIL data which measures key healthcare
metrics.
Similar to how a state may takeover the day to day operations of a
failing school, this legislation requires the establishment of highly
specialized teams to takeover the day to day operations of these worst
VA facilities in the nation, removing the medical centers from the
failed local and regional VA leadership.
Rapid deployment teams are empowered with enhanced legal
authorities so they have the tools necessary to truly make a difference
on day one. Legal authorities include:
Direct Hiring Authority and the ability to pay up to 125%
of the prevailing rate to address critical vacancies
Enhanced Personnel Accountability Authority (Terminations
and Transfers)
Simplified Contracting Authority
Given the challenging nature of this assignment, members of the
team are eligible for enhanced compensation and receive favorable
consideration for promotion with a two year tour.
The Office of Accountability and Review is required to prioritize
whistleblower retaliation cases at failing medical centers, and the
Inspector General is required to prioritize investigations related to
failing medical centers.
Upon sustained satisfactory performance (9 months) measured by
SAIL, these medical centers return to the operational control of local
and regional leadership.
The deployment teams are managed by the Office of Failing Medical
Center Recovery. In the legislation, this office is managed by a
presidentially-appointed Under Secretary who has a direct line of
access to the Secretary of the VA. However, I have recently met with
Undersecretary of Health Dr. Shulkin. I have accepted his
recommendation that this office fall under his direct control, and I am
amenable to modifying this legislation accordingly. I also welcome his
personal commitment that these failing medical centers will receive his
close supervision.
The legislation does impose statutory reporting requirements so
that Congress, the President, and the public have a clear report card
on the office's progress.
I welcome your questions and comments.
Prepared Statement of Honorable Jackie Walorski
Good morning Chairman Benishek, Ranking Member Brownley and members
of the Committee. I appreciate being given the opportunity to discuss
H.R. 3471, the Veterans Mobility Safety Act of 2015.
First, I would like to thank Chairman Benishek for holding this
hearing and Ranking Member Brownley for cosponsoring this important
legislation. Automotive mobility plays a vital part in helping our
disabled veterans live a normal life after being wounded on the
battlefield. This legislation ensures these veterans receive the best
equipment by requiring vendors who participate in the Department of
Veteran Affairs (VA) Automobile Adaptive Equipment, or AAE, program to
meet minimum certification or accreditation standards.
The AAE program provides eligible disabled veterans with a new
automobile or modification, such as wheelchair lifts and reduced-effort
steering and braking, to existing vehicles in order to improve their
quality of life. However, the VA does not require any type of
certification or accreditation from vendors to install or sell these
products. Since there are no requirements, VISNs operate based on their
own interpretations of VA procedures, which has resulted in VISNs using
inferior vendors in an attempt to reduce costs. The modifications we
are talking about are highly complex products, which means a lack of
quality and safety requirements is putting the veteran and driving
public at risk.
Two cases in my home state of Indiana illustrate this danger. In
the first case, the VA had a company install an EZ Lock system into a
veteran's vehicle. An EZ Lock system is a wheelchair docking system
that secures a wheelchair to the vehicle floor. However, the bolt was
improperly installed by the company and kept getting caught on things.
The veteran complained to the VA, which sent him back to the dealer,
whose solution was to cut off the bolt on the bottom of the chair in
order to give him more room. However, doing so meant that the
wheelchair could not lock into position - something the veteran didn't
realize it until his chair moved when a car cut him off and he had to
slam on his brakes. Thankfully, the veteran wasn't hurt, but it is an
illustration of the needless danger caused by this lack of standards.
In the other case, a dealer subcontracted an individual to come to
a veteran's home to install a wheelchair lift. However, that individual
never tested the lift. When the wheelchair was on the lift, it pushed
the lift down causing it to catch on and damage his bumper. The VA had
another dealer take a look at the lift. Their solution? Remove the
bumper. Finally, qualified professionals looked at the vehicle and
concluded that the lift wasn't even compatible with the vehicle and
shouldn't have been installed in the first place.
As a point of comparison, the VA currently requires a certification
to sell a veteran a bottle of oxygen, while the AAE program uses an
outdated handbook that was last updated in 2000. This inconsistency of
procedures has put veterans' lives at risk and resulted in taxpayer
dollars being wasted on shoddy or improperly-installed equipment.
My bill, H.R. 3471, Veterans Mobility Safety Act, ensures disabled
veterans receive the best quality, performance, safety, and value by
establishing a set of minimum standards for vendors who want to
participate in the AAE program. Specifically, vendors of adaptive
equipment modification services must be certified by a certification
organization or the manufacturer of the adaptive equipment, and must
adhere to the Americans with Disabilities Act of 1990 and the National
Highway Safety Administration's Federal Motor Vehicle Safety Standards.
Individuals performing these modification services must also be
certified by either a certification organization, manufacturer, or the
state. Lastly, this legislation puts the veteran in charge of what
equipment he gets by giving them the opportunity to make personal
sections of their automobiles or adaptive equipment.
Disabled veterans have given so much for our country and they
deserve the highest standard of mobility services. The robust,
enforceable set of standards that are prescribed in H.R. 3471 will
protect our veterans and the driving public while responsibly spending
taxpayer funds through the AAE program. I look forward working with the
members of this Committee, Veteran Services Organizations, and the VA
in addressing this critical issue for disabled veterans. I thank you
again for this opportunity to speak today.
Prepared Statement of Honorable John Kline
Chairman Benishek, Ranking Member Brownley, and members of the
Health Subcommittee, thank you for the opportunity to testify this
morning in support of H.R. 3549, the VA Billing Accountability Act, my
legislation that will keep faith with our veterans by protecting them
from flawed billing practices at the Department of Veterans Affairs.
Mr. Chairman, last week, we, as a nation, paused on Veterans Day to
honor those men and women who bravely wore our country's uniform. One
of the reasons I first came to Congress was to ensure promises made to
our veterans, troops, and their families were promises kept. While
Washington has made some strides to do more to keep those promises, we
can always do better.
Mr. Chairman, this summer I was notified the VA discovered unbilled
co-pay amounts for impatient care provided to Minnesota and Wisconsin
veterans over a five-year period. Most concerning, our veterans were
going to be immediately assessed co-pays after the VA erred in not
charging veterans at the time of care. To be clear: through no fault of
their own, Minnesota and Wisconsin veterans were set to receive on
their monthly statements unexpected charges for thousands of dollars
for care received, in some cases, several years ago.
Many of our veterans live on fixed incomes or may not have the
resources available to cover the unexpected costs caused by the VA's
erroneous and untimely billing procedures. These billing blunders can
unnecessarily cause confusion, frustration, and stress for many of the
veterans in Minnesota, Wisconsin, and across the nation who seek care
at the VA.
We owe a great deal to those who have proudly served our nation.
They should never be suddenly saddled with bills years later due to the
VA's inability to properly track, record, and bill for services.
That is why I am urging members to support my eight-page bill, the
VA Billing Accountability Act, which keeps our promise of a fair
billing process to veterans by giving the Secretary of Veterans Affairs
the authority to waive a required co-payment if the VA erred in not
sending the bill in a timely manner - timely being within 120 days.
The bill also requires the VA to inform veterans of their rights to
payment plans and waivers if the VA does not meet billing timelines
based on how and where a veteran received care. If a veteran received
care at a VA facility, the VA has up to 120 days to send a bill. If the
care is at a non-VA community facility, where the VA must sometimes
wait for a final bill to be completed beyond inpatient care times, the
VA has up to 18 months to send a bill. The legislation's billing
standards are modeled on VA's own stated timelines. If the VA fails to
meet their standard timelines shared with me in a letter, the VA must
notify the veteran of how to get a waiver and establish a payment plan
before they can collect a payment. To be clear, nothing in this section
stops the VA from billing a veteran after they inform the veteran of
their rights.
I want to thank my colleagues for their support, including
bipartisan cosponsors from Minnesota: Collin Peterson, Erik Paulsen,
Tom Emmer, and VA Committee member Tim Walz, along with Health
Subcommittee member Phil Roe of Tennessee. We worked hard to make this
bipartisan legislation, and I also am grateful to Senator Amy Klobuchar
for her leadership on this bill in the Senate.
Mr. Chairman, the federal government is expected to keep the
public's trust and meet our commitments - especially to those who have
sacrificed for our nation. We must work tirelessly to change the
culture of bungled bureaucracy and mismanagement at the VA, and restore
faith that our veterans will receive the health care they deserve.
I urge members of the committee to support the VA Billing
Accountability Act to ensure a promise made is a promise kept. Thank
you, and I am happy to answer your questions.
Prepared Statement of Honorable Gus M. Bilirakis
House Veterans Affairs Committee Subcommittee on Health Legislative
Hearing
Statement of the Honorable Gus M. Bilirakis on the ``PROMISE Act''
November 17, 2015
Chairman Benishek, Ranking Member Brownley and distinguished
Members of the Health Subcommittee,
Thank you for holding this legislative hearing today. Today's
hearing includes many important pieces of legislation that will improve
the services and care our Veterans receive for their dedicated service
to our great nation.
Among the bills under consideration in today's hearing, is my bill
the Promoting Responsible Opioid Management and Incorporating
Scientific Expertise Act or the ``Jason Simcakoski PROMISE Act.'' I
appreciate the Chairman's leadership in bringing this important issue
before the Committee and for allowing me to speak today on the PROMISE
Act.
The tragic death of Marine Corp. Veteran Jason Simcakoski in the
Tomah, Wisconsin VA Medical Facility prompted the need for
Congressional action. On August 2015, nearly one year from Jason's
death, the Office of Inspector General released their report titled:
``Unexpected Death of a Patient During Treatment with Multiple
Medications.''
The IG report concluded that Jason's cause of death was due to
mixed drug toxicity with the potential for respiratory depression and
the combination of various medications was the plausible mechanism of
action for a fatal outcome. Furthermore, the IG also found deficiencies
in the ``informed consent'' process, confusion among staff when
initiating cardiopulmonary resuscitation, and the absence of certain
medications available in emergency situations to reverse effects of
possible drug overdose. I request unanimous consent to submit this IG
report for the record in today's hearing materials.
As the guidelines used by the VA and DOD for opioid management have
not been updated since 2010, it is due time to ensure those treating
our Veterans have the necessary resources and training to effectively
treat Veterans with chronic pain. I want to be clear; the intent of
this bill is to improve patient safety, not to restrict access for
those who truly need these prescriptions for their wellness plan.
The PROMISE Act will increase safety for opioid therapy and pain
management by requiring the VA and DOD to update their Clinical
Practice Guidelines for Management of Opioid Therapy for Chronic Pain,
VA opioid prescribers to have enhanced pain management and safe opioid
prescribing education and training, and the VA to increase information
sharing with state licensing boards.
This bill also promotes needed transparency within the VA and will
further our efforts to hold the VA accountable by requiring GAO to
report on recommendations for improvement and assess the level of care
Veterans are receiving.
Additionally, the PROMISE Act will authorize a program on
integration of complementary and integrative health within the VA and
encourage more outreach and awareness of the Patient Advocacy Program
to educate Veterans on their care options.
Our Veterans have sacrificed so much for our country, and we have a
responsibility to ensure they are receiving the quality of care they
have earned and deserve. We must hold the VA accountable and encourage
quality care for all Veterans who have fought for the freedoms we enjoy
on a daily basis.
I want to thank all the VSOs for their support and for appearing
today to provide their testimony in today's legislative hearing. I also
want to thank all my colleagues on this Committee and in the House for
your support in signing on as an original cosponsor prior to this
hearing. With this strong list of bipartisan support, we send a clear
message to the Simcakoski family, our Veterans and those that have been
affected by such tragedies that we are dedicated in ensuring similar
failures will never happen again.
In closing, I am grateful we are here discussing these important
bills. I look forward to having a substantive discussion on how we can
improve the lives of our true American heroes. In upholding our sacred
vow and promise to our Veterans, I urge my colleagues to support this
bill and cosponsor the PROMISE Act.
Thank you Mr. Chairman and I yield back.
Prepared Statement of Adrian M. Atizado
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the DAV (Disabled American Veterans) to
testify at this legislative hearing of the House Veterans' Affairs
Subcommittee on Health. As you know, DAV is a non-profit veterans
service organization comprised of nearly 1.3 million wartime service-
disabled veterans that is dedicated to a single purpose: empowering
veterans to lead high-quality lives with respect and dignity.
DAV is pleased to be here today to present our views on the bills
under consideration by the Subcommittee.
H.R. 1319, the Ask Veterans Act
This bill would require the Department of Veterans Affairs (VA) to
contract with an experienced non-government entity to conduct an annual
survey, over a five-year period, to determine the experiences of
veterans in obtaining hospital care and medical services at each VA
medical facility. Survey questions would include but are not limited to
those relating to a veteran's ability to obtain hospital care and
medical services at the facility in a timely manner, the time between
the date the veteran requests an appointment and the date the
appointment is scheduled, the frequency with which scheduled
appointments are cancelled, and the quality of hospital care or medical
services received. Under the bill, the results of the surveys would be
made publicly available on the VA's website.
We understand the intent of this legislation is to better describe
the veterans experience in accessing and receiving VA medical care, as
a standard of comparison to VA's reported data. Wounded, injured and
ill members of DAV report they do experience delays in receiving timely
access to medically necessary services from the VA health care system.
Arguably, this kind of patient experience can be illustrated by various
VA reports such as its access reports (http://www.va.gov/health/access-
audit.asp) and the VHA Facility Quality and Safety Report (system
level: www.va.gov/health/hospitalReportCard.asp, and for local
facilities: www.va.gov/HEALTH/docs/QandS--Report--2013--data--tables--
fy12--data.pdf).
If this legislation is to be favorably considered, we urge the
Subcommittee to amend the legislation to require that surveys results
be acted upon in consonance with the continuous improvement philosophy
of the VA health care system. Perhaps also such information could be
used to require analyzing and/or revising existing policy or used as a
basis for developing new policy to ensure the VA health care system and
all its points of care meet the goal of consistently providing high
quality care that is safe, effective, efficient, timely, patient
centered, and equitable.
H.R. 1603, the Military Sexual Assault Victims Empowerment Act
This bill would amend the Veterans Access, Choice, and
Accountability Act of 2014 VACAA) to make eligible a veteran who was
the victim of a military sexual trauma (MST) which occurred on active
duty, active duty for training, or inactive duty training, for
treatment by a non-VA provider.
This bill would exempt such MST survivors from mileage and waiting-
time standards otherwise applicable to veterans to receive contract
care under the provisions of VACAA, and would remove the eligibility
date of enrollment before August 1, 2014, for survivors of MST.
DAV has not received a resolution from our membership in support of
the specific matter of contracting out counseling and care on demand
for victims of MST; therefore, DAV takes no formal position on this
bill. However, our resolution on treatment for MST recognizes VA as a
provider of specialized residential and outpatient counseling programs
and evidence-based treatments for MST survivors. Accordingly, enactment
of this bill would engender a number of questions that we ask the
Subcommittee to consider before advancing this measure.
This bill would provide access to the Veterans Choice Program for
survivors of MST by exempting them from certain qualifying or
eligibility aspects, but it leaves other patients with other
disabilities to comply with VACAA. Moreover, current law and VA
national mental health policy are positioned to honor the preferences
of MST survivors, such as meeting their designated preferences for a
female or male provider, or to be referred to private care and
counseling services when necessary.
We do not believe the failure of one facility is justification for
enacting this legislation - a bill that would do little to improve
every VA facility's ability to care for MST survivors. To refer MST
care and counseling to community providers would increase the risk of
fragmenting the holistic approach employed by VA using all available
resources, benefits and services across the Department that are
critical to optimal treatment outcomes for these patients.
Over the past decade, given the growing incidence of MST, VA has
made major strides to elevate this program, employ additional resources
and personnel, and ensure that treatment staff in every locale are
trained to deal with the sequalae of MST in the most effective manner.
Nationally, VA is now treating over 100,000 veterans for their needs
associated with MST. Over 800,000 annual outpatient visits are being
made by these individuals, and we believe the vast majority are well
satisfied with the services they are receiving.
We believe VA is the right choice for most if not all veterans who
have experienced MST and need specialized counseling and care in its
aftermath. Mental health is one of VA's most significant and successful
programs, and VA offers integrated and coordinated care to millions of
veterans. Accordingly, we urge this Subcommittee to exercise its
oversight responsibilities, and for VA to take action when local
facilities fail to comply with these policies to the detriment of
veterans' health and well-being.
H.R. 1904, the Wounded Warrior Workforce Enhancement Act
This bill would establish two VA grant programs. One would be made
to educational institutions to establish or enhance orthotic and
prosthetic masters and doctoral education programs, with an
appropriations limitation of $15 million; and the other to establish a
private ``center of excellence in orthotic and prosthetic education,''
with an appropriations limitation of $5 million.
DAV has no resolution from our membership that would support the
establishment of these specific activities. Nevertheless, prosthetic
and orthotic aids and services are important to injured and ill
veterans, and constitute a specialized medical program within the VA.
However, absent a defined shortage of individuals who possess related
skills and knowledge in these fields, justification for enactment of
this bill seems questionable. Also, assuming the grant programs that
would be established by this bill were to take form, graduating
students who benefitted from them would not be required to provide
obligated employment in VA to repay the government's investment in
their education such as is required in VA's existing health
professional scholarship programs under Chapters 75 and 76 of title 38,
United States Code. We believe this existing and highly successful
mandate for students in other health fields be considered in adopting
the concept embedded in this bill, to ensure that VA regains at least
some of the value of the work of these students following their VA-
subsidized education and training.
Finally, assuming the establishment of a center of excellence in
this particular field is warranted, DAV questions whether the center
should be outside VA, rather than become a new VA in-house center of
excellence along the lines of those centers already established in law
in Chapter 73 of title 38. We ask that the sponsor of this bill
reconsider and restructure this proposal in light of our testimony.
H.R. 2639, the Marriage and Family Therapists for Veterans Act
This bill would amend VA policy to require marriage and family
therapist candidates to pass examination by the Association of Marital
and Family Therapy, or pass an examination by a state board of
behavioral sciences or an equivalent activity of a state, as a
precondition to employment within the VA.
VA's various authorities under title 38, United States Code,
section 7402 (which would be modified by this bill) generally require
licensure in a state, or registration in the cases of nurses and
pharmacists, as a condition of clinical professional employment in VA.
Generally, any other requirements for VA employment of patient care
professionals are left to the discretion of the VA Secretary. In the
case of marriage and family therapists, current law requires a certain
level of educational achievement and a valid state license, unless the
Under Secretary for Health recommends to the Secretary a waiver of
licensure requirement for a reasonable period of time following initial
appointment.
On this basis, we cannot identify a valid reason that this one
particular category of patient care provider would need to undergo
additional qualification testing as a pre-condition to employment in VA
health care.
DAV has received no national resolution from our membership
specific to the matters proposed in this bill, and thus takes no
official position, but hopes the Subcommittee would take our views into
consideration.
We also would take this opportunity to remind the Subcommittee of
DAV's and VA's prior testimonies dealing with the topic of marriage and
family counselors and licensed mental health counselors, and their
potential employment in VA. DAV has long agreed with VA's position that
these individuals from these professions could be employed in the
Department's mental health programs without further acts of Congress.
We maintain that view with respect to this bill.
H.R. 3234, the Failing VA Medical Center Recovery Act
If enacted this bill would establish within the VA a new Office of
Failing Medical Center Recovery, led by an Under Secretary-level
official.
Under this bill, the Secretary would be required to establish a set
of key measurements against which to evaluate each VA medical center,
and the bill would specify the measurements to be used. If a medical
center were ranked and certified by the Secretary as ``failing'' under
this measurement scheme, operational control of the medical center
would be transferred to the new office. The office would be required to
dispatch a ``rapid deployment team'' to each such failing medical
center to examine and report on its resources, practices, health care
programs. The Under Secretary for Failing Medical Center Recovery would
be empowered to take a number of personnel actions, execute contracts,
and carry out other actions to improve the performance of failing
medical centers.
Both the VA Inspector General and the VA Office of Accountability
Review would be required by the bill to give priority to whistleblower
retaliation investigations emanating from failing medical centers.
The bill would define a number of terms associated with these new
authorities, and would specify qualifications of the individual
appointed to the position of Under Secretary for Failing Medical Center
Recovery.
A number of the authorities this bill would prescribe to the new
office are currently embedded in VA's existing organizational table, or
are parts of the functions of existing staff offices, including the
Office of Medical Inspector, the Office of Research Oversight and
Compliance, the Office of the Inspector General, as well as the
Governmental Accountability Office in its continuing reviews of VA
health care, most of which are directed by Congress. Numerous offices
within the Veterans Health Administration are responsible for ensuring
medical centers do not fail in their work. In our view, collectivizing
these responsibilities into one new office, while attractive on its
face, could create a number of unintended consequences and conflicts
with similar and preexisting VA functions. Also, we believe
establishing a single set of measurements to apply to every medical
center in the system could be very challenging, given the wide variety
of missions and histories of individual centers, producing distorted
results. Some are clearly academic health centers with major
affiliations with educational institutions; others are secondary-level
facilities, many in rural areas or small cities; and still others are
primarily long-term care oriented.
Finally, it should be noted that the bill is silent on addressing
the disposition of a failing medical center once it improves its
performance such that it is no longer ``failing.''
DAV has received no national resolution from our membership that
could be applied to this legislative proposal; therefore, DAV takes no
position on this bill.
H.R. 3471, the Veterans Mobility Safety Act of 2015
The intent of this legislation would be to ensure disabled veterans
receive the best quality, performance, and safety by establishing a set
of minimum standards for vendors who want to participate in the VA
Automobile and Adaptive Equipment (AAE) program. Specifically, under
the bill an AAE vendor would need to be certified by a qualified
organization or by the equipment's manufacturer. The vendor could also
be licensed or certified by the state where the modification services
are performed.
DAV recognizes that the intent of this legislation could be
beneficial to wounded, injured and ill veterans, but we urge the
Subcommittee consider addressing certain possible unintended
consequences. For example, a new provision may need to be added to this
bill in cases where a veteran who requires AAE repair, maintenance, or
replacement services resides beyond a reasonable distance from a
certified AAE provider or requires emergency repairs when the closest
provider is not certified as required by the bill. A strict requirement
without flexibility, such as a waiver or approved exception, could be
particularly troublesome for veterans residing in rural areas or when
traveling across a vast distance when the need for these services
arises.
H.R. 3549, the VA Billing Accountability Act
This bill would provide VA the authority to waive an otherwise
required co-payment if the veteran received a VA notification more than
120 days after the date the veteran received services or medication
from the VA, or more than 18 months later for services from a non-
Department facility, and that the notification delay was caused by an
error on the part of the agency. VA would also need to provide
information to veterans on arranging payment plans and applying for
waivers.
Based on Resolution Nos. 114 and 231, passed by our membership
regarding VA copayments, we support this legislation.
Draft Bill - the Promoting Responsible Opioid Management and
Incorporating Scientific Expertise ``PROMISE'' Act
Title I of this bill would establish a far-reaching and ambitious
new program to deal with, protect against, control, and report any
over-prescribing of benzodiazepines and opioid substances in the care
of veterans enrolled in health programs of VA. While VA has made recent
efforts to address overprescribing, its existing pain management
program is not well organized, and is insufficiently staffed in our
view, so enactment of this bill would call attention to the need for VA
to better manage and staff this function at both the national and local
levels.
DAV strongly supports Title II of the bill, which would establish a
formalized national patient advocacy program in VA. As a co-author of
the Independent Budget, DAV has called for improvements in patient
advocacy and ombudsman programs in VA for several years. We believe
this bill would give this program the weight and importance it deserves
to help veterans to better navigate the VA health care system.
Title III of the bill would enhance complementary and alternative
health care programs in VA. We support the advent of complementary and
alternative care, both in substitute to VA's use of pharmacological
agents, and to better respond to the needs and demands of a younger
generation of veterans, who often do not want traditional medical
management - especially if it involves the prescribing of pain and
psychotropic medications.
Title IV of this bill would require VA to strengthen its scrutiny
in hiring practices for physicians and other providers by validating
that such candidates for employment in VA carry no blemishes on their
state licenses. If a VA provider were to violate a requirement of
medical licensure, VA would be required by the bill to report such
violation to the state medical board(s) of the state(s) that had
granted licensure. Also, if the VA provider were to resign from VA, or
transfer from one VA facility to another, your bill would require VA to
determine whether there were any ``concerns, complaints, or allegations
related to the medical practice'' of the individual during VA
employment, and to take appropriate action in response. In respect to
these requirements, the sponsor or the Subcommittee staff may wish to
consider amending the bill to more clearly define the term
``provider,'' and whether the intention is to include all or only some
of the individuals identified as direct care providers in section 7401
of title 38, United States Code.
Title V of the bill would require the establishment and reporting
to Congress of a series of internal audits of VA administrations and
key offices.
In summary, based on Resolution Nos. 103, 116, 228, and 126 adopted
by our membership in our most recent National Convention, DAV supports
this bill. We appreciate the sponsor's introducing this omnibus
proposal, and we urge Congress to proceed with its enactment this year.
A VA legislative proposal to establish certain agreements for
purchasing medical care for veterans when care within VA facilities or
through contracts or sharing agreements is not feasibly available.
This draft bill would establish authority for VA to execute
purchase agreements for medical care for veterans when the VA and
contracts or sharing agreements are not feasibly available. According
to VA, this proposed language will streamline and speed the business
process for purchasing care for an individual veteran when necessary
care cannot be purchased through existing contracts or sharing
agreements.
The continuing problem harming disabled veterans and their families
was discussed in prior testimony from DAV on H.R. 1369, the Veterans
Access to Extended Care Act of 2015. Like VA's draft bill, which would
give VA the authority to enter into provider agreements, H.R. 1369
focuses on selected extended care facilities.
We support the intent of this draft legislation based on DAV
Resolution 217. However, as with H.R. 1369, we recommend this measure
be amended under subsection (e) to add federally recognized providers
of service--Aging and Disability Resource Centers, area agencies on
aging, State agencies (as defined in section 102 of the Older Americans
Act of 1965 (42 U.S.C. 3002)), and centers for independent living (as
defined in section 702 of the Rehabilitation Act of 1973 (29 U.S.C.
796a)). These entities serve on the front lines of a partnership
between the VA and the Department of Health and Human Services that has
served over 3,400 Veterans across 31 States and the District of
Columbia and Puerto Rico. These agencies provide severely ill and
injured veterans of all ages the opportunity to determine their own
supports and services to live independently at home.
This concludes my testimony, Mr. Chairman. DAV would be pleased to
respond for the record to any questions from you or the Subcommittee
Members concerning our views on these bills.
Prepared Statement of Laranda D. Holt
Chairman Benishek, Ranking Member Brownley, and distinguished
members of the subcommittee, on behalf of our National Commander, Dale
Barnett, and the over 2 million members of The American Legion, we
thank you for this opportunity to testify regarding The American
Legion's positions on the following pending legislation.
H.R. 1319: Ask Veterans Act
To direct the Secretary of Veterans Affairs to conduct annual surveys
of veterans on experiences obtaining hospital care and medical services
from medical facilities of the Department of Veterans Affairs, and for
other purposes.
This bill would require the VA Secretary to enter into a contract
with a non-government entity to conduct an annual survey to determine
the nature of the experiences of such veterans in obtaining hospital
care and medical services furnished at each medical facility. The
survey would look at the veteran's ability to obtain care in a timely
manner, the period of time between the requested appointment and the
scheduled appointment, the frequency in which scheduled appointments
are cancelled by the facility, and the quality of care the veteran
received at the facility.
The Veterans Health A7dministration (VHA) currently has a process
of conducting surveys to measure veterans health care experiences
through the Survey of Health Experiences of Patients (SHEP) process.
This process serves both quality improvement and performance
measurement functions. When a given standard falls substantially below
national benchmarks in a particular medical unit or clinic, process
action teams can examine the question scores to identify specific
barriers that addresses the overall patient experience.
Through The American Legion's System Worth Saving (SWS) Program,
which assesses the quality and timeliness of how VA delivers benefits
to our nation's veterans, The American Legion has helped educate our
federal government and our veterans as to the strengths and weaknesses
of the Department of Veterans Affairs (VA) health care system and all
of the services that VA is responsible for delivering to veterans. \1\
In 2012, The American Legion SWS Task Force Report specifically focused
on Veterans Health Administration's (VHA) Quality of Care and Patient
Satisfaction. In our report, we made the following recommendations: \2\
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\1\ American Legion No. 105: Reiteration of the System Worth Saving
Program: SEPT. 2015
\2\ American Legion System Worth Saving Report: Quality of Care and
Patient Satisfaction: 2012
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The SHEP scores data need to be sent to VA medical
facilities in a timely manner, rather than a three to six-month wait,
in order to adequately evaluate and measure ``real-time'' quality of
care and patient satisfaction.
VHA needs to adopt a single and consistent patient-
satisfaction survey tool such as Truth Point or Press Ganey to utilize
as the main tracking tool in order to make it more efficient and
effective to gather results.
Representatives from the veterans' community should be
involved and serve as a member of the facility's Customer Service Board
and Patient Satisfaction Committee meetings. The Veterans
Administration Voluntary Service (VAVS) National Advisory Committee
(NAC) has brought forward this recommendation to senior VA officials.
Following this recommendation, VHA has stood up a new Veterans
Experience Office and this office will be working with community
leaders nationwide to gain feedback on veterans' experiences at their
local VA medical centers.
The American Legion has no position on H.R. 1319 due to the fact
that VHA currently has a process of conducting surveys to measure
veterans health care experiences through the SHEP process.
H.R. 1603: Military Sexual Assault Victims Empowerment Act/Military
SAVE Act
To amend the Veterans Access, Choice, and Accountability Act of
2014 to improve the private treatment of veterans who are victims of
military sexual assault.
This bill would amend the Veterans Access, Choice, and
Accountability Act (VACAA) of 2014 to improve the private treatment of
veterans who are victims of military sexual assault. H.R. 1603 would
make a victim of a military sexual trauma potentially eligible for non-
VA care under the Veterans Choice Program.
Ultimately, this is about trying to find the right treatment for
every patient, and in the case of Military Sexual Trauma (MST), unique
challenges can shape treatment needs, and VA should be flexible to
ensure these veterans receive the care they need. The American Legion
is deeply concerned with the plight of survivors of MST and has urged
Congress to ensure the VA properly resources all VA medical centers,
vet centers, and community-based outpatient clinics so that they employ
a MST counselor to oversee the screening and treatment referral
process, and continue universal screening of all veterans for a history
of MST. \3\ A January 2011 landmark survey of women veterans conducted
by The American Legion found challenges for women veterans receiving
gender specific care sensitive to their needs, particularly with regard
to MST, and The American Legion has since fought for better awareness
training in VA for MST sensitivity, significant increases in outreach,
and more comprehensive care options for MST survivors including better
availability of female therapists, female group therapy and other
options to make MST care more accessible. \4\
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\3\ Resolution No. 67: Military Sexual Trauma AUG 2014
\4\ Resolution No. 18: Women Veterans OCT 2015
VA is working to improve in these areas, as is evidenced by VA
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publications that note:
VA knows that MST survivors may have special treatment
needs and concerns. For example, a Veteran can ask to meet with a
clinician of a particular gender if it would make him or her feel more
comfortable. Similarly, to accommodate Veterans who do not feel
comfortable in mixed-gender treatment settings, many facilities
throughout VA have separate programs for men and women. All residential
and inpatient programs have separate sleeping areas for men and women.
VA has specialized treatment programming available for
MST survivors. VA facilities have providers knowledgeable about
evidence-based mental health care for the aftereffects of MST. Many
have specialized outpatient mental health services focusing on sexual
trauma. Vet Centers also have specially trained sexual trauma
counselors. For Veterans who need more intensive treatment and support,
there are programs nationwide that offer specialized sexual trauma
treatment in residential and inpatient settings.
In VA, treatment for all mental and physical health
conditions related to MST is free and unlimited in duration. Veterans
do not need to have a disability rating (that is, be ``service-
connected''), to have reported the incident(s) at the time, or to have
other documentation that MST occurred in order to receive free MST-
related care. There are no time limits on eligibility for this care,
meaning that Veterans can seek out treatment even many years after
discharge.
Veterans may be eligible for free MST-related care even
if they are not eligible for other VA services. There are special
eligibility rules associated with MST-related care and many of the
standard requirements related to length of service or financial means
do not apply. \5\
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\5\ Top Ten Things All Healthcare & Service Professionals Should
Know About VA Services for Survivors of Military Sexual Trauma
However, implementation of change within VA can take time, and even
the best of programs can have irregular results from facility to
facility. Veterans should not have to suffer because the care they need
is not well implemented at their local VA facility.
The American Legion recognized that the Choice program was an
emergency measure to get care to veterans where VA was struggling to
deliver care. At the time of its passage in 2014, The American Legion
hoped lessons could be learned about how VA implements non-VA care and
how better systems could be devised to ensure veterans can use that
care seamlessly when needed, but still benefit from the healthcare
system specifically designed to meet their needs, the VA.
In recognition of the needs of an integrated system to deliver non-
VA care when need, The American Legion believes VA need to develop
``develop a well-defined and consistent non-VA care coordination
program, policy and procedure that includes a patient-centered care
strategy which takes veterans' unique medical injuries and illnesses
[emphasis added] as well as their travel and distance into account.''
\6\
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\6\ Resolution No. 46: Department of Veterans Affairs (VA) Non-VA
Care Programs OCT 2014
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One of the unique problems that survivors of MST face is that the
treatment environment at VA is not always conducive to their comfort
level, and comfort is critical in particular when dealing with issues
such as psychiatric care for Posttraumatic Stress Disorder (PTSD) which
is frequently a major side effect of MST. In the case of these
survivors, getting them to a treatment program within their comfort
level can mean the difference between a survivor continuing treatment,
or abandoning treatment and feeling further isolation and possibly
escalation of their symptoms.
For veterans who are suffering right now, they need to get the
treatment they need, but we should also be mindful this is not a
panacea for the problems faced by MST survivors, and ensuring
integration with the VA system is also beneficial to their overall
health picture. As with any care outside VA, The American Legion
stresses the importance of ensuring non-VA care has quality of care
standards equal to or better than they receive within VA, that the care
is coordinated effectively to ensure veterans are not stuck with
billing problems with outside providers that can adversely affect their
credit, and perhaps most importantly, that the providers have access to
VA healthcare records for the patient and vice versa. \7\ One of the
best assets of VA healthcare for veterans is the ability for providers
within the system to have a total picture of the veteran's health. By
seeing all interconnected conditions, and being aware of the unique
health challenges of veterans, providers can spot patterns leading to
early screening for conditions such as PTSD, health conditions related
to environmental exposures like Gulf War Illness and Agent Orange, and
other things an average civilian provider would miss. While sometimes
it's necessary for veterans to get the care they need outside the
system, it's important to make sure when that's done, they do not lose
out on the real and tangible benefits to care they get as part of the
integrated care network that is VA.
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\7\ Resolution No. 46: Department of Veterans Affairs (VA) Non-VA
Care Programs OCT 2014
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But first, for veteran survivors of Military Sexual Trauma, we have
to make sure they get the care they need in the environment that's
going to maximize the effects of treatment.
The American Legion supports H.R. 1603.
H.R. 1904: The Wounded Warrior Workforce Enhancement Act
To require the Secretary of Veterans Affairs to award grants to
establish, or expand upon, master's degree or doctoral degree programs
in orthotics and prosthetics, and for other purposes.
This bill would require the Secretary of the Department of Veterans
Affairs to award grants to establish, or expand upon, master's degree
programs in orthotics and prosthetics, and for other purposes. The
American Legion believes due to the shortage of physicians in certain
specialized areas, such as orthotics and prosthetics, Congress must
ensure resources and funding are available to support continuing
education and training of such physicians. \8\ Through this continuing
education program, VA would benefit from providers of these professions
being available to treat VA patients through their continuing education
program, and upon completion of the program becoming gainfully employed
by the VA.
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\8\ American Legion Resolution No. 311: The American Legion Policy
on VA Physicians and Medical Specialists Staffing Guidelines: SEPT.
1998
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The American Legion supports H.R. 1904.
H.R. 2639: Marriage and Family Therapists for Veterans Act
To amend title 38, United States Code, to provide for additional
qualification requirements for individuals appointed to marriage and
family therapist positions in the Veterans Health Administration of the
Department of Veterans Affairs.
Marriage and Family Therapists (MFTs) are mental health
professionals that are trained in psychotherapy and family systems.
These professionals are licensed and trained to treat mental and
emotional disorders within the environment of marriage, couples, and
family systems. H.R. 2639, would revise the eligibility criteria for a
marriage and family therapists to be employed by the Department of
Veterans Affairs by requiring those individuals to have a graduate
level degree in marriage and family therapy and/or mental health. The
additional requirements set forth in the bill will ensure Marriage and
Family Therapists that are employed by the VA are certified to be the
best in their field.
The American Legion has no position on H.R. 2639.
H.R. 3234: Failing VA Medical Center Recovery Act
To amend title 38, United States Code, to establish within the
Department of Veterans Affairs an Office of Failing Medical Center
Recovery, and for other purposes
This bill would add a new subsection Sec. 323 to 38 United States
Code (U.S.C.) Chapter 3- Department of Veterans Affairs \9\ entitled
``Office of Failing Medical Center Recovery''. This section would
establish the new Office of Failing Medical Center Recovery headed by a
new Under Secretary for Failing Medical Center Recovery within VHA. The
purpose of this office would be to carry out the managerial and day-to-
day operational control of each medical center of the Department that
the Secretary certifies as a failing medical center.
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\9\ https://www.law.cornell.edu/uscode/text/38/part-I/chapter-3
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The American Legion currently has no position on the creation of
such an entity and is researching the potential impact - both positive
and negative - of such a change on the ability to deliver health care
so that the membership of The American Legion will have a chance to
consider a resolution on the issue and solidify a formal position.
The American Legion has no position on H.R. 3234 at this time.
H.R. 3471: Veterans Mobility Safety Act of 2015
To amend title 38, United States Code, to make certain improvements
in the provision of automobiles and adaptive equipment by the
Department of Veterans Affairs.
This bill requires a vendor of automotive adaptive equipment to be
certified by a qualified organization or the manufacturer of the
adaptive equipment. Through the VA Automotive Adaptive Equipment (AAE)
program, VA provides physically challenged persons the necessary
equipment to safely operate their vehicle on the country's roadways.
Through the Department of Rehabilitation and Prosthetic Services VA
provides the necessary equipment such as: platform wheelchair lifts,
under vehicle lifts, power door openers, lowered floors/raised roofs,
raised doors, hand controls, left foot gas pedals, reduced effort and
zero effort steering and braking, and digital driving systems. Based on
our research, The American Legion has not found any issues with
veterans obtaining automobile adaptive equipment or automobile grants
and does not feel that there is a need at this time for additional
policy. The American Legion is continuing to research this issue and
should information change would consider working to develop a
resolution with our membership to provide specific policy guidance.
The American Legion does have a position on H.R. 3471 at this time.
H.R. 3549: VA Billing Accountability Act
To amend title 38, United States Code, to authorize the Secretary of
Veterans Affairs to waive the requirement of certain veterans to make
copayments for hospital care and medical services in the case of an
error by the Department of Veterans Affairs, and for other purposes.
No veteran should have to wait 30, 60, 90 or 120 days or more to
receive a copay bill immediately following VA hospital care or medical
services. The American Legion's National Commander Dale Barnett has
spoken to many veterans recently about the troubles caused with their
finances and credit due to discrepancies and problems with third party
billing. VA is required to provide timely health care to our nation's
veterans and should be held to similar standards for third party
billing. The American Legion thanks Congress for taking the leadership
steps necessary to require VA to establish regulations for first party
billing which conform with the time standard outlined in the bill and
to provide the Secretary the authority to waive the veterans first
party copayments.
The American Legion supports H.R. 3549.
Discussion Draft: Promise Act
To improve the use by the Department of Veterans Affairs of opioids in
treating Veterans, to improve patient advocacy by the Department, and
to expand availability of complementary and integrative health, and for
other purposes.
In the wake of serious concerns about over prescription of
medications at the Tomah Veterans Affairs Medical Center, the nation
has become more focused on ensuring veterans and service members are
treated properly with opioid medications and do not unduly suffer due
to mixed drug toxicity. The American Legion has been concerned about
increasing reports of overmedication with pain management even before
the stories began to circulate out of Tomah.
This legislation would work to improve pain management policies
between the Departments of Defense (DOD) and Veterans Affairs (VA)
through establishing better clinical guidelines, countering overdoses,
encouraging more collaboration between VA and DOD, and establishing
pain management boards across VA to ensure better compliance. The
legislation would also strengthen communication between VA and the
veterans' community, enhance patient advocacy, and improve research and
education on complementary and alternative care.
The American Legion firmly believes in increasing federal funding
throughout the Department of Defense, Department of Veterans Affairs
and the National Institutes of Health for pain management research,
treatment and therapies. Furthermore, The American Legion urges these
institutions to increase investment in pain management clinical
research by accelerating clinical trials at military and VA treatment
facilities, as well as at affiliated university medical centers and
research programs \10\. The increased use of complementary and
alternative medicine is directly in line with policies of The American
Legion regarding treatment for veterans with mental health and brain
injuries, and represents a welcome expansion of care in these areas.
\11\
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\10\ Resolution No. 190: Support for Pain Management Research,
Treatments and Therapies at DOD, VA and NIH - AUG 2015
\11\ Resolution No. 292: Traumatic Brain Injury and Post Traumatic
Stress Disorder Programs - AUG 2014
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The American Legion supports this discussion draft.
Discussion Draft: Department of Veterans Affairs Purchased Health Care
Streamlining and Modernization Act
To amend title 38, United States Code, to establish certain agreements
for purchasing medical care for veterans when care within facilities of
the Department of Veterans Affairs or through contracts or sharing
agreements is not feasibly available
Under title 38 U.S.C. Sec. 1703, entitled ``Contracts for hospital
care and medical services in non-Department facilities'', when
Department facilities are not capable of furnishing economical hospital
care or medical services because of geographical inaccessibility or are
not capable of VA furnishing the care or services required, the
Secretary, as authorized in section 1710 of this title, may contract
with non-Department facilities. Contracts between VA and non-VA
facilities are currently negotiated under Federal contract statutes and
regulations (including the Federal Acquisition Regulation (FAR), which
is set forth at 48 Code Federal Regulations (CFR) Chapter 1; and the
Department of Veterans Affairs Acquisition Regulations, which are set
forth at 48 Code Federal Regulations (CFR) Chapter 8.
Federal contract laws and regulations are not always the best
method for procuring individual services, which is why for many years
VA issued individual authorizations to providers, without following
contracting laws and regulations. VA General Counsel has informed VA
that they must comply with contracting laws and regulations, which will
make it more difficult for VA to procure individual services from non-
VA providers. Provider agreements would allow the Veterans Health
Administration (VHA) to procure non-VA health care services on an
individual basis in accordance with the terms and agreements set forth
in the law. The American Legion supports legislation that would allow
the Department of Veterans Affairs (VA) to enter into provider
agreements with eligible non-VA providers to obtain needed health care
services for the care and treatment of eligible veterans. \12\
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\12\ American Legion Resolution No. 32: Department of Veterans
Affairs Provider Agreements with Non-VA Providers: SEPT. 2015
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The American Legion supports this discussion draft.
Conclusion
As always, The American Legion thanks this subcommittee for the
opportunity to explain the position of the over 2 million veteran
members of this organization. For additional information regarding this
testimony, please contact Mr. Warren J. Goldstein at The American
Legion's Legislative Division at (202) 861-2700 or
[email protected].
Prepared Statement of Carlos Fuentes
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
On behalf of the men and women of the Veterans of Foreign Wars of
the United States (VFW) and our Auxiliaries, thank you for the
opportunity to offer our thoughts on today's pending legislation.
H.R. 1319, Ask Veterans Act
This legislation would require the Department of Veterans Affairs
(VA) to survey veterans to evaluate their views and experiences when
seeking VA health care. The VFW supports this legislation and has a
recommendation to improve it.
When the VA health care access crisis erupted in April 2014, the
VFW turned to our members to gauge the issues from their perspective.
We launched a series of surveys, held town halls, and provided a
mechanism for veterans to share their experiences and seek help
obtaining VA health care. What we heard from veterans was not
surprising to us, but it did provide a holistic view of the VA health
care system from the perspective of those it was designed to serve.
The VFW's first survey only included quantitative questions. While
these questions provided a clear picture of the health care access
crisis, they did not provide an empirical mechanism for us to determine
the reasons for certain outcomes. For example, we were able to
determine that 50 percent of veterans chose to keep receiving VA health
care when given the opportunity to receive community care. However, the
survey did not ask why veterans chose to stay with VA care. The VFW's
subsequent surveys included qualitative questions to close the loop.
That is why we urge the Subcommittee to amend this legislation by
requiring that the annual survey of veterans include both qualitative
and quantitative questions.
Currently, VA conducts a number of surveys to measure veterans'
experiences and evaluate its progress in meeting strategic goals. VA's
most notable survey is the Survey of Healthcare Experiences of
Patients, which surveys a random sample of veterans who have received
VA health care within a month. The problem, however, is that VA mainly
surveys VA patients or veterans who utilize VA benefits and programs.
The last time VA conducted a survey of non-VA users was in 2010 as part
of its National Survey of Veterans. That is why we recommend that this
legislation be amended to include veterans who may be eligible for VA
health care instead of only sampling veterans who have received VA
health care in the proposed survey.
H.R. 1603, Military Sexual Assault Victims Empowerment (SAVE) Act
This legislation would expand eligibility for the Veterans Choice
Program to any veteran who is the victim of military sexual trauma. The
VFW opposes this bill.
The VFW strongly believes that veterans who struggle with
psychological effects of military sexual trauma deserve timely access
to high quality care. With the extraordinarily high incidence of sexual
trauma in the military and the failure of many victims to report the
trauma to medical or police authorities, it is important to ensure
veterans who seek assistance are given the opportunity to receive
timely access to mental health care.
VA has made a concerted effort in recent years to increase its
capacity to deliver mental health care by hiring additional mental
health providers and integrating mental health into primary care
clinics. The VFW agrees that VA lacks the resources and capacity to
provide timely mental health care to all the veterans it serves.
However, veterans who have used the Veterans Choice Program also report
having long wait-times for care or not being able to find a private
health care provider willing to see them. While the VFW supports the
use of private sector care and has worked to improve the Veterans
Choice Program, we do not believe that expanding eligibility for the
Veterans Choice Program is the correct solution.
Instead of shifting the workload to the private sector, the VFW
recommends reforming the way we deliver health care to veterans by
seamlessly combining the capabilities of the VA health care system with
public and private health care providers in each community. Doing so
would ensure veterans receive high quality mental health care and give
private sector providers the cultural competency training needed to
deliver veteran-centric care.
H.R. 1904, Wounded Warrior Workforce Enhancement Act
This legislation would require VA to expand the availability of
training programs for orthotists and prosthetists. The VFW supports
this legislation and has a recommendation to improve it.
Orthotists and prosthetists are vital to ensuring VA provides the
prosthetics care and services veterans need and deserve. In 2014, VA
provided 17.5 million prosthetic items and services to more than three
million veterans and estimates a growing demand in future years. The
VFW strongly supports expanding the availability of orthotic and
prosthetic care for veterans. For this reason, we believe the
Subcommittee should amend this legislation by adding a requirement that
grant recipients offer reduced or no-cost education to any admitted
student who agrees to work at a VA medical facility for a period of
time specified by the Secretary, similar to service requirements under
other health professional educational assistance programs.
H.R. 2639, Marriage and Family Therapists for Veterans Act
This legislation would amend VA's hiring requirements to increase
VA's capacity to provide marriage and family therapy. The VFW agrees
with the intent of this legislation, but we defer to VA to determine
and justify the educational requirements of its therapists.
Suicide among military personnel and veterans presents a serious
challenge to VA, the Department of Defense and the nation. A recent
study of veterans from the Iraq and Afghanistan wars found that
recently discharged veterans are up to 61 percent more likely to commit
suicide compared to the United States general population. The study
also found that more than 9,300 recently discharged veterans committed
suicide between 2001 and 2007.
Without access to mental health care, those suffering from the
invisible wounds of war are forced to deal with their mental health
symptoms on their own, which makes recovery nearly impossible. This
legislation would expand access to VA mental health care by requiring
VA to accept regionally accredited master's degrees when hiring
marriage and family therapists. While the VFW strongly supports
expanding access to mental health care, we believe such expansion must
not diminish the quality of care veterans receive from VA. Ultimately,
VA is responsible for assuring the quality of care veterans receive.
That is why the VFW believes VA is best suited to determine and justify
the education requirements of its health care providers.
H.R. 3234, Failing VA Medical Center Recovery Act
This legislation would establish an undersecretary level office to
identify and take over failing VA medical facilities. The VFW cannot
support the legislation as written.
This past year VA deployed a rapid response team to the Phoenix VA
Health Care System to address the issues that drew national attention
to the VA health care access crisis. However, the problems the team
were asked to address were largely systemic issues with outdated
systems and processes that were not unique to Phoenix. The VFW has said
many times that Phoenix was not Ground Zero because the nationwide
access crisis could have started at any VA facility. The breakdown was
caused by a systematic failure at every level. These failures included
congressional and VA Central Office oversight that was too trusting of
people and the information they presented; a decentralized management
system that creates internal fiefdoms and breeds an employee culture of
indifference towards politically-appointed leadership; and the lack of
proper resources, both in human and fiscal capital.
The VFW supports efforts to identify and address facility specific
issues that negatively affect VA's ability to deliver timely and high-
quality health care. However, requiring the VA central office to take
over underperforming facilities would further degrade the relationship
between politically-appointed leadership and medical center staff.
Instead of establishing a new undersecretary position, Congress should
strengthen VA's Veterans Experience Office to ensure every VA medical
facility provides the timely and high quality health care veterans have
earned and deserve.
H.R. 3471, Veterans Mobility Safety Act of 2015
This legislation would establish minimum safety standards for the
Automobile Adaptive Equipment Program. The VFW supports the intent of
this legislation and has a recommendation to improve it.
The Automobile Adaptive Equipment Program was established to enable
severely disabled veterans to drive without the assistance of others by
making modifications to their existing vehicles or purchasing a new
vehicle with the specific accommodations they need. Because the VA
automobile grant is a one-time benefit, it is important that
modifications made to vehicles are safe and function properly the first
time.
Currently, VA prosthetic representatives are required to assist
veterans in locating an approved vendor and inspecting the workmanship
of vehicle modification. VA encourages veterans to verify that a vendor
is registered with the National Highway Traffic Safety Administration
(NHTSA), which is responsible for developing motor vehicle safety
standards. However, NHTSA does not conduct thorough compliance
evaluations to ensure registered adaptive equipment installers comply
with the established standards. The VFW recommends that any
certification organization used by VA to accredit installers conduct
thorough site visits to inspect installers and verify compliance with
safety standards. VA must also ensure that requiring certification does
not impede its ability to administer the Automobile Adaptive Equipment
Program.
H.R. 3549, VA Billing Accountability Act
The VFW supports this legislation, which would ensure veterans are
properly notified of their copayment obligations and would require VA
to waive copayment if it fails to properly notify veterans.
Earlier this year, more than 1,400 veterans where charged more than
$500,000 for five-years' worth of health care received from the
Minneapolis VA Medical Center. While disheartening, VA charging
veterans for years of copayments all at once is not rare. The VFW
continues to hear from veterans that VA has sent them large bills for
care they either had no idea they were liable for or were unaware they
had not paid. In most instances, veterans do not have the ability to
pay such debts and are not offered any other recourse but to have their
monthly disability benefits garnished until the debt is repaid. That is
why the VFW supports waiving medical debt when VA fails to properly
notify veterans. Veterans must not be punished for VA's inability to
get its house in order.
However, the VFW recommends that the Subcommittee amend this
legislation by authorizing VA to evaluate whether the 120-day and 18-
month requirements for notifying veterans of copayment obligations are
aligned with industry best practices.
Draft Legislation, Promoting Responsible Opioid Management and
Incorporating Medical Expertise Act
This legislation would reduce VA's reliance on pharmacotherapy to
treat mental health and complex pain conditions; expand VA research,
education, and delivery of complementary and alternative medicine (CAM)
treatments; and improve VA hiring and internal audits. The VFW supports
this legislation and has a recommendation to strengthen it.
Too often, the VFW hears stories of veterans who have been
prescribed high doses of pain medication to treat their mental health
conditions. Countless veterans have experienced first-hand the
dangerous side effects of pharmacotherapy. Many of these medications,
if incorrectly prescribed, have been proven to render veterans
incapable of interacting with their loved ones and even contemplate
suicide. With the expanding evidence of the efficacy of non-
pharmacotherapy modalities, such as psychotherapy and CAM, VA must
ensure it affords veterans the opportunity to access effective
treatments that minimize adverse outcomes.
Timely and accessible mental health care is crucial to ensuring
veterans have the opportunity to successfully integrate back into
civilian life. With more than 1.4 million veterans receiving
specialized VA mental health treatment each year, VA must ensure such
services are safe and effective. VA has made a concerted effort to
change its health care providers' dependence on pharmacotherapy to
treat mental health conditions and manage pain. In 2011, the
Minneapolis VA Medical Center launched its Opioid Safety Initiative.
Aimed at changing the prescribing habits of providers, the Opioid
Safety Initiative educates providers on the use of opioids, serves as a
tool to taper veterans off high-dose opioids, and offers them
alternative, non-pharmacotherapy modalities for pain management.
Unfortunately, VA has failed to produce a notable change since
implementing the Opioid Safety Initiative systemwide. This legislation
includes much needed reforms to ensure VA's clinical practice
guidelines for pain management are appropriate and includes the proper
compliance mechanisms, such as the pain management boards, to ensure
such guidelines are carried out.
The VFW has consistently heard from veterans that their patient
advocates are ineffective or seek to protect the medical facility's
leadership instead of addressing their concerns. For this reason, we
strongly recommend the Subcommittee amend this legislation to codify
VA's Veterans Experience Office. Established to collect and disseminate
best practices for improving customer service, coordinate community
outreach efforts, and serve as the subject matter experts on the
benefits and services VA provides to veterans, veteran experience
officers should replace patient advocates currently located in VA
medical facilities.
Patient advocates cannot effectively meet their obligations to
veterans if their chain of command includes VA medical facility staff
who are responsible for the actions and policies they are required to
address. In the markup of this bill, the VFW recommends that the
Subcommittee codify the Veterans Experience Office and expand the
duties of veteran experience officers to include: ensuring the health
care protections afforded under Title 38, U.S.C., a veteran's right to
seek redress through clinical appeals; claims under Section 1151 of
Title 38 U.S.C. and the Federal Tort Claims Act; and the right to free
representation by accredited veteran service organizations are fully
applied and complied with by VA medical facilities and contracted non-
VA health care providers.
With the growing body of research on the efficacy of CAM therapies,
such as biofeedback, mindfulness meditation, and other non-
pharmacologic approaches to treating mental health conditions and
managing pain, the VFW believes that more work must be done to ensure
veterans are afforded the opportunity to receive these safe and
effective alternatives to pharmacotherapy. This legislation would make
significant strides toward ensuring veterans who are tapered off high-
dose medications have effective alternatives.
Legislative Proposal, VA Purchased Health Care Streamlining and
Modernization Act
The VFW strongly supports this legislation, which would streamline
VA's ability to purchase health care from private sector health care
providers when VA health care is not readily available.
VA must have the ability to quickly provide non-VA health care when
it is unable to provide direct care to the veterans it serves. The VFW
is glad to see this legislation includes best practices, such as
requiring non-VA medical providers to return medical documentation, and
quality and safety mechanisms to ensure veterans receive high quality
care from non-VA providers.
The VFW has heard from veterans who live in contracted extended
care facilities that they may be required to leave the place they have
called home for years because VA does not have the authority to renew
provider agreements. The VFW urges this Subcommittee to quickly
consider and pass this important legislation to ensure severely
disabled veterans are not harmed by VA's inability to enter into
provider agreements.
Information Required by Rule XI2(g)(4) of the House of Representatives
Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW
has not received any federal grants in Fiscal Year 2015, nor has it
received any federal grants in the two previous Fiscal Years.
The VFW has not received payments or contracts from any foreign
governments in the current year or preceding two calendar years.
Prepared Statement of Janet Murphy
Good morning Chairman Benishek, Ranking Member Brownley, and
Members of the Committee. Thank you for inviting us here today to
present our views on several bills that would affect VA health programs
and services. Joining me today is Elias Hernandez, Chief Officer,
Workforce Management and Consulting; Harold Kudler, Chief Consultant
for Mental Health Services; and Susan Blauert, Deputy Assistant General
Counsel.
The Department of Veterans Affairs (VA) provided views on the
majority of bills on the agenda, but we are unable to provide cleared
views on sections 103, 501, and Title 3 of the draft legislation, the
Promoting Responsible Opioid Management and Incorporating Medical
Expertise Act, at this time. We will forward these views to you as soon
as they are available.
H.R. 1319 Ask Veterans Act
The proposed bill would require VA to enter into a 5-year contract
with a
non-government entity to conduct an annual survey of a
statistically significant sample of Veterans who reside in the
geographic area served by each of VA's medical facilities to determine
the nature of the experiences of such Veterans in obtaining hospital
care and medical services at each such medical facility. In developing
the survey, the contractor would be required to consult with Veterans
Service Organizations. The contractor would also be required to submit
each of its proposed surveys to the Comptroller General for review and
certification before conducting them. Furthermore, VA would be required
to make the results of such surveys publicly available on its website
within 30 days after their completion.
VA does not support H.R. 1319, as such activities would be
duplicative of current efforts already in place and, therefore, the
minimal benefit of such additional surveys would be substantially
outweighed by their significant costs. The provision that requires
contractors to obtain a certification from the Comptroller General
prior to a survey also contravenes the separation of powers. In its
Survey of Health Experiences of Patient (SHEP) Program, the Veterans
Health Administration (VHA) is already conducting ongoing surveys of
Veterans' experiences with hospital care.
VA uses a scientifically designed survey instrument, the Consumer
Assessment of Health Providers and Systems (CAHPS), and an external
contractor IPSOS. The CAHPS surveys are designed by a scientific
community that is sponsored by the Agency for Health Research and
Quality. CAHPS surveys are an integral part of the Centers for Medicare
and Medicaid Services efforts to improve healthcare in the U.S. For
example, some CAHPS surveys are used in quality ratings for Medicare
and Medicaid health plans, as well as other CMS initiatives such as
Value-Based Purchasing. The surveys have also been endorsed by the
National Quality Forum and the National Commission for Quality
Assurance . Furthermore, the surveys are widely used by commercial
health plans. The scientific properties of CAHPS surveys were examined
in peer-reviewed scientific literature, examples of which VA can
provide upon request. \1\ Because VA utilizes the same scientific
survey approach as the private sector, we are also able to compare our
performance to non-VA hospitals.
---------------------------------------------------------------------------
\1\ For a summary of the scientific evidence, see Price et al,
``Should health care providers be accountable for patients' care
experiences'' Journal of General Internal Medicine 2015 (Feb); vol 30:
pp 253-256. Additional information about CAHPS is available at
www.cahps.ahrq.gov
---------------------------------------------------------------------------
VA utilizes CAHPS surveys in its SHEP program, which currently
assesses over one million Veterans annually to obtain valid and precise
estimates of performance for each VA medical facility. Our survey
provider, IPSOS, has been certified by Medicare as meeting scientific
standards for sampling, survey administration, and data validation.
Furthermore, our SHEP protocols are approved by the Office of
Information and Regulatory Affairs.
VA regularly obtains input from Veterans Service Organizations
regarding our SHEP program, and we provide SHEP results annually to
them upon request. We also post updated facility-level SHEP results
quarterly on our public website. \2\ The SHEP program's surveys are
completed anonymously, and all of VA's posted results are fully de-
identified, aggregate data. VHA's Office of Analytics and Business
Intelligence enthusiastically welcomes the opportunity to provide a
more detailed briefing of our SHEP program to Congressional staff.
---------------------------------------------------------------------------
\2\ http://www.va.gov/qualityofcare/apps/shep/barchart.asp
---------------------------------------------------------------------------
H.R. 1603 Military Sexual Assault Victims Empowerment Act
H.R. 1603 would amend subsection (b) of section 101 of the Veterans
Access, Choice, and Accountability Act of 2014 (the Choice Act) to add
a provision specifically addressing eligibility for the Veterans Choice
Program (Choice Program) for victims of military sexual trauma (MST)
described in section 1720D(a)(1) of title 38, United States Code
(U.S.C.). The intent of this bill appears to make such victims eligible
for the Choice Program regardless of the date they enroll for VA health
care and without the need to satisfy the wait-time or residence
eligibility criteria.
New legislation is not needed to exempt MST victims from the Choice
Act enrollment date restrictions. The bill does not take into account
recent legislative changes to the eligibility provisions for the Choice
Act. Specifically, section 4005 of the Surface Transportation and
Veterans Health Care Choice Improvement Act of 2015, Public Law 114-41,
amended section 101 to remove the August 1, 2014, enrollment date
restriction, thereby making all Veterans enrolled in the VA health care
system under 38 Code of Federal Regulations (C.F.R.) Sec. 17.36
eligible for the Choice Program if they meet its other eligibility
criteria. If the intent of the bill is to make Veterans who meet the
requirements of 38 U.S.C. Sec. 1720D eligible for the Choice Program
without having to enroll in VA health care, that is not clear, and the
bill language would need to be clarified. The proposed amendment would
also make Veterans who are victims of MST as described in 38 U.S.C.
Sec. 1720D(a)(1) eligible for the Choice Program without regard to the
wait-time or place of residence eligibility criteria that apply to
other Veterans. VA does not support this provision for a number of
reasons.
VA supports the Choice Program, which creates a mechanism for
providing timely, local care to eligible Veterans for whom such care
would otherwise be inaccessible. The Choice Program provides this same
access to otherwise eligible Veterans who experienced MST; under
existing authorities, MST survivors already have the option to seek
Choice Program care based on the wait-time or place of residence
eligibility criteria.
There is, however, no clearly identifiable clinical advantage or
benefit to MST survivors, in terms of quality of care or patient
outcomes, to allow MST survivors to elect Choice Program care as a
first-option preference, rather than as a secondary-option based on
need under existing non-VA care authorities. As noted in VA's annual
report to Congress, required by 38 U.S.C. Sec. 1720D(e), care for MST-
related conditions is available through every VA medical facility and
Vet Center, and all VA health care facilities have sufficient staffing
capacity to meet the MST-related care needs of their local Veteran
populations. As such, there is no clear need to create an exception to
the existing Choice Program eligibility criteria on the basis of the
availability of MST-related care in VA facilities.
There are also some advantages to viewing VA as the first-option
provider of MST-related care whenever wait-time and place of residence
are not an issue. VA has the authority and infrastructure to ensure
that its providers have received training on evidence-based
psychotherapies for trauma-related disorders, and specifically on
provision of care to MST survivors. Currently all VA mental health and
primary care providers must complete mandatory training on MST as
specified by VHA Directive 2012-004. VA also offers a range of
continuing education opportunities for staff interested in furthering
their level of MST expertise. There are few checks to ensure that
private providers have the specialized training to offer a standard of
evidence-based care to match care available in a VA facility.
Further, it is not uncommon for Veterans who experienced MST to
have multiple health concerns and comorbidities and, within VA, to
receive care from a range of medical and mental health clinics. As a
single umbrella provider, VA is well positioned to provide this type of
coordinated, tailored care that ensures the Veteran's history of MST is
considered in all treatment provided. VA providers are familiar with
internal resources available to address new or emergent treatment
needs, and can provide timely internal referrals as needed. Every VA
health care system has a designated MST Coordinator whose role includes
assisting MST survivors with accessing needed services and facilitating
coordination of care. Given the considerable clinical benefit to MST
survivors of coordinated, trauma-sensitive, evidence-based care, and
the need to direct Choice Program resources towards addressing
accessibility gaps where they exist, VA maintains that VA MST-related
care should be considered the first-option treatment standard whenever
wait-time and place of residence are not an issue.
It is not possible to estimate costs for this bill without further
study to determine how many Veterans would choose to seek Choice
Program care under this new authority.
H.R. 1904 Wounded Warrior Workforce Enhancement Act
H.R. 1904, the Wounded Warrior Workforce Enhancement Act, would
direct VA to establish two grant award programs. Section 2 of the bill
would require VA to award grants to institutions to: (1) establish a
master's or doctoral degree program in orthotics and prosthetics, or
(2) expand upon an existing master's degree program in those areas.
This section would require VA to give a priority in the award of grants
to institutions that have a partnership with a VA medical center or
clinic or a Depatment of Defense (DoD) facility. Grant awards under
this provision must be at least $1 million and not more than $1.5
million. Grant recipients must either be accredited by the National
Commission on Orthotic and Prosthetic Education in cooperation with the
Commission on Accreditation of Allied Health Education Programs, or
demonstrate an ability to meet such accreditation requirements if
receiving a grant. VA would be required to issue a request for
proposals for grants not later than 90 days after the date of enactment
of this provision.
In addition to the two purposes noted above, grantees would be
authorized to use grants under this provision to train doctoral
candidates and faculty to permit them to instruct in orthotics and
prosthetics programs, supplement the salary of faculty, provide
financial aid to students, fund research projects, renovate buildings,
and purchase equipment. Not more than half of a grant award may be used
for renovating buildings. Grantees would be required to give a
preference to Veterans who apply for admission in their programs.
VA does not support the enactment of section 2 of this bill. We
believe VHA has adequate training capacity to meet the requirements of
its health care system for recruitment and retention of orthotists and
prosthetists. VA offers one of the largest orthotic and prosthetic
residency programs in the Nation. In fiscal year (FY) 2015, VA
allocated $877,621 to support 20 Orthotics/Prosthetics residents at 10
VA medical centers. The training consists of a year-long post masters
residency, with an average salary of $44,000 per trainee. In recent
years, VA has expanded the number of training sites and the number of
trainees. Moreover, recruitment and retention of orthotists and
prosthetists has not been a challenge for VA. Nationally, VA has
approximately 312 clinical orthotic and prosthetic staff.
VA offers in-house orthotic and prosthetic services at 79 locations
across VA; however, much of the specialized orthotic and prosthetic
capacity of VA is met through contract mechanisms. VA contracts with
more than 600 vendors for specialized orthotic and prosthetic services.
Through both in-house staffing and contractual arrangements, VA is able
to provide state-of-the-art, commercially-available items ranging from
advanced myoelectric prosthetic arms to specific custom fitted
orthoses.
We also note certain aspects of the bill that would make its
implementation problematic. First, the bill would not require grant
funded programs to affiliate with VA or send their trainees to VA as
part of a service obligation. Also, section 2, subsection (e) would
authorize appropriations ($15 million) in only one fiscal year, FY 2014
- which we presume the drafters intended to be FY 2016, consistent with
the language in section 3(e) - and specify that the funding would
expire as of September 30, 2016. This subsection contemplates that
unobligated funds would be returned to the General Fund of the Treasury
immediately upon expiration. Under 31 U.S.C. Sec. 1552(a), expired
accounts are generally available for 5 fiscal years following
expiration for the purpose of paying obligations incurred prior to the
account's expiration and adjusting obligations that were previously
unrecorded or under recorded. If the unobligated balance of these funds
were required to be returned to the Treasury immediately upon
expiration, then VA would be unable to make obligation adjustments to
reflect unrecorded or under recorded obligations. A bookkeeping error
could result in an Antideficiency Act violation. Lastly, we also note
that 90 days after the date of enactment of this provision would not be
enough time for VA to promulgate regulations and a request for
proposals (RFP) for these grants.
Section 3 of H.R. 1904 would require VA to award a $5 million grant
to an institution to: (1) establish the Center of Excellence in
Orthotic and Prosthetic Education (the Center); and (2) improve
orthotic and prosthetic outcomes by conducting evidence-based research
on orthotic and prosthetic education. Under the bill, grant recipients
would be required to have a robust research program; offer an education
program that is accredited by the National Commission on Orthotic and
Prosthetic Education in cooperation with the Commission on
Accreditation of Allied Health Education Programs; be well recognized
in the field of orthotics and prosthetics education; and have an
established association with a VA medical center or clinic and a local
rehabilitation hospital. This section would require VA to give priority
in the grant award to an institution that has, or is willing and able
to enter into: (1) a memorandum of understanding with VA, DoD, or other
appropriate government agency; or (2) a cooperative agreement with an
appropriate private sector entity. The memorandum of agreement would
provide resources to the Center and/or assist with the Center's
research. VA would be required to issue a request for proposals for
grants not later than 90 days after the date of enactment of this
provision.
VA does not support section 3 because VA would not have oversight
of the Center and there would be no guarantee of any benefit to VA or
Veterans. Further, we believe that a new Center is unnecessary. DoD has
an Extremity Trauma and Amputation Center of Excellence, and VA and DoD
work closely to provide care and conduct scientific research to
minimize the effect of traumatic injuries and improve outcomes of
wounded Veterans suffering from traumatic injury. VA also has five
Research Centers of Excellence that conduct research related to
prosthetic and orthotic interventions, amputation, and restoration of
function following trauma:
1. Center of Excellence for Limb Loss Prevention and Prosthetic
Engineering in Seattle, WA.
2. Center of Excellence in Wheelchairs and Associated
Rehabilitation Engineering in Pittsburgh, PA.
3. Center for Functional Electrical Stimulation in Cleveland, OH.
4. Center for Advanced Platform Technology in Cleveland, OH.
5. Center for Neurorestoration and Neurotechnology in Providence,
RI.
These centers provide a rich scientific environment in which
clinicians work closely with researchers to improve and enhance care.
They are not positioned to confer terminal degrees for prosthetic and
orthotic care/research but they are engaged in training and mentoring
clinicians and engineers to develop lines of inquiry that will have a
positive impact on amputee care. Finally, the requirement to issue a
request for proposals within 90 days of enactment would be very
difficult to meet as VA would first need to promulgate regulations
prior to being able to issue the RFP.
VA estimates that, if section 2(e)(1) referred to FY 2016, instead
of FY 2014, sections 2 and 3 of H.R. 1904 would cost $150,000 in FY
2016 and $21.6 million over 5 years.
H.R. 2639 Marriage and Family Therapists for Veterans Act
H.R. 2639, the ``Marriage and Family Therapists for Veterans Act,''
would amend the qualification standards for Marriage and Family
Therapists (MFT), prescribed under 38 U.S.C. Sec. 7402(b)(10).
Under current qualification standards, MFTs must meet two
requirements: (1) hold a master's degree in marriage and family
therapy, or a comparable degree in mental health, from a college or
university approved by the Secretary; and (2) be licensed or certified
to independently practice marriage and family therapy in a state.
H.R. 2639 would add a third prerequisite to the qualification
standards for MFTs, which would require that an MFT have passed a
marital and family therapy examination administered by the Association
of Marital and Family Therapy or an examination for a marriage and
family therapy license given by a state board of behavioral sciences or
its equivalent.
H.R. 2639 would also amend the first requirement in the
qualification standards to allow an MFT to fulfill that prerequisite if
he or she obtained a master's degree in marriage and family therapy, or
a comparable degree in mental health, from a regionally accredited
college or university. VA has a number of policy concerns about the
amendment to this requirement and consequently cannot support the bill.
Under current law, the Secretary has discretion to approve colleges
and universities that have master's degree programs in marriage and
family therapy. This discretion allows VA to require that MFTs graduate
from schools with programs accredited by the national accrediting body
for MFTs, the Commission on Accreditation for Marriage and Family
Therapy Education (COAMFTE). COAMFTE is a specialized accrediting body
that accredits master's degree, doctoral degree, and post-graduate
degree clinical training programs in Marriage and Family Therapy
throughout the United States and Canada and, since 1978, has been
recognized by the U.S. Department of Education as the national
accrediting body for the field of Marriage and Family Therapy.
Requiring a Marriage and Family Therapist to have a COAMFTE
accredited degree ensures that the MFT has completed a course of
professional preparation that meets specific standards established by
the discipline's accrediting body and that the individual has been
trained in the appropriate knowledge and skill areas required of the
profession. The requirement that MFTs graduate from a program
accredited by COAMFTE is similar to the requirements imposed on other
core mental health disciplines (e.g., Psychology, Psychiatry, Social
Work, Nursing, Licensed Professional Mental Health Counseling, and
Marriage and Family Therapy), in that individuals in these disciplines
must also graduate from programs that are accredited by a recognized
body.
Requiring that an MFT graduate with a master's degree in marriage
and family therapy or a comparable degree in mental health, from a
college or university that is regionally accredited, is problematic
because regional accrediting bodies accredit academic institutions but
do not examine the quality of education provided in a specific program.
In 2013, the American Association of Marriage and Family Therapy and
COAMFTE identified a number of regionally accredited universities with
marriage and family therapy programs. However, after reviewing the
academic curricula for the programs, COAMFTE staff determined that many
of these programs would not be eligible for COAMFTE accreditation since
the programs were unable to demonstrate they actually trained their
students in marriage and family therapy.
H.R. 3234 Failing VA Medical Center Recovery Act
H.R. 3234, the ``Failing VA Medical Center Recovery Act,'' would
establish an Office of Failing Medical Center Recovery (OFMCR) within
VA. Under the bill, OFMCR would manage day-to-day operations for VA
medical centers (VAMC) that are ranked as ``failing'' key health
metrics. VA has legal and policy concerns about H.R. 3234 as outlined
below.
Determining a VAMC's ranking
H.R. 3234 would require the Secretary to publish a quarterly list
of key health metrics for each VAMC. This quarterly list would also
include rankings for each VAMC as either ``excellent,''
``satisfactory,'' ``poor,'' or ``failing,'' based on Strategic
Analytics Improvement and Learning (SAIL) data. SAIL data is a web-
based balanced scorecard model that VA developed to measure, evaluate,
and benchmark quality and efficiency at VAMCs. VA designed SAIL for
internal benchmarking within VHA to spotlight the successful strategies
of VA's top performers to promote high-quality, safety, and value-based
health care across all of its VAMCs. SAIL is available on the VHA
Intranet website and accessible to all VA staff members who have
network access. In support of VA Transparency Program, VA published
SAIL benchmark tables for each medical facility on the Internet in
October 2014 to ensure public accountability and spur continuous
improvements in health care delivery.
Overlap of OFMCR with activities performed by VHA
The bill would require that VAMCs ranked as ``failing'' be
transferred by the Secretary from VHA to the newly established OFMCR.
OFMCR would then manage the day-to-day operation of the ``failing''
VAMC until the VAMC can achieve a ranking of ``satisfactory'' or better
under the key health metrics for three consecutive quarters, at which
time the VAMC would be restored back to VHA. Once the Secretary ranks a
VAMC as ``failing,'' the head of OFMCR, the Under Secretary for Failing
Medical Center Recovery (the Under Secretary), would assume all the
duties, responsibilities, and authority held by the director of the
``failing'' VAMC. Once the ``failing'' VAMC is under the control of the
OFMCR Under Secretary, he or she would retain the use of all resources
and services that would otherwise be made available to the covered
``failing'' medical cenver and would operate the center independently
from its respective Veterans Integrated Service Network (VISN).
A number of OFMCR activities are already performed by VHA. For
example, VHA already monitors performance in VHA facilities based on
SAIL data which encompasses 28 measures - 27 quality measures, which
are organized into 9 domains: acute care mortality; avoidable adverse
events; cause mortality register 30-Day mortality and readmission rate;
length of stay; performance measures; customer satisfaction; ambulatory
care sensitive condition hospitalizations; access; and mental health -
and an additional measure to assess overall efficiency. Based on the
SAIL data, VA facilities are benchmarked on individual measures and
domains, and using 10th, 30th, 70th, 90th percentile cut-offs of
overall quality score, each facility is designated a 1- to 5-star
rating for overall quality.
We are deeply concerned that this bill proposes to use percentile-
based ranking to identify ``failing'' medical centers. Applying a
percentile-based ranking schema ensures that there will always be a
certain number of medical centers that are certified as ``failing''
irrespective of how high their scores might be on the SAIL metrics.
This would perpetuate a continuous need for the OFMCR to sieze control
of various medical centers even if SAIL scores were to collectively
improve across all medical centers. We therefore propose that a
specific SAIL score threshold be established and used to identify
``failing'' VAMCs.
Based on SAIL data, VHA sends teams of subject matter experts out
to facilities to provide on-site consultative training to help
facilities in areas specific to their needs. In FY 2014, there were a
total of 62 consultative trainings that were provided. In
FY 2015, VHA provided at least 133 trainings. During these
trainings, facilities were provided with areas where they have
improvement opportunities, recommendations for improvement strategies,
and points of contact from VA medical centers where there are strong
practices they can borrow from. VHA provides follow-up consultation to
facilities within 30-60 days of the training. In FY2015, nearly 45% of
VA medical centers improved their overall performance from one year
ago. For VHA as a whole, significant improvements were found on patient
outcome measures such as mortality, length of stay, hospital
readmission rate, ambulatory care sensitive condition hospitalizations,
are healthcare acquired infections. All of these measures are
considered significant quality indicators that are publically reported
by agencies such as Centers for Medicare and Medicaid Services.
Authority of the Under Secretary for Failing Medical Center
Recovery
The Under Secretary would be directly responsible for the operation
of OFMCR. Under the bill, the Under Secretary can appoint individuals
in OFMCR using direct-hire authority in 5 U.S.C. Sec. 3304(a)(3) and
can pay these individuals at a prevailing rate that is 125 percent of
the rate of pay for the employee's position. OFMCR employees who serve
for 2 or more years with that office would also be entitled to receive
preferential treatment for promotion and advancement within VA. VA is
extremely concerned with establishing a new Under Secretary position to
manage and lead this office as it removes authority vested in the Under
Secretary for Health and moves it to what appears to be a non-medical
position. This would make it harder for the Under Secretary for Health
to manage Veteran medical care when his authorities are being shifted
out of the administration. A realignment of VHA functions for failing
medical centers under a new Under Secretary position would create
costly and duplicative functions at the national, regional and local
levels. Furthermore, VA does not believe a separate Under Secretary and
organization would be successful in achieving improved outcomes and
care.
The bill does not address funding for OFMCR or whether the
preferential treatment for OFMCR employees in applying for promotions
and advancement within VA trumps Veterans' preference.
The bill allows the Under Secretary to hire individuals as
employees of VHA at ``failing'' VAMCs; pay an employee at a ``failing''
VAMC at a prevailing rate that is 125 percent of the rate of the
employee's position; and carry out adverse actions, including transfers
or reassignments for all employees at a ``failing'' VAMC.
By allowing the Under Secretary to appoint individuals at
``failing'' VAMCs as employees of VHA, the bill fails to consider the
possible repercussions such appointments would have on VHA's budget,
which is typically managed by the Under Secretary for Health. Indeed,
the possible budgetary impact on VHA would be significant as the Under
Secretary can pay these employees or other employees at ``failing''
VAMCs at a prevailing rate that is 125 percent of the rate of the
employee's position.
With regard to paying an employee at a ``failing'' VAMC or OFMCR at
125 percent of the employee's rate of pay, the bill does not address
statutory limits on employee pay linked to the Executive Schedule,
which would, for example, cap a Registered Nurse at Level IV of the
Executive Schedule. The bill also does not consider pay retention for
employees paid at 125 percent of their pay rate. That is, whether an
employee who has been paid at 125 percent of their rate of pay would be
allowed to retain that pay increase if they leave the ``failing'' VAMC
or OFMCR, or, if the employee continues to work at the ``failing''
VAMC, once the VAMC is no longer designated as ``failing'' by the
Secretary. VA is also concerned that this flexibility to pay an
employee at the 125 percent rate would be limited to hospitals that are
deemed ``failing'' and not all facilities that face hiring challenges
and other difficulties.
The bill also would allow the Under Secretary to designate any
employee of a ``failing'' VAMC as an employee covered by 38 U.S.C.
Sec. 713, for purposes of removal, even if that employee is not a
senior executive. This provision would have broad implications on VA's
personnel system as any employee of a ``failing'' VAMC, regardless of
grade, pay level, or direct patient-care responsibilities, could be
removed under a section intentionally limited to VA senior executives.
Limiting the appeal rights for employees who are removed at these
``failing'' VAMCs would also create a two-tier system of employment in
VA. That is, employees at ``failing'' VAMCs would have fewer appeal
rights if they are terminated under 38 U.S.C. Sec. 713 than their
counterparts at other VAMCs and the rest of the Federal Government. To
that extent, high-performing employees at VAMCs, who through no fault
of their own, are employed at VAMCs that the Secretary has designated
as ``failing,'' may be reluctant to remain employed at those
facilities, when they can have better removal appeal rights at other
VAMCs or Federal agencies, or greater pay by joining the private
sector. Because VA is already hard-pressed to compete with the private
sector, especially in positions involving health care, the inclusion of
a provision curtailing employee removal appeal rights would be
detrimental to Veteran care and the operation of the impacted VAMCs.
Ultimately, the inclusion of this provision would make conditions
of employment in VA significantly less attractive than in other Federal
agencies or in the private sector, and as a result, would discourage
outstanding VA employees from remaining in VA and dramatically impair
VA's ability to recruit top talent, including Veterans. In addition, we
understand that the Department of Justice believes that the political
affiliation restriction for the Under Secretary raises Appointments
Clause concerns.
The Office of Personnel Management (OPM) may also have views on
H.R. 3234, as the bill would adversely impact the treatment of VA
employees under Title 5 personnel authorities administered by OPM.
VA is unable to determine the costs of H.R. 3234 at this time.
H.R. 3471 Veterans Mobility Safety Act of 2015
H.R. 3471 would amend 38 U.S.C. Sec. 3903 to require the Secretary
to ensure that, to the extent practicable, eligible individuals are
given the opportunity to make personal selections related to
automobiles or other conveyances provided under chapter 39 of title 38,
U.S.C. The bill would also set forth minimum standards for adaptive
equipment modification services - requiring the providers of such
services to be certified by a certification organization or the
manufacturer of the adaptive equipment. Individuals performing adaptive
equipment modification services on an automobile would also be required
to meet these certification requirements or be licensed or certified by
the state in which the modification service is performed if the service
is within the scope of practice. Under the bill, providers of
automobiles, adaptive equipment, or modification services would be
required to adhere to chapter 126 of title 42 (the Americans with
Disabilities Act of 1990), and to the ``make inoperative mandates'' of
the Department of Transportation National Highway Traffic Safety
Administration (NHTSA) Federal Motor Vehicle Safety Standards
prescribed pursuant to section 30122 of title 49. The bill would define
the terms ``certification organization'' and ``modification services.''
H.R. 3471 would also amend 38 U.S.C. Sec. Sec. 1718 and 3104 to
specify that if the Secretary provides adaptive equipment in providing
rehabilitative services or a rehabilitation program under chapters 17
or 31 of title 38, U.S.C., respectively, the equipment must meet the
minimum standards prescribed under 38 U.S.C. Sec. 3903(d)(2), as
amended by the bill. No later than 1 year after enactment, VA would be
required to prescribe regulations to carry out these amendments.
VA does not support H.R. 3471, as VA defers to the NHTSA on safety
compliance issues. NHTSA prescribes safety standards for adaptive
equipment and develops criteria to assist not just Veterans, but all
citizens, when selecting a modifier and/or alterer to modify their
vehicles (49 U.S.C. Sec. 30111; 49 C.F.R. Parts 571 and 567). VA does
not manufacture or install adaptive equipment on a beneficiary's
vehicle. Rather, VA pays for automobile adaptive equipment that
accommodates beneficiaries' driving and/or passenger needs as
identified by a VHA certified Drivers Rehabilitation Specialist.
We note that H.R. 3471 may be too restrictive and cause undue
hardship for small businesses that are not members of a certified
organization and/or certified by the state in which the modification
service is performed. This, in turn, may restrict the access and choice
Veterans have when selecting a modifier or alterer for adapting their
personal vehicles. Further, we note that there are no systematic issues
regarding automobile adaptive equipment safety (as authorized in
chapter 39 of title 38, U.S.C.) being reported across VA. Therefore,
the amendments in H.R. 3471 would provide no added value to support
Veterans and Servicemembers who are eligible to receive automobile
adaptive equipment under chapter 39 of title 38, U.S.C.
We do not expect H.R. 3471 to directly impact the provision of
benefits to Veterans by VA. Therefore, no benefit costs or savings
would be associated with this bill. Any administrative costs associated
with this bill would be minimal.
As a technical matter, we would read 38 U.S.C. Sec. 1718(h), as
added by section 2(b) of the bill, as applying only to automobile
adaptive equipment, and note that this amendment would tend to clarify
VA's authority to provide automobile adaptive equipment under chapter
17.
H.R. 3549 VA Billing Accountability Act
H.R. 3549 would add a new section 1709C to title 38, U.S.C., that
would require VA to notify Veterans of their copayment requirements no
later than 120 days after the date of care or services provided at VA
medical facilities, and no later than 18 months after the date of care
or services provided at non-VA facilities. If VA does not provide such
notice, VA could not collect the copayment, including through a third-
party entity, unless VA provides the Veteran: (1) information on
applying for a waiver and establishing a payment plan, and (2) an
opportunity to make a waiver or establish a payment plan. The Secretary
would be authorized to waive the copayment requirement in cases where
notification to the Veteran was delayed because of an error committed
by VA, a VA employee, or a non-VA facility (if applicable), and the
Veteran received notification beyond the specified timeframes. H.R.
3549 would also require VA, no later than 180 days after enactment, to
review and improve its copayment billing internal controls and
notification procedures, including pursuant to the provisions of the
bill.
VA supports the intent of H.R. 3549 to prevent delays in the
release of copayment charges due to operational error, avoid undue
burden to Veterans, and improve VA's copayment billing procedures.
However, the 120-day time period proposed in the bill is not reflective
of the timeline of normal business operations. Further, it is not clear
what specific copayment billing issues the bill would address.
We note that copayments are automatically generated by VA's
integrated billing system. Moreover, VA ensures that every Veteran is
given the notice of rights and the opportunity to request a waiver or
compromise, and to establish a repayment plan for copayment charges.
This information is included with every copayment billing statement
that VA sends to a Veteran. As a service to Veterans, VA holds
copayment bills until a Veteran's other health insurance (OHI) is
billed and either pays or denies the claim. This allows VA to
potentially offset the Veteran's copayment charges with payment
received from the OHI, reducing the Veteran's liability. When a Veteran
has OHI, the copayment charge is placed on hold for 90 days while the
OHI is billed. If no payment is received within 90 days, the charges
will automatically be released and a statement generated to the
Veteran. If a balance remains after an OHI payment is applied to the
copayment debt, the bill for the remaining balance is released to the
Veteran and he or she receives it within a variable timeframe that
ranges from 70 to 150 days depending on when the OHI payment is made -
a timeframe that can exceed the proposed 120-day standard in H.R. 3549.
VA financial policy for medical care debts specifies that Veterans who
do not have OHI should have the opportunity to satisfy copayment
obligations at the Agent Cashier's office prior to leaving the medical
facility. Otherwise, the record of service is prepared and the
copayment is released for billing on the Veteran's next scheduled
monthly billing statement, which is normally received anywhere from 14
to 42 days after the date of service.
Copayment bills may also be generated following income verification
under 38 U.S.C. Sec. 5317, which authorizes VA to validate certain
Veterans' reported income with the Internal Revenue Service (IRS) and
Social Security Administration information. This validation begins 18
months after the calendar year in which that income is reported due to
receipt of data, upon completion of tax processing, from the IRS. If VA
identifies unreported income, VA has authority to generate copayment
billings as a result of this verification process. VA also refunds
copayments, when appropriate, as a result of this income verification
process. The timeframe associated with this process exceeds the 120-day
standard proposed in H.R. 3549. We also note that private sector
billing industry standards allow for billing up to 12 to 18 months
after services are rendered - also exceeding the proposed 120-day
timeframe.
H.R. 3549 does not specify what constitutes an error, what would
justify a waiver, and whether the waivers and payment plans authorized
under the bill would differ from those currently authorized in
applicable statutes and regulations. VA has existing procedures under
38 U.S.C. Sec. 5302 to waive collection in cases where the Secretary
determines that recovery would be against equity and good conscience.
In these instances, an application for relief must generally be made
180 days from the date of notification of the indebtedness.
As a technical matter, we note that the bill does not define the
term ``third-party entity'' or specify how this language would be
applied. Further, we note that VA copayment requirements under 38
U.S.C. Sec. 1710(f)-(g), 38 U.S.C. Sec. 1722A, and 38 U.S.C. Sec.
1710B (which is not referenced in H.R. 3549, but requires copayments of
certain Veterans for extended care services) apply regardless of
whether the care or services was provided in a VA facility or
authorized by VA in a non-VA facility. Therefore, the 120-day timeframe
that would be added in section 1710(f)(3)(G)(ii) and section
1722A(c)(2) by the bill may be read as applying to care or services in
both VA and non-VA facilities. If copayments billings delayed beyond
120 days from date of service are waived, VA estimates a 5-year revenue
loss of $365.6 million and a 10-year revenue loss of $695.2 million
from the First Party Inpatient/Outpatient and Pharmacy Medical Care
Collection Fund.
Draft Bill Promoting Responsible Opioid Management and
Incorporating Scientific Expertise (PROMISE Act)
In general, this draft bill contains some very appropriate
requirements for opioid safety, many of which are already underway in
VA. We note, however, that Servicemembers' opioid use is often
initiated by DoD prescribers, and a major shortcoming of this bill is
that it lacks requirements for DoD to address opioid use at the
beginning of the process and instead focuses on VA interventions after
opioid use has been initiated. This problem cannot be resolved in
isolation; DoD and VA must both be accountable for opioid use by
Servicemembers and Veterans, respectively. To be more effective, this
bill should be strengthened so that VA's requirements are mirrored by
requirements for DoD.
Section 101 would require, within 1 year of the date of the
enactment of the Act, VA and DoD to jointly update the VA/DoD Clinical
Practice Guideline for Management of Opioid Therapy for Chronic Pain.
The guideline would have to include common recommended guidelines for
safely prescribing opioids for the treatment of chronic, non-cancer
pain in outpatient settings as compiled by the Centers for Disease
Control and Prevention (CDC); enhanced guidance in certain specified
areas; enhanced guidance with respect to the treatment of patients with
behaviors or comorbidities such as posttraumatic stress disorder,
psychiatric disorders, or a history of substance abuse or addiction,
that require consultation or co-management of opioid therapy with one
or more specialists; enhanced guidance with respect to the conduct by
health care providers of an effective assessment for patients receiving
opioid therapy; guidance that each VA and DoD provider, before
initiating opioid therapy, use VA's Opioid Therapy Risk Report tool to
assess the risk for adverse outcomes; guidelines to govern the
methodologies used by VA and DoD providers to taper opioid therapy when
adjusting or discriminating opioid therapy; guidelines with respect to
appropriate case management for patients receiving opioid therapy who
transition between inpatient and outpatient settings; guidelines on
appropriate hand-off of case management responsibility for patients
receiving opioid therapy who transition from receiving care during
active duty and post-military health care networks; enhanced standards
on the use of routine and random urine drug tests for all patients
before and during opioid therapy; and guidance that health care
providers discuss with patients before initiating opioid therapy, other
options for pain management therapies. Before updating these
guidelines, VA and DoD would be required to jointly consult with the
Pain Management Working Group of the VA/DoD Health Executive Council.
VA appreciates the intent of this thoughtful and comprehensive bill
and agrees that more needs to be done to support clinicians with
clearer guidance and training on prescribing medications for pain
management. This bill will, in effect, codify the spirit of the
recently released Presidential Memorandum requiring education for all
Federal prescribers. \3\ VA, because of its central role in training
physicians across the country, can provide leadership by training
clinicians in pain management and supporting a team approach to care.
There are cases where the use of opioids is clinically indicated,
albeit closely controlled and monitored, to control pain when nothing
else does. VA should have the flexibility to develop its own evidence-
based prescribing guidelines in partnership with DoD.
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\3\ Presidential Memorandum-Addressing Prescription Drug Abuse and
Heroin Use. White House Office of the Press Secretary. October 21,
2015. Available at https://www.whitehouse.gov/the-press-office/2015/10/
21/presidential-memorandum-addressing-prescription-drug-abuse-and-
heroin. Downloaded 11/13/2015
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In addition, the bill's requirement that VA and DoD health care
providers, before initiating opioid therapy to treat a patient, use the
VA Opioid Therapy Risk Report tool, including information from the
prescription drug monitoring program of each State, is problematic
because not every state has a functioning program and not every state
allows access by health care providers not licensed in that state. VA
has many providers who are not licensed in the state where they work.
Section 102(a) would require VA, within 180 days of enactment, to
expand the Opioid Safety Initiative to include all VA medical
facilities.
Section 102(b) would require VA to ensure that all providers
responsible for prescribing opioids to receive education and training
on pain management and safe opioid prescribing practices. The education
and training would have to cover a number of identified areas, and in
providing the training, VA would be required to use the
Interdisciplinary Chronic Pain Management Training Team Program.
Section 102(c) would require each VA medical facility to identify
and designate a pain management team of health care professionals
responsible for coordinating and overseeing therapy at the facility for
patients experiencing acute and chronic pain that is not related to
cancer. In consultation with VISN Directors, a consensus on established
protocols would have to be adhered to for the designation of a pain
management teams at each VA medical facility, and the protocols would
need to ensure that any health care provider without expertise in
prescribing analgesics or who has not completed required training does
not prescribe opioids, with limited exceptions. Within 1 year of
enactment of this Act, each VA medical facility would be required to
submit to the Deputy Under Secretary for Health and VISN Director a
report identifying the health care professionals that have been
designated as members of the pain management team at the facility, and
other specified information.
Section 102(d) would require, within 18 months of the date of the
enactment of the Act, that VA submit an acquisition and budget plan to
create a system that allows for real-time tracking and access to data
on the use of opioids and prescribing practices. VA also would be
required to ensure access by VA health care providers to information on
controlled substances prescribed by community providers through State
prescription drug monitoring programs (PDMPs). Within 18 months of the
enactment of this Act, VA would be required to submit to Congress a
report on the implementation of these improvements. As noted above, we
recommend that any such requirements also involve DoD. Also, we note
that VA already has trending reports available to monitor the key
clinical indicators of the Opioid Safety Initiative. In addition, VA
health care providers receive real-time order checks on all
prescriptions, including opioids. VA likely could not develop the
proposed system within 18 months, and the system would offer little
value to existing trending reports. Further, it is unclear what the
benefit or desired outcome would be to tracking mail-order
prescriptions of opioids prescribed to Veterans in real-time.
Section 102(e) would require VA to maximize the availability of
opioid receptor antagonists, such as naloxone, to Veterans and ensure
their availability for use by VA health care providers treating
Veterans. Within 90 days of enactment of this Act, VA would be required
to equip each VA medical facility with opioid receptor antagonists
approved by the Food and Drug Administration (FDA). VA notes that other
opioid receptor antagonists approved by FDA exist, but only one type
(naloxone) is approved for overdose reversal. This section would also
direct VA to enhance training of providers on distributing such
antagonists and to expand the Overdose Education and Naloxone
Distribution program to ensure all Veterans in receipt of health care
who are at risk of opioid overdose (as defined by the bill) have access
to opioid receptor antagonists and training on their proper
administration. Within 120 days of the date of the enactment of this
Act, VA would be required to submit to the Committees on Veterans'
Affairs a report on compliance with these requirements.
Section 102(f) would require that VA include in the Opioid Therapy
Risk Report tool information on the most recent time the tool was
accessed by a VA health care provider with respect to each Veteran and
information on the results of the most recent urine drug test for each
Veteran. VA would also be required to determine if a provider
prescribed opioids without checking the information in this tool first.
Section 102(g) would require VA to modify VA's Computerized Patient
Record System (CPRS) to ensure that any health care provider that
accesses the record of a Veteran will be immediately notified whether
the Veteran is receiving opioid therapy and has a history of substance
use disorder or prior instances of overdose, has a history of opioid
abuse, or is at risk of becoming an opioid abuser.
VA agrees that additional training for providers is necessary, and
will be compliant with the Presidential Memorandum. Clinicians want to
help Veterans and Servicemembers, but often do not have the skills and
resources to do so. A well-trained physician and clinical team will
know how to evaluate comprehensively a patient with pain, including
making clinical diagnoses and how to develop a goal oriented management
plan for pain, as well as how to engage the particular resource needs
of each patient. Regarding other parts of section 102, VA is currently
taking steps to fulfill the intent of many of these provisions. For
example, section 102(e) would require VA to maximize the availability
of opioid receptor antagonists approved by the FDA, and VA is currently
exploring ways to increase the availability of these life-saving
medications. Similarly, section 102(g) would require VA to modify the
CPRS to ensure that providers will be immediately notified about opioid
risks for each patient. VA's electronic health record already has real-
time mechanisms in place to alert VA health care providers of existing
opioid prescriptions to prevent prescribing of additional opioids to
Veterans who receive all their healthcare and prescriptions through the
VA system. These mechanisms include real-time order checks that alert
providers of prescriptions with potential problems with duplication,
drug interactions, and doses in excess of the maximum recommended
amount. We note that the Veterans Choice Program also allows VA
patients, in certain circumstances, to receive medicines outside of the
VA system.
Subparagraphs (A) and (C) of Section 102(d)(2) are duplicative of
existing Federal law and regulations, but their general language could
cause confusion as to the responsibilities of the Department and its
individual providers. More specifically, 38 U.S.C. Sec. 5701(l)
required VA to issue regulations authorizing the disclosure of
information about Veterans and their dependents to state PDMPs.
Accordingly, those regulations were published in 38 C.F.R. Sec. 1.515,
which sets forth the specific categories of information that may be
disclosed to state PDMPs. Some VA facilities already have policies in
place that mandate the querying of state PDMPs regarding patients who
are prescribed certain kinds of drugs. If Congress desires to make the
disclosure of information to state PDMPs mandatory, rather than
permissive, it should consider making that change within 38 U.S.C.
Sec. 5701(l), rather than in a separate law.
Section 104 would require VA to conduct a study on the feasibility
and advisability of carrying out a pharmacy lock-in program under which
Veterans at risk for abuse of prescription drugs would be permitted to
receive prescription drugs only from certain specified VA pharmacies.
VA would be required to report to the Committees on Veterans' Affairs
within 1 year of enactment on this study.
VA has numerous concerns with section 104. We believe a pharmacy
lock-in program, under which Veterans at risk for abuse of prescription
drugs are permitted to receive prescription drugs only from certain
specified VA pharmacies, would lead to negative patient outcomes. For
example, Veterans who are travelling or require emergent/urgent medical
care from a VA facility may need to receive a prescription from another
VA facility's pharmacy to treat the Veteran's emergent/urgent
condition. The pharmacy lock-in program would prevent medically-
necessary drugs from being dispensed to Veterans. VA health care
providers receive duplicate order checks from other VA facilities at
the point of prescribing. These duplicate order checks would notify the
provider and pharmacist in real-time that the Veteran is receiving
similar medications at another VA facility. Therefore we do not believe
a study on a pharmacy lock-in program would yield useful information.
Section 105(a) would require the Comptroller General, within 2
years of enactment of this Act, to submit to the Committees on
Veterans' Affairs a report on the Opioid Safety Initiative and the
opioid prescribing practices of VA health care providers. The report
would include recommendations for improvement, and under section 105(b)
VA would be required to report to the Committees on Veterans' Affairs
on a quarterly basis on the actions taken by VA to address any
outstanding findings and recommendations from the Comptroller General.
We defer to the Government Accountability Office (GAO) on this
provision. However, we note that we would construe the provision not to
require VA to implement the Comptroller General's recommendations, due
to the separation of powers concerns that would otherwise be presented.
See Bowsher v. Synar, 478 U.S. 714, 726-27 (1986). We would construe
section 105(b) as merely requiring VA to report the actions taken to
implement those recommendations, if any.
Section 105(c) would also require VA to conduct an annual report on
opioid therapy, and to submit this report to the Committees on
Veterans' Affairs. This report would include specified information on
patient populations and prescribing patterns for opioids. VA has a
number of technical concerns with section 105, and we would be glad to
meet with Subcommittee staff to discuss these further.
VA supports section 201, which would require VAMCs and community-
based outpatient clinics to host community meetings, open to the
public, on improving VA health care. This section is consistent with
current practices of hosting Town Hall meetings to hear from Veterans,
families, and other stakeholders.
Section 202 would require VA display at each VA medical facility
the purposes of the Patient Advocacy Program, contact information for
the patient advocate, and the rights and responsibilities of patients
and family members. VA supports increasing the awareness of the Patient
Advocacy Program and the rights and responsibilities of Veterans and
family members. This section is consistent with current practices of
posting this information in medical facilities and would only require
the addition of posting the Patient Advocacy Program's purpose.
Section 203 would require the Comptroller General to submit to the
Committees on Veterans' Affairs a report on VA's Patient Advocacy
Program, including recommendations and proposals for modifying the
program and other information the Comptroller General considers
appropriate.
We defer to GAO on this provision.
Section 204 would require VA, in consultation with DoD, to submit
to the Committees on Veterans' Affairs, within 180 days of the date of
the enactment of this Act, a report on the transition from DoD to VA
health care settings undergone by Veterans in receiving health care.
The report would have to include an evaluation of VA's standards for
facilitating and managing the transition undergone by Veterans in
receiving health care in VA and DoD health care settings, an assessment
of the case management services that are available, an assessment of
the coordination in coverage of and consistent access to medications,
and a study of the sufficiency of VA resources to ensure delivery of
quality health care relating to mental health issues among Veterans
seeking VA treatment.
VA does not support section 204 because its requirements would
duplicate multiple GAO investigations regarding the health care
transition of Servicemembers and Veterans, most notably a November 2012
report, Recovering Servicemembers and Veterans: Sustained Leadership
Attention and Systematic Oversight Needed to Resolve Persistent
Problems Affecting Care and Benefits. In response, DoD and VA are
enhancing care coordination and case management to improve transitions
across health care settings, including the development of an
Interagency Comprehensive Plan for Servicemembers and Veterans
requiring complex care coordination as well as a Lead Coordinator to
align and standardize care coordination processes, roles, and
responsibilities and to reduce confusion, duplication, and frustration.
In addition, GAO is currently conducting a study, Engagement on
Care Transitions and Medication Management for Post-Traumatic Stress
Disorder and Traumatic Brain Injury (GAO code 291282). GAO is
interviewing DoD and VA officials, as well as staff in the field. Thus
far, GAO has conducted interviews at the Washington, DC VAMC; at Fort
Hood, Texas; and at Fort Carson, Colorado. VA looks forward to their
objective, third-party assessment.
Section 401 would require that as part of the hiring process for
health care providers VA reach out to state medical boards to ascertain
whether a prospective employee has any violations over the past 20
years, or has entered into a settlement agreement for a disciplinary
charge related to the employee's practice of medicine. VA does not feel
that additional legislation is needed to accomplish this. VHA policy,
already in place, requires the verification of all current and
previously held licenses for all licensed health care providers. At the
time of initial appointment all current and previously held licenses
are verified with the state licensing board issuing the license.
Verification requires querying the state licensing board for not only
the issue date and expiration date, but also any pending or previous
adverse actions. If an adverse action is identified, the verification
requires obtaining all documentation available associated with such
action, including but not limited to copies of any agreements. At the
time of expiration of a license, as well as at the time of reappraisal,
VHA policy requires querying the state licensing board to confirm
renewal of the license, as well as whether or not there are any pending
or previous adverse actions. If the license is not renewed, VHA policy
requires confirmation that the license expired in good standing and, if
not, what was not in good standing.
At the time of initial appointment, all health care providers are
queried through the National Practitioner Data Bank (NPDB). The NPDB is
a national flagging system that serves as a resource for hospitals and
other healthcare entities during the provider credentialing process.
The NPDB provides information about past adverse actions of health care
providers. VHA also enrolls all independent, privileged providers in
the NPDB's Continuous Query program for ongoing monitoring of not only
adverse actions taken against a credential, but also paid malpractice.
VHA receives notification of a new report within 24 hours of the report
being filed with the NPDB.
Additionally, at the time of initial appointment, all physicians
are queried through the Federation of State Medical Boards (FSMB)
Federation Physician Data Center, a nationally recognized system for
collecting, recording and distributing to state medical boards and
other appropriate agencies data on disciplinary actions taken against
licensees by the boards and other governmental authorities. The report
returned from the FSMB Physician Data Center not only identifies if
there are any adverse actions recorded against a physician's license
but also lists all of the physician's known licenses, current or
previously held, serving as a double-check that the physician reported
all licenses during the credentialing process. In addition, the
licenses of all physicians are monitored through a contract with the
FSMB's Disciplinary Alert Service (DAS). Through this contract, all
physicians are enrolled in the DAS, which offers ongoing monitoring of
physician licensure. If a new action against a physician's license is
reported to the FSMB DAS, VHA receives a notification of the report
within 24 hours. The staff at the physician's facility then contacts
the reporting state licensing board to obtain the details of the
action.
If the facility learns of an adverse action taken against a
provider license, the staff at the facility must obtain information
from the provider against whom the action was taken and consider it as
well as the information obtained from the state licensing board. This
review is documented to include the reasons for the review, the
rationale for the conclusions reached, and the recommended action for
consideration and appropriate action by the facility.
Section 402 would require VA to provide the relevant state medical
boards detailed information about any VA health care provider that has
violated a requirement of his or her medical license. We also believe
in this case additional legislation is not required. VA has broad
authority to report to state licensing boards those employed or
separated health care professionals whose behavior or clinical practice
so substantially failed to meet generally-accepted standards of
clinical practice as to raise reasonable concern for the safety of
patients. The authority to report those professionals is derived from
VA's long-standing statutory authority, contained in 38 U.S.C. Sec.
7401-7405, which authorizes the Under Secretary for Health, as head of
VHA, to set the terms and conditions of initial appointment and
continued employment of health care personnel, as may be necessary, for
VHA to operate medical facilities. This authority allows VA to require
health care professionals to obtain and maintain a current license,
registration, or certification in their health care field.
The Veterans Administration Health-Care Amendments of 1985; Public
Law 99-166; and Part B of Title IV of Public Law 99-660, the Health
Care Quality Improvement Act of 1986, are acts requiring VHA to
strengthen quality assurance and reporting systems to promote better
health care. Pursuant to section 204 of Public Law 99-166, VA
established a comprehensive quality assurance program that includes
reporting any licensed health care professional to state licensing
boards who:
(1)Was fired or who resigned following the completion of a
disciplinary action relating to such professional's clinical
competence;
(2)Resigned after having had such professional's clinical
privileges restricted or revoked; or
(3)Resigned after serious concerns about such professional's
clinical competence had been raised, but not resolved.
The provisions of 38 U.S.C. Sec. Sec. 7401-7405, augmented by
Public Laws 99-166 and 99-660, provide VHA ample authority to make
reports to state licensing boards when exercised consistent with
Privacy Act requirements for release of information. VHA policy
requires the VA medical facility Director to ensure that within 7
calendar days of the date a licensed health care professional leaves VA
employment, or, information is received suggesting that a current
employee's clinical practice has met the reporting standard, an initial
review of the individual's clinical practice is conducted to determine
if there may be substantial evidence that the individual so
substantially failed to meet generally accepted standards of clinical
practice as to raise reasonable concern for the safety of patients.
Usually this review is conducted and documented by first and second
level supervisory officials. When the initial review suggests that
there may be substantial evidence that the licensed health care
professional so failed to meet generally-accepted standards of clinical
practice as to raise reasonable concern for the safety of patients, the
medical facility Director is responsible for immediately initiating a
comprehensive review to determine whether there is, in fact,
substantial evidence that this reporting standard has been met. This
review involves the preparation of a state licensing board reporting
file. VHA policy defines the process for collecting evidence, notifying
the provider of the intent to report, which affords the provider the
opportunity to respond in writing to the allegations, and the review
process to ensure that VHA has complied with the Privacy Act prior to
reporting.
It is VA's policy to cooperate whenever possible with an inquiry by
a state licensing board. VA medical facilities must provide reasonably
complete, accurate, timely, and relevant information to a state
licensing board in response to appropriate inquiries.
Section 403 would require VA, within 2 years of the date of the
enactment of this Act, to submit to the Committees on Veterans' Affairs
a report on its compliance with the policy outlined by this Act to
conduct a review of each health care provider who transfers to another
VA medical facility or leaves VA to determine whether there are any
concerns, complaints, or allegations of violations relating to the
medical practice of the health care provider and to take appropriate
action with respect to any such concern, complaint, or allegation.
VA does not support section 403 because appropriate reporting
systems are already in place. VA has broad authority to report employed
or separated health care professionals to state licensing boards when
their behavior or clinical practice so substantially failed to meet
generally accepted standards of clinical practice as to raise
reasonable concern for the safety of patients. VA medical facility
Directors are required to ensure that a review is conducted of the
clinical practice of a licensed health care professional who leaves VA
employment or when information is received suggesting that a current
employee's clinical practice has met the reporting standard. As
previously noted, VA has established a comprehensive quality assurance
program for reporting any licensed health care professional to state
licensing boards who was fired or resigned following the completion of
a disciplinary action relating to such professional's clinical
competence, resigned after having had such professional's clinical
privileges restricted or revoked, or resigned after serious concerns
about such professional's clinical competence had been raised but not
resolved. When a report is made to a state licensing board, a copy of
that letter is also forwarded to VA Central Office. VA would be happy
to provide this information upon request, but we do not believe a
statutory requirement to submit this information is warranted.
Draft Bill Department of Veterans Affairs Purchased Health Care
Streamlining and Modernization Act
On May 1, 2015, the Adminsitration transmitted to the Congress
adraft bill, the ``Department of Veterans Affairs Purchased Health Care
Streamlining and Modernization Act.'' We greatly appreciate the
Committee placing this measure on today's agenda. The draft bill would
clarify VA's authority to purchase care and services in the community
when such services are not reasonably available from VA or through
contracts or sharing agreements. Accomplishment of this goal is VA's
top legislative priority.
VA is developing its plan to consolidate and improve VA purchased
care programs in accordance with Public Law 114-41 and will be engaged
with the Committee in a far-reaching discussion of this comprehensive
plan. While those ideas are being considered, enactment of purchased
care reform will provide important clarifications and improvements that
can serve as a cornerstone for further consolidation and streamlining.
Section 2 of the draft bill would amend chapter 17 of title 38,
U.S.C., by adding a new section 1703A. Section 1703A, ``Agreements with
eligible providers; certification processes,'' would authorize VA to
purchase care in certain circumstances through agreements (Veterans
Care Agreements or VCA) that are not subject to certain provisions of
law governing Federal contracts, so that providers are treated
similarly to providers in the Medicare program. The draft bill would
provide explicit protections for procurement integrity, provider
qualifications, price reasonableness and employment protections while
ensuring that VA is able to provide local care to Veterans in a timely
and responsible manner.
Specifically, subsection (a) of section 1703A would authorize VA to
enter into VCAs with certain providers when the needed care is not
feasibly available within VA or though contracts or sharing agreements.
Subsection (a) would require VA to review VCAs of a material size every
2 years to determine whether it is practical or advisable to provide
the necessary care through VA facilities or contracts or sharing
agreements.
Subsection (b) would specify that VCAs are exempt from certain
provisions of law governing Federal contracting, specifically,
competitive procedures and certain laws to which providers and
suppliers of health care services through the Medicare program are not
subject. At the same time, it is important that providers entering into
these agreements are subject to any law that addresses integrity,
ethics, fraud, or civil and criminal penalties, as well as those that
ensure equal employment opportunity.
Subsection (c) would clarify that care provided under VCAs is
subject to the same terms and conditions as though provided in a VA
facility.
Subsection (d) would provide that, to the extent practicable, the
rates paid for care under this section shall be in accordance with the
rates paid by the United States under the Medicare program.
Subsection (e) would define eligible providers to include:
providers, physicians, and suppliers that have enrolled with Medicare
and entered a provider agreement or a participation agreement with
Medicare; providers participating in Medicaid; and other providers the
Secretary determines to be qualified under subsection (f).
Subsection (f) would require the Secretary to establish a process
for certification and re-certification of certain providers. This
process would include procedures for screening providers according the
risk of fraud, waste, and abuse and must require the denial of
applications from providers excluded from certain Federal programs.
Subsection (g) would specify that providers must agree to, among
other things, accept the rates and terms of VA payment, provide
services only in accordance with VA's authorization, and provide
medical records to VA.
Subsection (h) would outline when an agreement may be terminated by
VA or the provider.
Subsection (i) would require the Secretary to establish through
regulation a mechanism for monitoring the quality of care provided to
Veterans under this section.
Subsection (j) would require the Secretary to establish through
regulation administrative procedures for providers to present disputes
relating to VCAs. Providers would be required to exhaust these
administrative procedures before seeking judicial review.
Subsection (k) would direct the Secretary to prescribe regulations
to carry out section 1703A.
Section 3 of the draft bill would make conforming amendments to 38
U.S.C. Sec. 1745 to permit VA to enter into similar agreements with
State Veterans Homes. Section 3 would establish a separate effective
date for State Veterans Homes.
On continuing review since the time VA transmitted the draft bill
to Congres, we believe there are drafting improvements that can be made
to clarify aspects of the bill. We note that the Administration
strongly supports S. 2179, the ``Veteran Care Agreements Rule
Enhancement Act'', or ``the Veteran CARE Act,'' which was based on this
draft bill and provides what we believe is clearer language regarding
equal employment opportunities. We'd appreciate the opportunity to
discuss those improvements with your staff.
Mr. Chairman, this concludes my statement. Thank you for the
opportunity to appear before you today. We would be pleased to respond
to questions you or other members may have.
Statements For The Record
AMERICAN COUNSELING ASSOCIATION
The American Counseling Association is privileged and honored to
submit additional testimony in support of various legislation being
considered by the House Veterans Affairs Committee that would improve
access to care for millions of men and women that served our nation. At
the American Counseling Association, we hold our profession's service
to the veteran population in the highest regard and strive to provide
critical mental health care and access to those most in need.
HR 1319 - The Ask Veterans Act
With all of the recently documented issues at the VA in terms of
providing timely mental health care and other services, it is vital
that the agency understand the demands and outcomes directly from the
population it is serving. As a system, the VA is highly regarded but it
should be able to shift to demands in care and any other process issues
that might arise. Given the expected influx of veterans coming into the
system as the US brings additional troops home from stations overseas,
the VA needs to understand where the need for care is and the best way
to address it. This legislation is the first step in achieving that
goal.
HR 1603 - The Military Sexual Assault Victims Empowerment Act
As an organization representing licensed professional counseling,
our members and thousands of mental health professionals across the
country talk with patients dealing with trauma resulting from sexual
assault every day. Such a traumatic event needs to be addressed and
dealt with in a manner of urgency. We support the intent of this
legislation in bringing parity to sexual assault incidents within the
VA.
HR 3234 - The Failing VA Medical Center Recovery Act
As a nation, we should accept nothing less than the best for our
veterans. If there is a VA hospital that is not meeting the highest of
standards, it should be made public so that changes can be made. This
legislation represents a common sense solution to bring more
transparency to the care received by veterans to ensure their needs are
met.
VA Legislative Proposal - VA Purchased Healthcare Streamlining and
Modernization Act
We believe that the process that veterans go through to receive
care should be as streamlined and efficient as possible. We also know
from recent data that access to health care in rural areas is something
that the VA is focusing on intently. We support the Secretary entering
into agreements with providers outside the VA system but would caution
against a blanket reliance on other federal programs, such as Medicare.
The licensed professional counseling profession has been hit by this
inequity under the Choice Program, which overwhelmingly passed Congress
last year. There are 150,000+ LPCs across the country, predominantly in
rural areas, and they cannot participate in the Choice program because
they are currently not recognized by Medicare. Licensed Professional
Counselors ARE recognized by third party insurance providers, the DoD,
TRICARE, the VA, Medicaid, Indian Health Service; essentially all other
major healthcare payers in this country. In this proposal, there should
be flexibility provided to the Secretary to enter into agreements with
those providers recognized by the VA. A reliance on another federal
program could actually reduce access to veterans while trying to pass
legislation that is aimed at increasing that access.
Draft Bill - The PROMISE Act
Mental health care delivery has begun to change in this country
into a more integrated environment. There have been many pieces of
legislation passed in the last five years that brings mental health
care to parity with physical health care. There are numerous studies
showing a direct connection between treatment of mental issues and
physical ailments. Perhaps that is best understood with the veteran
population; PTSD and other mental health issues may become co-morbid
with a physical ailment such as a loss of a limb or other chronic pain.
A veteran suffering from PTSD or depression is less likely to keep up
with their physical needs if the mental issues are not being treated.
We must ensure that the VA is looking at the patient in their entirety
and consider the impact of the mental on the physical. The PROMISE Act
would put the VA on a path to creating that integrated environment that
will lead to more stable/predictable patient outcomes as well as a
healthier and more cost-efficient system overall.
One of the main issues facing veterans today is the over-
prescription of pharmaceuticals. The licensed professional counseling
profession is trained to treat patients suffering from mental disorders
without the use of pharmaceutical drugs. Too often, veterans are
medicated when all they may need is a talk therapy session that focuses
on their underlying issues/problems. Many mental health professionals
are comfortable working with physicians in private practice and can
refer a patient if advanced treatment is needed. The VA could put a
system in place that begins the treatment at the therapeutic level
while increasing treatment for those in need of that remedy.
We also support the PROMISE Act seeking to recognize other
variations of therapeutic delivery. There are a number of options
available to patients and people will respond differently to other
treatments. As an organization, the American Counseling Association
would like to work with Rep. Bilirakis and the Committee to educate
members on the availability and positive outcomes related to the other
types of therapy listed in the legislation.
Thank you again for the opportunity to provide testimony. We
cherish our ability to serve veterans and hope to increase the number
of highly qualified licensed professional counselors available to the
VA so that we can finally address mental health workforce access issues
across the system.
Please contact me with any further questions or clarifications.
Sincerely,
Art Terrazas
Director of Government Affairs
American Counseling Association
(703) 823-9800 ext 242
[email protected]
About The American Counseling Association
The American Counseling Association is a not-for-profit,
professional and educational organization that is dedicated to the
growth and enhancement of the counseling profession. With more than
55,000 members, we are the world's largest association representing
professional counselors in various practice settings.
AMERICAN ORTHOTICS AND PROSTHETICS ASSOCIATION
Chairman Benishek, Ranking Member Brownley, and Members of the
Committee,
Thank you for including HR 1904, the Wounded Warrior Workforce
Enhancement Act, for consideration in your hearing today, and for
offering AOPA the opportunity to submit this testimony in strong
support of this much-needed legislation.
AOPA is a national trade association that represents over 2,000
orthotic and prosthetic patient care facilities and suppliers that
design, fabricate, fit, and supervise the use of orthoses and
prostheses. Our members serve Veterans and civilians in the communities
where they live, and our goal is to ensure that every patient has
access to the highest standard of O&P care from a well-trained
clinician.
Wounded Warrior O&P Care Needs
Amputation and Traumatic Brain Injury have become signature
injuries of the wars in Iraq and Afghanistan. Although the death rate
is much lower than previous wars, the amputation rate has doubled:
according to the Department of Defense and the Department of Veterans'
Affairs, 6% of those wounded in Iraq have required amputations,
compared with a rate of 3% for past wars. The Congressional Research
Service reported that, as of November 2014, US service members had
undergone 1,573 major limb amputations; more than 80% of the amputees
lost one or both legs. The majority of these are young men and women
who, with continued, high quality prosthetic care, should be able to
live long and active lives.
Traumatic Brain Injury often manifests itself in the same way as
stroke, with drop foot and other challenges balancing, standing and
walking that require orthotic intervention. As has been widely
reported, the number of service members diagnosed with TBI is far
greater than those undergoing amputation. The Department of Defense
reports that from 2000-2014, there were 320,344 diagnosed cases of TBI
among service members. These service members and Veterans are also
predominantly young adults who may need decades of high quality care to
maintain their independence and quality of life.
Other Veteran Health Trends Add to the Need for O&P Care
The number of Veterans undergoing amputation is increasing
dramatically, and is expected to increase at an even more rapid pace in
the future. According to Dr. Joseph Webster, the Medical Director for
the VHA Amputation System of Care, between 2008-2013, an average of
7,669 new amputations were performed for Veterans every year. In the
year 2000, 25,000 Veterans with amputations were served by the VA. By
2013, that number had climbed to more than 80,000 Veterans.
As Dr. Webster describes, the majority of Veterans with amputations
have required an amputation because of diabetes or vascular disease.
Nationwide, 7% of the US population, or more than 22 million Americans,
are veterans. The VA reports that one out of every four Veterans
receiving care from the VA has diabetes; 52% of the Veterans in the VHA
primary care population have hypertension; 36% have obesity. All of
these conditions are associated with orthotic or prosthetic care needs
due to stroke, neuropathy, and amputation.
Additional Highly Qualified Clinicians are Needed to Meet Growing
Demand
From the battlefield to the aging Veteran population at home,
medical conditions requiring prosthetic and orthotic care have become
more complex and more challenging to treat. The technologies available
to address them are more sophisticated, and require more training and
experience to fit and maintain. In recognition of these challenges,
entry level qualifications for prosthetists and orthotists were changed
to require master's degrees. At the same time, many experienced
professionals in the field are themselves getting ready to retire.
Providing high quality services to our Wounded Warriors, Veterans,
seniors, and civilian amputees is going to require more master's degree
programs at American universities to prepare the next generation of
practitioners.
The National Commission on Orthotics and Prosthetics Education
(NCOPE) commissioned a study of the field, which was completed in May
of 2015. The evaluation reported that in 2014, there were 6,675
licensed and/or certified prosthetists and orthotists in the United
States. The study concluded that, by 2025, ``overall supply of
credentialed O&P providers would need to increase by about 60 percent
to meet the growing demand.''
Currently, there are thirteen schools in the US that offer master's
degrees in orthotics and prosthetics. The largest program,
Northwestern, accepts 48 students. The majority of programs have
classes of 20 or fewer students per year. A total of 230 students are
anticipated to graduate with master's degrees in orthotics or
prosthetics in 2015.
This means that current accredited schools will barely graduate
enough entry-level students with master's degrees to replace the
clinicians who will be retiring in coming years. Current class sizes
aren't adequate to prepare sufficient numbers to meet the growing
demand for prosthetic and orthotic care created by an aging population
and increases in chronic disease that often require prosthetic and
orthotic care.
The Wounded Warrior Workforce Enhancement Act
Despite the need for additional clinicians with advanced degrees,
O&P master's programs are costly and challenging to expand. The need
for lab space and sophisticated equipment, and the scarcity of
qualified faculty with PhDs in related fields, contribute to the
barriers to expanding existing accredited programs. Under current law,
there are no federal resources available to schools to help create or
expand advanced education programs in O&P. Funding is available for
scholarships to help students attend O&P programs, but do not assist in
expanding the number of students those programs can accept.
The Wounded Warrior Workforce Enhancement Act is a limited, cost-
effective approach to assisting universities in creating or expanding
accredited master's degree programs in orthotics and prosthetics. The
bill authorizes $5 million per year for three years to provide one-time
competitive grants of $1-1.5 million to qualified universities to
create or expand accredited advanced education programs in prosthetics
and orthotics. Priority is given to programs that have a partnership
with Veterans' or Department of Defense facilities, including
opportunities for clinical training, to help students become familiar
with the unique needs of service members and Veterans.
The Act in the 113th Congress
The Wounded Warrior Workforce Enhancement Act was first introduced
in the 113th Congress and gained bipartisan support. The bill was
endorsed by Vietnam Veterans of America and VetsFirst, which recognized
the need for additional highly qualified practitioners to care for
wounded warriors.
In May of 2013, the Senate Committee on Veterans Affairs held a
hearing to consider the Wounded Warrior Workforce Enhancement Act and
other Veterans' health legislation. The VA testified that the grants to
schools were not necessary because it did not anticipate any difficulty
filling its seven open internal positions in prosthetics and orthotics.
The VA described its O&P fellowship program, which accepted nineteen
students that year, as a sufficient pipeline to meet its need for
internal staff.
The Senate committee rejected the VA's argument because it did not
represent the reality of how Veterans access O&P care. Acknowledging
that more than 80% of prosthetic and orthotic care to Veterans is
provided by community-based facilities, the committee concluded that
the nineteen students enrolled in the VA fellowship program could not
meet the system-wide need for highly qualified O&P staff. Committee
members also agreed that increasing the number and pool of clinicians
with master's degrees benefitted Veterans, whether they were hired
internally at the VA or by community-based providers, particularly if
those students had clinical experience working with service members and
Veterans.
Responding to the need for highly qualified clinicians in every
setting that provides care to Veterans, the Senate committee included
provisions of the Wounded Warrior Workforce Enhancement Act in S. 1950,
which passed Senate VA Committee unanimously. Due to factors unrelated
to O&P, the omnibus bill did not advance and no resources for advanced
education in prosthetics and orthotics were made available to schools.
The Need and the Opportunity Are Present Today
That need for a larger pool and pipeline of highly qualified
prosthetists and orthotists to care for Veterans with limb impairment
and limb loss has only become more pressing. The competitive grants
created under the Wounded Warrior Workforce Enhancement Act could spark
the expansion necessary to meet Veteran needs for high quality care, in
Veterans' Administration facilities and community-based settings.
No Veteran should suffer from decreased mobility because of lack of
access to high quality care. The Wounded Warrior Workforce Enhancement
Act is a limited, cost-effective approach to training the skilled
clinicians who will care for Veterans for decades to come. Thank you
for considering this bill today, and for your commitment to providing
the highest level of O&P care for our Veterans. If you have any
questions or would like more information, please do not hesitate to
contact AOPA.
Respectfully Submitted,
Charles H. Dankmeyer, Jr., CPO, President
American Orthotic and Prosthetic Association
AMVETS
Distinguished members of the House Veterans' Affairs Committee, on
behalf of the 23 million American Veterans in this country, AMVETS, a
leader since 1944 in preserving the freedoms secured by America's armed
forces and providing support for Veterans, Active Duty military, the
National Guard/Reserves, their families and survivors, it is my
pleasure, to offer this `Statement for the Record' concerning the
following pending legislation:
HR 1319, the Ask Veterans Act -AMVETS supports this bill which
requires the VA Secretary to commission an survey, over a five-year
period, to determine veteran's patient experiences at every VA medical
facility. Importantly, the results of this survey are to be made
publically available.
The survey, which would include questions relating to:
timely access to hospital care and medical services;
the length of time between the request and the
appointment;
the frequency of appointment cancellation;
the quality of care received
These are the pillars that any health care system should meet and
be measured by. If these areas have poor metrics, then there's a major
problem with that facility. Additionally, it was help to identify both
the good and the bad. Those facilities with positive rankings should be
acknowledged and they should be required to share their best practices
system-wide. Those facilities with negative rankings should be
identified so that corrective action can be taken.
HR 1603, the Military SAVE Act -AMVETS supports this legislation
which amends the Veterans Access, Choice and Accountability act of 2014
to make victims of MST eligible for treatment in a non-VA entity. Since
victims of MST are scattered all over the country, including highly
rural areas, the option to seek care within their own communities would
be an amazing benefit and would encourage more victims to access care.
HR 1904, the Wounded Warrior Workforce Enhancement Act -AMVETS
supports this legislation which:
directs the VA to award grants to eligible entities to
establish a master's or doctoral degree programs in orthotics and
prosthetics;
seeks to expand existing programs in orthotics and
prosthetics;
requires a grant priority for institutions partnering
with VA medical facilities;
provides grants from $1 and $ 1.5 million;
requires the VA to establish a Center of Excellence in
Orthotic and Prosthetic Education; and
seeks to improve orthotic and prosthetic outcomes for
members of the military and veterans.
Though the `Choice' Act was no doubt crafted with the best
intentions, in practice, many flaws have surfaced. This legislation
gratefully attempts, at least in part, to address some of those
deficiencies.
HR 2639, the Marriage and Family Therapists for Veterans Act -
AMVETS supports this legislation which seeks to provide additional
qualification requirements for VA family therapy practitioners. Our
veterans and their families deserve world-class support services and it
is our belief that the quality of the practitioner is of the utmost
importance to the positive outcome of any therapy.
HR 3234, the Failing VA Medical Center Recovery Act -AMVETS
wholeheartedly supports this very important legislation which seeks to
improve poor-performing VA medical facilities by establishing an Office
of Failing Medical Center Recovery and an Under Secretary position to
head the Office. This dedicated Office which would take over the
managerial and day-to-day operations of every failing VA medical center
and would also:
publish, both in the Federal Register and on the VA
website the key health metrics for each VA medical center;
certify semiannually that each failing VA medical center
is subject to managerial and day-to-day operational control by the
Office;
would only revoke the certification of a VA medical
center as failing medical center on after achieving a rating of
`satisfactory' or better for three consecutive quarters;
submit to Congress a quarterly report on the office,
including corrective actions taken by the Under Secretary;
transfer direct control of each failing medical center
out of the pertinent VISN to the Under Secretary; and perhaps most
importantly,
establish rapid deployment teams to each failing medical
to ensure that each failing VA medical is returned to a `satisfactory'
status as quickly as possible.
The focus, expertise and rapid response of the deployment team,
under the direction of the Under Secretary should be very effective in
correcting deficiencies in a cost effective and timely manner. It is
our hope too, that this would help to improve the continuity of
services across the VA system.
HR 3471, the Veteran Mobility Safety Act of 2015 -AMVETS supports
this legislation which seeks to add a layer of security for eligible
disabled veterans who, due to their sacrifice, are provided a vehicle
or other conveyance by the VA by:
requiring the certification of any provider of adaptive
equipment modification services;
requiring the certification of any individual who
performs such modifications; and
requiring both the automobile/adaptive equipment provider
and the provider of modification services to adhere to specified
requirements of the ADA of 1990.
HR 3549, the VA Billing Accountability Act -AMVETS supports this
very important legislation which protects veterans from being billed by
the VA for certain medical expenses when those expenses are incurred as
a result of improper billing and notification on the VA's behalf.
Furthermore, it limits the ability of the VA to collect these payments,
unless a veteran has first been provided with information about
applying for a waiver (which takes between 45 - 90 days to process) and
given the opportunity to establish a payment plan (which takes the same
amount of time to process as a waiver).
I have recently had a personal experience with this exact situation
which I unsuccessfully attempted to resolve for several months. I
called the central VA billing office numerous times about the situation
and each time had to re-explain the situation after which I was told
that the problem would be solved. Unfortunately, the problem wasn't
resolved and the next time I called, I was told that my case would be
escalated. Eventually I was informed that if the balance on my account
was not paid, that it would be subtracted from my disability
compensation in November. It wasn't until early October, that any
mention was made about a possible payment plan, which I authorized
pending the resolution of the problem. When November rolled around,
even though I had agreed to a payment plan, the full amount of the
outstanding balance had been removed from my disability compensation.
When I called the VA to ask about why the full amount of the balance
had been taken, I was told that it takes 45 - 90 days to set up a
payment plan. It wasn't until the very end of this ordeal or
immediately after the money was taken, that anyone even mentioned the
possibility of a waiver and of course by then it was too late.
No veteran should be given the run around and mistreated in this
manner; it is our hope that this legislation will prevent this type of
situation going forward.
Draft Legislation, the Promoting Responsible Opioid Management and
Incorporating Scientific Expertise or ``Promise Act'' -AMVETS is
extremely grateful for the recognition of this critically important
issue which, in part, directs both VA and DoD to jointly update the VA/
DoD Clinical Practice Guideline for Management of Opioid Therapy for
Chronic Pain, including guidelines regarding:
prescribing opioids for outpatient treatment of chronic,
non-cancer pain;
contraindications for opioid therapy;
treatment of patients with post-traumatic stress
disorder, psychiatric disorders or a history of substance abuse or
addiction;
case management for patients transitioning between
inpatient and outpatient health care;
routine and random urine drug tests to help prevent
substance abuse; and
options to augment opioid therapy with other clinical and
complementary and integrative health services to minimize opioid
dependence.
The bill further specifies that VA shall:
expand the Opioid Safety Initiative to include all VA
medical facilities, including providing employees with pain management
training and establishment of pain management teams;
track and monitor opioid use, including through the use
of state program information;
increase the availability of Food and Drug
Administration-approved opioid receptor antagonists;
modify the Computerized Patient Record System to ensure
that any health care provider that accesses a veteran's record will be
immediately notified whether the veteran is receiving opioid therapy
and has a history of substance use disorder or opioid abuse;
establish a Pain Management Board in each VISN;
conduct a feasibility study for a program under which
veterans at risk for prescription drug abuse receive prescription drugs
only from certain VA pharmacies;
establish the Office of Patient Advocacy;
expand research and education on, and delivery and
integration of, complementary and integrative health services into
veterans' health care services, including services provided to veterans
with mental health or chronic conditions;
assess the feasibility of using wellness programs to
complement pain management and related health care services to veterans
and their families;
carry out a program of internal audits to improve health
care services to veterans and their families; and
provide to the medical board of each state in which a VA
health care provider is licensed information about such provider's
medical license violations.
The VA's own office of the Inspector General has issued numerous
reports over the years indicating that overmedication, including the
use of a wide variety of opioids, is a systemic problem at VA medical
centers. With this in mind, no reasonable person can doubt that there
must be some connection between the problem of over medicating veterans
and the tragic veteran suicide rate.
While AMVETS would never deny the benefits that some medications
may provide for certain patients, we must equally acknowledge that the
VA's reliance on a strictly pharmacological approach to treating the
health issues affecting our veterans, is certainly not the only option
and may not even be the best approach. Medication, in and of itself,
merely masks symptoms and does nothing to eradicate any under lying
mental or physical health problems. This then can lead to a life
threatening dependence on medications, many of which have side effects
more serious than the conditions they are meant to treat.
Acknowledging that many medical conditions require some level of
pharmaceutical interventions, AMVETS would encourage the VA in part to:
increase use of complementary, alternative and
integrative health practices;
use an interdisciplinary team approach to healthcare that
would more holistically treat patients with the goal being an improved
quality of life; and
require clinicians, prior to issuing prescriptions, to
fully inform veterans of both traditional and non-traditional therapies
that are available and appropriate alternatives for treating their
conditions.
This completes my statement and I thank you again for the
opportunity to offer our comments on pending legislation. Feel free to
reach out to me at [email protected] if have any questions.
Diane M. Zumatto
AMVETS National Legislative Director
Diane M. Zumatto of Spotsylvania, VA joined AMVETS as their
National Legislative Director in August 2011. Zumatto a native New
Yorker and the daughter of immigrant parents decided to follow in her
family's footsteps by joining the military. Ms. Zumatto is a former
Women's Army Corps/U.S. Army member who was stationed in Germany and
Ft. Bragg, NC, was married to a CW4 aviator in the Washington Army
National Guard, and is the mother of four adult children, two of whom
joined the military.
Ms. Zumatto has been an author of the Independent Budget (IB) since
2011. The IB, which is published annually, is a comprehensive budget &
policy document created by veterans for veterans. Because the IB covers
all the issues important to veterans, including: veteran/survivor
benefits; judicial review; medical care; construction programs;
education, employment and training; and National Cemetery
Administration, it is widely anticipated and utilized by the White
House, VA, Congress, as well as, other Military/Veteran Service
Organizations.
Ms. Zumatto regularly provides both oral and written testimony for
various congressional committees and subcommittees, including the
House/Senate Veterans Affairs Committees. Ms. Zumatto is also
responsible for establishing and pursuing the annual legislative
priorities for AMVETS, developing legislative briefing/policy papers,
and is a quarterly contributor to `American Veteran' magazine. Since
coming on board with AMVETS, Ms. Zumatto has focused on toxic wounds/
Gulf War Illness, veteran employment and transition, military sexual
trauma, veteran discrimination and memorial affairs issues.
Zumatto, the only female Legislative Director in the veteran's
community, has more than 20 years of experience working with a variety
of non-profits in increasingly more challenging positions, including:
the American Museum of Natural History; the National Federation of
Independent Business; the Tacoma-Pierce County Board of Realtors; The
Washington State Association of Fire Chiefs; Saint Martin's College;
the James Monroe Museum; the Friends of the Wilderness Battlefield and
The Enlisted Association of the National Guard of the United States.
Diane's non-profit experience is extremely well-rounded as she has
variously served in both staff and volunteer positions including as a
board member and consultant. Ms. Zumatto received a B.A. in Historic
Preservation from the University of Mary Washington, in 2005.
AMVETS, National Legislative Director
4647Forbes Blvd, Lanham, MD 20706
301-683-4016 / [email protected]
16 November 2015
The Honorable Jeff Miller, Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
335 Cannon Office Building
Washington, DC 20515
Dear Chairman Miller:
Neither AMVETS nor I have received any federal grants or contracts,
during this year or in the last two years, from any federal agency or
program.
Sincerely,
Diane M. Zumatto
AMVETS National Legislative Director
KENTUCKY DEPARTMENT OF VETERANS AFFAIRS
H.R. 1603 - (House Veterans Affairs Committee) - An Act Concerning
Healthcare for Military Sexual Trauma Survivors
Good afternoon. I am Heather French Henry, Commissioner of the
Kentucky Department of Veterans Affairs (KDVA). I come before you today
in support of the Karen Tufts Military Sexual Assault Victims
Empowerment Act (SAVE).
As the Commissioner, I am responsible for the health and wellbeing
of more than 330,000 veterans within the Commonwealth of Kentucky
including approximately 24,000 women veterans. While we don't operate
the VA Medical Centers within our state, we are responsible for 4
Veterans Nursing Facilities, 5 State Veterans Cemeteries and statewide
programming staffed by more than 740 employees in 120 counties. We are
also responsible to resolve complaints regarding the negligence of
veterans, especially when it comes to access of their healthcare. As
the daughter of a Vietnam Veteran who suffered for many years with co-
occurring issues with PTSD and substance abuse I take my job
personally. My father came home with physical wounds as well as
spiritual wounds. As Miss America 2000, I came before this committee on
numerous occasions addressing the issues facing our homeless veterans
and in 2001 the Heather French Henry Homeless Veterans Assistance Act
was passed. Today, once again, I want to address this committee in
support of those veterans who have suffered silently from Military
Sexual Trauma.
According to the Department of Defense, 19,000 service members
endure sexual assault while in the military. Most of those are never
reported. Of those that are reported, most offenders are never
prosecuted. Therefore, survivors do not feel confident our system will
provide them with the protection and services they require.
Of Kentucky's 330,000 veterans, 24,000 of who are women, we are
unaware how many may be survivors of Military Sexual Trauma. As these
cases go unreported and veterans choose to suffer in silence rather
than come forward.
The VA Health Care system is rightly lauded by both medical
professionals and the veterans who use it. But as we reach out to MST
survivors and persuade them to get help, their needs are proving
overwhelming for the VA health care system.
Appropriate care for MST survivors is available from private
medical providers throughout Kentucky. Preventing these veterans from
getting care from available private providers adds to the burdens they
already shoulder as MST survivors.
KDVA strongly supports the Karen Tufts Military Sexual Assault
Victims Empowerment Act, the SAVE Act.
With SAVE, KDVA's Women Veterans Coordinator and field staff can
reach out to MST survivors throughout the Commonwealth of Kentucky with
confidence that these veterans will be able to access appropriate care
close to home.
KDVA agrees with Congressman Barr that we need to ``put MST
survivors in control of their own healthcare. MST survivors have unique
needs and it is important that they feel comfortable sharing this
emotionally painful and very personal life-changing experience with
professionals who are trained and have the expertise to properly handle
these complex cases.''
Veterans are our greatest asset. Today, with so many pressures on
our local communities, we need our veterans to work and to lead. To do
that, they must be healthy both physically and mentally. And to make
and keep them healthy, we must remove the barriers they face in getting
health care.
On behalf of Kentucky's veteran community and veterans across this
nation, I urge you to pass the SAVE Act. Nothing less will fulfill the
commitment our country made to them in return for their service and
sacrifice.
Thank you for your time and consideration.
Sincerely,
Heather French Henry
Commissioner
Kentucky Department of Veterans Affairs
NATIONAL MOBILITY EQUIPMENT DEALERS ASSOCIATION
Chairman Benishek, Ranking Member Brownley, and esteemed Members of
the Subcommittee:
The National Mobility Equipment Dealers Association (NMEDA) thanks
you for this opportunity to comment on H.R. 3471. NMEDA stands in full
support of this legislation, which will establish enforceable minimum
standards for vendors participating in the Automobile Adaptive
Equipment (AAE) program administered by the Department of Veterans
Affairs (VA). For far too long, the VA has allowed unqualified vendors
performing unsafe and/or unreliable vehicle modifications and equipment
installations to participate in the AAE program. The Veterans Mobility
Safety Act of 2015 will put an end to this dangerous and costly
practice.
The VA aims to assist disabled veterans by providing reimbursement
(either to the vendor or to the qualifying veteran) for the sale,
installation, maintenance, and repair of automobile adaptive equipment
through the AAE program. Automobile adaptive equipment (which includes
but is not limited to platform wheelchair lifts, under vehicle lifts,
power door openers, lowered floors, raised roofs, raised doors, hand
controls, reduced- and zero-effort steering and braking systems,
digital driving systems, inside and outside power-chair/scooter lifts
and environmental controls) then enables veterans with disabilities to
accomplish daily tasks and participate in work, education, and
recreational activities. The AAE program has wonderful potential but
the current administration of the program is alarming, due in large
part to the absence of enforceable standards for vendors who wish to
participate.
Under current VA regulations, a JCAHO certification is required in
order to sell a bottle of oxygen to a veteran yet an individual is not
required to posses any certification (or to demonstrate any AAE
knowledge or expertise) in order to install a $30,000 high-tech
electronic driving control system on a disabled veteran's vehicle. In
practical terms, this means that virtually any individual or business
is currently able to provide - and currently able to receive payment
from the VA for providing - AAE services to disabled veterans.
The quality and safety of VA-funded vehicle modifications is
directly compromised by the VA's lack of AAE program requirements for
vendors. The VA currently pays for disabled veterans to have their
vehicles modified and serviced by inferior vendors (e.g., vendors
operating out of home garages/parking lots/mobile trucks; vendors
lacking insurance coverage; vendors employing uncertified welders and
technicians; vendors lacking the specialized tools, training
certificates, and equipment necessary to perform AAE vehicle
modifications; vendors unwilling to provide emergency service, etc.).
Quality concerns range from poor customer service to faulty wiring to
chronically unreliable power, steering, and braking systems. Such poor
quality installations have very real safety implications and can result
in automobile accidents, vehicle fires, injuries, or worse.
Unnecessary spending is another consequence of the VA's lack of AAE
program requirements for vendors. AAE installations often require a
significant financial commitment. When a veteran complains to the VA
about an unsatisfactory or unsafe installation, the VA has a history of
referring the repair work to a vendor certain to complete the job
properly. It often costs the VA more money to fix the inferior
installation than it costs to have the installation performed properly
to begin with. Congress can reduce this wasteful spending by
implementing H.R. 3471 and requiring the VA to establish standards for
vendors participating in the AAE program.
Automotive mobility products can be extremely complex. Even simple
installations, if performed incorrectly, can have a disastrous effect.
Current VA AAE program policy jeopardizes the quality and effectiveness
of installations, wastes taxpayer dollars, and puts the disabled
veteran - as well as the driving public - at risk. Through the
establishment of minimum standards for vendors participating in the AAE
program, H.R. 3471 will force the VA to address disabled veterans'
mobility needs responsibly and with long-overdue concern for quality,
performance, and safety.
Respectfully Submitted,
National Mobility Equipment Dealers Association
PARALYZED VETERANS OF AMERICA
Chairman Benishek, Ranking Member Brownley, and members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to present our views on the broad array of
pending legislation impacting the Department of Veterans Affairs (VA)
that is before the Subcommittee. No group of veterans understand the
full scope of care provided by the VA better than PVA's members--
veterans who have incurred a spinal cord injury or disease. Most PVA
members depend on VA for 100% of their care and are the most vulnerable
when access to health care, and other challenges, impact quality of
care. These important bills will help ensure that veterans receive
timely, quality health care and benefits services.
H.R. 1319, the ``Ask Veterans Act''
PVA generally supports H.R. 1319, the ``Ask Veterans Act.'' This
bill would direct the Secretary of the Department of Veterans Affairs
to contract with a non-government entity to conduct annual surveys on
veteran experiences in obtaining medical care through VA. The focus of
the survey would be patient wait times, access to health care, and the
quality of the care provided. The experience of the veterans receiving
care must be consistently included in order for VA to provide veterans-
focused care.
H.R. 1603, the ``Military Sexual Assault Victims Empowerment Act''
PVA supports the intent of H.R. 1603, the ``Military Sexual Assault
Victims Empowerment Act.'' This bill would allow survivors of military
sexual trauma (MST) to seek specialized care outside the Veterans
Health Administration through the Choice program by setting aside wait
time and distance eligibilities. While the VA continues to build its
capacity in mental health providers and clinical competency in treating
military sexual trauma there may be cases where VA cannot provide the
mental health services clinically indicated. In such instances VA
already has the authority to contract out such care in the community.
MST survivors have needs that often include more than mental health
services, such as primary care services, substance abuse treatment,
housing, and travel assistance. MST coordinators are available at every
VA medical center to assist veterans access services. Direct care in
the community cannot provide the veteran-specific, comprehensive care
many MST survivors need. VA must do more to ensure that all survivors
who seek care are able to receive it in a timely and competent manner.
While we understand the intent of this bill, we are concerned that
direct care in the community will fractionate the veterans health care
and prevent the receipt of benefits and support services they would
otherwise have access to.
H.R. 1904 ``The Wounded Warrior Workforce Enhancement Act''
PVA supports the goal of this legislation to the extent that it
attempts to rejuvenate a declining orthotics and prosthetics workforce.
We have a concern, however, as to whether the veteran community will
truly capitalize on the return on this investment if the legislation
does not require some level of service commitment from student
beneficiaries.
Quality orthotic and prosthetic care is of the utmost importance to
PVA members. No group of veterans understands the importance of
prosthetics and orthotics more than veterans with spinal cord injury or
disease. The Independent Budget Veteran Service Organizations maintain
that the VA must ensure that prosthetics departments are staffed by
certified professional personnel or contracted staff that can maintain
and repair the latest technological prosthetic devices. A key component
to this is continued support for the VA National Prosthetics Technical
Career Program which aims to address the projected personnel shortages.
In June of 2015, the National Commission on Orthotic and Prosthetic
Education (NCOPE) released its analysis projecting orthotics and
prosthetics workforce supply and patient demand over the next ten
years. The analysis showed that the overall number of credentialed O&P
providers will need to increase approximately 60 percent by 2025 to
meet the growing demand. This is in part due to the fact that attrition
rates from the profession will surpass the graduation rates of those
entering the field, ultimately resulting in a decreasing supply of O&P
providers. Failure to address both the decreasing supply of providers
and the increasing demand for their services will very likely cause the
workforce to shift toward non-credentialed providers. Our veterans
deserve to be cared for by competent and highly trained individuals.
This legislation is an important step toward ensuring that our
veterans continue to be treated by credentialed providers. It promotes
the expansion of a qualified teaching and faculty pool which will
provide the foundation to accommodate and train a growing number of
students seeking to become providers. In addition to the expected
dissemination of best practices and knowledge from the proposed Center
of Excellence, the legislation also provides eligible institutions
built-in flexibility to tailor the use the funds for educational areas
where they can achieve the goal of expanding the O&P workforce most
effectively. PVA also supports the proposed veterans preference in the
admissions process. As the Independent Budget VSOs have stated before,
employing veterans in this arena will ensure a balance between the
perspective of the clinical professionals and the personal needs of the
disabled veterans.
PVA's concern, though, is that the bill misses an opportunity to
capture a more predictable and tangible return on investment. Requiring
scholarship recipients to serve a commitment with the VA is a way to
strengthen the precision with which these funds are allocated without
reducing the previously mentioned institutional flexibility. The goal
of this legislation is, after all, to expand the orthotics and
prosthetics workforce in order to better serve veterans. While the
proposed approach of expanding the overall pool of qualified service
providers within the community writ large might have a trickle effect
of ensuring that the VA continues to offer certified providers, we
believe this suggested change would have a stronger and more immediate
impact.
H.R. 2639 ``Marriage and Family Therapists for Veterans Act''
PVA supports the ``Marriage and Family Therapists for Veterans
Act.'' When a veteran suffers a spinal cord injury, this life-changing
event not only impacts the veteran, but his or her family as well. PVA
members appreciate the importance of maintaining and strengthening
relationships with their spouses who so often step into the role of
being the veteran's primary caregiver. As the Independent Budget VSO's
have stated consistently, family caregivers supporting severely
wounded, injured, and ill veterans require considerable strength to
tend to the needs of family and home, assist their veterans with
everyday activities, take their veterans to appointments, or simply be
there in their veterans' times of need. With proper support, many
severely injured or ill veterans can benefit from residing at home
instead of being institutionalized. Support from family caregivers
plays a crucial role in improving veterans' psychosocial well-being,
but it takes endurance, commitment, love, and patience. As these
challenging circumstances test the strength of a veteran's marriage, it
is supremely important that they and their spouse have quality and
timely access to Marriage and Family Therapy mental-health services.
Currently, there are numerous qualified MFT practitioners willing and
able to serve the VA, but the current law's stringent requirements are
preventing them from becoming eligible to provide services for the VA.
This legislation will help eliminate those bureaucratic obstacles and
provide an important catalyst to the VA's current efforts to expand
access to MFT mental-health professionals.
H.R. 3234, the ``Failing VA Medical Center Recovery Act''
PVA does not have a position on H.R. 3234, the ``Failing VA Medical
Center Recovery Act.'' This bill would create within VA a new ``Office
of Failing Medical Center Recovery.'' The new office would be headed by
an Under Secretary for Failing Medical Center Recovery charged with
assembling VA's top managers and `deploying' them to fix Medical
Centers that are deemed `failing'. PVA understands frustration inherent
in the intent of this bill toward VA Medical Centers for not completing
patient appointments in a timely manner. However, the bill does not
address how the creation of a new bureaucracy within the existing one
will improve the access and quality of veterans health care.
H.R. 3471 ``Veterans Safety Mobility Act of 2015''
The adaptive automobile equipment grant is an important issue for
PVA members, as they are the highest users of this particular benefit.
Those veterans with catastrophic disabilities have a critical need for
mobility to help maintain a high quality of life and allow them to
continue to be active members of their community despite their
disability. PVA supports the effort to ensure veterans with mobility
impairment receive adaptive equipment and adaptations that meet
industry standards and specifications. As technology advances, new
automotive adaptive devices continue to open the door to more drivers
with disabilities. Each person with a mobility issue is unique and has
individual requirements and specific features that will allow them to
feel confident and comfortable while they drive. The law as it is
currently written requires that before providing an automobile under
this section, the Secretary determine that the eligible person is able
to operate the vehicle safely. In response to this provision, Veterans
currently receive training from the VA's Driver's Rehabilitation
Program on how to safely operate their new vehicle or equipment before
embarking out onto public roadways. The bulk of the training, however,
is rendered meaningless if the adaptive equipment itself fails.
Requiring that vendors offering such services be certified is simply a
matter of due diligence in line with the previously mentioned
requirements. One can easily recognize the gravity of harm that can
ensue upon not only the veteran, but other motorists, passengers and
pedestrians when this type of equipment fails due to faulty
installation or repairs. While competition and innovation provoke the
establishment of putative best practices and product benchmarks, this
legislation is an important step in ensuring that as the industry
evolves, veterans who are mobility-impaired can rest assured that
companies meet industry-determined certification standards for selling,
servicing and repairing adaptive vans and equipment. There are also
secondary benefits to this policy. It prevents duplicative costs
associated with failing to appropriately vet the vendor the first time
around. And in addition to limiting potential waste of VA funds, it
limits the financial exposure of already vulnerable veterans.
H.R. 3549, the ``VA Billing Accountability Act''
PVA supports H.R. 3549, the ``VA Billing Accountability Act.'' This
bill would authorize the Secretary of Veterans Affairs to waive the
requirement of certain veterans to make copayments for hospital care
and medical services in the case of an error by the VA. Many VA Medical
Centers struggle to send billing statements for co-payments to veterans
in a timely manner. For some veterans this means being sent a bill
years after the service. H.R. 3549 would mandate that a veteran receive
their bill within 120 days from receiving care at a VA Medical Center
and within 18 months if seen at a non-VA facility. Further, the bill
grants the Secretary the authority to waive the co-payment altogether
if these billing timelines are not adhered to. If the bill is sent
after the required time VA must notify the veteran of the option to
receive a waiver or create a payment plan before the payment can be
collected. Veterans and their families should not be burdened with
unknown debts resulting from mistakes in VA's own processes.
VA Legislative Proposal
PVA supports the VA Legislative Proposal ``Department of Veterans
Affairs Purchased Health Care Streamlining and Modernization Act.''
This bill is a necessary tool to allow the VA to meet the wide-ranging
and unique health care needs of veterans, particularly veterans with
spinal cord injury and dysfunction. Through various authorities VA
purchases private sector health care services for veterans, their
families and survivors. Among veterans and community providers, the
multiple avenues for procuring care often creates more confusion than
resources. Under this proposed rule, VA would be able to obtain
extended care services for veterans from providers who are closer to
veterans' homes and communities. The proposed legislation would protect
VA's ability to continue to purchase private medical care when not
otherwise available through VA, contracts, or sharing agreements. This
allows VA to purchase care through agreements that are not subject to
provisions of law governing federal contracts, ensuring providers are
treated similar to Medicare providers. This would enable VA to meet the
needs of veterans in an effective manner. This measure preserves the
protections against waste, fraud and abuse, based on the Federal and VA
Acquisition Regulations. However, this legislation will also accelerate
the purchasing process of a veteran's care by avoiding some of the
complicated contracting rules governed by Federal Acquisition
Regulations. This authority should prove extremely appealing to solo
practitioners and small practices.
Draft bill, the ``Promise Act''
PVA supports the ``Promising Responsible Opioid Management and
Incorporating Scientific Expertise Act'' discussion draft. This bill
targets problems identified in the VA's use of opioids in treating
veterans. Additionally, it seeks to improve patient advocacy by the
Department and expand availability of complementary and integrative
health Services.
This bill would require the Department of Defense (DOD) and the VA
to jointly update the VA/DOD Clinical Practice Guideline for Management
of Opioid Therapy for Chronic Pain that has not been updated since
2010. VA would adopt safe opioid prescribing guidelines for chronic,
non-cancer pain in outpatient settings. It would require each health
care provider of VA and DOD to use VA's Opioid Therapy Risk Report tool
before starting opioid therapy, emphasizing discussions with patients
about alternative pain management therapies. The education and training
of health care professionals would be improved for identifying patients
at-risk for addiction and effective tapering programs for patients on
an opioid regimen.
Additionally, the VA would be given the authority to increase the
availability of naloxone, or ``Narcan,'' a highly effective opioid
antagonist. This drug is on the World Health Organization's list of
essential medicines in a basic health system. Naloxone reverses the
effects of an opioid overdose (typically depression of the central
nervous system). When one is prescribed opioids there is always a
possibility of an overdose. The ability to respond to a worst case
scenario of overdose, accidental or otherwise, must be available at
every medical facility. According to a 2011 VA study based on 2005
data, veterans ages 30-64 who received care at VA died of accidental
overdoses at two times the rate of their civilian peers. Naloxone has
no risk of dependency and can be administered by a layman in the nasal
spray form. It is a critical tool that can save lives while the
department works to address the widespread use of opioids.
VA would also be required to develop mechanisms for real-time
patient information on existing opioid prescriptions from VHA as well
as patient prescription information from the state drug monitoring
program. This mechanism would alert pharmacists of potential ``double-
prescribing.'' A pain management board would be established in each
Veterans Integrated Service Network (VISN). It would serve as a
resource of best practices recommendations for veterans, families, and
providers alike.
Finally, this bill would require VA to incorporate alternative pain
management therapies like yoga and acupuncture. PVA fully supports the
use of complementary and alternative medicine and believes such care
options will give veterans with catastrophic injuries and disabilities
additional options for pain management and rehabilitative therapies.
This concludes PVA's statement for the record. We would be happy to
answer any questions for the record that the Committee may have.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the
following information is provided regarding federal grants and
contracts.
Fiscal Year 2015
Department of Veterans Affairs, Office of National Veterans Sports
Programs & Special Events--Grant to support rehabilitation sports
activities--$425,000.
Fiscal Year 2014
No federal grants or contracts received.
Fiscal Year 2013
National Council on Disability--Contract for Services--$35,000.
Disclosure of Foreign Payments
Paralyzed Veterans of America is largely supported by donations
from the general public. However, in some very rare cases we receive
direct donations from foreign nationals. In addition, we receive
funding from corporations and foundations which in some cases are U.S.
subsidiaries of non-U.S. companies.
Heather Simcakoski
I am Heather Simcakoski, the wife/widow of Jason Simcakoski and
mother of our now 13 year old daughter Anaya Simcaksoki. Jason I met
while both serving on active duty in the United States Marine Corps and
later settled in Stevens Point, Wisconsin, where we currently reside.
By passing this law, we protect our most courageous and honored
citizens - our veterans, their families and our communities. I cannot
think of anything more important or valuable than saving lives -
veteran's lives. The moment we even consider putting the cost of
passing a law before the lives of our veterans is the moment we have
confirmed that America values money more than human lives - all
veteran's lives. It tells us our country valued money more than it
valued Jason's life - my family's life.
In August of 2014, I physically lost my husband to what we now know
was caused by mixed drug toxicity (a lethal combination of drugs
prescribed to him while inpatient at the Tomah VA). However, I actually
began ``losing'' my husband long before that.
For years I watched Jason being prescribed insanely large amounts
of medications along with extremely high doses. I never could
understand why someone who originally checked in for an opioid
addiction would be prescribed these medications or the amount of
medication (dosages) he was given; however, it was the side effects of
the medication that confirmed something was terribly wrong with their
proposed treatment plan,
We watched Jason go from an honorable overachieving United States
Marine to someone we barely knew. Throughout the years we watched Jason
struggle to complete very basic tasks, due to the side effects of the
medication. We watched Jason fall asleep at the wheel of the car -
driving up on the median, one time ending up in a ditch, as well as
many times watching him nod off at the wheel. There were times when
Jason would sleep nearly all day - every day for weeks at a time. He
would miss very important family events such as sports games for his
daughter, holiday events, and even his grandfather's funeral. He would
have significant mood swings and at times could barely speak clearly as
his words were slurred. At times he would spend weeks in the Tomah VA
seeking help, yet it seemed like many times he would only continue to
come home with large quantities and doses of medications.
We watched Jason's health deteriorate right before our eyes,
eventually impacting his overall health and ability to function in
society. He was no longer dependable to work full-time, he refused to
go in most stores and his ability to interact with friends and family
was taken away, due to the impact of the medications both mentally and
physically causing significant difficulties in our family life. We
could no longer rely on Jason's ability to function or perform any
task.
It was almost a celebratory moment if we were able to get him to
leave the house to participate in any family event - even it if it was
just going to dinner on a Friday night. Anaya and I had to learn to
plan on him not being awake or able to participate in any plans we made
- as he was mentally and physically no longer able to commit to even
the simplest of things.
I watched him hurt because he did not want to be like that, as well
as the suffering it was causing his relationship with his daughter and
I. ultimately causing Jason to die a very slow, and miserable death.
I feel all of this was avoidable. I would encourage anyone
prescribing a patient these medications or any other similar cocktail
of medications to spend a full 24-48 hours with the individual. It will
not only break your heart but completely justify the reason we need to
change the way these medications are prescribed. Simply checking on an
individual or spending a little bit of time with them here and there
checking on them will never show the full picture of the destruction
caused to the individuals, families and society by over-prescribing.
Marvin Simcakoski
The Jason Simcakoski PROMISE Act is an important piece of history.
Helping our veterans get the best care possible is the ultimate goal.
The guidelines in the Jason Simcakoski PROMISE Act will help the VA
give our veterans and service men and women the best health care they
deserve. Our family doesn't want to see what happened to our son Jason
happen to another veteran our service person. Our family is proud to
support this bill.
Susan Moseley
My name is Susan Moseley and I am a veteran of the U.S. Army. I was
the typical young adult trying to find my way in the world and had
wasted a year of my parent's money on college with no goal or direction
in my life. I decided to enter the military and chose the Army. Most of
my family thought I would never make it through basic training much
less thrive in military setting.
I arrived to my permanent duty station in Ft. Bliss, Texas and my
joy was short lived when I arrived to the Battalion S-4 and I was told,
``Oh, I'm sorry but you will in Foxtrot Battery.'' I was perplexed and
I'm sure it read on my face when she said and I paraphrase Top 1SGT is
into girls like you and I should find a boyfriend of rank quickly or I
would be his. Fear did not kick in until I was introduced to him.
Little did I know, he would own me - mind and body and he tried to take
my soul.
My unit deployed to Saudi Arabia twice as a Patriot Missile system
was in place from the first Gulf War. This was a time that grooming and
manipulation began when he was with me by myself during Scud Alerts
training. That was the first time he touched me and kissed me. I still
trained at a high level and did well in my position; I always wanted to
be the best. When we returned he made a drastic change placing me as
his assistant in Head Quarters. I became a pro at dodging or planning
people to be in the CQ so I was with someone or on the phone until I
heard other voices to lower my stress levels.
He informed me that we would inspect the barracks and when we
arrived in the laundry room he locked the door. That pit in your
stomach that just makes you uneasy dropped. I had learned if I took
control and performed oral sex it was not as bad as the other things he
did to me. He had more than just me he did this to but I was his as he
always told me.
My parents had come to see me on their way to a national park, I
almost told my Mom but fear over took me. I had 18 months left on my
time in service and I had that feeling that I was owned by him. To say
no was to say I want to be placed on extra duty or jobs that everyone
would pass down the line and he could punish me for not giving him what
he wanted. I had no control and it was always in my mind evasion
tactics were used against my chain of command not on an enemy.
As time passed, I found that the one thing I could control was what
went in my mouth or did not for me it depended on the day. After a PT
test you are weighed in and they noticed how the number had lowered and
my physical appearance changed. My best friend knew without saying it
out loud what was happening to me. He kept me full of as much hope as
he could with we were close to ETS and then I could go home.
The last time he raped me with my face on my desk I was beyond
broken I wanted to die. Later that night I tried.
My section chief called my phone after I did not show up to PT and
I thought, ``oh no, it did not work, what will happen to me now?'' I
told him I tried to die and failed and he took me to the army hospital
and I was admitted. My doctor was trying to find me a facility for long
term treatment for bulimia when my commander and my 1SGT aka my
assailant came to the floor as we waited for the doctor to tell them
what was happening he whispered in my ear ``we are good right?'' By
this time, I had little tone in my voice and I nodded.
I was sent to my unit and I knew that I had little time left to
report him. After I left the Psych floor, I walked into Captain Duer's
office and broke down but he began the process. I was returned to the
hospital and was sedated.
I was sent to an inpatient facility and began to heal. When I
returned I was given a lie detector test and spoke to the CID and a
Master Sergeant and was doing all I could to get home. I was told I was
to mentally unstable to be given a trial. After a week of fellow
battery soldiers telling me and calling me horrid names because he had
been moved when I returned.
Finally, the last day had come, and I WAS GOING HOME!
When I walked out of my units doors a major in the S-3 called me a
whore and many other names but I was free. I was told about the VA but
never put too much thought into it. When I left the army, I was seen by
a doctor and even a dentist but no psych staff. I never knew what had
happened to me had a name.
I did not assimilate back into my home life and lost my soul. I
worried I would see him everywhere I looked. I had flashbacks and
nightmares. I separated myself from my family and friends, and was
quite reckless in my life. I was bounced from doctor to doctor and
never got the care I needed for several years.
I was welcomed into the LGBT community by a friend and I began to
work for a group that raised money for HIV groups and found a community
I felt safe. I was part of a group and that was what I needed.
I have had relationship problems for a long time and had one with a
great man whom was as broken as I was. In looking back, we coexisted
and I had turned away from my family not even showing up for my
birthday one year because I could not deal with my family trying to
help but not understanding what the reminders of MST did to me on a
daily basis.
The day I found out I was pregnant was when my mind allowed me to
want to live. My child saved my life. I know I would be dead today if I
had not been blessed with her.
I became a part of a MST survivors' group 9 years ago after seeing
a therapist named Karen Tufts. I worked on the skills I lacked and made
goals. I could only see her every 3 weeks but she gave up her lunch
every Friday for a group of girls (she also saw men) that helped each
other through thee trials and tribulations of daily life.
I was a people finder obsessed on my 1ST SGT or top to see if he
was still where it said he was many times a day. I would panic if I
even though that I had seen him. I can't count how many times I have
left a buggy at the grocery or left a University of Kentucky basketball
game only 2 times, but hypervigilant was my version of calm. At my
home, participating in activities, or when being with my daughter are
the only times I don't have that feeling of slight fear.
This has been hard on my family but with my therapist teaching my
Mother that this never goes away it's managed. My daughter is with me
when I have to leave my home and I don't feel anxiety. She has been
with me and understands that mommy can't always be ok and she knows I
love her and will always learn more ways to try.
Karen passed after the bill was introduced of lung cancer she was a
huge supporter to us all and hopes that VA uses money for more female
clinics and female doctors. Last month, a member of our group killed
herself by shooting herself in the stomach so she could die slowly
because she thought she deserved it and bled out over an hour. I was
told at VA I was lucky a female was on duty after a 7 hour wait. I am
still called ``Mr. Moseley'' and I can ask to be separated from males
but many don't have the voice I do and wait in the women clinic with
men.
I am triggered by VA every time I open the elevators by a sea of
men in various camouflages. I must walk by the walls with my sunglasses
on so I don't become overwhelmed by triggers of men that resemble my
assailant. I sit with my back to a wall and must see a door or know my
way out.
I was in the emergency room and waited and told the nurse I wanted
only female staff and after I was in the room a male nurse came in to
start an IV, I am sure he only had a healing hand but not even 20
minutes was my request upheld.
I have been in the psych ward and signed myself out many times as
other men walked around or into your room that cannot be locked and
have no program to go to PTSD and Substance Abuse programs don't fill
my needs. Only two VA facilities have a MST program in California and
Bay Pines, Florida. This was never a time I would be able to be so far
from my child and be able to be active in the program.
After Karen left the VA, we few that knew she saw patients at her
home had much luck with bonding and feeling like they could do core
work on MST and trauma based therapy. How could we when once a month
you couldn't even see a therapist. The VA gives travel pay and seeing
Karen at her home you had to pay for gas, this was a hardship for many.
The heart of VA is to help veterans get quality care but many
survivors avoid going for care other than Karen's Group. One of the
major reasons is that many specialists at the VA in my city are males.
Being touched by a male can be a huge trigger for us.
One of our group members died from heart disease which she would
not treat because she would have to take her blouse off. Many postpone
treatment until it becomes a major problem and don't attend preventive
care to avoid triggers the VA leaves with them.
I am asking you all to pass the Military Save Act for the men and
women who have suffered through the predators within our military. This
legislation would help to give hope to begin to be healthy, productive,
members of society. Directing my own care with great female healthcare
providers in my hometown and not fear going to the doctor is necessary.
Unfortunately, there are veterans across this country who suffers from
MST and if they don't get help they need, they could become a burden at
the state level when we have already fought for our country and help
these victims have a chance to be productive members of society.
I have finally received the approval I need for services outside
the VA to be seen only by female doctors. However, I still have
problems with prescriptions and follow-up testing in fear of having a
bill if it has not been approved.
I love the military and even with the circumstances of my time in
the Army, I would do it over and over again. I urge you to do
everything in your power to help ensure the passage or implementation
of the Military SAVE Act.
Thank you for your time and for allowing me to speak before you
today.
Respectfully,
Susan K. Moseley
Diane M. Zumatto
AMVETS National Legislative Director
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