[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR 2018
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
_________
SUBCOMMITTEE ON MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED
AGENCIES
CHARLES W. DENT, Pennsylvania, Chairman
JEFF FORTENBERRY, Nebraska DEBBIE WASSERMAN SCHULTZ, Florida
THOMAS J. ROONEY, Florida SANFORD D. BISHOP, Jr., Georgia
DAVID G. VALADAO, California BARBARA LEE, California
STEVE WOMACK, Arkansas TIM RYAN, Ohio
EVAN H. JENKINS, West Virginia
SCOTT TAYLOR, Virginia
NOTE: Under committee rules, Mr. Frelinghuysen, as chairman of the
full committee, and Mrs. Lowey, as ranking minority member of the full
committee, are authorized to sit as members of all subcommittees.
Maureen Holohan, Sue Quantius, Sarah Young, and Tracey E. Russell,
Subcommittee Staff
__________
PART 3
Page
Veterans Affairs............................................. 1
Office of the Inspector General.............................. 141
Public Witnesses............................................. 235
Veterans Affairs Electronic Health
Record....................................................... 321
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
__________
U.S. GOVERNMENT PUBLISHING OFFICE
28-157 WASHINGTON : 2018
COMMITTEE ON APPROPRIATIONS
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RODNEY P. FRELINGHUYSEN, New Jersey, Chairman
HAROLD ROGERS, Kentucky \1\ NITA M. LOWEY, New York
ROBERT B. ADERHOLT, Alabama MARCY KAPTUR, Ohio
KAY GRANGER, Texas PETER J. VISCLOSKY, Indiana
MICHAEL K. SIMPSON, Idaho JOSE E. SERRANO, New York
JOHN ABNEY CULBERSON, Texas ROSA L. DeLAURO, Connecticut
JOHN R. CARTER, Texas DAVID E. PRICE, North Carolina
KEN CALVERT, California LUCILLE ROYBAL-ALLARD, California
TOM COLE, Oklahoma SANFORD D. BISHOP, Jr., Georgia
MARIO DIAZ-BALART, Florida BARBARA LEE, California
CHARLES W. DENT, Pennsylvania BETTY McCOLLUM, Minnesota
TOM GRAVES, Georgia TIM RYAN, Ohio
KEVIN YODER, Kansas C. A. DUTCH RUPPERSBERGER, Maryland
STEVE WOMACK, Arkansas DEBBIE WASSERMAN SCHULTZ, Florida
JEFF FORTENBERRY, Nebraska HENRY CUELLAR, Texas
THOMAS J. ROONEY, Florida CHELLIE PINGREE, Maine
CHARLES J. FLEISCHMANN, Tennessee MIKE QUIGLEY, Illinois
JAIME HERRERA BEUTLER, Washington DEREK KILMER, Washington
DAVID P. JOYCE, Ohio MATT CARTWRIGHT, Pennsylvania
DAVID G. VALADAO, California GRACE MENG, New York
ANDY HARRIS, Maryland MARK POCAN, Wisconsin
MARTHA ROBY, Alabama KATHERINE M. CLARK, Massachusetts
MARK E. AMODEI, Nevada PETE AGUILAR, California
CHRIS STEWART, Utah
DAVID YOUNG, Iowa
EVAN H. JENKINS, West Virginia
STEVEN M. PALAZZO, Mississippi
DAN NEWHOUSE, Washington
JOHN R. MOOLENAAR, Michigan
SCOTT TAYLOR, Virginia
----------
\1\}Chairman Emeritus
Nancy Fox, Clerk and Staff Director
(ii)
MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR 2018
----------
Wednesday, May 3, 2017.
DEPARTMENT OF VETERANS AFFAIRS
WITNESS
HON. DAVID J. SHULKIN, SECRETARY OF VETERANS AFFAIRS
Chairman Dent Opening Statement
Mr. Dent. Good morning.
Today, we are pleased to welcome back a good friend, Dr.
David Shulkin, the new secretary of the Department of Veterans
Affairs. The last time you appeared before the committee, you
were VA. Under Secretary for Health. Now, you have been kicked
upstairs after a unanimous Senate confirmation vote--to repeat
that, it was unanimous and that says a lot in this political
environment. So congratulations.
With your extensive health background, I know you have got
a great background in the Philadelphia area. I just learned,
too, you were in Morristown in Chairman Frelinghuysen's
district for some time. You certainly bring a lot of experience
to the job, although I am sure these days that the challenges
are very daunting for you.
We realize this hearing is a little bit unusual. Rather
than the typical budget hearing we usually have at this time of
year, we are limited to a discussion of the skinny budget
materials that OMB had sent to the Hill in March. The two-page
entry for the VA doesn't give us much to go on in terms of
program priorities or plans for the Choice successor program.
But the skinny budget does give us one remarkable bit of
news for the VA. Apparently, the administration is proposing a
$4.4 billion or 6 percent funding increase for the agency. In
addition, there is $2.9 billion proposed in new mandatory
funding for the VA. You are probably the only domestic federal
agency not facing a substantial cut. And so I suspect I am
going to need a Kevlar vest when talking to my fellow
Appropriations subcommittee chairmen.
So when we see your full budget later this month, we will
be asking some tough questions about the merits of your
proposed increases when we know others will be struggling.
Despite not having a complete budget, I am sure the members
will find plenty of VA topics to ask you about this morning:
How do you envision VA striking a balance between care in VA
facilities, versus non-VA community facilities; making the
electronic health record work for veterans, especially as they
see more doctors through Choice; your efforts to tackle
appointment scheduling problems; how you plan to approach
disability claim backlogs and appeals; your plans to decrease
veteran suicide and homelessness; your campaign to limit opioid
abuse among veterans; and plans to access care for rural and
female veterans.
And that is probably just a start. The members will think
of other things I am sure.
So Mr. Secretary, we are going to include your full
statement today in the hearing record, and we will be pleased
to hear your oral statement. But before you begin, I will ask
our ranking member, Ms. Wasserman Schultz, if she has any
opening comments that she would like to make, then after that,
the chair and the ranking member of the full committee.
With that, Ms. Wasserman Schultz is recognized.
Ranking Member Wasserman Schultz Opening Statement
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
And welcome, Mr. Secretary. It has been a pleasure to talk
with you over the last few weeks and good to have you in my
office yesterday.
We do appreciate you being here in your new capacity and I
echo the chairman's comments, particularly given that it is an
awkward situation that we find ourselves in. You are operating
on a bigger stage than you were previously, and with greater
responsibility that comes with the duties of being the
secretary of VA.
Mr. Chairman, since fiscal year 2008, the VA has seen a
tremendous 70 percent increase in DVA accounts. DVA medical
accounts have grown from $36.7 billion to $64.4 billion. And
the overall discretionary accounts have increased from $43.6
billion to $74.3 billion. And fiscal year 2018 is no different.
The President's skinny budget even requests $78.9 billion for a
6 percent increase from the 2017 enacted level.
The 2018 budget also requests legislative authority and
$3.5 billion in mandatory authority to continue the Veterans
Choice Program. And what is a question that arises is that this
would support a program that was initially meant as a stop-gap
temporary fund.
Mr. Secretary, while I am certainly, you know, thrilled to
have you here today, it is unfortunate that we won't be able to
discuss the specifics of the VA budget request. And the lack of
detail makes it extremely challenging for the committee to
properly do our job.
Moreover, given this 70 percent increase over the past 10
years, it is critical that this committee has the opportunity
to analyze and understand these numbers, as well as know more
about why the VA continues to have issues of mismanagement,
wait times and less than adequate care.
While I can understand that this degree of growth has its
growing pains, it is crucial that we understand how these
issues are being addressed. And once we more fully understand
those issues, at what point do we ask if this continued growth
is unsustainable?
Mr. Secretary, I ask these questions with genuine concern
for the future of the VA.
Obviously our driving concern must be to provide the best
care to our veterans. However, if we don't control costs and
ensure that the resources this committee provides are used in
an appropriate and efficient fashion, we actually hurt our
ability to help veterans and deliver on our mission of
providing top-quality care.
You know, it comes to mind to that, while we are providing
additional resources, we are not seeing what would normally
come as the commensurate response from the people who are
receiving these services, because of the challenges that the VA
is having in providing those services efficiently.
Top-quality care is really our top priority and we need to
make sure that we help you deliver on that mission.
With that in mind, Mr. Chairman, it is imperative that we
discuss a number of key issues, including the Choice program
and the state of the VA's electronic health records.
How does the VA envision Choice, a mandatory program,
working with Community Care, a discretionary program? After
creating the Community Care Account, which includes $9.4
billion in advance fiscal year 2018 appropriations, why does
the budget request also include $3.5 billion for the Choice
program?
Additionally, where is the VA in implementing and improving
its electronic health records system, and in executing
Congress' mandate for full interoperability with the DOD
systems? As we discussed this past Monday in my office, Mr.
Secretary, a solution to this issue is long overdue.
And finally, I hope you can address the significant number
of vacancies at the department and when these positions are
expected to be filled. Currently, 11 Senate-confirmable
positions remain vacant, including the under secretary for
benefits, the under secretary for health, the under secretary
for memorial affairs, the general counsel, the assistant
secretary for information and technology, the assistant
secretary for policy and planning, the assistant secretary for
management and the chairman of the Board of Veterans Appeals.
And by the way, the veterans' appeals process is an
absolute mess. And so for it to have no chair for as long as
that has occurred is really unacceptable.
And from our discussions, I really believe that you
earnestly want to reform and improve the VA It is reflective in
the confidence that was placed in you, with a unanimous vote
for your confirmation from the United States Senate.
And it is our duty, I believe, to ensure that you have
adequate resources to do so and the proper oversight is in
place to guard against abuses and mismanagement. As you can
see, we have a lot to discuss today.
And, Mr. Chairman, thank you for the opportunity to share
my concerns, and I yield back.
Mr. Dent. Thank you, ranking member.
At this time, I would like to recognize the chair of the
full committee, Mr. Frelinghuysen of New Jersey.
Full Committee Chairman Opening Statement
The Chairman. Great. Thank you, Chairman Dent and Ranking
Member Wasserman Schultz.
So, first of all, I want to give you a shout-out for
passing your bill last year, September. Thank you for that
effort. You were the pace setters. I wish we could have
followed your pace, but in reality, we didn't. But I can't
think of a more important department than the Department of
Veterans Affairs.
I mean, those who have served our country, and serve our
country right now in dangerous places, deserve, when they get
home, to get the best care possible. And I know you from your
time in New Jersey and the wonderful things you did there.
And, for good reasons, you were unanimously confirmed by
the Senate. There is not a lot of unanimity over there, but I
am glad that they focused their attention and support for you.
Two areas of particular interest to me--I don't want to
take time away from your remarks or your questions. The
continuing appeals and benefits backlog, it is a nightmare. I
have even shared with you some of the 3- or 4-year waiting
periods for people. Obviously, evidence has to be collected and
verified, but in reality, it is a pretty nightmarish prospect,
and certainly the confirmation of your undersecretaries might
be helpful in that regard. So hopefully that will happen.
And over the years this has been a continual interest to
me--is electronic medical records. I think, 3 years ago, then-
Chairman Rogers hosted Chuck Hagel, the Secretary of Defense,
and Ric Shinseki, one of your predecessors. And we received a
commitment from former General Shinseki that we would have,
within a year, some sort of a solution.
I know the Department of Defense--and, given the resources
they have been given--is getting up to speed. But I do view
your systems as sort of the weak link.
So I just personally feel that this is something which is
enormously important. In a day and age when we have so much
information passing back and forth, obviously, encrypted and
protected, to not have that available to our health care
providers is pretty inexcusable.
But good luck and Godspeed, and thank you, Mr. Chairman.
Full Committee Ranking Member Opening Statement
Mr. Dent. Mrs. Lowey, I would like to recognize you.
Mrs. Lowey. Thank you very much. And I would like to thank
Chairman Dent and Ranking Member Wasserman Schultz for holding
this important hearing.
And I welcome Secretary Shulkin today.
We as members of Congress, and you as the Secretary of
Veterans Affairs, have a duty to provide the best care
available to our veterans, who have sacrificed and faithfully
served our Nation. The VA faces serious challenges in meeting
their health needs.
After working 4 years to reduce the claims backlog, it is
once again increasing, and the Choice Program will soon run out
of money and is in need of reform.
And the VA and Department of Defense are not significantly
closer to the interoperability of electronic health records
than they were years ago. We owe it to all current and future
veterans to tackle these challenges now, and this subcommittee
is committed to achieving that goal.
I must say, after reading your resume, I am so optimistic.
As was referenced before, Chairman Rogers and I had, I think,
four hearings, right, Chairman Frelinghuysen? We also met in
closed-door sessions. We hadn't been able to resolve this.
Now, I have my own personal preference about who is to
blame, as we were talking about it before, but that is
irrelevant now. And, looking at your resume, I am so
enthusiastic, and I know you are going to get this done.
In my own district, I have worked to secure federal funding
to improve rehab facilities and ensure that veterans can
receive a high quality of care. But for too many, the VA is
unable to provide the types of services they require.
From women struggling to find care in a health system that
has traditionally served men to veterans who were turned away
from VA facilities when they are most in need, the VA has a
responsibility to serve all veterans who seek the care and
treatment they have earned.
In light of these challenges, Congress awaits the details
of the President's fiscal year 2018 budget request. The budget
framework requests an increase of 6 percent for the VA, but
lacks detail, providing just seven bullet points of vague
proposals. While you may not be able to speak to details of the
budget proposal now, I hope you will return after its release
so we can fully discuss it.
Mr. Secretary, I again thank you for being here today.
Thank you for your commitment to improving the lives of
veterans, and thank you for assuming the responsibility. I look
forward to hearing about all your success, sooner rather than
later, so we won't, in a bipartisan way, continue to talk about
backlogs and the lack of records.
So we have confidence in you and I thank you for appearing
here today.
Mr. Dent. Thank you, Mrs. Lowey. At this time I would like
to recognize Secretary Shulkin for 5 minutes.
Secretary Shulkin Opening Statement
Secretary Shulkin. Chairman Frelinghuysen, Chairman Dent,
Ranking Member Lowey, Ranking Member Wasserman Schultz, and all
of you who are here today, I was so impressed with your opening
statements and so many topics that you have thought about and
that you care about, and that I know are serious issues--and we
are trying to do things differently at the VA--that I have a
terrific opening statement.
But I am willing to--Mr. Chairman, to actually forgo it and
get right into your questions, unless you would prefer me to go
through the opening statement, because I think we have so many
issues, and I want to use your time--most valuable. I have
submitted it for the record. I would be glad to read through
it, read through my whole statement, but I will leave it up to
you.
You would like to hear it?
Mr. Dent. Yes.
Secretary Shulkin. Good. Okay. Okay. I told you, it is
terrific.
Mr. Dent. The abridged version, about 5 minutes' worth.
Secretary Shulkin. Okay. I will try to do it quickly, but
thank you.
Okay. So thanks for the opportunity to be here today to
talk about the President's 2018 budget. I also want to thank
you all for your support of the 2017 budget that really gave
us, for the first time, our full budget from the start of the
fiscal year.
It really speaks well of the U.S. Congress, and really, of
the American people, that, despite all these differences--and
you have mentioned this several times--that we can come
together on this topic to support our Nation's veterans. I have
submitted the full statement for the record.
The President's 2018 budget reflects his strong personal
commitment to our Nation's veterans. It provides the necessary
resources to continue the ongoing modernization of the VA
system.
The budget requests $78.9 billion in discretionary funding
for VA, a 6 percent increase from the 2017-enacted level. It
provides $4.6 billion more for medical care, a 7.1 percent
increase, and the $3.5 billion more in mandatory budget
authority that was mentioned to continue the Veterans Choice
Program.
More veterans are opting for Choice than ever before--five
times more in fiscal year 2016 than fiscal year 2015--and
Choice authorizations are still rising. We have issued 35
percent more authorizations in the first quarter of fiscal year
2017 than in the same quarter of 2016. All told, including both
care VA facilities and in the community, we project a 6.6
percent increase in ambulatory care for 2018 over 2016.
I urge you to support and fully fund our 2018 request to
enable VA to meet increasing demand for VA services, to
modernize the VA systems and to invest in choice.
As you know, I came to VA during a time of crisis, when it
was clear that veterans were not getting the timely access to
high-quality health care they deserved. I know VA has made
significant progress in improving care and services to
veterans, but I also know that much more must be done if VA is
to continue keeping President Lincoln's promise to care for
those who have borne the battle.
Last week, I had an opportunity to meet two courageous
young Americans, Michael and Sarah Verardo of Rhode Island. All
Michael ever wanted to do was to be a soldier, and he became a
soldier serving his country--serving in the Army's 82nd
Airborne Division.
Then he lost a leg and part of his arm in an IED explosion
in Afghanistan. He suffered other wounds as well. They told me,
when he sought care from the VA in 2014, they did not receive
the care. We cannot allow ourselves to ever again fail our
American heroes like the Verardos. Meeting Michael and Sarah
underscored for me the urgency of VA modernization.
My five priorities as Secretary are to provide greater
choice for veterans, to modernize their systems, to focus
resources more efficiently, to improve the timeliness of our
services and suicide prevention among veterans.
We are already taking bold steps towards each of these
priorities. Two weeks ago, the President signed a
reauthorization of the Veterans Choice Act, ensuring veterans
can continue to get care from community providers.
Just last week, the President ordered the establishment of
a VA. Accountability Office, and we are moving as quickly as we
can within the limits of the law to remove bad employees.
VA has removed medical center directors in San Juan,
Shreveport, Louisiana, and recently, we have relieved the
medical center director right here in Washington, D.C., and
removed three other executive service leaders due to misconduct
or poor performance.
We simply cannot tolerate employees who act counter to our
values or put veterans at risk.
Since January of this year, we have authorized an estimated
6.1 million community care appointments, 1.8 million more than
last year, a 42 percent increase. We now have same-day services
for primary care and mental health at all of our medical
centers across the country.
Veterans can now access wait-time data for their local VA
facilities by using the easy online tool where they can see
those wait times. No other health care system in the country
has this type of transparency.
VA is setting new trends with public-private partnerships.
Last month, we announced a public-private partnership of an
ambulatory care development center with a donation of roughly
$30 million in Omaha, Nebraska, thanks to Mr. Fortenberry's
help there. Veterans now have--or will have a facility that is
being built with far fewer taxpayer dollars than in the past.
Finally, VA is saving lives. My top clinical priority is
suicide prevention. On average, 20 veterans a day die by
suicide. A few months ago, the Veterans Crisis Line had a
rollover rate to a backup center of more than 30 percent.
Today, that rate is less than 1 percent.
In support of our efforts to reduce suicides, we have
launched new predictive modeling tools that allow VA to provide
proactive care and support for veterans who are at the highest
risk of suicide. And I have recently announced that VA will be
providing emergency mental health care to former service
members with other than honorable discharges at all of our
medical facilities. We know that these veterans are at greater
risk for suicide, and we are now caring for them as well as we
can.
These are just a few of the efforts that are under way, but
are already improving the lives of veterans. But to keep moving
forward, we need your help. We need Congress to help us realign
our capital infrastructure, to dispose of property we don't
need and to support facilities where veterans can get better
served.
We need Congress to fund our I.T. modernization to keep our
legacy systems from failing and to increase the
interoperability of electronic health records essential to any
high-performing integrated health system. We are also weighing
options for adopting a commercial off-the-shelf alternative to
our legacy systems. I have scheduled the decision for this in
July.
If it makes sense to go to the off-the-shelf route, we will
need some additional support from you as well.
We need Congress to authorize the overhaul of our broken
and failing claims appeals process that many of you have
mentioned. Working closely with veteran service organizations
and other stakeholders, VA has drafted legislation to modernize
the system.
We have submitted our proposal to the 114th Congress, and
we have resubmitted it in this current Congress. We need
Congress to act on this.
Most of all, we need Congress to ensure the continued
success of choice for veterans. Extending the Choice Program
past its August end date was an absolute necessity, and thank
you for that. But extending the program was just the next step
towards the modernization of community care that veterans
deserve.
We have charted a course for modernization and are already
moving forward, but we need your help to keep up with the
Choice Program's growth, maintain our momentum, and make our
community care plan a reality for all veterans for generations
to come.
In closing, let me again express my thanks to the
Appropriations Committee and to this subcommittee for the
support that you have shown veterans in recent years. Without
that support, we could not have expanded Choice to a record
number of veterans while also curing so many veterans of
hepatitis C. You have made that possible, and 77,000 veterans
are now free of hepatitis C as a result.
Thank you for the opportunity to be here today. I look
forward to all the questions that you may have.
[The information follows:]
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Mr. Dent. Yes, at this time, I would like to recognize the
chair of the full committee, Mr. Frelinghuysen, if he has any
questions.
VISTA ELECTRONIC HEALTH RECORDS
The Chairman. Very briefly, you talk of the legacy system.
The acronym is VistA. Now, you are looking at an off-the-shelf
system.
Isn't the issue here different I.T. systems at every
hospital? So, where are you in the overall--very briefly, where
are you--in terms of some--maybe some good news in the mix?
Secretary Shulkin. Right. Well, we only have 130 different
systems, okay. So the VistA system is something that, frankly,
VA should be proud of. VA invented it. It was the leader in
electronic health records. But, frankly, that is old history,
and we have to look at keeping up, and to modernize the system.
I have said two things, Mr. Chairman, in the past. I have
said--number one is VA has to get out of the business of
becoming a software developer. This is not our core competency.
I don't see why it serves veterans. I think we are doing this
in a way that, frankly, we can't keep up with.
So, I have said that we are going to get out of that
business. We are either going to find a commercial company that
will take over and support VistA, or we are going to go to an
off-the-shelf product, and that is really what we are
evaluating now. We have an RFI out for essentially the
commercialization of VistA that we would no longer be doing
internally.
The second thing I have said is that--and I think it was
referenced in several of your comments--you have asked the
Department of Defense and VA to work together probably for 10
or 15 years. And we have always found ways not to do that.
Secretary Mattis and I have talked about this. We believe
that we need to find ways to work together.
So when I come out in July, I am going to be talking about
a process that led to a decision to get us out of the software
development business and to find a way to work even closer with
the Department of Defense than we have. And we are working
rapidly towards that decision, and I am committed to that date.
The Chairman. Thank you for that progress.
Mr. Dent. Thank you. At this time, I would like to
recognize Mrs. Lowey.
Mrs. Lowey. Thank you so much--thank you so much, Mr.
Chairman. There are so many questions, but I must continue this
discussion, having been part of this issue of records for the
last 5, 6, 7 years.
And I gather we have spent $1.4 billion on this--I don't
even know what I want to call it, project, search,
interoperability. But what I am confused about, it is my
understanding that the Defense Department has already rolled
out the system.
It seems to me you make a lot of sense saying, we are not
going to be in this business anymore, we want an off-the-shelf
system. However, in order to foster--to ensure there is
interoperability, what is wrong with the Defense program, and
why wouldn't you, at least at the outset, explore that?
Because if you choose another system, and they have their
system, what is it going to be? Another billion dollars that we
could use for suicide prevention, for treatment, for all kinds
of important things.
I have to tell you, as the ranking member, Chairman
Frelinghuysen and I go to a lot of committee hearings. But this
affects my heart. And when I talk to veterans in the district,
and I know the challenges they are facing, and I know that you
have all the competence, background to do it, why wouldn't you
start--or are you looking at the system the Defense Department
has rolled out?
Secretary Shulkin. Yes, so, first of all, I hear your----
Mrs. Lowey. Frustration.
Secretary Shulkin. That is probably a good word.
Mrs. Lowey. I am smiling, so--we have had hearings where
the anger was----
Secretary Shulkin. Yes, yes. No, listen, Congress has been
very clear on this for years and years. And that is why I
believe that you and the American people and the veterans
deserve a clear direction on this. And I am committed to doing
that.
I can tell you we are exploring all options. I am sure you
understand this is a highly complex issue. And I have lived
through personal electronic medical record conversions in
hospitals that I have led. These are not easy projects in
single hospitals, let alone talk about the size of the VA
system. So we are taking this very seriously. I can assure you
we are exploring all those options.
We also as we get more veterans out into the community, out
into the private sector hospitals, we have to be very concerned
about interoperability with those partners as well. So if there
was an easy solution here, I am sure it would have been made
already. But we are going to make a decision and we are going
to move forward with it, and we are going to need your help in
being able to implement that.
Mrs. Lowey. I just want to say thank you, Mr. Chairman. And
I want to thank you for assuming the responsibilities that our
veterans certainly are looking for and they deserve. And I wish
you the best of luck. And I look forward to your coming back
sooner rather than later, because I don't want to have another
hearing on interoperability.
Secretary Shulkin. Right.
Mrs. Lowey. So thank--and I want to remind you again, $1.4
billion has already been spent on trying to get the Defense
Department and the VA coordinated. So thank you so much again.
We look forward to hearing from you as soon as possible.
Secretary Shulkin. Thank you.
Mr. Dent. Thank you, Mrs. Lowey.
THE FUTURE OF COMMUNITY CARE
Mr. Secretary, we understand that you are floating ideas
for a system to consolidate the various non-VA care programs,
including Choice. While we realize your proposals are by no
means locked down, it sounds like you are contemplating a plan
that would allow veterans to seek urgent care outside the VA
system. It will be followed by a discussion with a VA care
provider about whether the veteran should be seen in the
community or by the VA. That decision would be based on the
results of a local health market analysis identifying the
capacity, quality and cost of the various services at the local
VA.
Is the basic premise of this proposal to keep services
within the VA, subject to availability, quality and capacity,
rather than open the doors more broadly to non-VA care?
Secretary Shulkin. Let me try to describe it, Mr. Chairman,
a little bit differently than that.
First of all, I think you are correct that what we have
identified coming out of the 2014 wait-time crisis out of
Phoenix was that the VA, I don't believe had the appropriate
management systems in place. And the way I believe that you run
a clinical system is that you put your clinical urgency first.
So, if somebody is waiting for a routine examination, that
is normal. But somebody shouldn't be waiting if they have a
tumor in their chest or if they have blood, you know, coming
out of parts of their body that they shouldn't have it coming
out of. That needs urgent care right away. So we are going to
prioritize and to make sure that veterans aren't waiting.
Secondly, we are trying to build an integrated system of
care. That means if you look at this from the veteran's
perspective, which is really the only perspective we should be
looking at this from, you want to take what the VA does best
for veterans that you can't find as well in the private sector.
And you want to take what the private sector does best that the
VA doesn't do as well.
And you want to make that an integrated experience for the
veteran. And that is what we are trying to do. Currently, one-
third of our care happens outside the VA walls; two-thirds
inside. And we are working now to get the proper mix in each of
the communities, because it will look different in New York
City than it will in Arkansas, and try to figure out in that
community what is the proper mix of inside VA and working with
the community. And that is what we are hard at work at doing.
And I think that this will benefit the veteran the most.
Mr. Dent. And to follow up on that. What cost governors
would you include to keep the program costs to a manageable
level?
Secretary Shulkin. Yes. Well, I am very sensitive to cost.
And my belief is that one of the reasons why we got into the
problems that we did in VA is because we were not properly
funding the actual demand. And that is why I think it is so
important that we, and you work with us, to get what the
President has requested for the 2018 budget. Because I think
that we need that.
But I am not looking for non-sustainable increases year
after year the way that we have in the past. And I think as
Congresswoman Wasserman Schultz said, that is an unsustainable
solution. The problems that we have in the VA are not primarily
financial. These are primarily system issues that we haven't
kept up with and we haven't modernized.
So I am looking for an investment this year to help us
modernize our systems. The I.T. system will be one example of
where we need to come back, but I am not going to be seeking
increases of this type in future years to come.
So, we do need to put cost mitigation strategies in place.
One of the areas that we are focusing on that I have already
announced is fraud, waste, and abuse. I think that there are
huge opportunities to identify waste and abuse in the current
system. There are not the proper safeguards in place. And we
are going to be taking some aggressive actions to do that.
There are other cost mitigation strategies that I am
seeking as part of Choice. One of them would be for the VA to
be able to do value-based purchasing. The private sector has
moved towards this where there are accountable care
organizations to focus on quality and cost, and where you can
purchase care based on the best value, which is cost over
quality.
We don't have those tools in the VA. In fact, we are
restricted from using that. We have to pay a flat Medicare fee
schedule. So, I am seeking the same tools that the private
sector has to be able to control costs and improve quality.
WORKFORCE AND FACILITY INFRASTRUCTURE NEEDS
Mr. Dent. And can I just quickly follow up? If Congress
were to adopt your ideas, what would that mean for workforce
and facility infrastructure needs?
Secretary Shulkin. In this budget?
Mr. Dent. Yes.
Secretary Shulkin. We are seeking the budget so that we can
hire the proper health care professionals. We now have 45,000
clinical openings in the Veterans Health Administration, and
another 4,000 openings outside of the Veterans Health
Administration. So for a total of 49,300 employees that we are
seeking.
I think that, frankly, the crisis that went through and the
lack of good press, and so the impact on the morale of the
workforce has really hurt us in recruiting. Of course, we had a
hiring freeze in place up until April 12th. So we have fallen
behind.
And, in particular, in my priority areas like mental
health, I need 1,500 new mental health professionals to join
the VA. So we are really prioritizing that right now and this
budget would allow us to get up to that staff.
Mr. Dent. Thank you, Secretary Shulkin.
At this time, I would like to recognize the ranking member,
Ms. Wasserman Schultz, for 5 minutes.
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
First and foremost, I just wanted to suggest that, as a
number of members have mentioned it, because the Secretary is
limited to only speaking about the skinny budget, it would be
incredibly helpful and important, once we have the President's
budget released, for us to ask him to come back and hold a
hearing on the actual, full budget request.
So, I would ask both the chair--both chairs--to please
consider doing that, just so we can delve into a little bit
more detail. Thank you.
VETERANS CHOICE PROGRAM
I want to focus on the Choice Program for a moment, because
you have asked for an additional $3.5 billion, and we talked
about it yesterday a little bit. But, you know, we recently
extended, as you mentioned, the Choice Program past the August
expiration date, and there was $950 million left in the Choice
account.
So, in part, obviously, rather than letting that funding
languish, and considering that there is still a need, that made
a lot of sense. But, we did envision the Choice Program to be a
temporary program initially.
My understanding, and correct me if I am wrong, was that it
was really supposed to be a bridge for the VA to transition to
the Community Care Program, until we could get the Community
Care Program in a place where it is able to provide the kind of
timely services that we need it to.
If that is not the case, then can you explain the
differences between the two? And you have also proposed Choice
2.0. So we have Choice, Choice 2.0 and Community Care. I am not
sure it would ultimately help us realize our goal of efficiency
if we have three different programs in the private sector to
help make sure we can meet the needs of our veterans.
Secretary Shulkin. Right. I couldn't agree with you more. I
am looking for one program. Three programs doesn't work. We now
know, having two programs, that didn't work very well. We
confused veterans.
We had two programs, Community Care and Choice. They had
different rules. They put veterans at risk in their credit
because some--some paid first dollar, and others didn't, and
you had to call different numbers to use them. We are proposing
a single program for Community Care.
As far as the intent of Congress for 3 years, look,
Congress stepped up in a big way after the crisis when,
basically, the country and Congress agreed that the current
situation with veterans waiting for care was unacceptable.
VA did exactly what Congress asked us to do, which was to
put into place additional options for veterans to get care in
the community. And now, we are seeing those authorizations and
appointments occurring in the community.
When I started at VA a little bit less than 2 years ago, we
had 20 percent of our care in the community. Today, it is about
32 percent. So you can see we are expanding those options. I
don't think there is any turning back from this.
So whether it was intended to be authorized for 3 years or
not--you know, I know that is what the legislation said--I
think what we have seen is veterans need that care. They are
coming to VA to seek that care, and we need to continue to
support that. That is my opinion. So the $3.5 billion that was
built into the program is very much a needed resource for our
veterans.
Ms. Wasserman Schultz. And I understand, given that your
goal is one program--are you analyzing which program,
ultimately, would be phased out? Because we have a tendency to,
instead of phasing out programs, because they have people with
a vested interest in them, simply, you know----
Secretary Shulkin. Yes.
Ms. Wasserman Schultz [continuing]. Going along to get
along, rather than rocking the boat. And so, if we are adding
$3.5 billion to the Choice Program and it--you know, it had
$950 million left, there have been challenges with the Choice
Program, and confusion, and there are still challenges with the
Community Care program, in what direction is the VA thinking of
going when we--and what is the timeline for ultimately----
Secretary Shulkin. Right.
Ms. Wasserman Schultz [continuing]. Phasing out one program
and only having one?
Secretary Shulkin. Right. Well, with almost certainty, I
can tell you there will not be three programs, because the
current Choice Program will run out of money by the end of this
calendar year. So that program is going to go away, and should
be through December of this year.
What we are hoping to do is to work with you so that we can
introduce a Community Care funding program--the chairman
referred to it as Choice 2.0--which is a program that makes
sense for veterans, which is a single program that operates
under one set of rules for how veterans get care in the
community.
And that new legislation, which we believe needs to be
introduced by late summer or early fall in order to make the
timeline, would end up with a single program.
Ms. Wasserman Schultz. So you would eventually envision
phasing out Community Care with the advent of----
Secretary Shulkin. Yes.
Ms. Wasserman Schultz [continuing]. Choice 2.0. Thank you.
I yield back.
Mr. Dent. Thank you.
At this time, I would like to recognize the gentleman from
Florida, Mr. Rooney, for 5 minutes.
Mr. Rooney. Thank you, Mr. Chairman. I would like to just
sort of continue on, you know, the same line briefly, or just
maybe make a statement that our chairman of the full committee,
as well as Mrs. Lowey, Ms. Wasserman Schultz--pretty much
everybody up here--agrees. We have been giving you all a lot of
money.
And I have been on this committee with General Shinseki,
who I served under at Fort Hood with Mr. McDonough. He was a
military man, Mr. McDonough, you know, businessman, you are a
doctor.
By the way, we have a lot in common. Even though I am from
Florida, I grew up in Philadelphia. I have got a Pittsburgh
connection, so I am rooting for you.
But you know--and you talked about working with General
Mattis and trying to get this continuity of care, and we all
talked about on the stump when we are, you know, down in our
districts that if you are--if you put the uniform on and serve
this country, we are going to take care of you. As you
mentioned Lincoln, we often reference Washington, the country
can measure itself by how it treats its veterans.
And one of the things that we say, from the time that you
enlist or the time that you get commissioned to the time that
you die, you will not be, you know, left out in the cold, we
are going to take care of you.
And one of the things that people ask me about is, well--
how--where does it fall through the cracks? And we often talk
about how, even though we are giving you all the money that you
need, that, you know, the difference between DOD and the VA is
way too big.
And whether it is, you know, the electronic records or just
the fact that you have to basically start all over when you
leave the military and you PCS and you get into the veterans,
you know, program--whatever it is.
INTEROPERABILITY WITH DEPARTMENT OF DEFENSE
I guess my first question to you is, if General Mattis has
a better idea than you do, will you agree to go to his program
just to get this moving? I ask you this just to get this
moving. I ask you this for this reason: you could be the best
VA secretary of all time if you solve this one problem.
And I mean, every time we sit up here and talk to people at
this table, that--we always keep asking the same question. And
I know that there is a lot of bureaucracy, and I know there is
a lot of pride, and whatever the problem is, but, you know, we
just hope that this--if it means you saying to Mattis, ``you
know what, you are right, you have a better program, we are
going to go with your program,'' will you do it?
Secretary Shulkin. Yes. First of all, thank you for your
comments, and I appreciate your perspective on this issue and
how important it is.
I am only here for one reason, and that is to solve the
problems that have plagued VA I wish it was only one problem,
by the way. But I agree with you, this is certainly an
important problem for us.
Anybody, whether it is Secretary Mattis or anyone else who
has a better idea than I have, I am going to take it. The
answer to your question is yes. We want to resolve this issue
in the best way, and if it means taking somebody else's idea,
we are going to do that.
Mr. Rooney. I mean, it would be so good to be able to go
home and stand up on the stump and tell these guys, I come from
a district with a lot of retirees in Florida, a lot of military
retirees--and tell these guys, ``if you put on the uniform of
this country, we are going to take care of you.''
Basically, if you need the health or the mental health
after you serve, it is--one of the advantages of joining, is
that you know that you are going to be taken care of when you
get out. So, that would be a huge help to all of us up here who
are trying to convince people that fighting for this country
has benefits well beyond just, you know, the pride of service.
TRANSITIONING CARE BETWEEN VA FACILITIES
One quick thing, since I am running out of time, and this
is more specific to my district. I am having--my constituent
services representatives down in Florida are telling me that we
are getting a lot of people that are moving to Florida, as they
always do, from other parts of the country.
And they are going in to get care at our VA, and because of
whatever breakdown in coverage, they are told that in my
district, that--they are told to start a new treatment plan or
return to the State--to where they came from, where they were
already getting care for whatever problems that they were
having.
And this is kind of absurd from the standpoint of that I--
we have actually got five or six specific cases where people
that live in Florida can't get the care that they were getting
in their other State, so they are actually, rather than
starting over in Florida, going back to their State where they
came from and using that VA, because they are already in that
system.
This, again, gets to that system where there shouldn't be
any lapse in coverage, but there is. Can you talk about the--
have you heard about this at all, or?
Secretary Shulkin. I haven't heard about your specific
situations, but I hope your directors are watching this right
now, because what you described is unacceptable. We have one VA
system. Veterans should be able to get care at any VA that they
go into, and that is our commitment.
I am not at all doubting that it doesn't work all the time.
I certainly hear many examples where it does work, and people
are able to get care--they are travelling, they lose their
medications, they are able to get to a VA, get them refilled,
get the care they need. That is the system that we are--that is
our expectation of how we manage the system, and I will
reclarify that to our field.
[The information follows:]
One of the many advantages to our Veterans is the seamless
care that we can provide throughout all of our VA facilities
and this is possible through our national electronic record.
All facilities need to make sure that front line staff offer a
consistent message that no matter what type of services the
Veterans are seeking, the site at which they are presenting has
immediate access to their VA healthcare record.
The Office of Primary Care Operations will be confirming
this expectation with field facilities during either the next
Primary Care VlSN Point of Contact call (May 18, 2017 at 1:00
pm EDT) and/or the Primary Care Interactive Office Hours (May
22, 2017 at 1:30 pm EDT).
Mr. Rooney. Thanks, Doctor. Good luck.
Secretary Shulkin. Thank you.
JOINT LEGACY VIEWER (JLV)
Mr. Dent. Thank you, Mr. Rooney. Mr. Secretary, if I could
just interject on that point for a moment, could you just
describe the current Joint Legacy Viewer----
Secretary Shulkin. Yes.
Mr. Dent [continuing]. And what it can do to share DOD and
VA records, just for the benefit of some of the members?
Secretary Shulkin. Right.
Mr. Dent. And we will go to Mr. Bishop.
Secretary Shulkin. Yes, and I am sorry--I am sorry that
Congresswoman Lowey left for this, because I didn't say this to
her, but we did certify interoperability with the Department of
Defense in April of 2016. That is through the Joint Legacy
Viewer, that is probably where a lot of her $1.4 billion went
to, although I don't think it was that much.
And what this does is this allows any VA clinician, any DOD
clinician, to be able to access records from the other system.
So it is a read-only system. It is being used tens of thousands
of times a month by our clinicians in both systems.
So, it does work and it is a lot better than before, when
we didn't have that ability. It is better care. But it is not
the complete interoperability that I think that all of us would
hope for. It is a read-only system at this point.
Mr. Dent. Thank you for that clarification.
Now, Mr. Bishop.
Mr. Bishop. Thank you very much, and welcome, Mr.
Secretary. And let me join my colleagues in congratulating you
and thanking you for your commitment to get these problems
fixed.
THIRD-PARTY BILLING
Let me go to an area of improving timeliness of service,
which is third-party, uncollected billing. The fiscal year 2016
report on the appropriations had directed the VA to submit an
annual report identifying the amount of third-party health
billings that are owed to the VA, and the annual amount that is
collected.
It additionally required that the VA include a plan to
capture uncollected third-party billings. The VA was directed
to initiate a pilot program and figure out how best to capture
the uncollected billings. The difference between billings and
collections in fiscal year 2015 was $4.7 billion. And in fiscal
year 2016, it was $5.164 billion.
This is alarming because it means that billions in
uncollected dollars are not available to the VHA to provide the
services to veterans. What is the status of the pilot program,
and who in the department is responsible for the fiscal
management of third-party billings and collections? And if you
could answer that quickly----
Secretary Shulkin. Yes, thank you.
Mr. Bishop [continuing]. I want to move to another area.
Secretary Shulkin. Congressman, I will try to answer this
quickly.
I think you have identified an area of significant risk for
us, that we have opportunity to do this in a much better way
than we are currently doing this, so I think you are correct.
We currently collect around $3.4 billion a year. We
actually will be asking for, in our new Choice legislation we
hope to work with you on, the ability to do this better.
We, right now, are not allowed to require that veterans
give us their other health insurance. So a lot of that gap
right there is because we don't know their insurance numbers,
and we don't know their insurance company from which to collect
it.
But we are looking at--and we have a RFP that will be
released in the next couple of weeks, to be able to see whether
the private sector can actually help us do collections better,
and that is part of our pilot work that we are doing. We are
actually using another federal agency to help us with these
collections, and that does seem promising.
So, I can get you a more detailed answer, because I don't
want to take up the time now, about the results of the pilot
project.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Bishop. Thank you very much and I look forward to that.
Secretary Shulkin. Yes.
MYVA INITIATIVE AND VISN REALIGNMENT
Mr. Bishop. Mr. Secretary, your predecessor, Mr. McDonald,
started an initiative known as MyVA, to modernize and reorient
the VA. The MyVA vision was to provide a seamless, unified
veteran experience across the entire organization and
throughout the country.
In your testimony, you mention that you intend to modernize
the VA as well. Can you tell us how your plan differs from Mr.
McDonald's, and how you plan to--and whether or not you plan to
build upon the MyVA? And, can you also provide an update of the
Veterans Integrated Service Network's realignment? That is the
first part of the question.
And then the other has to do with facility realignment. You
mention an actual infrastructure realignment strategy, and the
last time VA made a major effort to set infrastructure needs
was the Capital Asset Realignment for Enhanced Services, the
CARES project. Do you envision that the department will embark
on a similar effort?
And if so, when will we see a plan to invest and divest VA
capital assets? Is the strategy that you plan to propose
similar to the military base realignment--the BRAC process?
Secretary Shulkin. Yep. Well, there is a lot there,
Congressman, so I will try to do this quickly.
The MyVA program under Secretary McDonald, I think, no
doubt, has the correct intent, which is to design a veteran-
centric experience, and to focus on that experience. And we
know that there was significant and good improvement being done
under that program, because we could measure it.
What I have said to the Department is that one of the
benefits of me having been in the Department under Secretary
McDonald is that I already know what was working. And I don't
want to stop the progress that was being made.
But I also don't believe we were making progress fast
enough. So I am looking to essentially continue the parts of
that program that work. But I am seeking much broader, bolder
transformation of this Department because I think it is what is
needed. And that is why I have sent my five priorities forward.
In terms of the VISN realignment, we used to have 21 VISNs.
We are now down to 18. Whether 18 is the right number or not, I
think we are always continuing to take a look at that.
But we are going to change the role and function of the
VISN from what it currently is, which is another layer of
administrative complexity--some people may call that red tape--
to a much more profound function in managing their local
markets and moving toward this value-based purchasing concept
and making sure that veterans get the best of care in the
community and the best in VA care.
So we are working on that transformation as we are building
our Choice Program.
FACILITY REALIGNMENT
The realignment--the CARES program, I wasn't here when that
was implemented. I do know that we have closed 1,000
facilities, so that--there has been progress made in that in
the past. But I don't believe I have heard anybody, with
enthusiasm, bringing back the CARES model. I think that we
learned a lot of lessons in that.
Whether they are--whether the BRAC is a model that we
should take a look at, we are beginning to have discussions
with members of Congress about their suggestions. We do believe
that we have, I know, today, 431 vacant buildings and 735
underutilized buildings.
And we want to stop supporting our maintenance of buildings
we don't need, and we want to reinvest that in the buildings
that we know have capital needs. So we are going to be looking
forward to working with you on that.
Mr. Bishop. Thank you very much, Mr. Secretary.
Mr. Dent. Mr. Womack.
Mr. Womack. Thank you.
FOCUS ON CORE COMPETENCIES
Mr. Secretary, welcome. And thanks for the breakfast
yesterday and the opportunity to engage you in conversation
before this hearing.
It has been my experience, down through the years, that
organizations--particularly large organizations--that find
themselves in a bit of trouble sometimes, and many--many times,
stem from the fact that they get away from their core
competencies and they expand into areas where they are not
terribly knowledgeable, capable and certainly not efficient.
And they sometimes serve as kind of a weight, an albatross,
if you will, around the neck of the organization, and it causes
a lot of other things to be compromised in the process. And I
suspect that the VA probably fits into this category.
And so, specifically, my question is this: you have spent
some time talking about I.T., which, I am beginning to believe,
is not a core competency of the VA. We have had many
indications that the construction of property is not--Aurora,
Colorado, being, probably, the poster child for it recently--
not a core competency.
And you talked about collections just a moment ago. And
that would not necessarily be a core competency.
So I am going to throw this on the table and let you
respond. Is it your intent as the Secretary of VA to protect
the core competencies of the VA by outsourcing, for lack of a
better term, some of the other things that have served to kind
of bog down the system?
Secretary Shulkin. I think your assessment of what has
happened in VA is probably pretty accurate. I think that we
have learned the hard way and taken too long to make decisions
in areas that, frankly, we just don't deserve to be in that
business. And I think you have identified a few.
My only modification, if you wouldn't mind, on the I.T. is
I think I.T. has to be a competency of any organization
nowadays. I mean, I can't imagine not. What we don't want to be
doing is being in the software and product development
business. But managing I.T. systems does need to be a
competency of any successful company today, I believe.
I don't know whether ``outsourcing'' is the right word. I
do believe that, if we are going to serve veterans, we need to
be working with a core group of our employees and staff that
functions on our core functions.
But when we have strayed outside, building buildings, you
know, doing software development, doing--you know, claims and
billing, I do think that we should be looking toward private-
sector solutions, or, at the very minimum, private-sector--
private-public partnerships where we can get the competencies
into the Federal Government.
PREDICTING FUTURE DEMAND
Mr. Womack. The last question I have is that one of the
problems facing the Congress, and many previous Congresses, is
the fact that the entitlement programs that we know, the
mandatory side of spending, continue to chew up available
revenues, and--putting a lot of downward pressure on the
discretionary piece of the budget. And that is getting worse
and not better.
And I think part of that is because--and this is good
news--the people are living longer. They are receiving benefits
from those systems for a lot longer period of time than,
actuarially, they were expected to at the time.
Do we have a pretty good handle on the number of people
that will be entering the VA system, so that we can rightsize
the funding request to ensure that we meet those needs, and not
play from a position of weakness by being behind?
I have only got about 45 seconds left. But can you help me
have confidence in knowing that we know what is going to be
filling that pipeline, say, over the next generation?
Secretary Shulkin. We certainly have a handle on the
demographics of the veteran population. As you know, we have 22
million veterans today. And that is expected to decline.
What we can't predict is, obviously, new conflicts that
would happen, because that can change the picture. What we
can't predict is new science that would show that there is
additional mandatory coverage that we would need to include, as
science shows that there is a connection between military
service and some of the disabilities. And that work is always
ongoing.
So I think that we do have actuarial models in health care,
cemeteries, and benefits that we can share some of the
parameters for needs. But they are not fully accurate because
of the unknowns that are out there. So--but I think, for what
you are asking, we can share that with you.
Mr. Womack. Thank you for your service, and congratulations
on your appointment.
I yield back.
Secretary Shulkin. Thank you.
Mr. Dent. Thank you, Mr. Womack.
I would like to recognize Ms. Lee for 5 minutes.
Ms. Lee. Thank you.
Thank you. Good to see you, Mr. Secretary.
Secretary Shulkin. Good to see you.
Ms. Lee. I, too, want to congratulate you and just say I am
glad you are at the helm of the VA, say--and thank you for
being here.
Secretary Shulkin. Thank you.
OAKLAND REGIONAL OFFICE
Ms. Lee. A couple of questions, and I will try to ask them
very quickly. One is relating to the Oakland VA Regional
Office.
In January of 2014, the OIG found that there were
significant delays, of course, in processing the claims. And
the management didn't provide the oversight needed to ensure
timely and accurate processing of informal claims. We had about
1,248 informal claims. Now, this was before the National Work
Queue.
Now we are on the National Work Queue. And, I would like to
find out, has this helped reduce the claims backlog
significantly? And is it helping to streamline and reform
benefit claims processing, specifically regarding the Oakland
VA Regional Office? That is the first question.
HEALTH DISPARITIES AMONG MINORITY VETERANS
Second question has to do with what we have briefly
discussed as it relates to minority veterans. I have looked at
your health disparities report, which is a very thorough
report. And, of course, it cited the fact that minority
veterans were diagnosed with PTSD at rates higher than white
veterans.
Also in the report, you go into some of the recommendations
to begin to address not only PTSD in terms of its disparity,
but all of the others. And it says that we need more research
and more information.
And I am wondering, though, as it relates to this report
and the recommendations, as it--specifically relating health
disparities with minority veterans, where are we on any of it?
And are the recommendations being followed up?
I can't help but wonder why more research would be needed.
We have an Office of Minority Health over at HHS. And so I am
not sure if you are coordinating, in terms of health
disparities, with Health and Human Services.
Just exactly what is going on? Because this is, I think, a
very good report. And I know many, many minority veterans who
are really struggling with all of the issues around health
care, especially PTSD.
And finally--and I have asked this of the OIG, and also
when we were at the VA hospital--in terms of the utilization of
minority and women-owned businesses, it is my understanding
that you don't disaggregate the data.
I would like to find out how we are doing as it relates to
African-American, Hispanic and Asia/Pacific American--Islander
firms and companies. And we--I still haven't been able to drill
down and get that report. The VA is a significant entity that
contracts quite a bit of money out.
And I would like to find out how minority-owned contractors
are faring. But we need to understand what the data is showing
so that we can do better, because I have had a lot of
complaints that--from minority-owned businesses that they can't
seem to penetrate and get into the system for a fair shot.
Secretary Shulkin. Okay. Well, thank you, Congresswoman
Lee.
These are all really important issues. So, on the claims
backlog and what the impact of the National Work Queue has
been, we do believe that that has been helpful. And we are
seeing improvements in productivity.
I would like to get back to, for the record if it is okay,
the impact from where you were measuring it at 1,248, in
Oakland, and see where we are today so that we can track that
progress together, because I think that is important.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
On the health disparities report, I agree with you. I think
the work that our national center is doing has identified
significant issues. This, of course, is an example where I
think VA is actually leading, and addressing issues that are
important for all of the American public.
And in health care, we know that disparities are a very
significant issue, particularly in many of our geographies
across the country. I think VA is leading in this area, but we
still have additional work to do. And we are treating this as a
priority issue and looking at the recommendations you have
talked about.
The research that the report recommended I think, is
research on disparities in veterans. VA research has
significant health services research components to it. And the
difference between the health services research in VA and in
HHS, like in the Agency for Healthcare Research and Quality, is
our research is specific to veterans.
And so, we do believe that there are some questions that
are important to ask in order to understand what the most
effective interventions are. But I don't think that is a reason
for us not to be implementing the other recommendations. There
is important work to be done. And we are focused on this now.
Ms. Lee. Mr. Secretary, yes.
Secretary Shulkin. Yes.
Ms. Lee. Let me just comment on that, because I know the
research is very important. But I know, specifically, and when
you look at African-American veterans with PTSD, you have got
other factors that weigh in. And the Office of Minority Health
could let you know what those external socio-determiners----
Secretary Shulkin. Yes.
Ms. Lee [continuing]. Are.
Secretary Shulkin. Yes.
Ms. Lee. It would really weigh in to help come up with
treatment modalities that make more sense right away.
Secretary Shulkin. Yes. I completely agree.
The research that we--research is only good if you act on
it. And there are some things that we already know. And I think
that this is where we are looking at this in terms of
implementing the recommendations that we know need to happen.
And it is a way that, frankly, VA can lead and help the rest of
American health care also implement these interventions.
Ms. Lee. Do you have a working group that----
Secretary Shulkin. We do.
Ms. Lee [continuing]. You put together?
Secretary Shulkin. Yes.
Ms. Lee. I would like to talk to you a little bit more----
Secretary Shulkin. Great. Great.
Ms. Lee [continuing]. On that. Thank you.
Thank you, Secretary----
Secretary Shulkin. And then on the small businesses, on the
minority--I don't know how that data can be essentially
categorized to answer your questions. Let me, please, look into
that and get back to you on that.
[Clerk's note.--The Department of Veterans Affairs was
unable to provide a response to the question, despite having
had 120 days to produce it.]
Ms. Lee. Okay. Thank you.
Thank you, Mr. Chairman.
Mr. Dent. Thank you.
Ms. Lee. Thanks. Good seeing you.
Mr. Dent. I would like to recognize the gentleman from
California, Mr. Valadao, for 5 minutes.
Mr. Valadao. Thank you, Chairman.
BLUE WATER NAVY VETERANS ACT
Thank you, Mr. Secretary.
As I am sure you are aware, in 2002, the VA reinterpreted
the language of the Agent Orange Act of 1991 to apply only to
veterans who actually set foot in the Republic of Vietnam or
served in the inland rivers of Vietnam, or Brown Water
veterans.
Veterans who served on ships, or Blue Water veterans, were
not included, and must prove service connection and exposure to
Agent Orange. However, proven exposure for Blue Water veterans
is nearly impossible due to a lack of record-keeping and
inability to know the precise location of the dioxins--in this
case, Agent Orange--in the air or water runoff.
The VA continues to deny claims for Blue Water Navy
veterans, despite studies showing higher rates of cancer and
non-Hodgkin's lymphoma among shipboard veterans than those who
fought on the ground in the country.
This year I introduced legislation to right this wrong,
H.R. 299, the Blue Water Navy Veterans Act, which currently has
over 270 bipartisan cosponsors, including over half of this
distinguished subcommittee.
While I stand ready to work with my colleagues to pass this
bill, the Department of Veterans Affairs has the power to right
this wrong itself, without the help of Congress.
Have you been made aware of this issue since you have taken
over as Secretary? And to your knowledge, is the VA working
towards a solution on this issue?
Secretary Shulkin. Thank you for that question.
Yes, I have been made aware of this issue. I would say 20
percent of my in-box is on this issue, so I hear from a lot of
people. What I have done is, I have actually sat down and I
have met with some of the leaders in this Blue Water Navy
movement to understand exactly what they believe the science
shows and what they are recommending.
Commander Wells is certainly one of them; John Rossi,
another that I have recently met with in my office. They have
followed up with additional information which I really
appreciated because I am trying to bring myself up to speed on
this. The VA's position on this has been pretty much the
science isn't there.
I am not convinced that is the full story. And so, I have
asked them for additional information and additional
recommendations so that as you said if the Department of
Veterans Affairs has the ability, and I agree with you, to
change some of these, and if the evidence suggests that that is
the right thing to do for veterans, I am going to recommend
that.
So this is very active. I can tell you this week alone I
have been reviewing additional studies. So I will be, you know,
certainly willing to engage in further conversation with you
and I am aware of your legislation.
Mr. Valadao. Thank you. And I do appreciate the fact that
you acknowledge that there is other science out there. Because
there are some studies out there that, especially with the way
they treat the water, clean the water, that actually says it
concentrates the chemicals and makes the situation worse for
those serving.
Secretary Shulkin. Yes.
NEW THERAPIES FOR PTSD
Mr. Valadao. And I appreciate you bringing that up.
Then Mr. Secretary, I also understand that the Air Force is
conducting clinical human trials at Tinker Air Force Base to
investigate transcranial magnetic E-resonance therapy, MERT, on
veterans suffering from PTSD and TBI, traumatic brain injury.
After four weeks of active treatment, compared to the baseline,
the treatment reduced an average PCLM score from 66 to 37.
The Air Force concluded that the preliminary results
suggest that MERT is a promising treatment modality to help
veterans suffering from PTSD. With this information can you
please share with the committee what the VA is doing to
capitalize on this promising new treatment to address PTSD in
the veteran community?
Secretary Shulkin. Well, I am very familiar with the--with
the MERT technology and I am very concerned about finding new
therapies that help our veterans with PTSD, as well as other
conditions related to the brain. We do use--VA has extensive
use already of transcranial magnetic stimulation. The issue is
whether the MERT technology adds additional value to what we
are currently using.
I have recently, in the last 10 days, visited Walter Reed.
I have talked to them about this. We are looking at the
science. I would like to see the results of the Air Force
studies as they are coming on-line because basically if there
is evidence in science suggesting that this is helpful and
effective and especially a non-invasive technology, we
absolutely want to be using it.
Today, I am not aware of evidence that suggests that MERT
adds advantages in terms of scientific advantages, over the
transcranial magnetic stimulation that VA and Walter Reed and
others are using, and I have talked to my DOD colleagues. Now,
with new information coming out of the Air Force, I would be
very open to seeing that.
Mr. Valadao. All right. Well, thank you again.
Thanks, Chairman.
Mr. Dent. Thank you, Mr. Valadao.
At this time I would like to recognize the gentleman from
West Virginia for 5 minutes, Mr. Jenkins.
Mr. Jenkins. Thank you, Mr. Chairman.
Mr. Secretary, thank you also for the opportunity to visit
with you in advance of this meeting to talk about your
leadership and direction, and I applaud your efforts.
ACCESS AND QUALITY WEBSITE
Let me start off with a word of compliment. I learned
yesterday from the discussion with you about your push to
provide transparency, quality data, information about wait-
times, our veterans' satisfaction, patient satisfaction. And
you shared with us the Web site, accesstocare.va.gov.
Secretary Shulkin. Thank you for that plug.
Mr. Jenkins. And you didn't ask for this, but I'll give it
to you.
Secretary Shulkin. Yes.
Mr. Jenkins. But I did look after you made mention of this
and as I understand it from our discussion, this data has been
out there. It has been available, but nobody was willing to
authorize that the switch get flipped to make this available,
and you did that.
Secretary Shulkin. Yes.
Mr. Jenkins. So thank you for doing that and I encourage
people to take a look. Transparency is good.
ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION
I want to make mention of this most recent executive order
relating to some of the whistleblower and the accountability
efforts. I can't tell you the number of times, whether it be a
VA employee or others, about frustration or concern. Maybe very
briefly describe this executive order and what kind of
reassurances to those on the ground, at the grass roots, feel
as though their concerns, their voices are going to be heard
about reforming the system and truly holding it accountable and
holding people accountable for good--the need for good
performance.
Secretary Shulkin. Well I think it is--I think that it is
very important that people understand that we are taking these
issues extremely seriously. That any organization that has been
in trouble has to look towards its own leadership. And so we
want to make sure that the people who are serving in our
leadership positions are consistent and fulfilling the values
that we owe our veterans.
And so when we become aware of issues of poor performance
or people that have strayed from those values, we are taking
action. And I think you can see that there has been a large
number of those actions taken recently. Because of that, the
executive order has asked us to establish an accountability
office that will report directly to me as the Secretary.
As part of that, we are putting our whistleblower office in
that accountability office to make sure that our employees know
that if they raise issues to us, and if they are legitimate
issues, that those employees will be protected. We do not
tolerate retaliation and that is the way we learn and get
better as an organization by addressing issues that are brought
to our attention.
So these two concepts of adhering to our values and
protecting our employees that raise issues are absolutely
essential to our success.
PROVIDER PAYMENTS
Mr. Jenkins. One area I would like you to have staff look
into, we get a number of calls to our office relating to the
payment processes of the VA. You have described an effort to
work collaboratively with academic health centers, local
hospitals that have real connections to the VA, make one plus
one equal three, working together.
One of the challenges that I have heard, really starting
with the restructuring of the payment system of the VA, from
June of 2015 and it continues today.
I have got an academic medical center that really values
and appreciates their good working relationship. The problem is
the VA doesn't pay in a timely fashion. They have got literally
hundreds of thousands of dollars in accounts receivable, from
their standpoint--over 120 days. I have got a local hospital
with over $10 million in accounts receivable from the VA over
120 days past due.
So, I am not sure what is going on in the accounts payment
and claims processing, but I think we have got some real
timeliness issue. And I hope that that will be taken seriously.
Secretary Shulkin. Yes, you have to understand that this is
the world I came from. And I do believe, if you deliver a
service, that you deserve to be paid and you deserve to be paid
timely. It is too hard operating those health care
organizations and not get paid for the work that you are doing.
So I absolutely believe we have to get better at that. And
I am not being defensive about this. We are not doing a good
enough job in that area.
The way that I would suggest that we proceed is, when you
find a community hospital that thinks that they have $10
million that we owe, please let us know, because, when we have
dug into these, we absolutely owe them money. But it is usually
not the $10 million.
There are duplicate claims in there. There are rejected
claims in there that--sometimes they are looking at charges
instead of the fee schedule that we pay them.
But we can work through that. We can put a team on that and
get them the money that they deserve, and get it to them
quickly.
Mr. Jenkins. Thank you.
Thank you, Mr. Chairman.
Mr. Dent. Okay. Mr. Taylor.
Mr. Taylor. Thank you, Mr. Chairman.
And thank you, Mr. Secretary, for being here today.
And look, I--we understand that there is nothing little
about the big challenges that you face in your current
position, so appreciate you for that.
I just have a--and I come from an area that has Hampton VA,
which is the fastest growing--you know, OIF, OEF, women's
veteran population is there. Personally, I am in the VA system
myself, as well, so this is something that I am very passionate
about, and I am looking forward to working with you to figure
out some of these challenges and fix them.
CORRESPONDENCE POLICY
Quick question for you: if--one of us submits a question
for your office, what is the--what is your policy in terms of
the response? How many days?
Secretary Shulkin. Yes, we categorize them into two types
of responses. There are some that need urgent responses, and I
think that we are shooting for that for--I know I am going to
get this wrong, because we just shortened the timeframe to
become more responsive--14 days was our short one. And then--is
it 30 days for our longer one? So he says I got it right.
So if there is something really urgent, we are going to do
it in 14 days; otherwise, 30 days. And I know that that has not
been the past experience from VA to your offices. This is our
new commitment to respond to you in a more reasonable timely
way.
Mr. Taylor. Thank you.
SUICIDE PREVENTION TRAINING
Let me touch on the--I have a bunch of questions, but let
me touch on some of the most urgent ones.
Suicide is obviously something that has just been talked
about, something that is also dear. I have a friend that has,
you know, committed suicide. We have these issues, of course,
in our area.
One of the things that I did submit to your office and
haven't received yet is questioning your--the uniform policy,
because I understand that the VA, according to the I.G., of
course, is--has sort of decentralized, if you will. Is there a
uniform policy, currently, with people who are trained to
intake folks who come up, physically, that either, you know,
exhibit signs of suicide or say that they are--suicide?
And furthermore, is there a uniform policy for the crisis
hotline, which, I understand, is also being manned by call
centers? What is the uniform policy there? And what is the
training that those folks at the call centers get?
Secretary Shulkin. Yes, I have seen some communication. So
are you saying we are over 30 days already?
Mr. Taylor. Yes, Mr. Secretary.
Secretary Shulkin. Okay, well, this is how I learn, so
thank you. My guess is you will be getting a response pretty
soon.
Mr. Taylor. Appreciate it.
Secretary Shulkin. But I am aware of the issue--that there
was concern about a lack of consistency of training between
suicide prevention coordinators that live in our medical
centers and Veterans Crisis Line responders who respond either
from Atlanta or upstate New York.
They are different professionals. Our Veterans Crisis Line
responders are licensed mental health professionals. They
receive much more clinically intensive training. Our suicide
prevention coordinators don't have to be that. They are doing
different functions. Many of them came out of different
disciplines.
And so there are different trainings. But among those two
categories, there should be consistency among Veterans Crisis
Line responders and suicide prevention coordinators.
So we will take a look for your correspondence to make sure
we get you back the response very soon.
Mr. Taylor. I appreciate that, Mr. Secretary.
Also, just one other thing on suicide. Is there any
openness to a potential public-private type things with
qualified nonprofits?
So, for example, when I--when I say that, I--you know,
there are a lot of veterans of course who are not comfortable
with going to the VA or not comfortable with walking up or
calling, but may need help, but may feel more comfortable with
some of the nonprofits out there that--they themselves
typically are manned by a lot of veterans as well, too, have
gotten out and seen this problem firsthand.
Is there any openness to a sort of pilot program
potentially for public-privates to help with that?
Secretary Shulkin. Well, not only an openness. We think it
is absolutely essential. There is no other way to do this. Of
the 20 veterans a day that are taking their life by suicide, 14
of them do not get their care in the VA system. So they are out
in the community. Six are within the VA system.
So if we don't reach out and do the types of partnerships
that you are talking about, and getting everybody involved,
there is no way we can adequately address this. So we have been
outreaching. We are working with Give an Hour, working with the
Cohen Veterans Network, we are working with a lot of our VSOs
on this. We have public service announcements.
If you have groups--there is a new group I just reached out
to called Headstrong, the Galleon Organization. So, if you have
new partnerships you would like us to explore, we are
absolutely open to those.
Mr. Taylor. Thank you, Mr. Secretary.
Can you--I will have follow up, like I said, in the next
round. But, just really quick, you have mentioned earlier that
some of the under--underutilized buildings--I think there are
735--and then how many were vacant, you said?
Secretary Shulkin. 435.
Mr. Taylor. 435. I will hit you on the next round. Thank
you, Mr. Secretary.
Mr. Dent. Thank you.
At this time, I would like to recognize the gentleman from
Ohio, Mr. Ryan, for 5 minutes.
Mr. Ryan. Thank you, Mr. Chairman.
Thank you, Mr. Secretary. Good to see you again.
PATIENT-CENTERED CARE
Appreciate our meeting yesterday. Let me just say publicly,
I think what you are doing in your patient-centered care area
with Tracy Gaudet is some of the most exciting stuff going on,
not just in the VA, but in government today, of really figuring
out quality solutions, integrating care, all the rest.
I just want to say thank you for throwing your weight----
Secretary Shulkin. Thank you.
Mr. Ryan [continuing]. Behind that. I think it is really,
really important, and I think we are going to start seeing a
lot of savings because of that, and healing a lot of vets. So I
want to say thank you right out of the gate.
VETERANS CHOICE PROGRAM
In our conversations that we have had already, I appreciate
the balance that you are trying to strike between the VA
clinics and the Choice Program. And I know that is not always
easy.
One problem area that we have become aware of in my office
is that, despite the Choice Program being authorized and
appropriated, we still have veterans traveling significant
distances to try to get their care. And if a veteran has a
clinic within 40 miles, but the clinic doesn't offer the
services they need, the veteran is being told they are
ineligible for the Choice Program and being referred to the
nearest VA clinic with the services offered.
There appears to be no policy that places a cap on the
distance the veteran would have to travel if they fall into
this loophole.
And in my district, which includes veterans in Warren,
Ohio, traveling 3 to 4 hours to a round-trip weekly, sometimes
more than once a week, to receive treatment in Cleveland. And I
was at my son's little soccer practice and I had a couple of
vets at the same time grab me about this issue.
The primary care physician or primary coordinator of
benefits has independent authority to assign a veteran to
travel an extreme distance with no limit established by the VA.
Or they can refer them in the community of care to a local
doctor, or they can elect to refer them to Choice. However, it
requires a justification that there is an excessive burden on
the veteran.
And you mentioned in your testimony establishing a priority
on transparency. However, I can't find, and my staff can't
find, a readily issued pamphlet, flyer or billboard which would
explain to our veterans what defines a burden that would make
them eligible for Choice in this particular situation.
I have cosponsored legislation with Representative Stefanik
and Dr. Ruiz to correct this issue. So my question to you is:
Do you have the authorities you would need to fix the problem?
And what can we do quickly, instantly to provide more
transparency and enroll our vets in the decisions for their
care? And if we can't fix it immediately, is there a
legislative issue that we need to deal with?
And I guess lastly, and more comprehensively, will the
Choice 2.0 consolidation with Community Care correct this
problem?
Secretary Shulkin. Yes, well, lots of important questions
that you have in that.
So in designing a health care system, I would not
necessarily have picked mileage and wait-time as my criteria
for how to design the system. I understand why Congress did,
and you know frankly, to put a National program up so quickly,
I think it was a very well thought-out effort that Congress
had.
But now that we have had time to experience this, I believe
a health care system should have a clinical basis to the way it
is designed. So it is my intent in working with you to present
an alternative to 40 miles and 30 days; in other words, to
eliminate that and to replace it with something that makes
sense from a veteran's clinical needs.
So, to look at access and clinical quality as the
alternative to geography and wait-time. Under the current
system that we have, which is still having to follow the rules
that were set by Congress, 40 miles and 30 days, we do, as you
correctly said, have the ability to define excessive burden.
What we found, quite frankly, right after I became secretary,
was that we had put out five, sort of, bullet points about
examples of excessive burden.
The field had interpreted that as those were the only
exceptions they could use. We have now clarified that. What we
are trying to do is to get the veteran and their doctor, or
their provider, to have an interaction about what excessive
burden is.
And we have now loosened up the requirements so that the
field can make reasonable judgments about excessive burden.
Because some of the examples, like the ones you are giving,
really aren't acceptable.
Mr. Ryan. Right.
Thank you, Mr. Chairman.
Mr. Dent. At this time, I would like to recognize the
gentleman from Nebraska for 5 minutes, Mr. Fortenberry, vice
chairman of the subcommittee.
Mr. Fortenberry. Thank you, Mr. Chairman.
Secretary, welcome.
Secretary Shulkin. Thank you.
Mr. Fortenberry. Are you enjoying the new job?
Secretary Shulkin. Yes, thank you.
Mr. Fortenberry. Well, apparently you are and I am grateful
for your projection of an attitude of entrepreneurship and
innovation, as well as compassion for this essential mission.
So thank you very much.
Secretary Shulkin. Thank you. I appreciate that.
PUBLIC-PRIVATE PARTNERSHIPS
Mr. Fortenberry. In your opening statement, you also
referenced the new idea that has emerged that has now been
empowered by legislation, of a unique public-private
partnership that is going to happen in Omaha. I want to unpack
that a little bit more for the committee, just so that everyone
understands how potentially transformative this could be.
The community wanted to go on the point--community
leadership came to congressional leadership and said, you know,
we have built housing for veterans; we have built housing for
troops. Could we possibly participate, through some charitable
entity in updating and upgrading the hospital there which is in
serious need of not only a facelift, but serious innovation--
modernization.
So working with my predecessor, Congressman Brad Ashford,
we got the empowering legislation to you. The community has
committed about $30 million to build upon the money that had
been set aside for a new hospital, about over $50 million. And
we are going to move forward.
I think it is exactly the model of what you are talking
about in terms of creating the 21st century architecture for a
modern VA that is looking to community resources when available
to go, not just into looking for charitable funds for donation
purposes, but an integrated service environment as you
referenced earlier.
This new facility will be an add-on to the existing
hospital, ambulatory care facility; be proximate to Creighton
Med School, as well as the University of Nebraska Med School
who you already work with.
So the synergies of their design will become a bit
seamless, or as we say, non--the veteran won't know the
distinction between the type of care that they are getting.
They are just getting the best possible care under VA auspices
using private sector resources, charitable monies that have
gone into the clinic, because that is the objective.
So, I wanted to spend a little time just unpacking that
further, and hopefully, given the very difficult, sad
experiences we have had with watching burgeoning cost overruns,
the Denver hospital being the poster child, that this way of
proceeding forward is undoubtedly going to tap into a large
pool of good will that exists out there in the country among
charitable organization and leadership in various communities,
to want to assist you in modernizing, innovating and creating
the types of partnerships that utilize the best of the private
sector, but always under VA's auspices.
So I am excited by this, and I am sorry to spend so much
time on it, if you want to comment on that.
I also want to mention 50 miles down the road in Lincoln,
we have a traditional, beautiful campus for a VA clinic. A
similar type of dynamic is occurring where a charitable
foundation with the city has agreed to build out veterans'
housing on the site of the old clinic.
We are awaiting the decision as to what is going to happen
with the new clinic. So if you could give us some update on
that process, that would be helpful. But again, once again, the
synergies being created with existing facilities, preserving
traditional, beautiful architecture in proximity to the city's
own private sector medical resources, again is a new opening
dynamic of what I hope is a new chapter of the VA.
RECREATIONAL THERAPY
Third point, right quick. I have become aware and a little
bit involved with a charitable organization called Project
Hero. Your under secretary, Dr. Poonam Alaigh, has given a
memorandum of understanding to your VA directors that they can
partner with this organization using recreational activity,
bicycling primarily, to be integrated into VA's services.
Studies have--there are metrics on this already showing
improved health care outcomes, lower costs, sense of well
being, drops in suicides. The study comes out of Georgetown.
Again, I just wanted to highlight that for you because I think
this is one of those types of programs consistent with what I
said earlier.
It has been developed because of compassion and initiative
by the private sector, looking to partner with the VA. And we
have got a great opportunity here.
PUBLIC-PRIVATE PARTNERSHIP
Secretary Shulkin. Right. Well, thank you.
Just briefly on your three points. The project in Omaha,
Nebraska is exactly what I think we are looking to do in the
VA, which is do things differently. In this case, we are going
to build a new facility. It is going to be good for veterans
and absolutely good for taxpayers.
This is going to leverage the federal dollars in ways that
in the past we wouldn't have been able to do before. And if it
really wasn't for your leadership and support in getting this
through legislatively and the whole way through, it wouldn't be
happening. So I think this is a transformative model.
We have four other sites that you authorized after Omaha,
Nebraska, that we can do. So I am hoping that other committee
members are listening because we have a list of 20 sites that
now are eligible for this. I think this should become the way
that we build a future modern health care system, so thank you
for your leadership again on that.
LINCOLN, NEBRASKA CLINIC
Secondly on Lincoln, absolutely we are moving forward with
a new clinic there. It should be awarded this fall and through
the whole build and design process, even though I pushed really
hard, probably the opening gate is going to be in early 2020.
So it takes a while to do this. But that is well underway and
it is really towards the top of our list.
RECREATIONAL THERAPY
On your third point about Project Hero, you know, one of
the great things about VA is--is that it defines health care
much broader than just physical illness. It defines it as
physical, psychological, social, economic, and an example of
using sports and adaptive sports to help people get better and
have a sense of well being is something that frankly VA taught
me a lot about.
And this is a great example. And so we are very supportive
of this and other work around the country like this, and thank
you for bringing this to our attention.
Mr. Dent. Thank you, Mr. Fortenberry.
At this time, I will move into our second round of
questioning and I will start.
CHOICE PROGRAM FUTURE FUNDING
Dr. Shulkin, in the one-page fiscal year 18 skinny budget
we received in March, there is a VA request for $2.9 billion in
new mandatory funding, presumably to complete the fiscal year
2018 funding for the Choice Program, after the mandatory $10
billion of the program is completely exhausted in January.
Does this indicate the administration's intent to fund the
successor Choice Program with mandatory funding?
Secretary Shulkin. Yes.
Mr. Dent. Okay. Next question.
Being an appropriator, I always try to keep my eye on the
bottom line of new initiatives. I am aware of at least two
proposals. While we certainly support them from a policy
perspective, our budget antennas are on alert.
OTHER-THAN-HONORABLE DISCHARGES
You have announced that you intend to provide emergency
health services to veterans who have other than honorable
discharges. You have also testified in the Senate that you are
interested in expanding caregivers--to veterans from before the
post-9/11 era.
How do you plan to fit these added costs into your budget
when you are obviously already struggling to cover expenses for
your current VA patients?
Secretary Shulkin. Chairman, maybe this doesn't fit into
the budget but basically, I don't care. [Laughter.]
I sat in a session that was organized by members of
Congress, members of the House, where there was a young man who
sat right in the Capitol Rotunda who said that he had been
deployed to Afghanistan six times. And on his return, he found
out that his wife left him. And so he took off across the
country to try to find her. He was declared AWOL and other than
honorable.
You could see he was suffering from severe mental and
emotional disorders. And he went to a VA and he shows up at a
VA and says I am here because I need help, I am suicidal. And
the VA says, I am sorry, you are not a veteran. Well, he had
served our country six times--six tours. That is just not
acceptable.
When we say that there are 20 veterans taking their life
every day, we know it is this group that is among the highest.
No one wants to help them. Well, I am not just going to sit by.
So I don't want more money for this. We are going to find a way
to help these people and then connect them in the community to
resources and get them help because that is the right thing to
do.
So I am going to find the way to do that because I think
this is our----
Mr. Dent. That is a very compelling story and I am glad you
are taking that initiative.
Secretary Shulkin. And I am sorry, Chairman, what was the--
what was your other question?
Mr. Dent. Caregivers.
CAREGIVERS PROGRAM
Secretary Shulkin. Caregivers. Yes. So--so the Caregivers
Program is really, really important. We were authorized to be
able to do that for post-9/11 veterans and there have been
tremendous successes. But we frankly didn't get this program
right. We have been issuing in some areas up to 90 percent
revocations of caregivers that we had authorized. Something is
wrong there.
So we just issued a national suspension of revoking
caregiver status and we are now in a pause where we are going
to look at what are the right policies in order for veterans to
get access to caregivers. It is our intent to be able to bring
this to pre-9/11 caregivers because frankly, the most
vulnerable group right now are elderly veterans.
And the worst situation is when somebody is in their home
and they have to leave their home to go to an institution--a
nursing home. Because, one, most veterans don't want that; most
people don't want that. And secondly, it is the most expensive
way to care for elderly people.
If we can keep them in their home with caregivers, we
should be doing that. So we are looking at how do we use the
current money and potentially come up with even better policy
than what we have today. And we are going to be announcing that
in probably the next couple months.
Mr. Dent. Thank you.
SCHEDULING SYSTEM
The VA's antiquated scheduling system has been a particular
concern to you, I know. We understand you are on a dual-track
to modernize it, piloting a commercial system MASS, as well as
upgrading your existing system. I guess you call it VSE.
It seems like these efforts might lack a unified strategy.
Why are you interested in investing in two systems
simultaneously? And will the scheduling system be further
tinkered with in the electronic record overhaul?
Secretary Shulkin. Yes. On the surface, I agree with you.
This makes no sense at all. Why would you invest in two
different paths. We awarded a commercial off-the-shelf product
called MASS. That is the system that we think meets our
solutions and that is the one that we are implementing. We are
working right now on a pilot site to be able to create the
interfaces so that we can do that.
The rollout of that across a system as big as ours is going
to take several years. In the meantime, we had developed an
internal system, one of the, frankly, last I hope that we ever
develop, but this one is developed already with taxpayer
dollars. And we did an evaluation in the month of February. We
have rolled it out to eight sites. It is actually working. It
is much better than what we have right now.
So as an intermediate stop-gap measure, we are rolling it
out across the country because it has already been developed,
and it will help in that intermediate period of time until we
can get a commercial off-the-shelf system up.
Mr. Dent. Thank you, Secretary Shulkin.
At this time, I would like to recognize the ranking member
for 5 minutes in a second round.
MILITARY SEXUAL TRAUMA
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
I want to focus on military quality of life, because at
that hearing that we had in March when we had an opportunity to
meet with the senior commissioned officers, we discussed the
Marines United scandal, which we discussed in my office
yesterday.
Many of the victims of that really horrific social media
site are now veterans. And I have met with a number of them, as
have many of the women members. And I would like to know what
the VA is doing to provide them with the necessary care and
support they need, because these are women who have had, you
know, without their permission nude photos of themselves
posted. They have been subject to extreme humiliation.
With regard to the military sexual trauma system that the
VA has, how have you let veterans know that this service is
available and what outreach have you had?
Secretary Shulkin. The VA has an extensive system for
treating military sexual trauma. We actually have worked with
the Department of Defense so that the VA is a place where
people can go confidentially and get treatment. Women or men
who have suffered military sexual trauma can come into any of
our Vet Centers and there will not be a connection of their
medical record back to the Department of Defense.
Ms. Wasserman Schultz. Mr. Secretary, and I appreciate
that, but specifically what kinds of outreach are you doing to
not only make sure that victims of sexual assault in the
military are aware of those services, but also specifically the
victims of the Marines United scandal?
Secretary Shulkin. When we met in your office, you actually
suggested that that is something we should be doing. I don't
believe that we have done that. I agree with you it is
something we should be doing. And so as a result of our
conversation, we are putting together a plan for that specific
outreach. So thank you for that suggestion.
Ms. Wasserman Schultz. Okay. No, you are welcome. I mean,
we have female veterans that are committing suicide at a rate
of six times that of women civilians. And, you know,
identifying ways and implementing strategies to address the
unique mental health needs of women is critically important.
And so I would appreciate it if you and your staff would follow
up with us on that.
Secretary Shulkin. Yes.
[The information follows:]
VA is committed to assisting the individuals affected by
the Marines United issue to the fullest extent possible.
Since becoming aware of this situation, staff in VA's
national MST Support Team has reached out to colleagues in DoD
Sexual Assault Prevention and Response Office, leadership in
the Services' Sexual Assault Prevention and Response programs,
and DoD Health Affairs to remind them of the availability of
MST-related services through VA.
VA's current MST treatment authority (provided by
Sec. 1720D of Title 38, United States Code) requires that
sexual assault and sexual harassment experiences occurred while
a Veteran or Servicemember was on active duty, active duty for
training, or inactive duty training. As such, VA has concerns
that the authority may not cover care for all individuals
affected by this issue--for example, those incidents of
harassment occurring after an individual has left the military.
VA will continue to explore what is possible to provide under
its current authority, in order to extend support to as many
affected individuals as possible.
SENATE-CONFIRMED POSITION VACANCIES
Ms. Wasserman Schultz. The other question that I wanted to
touch base on is what I mentioned in my opening remarks. And
that is the--the openings--the really significant and serious
openings that you have in all of your Senate-confirmed
positions. And you mentioned that you were going to be making
an adjustment in how you fill those positions.
But I am actually wondering, one, if there are any problems
that the Administration is facing in identifying candidates for
those positions. Are you having trouble filling them? And in
particular, I find it extremely troubling that the Under
Secretary of Health, the Assistant Secretary for Information
and Technology, given the very serious problems we have talked
about here today, and the Chairman of the Board of Veterans
Appeals, are all positions that remain empty.
What is the timeline for filling those? And do you have
candidates that you are considering? And are you having trouble
filling them?
Secretary Shulkin. Well, I appreciate your concern about
that. I am very impatient, and of course, I want my team in
place. We have obviously very good career, acting professionals
that are handling these right now, but I want permanent people
in place. The Under Secretary for Health and the Under
Secretary for Benefits--I am not sure if you are aware--it is
mandated that we form commissions to actually search for those
positions.
The Under Secretary for Benefits Commission met
approximately 10 days ago to go through candidates and are
recommending several of them for me to see, and then me to
recommend to the President. And the Under Secretary for Health
Commission, I just saw the committee members appointed this
morning. That will be going forward in the next probably two
weeks as well.
For CIO, I have met a number of candidates. We are vetting
them right now, trying to move forward with an offer. And at
the Board of Veteran Appeals, we are also trying to vet a
candidate also.
So, I hope that, you know, these processes, having gone
through it myself, my own vetting process, 13 months, it takes
too long. And we are looking to move through this as soon as we
possibly can.
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
I will have one in the third round. So I appreciate it.
Yield back.
Mr. Dent. Thank you.
At this time, I would like to recognize the gentleman from
Florida, Mr. Rooney, for 5 minutes.
Mr. Rooney. Thank you.
CHOICE PROVIDER PAYMENTS
And Mr. Secretary, I just want to say that your office I
guess is watching this hearing and has already gotten with my
office regarding some of the issues that we are discussing with
our constituents. And I want to give a shout-out to Mary Kay in
Lake City. And if you are still watching, Mary Kay, I have
another issue for you to work on.
That is with regard to--a lot of my district is very rural.
And, you know, I do have some of the coast, but a lot of the
people that live in the district live in the countryside. And
one of the issues they complain was with the Choice Program is
that that is long wait-times. They are receiving complaints
about long wait-times for VA appointments, referrals, payments
through the Choice Program.
And the payment and reimbursement process to the providers
is difficult, probably exacerbated because it is rural. So we,
you know, obviously, in that situation, you have smaller
hospitals and clinics. And many of the providers that are
technically participating in the Choice Program are refusing to
accept Choice patients because they know that they will have to
wait a long time to get paid themselves.
So some providers that don't accept the Choice patients
will only do so if the veteran agrees to pay for the services
up front, and that leaves the veterans in that same bind they
were in before Choice, which was either face the excessive
wait-times at the VA facility with no option to obtain
immediate care elsewhere without paying out of pocket first.
And obviously, that is not the point, or that is not what we
are looking to do.
So, I mean, you as a doctor can probably appreciate, you
know, what these people that want to take the Choice Program to
help veterans, but they know that it is going to take forever
to get reimbursed. It would be like, ``hey, will you pay me
first, and then, you know, we will deal with getting reimbursed
later.'' I don't know if that is the rationale, but it sounds
like that.
The OIG has criticized the VA's monitoring oversight for
these contracts and reported that these contracts still don't
have performance measures to ensure the contractors pay their
providers in a timely manner. And the OIG made this
recommendation January 30th of this year.
So as you work to expand the Choice Program, how are you
implementing the OIG's recommendations specifically with regard
to timely reimbursements?
Secretary Shulkin. Well, there is no doubt that this is an
area of significant risk for us; that monitoring and making
sure that the providers are paid is critical because of the
issues that you are saying. The veterans are being put in the
middle. I would not recommend that veterans put out money for
this. That, as you said, is not the point of it.
What we have done is we have done multiple contract
modifications. We have actually advanced money to the third-
party administrators. I have suspended the requirement that
providers have to provide their medical records to us in order
to get paid.
We are improving our payment cycles through the Choice
program, but it is not perfect by any means. We have to get
better at our auditing of these processes. And those were the
I.G. recommendations, and we are working on doing that. So this
is a significant area of risk for us.
In the reauthorization, or the redesign, of the Choice
program, what we are calling Choice 2.0, we want to eliminate
the complexity of this process. The private sector does not
have to do the type of adjudication of claims that we do. They
do auto-adjudication. They do electronic claims payments.
We just are not able to, under this legislation, do all the
things that, frankly, we know are best practices. That is what
we want to get right in Choice 2.0.
Mr. Dent. Thank you.
At this time, I would like to recognize the gentleman from
Ohio, Mr. Ryan, for 5 minutes.
Mr. Ryan. Thank you, Mr. Chairman. It is nice of all you
Pennsylvania guys to let an Ohio guy participate in this
hearing. I appreciate that.
Mr. Dent. We beat Ohio State last year, that is why.
Mr. Ryan. Blind squirrel finds a nut every now and again,
Mr. Chairman. [Laughter.]
CHOICE AND COMPLEMENTARY MEDICINE
Mr. Secretary, a couple of quick questions, one with regard
to the Choice Program again.
There are a lot of people who want to--and we have seen
it--I have seen it in the last few years at the D.C. VA and
other VAs, where you have Centers of Excellence, where there
are all these complementary services that are being provided
that are having--showing significant success in reducing pain,
managing pain, reducing opiates, which is a huge thing for us
to be able to do, providing these alternative approaches.
And I just want to make sure, as we are moving to try to
better administer the Choice Program, that these evidence-based
programs are covered in the Choice program so that they can
access, whether it is acupuncture or mindfulness-based stress
reduction. I have seen programs like Project Welcome Home
Troops, where they do a lot of breathing exercises with these
veterans that are having transformative effects with their
post-traumatic stress. Transcendental meditation is another one
that they use.
There are a lot of videos online you can watch where these
vets that are on 10 or 12 prescription drugs, after going
through some of these therapies that aren't traditional, I
guess you would say, going down to two or three meds, which is
a huge savings for us.
And you are actually giving these vets the tools they need
to be able to go out into the world and function and get a job
and be productive members of our society. So I want to make
sure, as we move with the Choice Program, that these--again,
evidence-based programs are covered by the Choice Program.
Secretary Shulkin. Yes. Those types of services and
providers are part of the Choice Program. We are expanding the
network so that we have more access to those types of
providers.
Mr. Ryan. Great. I think that is going to be a big thing,
not just for the vets, but out in society as well.
APPEALS MODERNIZATION
The other issue is we are talking about dealing with the
appeals process. And we had this conversation, again,
yesterday. But the legislation currently is not going to affect
the hundreds of thousands, almost 500,000 people who are
already caught up in the stagnant appeals process.
So I say this not to you, because I have already said it to
you, but to members of the committee and to the public. I think
it is important for us to figure out how we can help you start
to reduce this backlog. How do we get more appeals judges,
maybe out of retirement, to get into this program?
Congressman Womack and I are already working on some
legislation to be able to do that. And so, if your department
can provide us with the necessary metrics that we would need to
figure out how many, you know, retired appeals judges from the
Board of Appeals do we need to get back in the system, even on
a part-time basis, to start getting through this backlog, and
so if you could make sure----
Secretary Shulkin. Yep. Yep.
Mr. Ryan [continuing]. You get us that information.
Secretary Shulkin. I appreciate that suggestion. At 470,000
backlog claims right now, so even after legislation was passed
and we fix the process going forward, we still have that
backlog.
I appreciate your offer to work with us and see if there is
a way to help with that. And we have already worked up some
numbers we would be glad to share with you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Ryan. Great.
Secretary Shulkin. Congressman Womack.
Mr. Ryan. Great.
Mr. Chairman, I think that is an important step for us, to
try to dig into this 470,000 number. Is with the appeals that,
some of them, are 30 years in the making. And for every
additional piece of evidence or paperwork that they add, it
just slows up the process.
And we--I think we have got to make a concerted effort.
Congressman Womack--I won't steal his term, but--was talking
about a surge for judges to help dig through this.
So thank you, again, Mr. Secretary, for all your
leadership. We appreciate it.
Thank you, Mr. Chairman.
Secretary Shulkin. Thank you.
Mr. Dent. Mr. Taylor from Virginia is recognized for 5
minutes.
FRAUD, WASTE, AND ABUSE
Mr. Taylor. Now I know that you are looking for
efficiencies, and waste, fraud and abuse, and all those things.
And I would like to just briefly touch on that.
And I--but I--first, I want to applaud you for taking the
stand and helping veterans that may have been dishonorably
discharged, and some of that, because of effects and stresses
that they had on their own personal lives and everything from
war, quite frankly.
That being said, even in our own VA, when we walk through
it, and we we noticed and asked questions, and certainly saw
that there were folks that were being treated there that may
not be eligible via the system currently. So in a couple areas
of Hampton, and it is in my letter to your office, as well,
too--or e-mail, I think it is.
It talks about how there are a couple of areas there where
we--you have these veterans that are honorable, veterans--no
issue. But, you know, when they need a knee replacement or
something like that that is not service-connected, that they
are not eligible for, that they may be getting treatment there
in the VA.
That is a huge cost, with zero reimbursements, potentially,
from Medicare, Medicaid or their private insurer, whatever that
might be. So one of the things that we sent in there--and I
don't know if you--there is an active study for it now--is, if
you exacerbate that across the whole VA system, that is
significant dollars.
And veterans, either knowingly or not knowingly, because
this is not a politically popular thing to say--but I am a
veteran and I don't care--if you know you are not supposed to
be treated there, then you don't get treated there, because you
are taking away from other veterans that should be treated.
That being said, we want to take care of people as much as
possible. But I am fearful that, in the political climate, that
maybe the VA is seeing folks that aren't supposed to be there,
that should be using their own private insurer, or whatever
they are on, insurance-wise.
So have there been any studies that are looking into that
to figure out what is it that is costing the VA across the
whole system?
Secretary Shulkin. Yes. We absolutely have looked at this.
As you know, there are--veterans are classified into eight
priority groups. The first three, generally, are service
connected. The next three, so four through six, are generally
income related, low income. So, when you start getting to seven
and eights, those are people that fall outside of that, and
currently that is frozen.
So not all veterans, as you are saying, are eligible for
care in the VA system and so we are focusing on those that are
service connected and lower income. So--and I think that is a--
--
Mr. Taylor. If I may?
Secretary Shulkin. Yes.
Mr. Taylor. Has there been any review, if you will, where
that may not be the case? I know that we are focused on the
folks that are supposed to be in the system--that is supposed--
that need care and everything like that. But has there been a
review across the whole spectrum to figure out, in fact, if
they are--I am not trying to say it is fraud necessarily,
maybe, but in some instances it may not be. They just may not
know otherwise. But have we had a report across the system to
figure out those inefficiencies and what those costs are for
the VA.?
Secretary Shulkin. Yes. We know exactly how many people are
in each of these priority groups.
Mr. Taylor. Not the priority groups. I am sorry. I didn't
mean to interrupt.
Secretary Shulkin. Yes.
Mr. Taylor. Not the priority groups, but I mean folks that
aren't supposed to be getting care that are getting treated.
Secretary Shulkin. Well, I am not aware of any veterans
that are getting care there that shouldn't be. If they are,
then we have to address that and stop that, because we do
check, except in emergency care, you know, eligibility criteria
when people come in. And if they are not eligible for care, we
generally are telling them that.
Now, you know, maybe you are aware of some situations and I
would really like to understand that better, because I think
you are correct in your assumption that our care needs to be
focused on those that are eligible for care, particularly when
we have access issues. So I would be glad to talk to you more
about that.
[The information follows:]
Hampton VA Medical Center (HAMVAMC)
VSSC Enrollment and User Data, FY2016 Non-Veteran/Humanitarian
Patients = 1,095
Urgent/Emergency Care: HAMVAMC is compliant with the Emergency
Medical Treatment and Labor Act (EMTALA) and accompanying federal
regulations. EMTALA requires hospitals with dedicated emergency
departments (ED) to provide a medical screening examination to any
individual who comes to the ED and requests such an examination, and
prohibits hospitals with EDs from refusing to examine or treat
individuals with an emergency medical condition. HAMVAMC ED will
provide necessary stabilizing treatment for emergency medical
conditions within the hospital's capability and capacity. Stabilized
patients who require additional care and are not eligible for Veterans
Health (VHA) enrollment are appropriately transferred to a community-
based hospital/provider.
Some patients who are pending VHA enrollment determination may
continue to receive VHA care until eligibility is adjudicated by the
VHA/Health Eligibility Center (HEC). If a patient is later determined
to be ineligible for VHA enrollment, VHA/HEC grants the patient a 60-
day waiver period in order for the patient to provide additional
evidence or documentation to support eligible-Veteran status. After 60-
days and no supporting evidence, the patient will be appropriately and
safely transitioned from VHA care to the community.
I do want to just mention two things. First of all, our
policy is for emergency mental health care for other than
honorable, not dishonorably discharged. Dishonorably discharged
we are not----
Mr. Taylor. Sorry if I misspoke.
Secretary Shulkin. Yes. Yes. Okay.
Mr. Taylor. But I do applaud you for--I know that there are
a lot of wounds that are mental of course and----
Secretary Shulkin. Absolutely.
Mr. Taylor. And I get that. I applaud you for those
efforts.
Secretary Shulkin. And the other thing I just want to
mention is that your letter of March 29th, we did respond by
April 6th. We actually made it in 14 days. There is additional
information that your office wants on the protocols on the
Veterans Crisis Line so we are providing that to you and
certainly want to get you that detail.
Mr. Taylor. Thank you. I appreciate it.
Mr. Dent. Thank you, Mr. Taylor.
At this time I guess we will move into a third round of
questioning for those who remain. So with that, I thought I
would just quickly touch on a couple of issues.
OPIOID ABUSE PREVENTION
First, Mr. Secretary, as you know we included $50 million
in the omnibus appropriations bill that is going to be
considered on the floor, I guess right now, for VA opioid abuse
prevention and treatment efforts. We realize that the VA has
really come a long way in opioid management efforts since the
horror stories at Tomah, Wisconsin and the Candy Land doctor
situation.
What are the most effective approaches the VA has
identified to keep severely injured veterans away from opioid
dependency? And how are you channeling your funding to achieve
those goals?
Secretary Shulkin. Yes. Well first of all, thank you for
that additional support. I can tell you it is money well spent.
We have seen a 32 percent reduction of opioid use in the VA
since 2010, but we have a lot more work to do. So this is
really a good investment.
I would say, very briefly, that the VA approach to this,
and we are leading American medicine in this--I just published
an article on this--is a multifaceted approach. One is veterans
need to sign an informed consent when they go on opioids.
Secondly, we actually monitor the profile of doctors so
they can compare themselves to how other doctors are
prescribing.
Third, we mandate participation in the State prescription
data monitoring programs.
Fourth, we do academic detailing where experts go out and
actually educate our clinicians on this.
And fifth, we are suggesting strong alternatives to opioids
and providing those like complementary or integrated medicine
in our facilities.
DISABILITY CLAIMS BACKLOG
Mr. Dent. I would also like to ask you, too, on--this
relates to disability claims backlog management issue. We were
pleased to learn last year that the VA had reached an effective
zero on the size of the disability claims backlog. And I know
some claims are always going to exceed the target deadline
because the VA is waiting for the veteran to produce some
additional information. But you have brought that number down,
I guess, from its peak of 611,200 in 2013.
But we understand that the backlog is creeping back up
because of your shift in workload priority from initial claims
to appeal cases. We know that the burgeoning appeals caseload
needs to be tackled, but this highlights the management dilemma
you face. And I think Congressman Ryan touched on that a bit.
What is your long-term plan to bring a balance between
activity on initial claims and appeals workloads?
Secretary Shulkin. Well, I don't think we are where we want
to be on this. So we have to make continued progress. We are at
100,000 disability claims over 125 days and that needs to come
down significantly. We are doing a number of changes to our
processes. One is called decision-ready claims. That will allow
a veteran to seek a much quicker resolution to their disability
claims and give them a choice when they have all their
information available to be able to do that.
We are still advancing our technologies, moving towards a
paperless system. We have 10 sites now that are completely
paperless. That moves everything through faster. We are looking
at a number of other alternatives to do that.
So we do have plans to get this down and we are not seeking
additional funds to do that. We see it through process
improvements.
Mr. Dent. Thank you.
OFFICE OF AMERICAN INNOVATION
And finally, Jared Kushner's White House Office of American
Innovation has apparently chosen the VA as its first target to
reshape federal bureaucracy by making it leaner and more
effective. Has his office fanned out staff at the VA to analyze
its operations and make suggestions at this point?
Secretary Shulkin. Yes. We are in close contact with Mr.
Kushner's office. They have been extraordinarily generous with
their time. And what they have really been doing is trying to
bring industry partners and industry best practices in to help
the VA. So I don't think that they are staffed to come in and
do their own assessments, nor do I think that is their intent.
It is more to identify solutions that already exist in the
private sector and bring them in and modernize our system.
Mr. Dent. Well, thank you for sharing that.
AGENCY REFORM PLANS
All federal agencies have received an executive order to
reorganize their departments by September, in line with their
fiscal year 2018 budget cost-cutting proposals. Your acting
deputy has said that the VA would like to get started sooner
than that.
What changes do you expect in the way VA is organized and
how it operates before the end of the year?
Secretary Shulkin. Well, we are underway with this right
now. I think, although I don't know all the specific solutions,
because we are still working on it. I think what you should
expect is that we are looking to have a smaller central office
function, more streamlined. We are looking to move towards more
shared services rather than siloed services in each of our
administrations.
And we are actually looking across federal agencies to see
other things that maybe other agencies are doing better that
they should be doing for us or vice versa, whether VA should be
taking on some of the functions that other agencies are doing.
We are working with other secretaries on that.
Mr. Dent. Thank you, Secretary. That completes my
questioning.
And at this time, I will recognize the ranking member for 5
minutes.
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
VETERANS CRISIS LINE
I wanted to just ask you about the Veterans Crisis Line,
because when we went to the D.C. VA hospital, we had a rather
confusing conversation with their personnel that made it
evident that there were a number of serious issues with the
decentralized nature of the Veterans Crisis Lines--there being
a National hotline, as well as a hotline at each hospital.
And so the I.G.'s report that came out highlighted how
significant the concerns are. And within days of the I.G.'s
report, the VA said that the issue had been fixed.
Can you explain how fixed it is and what does that mean?
And what you are doing to ensure that our veterans are
absolutely able when they are in crisis because of the risk of
suicide being so high, are able to get the services that they
need.
Secretary Shulkin. I apologize for the confusion. There is
only one centralized Veterans Crisis Line. Each of the medical
centers do not have decentralized crisis lines.
What the I.G. was referring to was the fact that when the
VA responders on the Veterans Crisis Line receive more calls
than they could handle, they went to backup centers that were
located around the country. Those backup centers are certified
SAMHSA backup centers, so they are trained responders as well,
but they are not VA responders.
We did not think that was satisfactory. So several months
ago, we went out--we hired over 200 new responders, had to get
them trained. They came online in the early part of 2017. We
opened up a second center in Atlanta, Georgia.
And now because of these new responders and the second
center that is online, we are able to handle the calls that are
coming in. We have less than a 1 percent backup center rollover
rate at this point. That is why we came out and said that we
fixed that problem.
We have many days where we have zero rollover calls.
Probably in the last 2 months, we average, you know, less than
10 rollover calls on a given day. We are responding to over
2,000 calls a day to veterans in crisis. We typically will send
out 60 to 65 emergency responses to save veterans' lives.
Ms. Wasserman Schultz. When we were at the VA hospital
here, they described a system that was one that was based with
their personnel, and one that kicked to the National system
when it was after hours.
Secretary Shulkin. Well, every--every VA has a mental
health service. We have same-day services available. So if a
veteran calls and is in crisis, they will be seen that day or
their issue will be dealt with that day. So that does happen.
Every one of our medical centers has a suicide prevention
coordinator. Many of them more than one. That is there to deal
specifically with the follow-up issues and to address people in
crisis on that day. But there is only one National veteran
crisis line, and that is run out of two locations in upstate
New York and one in Atlanta.
Ms. Wasserman Schultz. Do they all receive the same
training?
Secretary Shulkin. They all--well, as I was explaining to
the congressman, the Veterans Crisis Line responders all
receive the same training because they are licensed health care
professionals. And the suicide prevention coordinators all
receive the same training, but different training than the
Veterans Crisis Line responders because they are not all
credentialed or licensed mental health professionals.
OFFICE OF AMERICAN INNOVATION
Ms. Wasserman Schultz. Okay. And then you mentioned the
reorganization and Jared Kushner's office's goals. Are those
goals aligned with yours? Are you waiting for Mr. Kushner's
reorganization recommendations before you begin hiring?
Secretary Shulkin. No, no. Again, the American Innovation
Office is not intended to come in and do assessments and give
recommendations. That is the executive order has asked the
department to do that. So that is what we are doing. Mr.
Kushner's office is helping us in identifying industry best
practices and strategic partners that can help us advance these
modernization goals.
DISABILITY CLAIMS AND APPEALS BACKLOG
Ms. Wasserman Schultz. Okay. And then just as I run out of
time, on the Board of Veterans Appeals and the backlog and the
issue of the disability assessment backlogs as well, are you
aware of online electronic technology that exists that
previously had contracts with the VA that no longer do? And
that could significantly address some of this backlog?
Secretary Shulkin. No.
Ms. Wasserman Schultz. Okay. I would like to follow up with
your office so that you can be aware of this technology. And
while I have no preference for any particular contractors, the
timeline and story that I have heard about the process that
they have gone through leaves me frustrated that we have a
massive backlog and a potential avenue to help address it, but
no way in for a contractor like them to actually be a part of
it.
Secretary Shulkin. No--thank you, I would like to hear
about that.
Ms. Wasserman Schultz. Thank you.
I yield back.
Mr. Dent. At this time, I would like to recognize the
gentleman from Virginia, Mr. Taylor.
Mr. Taylor. Thank you, Mr. Chairman.
I just wanted to say before I give my question, you are
correct. We had the letter. I have it right here, so maybe I
misspoke in terms of, you know, getting the answers. You know,
yes, you responded. So the office responded.
Secretary Shulkin. Right. I am just glad we responded.
Mr. Taylor. Sure. Thanks. I look forward to working with
you on this.
FUTURE DEMAND ON VA
Continuing with the budget and, like I said, I understand
that you are looking for efficiencies. And you mentioned
earlier about 32 percent of the care being outside the walls of
the VA, which is a 62 percent increase in 2 years. Right?
So, what is your office doing in terms of looking at inside
and figuring out, yes, if we are looking at, and you are asking
for the monies for Choice and to fully fund that in the
mandatory--in the budget, that trajectory is pretty high.
Right?
So what are we looking internally in terms of reducing the
budget internally, if the care is being seen there? Are you
just seeing complete demand exploding?
Secretary Shulkin. Yes. I think the reason why we got into
the crisis in 2014 is because we were not being honest about
what the real demand is. And once we opened up both internal
access and community access, we started to see what the real
demand is.
So I think that we are reaching I believe--hope to be
reaching a steady state where we are not going to see continued
growth in the way that we have in the past, but that we are
meeting the health care needs of our veterans and honoring our
commitment.
Mr. Taylor. Okay. Thank you.
VACANT AND UNDER UTILIZED BUILDINGS
And the--back to the 735 under-utilized--do you have a
rough idea what the cost is that you guys are spending that you
don't need two per year on that.
Secretary Shulkin. Yes, and in fact I have a chart that I
gave to each of you, showing you where these are.
But the cost of the 435 buildings right now that are vacant
is $6.7 million a year. Our total cost is approximately $25
million a year for all these buildings.
SUICIDE PREVENTION TRAINING
Mr. Taylor. All right, thank you. And then, jumping back--
and I appreciate that, thank you. Jumping back to the suicide--
and you mentioned the two different folks that are trained----
Secretary Shulkin. Yes.
Mr. Taylor [continuing]. On suicide. So it is my
understanding that--like Hampton, for example--Hampton VA,
there is a call center that mans the suicide prevention
hotline--or the suicide hotline, is that correct?
Secretary Shulkin. No. No, the suicide hotline is a
National hotline. The--you know, during business hours, the
Hampton VA would be there to assist veterans in crisis.
The National hotline is run out of our upstate New York
office. And now, in Atlanta, they have a second office.
Mr. Taylor. So I was in a contractor's office as well, too.
And they said that they were the call center for the Hampton
VA.
Secretary Shulkin. Well, I am sorry. The--the VAs or--and,
in some cases, the VISNs run a call center. They do not run the
crisis line.
They run regular calls that come in and want to be, you
know, ask for appointments or get to certain places through a
telephone operator. We do run call centers across the country.
But they are--it is not--we only have one 800 number for
our Veterans Crisis Line, and that is run out of upstate New
York and in Atlanta.
Mr. Taylor. So that--the Veterans--I am just trying to
understand.
Secretary Shulkin. Yes.
Mr. Taylor. So the Veterans Crisis Line--and then--but if I
call the Hampton number, say I am suicidal--
Secretary Shulkin. Right. It will say, ``dial 7''. Right,
the Hampton VA call center, what it will say is, ``welcome,''
and, ``if you are having issues related to suicidal
ideation''--they use better words than that--``please dial 7.
You will automatically be connected to our National Veterans
Crisis Line.''
Mr. Taylor. Okay, thank you.
And I have no further questions. I look forward to working
with you. Thanks for your time.
Secretary Shulkin. Thanks.
Ms. Wasserman Schultz. Mr. Chairman.
Mr. Dent. Sure.
Ms. Wasserman Schultz. I thank you. Just I really think
that, if we are having a hard time understanding how the
Veterans Crisis Line works, then imagine how veterans must
feel. I don't think it is clear how it works and what happens
from beginning to end, every hour of every day.
I think--I am glad that you have an additional, you know,
service center that has your employees staffing it. But I don't
understand the difference between who handles suicide--suicide
calls on the Veterans Crisis Line and other mental health
calls. I don't understand how it works when you are outside of
business hours.
I am confident that there are different crisis lines that
are at local VA hospitals, because we were told that they had
people working at the D.C. veterans' hospital that handled
that, and that it only went to the Veterans Crisis Line when
they weren't open. So if you could provide, later, greater
clarity, that would be helpful.
Secretary Shulkin. What--this wouldn't be the first time
that I have learned information that, then, I would agree with
you. I would be confused, too.
I think I have an understanding that is clear. But, please,
let's make sure that it is the correct understanding. And I do
want this to be clear. There should be no doubt how a veteran
gets help when they are in crisis.
And obviously, if we are not communicating that well
enough, or if there is a system that I don't understand, I
appreciate you raising that, and I will get back to you on
this.
Ms. Wasserman Schultz. Thank you. Especially because we----
Secretary Shulkin. Yes.
Ms. Wasserman Schultz [continuing]. Have lives at stake.
Secretary Shulkin. Of course.
Ms. Wasserman Schultz. Thank you very much.
Mr. Dent. Thank the ranking member.
At this time, I would like to recognize Mr. Fortenberry for
5 minutes.
VACANT AND UNDERUTILIZED BUILDINGS
Mr. Fortenberry. Thank you, Mr. Chair. And thank you again,
Mr. Secretary, for listening to me earlier and, of course,
embracing the transformative ideas--what I believe to--and you
believe to be are transformative ideas that are kicking off in
Omaha.
And in this regard, as well--Congressman Taylor actually
touched on the question, and others have, as well--but back to
the idea of excess inventory. For instance, the Air Force is
going to come here shortly and tell us they carry 30 percent
excess inventory.
And while yours is, in terms of cost impact, much, much
lower, nonetheless, that is not a good use of dollars. Now, we
throw around the word BRAC. I highly suggest that you do not
use that term.
But what we can do is work with you, I think,
constructively--maybe you already have this option in law--to,
for instance, sell excess buildings to the community
surrounding you. Look at the types of services which the
military is starting to do--now, this is a little more
applicable to bases, but nonetheless, it might apply to you--
that can be contracted over--given over to local communities.
That includes like, landscape maintenance for military
bases, firefighting, some security as well. These are the types
of ideas that go toward the possibility of not pulling forward
things that are no longer applicable in an innovative VA
without running into the difficulties of impacting communities
adversely when you close something.
So don't ever use the word BRAC, because it brings up a lot
of bad memories. And it--you automatically set yourself up for
controversy.
I have suggested to the military that we call it MISC,
acronym for miscellaneous--Military Installation Savings
Commission. Maybe you can work on some word--acronym like that.
But it is a, again, I think it is very consistent with what
you are trying to do in terms of updating the VA.----
Secretary Shulkin. Yes.
Mr. Fortenberry [continuing]. Getting the best value for
the dollar, ensuring that old ways of thinking are transformed
into new ways to care for veterans. And while we are pulling
forward excess inventory, that just doesn't make any sense for
what you are trying to do.
So those are just some final thoughts I had. I know you
have covered that, when I was out of the room, more
extensively. So I wanted to leave you with that.
The other issue is I think you are going to forward to us a
working list of possible changes, one of which you brought up
the other day. You are in a catch-22 regarding not being able
to study things that we have actually mandated----
Secretary Shulkin. Right.
Mr. Fortenberry [continuing]. You to study because we have
mandated you can't study things.
Secretary Shulkin. Right.
Mr. Fortenberry. Ideas like that, even though they might be
small--again, back to the transformative theme, we look forward
to receiving those.
Secretary Shulkin. Yes. Thank you.
Mr. Fortenberry. Thank you, Mr. Chair.
Mr. Dent. Seeing no further questions, I would like to
thank everybody for their participation. Thank you, Dr.
Shulkin.
Again, I can see why you were confirmed unanimously.
Congratulations, again.
And this hearing stands adjourned. Any further subcommittee
hearings will occur after the President's budget submission in
late May.
Secretary Shulkin. Thank you.
Mr. Dent. Meeting is adjourned.
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Wednesday, March 22, 2017.
OVERSIGHT HEARING ON THE DEPARTMENT OF VETERANS AFFAIRS OFFICE OF
INSPECTOR GENERAL
WITNESS
HON. MICHAEL J. MISSAL, INSPECTOR GENERAL, DEPARTMENT OF VETERANS
AFFAIRS
Chairman Dent Opening Statement
Mr. Dent. Good morning, everybody. Thank you for coming out
to this hearing, and I appreciate all your attendance.
And since the full fiscal year 2018 budget hasn't arrived,
we thought it would be useful to begin our VA hearings with a
hearing focused on oversight issues. And the VA Office of
Inspector General is really ground zero for oversight of
veterans health and benefits.
Mr. Missal, we are delighted that you are here, and we are
glad the previous administration finally got around to making
your VA IG appointment. I know that you were confirmed in April
of last year, and so we were treading water far too long with
an acting IG.
And I understand you actually sought out this appointment,
leaving the private sector to take this job, which is a very
brave move, considering all the problems the VA has had and the
volume of work that awaits you.
We will be interested in the changes you have implemented
to sharpen the focus of the IG's work in the areas you believe
are most important in VA operations.
We will include your full statement in the record and will
appreciate your limiting your oral remarks to about 5 minutes.
But before we ask you to begin, I will turn it over to our
ranking member, Ms. Wasserman Schultz, for any remarks she
might have this morning.
Ranking Member Wasserman Schultz Opening Statement
Ms. Wasserman Schultz. Thank you very much.
It is good to see you again. Thank you for coming.
Clearly, the Inspector General plays a vital role in
ensuring that VA programs are implemented properly and that
funds appropriated by this committee are spent wisely and in
accordance with the law. And I really was very pleased with our
conversation. It is very clear that you understand exactly what
your mission is and are focused on it. And I look forward to
working with you as we continue to address the issues that
still persist at the VA and that we hold any and all bad actors
accountable.
We still have veterans waiting too long to receive both
care and benefits, and it is well past the time for a cultural
change at the VA and one that more vigorously embraces strong
oversight.
The Office of the Inspector General was integral in
investigating and responding to the 2014 Phoenix scandal, and
in response to this investigation, which uncovered numerous
issues, Congress passed the Veterans Choice Act.
The Office of the Inspector General was also crucial in
examining the cost overruns at the Denver Medical Center, where
the project costs increased from $604 million to $1.7 billion.
Most recently, the IG has helped identify extremely
troubling and wholly unacceptable issues at the Veterans Crisis
Line. According to the report that was released this week, the
Crisis Line continues to send nearly a third of its calls to
outside backup centers. And I see that the VA released a new
figure, that that is now at 1 percent, and I look forward to
asking you about the discrepancy between what your analysis is
and what this statement reflects. But that number was very
significant, even in spite of opening a second call center
designed to reduce that backlog.
The concerns that I have about the Veterans Crisis Line
already were confirmed by our visit to the D.C. VA Medical
Center the other day, because during a presentation on mental
health, we received conflicting responses on training and
protocol for employees at the Veterans Crisis Line.
Mr. Chairman, I know you agree that it is critical for the
IG to have the necessary resources to conduct aggressive
oversight and ensure that our veterans receive the health care
they both deserve and need and receive such care in a timely
fashion. No matter what steps the VA takes to address the
challenges it faces in delivering health care, the VA will be
unable to do so without proper oversight. Oversight and true
reform lie squarely with Congress and the Inspector General,
working together.
Mr. Missal, I commend your work thus far, but I think we
would both agree that there remains much to be done to repair
both our veterans' and our Nation's trust in the VA system.
And, again, thank you for being here today, and I look
forward to working with you to address these issues.
Mr. Chairman, I yield back.
Mr. Dent. Thank you. I thank the ranking member.
Let's go right to Mr. Missal.
And we look forward to receiving your testimony. Please,
you are recognized.
Mr. Missal. Thank you.
Hon. Michael J. Missal Opening Statement
Mr. Chairman, Ranking Member Wasserman Schultz, and members
of the subcommittee, thanks for the opportunity to discuss the
oversight the Office of Inspector General provides to VA
programs and operations.
I have had the great honor and privilege of serving as the
IG since May 2016, and today is my first opportunity to testify
before this subcommittee.
I would first like to thank the Congress for the increase
in our fiscal year 2017 appropriation. Our fiscal year 2018
appropriation of $159.6 million will greatly assist our ability
to fulfill our mission of effective oversight of the programs
and operations of VA.
Although I did not come into this role with any
preconceived notions of specific changes to make, I stated to
the staff on my first day that we will always strictly adhere
to the following three principles:
First, we must maintain our independence and make sure that
we do not have even the appearance of any impairment to our
independence.
Second, we must be fully transparent by promptly releasing
reports of our work that are not otherwise prohibited from
disclosure.
Third, we must maintain the highest integrity of our work.
This means that each of our reports must meet at least the
following five standards: It must be accurate, it must be
timely, it must be fair, it must be objective, and it must be
thorough.
In the past 10 months, we have made or are in the process
of implementing a number of enhancements to our operation.
Several of these initiatives represent concerted efforts by us
to focus on the high-risk areas throughout VA, with the goal of
being more proactive in our oversight. I believe that these
changes will enable us to perform more impactful work in a
timelier manner.
We are a relatively small office compared to other Federal
OIGs as a percentage of both the agency's full-time-equivalent
staffing and budget. We are comprised of approximately 725
full-time employee equivalents organized into five major
directorates: Investigations; Audit and Evaluations; Healthcare
Inspections; Contract Review; and Management and
Administration. About 225 employees are based in Washington,
DC, while the remaining 500 are dispersed throughout our
approximately 40 field offices nationwide.
Since fiscal year 2014, we have received approximately
39,000 contacts to our hotline annually. Each year, we average
about 350 reports and other work products, 475 arrests, 330
convictions, and $3.125 billion in monetary benefits.
Our return on investment averages $30 for every $1 expended
on our oversight. This is a strong return and supplements the
inestimable value we bring by helping VA improve its health
care and benefits services that impact so many lives.
We crafted our fiscal year 2017 appropriation with the
intention and hope that it will be the first of several tiered
increases to right-size our office over the next several years.
The expansion plan would increase staff to 1,160 by fiscal year
2021 and bring us to a level more equivalent with the increase
in staffing and resources at VA and comparably situated OIGs.
In consideration of the hiring freeze and the
administration's anticipated efforts to scale back the size of
the Federal Government, we reduced our fiscal year requirements
by $27 million from the $197 million figure submitted last year
as part of our 3-year expansion plan.
Our budget request for fiscal year 2018 of $170 million,
coupled with the anticipated fiscal year 2017 carryover, will
cover the costs of normal inflation assumptions and at least
100 additional staff over fiscal year 2017.
The administration is proposing to straight-line funding
for 2018 and 2017 enacted levels for a number of VA
discretionary programs. Under this scenario, our fiscal year
2018 budget would be $159.6 million, the same as 2017.
This funding level overlooks potential inflation costs of
at least $3 million for staff pay raises and infrastructure.
Although we do not project that our operations would be
adversely impacted at this funding level for 2018 because of
available carryover funds, for subsequent years we would likely
need to request a significant increase to our current funding
to maintain current operations.
In conclusion, with continued support from Congress, we
look forward to increasing our ability to conduct impactful
oversight of VA programs and operations for the betterment of
our veterans, their families, and American taxpayers.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions that you may have or other members of
the subcommittee.
[The information follows:]
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Mr. Dent. Thank you very much, Mr. Missal, for your
testimony.
PROBLEMS WITH SUICIDE HOTLINE
Last year, the IG issued a report that was fairly damning
in its critique of the operations of the Veterans Crisis Line,
the suicide hotline, VA's major tool to prevent veteran
suicide. At that time, VA countered that the IG report was
using old data and the agency had made improvements to its
operation, adding substantially more funding, installing new
leadership.
But the followup IG report issued on Monday suggests that
the VA is still having significant problems with the suicide
hotline. The new leadership has already left; the secondary
site in Atlanta is understaffed; clinical guidelines are not
being transmitted; quality-control measures are not being
implemented; and staff lack training.
Do you think the VA has made any progress in improving the
performance of the hotline since last year?
Mr. Missal. We took a look at the hotline and did our
review beginning in June of 2016. I would note that there were
seven outstanding recommendations that were still open from our
February 2016 report. They were scheduled to be completed,
according to VA's plan, by September of 2016. Those 7
recommendations from our last report remain open, as well as
the additional 16 that we had here.
So I guess I would say that there are still many
significant issues that we found with respect to the VCL.
Mr. Dent. Members of Congress were very concerned last
year, so we included language in the bill requiring the VA to
maintain suicide hotline standards consistent with the
guidelines of the American Association of Suicidology.
POSSIBLE VIOLATION OF APPROPRIATIONS LAW
At that time, VA had assured us that the hotline met those
guidelines. And with your new report findings, do you think
that the VA is in violation of our appropriations law?
Mr. Missal. I don't know if I can make that assessment. We
didn't look at it quite that way. We identified a number of the
shortcomings in the training, in governance, in staffing, in
leadership, et cetera. And so I think we did raise some
significant issues.
IMPROVEMENTS IN SCHEDULING DELAYS
Mr. Dent. There are some audits showing continued medical
appointment scheduling delays that I wanted to discuss.
Over the last 2 years, the IG has had the enormous job of
auditing all the VA medical centers about allegations of
scheduling delays and malfeasance. We understand that you have
revisited some regions and have found that problems have been
resolved in some areas but not in some others.
What are the factors that have been key to improvements in
some of these regions, if you could share that with us?
Mr. Missal. I think, one thing I have found in the 10
months since I have been here is the importance of leadership
at various levels. VA health care is a very decentralized
operation, and what is pretty clear when you go to either
medical centers or the VISNs, the regions that they have
divided the country into, the leadership at those areas are
really critically important to the performance of either the
medical center or the VISN.
VA'S ANTIQUATED FINANCIAL MANAGEMENT SYSTEM
Mr. Dent. I would like to now move to the VA's antiquated
financial management system. Your reviews of nine VA care
programs revealed a morass of problems in financial accounting,
timely payment to providers, and inadequate internal controls.
A significant share of these problems seems to be associated
with the antiquated financial management system VA continues to
use after its previous efforts to replace it had failed.
Do you think the VA's selection of the Department of
Agriculture as its Federal shared service provider to deliver a
modern financial management system will work for the VA where
prior attempts for new systems have failed?
Mr. Missal. That is something we are going to look at very
closely. They had a number of material weaknesses and
significant deficiencies in their financial statements this
past year, which was an increase over the previous year. They
made the commitment that they are going to go with a shared
service model, and we will test it and see if it has any
improvements.
SHIFT TO COMMERCIAL/IT SOFTWARE
Mr. Dent. Okay.
And I would also like to just briefly mention the VA shift
to commercial IT software for the health record. Secretary
Shulkin has announced that he believes the VA should use
commercially developed information technology software rather
than continuing to build it in-house.
From the OIG's review of VA IT, do you think this is the
appropriate path for the VA to take? And with its current skill
set, is VA capable of procuring IT and managing contracts
sufficiently and diligently?
Mr. Missal. IT has been a significant problem that we have
identified in various programs and operations at VA. I heard
the Secretary make that commitment, statement that he was going
to go forward, and I think it remains to be seen whether or not
that will be successful.
RISK OF PURCHASE OF COMMERCIAL/IT SYSTEMS
Mr. Dent. And can you just quickly elaborate on any risks?
What are the risks that you see with the purchase of commercial
IT systems for a healthcare system as enormous as the VA's? And
how can the VA mitigate those risks?
Mr. Missal. I think it is integrating those systems into
VA. VA has a number of different IT systems and they need to
make sure that they all work together. They have to make sure
that they have the proper staffing, the proper training, and
the proper funding to get it done.
Mr. Dent. Thank you.
At this time, I would recognize the ranking member, Ms.
Wasserman Schultz, for 5 minutes.
CHALLENGES OF VETERANS CRISIS LINE ROLLOVER CALLS
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
Mr. Missal, I want to continue the chairman's line of
questioning on the Veterans Crisis Line.
You released a report on Monday----
Mr. Missal. Correct.
Ms. Wasserman Schultz. This report addressed the challenges
that the Veterans Crisis Line was experiencing, particularly
with rollover calls to the backup call center. And that was in
spite of adding the Atlanta call center, a second call center.
There were significant percentages of rollovers, which is why I
find it baffling that, a day later, the VA releases, you know,
a statement saying that they have addressed it and that now
their rollover is 1 percent.
That seemed completely incongruous with your report and
nearly impossible for it to have been resolved in 24 hours. So
can you address that pretty significant discrepancy and whether
you think that the VA has addressed the problems in the report?
Additionally, when we were at the D.C. VA Medical Center
the other day, it seemed very clear, to all of us that there is
not uniform training across the board between local medical
centers and the national Crisis Line training. And that also
seems to be causing problems for veterans who are in dire need
and could risk life. And, in fact, there has been life lost due
to lack of training.
Mr. Missal. Sure.
Okay. With respect to the rollover calls, our inspection
period covered the middle of June to the middle of December
2016. So we had the most recent data. I believe our last month
was November of 2016. So we listed in our report all those
numbers.
The Atlanta operation was brought about to try to, among
other things, limit the dependency on these backup centers.
They started bringing it up in stages, beginning in the fall.
As of the middle of December, it still was not fully
operational.
So we have not looked at it since that time, in the 3\1/2\
months or so since then. So I really can't comment whether or
not their numbers are 1 percent or some other number.
Ms. Wasserman Schultz. I think you can understand the doubt
that I feel, given that the VA has already had a problem with
fudging and altering data to reflect better numbers than
reality.
So do you have plans to follow up and actually take another
look at the last few months so that you can confirm these
numbers? Because it is hard to have confidence in these
numbers, given their track record.
Mr. Missal. Yes. There are 7 outstanding recommendations
from our February 2016 report, 16 open from our current report.
We consider both of those reports still open until we get
satisfaction that they have met their commitments to complete
those recommendations. So we will continue to look at the VCL,
at a minimum, until those recommendations are fulfilled.
CHOICE PROGRAM
Ms. Wasserman Schultz. Thank you. Because there are
literally lives at stake from getting it wrong.
In my remaining minute and a half, I just want to ask you
about the Choice Program. Your report found that veterans are
still waiting months for appointments made through the Choice
Program.
I just went to my own Miami VA Medical Center, and they
gave me a very glowing picture of how much the wait times have
been reduced. But, according to your report, veterans covered
by Health Net, which is where the Miami VA is, on average,
waited 84 days to get an appointment--42 days for the
authorizations to be provided and then another 42 days for the
appointment to be scheduled and the service provided.
So, first, why is it taking the VA 42 days to provide
authorization? And why is it taking Health Net 42 more days
after the authorization?
Mr. Missal. Right. The numbers you are talking about relate
to our report on VISN 6. What we had previously done is we had
looked at a specific facility. What we decided to do is look
more broadly. VISN 6 governs VA facilities in the Virginia and
North Carolina.
And the reason it took as long as it did was there was a
lot of administrative issues involved in doing that. There was
confusion. The rules for Choice are very complex, for example,
who is eligible to qualify.
And so the funding for Choice is expiring in the middle of
August of this year. One of the things I think needs to be done
is to make it as uncomplicated as possible so that it is easier
to sign people up, that veterans know exactly what their
options are, and that the third-party administrators can move
people through the system more quickly.
Ms. Wasserman Schultz. Thank you.
I yield back.
Mr. Dent. Mr. Jenkins is recognized for 5 minutes.
Mr. Jenkins. Thank you.
AIR QUALITY ENVIRONMENTAL CONCERNS
Good morning, and welcome.
The community outpatient clinic in Greenbrier County, as
you well know, several years ago had complaints of air quality
environmental concerns, both from employees and our veterans
who were seeking care and treatment there. A report was issued
by the OIG, and we had to go to bat to make sure that that CBOC
continued, in a new location, in Greenbrier County.
But can you go back, the status of your findings from that
2015 report--what actions has OIG done with regard to that
report? Which I believe you all did find environmental air
quality concerns at that CBOC in Greenbrier County.
Mr. Missal. Right. We did note ongoing air quality issues
in that CBOC in 2015. It was closed as you know. It was the
VA's responsibility to fix it. We have not been back since then
to look at it, but we are well aware that these are commitments
they made, and they need to follow through on those.
Mr. Jenkins. Well, that facility is closed. It is not being
used. There is a new CBOC facility. So the old issues are going
to be at that old facility; we are not there anymore.
But the OIG, obviously, hopefully, takes these issues of
complaints from patients, our veterans, and employees seriously
on environmental air quality. So one of my interests is
followup activities after that report has been issued.
Mr. Missal. Yes. I would say that we have a very active
healthcare inspection program, where we get around to the
medical centers, some of the CBOCs as well. And environment of
care is one of the areas we look at very carefully. So for
every facility we go in, we check the environment of care for
issues just as you raised.
STATE PRESCRIPTION DRUG MONITORING PROGRAMS
Mr. Jenkins. Second, under care of the addiction recovery
relating to opioid abuse/misuse, there is a real emphasis, and
it was in that legislation, asking the VA to start
appropriately sharing the prescription information to State
prescription monitoring programs, PDMPs. It is referred to in a
lot of different ways. Most every State has one up and running.
What is the OIG doing to ensure appropriate information-
sharing from the prescription issuance on the veterans side,
getting into State PDMPs so we make sure we enhance the quality
of care, and also make sure we are avoiding diversion and not
adding to the drug crisis, and opioid diversion problem?
Mr. Missal. Right. Opioid misuse and other controlled
substance misuse is a very great concern to us, and we have a
very active program in this area.
With respect to the PDMPs, we do have access to those. It
is VA that can enter data. We can, though, see it, and we do
use it on occasion in our work.
With respect to opioid misuse/abuse and, actually, the
stealing of opioids and other controlled substances, we have a
number of investigations going on currently, and we have
brought a number of cases recently which have resulted in jail
time and other sanctions against individuals.
Mr. Jenkins. Well, I understand a doctor at a VA will have
access. They are an authorized recipient of data. They can tap
in and look at the prescribing history.
My question is, under CARA's direction to the VA, to have
the VA actually submit information to State PDMPs, what is the
VA doing about complying with that expectation?
Mr. Missal. We haven't looked specifically at that. Given
how decentralized it is, it is really going to be facility by
facility to see whether or not they are complying with the
rules. But that is something we are considering looking at more
closely, because we agree, it is a major concern.
Mr. Jenkins. Well, Bob McDonald, the previous VA Secretary,
he said publicly multiple times the VA is going to start
submitting their prescribing data to PDMPs. So I would
encourage you--I appreciate your statement of, we are going to
be looking into this. I think this is a priority issue, with an
opioid crisis in so many parts of this country. I would hope
you would move it from a ``we intend to look into it,'' because
I do believe now there is actually a congressional mandate
relating to the VA. And I think the OIG plays a key role in
making sure that the VA fulfills its statutory obligation.
This is back to this life-and-death issue, and we have to
have better information systems. The VA has a responsibility,
and I hope you will make sure the VA lives up to that
responsibility.
Mr. Missal. Yes, sir. We share your concern, absolutely.
Mr. Jenkins. Thank you.
I yield back.
Mr. Dent. Thank you, Mr. Jenkins.
At this time, I would like to recognize the former ranking
member of the subcommittee, Mr. Bishop, for 5 minutes.
Mr. Bishop. Thank you, Mr. Chairman.
Welcome, again, to our distinguished IG.
VA INFORMATION SYSTEMS VULNERABILITIES
It is critical that we put measures in place to protect
sensitive information and to defend against those who would
seek to gain unauthorized access to that information. The VA
has an obligation to safeguard the data that we hold on
veterans, and I know that everybody takes that responsibility
seriously.
In your statement, aspects of the VA IT security have been
continually reported, you indicate, as material weaknesses for
some 17 years.
Mr. Missal. Correct.
Mr. Bishop. From my understanding, in the latest
information security information audit, you recommended 35
actions that would improve the information security program.
How many of those have been implemented? And what is your
current assessment of the VA's vulnerability against cyber
attack and ability to respond effectively to a successful
attack?
Mr. Missal. I don't have the precise information of how
many of those recommendations they have implemented. We have
talked to them frequently about this issue.
We are just now starting our work for this year on
cybersecurity and IT security, and we are going to be very
aggressive in looking at it. And to the extent there are issues
that we see as we are going through the audit, we will raise it
again with them. We consider this very important, and hopefully
they will make progress.
Mr. Bishop. Can you submit that information to us in
writing at a later date?
Mr. Missal. Sure. Happy to do so.
[The information follows:]
In the OIG's FISMA report for FY 2015, we made 35
recommendations. During our work for FISMA in FY 2016, we
closed five of the 35 recommendations from FY 2015. However,
for FY 2016, we added three additional recommendations so we
have a total of 33 open recommendations related to FISMA. We
also perform other IT security related work and currently
recommendations remain open in two other reports:
``Review of Alleged Transmission of Sensitive VA Data Over
Internet Connections''--Issued on March 6, 2013--Recommendation
1 remains open.
``Review of Unauthorized System Interconnection at the VA
Regional Office in Wichita, Kansas''--Issued on April 6, 2017--
Recommendations 2, 4, and 6 remain open.
Mr. Bishop. Thank you.
PROCUREMENT DEFICIENCIES
In your statement, you noted that the VA has systemic
deficiencies in all phases of its procurement process. From
your assessment, is it that the VA does not have the proper
policies and procedures in place, or is it that they are not
performing in accordance with the procurement standards? Or is
it both?
Mr. Missal. Procurement is an area that we feel is one of
our priorities, because of the amount of taxpayer dollars at
issue here. And what we have found is both. We have found both
policies and procedures that are not up to what we would
expect, and we have also found situations where they haven't
followed the policies and procedures as well.
COLLECTING RACE AND ETHNICITY DATA
Mr. Bishop. On another subject, after reviewing the 2016
Advisory Committee Report on Minority Veterans, I am concerned
the VA doesn't consistently collect race and ethnicity data.
According to the Center for Minority Veterans, by 2040,
minority veterans are projected to represent over a third of
all of the veterans, despite the overall veteran population
decreases. This is information that could be used to suggest
policy reforms and recommendations to address the needs of an
increasing minority veteran population, to include health
disparities, academic affiliations, unconscious bias in hiring
practices that may lead to a lack of diversity and specifically
at the senior management level.
Do you have any planned or any recent audits, inspections,
or evaluations that focus on minority veterans and on women
veterans? And if so, what are some of the recommendations, and
how many of those remain open?
Mr. Missal. We don't currently have anything on minority
veterans.
On women veterans, we are doing a national healthcare
inspection to see the treatment of women veterans and how VA
accommodates women veterans. That should be released shortly.
I recognize the importance of all the issues you raise. And
that is something, as we are looking at our workload going
forward, it is something we will consider.
Mr. Bishop. How can we make sure that the VA collects data
on race and ethnicity so that we will have the data from which
to make assessments?
Mr. Missal. I am not aware of what process they have in
place and what they are doing in that area to know. But,
obviously, they should have policies and procedures for any
program that they have. And that would be something, if we
looked at that, we would focus in on the policies and
procedures and how they are implementing those policies and
procedures.
Mr. Bishop. I was told that the VA does not collect data on
ethnicity. So, for example, I couldn't ask you how many black
veterans you have or how many Hispanic veterans you have or how
many Asian veterans you have, because the VA doesn't collect
that kind of data.
And what I am suggesting is that we need to collect data in
those categories. This data would assist you in your audits; it
would assist us in our oversight. But we don't have that
information. Perhaps you can make recommendations on what we
need to do to get that information or if we can just ask for
it.
Mr. Missal. Sure. We can look into that, certainly.
Mr. Bishop. Thank you.
My time has expired.
Mr. Dent. Mr. Valadao.
Mr. Valadao. Thank you.
Thank you again for taking some time today. And I know we
are hitting on the wait times quite a bit, but I do want to
follow up on that a little bit.
PATIENT WAIT TIMES
The VA publishes a bimonthly patient access report for all
VA medical centers and community-based outpatient clinics,
which include information such as average wait times for
veterans enrolled in the Veterans Health Administration.
Currently, the VA medical center in Fresno, California,
represents an average wait time of 12 days to see a specialist.
However, I am hearing from constituents of mine all the time
who report waiting a couple of months or more to get in to see
the doctor. While I understand that 12 days is the average wait
time, there is a big difference between 12 days and 2 months.
In your experience, do you believe the average wait time
data in the bimonthly patient access report accurately reflects
the wait times that veterans experience?
Mr. Missal. I haven't looked specifically at those, but
what I can tell you is, in our VISN 6 report, where we looked
at wait time across a large group of medical centers in
Virginia and North Carolina, that the wait times that we
calculated were significantly different than the wait times
that the facilities had and the VISN as well. It was not just
one; it was a number of different facilities had significantly
different wait times.
It is somewhat complicated because there are so many
different dates that they use to calculate wait times. And what
we found is the policies that were in place at the time were
not being followed, and that is why our numbers were so
significantly different.
Mr. Valadao. Okay. Is there anything we can do to improve
that? I mean, should we mandate some sort of--I mean, I don't
like mandates normally, but it seems pretty simple. If someone
calls in to make an appointment and it takes them 2 months,
where is the confusion?
Mr. Missal. I think they need to simplify how they
calculate wait times, the number of different measurements they
have. I can't emphasize enough how important oversight is to
make sure that when they have a policy and procedure that they
follow it and they follow it accurately.
ROLLOUT OF ONLINE SCHEDULING
Mr. Valadao. And then there was a rollout in January 2017
of the online scheduling. Have you had any experience with it?
Have you seen how it is performing? Any early indicators that
show any progress at all?
Mr. Missal. We have not looked at it. I understand it is a
pilot, but we haven't looked at it in any kind of detail.
Mr. Valadao. All right. Thank you.
I yield back the balance of my time.
Mr. Dent. At this time, I would like to recognize Mr. Ryan
for 5 minutes.
Mr. Ryan. Thank you, Mr. Chairman.
Thank you for your service. The deeper I get into the
Appropriations Committee, the more valuable I find what you and
your team do, so thank you for that.
OPIOIDS TREATMENT MANAGEMENT
I want to just kind of continue on the line of questioning
that Representative Jenkins was asking you about, CARA and
opiate issues with regard to the VA. We also have reports in
Ohio that were allegations of little or no oversight of the
refills for opioids.
Services other than medication therapy can reduce the need
for opiates to deal with pain, as well. We saw in our trip a
couple days ago to the D.C. VA Medical Center, they have a
center of excellence, that they have done incredible work in
the area of providing integrative medicine, and the clinic
found significant evidence of decreased dependence on opioids
through some of these techniques.
A lot of these integrative treatments--yoga, meditation,
acupuncture, art therapy--they are in very, very high demand.
And I was surprised, because I went to the D.C. VA a couple
years ago to look at these programs, and the scheduling a few
years back versus the scheduling now, of people just being able
to walk in and access some of this care, has increased
significantly, which I think is--you know, the veterans are
voting in the marketplace of what their options are there.
So, when reviewing the recent clinical assessment program
reviewed for Cleveland, Ohio's VA clinic, I don't see any
mention of routine reviews for the opioid management or
reviewing inclusion of integrative medicines. And the report on
opiate addiction treatment protocols fails to recognize
SAMHSA's inclusion of non-opioid options for treatment of
opiate substance use disorders. This includes options such as
non-opiate 30-day shots, which you know about, that is
minimally invasive for veterans' lives and removes the high
provided by opioids.
OVERSIGHT FOR OPIOID PRESCRIPTIONS
So my question is, what are we doing to appropriately
provide oversight for these opioid prescriptions within the VA?
And are we providing the appropriate amount of resources to the
clinics to provide both the reduced opioid use within the realm
of integrative medicine?
Mr. Missal. Sure. We are doing a number of different things
in this area.
First of all, in our inspection program, we change up the
various areas that we look at just so we can cover as many as
possible. And a couple of years back, we did look at medication
and how they were controlling the opioids and other controlled
substances. We are now going to likely be putting that back
into the upcoming inspection program that we have. We have had
recent discussions on that.
Secondly, we are working on a pain management report,
covering how does VA deal with pain management issues, which
would be opioids and other medication. That will hopefully be
out relatively shortly. It is a national review of what they
are doing. VA has an opioid safety initiative going on in an
attempt to bring down the amount of opioid use, so we are
looking at the impact of that as well.
In addition, as we both are proactive and get referrals on
potential misuse of opioids, we are aggressively looking at
that as well. And we have a number of open investigations and
have brought some other ones as well, aside from making sure
people who have done something wrong are brought to justice as
a deterrent effect as well, to make sure people know we are
watching this as carefully as possible and will bring action as
appropriate.
ACTIONS AGAINST PRESCRIPTION DRUG THEFT
Mr. Ryan. So how many people up to this point have we
brought action against that was selling pills, stealing pills?
How prevalent is that up to this point? I mean, do you have any
early data on those?
Mr. Missal. It is definitely in the hundreds of cases that
we have brought or individuals involved over the years. I
believe we have something like 90 active cases right now, which
could involve more than one person.
So it is an issue out there, and we are looking at it very
closely.
Mr. Ryan. So they are stealing and selling.
Mr. Missal. They are stealing and selling, or some of the
staff use it in the facilities themselves and then substitute a
saline or other substance for the patients.
Mr. Ryan. Thank you.
I yield back.
Mr. Dent. Thank you, Mr. Ryan.
At this time, I would like to recognize the gentleman from
Virginia, our Navy SEAL, Mr. Taylor, for 5 minutes.
Mr. Taylor. Thank you, Mr. Chairman. I have a bunch of
questions.
Thank you for being here. We really appreciate it. This is
certainly a personal issue for me. And our district has many,
many veterans, fastest growing population of women veterans and
OIF/OEF veterans. So I appreciate your time and your work.
RETIRING LEGACY SYSTEMS
Let's talk about legacy systems really quickly. Is there a
push in the VA currently to get rid of legacy systems? Because
some of these systems are from the 1980s, which is incredible.
And I understand it is expensive.
That being said, is there a push to procure new systems
that are relevant to today so you are not looking for parts or
hardware and stuff like that that is not even made anymore as
opposed to building on legacy systems that are still there?
Mr. Missal. Right. Secretary Shulkin has made several
recent statements about that, and what he has stated is that he
is looking very closely at this issue. He wants to study and
analyze whether certain systems should be replaced and how
exactly to do it.
So, at this point, my understanding is VA has not made any
final decisions on what they are going to do with respect to
their legacy systems as a whole.
Mr. Taylor. Any idea on timing, like, when those decisions
will be made?
Mr. Missal. I hope it is as quickly as possible, because IT
is an issue that we have identified as a problem in a number of
our reports.
Mr. Taylor. Thank you.
UNIFORM TREATMENT PROTOCOLS FOR SUICIDAL VETERANS
Shifting gears really quickly, on the suicide--and I
understand the hotline and everything like that. But what is
the proper procedure--not the procedure, but is there a uniform
procedure if a veteran, any veteran, walks into a facility and
says that they are, in fact, suicidal or having suicidal
thoughts? What happens there? And is that uniform across the
board?
I know that you mentioned the VA being decentralized, but
that seems like it would be something that would have to be
uniform policy, you know, if somebody--not the hotline, but
they walk in and they are a veteran and they have suicidal
thoughts. What happens?
Mr. Missal. Right. There are suicide prevention officers at
the various facilities, and they are supposed to be notified
immediately if a veteran is in danger in any way. And so they
should be getting appointments immediately, depending on the
urgency of the situation.
Mr. Taylor. So if somebody--just a followup. If someone
walks in--I walk in and I say I am having suicidal thoughts,
what happens? You said, you know, they see about the urgency.
They don't take me in?
Mr. Missal. They should take you in right away. For
something like that, I would expect them to take you in right
away and have you see a provider immediately.
Mr. Taylor. Just one other followup. I apologize. Is there
a uniform policy across the board?
Mr. Missal. I believe VA does have policies, but as I said
before, they are decentralized. And they do change the
application of some of the policies if it makes sense at a
particular medical center.
Mr. Taylor. I appreciate that.
Just because I am dumb, just to clarify, so it is
decentralized, but you are not positive that there is a uniform
policy, if somebody walks in and they have suicidal thoughts,
what happens.
You know, I am not being argumentative, but I want to know,
because this is an issue that has come up in our own VA, as
well, too.
Mr. Missal. I don't know of the specific policy, but my
understanding is that if you are a veteran in urgent need that
you will be seen immediately, or you should be seen
immediately. And my understanding is that they would have some
policies that cover that. I don't know how specific it is on
the suicide perspective.
Mr. Taylor. Okay. I will talk to you about that offline, I
guess.
Mr. Missal. Sure.
ELECTRONIC HEALTH RECORDS
Mr. Taylor. I wanted to follow up on the interoperability
and legacy systems, as well, too. I understand there is more of
that. There has, you know, been a big push for electronic
health records.
Are you able to speak to the DOD, 100 percent--so if I come
in and I am applying for VA disability, I get out of the
military--obviously, 100 percent from VA are from DOD--are you
able to see everything that I was treated for, where I was
treated for, all those things, so that in fact you are able to,
one, expedite that claim but also, two, reduce fraud? Because,
obviously, veterans--and you may not hear this from this side
that often, but veterans commit fraud sometimes, as well, too.
So are you able to see those things with the current technology
that is there?
Mr. Missal. They have different systems right now. I know
that is another issue under discussion, is should they try to
have one system. There are workarounds, so there is information
that is being transferred from DOD to VA----
Mr. Taylor. So there is still discussion about whether they
should talk or not or what system they should talk--even though
100 percent of people in the VA are from DOD.
Mr. Missal. That is correct.
Mr. Taylor. Incredible. Thank you.
Thank you, Mr. Chairman.
Mr. Dent. Thank you, Mr. Taylor.
I guess at this time we will move into our second round of
questioning.
VA/IG STAFF EXPANSION
A couple things about your agency's growth, Mr. Missal. As
you are aware, Congress provided the IG a generous increase for
fiscal year 2017 as part of what your predecessor describes as
a multiyear increase to right-size the agency. And I think we
took you up to about $160 million in fiscal year 2017, which is
about $23 million above what you were in fiscal year 2016, or
it is about a 17-percent increase.
And I think you have about 790 full-time equivalents,
plus--that is about 100 above what you were the year before. Is
that correct?
Mr. Missal. That is the plan. Correct.
Mr. Dent. All right. So what progress have you made in
expanding staff and adding new locations, especially out west,
where you had not very much of a presence?
Mr. Missal. Right. Well, we are in the process of trying to
hire as aggressively as we can. We are looking for quality
people. We want to make sure the people that we hire are of the
very highest quality. Every day it seems we have other
announcements going out, as we have exemptions to the hiring
freeze that is in place now. And we will continue to do that
until we get fully staffed up.
With respect to new facilities, we are going to be opening
a new office in Salt Lake City. We think that is strategic for
our office, and we believe there is plenty of need in that
area. And that is one of the offices we are opening; we are
considering some other ones as well.
Mr. Dent. Why Salt Lake City? You said it is strategic.
Mr. Missal. Because of the medical centers in the area and
the regional office for benefits. We don't have anything that
close to that area. We also think it is a good workforce where
we can attract good people.
FOR PROFIT SCHOOLS USING THE POST-9/11 GI BILL
Mr. Dent. Okay.
I want to just talk briefly about for-profit schools using
the Post-9/11 GI Bill. There have been questions from Congress
about the quality of education some for-profit schools are
providing veterans who use the Post-9/11 GI Bill. The stories
we hear about flight schools, beauty schools, truck-driving
schools, et cetera, that are charging high tuition with almost
no class time and no job prospects, all paid for by the Post-9/
11 GI Bill.
The Student Veterans Association of America recently
published research saying that public schools received 34
percent of all Post-9/11 GI Bill funding and produced 64
percent of the degrees, but the for-profit schools use 40
percent of the Post-9/11 GI Bill funds and produced only 19
percent of the degrees.
So is your office investigating high-cost, low-performing
for-profit schools that are profiting from the Post-9/11 GI
Bill?
Mr. Missal. Yes. We have brought a number of criminal cases
involving schools that have not lived up to the commitments
that they made.
In addition, we have an audit now involving the State-
supported agencies that are required to get involved in the
authorization for those funds to be used. And we should have
that report out in the next few months.
Mr. Dent. Okay. I was going to ask you about that. So the
audit is coming in the next few months.
Mr. Missal. Yes.
DISABILITY CLAIMS BACKLOGS
Mr. Dent. All right. Very good.
On the issue of disability claims backlogs, we understand
that there has been a small uptick in the size of the backlog
of VA disability claims. Is your agency continuing to review
the processing of claims to judge whether VA needs to implement
new systems or workforce increases to keep the size of the
backlog low?
Mr. Missal. Yes. We have a benefits inspection group that
goes and inspects the 56 regional offices and puts out reports
as they finish their audits and reviews. So, yes, we are
actively looking at the benefits.
GAO HIGH RISK REPORT
Mr. Dent. Thank you.
And then, on the GAO high-risk report, I guess the GAO's
February report continues to categorize the VA as a high-risk
enterprise in five areas--for example, ambiguous policies and
inconsistent processes; inadequate oversight and
accountability; information technology challenges; inadequate
training; and unclear resource needs and allocation
priorities--although the GAO report acknowledges the VA has
made some improvements, notwithstanding.
Do OIG findings lead you to that same conclusion?
Mr. Missal. Yes. We recognize the five areas that GAO
found, and many of our reports include one or more of those
same inadequacies.
PROGRESS IN REDUCING TIME BETWEEN REPORTS
Mr. Dent. And on transparency and timeliness, you made a
commitment to make publicly available all IG reports.
Mr. Missal. Correct.
Mr. Dent. We truly appreciate your leadership on that
score. In last year's hearing, members were very frustrated
that the IG was choosing not to release some reports.
What progress are you making in reducing the amount of time
between an investigation and the publication of the report?
Members were also frustrated by that issue in last year's
hearing as well.
Mr. Missal. Right. I think we are making progress. We still
have some work products that were in the works when I started
that we are still pushing to get out that may be of an older
time period. But I think the VCL is a good example of a model
of where we want to go. We started that inspection around the
beginning of June, and we now have it out in well less than a
year. And we are going to try to do better than that.
Mr. Dent. Thank you, Mr. Missal.
My time has expired. I now recognize the ranking member for
her questions.
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
Mr. Taylor, when we were at the VA medical center on
Monday, the very concern that you raised, about the
inconsistency of the training, was evident in their description
of how it works between the national crisis hotline and their
local hotline. And I would like to talk with you more about the
concerns, because I share them.
Mr. Taylor. Sure.
DISCREPANCIES IN WAIT TIMES DATA
Ms. Wasserman Schultz. Mr. Missal, I just want to ask a
followup question about the discrepancy in your data on the
wait times and what you attribute that to.
I mean, can you clarify what you think is driving the
discrepancy between the IG's data on wait times and the VA's
data? Because you seem to allude to training and a lack of
clarity on policies to be the cause. Do you think there is also
a possibility that it is still manipulation?
Mr. Missal. We don't rule out any possibility.
With respect to VISN 6, where we found very different
numbers than VA, I will give you a concrete example of the
difference. So if a veteran has a preferred time, a veteran
comes in and says, ``I want to be seen on June 1st,'' the
policies in effect at the time said the scheduler is supposed
to put a note there just to, again, make them do an extra step
to double-check that that is a real date.
And so we found many instances where there was no note. So
if there was no note, then it would default to another date.
And that is where we used the other date. VA, in calculating
their wait times, didn't do that. So we considered it was in
violation of the policy, and so----
Ms. Wasserman Schultz. Because they didn't use the
veteran's preferred date.
Mr. Missal. They shouldn't have used the veteran's
preferred date if there was no note there.
CHOICE PROGRAM MEETING REQUIRED SPENDING TARGETS
Ms. Wasserman Schultz. Okay. I see. Thank you.
Another troubling aspect about the IG report noted that the
VA was meeting--the Choice Program was meeting its required
spending targets. And that is kind of odd, because we gave them
$15 billion. And part of it was for infrastructure; the other
part was for care.
Right now, the Choice Program is on track to hit its
expiration date with money left over. So how is it possible
that the program didn't have adequate resources?
Mr. Missal. I think the issue was with the start-up of it.
It started up within 90 days from the legislation. It just took
them a while to get the network up where they would be able to
be more operational with respect to it. So the first part of
it, they just didn't spend the money that was allocated to
them.
Ms. Wasserman Schultz. So, in the beginning, they seemed to
not have adequate resources, or they weren't using the
resources that they did have appropriately?
Mr. Missal. They weren't using the resources because they
hadn't yet built up the network of doctors and providers out
there who the money would be going to.
Ms. Wasserman Schultz. Okay.
VA OIG RESOURCES NEEDS
And in the spirit of making sure that you continue to have
the resources that you need, do you have the resources that you
need at the moment to conduct proper oversight?
And, I mean, I know that you mentioned during our meeting
you were having a tough time getting reports out. Is the hiring
freeze a problem now, and do you anticipate it making the
problem worse?
Mr. Missal. The hiring freeze clearly impacts us. It is
hard to give you a precise estimate of the impact, but we are
not able to hire the people that we would like to hire so that
we can continue to do our effective oversight. And we are
hoping, going forward, with additional funds, that we can put
to good use every additional person that we are hiring.
Ms. Wasserman Schultz. And you don't qualify for an
exemption in the hiring freeze policy?
Mr. Missal. Some of our positions do. According to OPM and
OMB guidance, I am the head of the agency and allowed to grant
the exemption. And under the memorandum, you can do it for
national security or public safety. Much of what we do is in
the public safety realm.
We have given our plan for the exemptions to OMB and OPM,
and they said to go ahead and follow that plan that we had, and
we have been doing that.
Ms. Wasserman Schultz. So are you concerned that you will
be unable to hire the necessary additional auditors and
employees that you need to be able to do the appropriate amount
of oversight that is necessary here?
Mr. Missal. I am concerned we are not going to have enough
of them to do the oversight that we see we should be doing,
yes.
Ms. Wasserman Schultz. Because of the hiring freeze or not
enough resources or both?
Mr. Missal. A little bit of both, but the hiring freeze
definitely is impacting the number of people we are going to be
able to hire.
Ms. Wasserman Schultz. In spite of the fact that you have
the flexibility in those two areas.
Mr. Missal. We can grant exemptions but only in certain
situations. So, for our open positions, we estimate it is 50
percent or so of the people in the open positions we are going
to be able to hire pursuant to exemptions.
Ms. Wasserman Schultz. I would suggest to all my colleagues
on the committee that if there is a place that cries out for an
exemption if this hiring freeze is going to continue, it would
be the OIG at the VA.
Thanks, Mr. Chairman. I yield back.
Mr. Dent. Thank you, Ms. Wasserman Schultz.
At this time, I recognize the gentleman from Arkansas, Mr.
Womack.
Mr. Womack. Thank you.
I appreciate your testimony, sir. Thank you for your
service.
PROACTIVE OIG AUDITING
As you know, one of the things that we are able to do from
time to time at this level is take care of our veterans by
putting them on some solid ground from a small-business
perspective, both from a service-disabled small business or
just a veteran-owned small business. I have read and I have
seen some data that shows that there is good oversight, or at
least oversight, on the programs, but I don't think it has been
audited since 2011.
So my question would be specifically, other than just
prosecuting people for fraudulent-type activity in these
programs, which, as I said, we have read and heard about, is
there something, in your experience, that we could be doing
that would be more proactive in nature? Instead of us always
reacting to a fraudulent activity, what can we do proactively
that can give us the proper filters to ensure that we are not
having to be reactive on some of these issues?
I hope I am clear in my question.
Mr. Missal. Sure.
Mr. Womack. What would you recommend, if anything, that we
can do that we are not presently doing?
Mr. Missal. Well, a few things. One is the oversight, what
kind of information you ask for about the program to see if it
is fulfilling the goals that you have. Secondly is
accountability, when you see that the programs aren't operating
as they should be or there are issues, is to take action as
quickly as possible.
When we do an audit of a program, we are looking at a lot
of different things. And we want our work--to answer four
questions: First, why is it important to do? So, as you point
out, those programs are very important. Second, what happened
here? And third, why did something happen? Again, that gets to
the root cause. If there are issues and for the sake of being
able to anticipate, you want to get to the root cause. And
finally, who is responsible for accountability?
And so that is what we try to do, and, in your oversight
role, I know that you try to accomplish the same objectives as
well.
Mr. Womack. Yeah, we can't see it all and uncover it all,
but my concern is that there are likely some things we can do.
Specifically, are we hampered, are we handcuffed at all by
privacy information, by doctor-patient relationships, HIPAA-
like restrictions? Is there anything that we could be doing
proactively from a legislative point of view that would kind of
free up the organization to better understand or control these
programs?
Mr. Missal. Right. It depends. Obviously, VA, with their
healthcare system, has certain privacy issues that are going to
impact your oversight role. I think it really depends on the
various programs that you have.
But there are lots of opportunities to look at oversight.
We try to be as broad as possible in what we look at, and that
is why we use inspections, audits, reviews, and investigations,
so that we can cover as broad an area as possible.
Mr. Womack. Of the known and prosecuted cases, has there
been established any kind of a pattern of conduct? Or are they
just random? Do they cover the waterfront in terms of
fraudulent activity?
Mr. Missal. They really cover the waterfront. Obviously,
the colloquialism ``rent a vet'' is very prevalent out there,
so we look very carefully at those matters to make sure that
the contracts are going to the veterans who qualify for it.
Mr. Womack. Is there a geographic area more susceptible to
this kind of behavior? I know, for example, in some of the
Medicare issues that we see surfacing, there are pockets of
places where this seems to be more prevalent than other places.
Mr. Missal. Nothing has come to my attention that it is
focused on particular geographic areas.
HIRING FREEZE IMPACT
Mr. Womack. And then, finally, as it pertains to the hiring
freeze, I have a whole other set of questions on that. In your
opinion, just in a few words, what limitations does the hiring
freeze or any other personnel actions have on the ability to
deal with the veteran-owned small-business or disabled-veteran
business opportunities?
Mr. Missal. We have to pick and choose among the matters
that we----
Mr. Womack. But is it a priority?
Mr. Missal. It is a question of priorities, exactly. And
the fewer people we have, the tougher it is going to be to hit
our priorities.
Mr. Womack. Okay. I know I am out of time. Thank you very
much for your testimony.
Mr. Dent. Thank you, Mr. Womack.
At this time, I would like to recognize the gentlelady from
California, Ms. Lee, for 5 minutes.
Ms. Lee. Thank you very much.
COLLECTING DATA BASED ON RACE AND ETHNICITY
Good morning, I apologize for being late. I would like to
follow up on one of the questions that Mr. Bishop asked with
regard to data collection, in terms of disaggregating data
based on race and ethnicity.
Earlier this year, we had the chance to visit the VA
medical center here in Washington, DC. One of the questions I
wanted to get answered but couldn't quite get answered was the
utilization of data to track minority-, women-owned businesses,
and disabled-veteran-owned businesses. They were able to break
down, for example, the percentage of women-owned businesses and
other categories, but they did not break it down by race.
So I want to find out--are you capable of doing that?
Because it is extremely important to make sure that all
companies are given equal opportunities. And when you don't
have the data, we don't know if African-American businesses, if
Latino businesses, or Asian-Pacific American businesses are
participating in the contracting opportunities.
Mr. Missal. Right. Well, I know that VA keeps data in a lot
of different ways. We have access to VA's databases, but it is
really up to them to decide how they want to categorize things.
Obviously, if we see something that we think should be covered,
we could make a suggestion, but it is really their
responsibility to keep their data.
Ms. Lee. But we do have some Federal Government
requirements to be sure there is nondiscrimination and equal
opportunity for all people in all companies.
Mr. Missal. Sure.
Ms. Lee. So I would think, in your position, in terms of
investigating and making sure they are compliant, that is not
their decision. I mean, we have laws that they should comply
with to ensure that African-American, Latino, and Asian-Pacific
American businesses are being treated fairly and equally.
Mr. Missal. Absolutely. And that is something we could
certainly look at, and then we would have to work with them to
see how they can get the data.
Ms. Lee. Okay. Could you do that, please?
Mr. Missal. We can look into that, absolutely.
Ms. Lee. Okay. Thank you very much.
EFFICIENCY IN PROCESSING CLAIMS
Now let me ask about the Oakland office. First, I thank you
very much for following up with some of the requests we have
made. Last year, I am told that 53 percent of claims were
processed, but we still have about 54 percent in terms of
backlog.
What needs to happen to become more efficient in processing
these claims? We have had terrible problems at Oakland, and we
are trying to get our hands around it. We have made some
progress, but 54 percent of claims unprocessed, is not good.
Mr. Missal. I think you see great discrepancies among the
regional offices in terms of the backlogs they may have, how
quickly they can get through the processes. And, again, I think
one of the major issues is leadership and oversight of
particular offices there. And so that is something VA should
look at, to make sure that they have the proper people doing
it, that they are following the policies, and they are moving
the claims through as quickly as possible.
Ms. Lee. What would be your oversight role in that, if any,
to determine whether or not they are compliant with what we
have requested? Do you audit them? Or review?
Mr. Missal. We could audit. We could do a less formal
process, which would be a review of some kind.
Obviously, when we look at something, we generally make
recommendations. We keep a report open until they complete the
commitments they made in the recommendation. If we think later
on that they have fallen back or they haven't fulfilled what
they had said they would and they look like they had at one
time, we will definitely go back in and look again.
Ms. Lee. So I would have to make that request of you.
Mr. Missal. You have just made it.
Ms. Lee. Thank you very much.
Mr. Dent. Thank you, Ms. Lee.
At this time, I would like to recognize the gentleman from
West Virginia for 5 minutes, Mr. Jenkins.
ALLOCATION OF FUNDING INCREASE
Mr. Jenkins. Thank you, Mr. Chairman.
There were discussions relating to your budget, and from
the appropriations standpoint, a $159 million annual budget.
You had this bump up. You identified 725 FTE equivalents, and
you identified 5 areas.
I want to talk about where you are putting the increased
funding this last year and into which of these categories from
an FTE--you mentioned you do investigations, you do audits, you
do contract reviews. I am curious about what staff increases in
the subcategory of investigations. And a followup on that
topic.
Mr. Missal. Sure. We have a number of offices which include
investigators, and so we probably have more offices with
investigators than any of the other directorates, just because
we want to cover as broad an area as possible across the
country. So what we have done is we have taken a look at all of
the offices, the current staffing, and whether or not it makes
sense to add staffing to that.
My personal view is we have a number of smaller offices of
investigators. We might have two or three. And, to me, it is
just harder to be as productive as you can be. If you are going
to work in teams and you have people going off doing different
things, it is just harder to do that.
So one of the things we are looking at is building up our
smaller offices, because we think that will actually increase
the productivity. It is almost as if one plus one equals three,
as opposed to two.
Mr. Jenkins. Can you share a breakdown of this, under the
fiscal year 2017 budget increase that you got and the ability
to hire new people, where in these five subcategories you are
actually putting these FTEs?
I hear you about the office size and the number of offices.
What I am interested in is what your priorities are. You are
putting more staff into contract review? More staff into
audits? More staff into investigations? I would like to see
where this staff is going and also, moving forward, where you
think they need to go.
You know, a little bit of this is audit the auditor. And my
curiosity, while we appropriately have asked lots of questions
about you holding the VA accountable to what we expect from the
VA--I have two VA hospitals in my district. I hear oftentimes
from employees, whistleblowers, about their concerns, what they
are seeing. And we, of course, turn these folks, appropriately,
over to your office.
Mr. Missal. Right.
TIMELINE IN RESPONDING TO COMPLAINTS
Mr. Jenkins. Tell me about your timeliness in terms of
responding to complaints, the followup with that whistleblower.
Because we often hear concerns that we have made the call, we
don't get the time and attention, we don't get substantive
followup.
How do you evaluate your performance in responding to
whistleblower concerns, the employees of these VA hospitals?
Mr. Missal. With respect to responding to whistleblowers,
we definitely can improve our performance there.
We have a hotline group. The hotline group is in our
management and administration group. And they are the ones who
take the first look at the approximately 39,000 contacts we get
to our hotline.
Every one of those is triaged. So we triage each one of
those 39,000. Some we can immediately deal with; others require
additional review. Others we will share with some of the other
directorates. If somebody says, one of your medical centers in
West Virginia, they say there is a problem with a doctor, that
will immediately go to our healthcare group. They will look at
it to see what should be done. So, if it is an urgent
situation, we look at it very, very quickly.
But to your question about where am I looking to increase
staff, hotline is one of them. I think we can do more. We can
personalize more of the responses that we give to individuals.
And the other area is in our healthcare inspection group.
Right now, we have over 200 staff in investigations, over 200
staff in audit. We have about 125 in health care. And given the
focus of VA on health care, we need to increase that pretty
dramatically.
Mr. Jenkins. Well, I am very interested in serving our
veterans and the employees who are taking care of the veterans.
I appreciate the interest in the hotline needing to staff up,
but I appreciate your sensitivity of the statement, quote, ``We
can improve.''
I will be looking for that improvement so that those who
are contacting the Inspector General Office with a concern,
that they don't feel like that is going on deaf ears. They
don't hear back at times, and they think nobody is listening. I
want to make sure you are listening. And from a staffing
standpoint, that is why I want to see, are you investing in the
area for the personnel to make sure we are responding to those
concerns.
Mr. Missal. I agree. Responsiveness and prompt
responsiveness is very important to me, because if we don't
have it, we are not going to have the confidence that we need
to have for veterans and others to think we are doing our
oversight work properly.
Mr. Jenkins. Thank you.
I yield back.
Mr. Dent. Thank you, Mr. Jenkins.
At this time, I recognize the gentleman from Georgia, Mr.
Bishop, for 5 minutes.
Mr. Bishop. Thank you very much.
Your audit report found that the VA made about $247 million
in improper GI Bill payments and $205 million in missed
recoupments annually.
GI BILL BACKLOG AND PROCESSING DELAYS
On 17 March, which was last Friday, the VBA website posted
a message stating that veterans and servicemembers can expect
processing delays due to an internal audit.
When do you expect that the audit will be completed? How
many current GI Bill claims are currently backlogged? And when
will the VBA be able to start working through the growing GI
Bill backlog?
Mr. Missal. I don't have the specific numbers there.
The report that you mentioned identified significant issues
with both the payment and the recoupment, and we projected out
what the impact could be if they didn't fix it as quickly as
possible. So we are following up on that, since they are open
recommendations, with respect to that report and that issue to
make sure that they fulfill their commitments.
Mr. Bishop. Do you expect any criminal investigations to
come out of that?
Mr. Missal. We do have criminal investigations as it
relates to the GI Bill funding. And we have had a number of
prosecutions, and we have active cases right now.
Mr. Bishop. Okay. No further questions. Thank you.
Mr. Dent. Thank you, Mr. Bishop.
At this time, I would like to recognize Mr. Taylor.
Mr. Taylor. Thank you, Mr. Chairman.
TREATMENT OF INELIGIBLE VETERANS
I have a question, and this is something that maybe you
don't get often from this side, I think. But, you know, I
walked through my VA and asked a lot of questions, and it was
pretty clear there were some folks there that probably were not
eligible for the care that they were receiving.
And, again, I mean, from this side, the political pressure,
I think, is to treat veterans and be pro-, pro-veterans. But if
there are folks that are not supposed to be--you know, they are
not rated or they are not supposed to be treated there, then
that is, you know, a pretty excessive cost potentially.
My question is--and, like I said, I walked through and I
saw this and asked a question, and they definitely verified
that. Have there been any reports that are out there, or have
you guys looked into it, as far as potential veterans that are
being treated that aren't necessarily supposed to be being
treated at the VA?
Mr. Missal. I don't believe there has been any report
certainly since I have been there. I don't know how far back to
go to know whether or not we have done that. Certainly in
recent time I don't believe we have looked at it.
We do look at the Health Eligibility Center, which
determines eligibility for care. We have done a lot of work in
that area, but not to see whether people are getting services
who should not be.
Mr. Taylor. Obviously, we want everybody to be treated, of
course. That is not the point. But, as you can imagine, if
there are folks who are not rated to be treated but being
treated at a VA, that could be tremendous costs across the
whole system.
So is that something that you would be interested in taking
up or doing a report on to figure out? You know, ``I have the
eligibility right here,'' and veterans know if they are
eligible or not, based upon, you know, what is there, of
course.
So is that something that your office would be willing to
do and a report on to figure out, okay, are there, across the
board, in different--whatever the treatment might be, but folks
that are--not necessarily that they are abusing it, but if they
are not supposed to be treated, then they are not there. And
then what is that cost to the VA? Is that something that you
would be willing to do a report on?
Mr. Missal. We would certainly look at it to see if it is a
systemic or other large problem. Any information that you have
that would be helpful to us, we would really value getting it
from you.
Mr. Taylor. All right. I appreciate that. I would love to
follow up with you on that to get that report done. Thank you.
Thank you, Mr. Chairman.
Mr. Dent. The gentleman yields back.
At this time, I recognize the gentleman from Ohio for 5
minutes.
Mr. Ryan. Thank you, Mr. Chairman.
I want to review the numbers from your testimony for a
minute here.
As I understand it, your organization has a return of
investment of $30 for every dollar of Federal funding, which is
pretty impressive. Despite that, the skinny budget from the
President is proposing to flat-line the VA discretionary
programs, which you are included in. And so my concern is that
this one-size-fits-all plan ignores your planned staffing
increases designed to champion and protect our veterans health
care and benefits, as you already do, by reducing costs.
In addition to failing to meet this promise, if I continue
to follow the math correctly, we talk about a potential repeal
of the healthcare bill would cause 24 million Americans to lose
their health care, which would increase veterans' participation
into the VA program and generate an even larger need for you
and your oversight and the precious funds that you have.
UNMET FUNDING NEEDS
So the question is, is that a reasonable estimation to say
that $30 million would be the number if we follow the
President's intended funding? And if the VA sees an increase
from the repeal of the current healthcare system options that
many veterans take advantage of, would your staffing and budget
needs also increase?
Mr. Missal. It likely would. I don't know and I haven't
seen the numbers of what the impact would be if there is a
repeal, but any type of increase in the use of VA, whether it
is the healthcare system, whether it is benefits, would then
cause us to have additional responsibility.
So there are other variables that could come into play that
could impact the funding that we have and our ability to do
effective oversight.
Mr. Ryan. So you are flat-lined. And for every dollar, you
save 30.
Mr. Missal. Correct.
Mr. Ryan. And if 24 million people lose their health care,
I don't know what the exact number would be, but we would
assume that hundreds of thousands, at least, would be
veterans----
Mr. Missal. Right.
Mr. Ryan [continuing]. Who would then go into the VA system
because they wouldn't have anywhere else to go. So that, to me,
seems like it would have a huge impact on the VA and your
ability to try to continue to save us money.
Mr. Missal. Right.
And if I could just add one thing, on the 30 to 1, that is
the amount of dollars that we save or the impact that we have.
We are one of the few IGs that also has healthcare
responsibilities. And so on those, it is not a dollar return.
What you are talking about is helping to save lives, helping to
have better medical care. And so that should be on top of the
30 to 1. And to use a commercial, we consider that priceless
and very important to what we do.
Mr. Ryan. Excellent. Thank you.
Mr. Dent. At this time, I would like to recognize the
gentleman from Arkansas, Mr. Womack, for 5 minutes if he has
questions.
HIRING FREEZE EXEMPTIONS
Mr. Womack. I won't need all that time. I just want to go
back to hiring freezes for just a minute.
You detailed in your written statement that, based on
guidance from OMB and OPM, you have the authority to determine
what positions in the OIG are subject to the Presidential
memorandum on the freeze of hiring. You also stated you
exempted some on the basis they were involved in national
security or public safety responsibilities.
And I apologize if this has already been covered. I got
here late today.
With that in mind, can you give us an example of a position
within the OIG that involves national security or public safety
responsibilities that would be exempted?
Mr. Missal. Sure.
On public safety, we have a number of positions that we
feel should be exempted under public safety and we have
exempted under public safety, such as criminal investigators,
such as auditors looking at significant programs which could
have a significant impact on taxpayer dollars, and our
healthcare inspectors and providers who are looking at the
medical centers, medical facilities to help make the healthcare
providers at VA work more effectively.
Mr. Womack. How tight are those conditions? In other words,
you could probably make an argument from agency to agency that
a lot of these types of positions are geared to do exactly what
you just said. So is it as simple as giving it a general
umbrella that because they work in this particular area that we
can automatically exempt, or are they pretty tightly reserved
there?
Mr. Missal. We are looking at every position on a case-by-
case basis. We are taking the memorandum very seriously. We
were asked to consult with OMB and OPM, and we did so. And they
agreed with our plan in terms of the types of positions we were
going to grant exemptions to.
Mr. Womack. In those positions, what would be the churn
rate, typical churn rate of in and out? Are these revolving-
door positions, or are these people who have been there a long
time? How would you characterize the general character of this
particular lot of employees?
Mr. Missal. Our turnover rate is relatively low. We have a
very dedicated and committed staff that is really focused on
our important mission. And so when people come to us, they stay
for quite a few years. Our hope is that when they come to us,
that they are going to be there for a long time.
Mr. Womack. And then, finally, for those that would not fit
under that category that you discussed a moment ago, what would
be an example of those kinds of positions?
And then, if you can, is there a general breakdown as to X
percent of my team should be exempted and X percent could be
not considered for an exemption status?
Mr. Missal. Right. A lot of the administrative positions
that we have, I think, are harder to make the public safety or
national security argument for. You are right; I mean, you can
make arguments for virtually everything, because what we do is
help improve the VA's programs and operations, help make them
as effective as possible, and to ensure taxpayer money is spent
properly. Everybody in our office, to some degree, is focused
in on those two missions.
But it is hard to say at this time exactly how many we will
have. We estimate it is around 50 percent of the open
positions. But we are looking at them position by position.
Mr. Womack. That is all I have, Mr. Chairman. Thank you.
Thank you again for your testimony.
Mr. Missal. Thank you.
Mr. Dent. Thank you, Mr. Womack.
At this time, I recognize the gentlelady from California,
Ms. Lee, for 5 minutes.
DATA REPORTING BY RACE AND ETHNICITY
Ms. Lee. Great. Thank you again, Mr. Chairman, for giving
me a chance to ask my second round of questions.
I want to go back to the questions I asked you earlier with
regard to the disaggregation of data as it relates to ethnic
and racial inclusion in the business aspects and contracting
opportunities.
The ``National Veteran Health Equity Report'' ``released in
2016'' suggested that ``tools for measuring parameters of
interest by race/ethnicity should be incorporated into the next
generation of the VA electronic health record user interface.''
As this data base develops, interventions to reduce health and
healthcare disparities should be implemented and evaluated,''
especially identifying the causes of racial and ethnic
disparities in the VA.
Now, in this report, I didn't find the answer to some of
the questions I had--specifically relating to emergency rooms,
and wait times to see a doctor. I wanted to see, as it relates
to the average wait time in an ER, this data disaggregated by
race and ethnicity overall. Are all things equal? Are all wait
times not very good, or are all of them are great? Or for
veterans of color, is there a lower wait time? A higher wait
time?
I would like to get that information clarified, because I
have had personal experience with this. I have visited in
several emergency rooms in different parts of the country, and
looking at the population of veterans, there seems to be some
disparities there. I would like clarity on that.
Mr. Missal. Okay. That is something that we can look at and
we can see what data the VA has and what they should have as
well. At this point, we have not looked at those particular
questions.
Ms. Lee. Okay. Well I would appreciate you looking into
this. Because this is very serious, and I have seen many cases
in California that give me some concern. We need to address it.
NURSING PAY SCALES
Secondly, in a September 2016 report, you found that
nursing care was the top critical need occupation for fiscal
year 2016. To ensure adequate levels of staff to provide timely
access to care, of course, continuity of care is extremely
important.
Going back to the Oakland regional office--there is a real
discrepancy in the pay scale for registered nurses in the
Oakland-Fremont area. There are regional pay disparities, which
is causing a huge problem in retention at the VA outpatient
clinic. I think Fremont is 30 minutes away from Oakland--and we
can't figure out how to address these pay discrepancies, which
cause retention problems in the medical facilities. I wanted to
see if you found any recommendation on how to address that.
Secondly, there is not a nursing shortage--but there are
nurses, qualified nurses, who are unemployed and can't seem to
find a job. So I am wondering, if there are licensing issues
with the VA? Why is it that this gap still exists?
Mr. Missal. Right.
So we were asked legislatively to look at the largest
number of open positions. You have identified nursing as one;
there were five others that we looked at. And I think this was
our third year that we did it. We are going to be doing it over
5 years.
One of our recommendations was that VA needs to have a
staffing plan to do precisely the issues that you raise--to
make sure that they have proper staffing, it is allocated the
proper way, et cetera. And so we are still following up with
them to ensure that they do have that proper staffing plan, and
we will continue to do so.
Ms. Lee. I know they don't have a plan. I don't know about
other regions, but I know they just don't have it in my
district. And I know that pay disparities and discrepancies are
a problem in California. I also know that they are not hiring
nurses who are looking for jobs. So that is another layer of
trying to figure out what is going on. Also how are they
following up or are they just not following up?
Mr. Missal. I believe there was legislation introduced in
the last Congress about increasing pay for certain positions at
VA. And, you know, that could be one way to address the
situation.
Ms. Lee. Thank you very much. I appreciate your being very
candid with us in your answers.
Mr. Missal. Thank you.
Mr. Dent. Before we conclude, I would like to recognize Mr.
Bishop.
VA ANIMAL RESEARCH
Mr. Bishop. Thank you.
Just one matter. You recently received a letter, which was
copied to members of our subcommittee, from the White Coat
Waste Project requesting that you conduct an investigation
regarding animal experimentation at the McGuire VA Medical
Center.
Do you intend to undertake that investigation? And do you
have any idea how long that will take and whether or not--well,
could you just furnish us with whatever your findings are?
Mr. Missal. Sure. I got the letter about 5 o'clock last
night.
Mr. Bishop. Right.
Mr. Missal. I read the letter. I responded to the gentleman
who sent it, saying we will review it. And we are in the
process of reviewing it and will determine whether or not it is
something that makes sense for us to do.
Mr. Bishop. Thank you.
Mr. Dent. Thank you.
I have no further questions, although I will submit--I do
have questions, actually, but I am going to submit them for the
record for you to respond to, Mr. Missal.
And, again, I want to thank you and thank the ranking
member and all the members who attended today's hearing.
So, again, appreciate your testimony and your
responsiveness.
I should mention one thing before I adjourn. The
subcommittee's next hearing is Wednesday, March 29, at 10 a.m.
in this room. We are going to hear from outside public
witnesses.
So, having said that, this meeting is now adjourned.
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Wednesday, March 29, 2017.
PUBLIC WITNESSES HEARING
Chairman Dent Opening Statement
Mr. Dent [presiding]. Good morning. I would like to bring
to order this hearing of the House Subcommittee on Military
Construction and Veterans Affairs. Today we are going to take
testimony from public witnesses to hear the views of their
organizations on matters related to this subcommittee's
jurisdiction.
We welcome you all here this morning.
And I am happy to say that we were able to accommodate all
the witnesses who wished to testify regarding the fiscal year
2018 appropriations and oversight matters for MILCON-VA. As it
turns out, all the witnesses are commenting on VA issues.
I wanted to note that there are multiple appropriations
hearings today at 10 o'clock, so several subcommittee members
have conflicts and may not be able to join us or will be here
intermittently.
We will also be sure to share your views with them and with
the committee as a whole. So again, thank you for being here.
For public witnesses hearings we move quickly to
accommodate everyone. Each witness will have 5 minutes to
testify. I would not expect many questions, but if there are
any from members please try to answer them as briefly as you
can.
The full written testimony that each of you submitted will
be entered into the official record.
With that said, we appreciate that you have taken time to
share your expertise and viewpoints on current and future
veterans affairs issues with the committee and look forward to
a valuable meaningful discussion this morning.
Let me turn to the ranking member of our subcommittee, Ms.
Wasserman Schultz, for any remarks that she may have. I
recognize the gentlelady from Florida.
Ranking Member Wasserman Schultz Opening Statement
Ms. Wasserman Schultz. Thank you so much, Mr. Chairman, for
yielding, and I appreciate you agreeing to hold this important
public witness hearing.
Today's witnesses work tirelessly to assist our veterans
daily as they navigate the--as I have been increasingly
discovering--too often cumbersome VA system; the transition to
civilian life; and the physical, emotional, psychological, and
financial challenges that our veterans face upon returning
home. To best identify the needs of our veterans it is
important that we hear from them and partner with those who
know them best, our VSOs.
While the VA has made great strides in recent years, we
know our work is far from done. This type of hearing is vital
for us as appropriators and provides the opportunity to zero in
on the issues the American public and the veterans community
rely on this committee to address, particularly as we approach
our process of marking up our bill.
So thank you all for joining us today, and also thank you
for joining us yesterday at Leader Pelosi's VSO roundtable. I
look forward to participating in that going forward as well as
hearing your testimony this morning.
Thank you. Yield back.
Mr. Dent. Thank you.
Thank the gentlelady from Florida.
At this time I would like to ask Mr. Blake to please take
the seat. Mr. Blake is the associate executive government
relations with the Paralyzed Veterans of America.
Thank you for joining us, and you are recognized for 5
minutes.
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Wednesday, March 29, 2017.
PARALYZED VETERANS OF AMERICA
WITNESS
CARL BLAKE, ASSOCIATE DIRECTOR OF GOVERNMENT RELATIONS
Mr. Blake. Thank you, Mr. Chairman, Ranking Member
Wasserman Schultz. I appreciate the opportunity to be here
today.
Let me first say that we are pleased to be able to have
this opportunity once again. This used to be a regular
occurrence with this subcommittee, having the VSOs come before
you as outside witnesses, but that hasn't happened in a number
of years and we are pleased to have that opportunity once
again. We find this exchange very important.
I am here on behalf of Paralyzed Veterans of America, as
well as my partners in The Independent Budget, Disabled
American Veterans, and Veterans of Foreign Wars, who will also
be testifying before you this morning. We will be discussing
various aspects of the Department of Veterans Affairs funding
for fiscal year 2018, as well as advance appropriations for
fiscal year 2019.
This is our annual budget report that we have drafted. It
outlines our recommendations in detail about all of the funding
requirements of VA.
With the chairman's indulgence, we would like to submit
this into the official hearing record?
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Dent. Without objection, we will receive that.
Mr. Blake. Thank you.
You can also find this report at www.independentbudget.org,
and it can be downloaded there, as well.
Let me begin by saying that while we appreciate the
administration has stated that it intends to recommend an
increase in the Department of Veterans Affairs budget for
2018--less clarity about fiscal year 2019 as it relates to
advance appropriations--the fact is that the devil will be in
the details. There are still many questions that remain about
how the Administration will fund the priorities for the VA when
the more detailed budget comes out later this spring.
The fiscal year 2018 projections are of particular concern
for us with the Independent Budget. The previous secretary of
VA, Robert McDonald, actually testified last year that they
knew that their fiscal year 2018 advance appropriations
recommendations were not going to be sufficient to meet what
they projected to be demand; yet, Congress acted upon that
recommendation last year in the appropriations bill.
It will be critically important for this subcommittee, for
the full committee, for the House and the Senate to address
what we know is a shortfall that the VA itself identified in
continued funding for fiscal year 2018 that will come into play
beginning in October of this year.
We also believe it is necessary to consider the projected
expenditures as it relates to the Choice program. Obviously the
Choice program is a hot topic on the Hill, in the VA, and the
VSO community.
Last year in the VA's budget they projected as much as $5.7
billion in remaining funds for Choice. That was a year ago.
That number was revised to about $2.9 billion later through
the course of the year. Currently the VA is projected to have
as much as $1 billion remaining when the Choice program is set
to expire in August.
We support the legislation that has been moved by the House
that will relieve the VA of its authority based on the date of
expiration for the Choice program, but I would say that we
don't believe that the Choice program, as currently
constructed, is the optimal way forward. I don't think anybody
actually disagrees with that notion. I think it obviously needs
some changes, some improvements, or maybe something that is
just better.
But there are still a lot of questions remaining about how
the Choice--or how that concept will look going forward and the
funding associated with it.
The current Choice program is covered under emergency
designation as mandatory spending. What will that look like
beginning after August or beginning in the next fiscal year?
That is a serious question for us, a serious concern. Certainly
it is a serious issue that you all will have to grapple with.
As outlined in our budget, the I.B. recommends
approximately $77 billion in total medical care funding for
fiscal year 2018. Congress previously appropriated about $70
billion; that takes into account collections, as well.
I think the important thing to understand about how the
Independent Budget makes its recommendations is we provide an
overall snapshot of exactly what it costs to provide care from
the VA, and that is a combination of things, from providing
care as an inpatient or in the system of care of the VA,
whether it be in the community, whether it be through Choice.
Our view is the total view of what it actually requires to
provide services to VA--or to veterans secondary to VA. That is
outlined in greater detail in our budget report.
There are a couple of issues I would like to highlight
quickly that are included in our recommendations.
One is continued funding and increased funding for women
veterans programs. Obviously this has become a growing issue.
This is a fast-growing population that VA is serving. We
recommend about $110 million additional dollars in 2018, $120
million in fiscal year 2019, and that is explained in detail.
Another hot topic is reproductive services, assisted
reproductive technology, that was included in the
appropriations bill, which we thank you all for, last year. It
carries us, as we understand it, through the end of fiscal year
2018. It is critical that that program gets carried forward.
And then lastly, the Staab ruling involving emergency care
services. Everyone believes that the VA has interpreted the
ruling--misinterpreted the legislation that was passed all the
way back in 2009 about its obligation for meeting emergency
care costs for veterans, and they now are on the hook for what
may be as much as $10 billion over the long haul because of
their decision to not pay for those services, as they are
required by law.
Lastly, we include a recommendation for medical and
prosthetic research to the tune of about $713 million, along
with additional money targeted at the Precision Medicine
Initiative that the VA has designated. That would bring the
total for research up to about $778 million. It cannot be
overstated enough the importance of research as a part of the
mission of VA.
With that, Mr. Chairman, I thank you for the opportunity to
testify. Be happy to answer any questions that you or the
members of the subcommittee may have.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Dent. Thank you very much for your testimony, Mr.
Blake. We really appreciate it.
We haven't seen a detailed budget yet for the VA,
obviously, but we know from what the administration has
provided in the skinny budget that your fiscal year 2018
Independent Budget comes in at more than $9 billion above the
President's request. Since the budget treats VA far better than
any other domestic discretionary program or agency, I don't
know how our subcommittee would be able to provide that kind of
funding increase.
PROGRAMS WITH THE MOST URGENT NEED FOR INCREASED FUNDING
So I only have really one question: Realizing that we won't
be able to handle your total request, which areas can you
identify within the VA that have the most urgent need for
increased funding?
Mr. Blake. Well, I think there is no question but the
medical care section, particularly under medical services, is
the most critically important.
To understand how the I.B. frames its recommendation, our
medical services recommendation, if you were to line it up with
what the VA recommends for its dollars, the VA's comparable
recommendation would look like their medical services, plus
their medical and community care account, plus their Choice
program funding that they have planned.
So that is how you align what we recommend. We don't break
those out because truthfully, from our perspective it is a
complicated proposition to figure out what community care
spending might actually be.
So medical care in particular is by and large the most
important.
I think where you see one of the big deviations in our
recommendations from the administration is in the construction
area. That has been the case for many, many years now. One of
our long-running frustrations is particularly in the area of
major construction, to a lesser degree minor construction.
The VA has billions of dollars in projects that are setting
in the queue, and my colleague from the VFW will talk about
that so I won't steal his thunder in that respect. But that is
a serious concern that we have because there hasn't been enough
commitment.
From the I.B.'s perspective we have considered in our
policy agenda, you know, innovative ways to address the
construction issue, recognizing that that part of VA is under
scrutiny in places like Denver, New Orleans, Orlando--places
where we are not satisfied with how that was handled; I know
you all are not satisfied how--with how those things were
handled.
So construction remains a serious issue.
I think in light of the VA's announcement about its plans
for information technology, a star needs to be put next to that
because it is going to be hard to rationalize the cost in I.T.
with what the new secretary has stated as his desired goal, to
move towards a commercial off-the-shelf, and how that might
impact the funding.
I.T. has increased year over year for a number of years
now, but we don't know what impact that this decision might
have on that decision by the VA moving forward.
So I think I.T. is critical, as well.
We try to take a view that a number of the administrative
accounts are--we take a conservative approach to a lot of the
administrative accounts. You see that in our recommendations
for medical support and compliance, general administration,
some of the areas where we believe there is probably too much
bloat in the VA and that--we don't necessarily ascribe to the
belief that those should just increase for the sake of
increasing.
So I think if you look at our recommendations you will see
that we try to treat those fairly without going out of the
bounds of what seems reasonable.
So short answer to your question, medical services for
sure, the construction areas for sure, I.T. for certain.
I also will just sort of touch on the issue that my other
colleague from the DAV will mention: funding for the Veterans
Benefits Administration. The number of claims is not going
down.
We still also have to grapple with the issue of appeals
modernization, the cost associated with that. And I think the
subcommittee is going to have to figure out how to rationalize
what the authorizers are trying to do, along with the VSO
community and the VA, in appeals modernization and how that
impacts the larger claims process, as well.
Mr. Dent. Ms. Wasserman Schultz.
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
ASSISTED REPRODUCTIVE TECHNOLOGY
First, thank you for your service and your testimony.
On the assisted reproductive technology language, I was
proud to join my colleague, Congresswoman Brownley, in making
sure that that language was there, and we followed up with a
letter to the VA to make sure that there was a clear
understanding that the idea is that this is not just a 1-year
policy and that we expect that they would permanently make sure
that we can provide this assistance and coverage. So as someone
whose--two of three children were conceived through in vitro
fertilization, so I certainly know what it is like to struggle
with the challenge of infertility no matter what its cost.
PARKING AT VA FACILITIES
I do want to ask you on--about the challenges that your
members might have with parking at VA facilities, because I,
you know, represent the Miami area, and I--when I went to the
University of Florida, I have never seen a parking problem like
they have at the Miami VA--and that is saying something.
So come to find out that it is actually against the law to
shuttle employees of the VA, as opposed to shuttling veterans.
So when a medical center comes up with a solution to park
employees in an offsite lot and shuttle them, versus parking
veterans at an offsite lot and shuttle them, or have veterans
park at the further part of the--end of the parking lot and
shuttle them versus employees, that seems to me to be somewhat
backwards.
So I am going to be filing legislation--likely along with
Chairman Roe and hopefully Chairman Dent--and we are working
with the secretary--to correct that. But I wanted to see--I
would imagine that it is a unique and particular problem for
the paralyzed veterans, so----
Mr. Blake. Well, ma'am, I would say, being a regular user
of the VA--and I go to the Richmond VA. I have been using that
VA for 17 years now, and all I have seen is the parking lot
grow to the point that they have knocked down towns around it
to build out more parking lot. If you don't go there--if you
have a 9 o'clock appointment and you are not there at 6:30 or 7
o'clock you are not parking in the parking lot.
I can make the argument that that is a reflection of the
demand being placed on the system. Parking is sort of a
microcosm of the larger demand for health care services.
And that is the demand on a facility like Richmond. Many of
the major VA hospitals are like that.
I was not aware of the legal challenge you referenced
there, but it seems kind of silly. I am sure there are some
liability issues that make it more complicated than I would
like to believe, but----
Ms. Wasserman Schultz. Well, the secretary----
Mr. Blake [continuing]. But there is no question but that
parking is a serious problem. I mean, many of the facilities
have brought in valet as an option. All that has done is
squeeze, you know, drive-up-and-park parking. I mean, it is
certainly a major issue.
Ms. Wasserman Schultz. It is hard to imagine what member of
Congress thought it would be a good idea to prohibit employees
from being shuttled, but hopefully we are going to be able to
correct that.
PARALYZED VETERANS HAVING ACCESS TO CHOICE PROGRAM
And then the other question I had was how are paralyzed
veterans experiencing access inside and outside the VA to the
Choice program?
Mr. Blake. I would say that primarily our members don't use
Choice because there is not a whole lot of comparable systems
to the VA's SCI system of care outside of VA. You do have 14
model systems of care around the country. The majority of those
don't even meet CARF certification, which is one of the--sort
of the overarching rehab certifications used for many of the VA
SCI systems of care.
We encourage our members to use VA's spinal cord injury
system, particularly for annual physicals and preventive care.
There are barriers and challenges to that.
But by and large our members have not taken advantage of
the Choice option. I do know that, much like many of the other
veterans that have taken advantage, they have struggled when
they have taken advantage of the opportunity.
I think one of the common problems our members have seen is
when taking advantage of the opportunity to use Choice, they
find that waits are just as long in the community to receive
care or that the service that they are trying to avail
themselves of is not necessarily available in the community in
which they live.
So I think that in the event of our members using Choice,
their experiences are not uniquely different necessarily than
what the larger population that is taking advantage of it have
experienced.
Ms. Wasserman Schultz. Thank you.
Yield back.
Mr. Dent. Mr. Taylor.
Mr. Taylor. Thank you, Mr. Chairman.
Thank you for--appreciate your service, appreciate that you
are in Virginia, and----
EMERGENCY CARE COURT DECISION
Mr. Blake. Yes, sir. Thank you.
Mr. Taylor [continuing]. And certainly appreciate your
advocacy. So thank you very much.
Just really quick, emergency care in the VA paying by law:
Can you just expound upon that for people like me who are new
here and haven't seen that?
Mr. Blake. So in 2009 legislation was enacted--and I am not
the subject matter expert, so I will freely admit that--
legislation was enacted that basically obligated VA to
provide--to pay for your care when you have to get emergency
care in the community.
The VA, as I understand it, has interpreted that
legislation so that they don't--they have not. This gentleman,
Staab, sued the VA because he had an experience where he had
had to take advantage of emergency care in the community and
his bills were not paid. And the court at the federal level
ruled in his favor.
The VA is currently appealing a ruling that everyone knows
they are going to lose. At every level that has already been
determined.
I think the secretary maybe understands this, but they
continue to resist what is the inevitable. And because of their
resistance, the bill is just continuing to build.
And so the $10 billion cost is over I think a 10-year
period, but the current-year cost for the reimbursement is like
$1 billion. And it is sort of a trickle-up effect, but it stays
in that realm.
Bottom line is the VA is on the hook to pay for these
emergency bills for well over $1 billion each fiscal year now,
and they are not paying any of that.
Mr. Taylor. Thank you.
Thank you, Mr. Chair.
Mr. Dent. Thank you, Mr. Taylor.
At this time I recognize Mr. Bishop.
Mr. Bishop. Thank you very much.
And welcome, Mr. Blake.
CONSOLIDATING COMMUNITY CARE PROGRAMS
As you are aware, in 2015 the VA delivered a plan to
Congress outlining steps to consolidate community care
programs. The plan would consolidate and streamline existing
community care programs into an integrated care delivery system
and enhance the way that VA partners with other federal health
care providers, academic affiliates, and community providers.
But the Choice and Community Care programs are currently
funded from different accounts. There seems to be some problems
with their being funded from two accounts--for example, with
the Choice being funded from a subsidy-managed account at VA
and Community Care being funded at the medical center level.
That can present inconsistency of the implementation there,
depending on what the local budget is at the community level,
at the medical center level.
Can you speak to that? Do you think that the provisions of
Choice and Community Care programs should be funded from the
same account, or you think that that would provide better
services to our veterans?
Mr. Blake. Well, Mr. Bishop, the I.B. organizations
generally supported what the VA had laid out as a plan back in
2015 for its consolidation. We believe that that is a
reflection of the right way forward.
Continuing to have clearly defined, separate programs, from
Community Care over here in VA and Choice, is not the way
forward. I think VA recognizes that.
When the VA presented its plan in 2015 to the authorizers
almost universally the committee supported it. Yet, we seem to
have reached a point of collective amnesia that they might have
actually supported that. But I think that is the right way
forward, and I think the VA has been working towards that end
for the last year-and-a-half.
There are a number of legislative authorities that are
still hanging in the balance that are required to effect those
changes.
At the end of the day, the I.B. has supported a singular
Community Care program. Our policy agenda, which we released
back at the end of January and can also be found on our Web
site at www.independentbudget.org, explains our view of how
that whole integration process should work, our own
recommendations to affect the implementation of that, and how
it should work.
But I think it is not a good idea to continue forward
indefinitely with Choice over here and Community Care over
here. If nothing else, you run into the problem we had early
last year, where the VA took advantage of its Community Care
and over-obligated itself, and then they were forced to come to
the Hill and say, ``Hey, we need to borrow money from
ourselves, which is in the mandatory account of Choice over
here, just to be able to pay the bills that we had obligated
for care in the community.''
So I think that that creates an obvious problem for the VA
in managing its total Community Care----
Mr. Bishop. Thank you very much.
Mr. Dent. Thank you, Mr. Bishop.
Mr. Blake, thank you so much for your testimony. We
sincerely appreciate it, and we are going to take the rest of
your remarks under advisement. So thank you, and----
Mr. Blake. Yes, sir.
Mr. Dent [continuing]. We appreciate your testimony before
us today.
Mr. Blake. Thank you very much.
Mr. Dent. At this time I would like to recognize Mr.
Varela--Paul Varela. Paul is the assistant national legislative
director at the DAV, Disabled American Veterans.
So, Mr. Varela, we are pleased to have you, and when you
are settled and ready we will recognize you for 5 minutes.
Again, thank you for joining us.
Mr. Varela. Thank you, Mr. Chairman.
Mr. Dent. You are recognized for 5 minutes.
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Wednesday, March 29, 2017.
DISABLED AMERICAN VETERANS
WITNESS
PAUL VARELA, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR
Mr. Varela. Chairman Dent, Ranking Member Wasserman
Schultz, and members of the subcommittee, good morning. Thank
you for providing DAV and our Independent Budget partners with
an opportunity to discuss our recommendations for fiscal year
2018 funding requirements essential to the Department of
Veterans Affairs' ability to efficiently process and deliver
benefits to veterans, their families, and survivors.
As one of the co-authors of the Independent Budget, I will
focus my comments on resource requirements for programs within
the Veterans Benefits Administration--VBA, and the Board of
Veterans Appeals.
Compensation services is responsible for processing claims
related to disabilities and other non-disability-related
claims, such as those based on changes in dependency status and
award adjustments based on veterans returning to active duty.
Additionally, VBA is responsible for processing local-level
appeals.
For fiscal year 2018 the Independent Budget recommends
increasing staff by 750 new FTEE. This staffing increase is
needed to address the rising disability rating claims backlog,
the appeals backlog, and backlog of non-rating-related claims.
Today VBA is responsible for roughly 380,000 appeals at
various stages in the appeals process. Of the 750 new FTEE
request, we recommend that 1,000 FTEE be dedicated to driving
down the appeals inventory. With this infusion of much-need
manpower we estimate the appeals inventory could be reduced to
a manageable level within the next 3 years.
Next, vocational rehabilitation and employment services,
VRE, provides critical counseling and other adjunct services
necessary to enable service-disabled veterans to overcome
barriers as they prepare for, find, and maintain gainful
employment. For fiscal year 2018 the Independent Budget
recommends increasing staff by 266 new FTEE.
Over the past few years VRE program participation has
increased steadily without commensurate staffing increases.
Furthermore, as VBA continues to expand VRE eligibility to more
service-connected veterans due to increased claims processing
and changes in law, we project that total program participation
for fiscal year 2018 will grow by at least 5 percent, for a
total caseload of close to 155,000 participants. Therefore,
commensurate staffing levels are critical to ensure VRE
services are delivered in a timely and efficient manner to
facilitate successful program participation.
Finally, the Board of Veterans Appeals must be permitted to
on-board the full complement of FTE that was authorized for
fiscal year 2017. Congress authorized the Board of Veterans
Appeals a total of 922 FTE for fiscal year 2017. To date, they
have only been able to increase their FTE by roughly 880.
The issue of timely and efficient appeals processing has
received considerable attention and been the subject of much
debate--rightfully so. On average, it can take close to 5 years
to get a resolution on an appeal that is being considered by
the Board of Veterans Appeals.
As I am sure we can all agree, subjecting veterans to a 5-
year wait period in any capacity is simply unacceptable, and
they are counting on us to correct this inequity.
However, there is some good news. Congress, VA, the
Independent Budget partners, and other stakeholders have been
working diligently to reform the appeals process to make it
less complicated and more efficient overall. This reform has
often been referred to as ``the new framework.''
Legislation has been introduced in both the House and
Senate, and we are hopeful it will be enacted into law this
year. We believe this will provide veterans with more timely
and accurate decisions while protecting their rights.
However, regardless if appeals reform legislation becomes
law, an essential component going forward will be adequate
resources for the Board of Veterans Appeals to process not just
appeals within the new framework, but processing equitability
for appeals within the current inventory in a timely and
efficient manner.
We must ensure that appeals languishing within the current
system are not treated as a lesser priority in favor of a more
expeditious appeals processing within a new system. Each and
every veteran within the appeals process must be treated fairly
and equally.
Chairman Dent, Ranking Member Wasserman Schultz, and
members of the subcommittee, thank you again for this
opportunity to present the Independent Budget's resource
recommendations for fiscal year 2018, and I look forward to
your questions.
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Mr. Dent. Thank you, Mr. Varela.
ADDING MORE VBA STAFF OR THE USE OF TECHNOLOGY
And just wanted to ask one question: The Independent Budget
includes a large fiscal year 2018 request for more VBA staff.
Do you feel that additional staff are the ultimate answer to
keeping the disability claims backlog down, rather than the use
of technology?
Mr. Varela. They are symbiotic. They are both interrelated.
You are going to need--as we can see, VBMS has given the VA
quite a lift in claims processing. They were able to keep
processing record number of claims each year.
But in addition to that, while they were making those
strides they diverted a lot of their workforce from the appeals
workforce to process those claims. So what that tells you is
that yes, you have the I.T. component that is helpful, but you
still need the manpower as well, and these two things are
interrelated.
Mr. Dent. Thanks.
I would recognize the ranking member, Ms. Wasserman
Schultz.
HIRING FREEZE AND PROCESSING CLAIMS
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
Mr. Varela, given the administration's hiring freeze and
your organization's position that staffing levels need to be
addressed, how does the hiring freeze affect our ability to
achieve that goal?
Mr. Varela. It is my understanding that recently some
positions within the Board of Veterans Appeals have been
exempted so they can reach their full complement of 922 FTE.
They probably won't get all of that, but they will get most of
it.
Without the bodies to do the work, every day that is
delayed in hiring new personnel to do the work is an extra day
of delay in the claims and appeals process.
Ms. Wasserman Schultz. So is it your impression that the
claims process is negatively impacted by the hiring freeze?
Mr. Varela. Yes, it is.
Ms. Wasserman Schultz. Thank you.
Mr. Dent. Mr. Valadao.
Mr. Valadao. Thank you very much for your service and for
being here today.
TRANSITIONING SOLDIERS TO OBTAIN LICENSES AND CREDENTIALS
In the Independent Budget's agenda that you released this
year you mentioned the need for Congress and the Department of
Defense to work together to assist soldiers who are
transitioning from civilian life to obtain occupational
licenses and credentials. Recently the senior enlisted
noncommissioned officers from each service testified before
this committee and talked extensively about credentialing being
one of their top priorities in helping prepare servicemen and
women to transition to civilian careers.
Now, I know some progress has been made in the Department
of Defense, but to your knowledge, has the VA been working with
the services to assist with this issue? And in your opinion,
how can the VA work with the services and States to streamline
the process for transitioning soldiers to obtain these licenses
and credentials?
Mr. Varela. I believe the VA has been very supportive of
that cross-certification. What it really boils down to is the
licensing and certification that you get in the service has to
translate to what is acceptable within the States.
So it is going to be a matter of not just what we can do
here with the VA--which they are very supportive of that; DAV
also has a resolution that calls for Congress to enact
legislation to make that happen--but we have got to get that to
trickle down to the States for them to say, ``Yes, that
credentialing is acceptable,'' so that a nurse from the
military can simply just come out of the military and be a
nurse in any State.
Mr. Valadao. And yes, you pointed out the States, but here
at the federal level what do you think we can do to be of
assistance to streamline that or--there is probably not a whole
lot.
Mr. Varela. Yes.
Mr. Valadao. A lot of it falls on the State.
Mr. Varela. Here at the federal level we have to ensure
that Congress makes it a requirement for the DOD to say that,
``You will outline your certifications to either match what is
acceptable within the State or somehow establish those
partnerships,'' you know, force them to say, ``We need you to
set up a program that allows those skills and credentials to be
translated directly into the community.''
Mr. Valadao. Well, thank you.
And I yield back.
Mr. Dent. Thank you, Mr. Valadao.
Recognize Mr. Bishop.
Mr. Bishop. Thank you.
Welcome, Mr. Varela.
The chairman emphasized--and, of course, I am equally
concerned about the overall rise in the disability claims and
the growing appeals claims backlog. And, of course, I agree
with you that the I.T. investments will supplement and augment
addressing that.
LIMITATIONS ON APPEALS WHILE THE RECORD IS SUBMITTED
But one of the things that the VA has recommended and I
think the authorizing committees have been considering, with
which I have had some concern, is that they want to limit the
appeals and the opportunity for veterans to supplement the
record while it is pending, once it has been submitted, which
is another opportunity for veterans to provide more current
medical information to bolster their claim. And, of course, the
department has said that that adds to the backlog and that it
makes it more difficult for them to alleviate that backlog.
So there is some tension there between making sure the
veteran gets full consideration, and also expediting the
appeals or the reconsideration. What is your view in terms of
how to deal with that situation?
I have always, and I think the VA has historically, wanted
to resolve that in favor of the veteran by allowing the veteran
to submit any information at any time which would allow the
more favorable consideration of their claim. How do you feel
about that and the legislation now that is moving forward that
would limit the veteran's ability to do that?
Mr. Varela. Okay. So there are two tracks there.
One is the current environment and a veteran's ability to
submit evidence. In the current environment that has to be
maintained because you are dealing with crucial benefits that
can be awarded, effective date issues. And as you mentioned,
sometimes it is not easy for veterans to come up with the
evidence at a particular juncture, so they need to have an
opportunity to submit that.
And we understand it is additional work for the VA, but it
is work on behalf of disabled veterans. So that is where the
efforts should be.
In the new environment, in this proposed new framework,
there are still opportunities to submit evidence, particularly
if a veteran wanted to go to the Board of Veterans Appeals. It
is limited. We are working out the finer details and what
happens if you submit evidence after that, but we are very
comfortable that we will still be able to preserve that
effective date to that filing and allow that evidence to be
considered either at the board or at the VBA level.
Mr. Bishop. Yes. That is what the rub is, and I don't quite
know how to resolve that because my caseworkers have been able
to supplement the records many times with medical evidence that
the veteran didn't initially have or didn't submit and end up
with a positive outcome.
But if they are cut off and shut out from being able to do
that until after a decision is made then they have got to start
all over again, which, again, is a protracted work for the VA
as well as anxiety for the veteran.
Mr. Varela. Yes.
Mr. Dent. Thank you, Mr. Bishop.
And, Mr. Varela, we appreciate your testimony and appearing
before this subcommittee today. Thank you very much.
Mr. Varela. Thank you, Mr. Chairman.
Mr. Dent. At this time I would like to invite Carlos
Fuentes, director, National Legislative Service for the
Veterans of Foreign Wars, VFW. So we welcome Mr. Fuentes,
Carlos Fuentes, before us today.
And with that, you are recognized for 5 minutes.
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Wednesday, March 29, 2017.
VETERANS OF FOREIGN WARS
WITNESS
CARLOS FUENTES, DIRECTOR NATIONAL LEGISLATIVE SERVICE
Mr. Fuentes. Chairman Dent, Ranking Member Wasserman
Schultz, and members of the subcommittee, on behalf of the men
and women of the VFW and our auxiliary, I do thank you for the
opportunity to present our views on VA's budget.
I would like to first start by thanking you for your hard
work last year on fiscal year 2017 appropriations. And because
of your hard work, the MILCON-VA appropriations bill was the
only one to have completed regular order and, as a result, VA
is the only department with full fiscal year 2017
appropriations.
Mr. Dent. Could you say that again? [Laughter.]
Mr. Fuentes. And we have seen the impact on the number of
departments who are operating on the continuing resolution, and
no other sticks out more than DOD. And I am sure you are also
tracking that part of the military construction aspect of the
jurisdiction.
Yet, those appropriations levels that were included in the
conference report were more than $600 million short of the
administration's request and significantly less than the
Independent Budget recommendations. We know, however, that your
ability to properly fund VA appropriations accounts are
severely limited by outdated budget caps established by the
Budget Control Act of 2011 and subsequent budget agreements.
The threat of sequestration and draconian spending cap
limits our Nation's ability to provide servicemembers,
veterans, and their families the care benefits they have
earned. The VFW calls on this subcommittee to join our campaign
to finally end sequestration and do away with federal budget
processes based on arbitrary spending caps.
The VFW is glad to see President Trump has proposed a 6
percent increase in VA's fiscal year 2018 budget. However, we
feel that the proposal falls a bit short.
And my colleague from PVA has described our recommendations
for VA health care, and I would like to associate the VFW with
those remarks.
I would like to focus my testimony on VA's need for capital
infrastructure. For more than a decade the I.B. VSOs have
warned Congress and VA that perpetual underfunding will allow--
would allow VA infrastructure to erode while its capacity to
meet demand has swelled from 81 percent in 2004 to as high as
120 percent in 2010.
The events of 2014 and subsequent access issues at VA
health care facilities have illustrated how chronic
underfunding of VA capital infrastructure and the lack of
capacity to keep pace with demand has resulted in VA rationing
care and veterans waiting too long for the care that they have
earned.
The I.B. VSOs are working with VA to reform its
construction process so facilities can be delivered on time and
on budget. Previous errors must be corrected to ensure the
issues that occurred in Aurora, Colorado never occur again.
However, this subcommittee must not punish veterans who are
awaiting desperately needed health care facilities because of
the incompetence of bureaucrats who no longer work at VA
Currently, VA has 24 partially underfunded construction--
major construction projects, which need a clear path to
completion, some of which have been in the works for more than
12 years. VA's fiscal year 2017 priority list, which includes
seismic corrections, cannot take a systemic pause while
Congress and VA decides how to manage capital infrastructure
long term.
VA will need to invest more than $3.5 billion to complete
all 24 partially funded projects. Of the top five projects,
many of them are seismic deficiencies and part of VA's core
missions, such as mental health and spinal cord injury centers.
The I.B. VSOs recommend that Congress appropriate at least
$1.5 billion for major construction in fiscal year 2018. This
amount would ensure--will fund the next phase or fund through
completion of the existing projects and begin advance planning
and design development for VA's major construction projects.
I would also like to quickly mention and thank the
subcommittee, and especially Chairman Dent, for your leadership
on expanding VA's fertility treatment options. VA, as we know,
has announced that they will begin providing these treatments
soon. However, the authority is limited and folks who--or
veterans who aren't able to use assisted reproductive
technology or adopt a child before the end of fiscal year 2018
will be left to bear the full cost of starting a family.
And these are severely disabled servicemembers who have
lost their ability to reproduce due to their service, and we
feel that that is unacceptable. We are working with the
authorizing committees to make this authority permanent, but we
ask that you continue to carry that authority into fiscal year
2019 and 2018 so that these veterans aren't left behind and
that they continue to have that opportunity.
Mr. Chairman, thank you for the opportunity to testify.
This concludes my remarks, and I am happy to answer any
questions you or the members of the committee may have.
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Mr. Dent. Thank you, Mr. Fuentes, for your testimony, and
thank you, too, for your kind words about the in vitro
fertilization, IVF, provision that was included. A lot of
people were very interested in that--Mr. Larsen I know, Ms.
Brownley, Mrs. Roby, and many others all, you know, were very
strong advocates. So thank you for your good words on that.
INFRASTRUCTURE NEEDS WHEN NON-VA CARE IS INCREASING
Also, just wanted to highlight the enormous infrastructure
needs of the VA and how it is struggling, given all the aging
buildings and the shifting veteran population. We know that
last year the VA calculated its infrastructure shortfall as
being as high as about $50 billion. Setting aside the problem
that we are unlikely to be able to provide the funding
required, is it appropriate to continue to plan a massive VA
infrastructure effort when VA is increasing its use of non-VA
care that uses private facilities?
Mr. Fuentes. What we want to make sure is not forgotten or
ignored when discussing the Choice program and Community Care
is VA's ability to provide direct care, right? We have 80
percent of the VFW's membership relies on VA for their health
care, and the community is part of the solution.
As we increase VA's funding for Community Care we cannot
ignore its medical services appropriation and the impact that
construction has on VA's ability to meet the needs.
The lack of funding for VA's capital infrastructure has
really resulted in a lot of these wait-time issues because it
takes way too long for VA to construct these facilities. We
need to reform its capital infrastructure process, but we can't
ignore that they need the funding to continue to expand.
Mr. Dent. Ms. Wasserman Schultz.
Ms. Wasserman Schultz. Thank you.
IN VITRO FERTILIZATION
Just to underscore your point about in vitro fertilization
and other assisted reproductive technologies, for those
unfamiliar with the process--and I won't go into any of the
details, but it often does not work the first time,
particularly for individuals who have a service-related injury
and whose infertility is caused by their service or their
injuries.
So leaving it in place just for one fiscal year and having
it expire would be devastating to people who are in the midst
of a fertility cycle because these are--this is a process that,
as you go through it, is dependent on nature's timing, not our
fiscal year calendar.
So it is really important that we make sure that we don't
cut off the access to procedures that our service-related
injured veterans might be in the midst of, denying them the
opportunity to start their families.
So I don't have a question. I just want to make sure you
know you have my support.
Mr. Dent. Thank you.
Mr. Taylor.
Mr. Taylor. Thank you, Mr. Chairman.
And thank you again for your service and your advocacy, and
yours as well, too. Go Navy. And I am Post 392. Thank you.
Lifetime member.
MENTAL HEALTH CARE AWARENESS INITIATIVES
Quick question. Two things. First, you were mentioning
spinal cord injuries. I didn't hear you talk about TBI or PTSD.
Can you just mention if there are any initiatives with VFW and
what you are supporting for increased help in those arenas?
Mr. Fuentes. Sure. My testimony, as a co-author of the
I.B., focused on the infrastructure needs of VA, but we
certainly have made mental health care awareness a priority for
the VFW this year.
Our national commander actually launched a campaign to
really change the direction and the narrative around mental
health because there is a stigma around mental health where
veterans fear going to receive the mental health care that they
need. And it is really just as any other type of health or any
other body part, it needs to heal. You need treatment to get
better.
So we certainly support expanded mental health care
services and also believe that there is this need for outreach
in order to really de-stigmatize mental health.
Mr. Taylor. Thank you.
USE OF VA VERSUS COMMUNITY CARE
So with the understanding that there is a shortfall in the
construction budget and construction plays a big impact,
potentially, on wait times; also with the understanding that
the VA, of course, is responsible for our veterans' care, does
the VFW support more use of private care, whether it might be
redundancies or duplication of primary care services, for
example, where there are private facilities that are right
there? Not, of course, the injuries that are unique to
veterans, but other private care that is accessible and easily
accessible. Do you guys support that or are you are saying no?
Mr. Fuentes. Yes, we do.
So just to be clear, VA needs to really conduct a manpower
capacity analysis in each community. Health care is local--you
know, there are areas in the country where it will take 6
months in the private sector to receive a dermatology
appointment. In other areas like San Diego it is more readily
available.
So VA needs to see what the demand is for veterans in each
community and see what its capacity to meet that demand, but
also incorporate the private sector, but other public health
care facilities like DOD, Indian Health Services, and federally
qualified health centers, so to take that integrated approach
so you are not duplicating and you are leveraging the best
capacities in that community.
Each community is going to look different. So sometimes
there may be more private primary care, and in other areas
private primary care may not be readily available so VA will
have to build that.
Mr. Taylor. Thank you.
Thank you, Mr. Chairman.
Mr. Dent. Thank you, Mr. Taylor.
Mr. Bishop.
Mr. Bishop. Thank you very much.
Again, welcome, to you, Mr. Fuentes.
CONSTRUCTION OF RESEARCH FACILITIES
I am sure that Ms. Kelly will probably touch on this when
she testifies, but I would like to know what the VFW's position
is with regard to the construction of research facilities.
In 2012, at the request of Congress, the department Office
of Research and Development did an in-depth study and an
analysis of the physical condition of the VA's aging research
infrastructure, and they reported that the average VA building
that houses research laboratories is over 50 years old.
Of course, the American Psychological Association argues
that VA lacks the state-of-the-art research facilities and that
modern research can't be conducted in facilities that closely
resemble a high school science lab.
As a result, they are recommending $50 million for five
major research facility construction projects and $175 million
for minor construction maintenance projects. What is VFW's
position on that? Do you support that analysis and that
request, in light of the other request for major construction
that is a lot more expensive?
Mr. Fuentes. We fully support. Research is one of VA's four
core missions, and you are absolutely right. I have also
visited some of those research facilities that are out of date.
You know, fortunately there are some that you see as an
examples of what state-of-the-art research facilities should
look like and, as a result, you see VA making a lot of progress
and really leading the industry, in many respects, when it
comes to research when they are given the proper tools. And
that just speaks to, again, the lack of attention and, frankly,
resources devoted to VA's capital infrastructure.
Again, not ignoring the fact that we need to make sure that
buildings are delivered on time and on budget, but the need for
resources cannot be ignored.
Mr. Dent. Thank you, Mr. Bishop.
And, Mr. Fuentes, we thank you for your testimony. We
really appreciate all that you are doing. Thank you very much.
Mr. Fuentes. Thank you, Mr. Chairman.
Mr. Dent. At this time I would like to call to the witness
table Dr. Heather O'Beirne Kelly. She represents the American
Psychological Association.
Dr. Kelly. Good morning, Chairman Dent.
Mr. Dent. Dr. Kelly, welcome, and you are recognized for 5
minutes.
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Wednesday, March 29, 2017.
AMERICAN PSYCHOLOGICAL ASSOCIATION
WITNESS
DR. HEATHER O'BEIRNE KELLY, DIRECTOR VETERANS AND MILITARY HEALTH
POLICY
Dr. Kelly. Thank you.
Chairman Dent, Ranking Member Wasserman Schultz and members
of the subcommittee I am Dr. Heather Kelly, a psychologist and
director of veterans and military health policy at the American
Psychological Association. I also come from a family of career
military officers and combat veterans, so I do care deeply
about these issues of veterans care, both personally and
professionally.
As you may know, APA is our country's largest scientific
and professional organization, with more than 115,000
psychologists. And the Department of Veterans Affairs, or the
VA, is the largest single employer of psychologists.
VA's psychologists work both as research scientists and
clinicians committed to improving the lives of our Nation's
veterans. As the largest provider of training for
psychologists, the VA also plays a vital role in equipping the
mental health workforce to provide culturally competent and
integrated mental health services to veterans and their
families.
I have provided more detail in APA's written testimony, so
I would like to focus on three priority areas today and get to
Congressman Bishop's question in particular, and I would like
to also echo the priorities of my VSO colleagues who have gone
before me. We agree on all of the same issues and, in fact, we
were one of the members who co-wrote the research section of
the I.B.
So, Congressman Bishop, we thank you for mentioning our
concerns about research facilities, and that is also echoed in
the Independent Budget. You are not going to attract the
highest-quality psychologists, particularly who are often both
researchers and clinicians, to the VA unless they can do their
research in facilities that at least have computers. We are not
even talking about really high tech in some cases, but really
that have desks and computers. So thank you for calling
attention to that issue.
So the three priority areas I would like to focus on are VA
research, clinical care for veterans, and the scope of practice
for VA psychologists.
In terms of research, APA joins the Friends of VA Medical
Care and Health Research coalition, or FOVA, in urging the
subcommittee to provide $713 million in fiscal year 2018 for VA
medical and prosthetic research. As my colleagues have
mentioned, a strong VA psychological research program provides
the scientific foundation for high-quality care within the VA
system, which is absolutely vital for serving veterans
suffering with post-traumatic stress disorder, PTSD; traumatic
brain injury, or TBI; substance abuse; aging-related and other
disorders requiring physical and psychosocial rehabilitation;
and, of course, suicidal ideation.
We have better treatments now for all of these issues
because of your prior investments in VA intramural research,
and we desperately need to further advance our knowledge of
these signature wounds of war to alleviate veteran suffering--
and not only to alleviate suffering, but to help them regain
lives of purpose and of joy.
In terms of clinical care, APA echoes the many concerns and
suggestions of the VSOs regarding VA mental health services
outlined in their Independent Budget, as I have mentioned. We
also share VA Secretary Shulkin's recently announced priorities
related to enhanced suicide prevention efforts, extension of
mental health care to veterans with other-than-honorable
discharges, and expansion of caregiver benefits to include pre-
9/11 veterans' families.
These were the initiatives, as you, I am sure, know must
come with more resources to be implemented. If you open the
doors wider, you need more money to serve those people whom you
have invited in.
We urge Congress to provide ample resources for VA mental
health programs and the VA psychologists who serve veterans
through increased hiring of VA psychologists--and I would ask
that we finally make the move and move psychologists into the
Title 38 hiring authority; by holding community partners and
contractors to the high standards of quality assessment and
care that exist in the VA; increasing support for primary care
mental health integration models and telemental health
services; and replacing the scheduling package in the
electronic medical record. All of these are critical for
improving patient experience and patient care within the VA.
And finally, within the terms of the VA psychologists'
scope of practice and improving mental health care access at
the VA, I strongly urge you to direct the VA secretary to grant
specially trained VA psychologists prescriptive authority
analogous to that granted by the Department of Defense almost
20 years ago. DOD has had zero adverse effects or complaints
reported during that entire period, and if any of you are
familiar with health care, zero adverse effects and zero
complaints are unheard of.
DOD psychologists--medically prescribing psychologists--
have served thousands and thousands of active duty military
personnel. This is another safe, effective way to increase
mental health care access, and the VA is behind in granting
this authority to appropriately trained psychologists.
I should mention, these are psychologists like me, who have
master's degrees and Ph.D.s and then go out and get a separate
master's in pharmacology on top of their existing M.A. and
Ph.D. These are really well-trained psychologists and the only
doctoral-level professionals in the VA who do not have
prescribing authority.
As I mentioned, VA is behind in granting this authority,
and behind not only DOD but behind States like Louisiana,
behind territories like Guam, and behind the tribal
reservations of Indian country in granting this prescribing
authority.
A veteran in Pennsylvania, a veteran in Florida, a veteran
in Georgia, a veteran in Virginia should have access to the
same high-quality mental health care as a nonveteran in
Louisiana or Guam.
And remember that the power to prescribe is also the power
to un-prescribe medication, which is a particularly important
issue facing both civilian and veteran populations across the
country.
So I urge you to direct the secretary at the very least to
begin with a pilot program in VA, particularly in VA medical
centers with the most dire mental health care access needs, and
those tend to be the rural areas.
In conclusion, the VA, in the face of increasing demand for
mental health care and recognized access difficulties in rural
areas in particular, must remain a pioneer in the health care
arena by allowing specially trained and certified psychologists
to work at the full scope of their practice and to serve
veterans with the expertise and dedication they already employ.
Thank you for the opportunity to testify, and I am happy to
answer questions.
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PREVENTING VETERAN SUICIDES
Mr. Dent. Thank you, Dr. Kelly, for your testimony. We very
much appreciate your being here.
I only have one quick question. In our hearing last week
with the VA inspector general we heard about the problems with
the VA suicide hotline.
Dr. Kelly. Yes.
Mr. Dent. More generally, I guess, how does your
association think the VA is doing in its efforts to prevent
veteran suicide?
Dr. Kelly. In general, VA mental health care is superior to
any other mental health care anywhere in the world. I have
veterans in my family, and if they had mental health issues I
would send them immediately to the VA.
So in general, superior care. All the reports coming out of
RAND and other reports you have seen, VA mental health care is
either equal to or superior to that you can get often in the
civilian sector.
Suicide prevention is as important as it is difficult. It
is a very low base rate behavior that we desperately want to
prevent, and I would say that VA has made remarkable strides
into lowering the rates of veterans who come to the VA for
their mental health care. The suicide rate for veterans who get
care outside of the VA is much higher, so we want them to come
to the VA for their care.
There are issues with the suicide hotline that need to be
resolved. There are issues with access more than with the
quality of VA mental health care, so if we can increase
access--and there are a variety of ways to do that; pulling
apart the VA's integrated system is not one of them.
We are watching very carefully the hotline in particular. I
think most of the issues have actually been with the civilians
who call the prevention line and are more often put on hold
than the veterans.
So we have issues with the suicide hotline in general, but
are watching it very carefully. And I think they are being
taken very seriously by the VA.
Thanks.
Mr. Dent. Thank you, Dr. Kelly.
Ms. Wasserman Schultz.
TRAINING FOR CRISIS HOTLINE
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
Just to follow up on the chairman's line of questioning, we
did extensively ask the I.G. questions about problems with the
crisis hotline, and training appears to be one of the
significant obstacles that they have.
Have you given them any guidance on how they can improve
their training? What it appears is that there is very
inconsistent training from the national hotline to the local
crisis lines that are housed at each medical center.
Dr. Kelly. And that is a classic issue, frankly, and there
are a couple things I would like to say about that. One is it
may seem unrelated, but some of the restrictions on federal
employee conference attendance and travel have actually
affected VA training rather substantially, and so anything you
all can do to get rid of the restrictions on federal employees
of all kinds, but VA federal employees, traveling--there were
things in Florida happening where a number of psychologists
were hired a couple of years ago by the VA and weren't allowed
to travel six miles down the road in their own car for the
mandatory new mental health training.
So there are some really crazy ramifications of some of
those rules, so I am not surprised that training is an issue.
Part of what you all need to know we are all struggling
with is that VA has always provided community care, and this is
an issue of care when more people in the communities are
staffing those hotlines. It is very important that all
community partners be trained and held to the same standards of
assessment and care as VA staff and mental health professionals
are, and right now that is not the case.
And so I echo your concern about training and maintaining
and assessing quality of care.
TRAINING THAT VA PROVIDES VERSUS PRIVATE SECTOR TRAINING
Ms. Wasserman Schultz. And speaking of training, that was
actually my next question in terms of the difference in
training that the VA provides versus the private sector
training.
Are they comparable? You alluded now that they are not.
Where would you think there need to be improvements on the VA
side of training, or is the VA already superior, not just on
the crisis line, but across the board?
Dr. Kelly. Thank you. It is a great question and one that
we are really involved in trying to tackle, because obviously
at the American Psychological Association, I am in charge of
the side that deals with military and veteran populations, but
we certainly care very much about our civilian providers.
This civilian-military divide--this is one of the places
where it shows. And so we have been very involved with partners
like PsychArmor, the VA itself, who have a number of modules of
training in military culture and veteran cultures, thorough,
that have been developed and vetted and provided for free to
civilian providers. PsychArmor now has MOUs with all of the
major health care providers--civilian health care providers and
offers corporations, staff, counseling centers at colleges
training in military culture and veterans culture for that
exact reason, is to begin to bring some of the civilian
providers at least some more competence in that area, which is
completely separate from some of the things you have seen,
again, in some of the RAND reports.
``Ready to Serve'' is the most important recent report
showing that even on some of the evidence-based
psychotherapies, which APA obviously recommends for treatment,
in particular with PTSD and depression and anxiety, civilian
providers are behind VA providers in their provision of
evidence-based mental health care. And so when we talk about
moving veterans into getting more community care, I have very
deep concerns about the quality of the care that they would
receive there.
And so we are working very hard to make sure that any
relationship that the VA has with community providers must
entail training and assessing and constant monitoring of that
care in the community to make sure that our veterans are
getting the quality of care that they deserve.
Ms. Wasserman Schultz. Thank you.
Mr. Dent. Mr. Taylor.
Mr. Taylor. Thank you, Mr. Chairman.
Thank you for what you do and all those degrees that you
got. [Laughter.]
Thanks a lot. We really appreciate it.
LACK OF UNIFORMITY IN SUICIDE PREVENTION POLICIES
Quick question along the lines of the suicide hotline. That
is something that has been talked about, but one of the other
things that we talked to the I.G. with, that my office actually
has requested a report on is not just the suicide hotline but
the physical walkups, people come to the facilities and say,
``Look, I am suicidal,'' or they exhibit those tendencies or
something like that, and the non-uniform-type policy with the
VA. One of the things that the I.G. said was that there is
decentralized across the whole VA spectrum.
Has APA helped with that in terms of trying to create a
uniform policy for the VA across everywhere that says anyone
who comes in, that they are not turned away and the unfortunate
thing happens, potentially?
Dr. Kelly. Yes. I have been very vocal--Dr. Shulkin will
tell you--with him personally and with his staff for many years
on this issue in his previous role and now in his current role.
My understanding is that any veteran who calls or appears at a
VA medical center with urgent self-harm or harm-to-others
concerns will be seen immediately.
There are some metrics there that we are watching very
carefully--that is supposed to be true of all VA medical
centers. I am not sure if they have reached that at this point.
But same-day urgent care absolutely is the standard that VA is
looking to meet.
And I think sometimes the issue--two things: One, that is
precisely why you also want the primary care mental health
integration. You want someone who is much more likely to walk
up into an E.R. or to come through primary care to get
automatic assessment.
You know, a lot of these people are not going to tell you--
some will, but some won't tell you and a really quick but
really careful diagnostic assessment of anyone that comes in--
frankly, we find out about suicidal behavior much more often by
asking about sleep issues and some other concerns. I mean, it
is the gateway into a lot of health care problems for veterans
in particular.
So we want psychologists in most VA facilities--in all of
the big ones, and we are trying to make sure it goes all
throughout the VA. There are psychologists embedded in primary
care for those reasons of stigma that you have heard about. You
know, someone doesn't have to walk to another floor with a door
that says ``mental health'' above it, but literally gets a warm
handoff to a physician or a psychologist standing right there
to talk about those issues.
So same-day access is vital, and I think it is certainly a
VA standard.
What is often the issue is the second appointment, so how
quickly can that veteran then be seen, depending on what the
diagnostic assessment is, for the next kind of care--if it is
outpatient, for the next level of outpatient care? There are
never enough inpatient beds anywhere in the entire U.S. health
care system, but in the VA also we need more inpatient beds for
psychiatric issues.
But certainly same-day access, and this is an issue I work
on every day with the VA and the VA psychologists in
particular.
Mr. Taylor. Thank you very much.
And just we would love to speak with you offline about the
pilot program. So thanks. Thanks a lot.
Dr. Kelly. Thank you.
Mr. Dent. Thank you, Mr. Taylor.
Mr. Bishop.
Mr. Bishop. Thank you very much.
And, Dr. Kelly, thank you so much, and we appreciate your
insights as well as your level of training, particularly in
pharmacology.
Dr. Kelly. Well, I didn't go get the extra one in
pharmacology. My colleagues have, but I can talk to you but I
can't give you any medication.
Mr. Bishop. Okay. That level of training and becoming a
pharmacologist is probably unique among the VA psychologists--
--
Dr. Kelly. Yes.
Mr. Bishop. We, at the committee, have to deal with the
tension between scope of practice issues, the professional
associations and the VA, that often has difficulty getting the
high-level professionals in the specific disciplines. And so
the prescribing authority that you recommended sometimes brings
us into conflict with the professional associations, the M.D.s,
the medical doctors who say that, ``No, no, they don't need to
have that.''
And so we get in the middle between what is the best care
for veterans and what will protect veterans, versus what is
most convenient and most economical for the VA. So that is
something that we need your help in dealing with.
CARE FOR SEXUAL ASSAULT VICTIMS
But I wanted to explore another issue with you,
particularly as a psychologist. We are now experiencing the
first generation of women who have served in combat roles, and
many of them will return home with the same psychological scars
as men.
But according to the Department of Veterans Affairs, women
have a higher risk of exposure to sexual harassment and sexual
assault than men, which may lead to trauma. Furthermore, many
of the women will be in their teens and their early 20s when
this happens.
In your opinion, is the VA adequately postured to ensure
that there is adequate access to quality care for women
veterans to deal with these myriad of issues that they will be
experiencing in escalating numbers going forward?
Dr. Kelly. Let me touch on your first question and then
your second.
In terms of the first question and the turf issues between
medicine and other disciplines for whom prescribing authority
is appropriate and the fullest extent of our practice, I will
tell you what I told a young staffer who was trying to work
with me on this issue: Regardless of what you may hear from the
medical societies, many of whom have been supportive of our
prescribing authority in the States, in Illinois in particular,
I refuse to do turf battles over people who have served in
actual battles.
So that is something that people in associations need to
get over and deal with, and I care about what care the veterans
get. And if you have a psychologist in the Department of
Defense who can prescribe medication and other kinds of
therapy--which are always going to be the first attempt for us;
we are never going to go to medication first, and that is
something I think that is incredibly valuable--they can walk
across the hall in El Paso from seeing a DOD psychologist and
can't see a VA psychologist once that member is now a veteran
who can provide the same service. That doesn't make any sense
to me.
But the turf battles are purely that, and we need to get
over that.
In terms of the second question, much more serious question
of sexual assault and sexual harassment in the military for
both men and women, but because women are increasing in numbers
and increasing percentage of the services and now the veteran
population, it is a massive problem and we are very concerned
about it.
In terms of the VA's capacity to handle, I have seen great
strides in terms of their establishment of the women's office.
They have women's research programs going that are just
exquisitely set up. So I am very impressed with what I see.
Certainly, you know, women veterans' suicide rates are much
higher than the cohort of women in the civilian population,
which should not be a surprise to us. Most people who die by
suicide die with guns, and women civilians don't tend to have
guns or be as accurate with guns, and women veterans are
because that is the nature of their work.
So we have our work cut out for us to address the issue of
guns and suicide in the veteran population very directly
without being shy about it. I think that the VA is making some
strides in that area as well, but women veterans need more
access, just like any other issue, be it fertility-related or
mental health-related. Those are often interrelated.
There need to be enough mental health professionals within
the VA to see them, and so it always comes back to just the
staffing level.
Mr. Bishop. Thank you.
Dr. Kelly. Thank you.
Mr. Fortenberry [presiding]. Thank you, Dr. Kelly.
I am Congressman Fortenberry from Nebraska and I am pinch-
hitting for the chairman for a moment, but I have a question,
as well. Before I enter it in mind, you said sexual assault is
a massive problem. Would you unpack that a little bit more,
please?
Dr. Kelly. So in the civilian population and the veteran
population, certainly rates of sexual harassment are quite high
and sexual assault I think is on the minds of many of us, in
particular in relation to the military with some of the issues
going on on the online issues that we are facing.
Mr. Fortenberry. With the appropriate attentiveness to this
problem and the growing awareness, and the creation of
infrastructure and policy to deal with this more directly, do
you think that this is declining or is it still in a phase
where we do not have appropriate management of this grave
problem?
Dr. Kelly. So as a good scientist I am loath to go beyond
the data. I would say I don't see it declining. I think you see
more----
Mr. Fortenberry. Why is that?
Dr. Kelly. I think there are multiple reasons for that, one
of which is it is hard to detangle sometimes whether the actual
incidence is increasing or whether people are reporting and
feeling more comfortable reporting. It is hard to untangle
that.
Mr. Fortenberry. That actually could be progress, even
though it shows as a statistically higher increase, the
progress that this is----
Dr. Kelly. It could be. It could be. And we have ways of
addressing that.
Mr. Fortenberry [continuing]. The culture is creating
mechanisms for reporting and decreasing inhibitions.
Dr. Kelly. I hope that that is the case. I hope that it is
solely an increase in reporting. I would not stake my expertise
on that.
I think it is a particular issue, and I think that women
veterans that, anecdotally with whom I talk--and male veterans
who are sexually assaulted--this is a population that is hardy
and tough and they want to keep doing their jobs.
I come from a military family. I understand the hierarchy;
I understand the need for it. All of those issues provide a
context in which coming forward is very, very difficult, and
the more we can do to set up infrastructure such that
commanders deal with that appropriately, the more that I think
we will see it dealt with appropriately.
Mr. Fortenberry. In this regard, you mentioned that women
veterans suicide rates are higher than nonveteran populations.
Are their suicide rates higher than male veteran populations?
Dr. Kelly. I would have to look at the data on that and by
age, because suicide has sort of a bimodal activity, more
likely in the young and more likely in the old. I would have to
look and see for women veterans if their rate is higher than
their male veteran counterparts.
I do know that it is significantly different from women
civilians of their same age.
Mr. Fortenberry. And then the correlation to a culture
that, as you are saying, as we know, has had difficulties with
the issue of sexual assault, there has got to be a variable
there that is significant, I would think.
Regarding sleep, I was interested to hear you say that. I
was talking with--actually, there is a psychologist here in the
House who is a member of the military and he has counseled
commanders who have sometimes, in terms of punishment,
increased the duty and assignments on young people that create
a cycle of a lack of sleep and then suddenly we are into deeper
problems. And his first recommendation is, ``Go to bed.''
Dr. Kelly. Yes.
Mr. Fortenberry. ``Talk to you in 2 days.''
Dr. Kelly. Yes.
Mr. Fortenberry. I thought that was very insightful, and I
think that even medical school training is shifting in this
regard.
Dr. Kelly. I was just going to say the analogy between
training physicians in particular--you know, my dad was a
nuclear submariner, and one of Rickover's boys, and the lack of
sleep standing duty on subs is just immense, but we do the same
thing to our physicians. And the results are life-or-death
sometimes.
Mr. Fortenberry. Maybe we should make note of that here in
Congress, as well.
Dr. Kelly. Yes.
Mr. Fortenberry. Adequate rest.
Finally, I have been working with an outside entity that
really has a fascinating project. There is a pilot project
going on. Their outcomes are measurable in terms of the
increase in wellness, the reductions in mental health stress,
plus harder-to-define outcomes such as feeling a sense of
belonging to your community for wounded veterans, disabled
veterans participating in group recreational programs. This one
is bicycling.
So apparently the new secretary is considering authorizing
VA medical center directors to support this particular
activity.
I think this is very smart. I mean, we have got
demonstrable outcomes in one area, and if VA directors locally
are empowered with community volunteers and outside entities
that will actually create these programs that have continuity
but are embedded inside the VA.
Dr. Kelly. Yes. I would love it.
Mr. Fortenberry. It is not--as opposed to outside things,
which are, of course, excellent and good, but bring embedded
with the VA creates mechanisms of continuity that aren't always
there.
Dr. Kelly. I couldn't agree more. You know, at the Warrior
Games--and I was at Invictus this past year when it came to
America--the physical activity and all of the equine groups,
the Team Rubicon, the Red White and Blue, all of these groups,
many of which have the physical component, I agree.
These are young men and women who are at the height of
their athleticism. There is a reason why they still enjoy doing
those activities when they come home.
And at the same time, what we often--again, anecdotally--
talk to veterans about is the--and what a lot of civilians
don't understand when they say they miss being in the military
at a time when we are at war--is they miss the sense of
belonging and belonging to a group that has purpose.
So those kinds of programs serve all of those, and we are
very much in favor of them.
Mr. Fortenberry. Great. Thank you for your testimony.
Dr. Kelly. Thank you.
Mr. Dent [presiding]. Thank you, Dr. Kelly.
And at this time I would like to invite our final witness
to the desk. It is Mr. Fred Sganga.
Fred, we appreciate your being here with us today, and I
know you are a legislative officer at the National Association
of State Veterans Homes. We appreciate your participation this
morning and we look forward to receiving your testimony. You
are recognized for 5 minutes.
----------
Wednesday, March 29, 2017.
NATIONAL ASSOCIATION OF STATE VETERANS HOMES
WITNESS
FRED SGANGA, LEGISLATIVE OFFICER
Mr. Sganga. Thank you, Chairman Dent, Ranking Member
Wasserman Schultz, members of the subcommittee. On behalf of
the National State of Veterans Homes, thank you for the
opportunity to provide testimony recommending $300 million for
the Grants for State Extended Care Facilities program, commonly
referred to as the State Home Construction Grant program, for
fiscal year 2018.
As you know, for more than 125 years state homes have been
in partnership with the Federal Government to provide long-term
care services to honorably discharged veterans. There are
currently 153 state veterans homes located in all 50 States and
the Commonwealth of Puerto Rico.
The National Association of State Veterans Homes, which
represents the homes, was established in 1952 to promote strong
federal policies and share experience and knowledge among state
home licensed nursing home administrators to allow us to care
for our Nation's heroes with the dignity and the respect they
deserve.
With over 30,000 beds, the State Veterans Home program is
the largest provider of long-term care for our Nation's
veterans, offering skilled nursing care, domiciliary care, and
adult day health care. The Department of Veterans Affairs
provides state homes with per diem payments for these purposes,
which covers about one-third of the daily cost of care to these
veterans.
VA also provides construction grants to build, renovate,
and maintain the state veterans homes, with the States required
to provide at least 35 percent of the cost for such projects in
a matching fund program. The State Veterans Home program allows
the VA to leverage federal resources to expand long-term
services and support for veterans through partnerships with all
50 States.
Federal State Home Construction Grants are awarded based
upon when a grant is received, where it falls among the
statutory priority groups, and when state matching funds are
certified as available. Projects that have been certified state
matching funds are included in the VA's priority group one
projects list, which includes critical life and safety projects
as well as the new construction of state homes in states that
will have a great need, as defined in the statute.
Grant requests that do not yet have state matching funds
secured are placed in VA priority group two through eight on a
list according to when they are submitted and according to
their specific priority status.
Over the past several years VA has requested, and Congress
has provided, between approximately $85 million and $90 million
annually, which was barely enough to keep up with the new grant
requests from States and failed to make any significant headway
with the existing backlog of priority one projects awaiting
federal funding.
The most recent VA State Home Construction Grants priority
list for fiscal year 2017, released in January, includes 99
requests; 57 are in priority group one, with a total federal
cost share of approximately $639 million, an increase of $89
million to the backlog compared to fiscal year 2016.
There are also additional 42 grant requests among priority
two groups through eight. Once those projects have been
certified with state matching funding, they will, too, move to
priority list one.
Overall, there are more than $1 billion of State Home
Construction Grant requests that have been submitted to the VA.
With just $90 million for fiscal year 2017, VA will only be
able to provide funding for the first 10 projects on the list,
leaving 47 priority one projects awaiting a future year's
funding.
For each of the past three fiscal years--fiscal year 2015
through fiscal year 2017--NASVH has recommended to Congress--to
the VA and Congress that $200 million be allocated for the
State Home Construction Grant program, a sum that was also
recommended by the Independent Budget organizations.
For fiscal year 2018 NASVH recommends that $300 million be
provided to the State Home Construction Grant program, which
would provide sufficient funding to cover approximately half of
the pending priority one projects. The I.B. also supports the
recommendation of $300 million for fiscal year 2018 funding.
At this time it is not clear what level of funding the
administration will request for fiscal year 2018. However, if
the same inadequate amount of $90 million were to be
appropriated for fiscal year 2018 it would support just the
next seven priority one projects.
Given the recent trends of state matching funding, it is
likely that this will result in little or no net decrease in
the existing backlog of $639 million priority one projects.
Among these projects that would not be funded at that level are
two in Pennsylvania, two in Florida, two in California, and two
in Ohio. All of those and 17 others, however, would receive
funding next year if the $300 million were appropriated for
fiscal year 2018.
As the veteran population continues to age and federal
budgets continue to get tighter, there is no better investment
of federal long-term care dollars than the State Home program,
and we urge the subcommittee to significantly increase the
funding for next year.
Mr. Chairman, I would also like to bring to the
subcommittee's attention another issue that is beginning to
have a significant impact on the level of funding required to
sustain the state veterans home system: the VA's new Community
Living Center, or CLC, design and construction guidelines.
These new guidelines call for the state homes to use what is
called the small house design when constructing new or
renovating existing homes.
The small house design model is based on housing veterans
in small group homes, or pods, each with their own kitchen,
cleaning, and other basic facilities, along with separately
assigned staff for each small group home. The homes are
physically connected through common areas for social, medical,
and other purposes.
However, compared to the economies of scale that are
achieved in traditional state veterans homes, the small house
design has proven to be between 30 to 40 percent more expensive
both to construct and to operate, imposing new financial
burdens on the States. While some States have favored the small
house design, others have found that many of the veterans
prefer more traditional, larger state home model.
NASVH is recommending that the VA modify the Community
Living Center design and construction guidelines to allow
States sufficient flexibility in using the small house design
so they can better meet the different needs of their respective
veteran populations in a financially responsible manner.
Without such flexibility, Congress will need to
significantly increase the level of funding for State Home
Construction Grants to make up for the increased per capita
costs as well as per diem rates to cover the higher operating
costs.
Mr. Chairman, that concludes my testimony. Thank you for
the opportunity to be here today before the subcommittee, and I
would like to answer any questions you might have.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Dent. Thank you, Mr. Sganga, for your comments.
I also appreciate the work your folks are doing in our
State, with six state veterans homes.
MISMATCH BETWEEN LOCATION OF VETERANS AND STATE HOMES
Mr. Sganga. Thank you.
Mr. Dent. Just one question: Given that veterans as a
group, are moving away from many of the areas in the Northeast
and Midwest where state veterans homes are located, would it be
better to contract out for long-term care rather than to
continue to build or repair facilities in areas with declining
veteran populations?
Mr. Sganga. In my experience as a licensed nursing home
administrator for over a 30-year period I do find, Mr.
Chairman, that you will have Northeastern retirees that will go
to other parts of the country for retirement, but I will tell
you a significant amount of those veterans and their spouses
return back to their original place of residence in order to
receive long-term care services.
Mr. Dent. Are you saying my constituents are heading down
to Ms. Wasserman Schultz's district? Is that what you are
telling me?
Mr. Sganga. Yes.
But they come back to die back in Pennsylvania. I mean,
that is what happens.
Mr. Dent. On that point, there are statistics showing that
if you are born in Pennsylvania you are likely to die in
Pennsylvania.
Mr. Sganga. Right. I have seen that. And spend 20 years in
Florida.
Mr. Dent. People in Pennsylvania do like to spend time in
Florida. Maybe not 20 years, though.
Mr. Sganga. But I think that answers the question. The
whole notion of long-term care, the trend that we are seeing is
a lot more of our veterans are coming to homes much older.
Typically in my home--I am the executive director of the
Long Island State Veterans Home in Stony Brook, New York--it is
not unusual for a World War II veteran to be entering in their
early 90s to the home.
Mr. Dent. Thank you.
Ms. Wasserman Schultz.
Ms. Wasserman Schultz. Well, from a Long Island girl to a
Long Island boy----
Mr. Sganga. There you go.
Actually, I was born in Queens.
Ms. Wasserman Schultz. Me too--Forest Hills. Long Island,
Jewish, just like most of my constituents.
Which is why, Mr. Chairman, I always say that you should
care about two people who represent you, particularly when I am
up north: the person who represents you now--say, Mr. Dent--and
me, because I am going to represent you when you retire and
move to my district in about 20 years.
ALTERNATIVE TO LONG TERM FACILITIES
That having been said, Mr. Sganga, I do share the interest
of the chairman in answering the question, particularly because
people always prefer to age in place if they can, that not only
should we explore long-term care options in other places, but--
besides just the Northeast, where I guess more of the homes are
located and being constructed. I mean, we do have state nursing
homes in Florida, and hopefully we will continue to build more
of them because there is a real shortage of beds.
But I would think that your organization would be
interested in trying to make sure that we could provide
services to veterans where they would like to age, not
necessarily in a particular home or facility. So have you ever
explored broadening your mission?
Mr. Sganga. That is a great question. Actually, three of
our homes--Stony Brook, New York; Hilo, Hawaii; and
Minneapolis, Minnesota--provide medical model adult day health
care services, so that is one way that we do that. We would
like to expand that.
I would like the subcommittee to know that we have been
waiting 8 years for the VA to have the adult day health care
regulations revised. We think as an association this is a
disgrace, in terms of the time that it is taking to revise
those regulations.
We have about 16 to 20 States who are on standby now to
provide medical model adult day home care--health care to
veterans and their spouses and widows, as well as gold-star
parents, but they are not moving forward until they see
publication of those regulations.
Ms. Wasserman Schultz. Eight years?
Mr. Sganga. That is correct.
Ms. Wasserman Schultz. It has taken 8 years for them to----
Mr. Sganga. We don't have them yet, so----
Ms. Wasserman Schultz. Why?
Mr. Sganga. You will have to ask the VA.
Ms. Wasserman Schultz. I will.
Mr. Sganga. Okay. Thank you.
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
Mr. Dent. Thank you, Ms. Wasserman Schultz.
I would like to recognize at this time the vice chairman of
the subcommittee, Mr. Fortenberry.
Mr. Fortenberry. Thank you, sir, for appearing.
The veterans homes approximate to my district seem to be
very happy places, to be honest with you.
Mr. Sganga. That is correct.
VETERANS ORAL HISTORY PROJECT
Mr. Fortenberry. And the decided focus on the particular
needs of the veteran but also the celebration of the lives of
the veteran and an inclusion of families is a dynamic that I
have witnessed that, frankly, I am very proud of, so thank you
for your work.
One thing I would encourage you to do if you haven't
already is there is a veterans history project coordinated
through the Library of Congress, and we have made several
offerings to veterans in our community--one at the vets home,
which we actually facilitate the recording of the veterans'
stories. And I remember one time a woman veteran, World War II
veteran, told me, ``Well, I didn't really have anything great
to say about my service in the war. I mean, I joined after my
five brothers joined.''
I said, ``What? There were six of you from one family?''
``Oh, yes.''
And I said, ``Well, tell me''--in other words, this person,
her own greatness, her own willingness to sacrifice, her own
understanding of what she did as simply dutiful and not
extraordinary was a reason itself that it was so extraordinary
and a reason to capture that memory.
So one of the things I just wanted to suggest to you is if
it is not already a part of the culture that for veterans who
are in your homes to get those stories recorded and be
permanently here in our nation's archives. And I think it has a
lot of meaning to them, particularly the older veterans for
whom, as you are quite aware, there wasn't a culture in which
people talked about their service or what they saw.
In fact, we did one of these recordings with a veteran--a
World War II veteran; I believe he was about 90 at the time--
who, through that interview, we actually were able to determine
that there was post-traumatic stress disorder that had never
been caught, diagnosed. And now he is receiving some treatment
at a very old age.
Nonetheless, it is a great way to continue this celebration
of vet services, and you, as a platform, a home for so many
veterans, I think the more we can do to capture those stories,
it is not only beneficial for the Nation but it is a great
service to the individual.
Mr. Sganga. Mr. Vice Chairman, thank you for recognizing
the special culture that does exist at any state veterans home.
I can tell you that a typical nursing home in the United
States of America is probably 75 percent women, 25 percent men.
In Stony Brook where I am, and a lot of my colleagues, we are
about 90 percent men and 10 percent women. So that does create
a little bit of a different atmosphere. If we were to return in
50 years I am sure it would be a lot different.
But as a licensed nursing home administrator in a state
veterans home, we are constantly looking out for the needs of
both men and women whose service provided the freedoms we enjoy
today.
And I want to let you know that, indeed, a good portion of
our state veterans home program participates in the Veterans
Oral History Project.
Mr. Fortenberry. Great. Good. Thank you.
Thank you, Mr. Chair.
Mr. Dent. Mr. Bishop.
Mr. Bishop. Thank you, Mr. Chairman.
Mr. Sganga, thank you so much for your service, and thank
you for supporting the grants for state extended care
facilities programs.
All of our States have stressed budgets and, of course,
that program would certainly supplement what the States are
able to do, and so I thank you for that.
I don't have any questions for you.
I yield back, Mr. Chairman.
Mr. Dent. Thank you, Mr. Bishop.
And before we adjourn I just want to make a few comments.
First, the Capitol Police advise us that Independence
Avenue is still blocked due to an ongoing investigation or an
incident, actually. For your safety we would ask that our
witnesses and guests use the first-floor exit for the Rayburn
Building, which is open to South Capitol Street. You will be
directed to walk east away from the mall. So we just wanted you
to be aware of that.
I would also like to mention to the group that today's
hearing is being webcast. It will be available on the
committee's Web site, Facebook page, and YouTube link, so I
wanted you to be aware of that, as well.
And finally, I just wanted to say thanks to all of our
witnesses today and to your organizations for the very
important work that you are doing on behalf of our Nation's
veterans. Your advocacy and your dedication and commitment are
deeply appreciated, and we just want to say thank you for that.
So with that, this hearing will be adjourned. Our next
hearing is on Wednesday, May 3, with the secretary of the VA.
Thank you all. Have a good day.
Wednesday, November 15, 2017.
VETERANS AFFAIRS ELECTRONIC HEALTH RECORD
WITNESSES
HON. DAVID J. SHULKIN, SECRETARY, DEPARTMENT OF VETERANS AFFAIRS
JOHN H. WINDOM, PROGRAM EXECUTIVE, ELECTRONIC HEALTH RECORD
MODERNIZATION
SCOTT R. BLACKBURN, EXECUTIVE IN CHARGE, OFFICE OF INFORMATION AND
TECHNOLOGY
Opening Statement Chairman Dent
Mr. Dent. Good morning. Well, thank you all for coming out.
We have convened this hearing with the Secretary of the VA
to discuss a very important and expensive issue that was first
presented to us last week--VA's plan to sign a contract with
Cerner Corporation for an electronic health record. The record
will use the same platform the DOD has purchased from Cerner
for its health record.
Since this need developed after the fiscal year 2018 budget
was submitted and before we received the fiscal year 2019
budget, the VA proposes to begin funding it through a
reprogramming request.
We understand that you have not completed negotiations with
Cerner, so there are some total cost issues you are not able to
discuss in open session out of concern about generating bid
protests. We intend to pursue those issues in a closed session
that will follow this one. However, we are confident we can
discuss the major elements of the contract in public.
For veteran members of the committee like Chairman
Frelinghuysen and Ranking Member Lowey, the creation of a
electronic health record has become a tired refrain. They have
been hearing about it since the mid-1990s. VA Secretaries have
come and gone, promising that their records were achieving
interoperability or that they were developing the same record
as DOD or that they had decided to have two different systems
that would talk to each other.
Now the pendulum has swung back once again to creating one
record to be used by both departments, the position this
committee has argued for from the start. The number of years
and dollars that have been wasted reaching this point is
extremely troubling.
Mr. Secretary, we know that we cannot lay this past history
at your feet, but you will forgive us for being a little
skeptical that, at this late date, the VA has now found the
answer to its electronic health record conundrum. We know you
are anxious to sign the contract with Cerner, but the committee
will need more information before it is comfortable with
approving this first step down a long and expensive road.
Before we ask you to give a statement, I would like to
inquire if Ranking Member Wasserman Schultz has any comments.
Ms. Wasserman Schultz. I do. Thank you, Mr. Chairman.
Mr. Dent. You are recognized.
Opening Statement Ranking Member Wasserman Schultz
Ms. Wasserman Schultz. And welcome, Secretary Shulkin.
Thank you, Mr. Chairman.
And we do appreciate you being here on fairly short notice
so that we can discuss the VA's efforts to modernize its
electronic health records platform.
But I really think, especially because we have some new
members, including a relatively new member, myself, that we
walk everyone through the EHR timeline thus far and the
unbelievably lengthy process that this has been, even for
government.
Mr. Chairman, as you know, in 1998, during the Clinton
administration, a Presidential review directive acknowledged
that DOD and VA systems were not compatible and that actions
should be taken to identify data exchange systems.
In 2003, President Bush established a task force to improve
healthcare delivery for veterans, and it recommended that the
Departments develop an interoperable record.
In 2007, the President's Commission on Care for America's
Returning Wounded Warriors also supported interoperability, the
genuine ability of these two systems to seamlessly exchange and
make use of the other's information.
Then, in 2009, President Obama announced that DOD and VA
would be working together to build a seamless system of
integration.
Fast-forward to 2011, when VA Secretary Shinseki and DOD
Secretary Gates announced plans to create a single electronic
record.
However, just 2 years later, in 2013, the two Departments
announced that they would no longer create a single, common
health record and, instead, solely focus on interoperability.
The VA chose to modernize its existing VistA health record in-
house, while DOD announced it would contract a commercially
produced health record.
In response to that problematic announcement, the House-
reported fiscal year 2014 MILCON-VA bill directed the VA and
DOD to develop a single electronic health record. I stress:
directed the VA and DOD to develop a single electronic health
record.
Unfortunately, the committee was forced to remove that
requirement after discussions with the House Armed Services
Committee. The final appropriations language permitted either a
single system or two interoperable records.
After that battle was lost, DOD went on to award a $9
billion contract to Cerner to develop the DOD health record,
while, at the same time, VA efforts to modernize VistA
underwent further review.
Mr. Chairman, I believe we can agree this would not have
led to genuine interoperability, and the patchwork of the Joint
Legacy Viewer has left much to be desired.
Finally, earlier this summer, the VA announced its
intention to award a single-source contract to Cerner to
provide VA the same electronic health record DOD is developing,
as well as follow the same rollout cycle being operated by DOD.
So, Mr. Chairman, this issue could have and should have
been resolved years ago. It is no wonder that our constituents
get incredibly frustrated with the insanity of the bureaucracy
of many Federal agencies, and this is a textbook case. When I
think about the time and resources that have been wasted over
the years on this endeavor, it is easy to see why members have
such strong feelings and such frustration concerning this
issue.
And I share the chairman's recognition that it is certainly
not at your feet, but it is at your predecessors' feet and
people who have been working on this for probably all of those
years.
And while I am pleased that the VA is moving in the
direction of creating an integrated health record system,
finally, with DOD, like we thought should happen years ago, I
was not thrilled about getting a $782 million reprogramming at
the end of October that needed to be acted on by November with
no real details.
I am also concerned about how this new system will work
with the private-sector providers. And that is a question that
I hope you are going to address in your testimony. If not, I
will ask you. With veterans taking advantage of community care
in significant numbers, we need to ensure that the new EHR
system will be able to seamlessly exchange data between the
private sector and the VA.
Years down the road, I hope to not be at a hearing where we
are discussing our frustration over the less-than-complete
interoperability and ability to seamlessly move electronic
health records from DOD and military service all the way
through, including to the private sector. So I look forward to
the opportunity to hear your thoughts and share my concerns.
And I yield back.
Mr. Dent. I thank the ranking member.
At this time, I would like to recognize the chairman of the
full committee, Mr. Frelinghuysen.
Opening Statement of Full Committee Chairman Frelinghuysen
The Chairman. Great. I want to thank you, Chairman Dent and
Ranking Member Wasserman Schultz, for scheduling this hearing.
And I want to thank everybody for being here today.
Dr. Shulkin, it is good to be with you and your colleagues.
We are here today because of your reprogramming request for
additional resources for your electronic health records
project. As all of us are painfully aware, the VA and DOD
electronic health record compatibility, as has been mentioned,
has been an issue for over 20 years.
In fact, 4 years ago, your predecessor, Rick Shinseki, and
Department of Defense Secretary Chuck Hagel met with Mrs. Lowey
and with my predecessor, Hal Rogers, and made a fairly public
commitment to get the damn job done. And some sort of a
solution was supposed to be reached within a year. It was never
done. DOD went one way; VA went another way.
Despite those decisions, Congress has supported in a
bipartisan way, the joint effort by providing billions of
dollars over the years for these different projects. So when
the committee was asked on short notice to approve a
reprogramming to get yet another proposed project started and
one that would require many billions of dollars over a long
period of time, it was clear we needed some answers.
Today, we need answers: True cost? What can be salvaged
from the old system? And when it is all said and done, will the
systems be seamless? And will this investment take away from
dollars needed to replace existing old IT systems in the many
veterans hospitals we have around the country? We have dozens
of them, old systems.
And will it take away from meeting the challenges of the
new Choice Program and, may I say, a constant irritant to me,
the embarrassing backlog of cases? I mean, some of these men
and women are in their eighties and they are waiting for some
sort of adjudication of their cases. Totally inexcusable.
I know the focus here is on electronic medical records. Two
priorities for the entire Appropriations Committee, not just
this subcommittee, which Chairman Dent runs well, is that we
ensure that we are providing the best medical care for our
veterans and that we are setting out a fiscally responsible
course to meet their needs. All of us want to hear in detail
and for the record how that is going to be done.
Thank you, Mr. Chairman.
Mr. Dent. Thank you, Chairman Frelinghuysen.
At this point, I would like to ask the Secretary to
introduce his panel and then proceed with your testimony.
Thank you, Mr. Chairman.
Thank you, Mr. Secretary. You are recognized.
Secretary Shulkin Opening Statement
Secretary Shulkin. Well, Chairman Frelinghuysen, Chairman
Dent, Ranking Member Wasserman Schultz, and all the members of
the committee, thank you for being here. And our intent is to
be candid and answer all your questions this morning.
I have with me, to the right, Scott Blackburn, who is the
executive in charge of information and technology, and, to my
left, John Windom, the executive for the electronic health
record modernization.
And, as you know, VA and DOD have been working on trying to
get interoperable electronic medical records for quite some
time. I was only able to trace the history for 17 years, but I
am going to defer to the ranking member, who I think did a much
better historical record of this than I did, so we are going to
use her timeline. It has been quite a while.
And, Chairman Dent, I think skepticism is appropriate. I
don't know any other way to interpret history than to say that
this has taken way too long, and there have been many false
starts along the way. So I am right with you.
I think that there is enough blame on both sides here, with
DOD and VA. So I am not going to spend a lot of time on the
history. I will tell you, right now--because that is really my
best chance to sort of assess the situation--I have never seen
better cooperation between DOD and VA. And I have to give a lot
of credit to Secretary Mattis and Deputy Secretary Shanahan for
leading this and saying we are going to get this done. So I
think everyone is in agreement, this has taken too long.
Even besides the fact that we don't have interoperable
systems, VistA by itself is not a system. It is 130 different
instances of an electronic medical record. That is insane, but
that is the system that we have today.
So we could continue down the same path that we are right
now, without DOD and VA being interoperable, with VA having 130
different electronic medical records. But we could,
alternatively, go for a commercial, off-the-shelf system that
is going to provide a single system with DOD and give veterans
seamless care and this integration with community providers
that the ranking member mentioned.
From my perspective, maintaining the status quo is just not
acceptable. The health and safety of our veterans is our
Nation's highest priorities--among our highest priorities. On
that, I know that everyone here agrees in a bipartisan way.
Critical to meeting that priority is a complete and
accurate veterans health record in a single common EHR system.
Adopting the same EHR as DOD will vastly improve VA services
and significantly enhance the coordination of care for
veterans, not only at VA facilities but also at the Department
of Defense and with community providers.
Continuing to pursue VistA EHR interoperability would fall
short in providing veterans the quality healthcare that we can
give while throwing good money after bad. So, on June 5th of
this year, after carefully looking at the data, I announced my
decision to adopt the same electronic health record as the
Department of Defense.
And I am convinced adopting the same EHR system that DOD
uses is the best solution. It will allow VA to keep pace with
health information technology and cybersecurity improvements
that VistA simply cannot achieve. Veterans' health information
will reside in a single common system, providing seamless care
between the Department of Defense and VA. We will be able to
share veterans' health information with our community partners.
And for those transitioning servicemembers, veterans' medical
records will be at VA on day one.
In working hand-in-hand with DOD on the same system, we are
going to gain the advantage of their lessons learned, while
making sure we fully achieve interoperability objectives. We
are also committed to working with other EHR vendors besides
Cerner and leading technology companies to create
interoperability with our academic and community partners
within the communities where our veterans live.
This is the best decision for veterans in the short term
and long term, and it is the best decision for taxpayers.
Upgrading and maintaining VistA to industry standards will cost
approximately $19 billion over 10 years--that is an independent
study that was done by Grant Thornton--and we will still not
achieve the necessary VA-DOD interoperability that the new EHR
system that we are proposing will provide.
The new EHR system over 10 years will be billions less than
the $19 billion required for our current system. We are going
to discuss the specifics in closed session, as you suggested,
Mr. Chairman.
And by moving from over 130 instances of VistA to a single
instance of the new EHR, we will save billions more in
efficiencies and quality improvements. I look forward to
discussing those details, as well, in the closed session. But
what I can say here is that we are achieving substantial
discounts, choosing the same system as DOD and aligning our
system deployment with theirs.
Mr. Chairman, we want to work with Congress to find a
common solution to funding this EHR modernization plan in
fiscal year 2018. We prefer to fund the plan as part of the
enacted 2018 appropriations bill, as I think you do too;
however, we have to do this quickly.
We have achieved substantial discounts by aligning our EHR
deployment and implementation with the Department of Defense's.
Absent an appropriation bill by the end of the calendar
year funding the plan, we ask Congress to consider approving
our transfer request so we can promptly award the contract.
This contingency enables VA to avoid cost increases and allows
us to move forward with IT infrastructure modifications and
expanding our program management office to provide the
necessary oversight and manage implementation.
I do ask you consider establishing a new, separate
appropriation account for EHR modernization costs. That way, we
can capture everything in one place for the sake of full
transparency and accountability, from our initial operating
capacity to full deployment and other important decision points
along the way.
Mr. Chairman, the electronic health record modernization
plan is right for veterans' healthcare, and it is right for
taxpayers. It will significantly improve VA services and
enhance the coordination of care at VA, DOD, and in the
community.
Thank you for the partnership in helping us improve how we
care for our Nation's veterans.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Dent. Thank you, Mr. Secretary.
Would you introduce your panel that's with you today,
please?
Secretary Shulkin. Yes. Mr. Scott Blackburn, the executive
in charge of information and technology, and Captain John
Windom, who is in charge of our EHR modernization.
Mr. Dent. Thank you.
At this time, let's go right to questions.
DESCRIPTION OF PROPOSED EHR SYSTEM
Mr. Secretary, could you please start by laying out for us
the type of records system you are contracting for, what
capabilities VA needs, the timeframe and geographic rollout you
plan nationwide, and the impact it will have both financially
and in terms of patient healthcare?
Secretary Shulkin. Well, we have been working very hard to
answer all those questions. And we do have a very specific
timeline/project plan objectives. And in order to do this in
the most succinct and accurate way, I am going to ask Captain
Windom to respond to that.
Mr. Windom. Retired, sir.
Secretary Shulkin. Okay.
Mr. Windom. I appreciate the opportunity, and thank you,
Mr. Chairman.
Because we have a closed session forthcoming, I can speak
in greater detail in a closed session. But, overall, we intend
to award a 10-year contract. Within that 10 years, we
anticipate deploying to the full enterprise the full breadth of
the 1,600-plus facilities and community providers that support
those respective facilities. We believe that within that 10-
year timeframe that is very much achievable.
And following the signing of the D & F back on June 5 by
Secretary Shulkin, we entered into immediate and direct
negotiations with Cerner Corporation such that, as part of an
alpha contracting process, we are able to communicate across
the table to fully assess not only their concerns for
deployment but to offer them full understanding of the
environment that they are going to be deploying to. And,
therefore, we are very comfortable with a plan that deploys
across the enterprise in less than 10 years.
We intend to align our efforts to those of DOD today. I was
fortunate enough to lead the program office for DOD that
successfully acquired Cerner through a competitive acquisition.
So very comfortable that I have seen both sides of the fence.
I am also very comfortable that we are leveraging the
lessons learned that DOD has in their associated deployment
challenges. But that alignment, that critical alignment early
in the process allows us to move out more aggressively in our
approach, to be more efficient in our approach, and, again, to
maintain the requisite configuration management over both
sides, DOD and VA, that will support seamless information
exchange well into the future.
So hopefully I answered your question, but subject to your
additional questions, I will pause.
ROLLING OUT SYSTEM GEOGRAPHICALLY
Mr. Dent. Yes. Mr. Windom, you said you were going to roll
this out across the whole system. Geographically, in what areas
are you going to start?
Mr. Windom. So, presently, DOD is in the Pacific Northwest.
They just went live in Madigan Hospital, and they have gone
live at three other facilities. So it is our intent to deploy
also to the Pacific Northwest.
It is inherent economies of scale gained by labor
efficiencies. I can't speak for Cerner Corporation, and I won't
delve overly into the specifics of the negotiation, but there
is clearly--by us deploying into the same geographical area, we
will be able to leverage the resources that are already in that
area. If we deployed east, clearly they would have to stand up
a full-team that would have to, again, support our deployment
on the opposite part of the country that DOD is in fact
deploying.
So we believe and have seen as part of the negotiation
process substantial efficiencies in that area and in that
strategy.
Mr. Dent. Back to Secretary Shulkin, your reprogramming
proposes to move funding in two ways, from medical services and
medical support and compliance, to jump-start the program, with
appropriated funding first assumed for fiscal year 2019.
The first wave of transfers is $324 million from medical
services and $50 million from headquarters staff hiring. We
understand the hiring freeze has generated the $50 million, but
the $324 million from medical services will be a hard sell to
outside organizations, some of whom are probably represented
here today.
I know you say it is for medical equipment purchases that
can be recouped at the end of the year, but your fiscal year
2018 budget already starts out with a $245 million cut to
medical equipment. So merely getting back to the original cut
level isn't particularly reassuring.
How are you going to characterize this publicly?
Secretary Shulkin. Well, first of all, we would prefer to
take the strategy that I believe that you would also support,
which is not to do this transfer but to get the 2018
appropriations done before the end of the calendar year.
We are in somewhat of a time crunch, in that, in order for
us to achieve the efficiencies that Mr. Windom just talked
about, we do need to align closely with the DOD implementation.
And so we are trying to do the best thing for taxpayers here.
What we have proposed is an alternative if we are not able
to get the 2018 appropriations bill done, where we would use
some money that was from carryover from 2017 as a stopgap to be
able to start this project, and then we would refund it, we
would replenish that money so we do not believe that this will
end up delaying or hurting veterans' healthcare. But it is not
our preferred strategy.
Mr. Dent. Thank you.
I have additional questions, but we have a lot of members
here, so I want to go right to their questions.
Ranking Member Wasserman Schultz is recognized for 5
minutes.
Ms. Wasserman Schultz. Thank you, Mr. Chairman.
CATCHING UP TO DOD EHR DEPLOYMENT
The frustrating thing here is that the VA--and I say VA,
not you--but the VA's foot-dragging and missteps have become
our emergency.
Because DOD has jumped ahead and gone forward with what we
should have been doing in parallel. You know, as an
appropriator for a long time, that is not really the fiscally
responsible way to deal with things. So I just will express
that frustration out loud.
To follow up on the chairman's question, I was going to ask
this in closed session, but since you were able to answer it in
the open, I will ask it. At the locations where the VA missed
the opportunity to piggyback on DOD, are you going to deploy at
those sites last? Or is a second Cerner team going to have to
go to those sites?
Secretary Shulkin. Well, we don't think we have missed any
yet. They are just now implementing in the Pacific Northwest. I
think they had their opening 2 weeks ago or a recognition of
that. Today, maybe, is their official.
So that is why we are trying to do this quickly. And we
recognize you have been extraordinarily responsive in trying to
keep up with that timeline. But we haven't missed any sites
yet, and so we don't want to be in the position of having to go
back and correct for that.
TIMEFRAME TO DEPLOY THE CERNER SYSTEM
Ms. Wasserman Schultz. On the timeframe to fully deploy the
Cerner system, theirs is a 15-month deployment schedule per
location. Is that a timeframe that is set in stone, or are you
going to be able to shorten it as you learn best practices?
Secretary Shulkin. Yes. Working with DOD and the fact that
they have been so generous in sharing their lessons and their
implementation plans, we can clearly shorten this.
The DOD healthcare system is one-third the size of VA. So
let's just, from the start, say ours is a much more complex and
larger implementation. But we believe that if the contract is
signed that we will be implementing our first site within 18
months. And then it will be this 7- to 8-year rollout that will
get you to the full 10-year period.
But we have to implement much faster and more aggressively
than DOD, just because the number of facilities that we have
are two-thirds more than what they have.
Ms. Wasserman Schultz. When I got on the Appropriations
Committee, I inherited, as the then-chair of the Leg Branch
Subcommittee, helping to bring in for a landing the really
unbelievably blown timeline and cost of the CVC. So, at a
certain point, we had to bring in GAO to manage the completion
of it so that we could stop the bleeding.
IS THE TIMELINE TOO AGGRESSIVE
So I have a little experience in oversight of something
this significant, which concerns me--just to use an example of
the question I am going to ask you, my husband for years--I am
almost always late. My husband will be early to his funeral.
And in our 27-year marriage, he has told me, ``Debbie, it is
just better to tell me the real time you are going to be here
than to give me a time that is a lot sooner than you really
likely are going to arrive.''
So that begs the question, it took DOD 26 months from
generation until contract award, and you have a faster timeline
than DOD and a larger system, so is there any concern that your
timeline is too aggressive?
Secretary Shulkin. Well, first of all, I think your example
is a very good example we can all understand. But there is no
doubt that we are being aggressive with this. But we are also
doing business differently, and we are trying to do business
differently. Now, that doesn't assure that we are going to be
100-percent successful at this, but I think the right thing to
do in this situation is to act with urgency and to be
aggressive and to establish sharp timelines.
The major difference that we are going to do in
implementing this versus other VA IT projects, which does not
have a great history of on-time, on-cost----
Ms. Wasserman Schultz. No.
Secretary Shulkin [continuing]. And we understand that--is
we, first of all, have given up on the idea that we are going
to be doing software development ourselves. That was the
initial plan, which is that we are going to buy commercial,
off-the-shelf systems and we are going to rely upon industry
partners who have good track records.
Secondly, we are going to do the governance of this project
and the oversight of this project directly out of the
Secretary's office. That has not been done before. Part of the
root cause of some of our problems at VA has been the silos
between IT and the health system. And so this is going to
report directly to the Deputy Secretary, who will have
oversight. And there will be a new governance committee
established that will have VHA and IT working as part of that
governance structure.
Third is we are using the lessons from DOD. If they weren't
talking to us and sharing this, I would be much more concerned.
But they are so fully committed to our success that I believe
that saves a lot of time and a lot of money for taxpayers.
And, fourth, we are taking advantage of the private-sector
CIOs. Mr. Blackburn is going to be on a call with five of the
leading CIOs in the country getting their advice, asking what
mistakes are likely to happen, and essentially using private-
sector input.
I have been a private-sector CEO. I have done EHR
implementations. It doesn't mean I have done anything like this
or this complicated. Nobody has. But I think we are committed
to working with the private sector and DOD in ways that VA
before just hasn't been willing to do.
Ms. Wasserman Schultz. Mr. Chairman, Mr. Secretary, I look
forward to being surprised. Thank you.
I yield back.
Mr. Dent. At this time, I would like to recognize the
chairman of the full committee, Mr. Frelinghuysen, for 5
minutes.
The Chairman. We are admiring of the work you are doing and
the fact that you are putting your shoulder to the wheel.
Just let's say for the record, the House did all of its 12
appropriations bills. We are waiting on the Senate. And the
first bill out of the hopper was this bill.
Secretary Shulkin. Yes.
The Chairman. And may I say for the record, no
disagreement, we forward-funded the VA. No one else gets that,
and we do it for a reason.
The issue here is that we are about to approve a
reprogramming of a certain amount, which commits us to a long-
term obligation. And that is why we are here, is just to have
some assurances that we know where we are going here. That is
really why we are having this hearing here.
ELEMENTS TRANSFERABLE FROM VISTA
For me, just a couple of comments. Is there anything
salvageable from what we have already invested in? Which I have
indications there is.
And we have other financial systems in a variety of VA
facilities that are subpar, ancient, all different.
And I assume you feel that those are systems that need to
be replaced, rejuvenated, and whatever.
But, you know, the issue here is we sign on the dotted line
with this reprogramming. We are committing this Congress and
future Congresses to the implementation of this plan.
We want to get it headed in the right direction.
Secretary Shulkin. Right.
I think that, Mr. Chairman, you were absolutely correct in
all of your comments here and your perspective on this. VA has
always shared the goal of getting interoperability and has
shared the goal of getting interoperability and has shared the
goal of getting to one instance instead of 130 of our EMR. It
is just that we thought we would build this ourselves. And so
we have been trying to be a software development company. And
we have literally spent billions of taxpayer dollars and lots
of years and haven't gotten there.
And what we are saying now is that we are going to go to
commercial, off-the-shelf technology. But what we have worked
on isn't completely wasted. We have a lot that we have achieved
that we are going to use in this implementation. Part of why it
gives us a little bit more confidence that we will get there
and that we can make up on some of these timelines. Because a
lot of the work that we have done in process mapping of getting
towards a single instance, which we had called VistA Evolution,
is not going to be wasted, and we are going to need that.
We are also going to be running our VistA system in
parallel while we bring up Cerner, because we cannot afford to
let any veterans' healthcare fall down.
Mr. Dent. I would now like to recognize the gentleman from
Georgia, Mr. Bishop, for 5 minutes.
Mr. Bishop. Thank you very much.
Let me welcome you, Mr. Secretary, Mr. Blackburn, Mr.
Windom.
CONNECTION TO COMMUNITY PROVIDERS
Let me get right to the point. As you know, the issue of
creating a fully interoperable health record for our veterans
has been a concern of Congress for a long, long time. It is my
understanding that the proposal from Cerner is focused on DOD-
VA interoperability but that the strategy to connect community
physicians who provide care for veterans is not yet defined.
Given the growth of the Choice and the Community Care
program, this challenge is something that really needs to be
addressed immediately, particularly in rural areas. I, for one,
would be much greater reassured if we knew that you had plans
to address the interoperability with the community providers,
as well as to ensure that all veterans can benefit from the
interoperability.
As such, what provisions are in the Cerner contract that
will develop interoperability solutions to improve connectivity
between the providers and the community? And by that, I don't
mean a Joint Legacy Viewer.
Secretary Shulkin. Yes. Your question is absolutely the
critical question that we have set forth to achieve.
So, first of all, we will achieve DOD interoperability.
That is one piece of it. We will achieve better
interoperability among the 130 different instances because I
practice in the VA; I have to leave my system that I use to go
into one across the country. So it is not, even in the VA
system, true, easy interoperability.
VA already has several hundred health information exchanges
with community providers. So we are doing interoperability with
our community providers in the network. As you know, one-third
of our care is now out in the community.
Mr. Bishop. Right.
Secretary Shulkin. So we are going to already have that.
Cerner, itself, has an interoperability tool that connects
with thousands of additional providers with standards that are
common. So we will have that.
But we absolutely need to engage other IT vendors, other
EHR vendors, besides Cerner, in order to achieve the objective
that you have laid out, and that is a program that we have just
put out an RFI for to industry to ask how we can best do this
and work with them to achieve the goal you have stated.
We call it the digital health platform. It is a central
component of achieving the goal that we need for our veterans,
which is interoperability with community partners. And we are
going to be working with industry to get that done.
CYBERSECURITY CHALLENGES
Mr. Bishop. One of the real challenges, particularly in
this day and time, is going to be the cybersecurity aspects of
the Community/Choice program connectivity, as well as the DOD-
VA interoperability.
Secretary Shulkin. Yes.
Mr. Bishop. So that is going to be a real challenge, and we
will be very interested to know how you are going to make that
happen.
EHR PROGRAM MANAGEMENT OFFICE
You mentioned that the electronic health record program
will be run out of your office. Will you set up a new sub-
office? Will we see this in the fiscal year 2019 request? Or
are you going to try to do it----
Secretary Shulkin. Yes. This is all part of the overall
program cost.
And, Scott, you may want to talk about the PMO and how we
are going to do this.
Mr. Blackburn. Absolutely.
So there will be a separate office. That is currently being
led by Mr. Windom. So it will be a program management office
that will be made up of both clinicians from VHA as well as
technologists from OI&T. We feel it is incredibly important to
put them together in one team, one integrated team that is
working together, with a joint governance structure over that
that includes the CIO, that includes the Under Secretary of
Health and the Deputy Secretary.
PROJECT GOVERNANCE
Mr. Bishop. Quickly, let me ask you, where you have these
CIOs working together, for key decision points that might
impact both departments, who will serve as the responsible
personnel that is accountable? DOD? VA? Who is going to be
ultimately responsible for making those decisions?
Mr. Blackburn. I will defer to Mr. Windom on the joint
governance structure.
Mr. Windom. We believe that governance is a critical part.
We want to stay on converging paths to seamless care, not
diverging paths. So governance has been something we have been
working on hand-in-hand with our DOD counterparts, and we have
created an interagency governance board. That interagency
governance board is chaired at the highest levels. We would
like to think that much of the decisionmaking and results
will----
Mr. Bishop. Who will chair that?
Mr. Windom. Well, it will be chaired at the DepSec level
for us, and it is at the AT&L level for DOD.
And so that board, there will be technical and functional
governance elements under those levels that, hopefully, most
problems will be resolved in.
There will be participation by Cerner Corporation, as a
nonvoting member, because they are the developer of the
software. DOD, as you know, has Leidos as a prime contractor,
so they will be a participant.
So it is important that we all stay in tune to the changes
that each side is making or desires to make, DOD-VA, with a
clear understanding that we will manage, you know, in a
configuration management schema, those changes. Because,
typically, most changes are good for both sides of the
enterprise, not for a single side.
So, sir, that construct under that interagency platform is
going to be how we are going to ensure that we stay aligned in
our methodologies and moving forward.
Mr. Dent. I would like to recognize Mr. Jenkins for 5
minutes.
Mr. Jenkins. Thank you, Mr. Chairman.
And, folks, thanks for being with us.
Two areas of inquiry.
OPIOID CRISIS
One, we are amidst, nationally and certainly at ground
zero, an opioid crisis. And I appreciate the work that the VA
is doing trying to address this within our veteran population.
We obviously have a patchwork of prescription drug
monitoring programs at the State level around the country. We
have had issues about trying to make sure the VA is sharing
information for these PDMPs and also that the healthcare
providers at the VA have full access to the appropriate medical
history for best prescribing practices.
Can you reassure me about the interoperability of this
system being able to integrate the information from State PDMPs
and what the status is on the VA sharing information the other
direction, with State PDMPs, about prescribing issues?
Secretary Shulkin. Yes.
Well, first of all, as you know, the VA is fully committed
to complying with the State regulations and the State laws, and
we do. That is our current policy, that we use the PDMPs. And
it is part of our multifaceted approach to reducing opioid use
and one of the reasons why we have a 36-percent reduction in
opioid use among veterans since 2010.
We are concerned about data that shows that when veterans
leave the VA out into the community that there are actually
higher rates of opioid abuse happening out in the community. So
this is one of the reasons why this interoperability with
community providers is absolutely key to us.
But Cerner Corporation, in this contract, is committed to
complying with the State regulations. And that is something
that we just won't see any misstep from in the transition.
Mr. Jenkins. Thank you.
The second, I am a big believer that you have to be able to
walk before you run. And I know what you are describing here is
running with an integrated system, working with community
partners, but I still remain very concerned about the existing
system and the breakdowns.
PAYMENT SYSTEMS PROBLEMS
Let me just give you an example. I was in my hometown, at
Cabell Huntington Hospital, one of the largest hospitals in the
State. Many veterans get care there, coupled also with our
wonderful VA medical center in Huntington.
But in my meeting with Cabell Huntington Hospital, they
were sending claims for the direct VA care to Mountain Home VA
Health Center in Tennessee. And they were having a 40-percent
rejection rate just because the folks at Mountain Home VA
Health Center, as I understand it, generally, maybe not in
every case, was sending them to the wrong VA center.
So Cabell Huntington Hospital has to start stamping each
claim that they submit to say where Mountain Home needs to send
it. And they have improved. They are at the 25- or 30-percent
level.
And then, when Cabell Huntington tries to call, very often,
nobody answers; there is no ability to leave a message.
So, fundamentally, I still think we have serious, serious
payment system problems. We have an administrative challenge,
to be polite about it. Because this is to the tune, for a
community of 50,000 people, a hospital, they have accounts
receivable to the tune of $7-million-plus waiting for payment.
That impacts healthcare delivery for our veterans.
So what assurances can you provide that, while we are
thinking visionarily about this new integrated EMR-EHR system,
we are still making a commitment to getting the payments done
in a timely, accurate fashion and addressing the flaws in the
existing system?
Secretary Shulkin. Yes. You know, I come from the world of
running hospitals, and I fundamentally believe that if you
deliver a service, you need to be paid for that. And the VA, in
too many cases, as you are saying, is falling short on that.
There is, again, enough blame for this to go around. We
have had problems with our third-party administrators in some
cases, our contractors and payments. But, clearly, a lot of the
responsibility is also on the VA.
We are working very hard to improve those areas of
communication, that what you are describing is unacceptable. We
are trying to build timely payment standards into new Choice
legislation that we hope that you will soon have an opportunity
to consider. And we are trying to simplify the payment systems,
which right now require 100-percent adjudication, which is not
an industry standard. You wouldn't find that in the private
sector.
So I think that we are trying to move much more to where
the private sector has gotten to on timely payments, and we
need to do that. And I would be glad to look into your
particular situation there so that we can get that corrected,
as well.
Mr. Jenkins. Thank you, Mr. Secretary.
Mr. Dent. I would like to recognize the gentlelady from
California, Ms. Lee.
Ms. Lee. Thank you, Mr. Chairman.
PROBLEMS FINDING MINORITY & SMALL BUSINESS SUB-CONTRACTORS
Welcome, all of you. Thank you for being here.
Of course, this is a sole-source contract, 10 years. You
have been very aggressive, in response to Congresswoman
Wasserman Schultz, in terms of getting this done.
Now, Small Business Administration negotiates prime and
subcontracting goals with each Federal agency. So, given this
contract, given that it has been pending, as we know--I mean,
this work has been pending for many, many years, let me ask you
a couple of questions just about this in terms of the VA.
Now, I know the VA got a passing grade of B on the prime
subcontracting goals of 30 percent of small-business-eligible
contracts. That is the VA. Now, your newly negotiated goal for
fiscal 2017, actually, that has been downgraded--I don't know
why--to only 28 percent.
Now, the VA notes in your report that providing timely
patient care requires that we continue to rely on national and
regional contracts for procuring healthcare outside the VA
system but that the VA will seek subcontracting opportunities
for small business.
Now, the VA did exceed its general small-business
subcontracting goal of 70 percent, but you failed in all these
other categories that are in statute. Let me give them to you.
Okay. You are required 5 percent of all prime
subcontracting goals. You reached 2.2 percent for women.
For small, disadvantaged businesses, 5 percent of all prime
and subcontracting awards. You got to 1.4 percent. And let me
remind you, this is where the minority-owned businesses are,
okay? African American, Latino, Asian, Pacific American, 1.4
percent total. That is outrageous.
Service-disabled veteran-owned businesses, 3 percent of all
prime and subcontract. You got to 0.3 percent.
And for HUBZones, you have a requirement of 3 percent. You
got to 0.5.
Now, given the enormous amount of money Cerner is going to
make off of taxpayers in this VA contract, let me ask you what
you have required of them to comply with Federal law to meet
all of these goals. Because what you are doing, you are going
backwards now, in terms of most of these businesses that you
should be requiring the subcontracting goals--contractors to
reach.
So let me hear your thinking on that and what you are doing
about this Cerner Corporation subcontracting goals.
Secretary Shulkin. Yes. So you are asking about what
requirements will we put on Cerner to subcontract with small
business and some of the particular----
Ms. Lee. Yeah. In compliance with the law.
Mr. Windom. Ma'am, within the terms and conditions of the
contract, the VA small-business goals are fully captured. I
can't site those for you directly. I can get back to you with
those numbers, but I could tell you exactly what percentages
are going to whom. What----
Ms. Lee. For Cerner. You are talking about now, for this
contract.
Mr. Windom. For this contract.
Ms. Lee. Yeah. Okay. For small business. Okay.
Mr. Windom. Cerner is fully on board with those--they have
to provide as part of the process a small-business plan on how
they are going to achieve those goals.
Ms. Lee. Right.
Mr. Windom. It is really the enforcement of those terms and
conditions that are important.
Ms. Lee. Yes.
Mr. Windom. My program management office will be enforcing
those goals rigidly. I can't speak for the other elements of
the VA. That is all new information to me. But I can assure you
that, in overseeing the Cerner contract, those small-business
objectives will be of the foremost importance to us to achieve.
Ms. Lee. But, Mr. Windom----
Mr. Windom. Yes, ma'am.
Ms. Lee [continuing]. Small-business goals are one. You are
not aware of minority-owned-business goals?
Mr. Windom. I am absolutely aware of minority-owned-
business goals.
Ms. Lee. Then what are they and what have you required of
Cerner for women-owned businesses and minority-owned businesses
in this contract?
Mr. Windom. Ma'am, the way the contract is broken down,
there are--again, I can't site the specific percentages, but
each one of those categories have a percentage of the total
contract value that they are entitled to be awarded as part of
contracted work subcontracted to Cerner.
Ms. Lee. Does anybody have those requirements here?
Mr. Windom. I can get back to you. Ma'am, I don't want to
cite inaccurate--but I can give you those percentages, broken
out by categories, as you requested. That is no problem. As a
matter of fact, I may even be able to get it in time during the
closed session.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Lee. Thank you.
And, Mr. Secretary, let me just ask you, just overall,
generally, what is going on over there? I mean, you know, we
are trying to ensure parity and equal opportunity and
nondiscrimination, and here you have 1.4 percent this year for
minority-owned companies?
Secretary Shulkin. Well, first of all, we are committed to
this. Those are numbers that are different numbers than I have,
so I would like the opportunity to be able to sit down with you
and----
Ms. Lee. This was from the Department of Veterans Affairs,
your procurement division.
Secretary Shulkin. In what time period?
Ms. Lee. This is February--we requested it for February
2017. Subcontracting data as of March 14, 2017, for fiscal
2016.
Secretary Shulkin. Yes. As I said, those are different
numbers than I have seen.
As you know, the Kingdomware decision has completely
changed the approach that the Department of Veterans Affairs is
doing for contracting with small businesses. And we have had a
strategic pause and have relaunched to be able to meet these
objectives.
This is a goal that we share, we take seriously. As you
said, our overall goals are always above our targets here. And
if we are falling short in some areas, I want to make sure that
you and I have the same information, but I can tell you we are
going to be committed to improvements. If the data that I have
is different than what you have, then I want you to have that
information as well too.
Ms. Lee. Okay. Thank you. And I look forward to getting the
specifics on Cerner. Thank you.
Mr. Windom. Absolutely, ma'am.
Mr. Dent. Okay. Mr. Taylor is recognized for 5 minutes.
Mr. Taylor. Thank you, Mr. Chairman.
And, Mr. Secretary, thanks for being here.
Let me first say, number one, let me echo some of my
colleagues' comments in talking about how long it has taken.
And I just appreciate that you are a hard charger, that you are
aggressively moving to get the damn thing done. Because it is
inexcusable, in my opinion, how it has been before you and I
both got here.
But I appreciate that you are doing that, but we do have
some questions, of course, on some of the cost savings and
timeline issues.
But I do want to address one thing that I just heard that I
think is important. Sure, you know, it is extremely important
for the VA to meet statute, to meet goals, in terms of service-
disabled veterans and minority- and women-owned businesses and
stuff like that. I am curious what Cerner's own goals are. But,
at the same time, I don't want forced equality on unequal
things, in terms of understanding that those statutes and goals
are overall in the VA Department, so if there is a specific
contract that there aren't qualified folks that can do the
work, if we force that to happen, then you are hurting
veterans.
So I definitely want to say that for the record. That is
not something that I want to see happen. But I do, of course,
you know, like my colleagues, want you guys to meet your goals
and statute.
That being said, a couple quick things. Let's see.
IMPACT OF FAILURE TO RECEIVE REPROGRAMING
Let's say you aren't able to get this reprogram, these
moneys, how will that affect you? What would the timeline be?
What would the cost be? Would it be a complete stop for your
efforts?
Secretary Shulkin. Yes, we think it will add--and, Mr.
Windom, please correct me if I am not being as accurate,
because we want to be as fully transparent as we can in open
session. We think it will add at least 5 percent to the total
project cost if we miss that alignment with the Department of
Defense.
Mr. Taylor. So, on the alignment--so it would seem that
they are actually getting the best efficiency, the DOD, as
opposed to your guys, because you are much bigger and you are
more complex, which is fine. That is great. We want to make
sure you guys are there.
In terms of if you didn't have the DOD in this, what would
that also be in terms of cost and timeline?
Secretary Shulkin. Well, it would be a longer timeline and
more expensive.
Mr. Taylor. No question. No question.
Secretary Shulkin. I mean, in closed session, Congressman,
we would be glad to share with you what we believe we have been
able to negotiate in terms of efficiencies.
I do believe we have achieved substantial savings and
efficiencies and timelines because of DOD's experience here.
And we have also learned from them what they would do if they
could do it over again so that we are not making the same
mistakes, which are costly, to make mistakes.
Mr. Taylor. When you are speaking about your community
partners--which, in my area, I know that you guys do have that,
you do have some exchange in information there.
Secretary Shulkin. Uh-huh.
ADDITIONAL FUNDING TO COMMUNITY INTEROPERABILITY
Mr. Taylor. Is that going to be another appropriation to
make sure--obviously, Cerner has 27,000 facilities that use
their information. Is that an easy fix, to be able to talk to
community partners and everything? Or is that something that
you will come back to us and ask for more money for?
Secretary Shulkin. Yes, we can absolutely take advantage of
the health information exchanges that already exist within VA.
We have 700 of them. And it is built into the contract to take
advantage of Cerner's interoperability with community partners.
This Digital Veterans Platform, which is to seek outside
industry to help us create the true interoperability that,
frankly, everybody in healthcare is looking for--this isn't
just a VA issue. We think VA and DOD can lead this for the
country. That digital veteran platform, right now we are just
going out and asking an RFI, request for information, that will
turn into an RFP for outside industry help.
And so we don't anticipate--we are not asking for an
appropriation for that for several reasons: We don't anticipate
that happening in these next couple fiscal years, and the work
that does happen will be funded internally at VA. But, also,
healthcare technology is changing so rapidly and there are so
many new advances that we don't exactly know what that is going
to look like.
Mr. Taylor. Will this system allow for you to be--you know,
that we are not building on legacy systems and MS-DOS and all
that stuff but----
Secretary Shulkin. It automatically includes the new
advances, the new updates----
Mr. Taylor. With software that just changes----
Secretary Shulkin. Absolutely. That is part of this
contract negotiation.
100 PERCENT INTEROPERABILITY GUARANTEE
Mr. Taylor. Can you guarantee 100 percent after this
change, if we, you know, reprogram these funds, that you will
speak to DOD--or that the interoperability will be 100 percent,
DOD and VA?
Secretary Shulkin. I don't think I have ever guaranteed
anything 100 percent. But Mr. Windom is willing to.
Mr. Windom. I mean----
Secretary Shulkin. Yes.
Mr. Taylor. He has been shaking his head over there.
Mr. Windom. I am willing to say that, because we will be on
the same Cerner Millennium platform. We will be hosting our
data in the same hosting facility. We will communicate
seamlessly across the respective DOD and VA environments
because of those reasons. So I expect it to be 100 percent. And
I am a veteran, so I am banking on it.
Mr. Taylor. All right.
Thank you, Mr. Secretary.
Thank you, Mr. Chairman.
Mr. Dent. At this time, I would like to recognize the
gentleman from Ohio, Mr. Ryan, for 5 minutes.
Mr. Ryan. Thank you, Mr. Chairman. I appreciate it.
Thank you, Mr. Secretary. Thank you for your service.
Gentlemen, we appreciate you and all the work that you do.
ALTERNATIVE MEDICINE FOR OPIOID ADDICTION
I come from Ohio, and we have, as you know, an opiate
epidemic that is of immense proportions for us. In 2016, we
lost 4,000 of our fellow citizens in the State of Ohio to
overdose, primarily from opiates. As you know, in 2016, we lost
over 60,000 people across the country to overdose deaths, more
than we lost in the Vietnam War.
So this is something that we continue to struggle to deal
with. And I know, Mr. Secretary, that we have talked about this
before.
Last month, I noticed that another substantiated report was
released by the VA Office of Inspector General following a
confidential complaint that the VA clinic in Baltimore,
Maryland, was failing to provide appropriate quality control
through the opioid treatment program.
A 2014 investigation revealed a disturbing lack of
attention on opioid management. Only 6.4 percent of new
patients were prescribed opioids in accordance with the
clinical practice guidelines. For our highest-risk veterans,
those with active substance use diseases prescribed opioids for
more than 90 days, less than 19 percent received appropriate
testing and therapy, with some clinics providing no testing and
therapy at all. The death rate from opiate overdose among the
VA is almost double the national average. And issues span many,
many facilities.
Further complicating the opioid overprescription problem is
a lack of appropriate software in our clinics. As we discuss
electronic records and electronic health record management, now
is the right time to also address including appropriate
software to provide opioid oversight.
What is the VA doing nationwide and in communities like
mine in Ohio to implement technology solutions to assist
clinicians in delivering improved and preventative patient care
so that opioid prescriptions and other medication are properly
prescribed?
Secretary Shulkin. Well, we share, Congressman, your
absolute concern and believe that, although we have begun to
really focus on opioid safety in 2010, that we need to do much
more on this. And so I have personally participated in the
President's commission for opioid reduction and addiction, and
we are going to redouble all of our efforts. So, when we find
situations like the IG did in Baltimore in 2014, that was
really a call to doing more in terms of oversight and action.
In terms of technology, we have something called the Opioid
Safety Initiative that has a dashboard. We can track opioid
prescribing not only by facility, by clinic, by provider. And
that triggers for us the ability to go in and intervene with
the provider, using academic detailing, which is education by
our pharmacists and by other subject-matter experts; by
developing alternatives to prescribing medication. We adhere to
the stepped-care management approach, the DOD-VA guidelines
that do not go first to opioids but look for alternatives. We
are investing heavily in complementary or integrative medicine
approaches as alternatives in pain management.
But, as you know, 50 percent of the people we care for in
the VA system complain of chronic pain. So this is a very tough
population to get their pain level correctly, and simply not
prescribing is not always the best answer either.
So we are working on this. We are using technology. It is
going to be built in to the work that we have done, built in to
a new electronic health record. And we are going to stick at
this and actually, I hope, be one of the leaders in this in the
country to try to solve this problem.
Mr. Ryan. So are you seeing steps in the right direction? I
mean, you are looking at, you know, only 19 percent received
the appropriate testing and therapy.
These are high-risk populations, as you know. And they are
in a lot of pain. So----
Secretary Shulkin. Right. Those are referring to urine
tests for concomitant benzodiazepine use--again, something that
we think is a risk, when you put a patient on both an opioid
and a benzodiazepine. And being able to track those urine tests
to make sure that there are not other drugs being used, that is
part of the State prescription data monitoring program, as
well.
So this is really a very multifaceted program. Nineteen
percent, of course, is not anywhere near what is acceptable. If
you went back to Baltimore today--that was 3 years ago--you
would find much higher rates. And we do have the ability to
track this now. That is how the IG was able to find those
rates.
I have recently been to facilities in Cleveland. We
actually brought the entire commission, Governor Christie and
Congressman Kennedy and others, there to Cleveland because they
are one of the leaders in the country in the lowest rates of
opioid prescribing. So we are taking those best practices from
Ohio and spreading them throughout the country.
Mr. Ryan. You talked about the stepped-care management
approach. Can you just walk us through for 30 seconds--if you
can indulge me, Mr. Chairman--of what those steps are? Because
I think that is an important point that we kind of ignore. The
default position, give the scripts. There are these other
approaches. Can you talk to us a little bit about what those
are?
Secretary Shulkin. Sure.
First of all, all of our stepped-care protocols and our VA-
DOD guidelines for pain management are all publicly available.
So we share these freely with anybody who wants to, because we
think they are very good work.
But what it basically says, as a prescribing doctor--and,
as you know, I am a practicing physician--you do not start with
reaching for your prescription pad or, now, your computer mouse
and prescribing opioids, that you take people through what
would be a reasonable approach for pain management and starting
with the least addictive options and, often, nonpharmacologic
options, if that is appropriate.
One of the recommendations that has come out nationally--
and you have seen CVS actually take a lead in this--is not
prescribing a month's worth of drug but really seven days'
worth of drug. Part of the problem of addiction is not even to
the person you are prescribing, but it is that they put the
remaining drugs in their medicine cabinets and their kids get
them or somebody else in the family gets them.
So there are so many things that we can do with this
stepped-care approach of how you adequately get to a point
where you would prescribe opioids.
Mr. Ryan. Using acupuncture? What are the----
Secretary Shulkin. Absolutely.
Mr. Ryan. Are we going to have another round, Mr. Chairman?
Mr. Dent. Yes. We are going to go into closed session.
Mr. Ryan. Okay. I will get you next time. Thanks.
Mr. Dent. Mr. Womack is recognized for 5 minutes.
Mr. Womack. Thank you.
LENGTH OF TIME TO DEVELOP EHR
Mr. Secretary, gentlemen, thank you for being here.
I am from Arkansas, and I know sometimes we are
stereotypically slow. We have been doing this--in your
testimony, you talked about how we have been in this discussion
now for 17 years, how we have been trying to address this
issue--not you guys, because you haven't been doing it that
long. And I commend you for the decision to go to the platform.
It just would seem to me that that was a decision that should
have been made a long time ago.
And I make this observation not because of the money that
we have spent and the difficulty getting this interoperability,
as we call it, but because it just makes absolute sense to me
that if you are going to want to talk to DOD, if VA and DOD are
going to talk together, they should be on the same platform.
Am I missing something as to why we have been in this rut
now for 17 years?
Secretary Shulkin. I think it is important to understand
why this has happened, because what it says is it is at risk of
happening again.
In 2011, on March 5, 2011, Secretary Shinseki and Secretary
Gates, I believe it was, committed, probably in a hearing room
like this, that they were going to do it. And I believe that
they meant that. I believe that they meant that. And then what
happened is Secretaries change and Congress changes, and all of
a sudden people say, no, we are going to go a different
direction.
So I think what is important is, if we get your support in
moving forward, that we do not allow that to happen, that we
stay--because this is the right decision. This is the right
thing for veterans. And so we have to stick at this.
And it is going to be hard, and there are going to be
stumbles. That is why I never say 100 percent. But this is
something that we have to get done for the country. And,
frankly, the fact that we are following DOD on this gives me
greater assurance that we can get this done.
TRANSITIONING FROM THE VISTA SYSTEM
Mr. Womack. The only experience I have in anything along
this line, on a much, obviously, smaller scale, was I was a
mayor once upon a time, and our court system had a bad computer
system, and they went to a new system, which was fine, but they
made one real major error, and that is they scrapped the old
when they transitioned.
Secretary Shulkin. Right.
Mr. Womack. It wasn't much of a transition, but they just
scrapped the old.
So, in your testimony, you talked about keeping the VistA
system alive. What does that mean? And how long can we expect
that we have two systems kind of running simultaneously?
Secretary Shulkin. Right. So we have 130 VistA systems.
Part of what we are planning on doing is we will shut them down
one at a time. When we have a successful Cerner implementation
and we are confident, we can shut that one down, start to save
some money. But by the time we get to the very last medical
center at the end of this full 8-year implementation after we
start, that will be when we can finally turn off the system.
And, by the way, even then, I think there are 37 subsystems
that we haven't figured out yet how to transition off of VistA.
Now, we are working on that.
But we are planning on running a dual system for the
foreseeable future because we don't want to have what happened
to your court system. I mean, we can't afford to put veterans'
health at risk.
Mr. Womack. Absolutely.
BEST PRIVATE SECTOR MANAGEMENT PRACTICES
And then, finally, Mr. Secretary, you have been to my
district, and you know how interested I am in seeing that our
Federal bureaucracy learn best management practices from the
private sector.
Secretary Shulkin. Yes.
Mr. Womack. You have personally been to my district to
witness that, talk with people.
In the testimony earlier--and I think it was Mr. Blackburn
that talked about, I kind of look at it as third-party
validation. You have some kind of a CIO board, people from
outside the universe, that are going to be looking at the
process that we are implementing, this Cerner platform.
Are you at liberty to say who these people are? Do they
have a connection to Cerner? Is there any potential, you know,
for a conflict of interest in that regard?
Mr. Blackburn. From what I have seen, I think the whole
American medical community that I have spoken to wants to see
us succeed.
So, as an example, this afternoon, I will spend 2 hours on
the phone with the CIO of the Mayo Clinic, the CIO of Partners
HealthCare, the CIO of Johns Hopkins and Kaiser Permanente. And
they will be providing feedback, you know, on--they are
reviewing the contract, they are taking a look and saying, hey,
you know, here are some of the things that we would do
differently, providing us feedback and helping coach us.
As I have reached out to various academic, medical, and
healthcare providers, everybody is rooting for us. This is
going to be a game-changer for American healthcare. They are
providing input. We are even talking about borrowing talents
that have gone and done these implementations.
But I would say the support that we have gotten from the
healthcare community is fantastic.
Mr. Womack. Very good.
I yield back.
Mr. Dent. Thank you, Mr. Womack.
At this time, I would like to recognize the gentleman from
California for 5 minutes, Mr. Valadao.
Mr. Valadao. Thank you, Mr. Chairman.
Thank you, gentlemen, for appearing today.
PORTABLE ACCESSIBILITY TO THE EHR
I personally would like to applaud your decision to adopt
the same electronic healthcare system as the DOD. Obviously,
for nearly two decades, the VA has been seeking to achieve this
interoperability between VA's VistA and the DOD system. It
makes much more sense to me if both DOD and VA utilize the same
system.
There has been some debate recently about a veteran's lack
of ability to access their personal healthcare information. Do
you foresee in the transition the establishment of a secure,
patient-centered, portable medical records system, that a
veteran can access their own comprehensive medical records?
This is something that has been available to the private
sector for quite some time, so it is only natural we afford the
same ability to our veterans as well.
Secretary Shulkin. Yes. Well, I may ask one of my
colleagues just to chime in with the details. But our system
now, My HealtheVet, is used by millions of veterans. It is a
portable system where they are able to access and message with
their providers. Used probably more extensively than any other
system in the country. So we believe in that. We think that is
important.
The transition of that over to Cerner, maybe I would ask
Mr. Windom to talk about that.
Mr. Windom. And I will defer to Mr. Blackburn, but I can
say simply, yes, mobility, the ability to access your record
via your phone, via web-based access, definitely at the
forefront of the terms and conditions of our contract and that
we are pursuing all of the state-of-the-art technology that the
commercial environment can produce.
So, Mr. Blackburn, I will pass to you.
Mr. Blackburn. I agree. And, you know, as an example, I
think I am personally a good example. I am a veteran, an Army
veteran. The DOD has a part of my healthcare record. I got out
of service, moved back to my hometown of Boston, where Partners
HealthCare had part of my healthcare record--I then moved to
Cleveland. Cleveland Clinic has part of my healthcare. When I
came to the VA 3 years ago, I enrolled in VA healthcare and get
my care right now at the Washington VAMC Orange Clinic. I also
get care in the community.
Every single one--and I think I just named about five
different entities that have different pieces of my medical
record that, right now, are not shared well. I had to print out
my Cleveland Clinic records and give them to my VA doctor so
that he had them. My VA doctor does use the Joint Legacy
Viewer, but I got out in 2003, so not much is in there. My
records were destroyed in a flood.
So, with that, the ability for a veteran or a citizen to be
able to get those pieces and put them together is something
that is coming. And we are very excited that this will begin to
facilitate that process by linking DOD and VA, with the Digital
Veterans Platform beginning to link in all these other systems
as well.
It will take a little bit of time to get to where we are
going to be in 10 years, where you are going to have this all
together on your iPhone, but we are taking the first steps to
get there.
Mr. Valadao. All right.
PROTECTION OF VETERANS' PERSONAL IDENTITY INFORMATION
And then I am going to go in the opposite direction,
because, obviously, access means there is an issue with
security.
So, Mr. Secretary, one of the issues I have focused on in
my career and my actual first piece of legislation I ever
signed into law had to do with securing someone's ID and their
personal information. Government agencies have to take steps to
protect people's personal information.
Can you speak to the cybersecurity enhancements the VA is
undertaking in this transition? This system will obviously
contain the very sensitive personal information of millions of
veterans. What is the Department doing to ensure the safety of
that information?
Secretary Shulkin. Yes.
Mr. Windom, do you want to talk about the cybersecurity
requirements in the contract?
Mr. Windom. I will touch on--and then I will defer to Mr.
Blackburn again.
I come from the DOD side of the house. And, you know, the
OI&T efforts right now are leveraging fully the security
posture of DOD. And I can assure you the level 2, 3, 4, 5
certifications that exist within the framework of DOD's
security posture are being adopted fully. We just had a session
with DOD to highlight the importance of the reciprocity
agreements that would be necessary between VA and DOD in order
to leverage their posture fully. Those are being consummated as
we speak.
So there is not going to be this separate VA security
posture, separate DOD. There is going to be a joint security
posture that is going to support the transition of a soldier,
sailor, airman, marine from the Active Duty environment to the
veteran environment. So that is of the utmost importance to us.
Mr. Blackburn.
Mr. Blackburn. Yes. I share your concerns on cybersecurity.
The VA does not have a great track record. I think we have been
on the GAO high-risk report as a material weakness for 16
consecutive years, which is a streak that we are not proud of.
But I am proud that we have made great strides over the last 2
or 3 years, and we have gotten good feedback from GAO and OIG
on that.
I think one of the reasons we have been so vulnerable is
having these 130 instances on an antiquated system, so this
will help that out. But, in the future, we will be looking, you
know, at new emerging technologies, whether it is blockchain or
whatever it might be, to get that even more secure.
Mr. Valadao. I just feel that the transition period is
something we need to be very careful with.
So my time is up, and thank you very much.
Mr. Dent. At this time, I would like to recognize the
gentleman from Nebraska for 5 minutes, Mr. Fortenberry.
Mr. Fortenberry. Gentlemen, good morning.
Mr. Secretary, nice to see you.
ALTERNATIVE WAYS TO ACHIEVE INTEROPERABLE EHR
You have an extensive background in healthcare management,
running facilities, being an entrepreneur. If someone told you
this was going to take you 10 years before an implementation of
an interoperable system in one of your hospitals, you would
find that absolutely unacceptable.
Now, this is a big, massive project that a lot of the
difficulties, or, put more succinctly, mess, you have
inherited, I get that, but this has been going on for a very
long time.
So let me just try to simplify this so that I can
understand and perhaps we can unpack a lot of this technical
language. But I have about four things I want to get to,
including some issues of late in Nebraska.
You have a system now where you are on one screen, you can
show DOD records and your records, right? That is
interoperability at the moment. This is going to be combined so
that one button pulls up everything from a former
servicemember's life, right?
Secretary Shulkin. Yes.
Mr. Fortenberry. Okay. Why 10 years?
I very much appreciate what you are saying, that we are
getting out of the software business, because why would we
build out the expertise in that area when that is not our
expertise? You want to deliver care. I get that.
Why 10 years? What do you expect the outcome to be? Are
there progress measures along the way so that in another year
the system is not going to say, ``We have another significant
delay, and it is 2 more years.''
Let me throw everything out on the table----
Secretary Shulkin. Sure. Absolutely.
Mr. Fortenberry [continuing]. First, and then I would like
you to get to it.
We have some information that the VA has always worked with
the Indian Health Service to help them with their electronic
medical records, but there is some indication that you may
desire to move away from that. I would like your comment on
that. Because that is some slippage that may cause significant
difficulty for another part of government that we would not
like to see.
Secretary Shulkin. Sure.
Mr. Fortenberry. Finally, there is a glitch in the
outpatient clinic contract in Lincoln. Give me your assessment
of that situation. And explain the criteria for site selection,
because I think there is some murkiness there that has caused
some possible confusion.
Then I have, hopefully, an answer to all of your problems,
if we have enough time.
Secretary Shulkin. Okay. I would like to hear the answer.
Are you sure you don't want to start with the answer?
Look, I think the implementation is, frankly, 18 months.
From the time we sign the contract till we get our first site
up is 18 months, which is consistent with a private-sector
practice in terms of from contract to full implementation.
We will begin to, after that first implementation, start
shutting down what will be 130 successive implementations after
that. So, by the time we reach all of our facilities across the
country, which are around 1,600, but 130 different systems
control those 1,600, it will be around 8 years after the first
18-month implementation.
Mr. Fortenberry. So, after 18 months, what percent of
systems will have successful interoperability?
Secretary Shulkin. Well, we will start with one, and then--
--
Mr. Fortenberry. But what percent of veterans does that
represent?
Secretary Shulkin. Oh. Well, that would be a very small
percent of veterans. But what we have is a detailed project
implementation timeline, which we would be glad to show you,
how we get from one system in 18 months all the way through.
Mr. Fortenberry. That is not really necessary. You
understand the nature of the question. Obviously, you are going
to try something to make sure it works. But the larger number
of veterans that is going to actually be served as a priority
would seem to me to be a prudent way forward.
Secretary Shulkin. Yes. The longer we take to implement
this, the more costly it is and the greater we think that the
risk is to veterans. So we are trying to do this as
aggressively as we possibly can.
Mr. Fortenberry. Okay.
INDIAN HEALTH SERVICE EHR
My time is running short. I am sorry. Can you, in 30
seconds, address the Indian Health Service question?
Secretary Shulkin. Yes. The Indian Health Service does use
our VistA system. That will remain available. This is an open-
source system. We won't withdraw that from them. They may have
to look at alternative systems, just as we are, and we would be
glad to work with them on that. We have no desire to hold----
Mr. Fortenberry. We don't want to put them in a situation
where they are having to go out on their own and redesign an
entire system.
Secretary Shulkin. Right. Exactly.
Mr. Fortenberry. So anything they can leverage from your
experience would be most helpful.
Mr. Windom. Can I touch on this?
Secretary Shulkin. Yes.
Mr. Windom. So we have been in communication with Indian
Health Services. And we are firmly committed to supporting
them----
Mr. Fortenberry. Great. Thank you. I am sorry to interrupt.
Time is ticking.
LINCOLN, NEBRASKA CLINIC
Secretary Shulkin. Okay. And Lincoln, Nebraska, we will get
back to you on that. But that was a small-business issue, in
terms of the award, where we have had to go now back out for
contract. We are committed to that contract. It is off-schedule
because of small-business issue, but we can get back----
Mr. Fortenberry. As we have discussed before, a lot of very
creative public-private-public partnerships are on the line
here that will provide additional housing and additional
development opportunities on a beautiful historic site.
Secretary Shulkin. Right.
Mr. Fortenberry. We just need for this to move, and move
quickly, because there is a lot on hold.
Secretary Shulkin. Yes. I will follow up with you on that.
[The information follows:]
In fiscal year 2014, Congress passed the Veterans Access,
Choice, and Accountability Act, which authorized VA to procure
27 Major leases, one of which was an Outpatient Clinic (OPC) in
Lincoln, Nebraska. This project will support the VA Nebraska-
Western Iowa Health Care System's Omaha VA Medical Center
(VAMC). Clinical services currently housed on the existing 60-
acre Lincoln campus will be moved to this proposed OPC.
On October 18, 2017, the Department of Veterans Affairs
(VA) announced it will start a new, competitive lease
procurement process for the Lincoln, Nebraska Outpatient
Clinic, which will be initiated in fall 2017.
This decision follows an August 2017 bid protest that an
interested party filed with the U.S. Government Accountability
Office, regarding VA's prior competitive procurement action.
In that action, the U.S. Small Business Administration
determined that the proposed awardee no longer qualified as a
small business. Accordingly, VA excluded the protestor from the
competition, reviewed the remaining offers, and ultimately
determined it was best for VA to cancel that procurement. VA
now plans to revise its solicitation to update and adjust its
actual leasing requirements. This will bring the project more
in line with industry standards, reduce costs proportionately,
and provide stronger value to the Government and taxpayers.
VA anticipates release of the new Lincoln Request for Lease
Proposals in Spring 2018, with a potential award in CY 2018. VA
is committed to delivering a long-term clinical solution that
meets the needs of Veterans and their families in the Lincoln,
Nebraska area. VA will continue to provide care at the current
Lincoln VA clinic during this process.
Mr. Fortenberry. Thank you so much.
Mr. Dent. Thank you, Mr. Fortenberry.
Before we move into the closed session, which will happen
in moments and members can ask additional questions, I did have
two questions that I felt needed to be asked in open session to
the Secretary.
ADMINISTRATION COMMITMENT
One is, what is OMB's commitment to this entire project? We
noticed that OMB has not submitted a fiscal year 2018 budget
amendment as it did for the Department of Defense. I think that
is very important we establish in the open session.
Secretary Shulkin. Yes. As you know, we have been working
very closely with OMB, just like we have come to you and asked
for your assistance, and they are both aware and supportive of
this initiative.
Mr. Dent. And there is one final question.
EHR VULNERABILITY TO POLITICAL CHANGES
Mr. Secretary, you and I have joked that neither of us will
be in the jobs we currently hold in 10 years. But, in a serious
vein, I am concerned that, without consistent leadership, this
expensive project could be derailed or reconfigured, given the
long implementation time. We have seen the electronic health
record whipsaw back and forth every time a new Secretary of VA
or DOD comes to the scene.
Is it a fair concern for the committee that this health
record won't be able to withstand changes in political
leadership or budgetary shortfalls?
Secretary Shulkin. Well, first of all, if you commit to
stay, then I will consider that too.
But, no, I think that it would be--once we step in this
direction--and I think as all of you have really reflected,
this is the right thing to do. This is the right thing; it
should have been done years ago. I do not believe this is going
to be subject to political back-and-forths.
And we are going to set this up in a way that, when we
start this, there is the full commitment. And, while anything
could happen, I don't believe that this is likely to be
derailed.
Mr. Dent. Thank you.
I was going to ask Ms. Lee to ask a question in open
session. And then members will have a next round in closed
session, so anything you want to ask, you can ask in there.
Ms. Lee.
Ms. Lee. Okay. Thank you very much.
FATE OF EMPLOYEES TRAINED ON VISTA
I just want to find out who is going to maintain this
system once the new system is rolled out and fully implemented.
And what is going to happen to VA employees maintaining VistA
once the Cerner system is rolled out, and will they move over
to the new Cerner system?
Secretary Shulkin. Yes. The basic upkeep and modernization
of the new system is going to be done by the Cerner
Corporation. That is the whole point of us getting out of the
software development system.
Our current employees, we need every one of them. It is
very rare to find software engineers who know MUMPS, which is
our system, which started back in 1977. But they will--we want
them to stay, we need them to stay over this implementation
period. And any staff, once we shut down the VistA system, will
be utilized as part of our current IT software--part of our
infrastructure needs.
Ms. Lee. So no job loss.
Secretary Shulkin. We do not believe this will be a job
loss.
Ms. Lee. Okay.
Thank you, Mr. Chairman, very much.
Mr. Dent. Thank you, Ms. Lee.
At this time, I think our members have had a good
opportunity to ask questions about the electronic health record
in the public setting. We will now adjourn and move to closed
session so that members may discuss with the Secretary issues
that could compromise contract negotiations if discussed
publicly.
We ask members of the public to leave the room at this
time. Associate staff members, committee staff, VA staff, and
our court reporter, of course, may stay.
So, with that, we will adjourn and go into closed session.
I N D E X
----------
Department of Veterans Affairs Budget
May 3, 2017
Witness
Page
Shulkin, Hon. David J.,.......................................... 5
Prepared statement........................................... 9
Chairman, Statement of........................................... 1
Ranking Member, Opening Statement of............................. 2
Full Committee Chairman, Opening Statement of.................... 3
Full Committee Ranking Member, Opening Statement of.............. 4
Access and Quality Web site...................................... 42
Accountability and Whistleblower Protection...................... 42
Agency Reform Plans.............................................. 62
Appeals Modernization............................................ 55
Blue Water Navy Veterans Act..................................... 40
Caregivers Program............................................... 50
Choice and Complementary Medicine................................ 54
Choice Program Future Funding.................................... 49
Choice Provider Payments......................................... 53
Correspondence Policy............................................ 43
Disability Claims and Appeals Backlog............................ 64
Disability Claims Backlog........................................ 61
Facility Realignment............................................. 33
Focus on Core Competencies....................................... 33
Fraud, Waste, and Abuse.......................................... 59
Future Demand on VA.............................................. 65
Health Disparities among Minority Veterans....................... 35
Interoperability with Department of Defense...................... 27
Joint Legacy Viewer (JLV)........................................ 28
Lincoln, Nebraska Clinic......................................... 49
Military Sexual Trauma........................................... 51
MyVA Initiative and VISN Realignment............................. 32
New Therapies for PTSD........................................... 41
Oakland Regional Office.......................................... 35
Office of American Innovation....................................62, 64
Opioid Abuse Prevention.......................................... 61
Other-Than-Honorable Discharges.................................. 49
Patient-Centered Care............................................ 45
Predicting Future Demand......................................... 34
Provider Payments................................................ 42
Public-Private Partnerships......................................47, 48
Recreational Therapy.............................................48, 49
Scheduling System................................................ 51
Senate-Confirmed Position Vacancies.............................. 52
Suicide Prevention Training......................................44, 65
The Future of Community Care..................................... 22
Third-Party Billing.............................................. 29
Transitioning Care Between VA facilities......................... 27
Vacant and Underutilized Buildings...............................65, 67
Veterans Choice Program..........................................24, 45
Veterans Crisis Line............................................. 63
Vista Electronic Health Records.................................. 21
Workforce and Facility Infrastructure Needs...................... 24
----------
Department of Veterans Affairs--Office of Inspector General
March 22, 2017
Witness
Missal, Hon. Michael J., Inspector General, Department of
Veterans Affairs opening statement............................. 142
Prepared statement........................................... 145
Chairman, Opening Statement of................................... 141
Ranking Member, Opening Statement of............................. 141
Actions against Prescription Drug Theft.......................... 183
Air Quality Environmental Concerns............................... 177
Allocation of Funding Increase................................... 192
Challenges of Veterans Crisis Line Rollover Calls................ 176
Choice Program................................................... 177
Choice Program Meeting Required Spending Targets................. 188
Collecting Data Based on Race and Ethnicity...................... 191
Collecting Race and Ethnicity Data............................... 180
Data Reporting by Race and Ethnicity............................. 197
Disability Claims Backlogs....................................... 186
Discrepancies in Wait Time Data.................................. 187
Efficiency in Processing Claims.................................. 191
Electronic Health Records........................................ 185
For-profit Schools Using the Post 9/11 GI Bill................... 186
GAO High Risk Report............................................. 186
GI Bill Backlog and Processing Delays............................ 194
Hiring Freeze Exemptions......................................... 196
Hiring Freeze Impact............................................. 190
Improvements in Scheduling Delays................................ 174
Nursing Pay Scales............................................... 198
Opioids Treatment Management..................................... 182
Oversight for Opioid Prescriptions............................... 182
Patient Wait Times............................................... 181
Possible Violation of Appropriations Law......................... 174
Proactive OIG Auditing........................................... 189
Problems with Suicide Hotline.................................... 174
Progress in Reducing Time Between Reports........................ 187
Procurement Deficiencies......................................... 180
Retiring Legacy Systems.......................................... 183
Risk of Purchase of Commercial IT Systems........................ 175
Rollout of Online Scheduling..................................... 181
Shift to Commercial IT Software.................................. 175
State Prescription Drug Monitoring Programs...................... 178
Timeline in Responding to Complaints............................. 193
Treatment of Ineligible Veterans................................. 194
Uniform Treatment Protocols for Suicidal Veterans................ 184
Unmet Funding Needs.............................................. 195
VA Animal Research............................................... 199
VA IG Staff Expansion............................................ 185
VA Information Systems Vulnerabilities........................... 179
VA OIG Resources Needs........................................... 188
VA's Antiquated Financial Management System...................... 175
----------
Public Witnesses Hearing
March 29, 2017
Blake, Carl, associate executive director of government
relations, Paralyzed Veterans of America....................... 236
Prepared statement........................................... 261
Fuentes, Carlos, director national legislative service, Veterans
of Foreign Wars................................................ 281
Prepared statement........................................... 284
Kelly O'Beirne, Heather, director, Veterans and Military Health
Policy, American Psychological Association..................... 292
Prepared statement........................................... 296
Sganga, Fred, legislative officer, National Association of State
Veterans Homes................................................. 308
Prepared statement........................................... 311
Varela, Paul, assistant national legislative director, Disabled
American Veterans.............................................. 271
Prepared statement........................................... 273
Chairman, Opening Statement of................................... 235
Ranking Member, Opening Statement of............................. 235
Adding More VBA Staff or the Use of Technology................... 279
Alternatives to Long Term Facilities............................. 317
Assisted Reproductive Technology................................. 267
Care for Sexual Assault Victims.................................. 304
Consolidating Community Care Programs............................ 269
Construction of Research Facilities.............................. 00
Emergency Care Court Decision.................................... 269
Hiring Freeze and Processing Claims.............................. 279
In Vitro Fertilization........................................... 290
Infrastructure Needs When Non-VA Care is increasing.............. 290
Lack of Uniformity in Suicide Prevention Policies................ 303
Limitations on Appeals While the Record is Submitted............. 280
Mental Health Care Awareness Initiatives......................... 291
Mismatch Between Location of Veterans and State Homes............ 317
Paralyzed Veterans Having Access to Choice Program............... 268
Parking at VA Facilities......................................... 267
Preventing Veteran Suicides...................................... 301
Programs With the Most Urgent need for Increased Funding......... 266
Training for Crisis Hotline...................................... 301
Training that VA Provides Versus Private Sector Training......... 302
Transitioning Soldiers to Obtain Licenses and Credentials........ 279
Use of VA Versus Community Care.................................. 291
Veterans Oral History Project.................................... 318
----------
Veterans Affairs Electronic Health Record
November 15, 2017
Witness
Shulkin, Hon. David J............................................ 324
Prepared statement........................................... 327
Chairman, Statement of........................................... 321
Ranking Member, Opening Statement of............................. 322
Full Committee Chairman, Opening Statement of.................... 323
Additional Funding to Community Interoperability................. 361
Administration Commitment........................................ 371
Alternative Medicine for Opioid Addiction........................ 362
Alternative Ways to Achieve Interoperable EHR.................... 368
Best Private Sector Management Practices......................... 366
Catching Up to DOD EHR Deployment................................ 337
Connection to Community Providers................................ 339
Cybersecurity Challenges......................................... 340
Description of Proposed EHR System............................... 335
EHR Program Management Office.................................... 340
EHR Vulnerability to Political Changes........................... 371
Elements Transferable from VistA................................. 339
Fate of Employees Trained on VistA............................... 372
Impact of Failure to Receive Reprogramming....................... 361
Indian Health Service EHR........................................ 370
Is the Timeline Too Aggressive?.................................. 337
Length of Time to Develop EHR.................................... 364
Lincoln, Nebraska Clinic......................................... 370
100 Percent Interoperability Guarantee........................... 362
Opioid Crisis.................................................... 342
Payment Systems Problems......................................... 342
Portable Accessibility to the EHR................................ 366
Problems Finding Minority and Small Business Subcontractors...... 343
Project Governance............................................... 341
Projection of Veterans' Personal Identity Information............ 367
Rolling Out System Geographically................................ 336
Timeframe to Deploy the Cerner System............................ 337
Transitioning From the VistA System.............................. 365