```

[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]

  LEGISLATIVE HEARING ON H.R. 2460; H.R. 3956; H.R. 3974; H.R. 3989; 
DRAFT LEGISLATION TO ENSURE THAT EACH VA MEDICAL FACILITY COMPLIES WITH 
     REQUIREMENTS RELATING TO SCHEDULING VETERANS FOR HEALTH CARE 
APPOINTMENTS AND TO IMPROVE THE UNIFORM APPLICATION OF DIRECTIVES; AND 
   DRAFT LEGISLATION TO DIRECT VA TO ESTABLISH A LIST OF DRUGS THAT 
             REQUIRE AN INCREASED LEVEL OF INFORMED CONSENT

=======================================================================

                                 HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                       WEDNESDAY, APRIL 20, 2016

                               __________

                           Serial No. 114-66

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       

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         Available via the World Wide Web: http://www.fdsys.gov
                      
                      
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
25-155 PDF                  WASHINGTON : 2017                     
          
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                      COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             BETO O'ROURKE, Texas

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                           
                           C O N T E N T S

                              ----------                              

                       Wednesday, April 20, 2016

                                                                   Page

Legislative Hearing On H.R. 2460; H.R. 3956; H.R. 3974; H.R. 
  3989; Draft Legislation To Ensure That Each VA Medical Facility 
  Complies With Requirements Relating To Scheduling Veterans For 
  Health Care Appointments And To Improve The Uniform Application 
  Of Directives; And Draft Legislation To Direct VA To Establish 
  A List Of Drugs That Require An Increased Level Of Informed 
  Consent........................................................     1

                           OPENING STATEMENTS

Honorable Dan Benishek, Chairman.................................     1
Honorable Julia Brownley, Ranking Member.........................     2

                               WITNESSES

Honorable Elise Stefanik, U.S. Hous of Representatives, 21st 
  Congressional District; New York...............................     4
    Prepared Statement...........................................    32
Honorable Mike Bost, U.S. House of Representatives, 12th 
  Congressional District; Illinois...............................     5
    Prepared Statement...........................................    33
Honorable Ann Kuster, U.S. House of Representatives, 2nd 
  Congressional District; New Hampshire..........................     6
    Prepared Statement...........................................    34
Honorable Jackie Walorski, U.S. House of Representatives, 2nd 
  Congressional District; Indiana................................     8
    Prepared Statement...........................................    35
Honorable Lee Zeldin, U.S. House of Representatives, 1st 
  Congressional District; New York...............................     9
    Prepared Statement...........................................    36
Diane M. Zumatto, National Legislative Director, AMVETS..........    12
    Prepared Statement...........................................    37
Shurhonda Y. Love, Assistant National Legislative Director, 
  Disabled American Veterans.....................................    14
    Prepared Statement...........................................    40
Fred S. Sganga, Legislative Officer, National Association of 
  State Veteran Homes............................................    15
    Prepared Statement...........................................    43
Maureen McCarthy, M.D., Assistant Deputy Under Secretary for 
  Health for Patient Care Services, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............    23
    Prepared Statement...........................................    45

        Accompanied by:

    Susan Blauert, Chief Counsel, Health Care Law Group, Office 
        of General Counsel, U.S. Department of Veterans Affairs

                       STATEMENTS FOR THE RECORD

The American Legion..............................................    51
American Psychiatric Association.................................    54
Easter Seals.....................................................    56
National Association of Mental Illness...........................    58
Veterans Affairs Physician Assistant Association.................    59
Veterans of Foreign Wars of the United States....................    63

 
  LEGISLATIVE HEARING ON H.R. 2460; H.R. 3956; H.R. 3974; H.R. 3989; 
DRAFT LEGISLATION TO ENSURE THAT EACH VA MEDICAL FACILITY COMPLIES WITH 
     REQUIREMENTS RELATING TO SCHEDULING VETERANS FOR HEALTH CARE 
APPOINTMENTS AND TO IMPROVE THE UNIFORM APPLICATION OF DIRECTIVES; AND 
   DRAFT LEGISLATION TO DIRECT VA TO ESTABLISH A LIST OF DRUGS THAT 
             REQUIRE AN INCREASED LEVEL OF INFORMED CONSENT

                              ----------                              

                       Wednesday, April 20, 2016

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:01 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Benishek, Roe, Coffman, Wenstrup, 
Abraham, Brownley, Takano, Ruiz, Kuster, and O'Rourke.
    Also Present: Representatives Bost, Walorski, and Zeldin, 
and Kuster.

          OPENING STATEMENT OF DAN BENISHEK, CHAIRMAN

    Mr. Benishek. The Subcommittee will come to order, and 
before we begin, I would like to ask unanimous consent for our 
colleagues and fellow Committee Members, Representative Zeldin 
from New York, Representative Bost from Illinois, 
Representative Kuster from New Hampshire, and Representative 
Walorski from Indiana, to sit on the dais and participate in 
today's proceedings. So without objection, so ordered.
    Good morning, and thank you all for joining us for today's 
legislative hearing. Our agenda this morning includes six 
bills. The bills are H.R. 2460, to improve the provision of 
adult day health care services for veterans; H.R. 3956, the VA 
Health Center Management Stability and Improvement Act; H.R. 
3974, the Grow Our Own Directive: Physician Assistant 
Employment and Education Act of 2015; H.R. 3989, the Support 
Our Military Caregivers Act; and draft legislation to ensure 
that each VA medical facility complies with the requirements 
related to scheduling veterans for health care appointments, 
and to improve the uniform application of directives; and draft 
legislation to direct the VA to establish a list of drugs that 
require an increased level of informed consent.
    These pieces of legislation cover a wide range of topics 
facing our veterans and their families. One bill on our agenda 
that I look forward to discussing is H.R. 3956, the VA Health 
Center Management Stability and Improvement Act. This bill, 
which is sponsored by Representative Bost, would require the VA 
to develop and implement a plan to hire directors at VA medical 
facilities, prioritizing those that have been without permanent 
leaders for the longest time. The number of VA medical 
facilities that have gone without stable, consistent, long-term 
leadership is alarming. We have to encourage the VA to take 
every possible action to bring high-quality leaders to the 
helm.
    Another bill I look forward to discussing is H.R. 2460, a 
bill sponsored by Lee Zeldin that would authorize the VA to 
cover costs for adult day health care at State veterans' homes 
for certain veterans. It is critical that we increase long-term 
care options for our veterans, particularly for those who can 
and want to live at home for as long possible, but need 
additional assistance during the day.
    I am also here to discuss H.R. 3989, a bill sponsored by 
Representative Stefanik, to address the growing application 
backlog in the Family Caregiver Program, and draft legislation 
sponsored by Representative Walorski to ensure that VA medical 
facilities comply with scheduling directives.
    I am grateful to all my colleagues for introducing the 
bills on our agenda this morning and thank them for being here 
today to discuss them with us. I am also grateful to the 
representatives from our veterans service organizations and to 
the Department of Veterans Affairs for being here this morning 
as well, and I will now yield to the Ranking Member, Ms. 
Brownley, for any opening statement she may have.

      OPENING STATEMENT OF JULIE BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman, and thank you for 
holding this hearing today. Among the many bills being 
considered today is my draft legislation on increased informed 
consent. Over the past few years the Committee on Veterans 
Affairs has heard testimony from veterans using opioids for 
long-term pain management and the severe side effects that are 
often associated with that treatment. Time and time again we 
have heard from veterans who were not fully aware of the 
potential side effects of these medications or that alternative 
treatments to prescription medications were, indeed, available. 
My draft legislation is designed to open up a meaningful 
dialogue between the veteran and the physician by raising the 
standard for informed consent for certain drugs prescribed by 
doctors at the Department of Veterans Affairs. It would also 
require the Veterans Health Administration to form a clinician 
panel that would establish and maintain a list of drugs which 
may only be furnished to a patient with increased informed 
consent. In the past few years, the VA has worked to address 
the prescription drug crisis. While I appreciate the 
Department's work to prevent prescription drug abuse and 
overdoses, I still feel their efforts have not gone far enough. 
The goal for the draft legislation is to encourage a real 
conversation between the veteran and doctor at the point when a 
treatment plan is presented to the veteran and a conversation 
that goes beyond the VA's existing standardized form, which was 
last updated in 2014. Under the discussion draft, if a drug 
identified by the clinician panel, is prescribed by a VA 
doctor, that provider would prepare and present a written, 
improved consent form to the patient.
    For drugs with improved informed consent, the veteran's 
doctor would provide written information and discuss with the 
veteran the risk of dependency, known interactions between the 
drug and other drugs or substances including alcohol, if the 
drug has an FDA black box warning, and if any alternative 
treatments are available and might be helpful. This form would 
not require the patient to commit to that treatment plan. It 
would also give the patient the opportunity to review the 
information provided regarding the recommended treatment and 
any other possible treatments. Additionally, the patient would 
have the opportunity to speak to a VA pharmacist if the patient 
has additional questions about the drug being described. I 
recognize that veterans, their families, or, indeed, some 
Members of this Committee, like me, are not experts in medical 
care. The intent of this legislation is to not tell doctors how 
to treat their patients, but to ensure that veterans are 
confident they have the information they need to make an 
informed decision about what would be best for their long-term 
health. Before they pick up that first prescription, the 
veteran deserves to have all of their options laid out.
    Since the discussion draft was released, I have received 
support on the principles behind the draft from many veteran 
groups and constructive comments from health care providers 
regarding the scope of the language. I look forward to working 
with all interested parties to improve on the proposal and 
bring some level of control and decision back to the veteran 
when the treatment of his or her injury or illness is being 
addressed.
    I thank the VA for their testimony this morning as well as 
their willingness to meet with my staff to address the concerns 
raised in the draft language. We can all agree that including 
the veteran in the decision-making process in a meaningful way 
is the right way to go when it comes to the veteran's health 
care. This language is my attempt to bring that about.
    Thank you for this opportunity, Mr. Chairman, and I yield 
back the balance of my time.
    Mr. Benishek. Thank you, Ms. Brownley. I am honored to be 
joined this morning by several of my colleagues to speak in 
support of their legislation. I think Mr. Zeldin will be 
joining us. We do have the Honorable Mike Bost from Illinois, 
the Honorable Ann Kuster from New Hampshire, the Honorable 
Elise Stefanik from New York, and the Honorable Jackie Walorski 
from Indiana. Thank you all for being here today.
    I am going to yield first to Representative Stefanik and 
then Mr. Bost because I understand they both have markups to 
attend in other Committees this morning.
    So Representative Stefanik, please proceed with your 
testimony.

                 STATEMENT OF ELISE M. STEFANIK

    Ms. Stefanik. Chairman Benishek, Ranking Member Brownley, 
thank you for the invitation to testify on this important 
legislation. I truly appreciate the opportunity to appear 
before you and look forward to discussing this key issue. As a 
Member of the House Armed Services Committee with a critical 
Army base and Navy nuclear training facility located in my 
district, I am dedicated to providing support to 
servicemembers, veterans, and their families.
    Since September 11, 2001, the Army's 10th Mountain Division 
at Fort Drum has been the most actively forward deployed 
division in the global war on terror. Over the last 15 years of 
war, our servicemembers have bravely served our Nation, and 
their families have sacrificed an immeasurable amount. So it is 
vital that we ensure they receive the best possible care. This 
is especially true for our military caregivers, loved ones of 
our servicemembers who selflessly care for our heroes behind 
the scenes. These men and women are often left out when 
discussing veterans' issues. Military caregivers are essential 
component of the communal and family support system for our 
disabled veterans. They are usually spouses and other family 
members who spend their days transporting and caring for 
disabled veterans in order to provide an environment that 
enhances their everyday lives.
    In 2010, Congress passed a law implementing the Family 
Caregiver Program. This was an important piece of legislation 
that made veterans who sustained injuries in the line of duty 
eligible for a package of benefits that includes access to a 
primary caregiver. These benefits would ensure that the family 
members who dedicate their lives as caregivers, receives access 
to health care, caregiver training, and stipends for additional 
costs associated with their disabled veteran. Unfortunately, 
the Department of Veterans Affairs has had a difficult time 
managing the high demand of family caregiver enrollees, which 
is much larger than originally accounted for during 
implementation.
    According to the Government Accountability Office, VA 
officials estimated they would receive 4,000 enrollees and 
staffed the program based on this estimate. However, in the 
first few months of implementation, there were over 15,000 
enrollees to the Family Caregiver Program. VA medical centers 
lack sufficient caregiver support coordinators and the 
necessary clinical staff to carry out medical assessments for 
eligibility for this program. These implementation issues have 
led to a delay in both the application and the appeals process. 
Application deadlines are not being met by their own internal 
standards, and the staff is still shorthanded.
    These issues are not only unacceptable, but I believe they 
are preventable, and after meeting with a constituent who is a 
caregiver facing the burden of the VA backlog, I introduced 
H.R. 3989, the Support Our Military Caregivers Act. This bill 
would use preexisting funds already appropriated for the 
current review and appeals process to then allow for an 
objective, independent party to conduct external clinical 
reviews. This bill would ensure that new, or modified processes 
are veteran-centric, outcome-based, and continually improved 
through the use of best practices. We can accomplish this by 
permitting a third party to work within the VA to streamline 
claims and reduce the caregiver backlog through a more clinical 
analysis, rather than benefits adjudication. The VA would 
maintain this third party until appeals are streamlined, and 
the backlog is down to an acceptable rate and addresses the 
issues highlighted by the GAO.
    Military caregivers are truly the silent heroes in our 
communities and deserve the respect and benefits proportionate 
to their significant contributions. I would also like to 
highlight that this legislation is supported both by the 
Elizabeth Dole Foundation and American Veterans. I look forward 
to discussing this issue further in order to implement a 
solution and get our military caregivers the benefits they 
deserve. Thank you.

    [The prepared statement of Elise Stefanik appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Ms. Stefanik. Mr. Bost, 
you are now recognized.

                     STATEMENT OF MIKE BOST

    Mr. Bost. Thank you, Mr. Chairman, Chairman Benishek, 
Ranking Member Brownley. Thank you for allowing me to testify 
on this bill today. We must be very, very careful in 
consideration of how to reform the Department of Veterans 
Affairs and ensure access to quality health care our veterans 
deserve. As a Marine and the father of a Marine, I recognize 
the sacrifices that so many Americans have made in defense of 
our freedom. There is no doubt that we must fight for the brave 
men and women who have fought for us. I know my colleagues on 
both sides of the aisle feel the same way. But we need steady 
leadership and long-term vision. No organization can operate 
under a revolving door of interim leadership, and certainly not 
one that is given the task of caring for our American heroes.
    Yet, this revolving door is occurring at VA medical centers 
across this country. This undermines the quality and speed of 
the care that our veterans receive. That is unacceptable. That 
is why I introduced House Resolution 3956, the VA Health Center 
Management Stability and Improvement Act. The bipartisan 
legislation requires the VA Secretary to create a plan for 
hiring a permanent and qualified director at every VA Medical 
Center. My bill is endorsed by the American Legion, Vietnam 
Veterans of America, Paralyzed Veterans of America, AMVETS, 
Disabled American Veterans, and the Association of the United 
States Navy.
    The issue first came to my attention in my own back yard. 
Many southern Illinois veterans receive treatment from the St. 
Louis VA Medical Center. The St. Louis VAMC provides health 
care for 45,000 veterans annually, all under the cloud of 
temporary leadership. I remain very concerned about the lack of 
stability and how it impacts system operations.
    Over the last several years, the St. Louis VA has been 
managed by more than seven different acting directors. After I 
began looking into the local issue at the St. Louis VA Medical 
Center, it came to my attention that this isn't a problem that 
just exists in that area. Upon further investigation, I found 
dozens of VA medical centers that have lacked a permanent 
director for quite some time.
    The problem is due to the OPM requirements, which stipulate 
that the temporary directors can serve no more than 120 days 
with a 240-day maximum total if their tenure is extended. The 
lack of stability and permanent leadership is no doubt one of 
the reasons the Department of Veterans Affairs has been 
struggling to provide appropriate health care to those it 
serves. House Resolution 3956 seeks to fix the problem and fix 
it now. Specifically, it requires the VA Secretary to, one, 
report the status of any unfilled vacancy to the House and 
Senate Veterans' Affairs Committee; two, identify possible 
issues leading to the lack of staffing for these unfilled 
permanent positions, directors' vacancies; three, assess the 
possibility of promoting and training qualified candidates from 
within the VA for promotion to these leadership positions; 
four, develop a plan to hire highly qualified medical directors 
for each VA Medical Center which lacks a permanent director; 
and, five, submit this plan to Congress within 120 days of 
enactment of the bill.
    I have reached out to my local congressional colleagues and 
sent letters to the department regarding the lack of leadership 
at the St. Louis VAMC. Last week, I received a reply from the 
VA Under Secretary of Health giving me an update on the issue. 
According to his timeline, the St. Louis position has been 
vacant since July 14, 2013. That is 33 months. I have enclosed 
a copy of the St. Louis VA Medical Center Director timeline 
with a formal statement to illustrate just how long this gap 
has been.
    This problem doesn't end in St. Louis. Unfortunately, 
similar scenarios can be found in the Department of Veterans 
Affairs Medical Centers across the country. According to the VA 
Health Under Secretary Shulkin yesterday, in his testimony 
before this Committee, there are currently 34 VAMCs without 
permanent directors. House Resolution 3956 would help improve 
the leadership at the VA medical centers and so many of our 
Nation's veterans rely on.
    I thank the Subcommittee for considering House Resolution 
3956, and I look forward to working with you in a bipartisan 
way to advance this legislation, and thank you. And I yield 
back.

    [The prepared statement of Mike Bost appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Bost. Ms. Kuster, 
you are now recognized.

                   STATEMENT OF ANN M. KUSTER

    Ms. Kuster. Thank you very much, Chairman Benishek, and 
Ranking Member Brownley, and the Members of the Subcommittee, 
for the opportunity to discuss H.R. 3974, the Grow Our Own 
Directive: Physician Assistance Employment and Education Act of 
2015. Our full Committee has worked hard to improve veteran 
access to health care and to create opportunities for veteran 
education and employment. This legislation will allow us to 
merge those efforts and allow veterans to continue serving 
their country while in service to their fellow veterans.
    In the 14-1/2 years since September 11, and the 13 years 
since the invasion of Iraq, the men and women of the United 
States military have repeatedly demonstrated their skill, valor 
and professionalism. They have repeatedly placed their lives on 
the line, been separated from their families, and deferred 
their own personal life goals in order to serve our country. As 
many in this room recognize, that service on our behalf creates 
an obligation on our part to ensure that our veterans have the 
opportunity to succeed, and have access to the medical care 
they may require.
    Veterans today often leave the service with an incredible 
skill set. Our corpsmen and medics have proven medical 
experience in high-pressure training and real-world 
environments. They have also demonstrated an interest in public 
service by volunteering to serve in the military, and many hope 
to continue in service to the public after they leave active 
duty. Meanwhile, as this Subcommittee in particular knows well, 
veterans often face challenges in accessing care. As we 
discussed last week, sometimes this is due to IT and scheduling 
changes, but at other times, it is due to a lack of medical 
providers available.
    In a time of shortage for primary care providers both in 
the private sector and in the VA, with the Office of Inspector 
General listing physicians assistants as one of the VA's top 
five occupations with the largest staffing shortages, creating 
a pathway of opportunity for our veterans to fill that gap, and 
continue to serve their country seems to me to be like an 
excellent opportunity. H.R. 3974 would accomplish that 
objective by creating a pilot program to provide educational 
assistance to qualifying veterans for education and training as 
VA physician assistants.
    A veteran would qualify for this program who has medical or 
military health experience gained while serving in the Armed 
Forces, has received a certificate, Associate's degree, 
Baccalaureate degree, Master's degree, or post-baccalaureate 
training in a science related to health care, has participated 
in the delivery of health care services or related medical 
services, and does not have a doctorate in medicine, 
osteopathy, or dentistry.
    Eligible veterans would be able to apply during the 5-year 
pilot program to receive one of 35 scholarships available each 
year to cover the cost of obtaining a Master's degree in 
physician assistant studies or a similar Master's degree. 
Selection would be prioritized for those veterans that 
participated in an earlier veteran recruitment program known as 
the Intermediate Care Technician Pilot Program, and those 
veterans agreeing to be employed by the VHA in a community that 
is medically underserved and in a State with a significant 
veteran population.
    Those veterans that use the program would then owe the VHA 
a period of obligated service, based either on the scholarship 
program used or 3 years. To ensure that veterans are prepared 
to succeed, participants will be paired with a mentor at their 
facility, and the VA will partner with institutions of higher 
learning to guarantee physician assistant educational seats.
    As it is currently written, the bill would also establish 
standards to improve the education and hiring of VA physician 
assistants, and enhance retention and recruitment through 
competitive pay standards. As this bill moves through the House 
and the Senate, there have already been several discussions to 
find ways to improve the bill to increase its chances of 
passage and to create this opportunity for our veterans. I am 
happy to continue those conversations in the coming weeks and 
days, and based on feedback from this hearing and from my 
colleagues.
    Mr. Chairman, this concludes my statement, and I would be 
happy to answer any questions. Thank you.

    [The prepared statement of Ann Kuster appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Ms. Kuster. Ms. 
Walorski, you are now recognized.

                  STATEMENT OF JACKIE WALORSKI

    Mrs. Walorski. Thank you, Mr. Chairman. Good morning, and 
good morning, Ranking Member Brownley and my fellow colleagues. 
I appreciate the opportunity to discuss House Resolution 4977, 
the VA Scheduling Accountability Act.
    In 2014, news reports uncovering gross mismanagement and 
schedule manipulation at a Department of Veterans Affairs 
hospital in Phoenix shook us all to the core. Through hearings 
held in this Committee and investigations by the VA, OIG, and 
GAO, we, together, substantiated many of the allegations of 
manipulated schedules and falsified wait times data at the 
Phoenix facility. The manipulation of appointment schedules and 
data in Phoenix led to at least 40 veterans dying while they 
were waiting for care. However, as we all took a closer look, 
we discovered that, sadly, this was not an issue unique to 
Phoenix. It was systemic.
    Here we sit 2 years later, digging deeper into some of the 
root causes to ensure that no veteran ever dies again waiting 
for care. So I introduced legislation this week, the VA 
Scheduling Accountability Act, that gets at one of the key 
drivers of the wait-time manipulation, a 2010 VA directive in 
VA's implementation processes and procedures policy for 
scheduling at their facilities, and contains 19 different items 
on the checklist. The directive requires the annual 
certification of full compliance with all items on the list. 
For instance, facilities are required to ensure completion 
using VISN-approved processes and procedures of a standardized 
yearly schedule or audit of the timeliness and appropriateness 
of scheduling actions and of the accuracy of desired dates.
    They are also required to ensure that deficiencies in 
competency or performance are identified by the annual schedule 
or audit are effectively addressed. An August 2014 OIG report 
uncovered that in May of 2013, the then-Deputy Under Secretary 
for Health For Operations Management waived that fiscal year 
2013 annual requirement for facility directors to certify 
compliance with the VHA scheduling directive, allowing 
facilities to only self-certify reduced oversight, over wait 
time, data integrity, and compliance with appropriate 
scheduling practices. This, in turn, allowed VA's data to be 
easily manipulated, contributing to the wait-time scandal. 
There was a noticeable substantial improvement in VHA's 
appointment scheduling after VA waived the directive, but as we 
all know now, that improvement was an illusion.
    Although VA has reinstated the certification requirement, 
there is nothing stopping them from waiving it again. The VA 
Scheduling Accountability Act would simply require each 
facility's director to annually certify compliance with a 
scheduling directive or any successor directive that replaces 
it, and it prohibits any waivers in the future.
    Should a director be unable to certify compliance, either 
because the facility is not in compliance, or the director 
refuses to sign the certification for some other reason, the 
director must submit a report directly to the Secretary 
explaining why the facility is out of compliance. The Secretary 
will then have to report yearly to the House and Senate VA 
Committees with a list of facilities in compliance and those 
that are not with an accompanying explanation as to why they 
were not in compliance. This will provide more oversight of the 
Department and ensure Congress is aware when VA is waiving 
these policies.
    Waiving compliance requirements was a key driver in the 
wait-time scandal, which continues to be an issue at the 
Department. This legislation will begin to end that reckless 
practice once and for all, while increasing accountability and 
transparency at the VA, as we work on ways and continue to work 
on ways to ensure that those who risk their lives for their 
country receive the prompt quality care that they have earned.
    I look forward to working with the Members of this 
Committee, veterans service organizations, and the VA, 
addressing this critical issue, and I, again, thank you for 
allowing me the opportunity to speak today. And I yield back.

    [The prepared statement of The Honorable Jackie Walorski 
appears in the Appendix]

    Mr. Benishek. Thank you, Ms. Walorski. Mr. Zeldin, you are 
recognized.

                   STATEMENT OF LEE M. ZELDIN

    Mr. Zeldin. Good morning, Chairman, and thank you for the 
opportunity to testify on behalf of my bill, H.R. 2460, which 
provides no-cost medical model adult day health care services 
for our 70 percent or more service-connected disabled veterans. 
It must always be a top priority of Congress to ensure that all 
veterans receive the proper treatment and care they deserve 
after fighting for our country. While overseas, these brave men 
and women are exposed to hardships and trauma, and when they 
come home, many return with the physical and mental wounds of 
war. Despite various care options for veterans, their choices 
are often limited and can come at a great expense.
    Servicemembers who are 70 percent or more disabled from a 
service-connected injury often require significant assistance 
from others in order to carry out basic everyday tasks. In many 
instances, veterans must rely on family members for assistance, 
creating many financial and emotional hardships. Alternatively, 
some veterans, without the proper support system, may even be 
forced to rely on the assistance of trained medical 
professionals and reside in an institutionalized facility for 
daily assistance. Veterans in these facilities often spend 
significant sums of money each day just to be enrolled, and 
these expenses can be expected to span the remainder of the 
veteran's life in many cases.
    While alternative options currently exist, accessing these 
services, however, can often be very difficult. One such 
program that is currently available is adult day health care, a 
daily program for disabled veterans who need extra assistance 
and special attention in their day-to-day lives. Adult day 
health care programs provide disabled veterans and their 
families with a high-quality alternative to nursing care, 
providing quality outpatient services for those suffering from 
debilitating illnesses or disabilities.
    These programs provide a range of services from daily 
activities such as bathing, to full medical services like 
physical therapy. Adult day health care is only offered 
currently at three facilities in the United States. Long 
Island, where I represent, is fortunate to be the home of one 
of these three locations, which offer adult day health care, 
the Long Island State Veterans Home in Stony Brook, New York.
    But this program could easily be offered at any of the 153 
State veterans homes across the country. However, the 
Department of Veterans Affairs does not currently cover the 
cost of participation in this program at State veteran homes, 
and the expense of the program is put directly on the veteran 
and their family, which significantly limits the number of 
veterans who can enroll.
    In an effort to address this and expand access to care for 
our heroes, I introduced bipartisan legislation, H.R. 2460, 
which would ensure that 70 percent or more service-connected 
disabled veterans are able to receive adult day health care at 
no cost to the veteran and their family by defining the program 
as a reimbursable treatment option through the VA. My bill 
would guarantee that all severely disabled veterans are able to 
access adult day health care.
    By providing disabled veterans with access to adult day 
health care programs, we can assure that all veterans receive 
the best and most efficient outpatient services to provide them 
with the assistance and special attention that they need in 
their day-to-day lives, while still allowing them to maintain 
their independence.
    Adult day health care also helps keep families together and 
strong. With the inclusion of adult day health care services as 
a covered VA expense, family members and caregivers can rest 
easier knowing that their loved ones are receiving topnotch 
care during the day, while being treated with the same respect 
and dignity that they would receive at home.
    Not only does the adult day health care model care for the 
medical needs of a veteran, but it also addresses their social 
and emotional needs as well. Adult day health care allows 
veterans to interact and socialize with their peers and other 
individuals enrolled in the program. Rather than sitting home 
alone all day, participants in the adult day health care 
program receive one-on-one attention from medical and support 
staff, while also maintaining an active social schedule through 
planned events and activities. Family members and caregivers 
can go about their day without the worry that their loved ones 
are unattended, and the veterans can continue to remain as 
active members of their community.
    It should be noted that treatment at adult day health care 
is $40 to $50 less on average than nursing care would cost.
    It is a top priority of mine to ensure that all veterans on 
Long Island and across the country receive the proper treatment 
and care they deserve, which is why I fully support the adult 
day health care program. Thank you, Chairman, and I yield back 
the balance of my time.

    [The statement of The Honorable Lee Zeldin appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Zeldin. Do any of the Members 
here have questions for these Members that have proposed 
legislation before us? Dr. Roe.
    Mr. Roe. I do. I think one of Ms. Brownley's legislation, 
I, at least from a practicing-physician standpoint, it makes it 
extremely difficult as it is. I would like to work with you on 
that, but this is virtually impossible to do as it is currently 
written. There is not enough time in a day to go through all 
the possibilities that you have laid out.
    And I pulled up fluoxetine, which is Prozac, and just went 
through the list of side effects of that drug. It would take 
you a day to go through all that the way it is listed. I think, 
certainly, the intent is to inform people about the possibility 
of addiction to opioids. That, everybody at this dais agrees 
on. The question is just how to do it. I know as I read this, I 
thought I don't see how I could do this the way it is currently 
written and see patients the rest of the day. I would like to 
hear some of my other colleagues step up, Dr. Ruiz or others. I 
will yield to Ms. Brownley.
    Ms. Brownley. Thank you, Dr. Roe, and I appreciate the 
comments and would like very much to work with you. I think, 
you know, part of the bill says we are going to set up a panel 
of clinicians to decide those, in my layman terms, most 
dangerous drugs to have this interaction with. So it wouldn't 
be--Prozac probably wouldn't be on the list. It would just be 
those opioids and other kinds of high-level drugs that we see 
as sometimes can have the wrong effect.
    So, I think, you know, this is draft legislation right now. 
That means it still needs to be worked on, but I wanted to 
introduce it to the Committee to get people's feedback so that 
we can get to a bill that everyone can support, so I appreciate 
the feedback.
    Mr. Roe. I would like to work on it. And just to give you 
an example here of one particular drug, if you have stiff 
muscles, high fever, sweating, fast or uneven heartbeat, 
tremors, overreactive reflexes, nausea, vomiting, diarrhea, 
loss of appetite, feeling unsteady, loss of coordination, 
headache, trouble concentrating, memory problems, weakness, 
confusion, hallucinations, fainting, seizures, shallow 
breathing, breathing that stops--I would certainly think that 
would be a problem--skin reactions, fever, sore throat, 
swelling on your face or tongue, burning on your skin--I could 
go on for another 15 minutes.
    So this is why I think we have to back up and really narrow 
this down so that we--people understand, look, if I am 
progressively increasing more and more narcotic, I have a high-
risk. That is something fairly reasonable. I would love to work 
with you on it. I know the intent, but the application of this 
could be very difficult, I think.
    Ms. Brownley. Very good. Thank you.
    Mr. Benishek. Any other questions? Well, I thank--I guess 
most of the people on that panel are gone. Ms. Kuster, thank 
you for participating this morning. I appreciate you being 
here. So the first panel is excused.
    I now welcome our second panel to the witness table. 
Joining us on the second panel is Diane Zumatto, the National 
Legislative Director from AMVETS; Shurhonda Love, the Assistant 
National Legislative for the Disabled American Veterans; and 
Fred Sganga, the Legislative Officer for the National 
Association of State Veteran Homes. I would like to thank you 
all for being here and for your hard work and advocacy on 
behalf of our veterans, so I look forward to hearing the views 
of your Members.
    And, Ms. Zumatto, you may begin when you are ready.

                 STATEMENT OF DIANE M. ZUMATTO

    Ms. Zumatto. Thank you, Mr. Chairman. I am happy to be here 
today on behalf of AMVETS. Before I begin my specific remarks, 
I just want to ask that this Committee remembers that the 
health care obligations imposed by the sacrifices of our 
veterans are met in a timely, professional, and compassionate 
manner. I would also urge you to reject any plan to eliminate 
the VA from hands-on care of our veterans.
    As far as H.R. 2460, AMVETS supports this legislation, 
which seems like the best of both worlds in that it provides 
the appropriate and necessary care for veterans in a more cost-
effective manner, while also providing an improved quality of 
life. The legislation directs the Secretary of the VA to enter 
into an agreement or contract with each State home to pay for 
adult day health care for a veteran eligible for but not 
receiving nursing home care.
    H.R. 3956, AMVETS supports this legislation, which seems to 
be a bit of a no-brainer to us. Medical centers without 
directors will most likely not perform as well or as 
consistently as those that do.
    H.R. 3974, AMVETS supports the legislation which builds 
upon and leverages the training and experience of former 
military members. This bill directs the VA to carry out the 
Grow Our Own Directive Pilot Program to provide educational 
assistance to certain former members of the Armed Forces for 
education and training as VA PAs.
    3989, AMVETS is very supportive of this bill, which permits 
an individual to elect to have an independent contractor 
perform an external clinical review related to their caregiver 
or their caregiver benefits. This is important because things 
change over time. The needs of both the veteran and the 
caregiver are likely to change, including but not limited to, 
the amount of care the veteran requires, could increase or 
decrease the amount of time the caregiver has available to 
assist that veteran, could increase or decrease.
    The caregiver might prove to be unable to perform the 
necessary duties. The caregiver also might prove to be 
unethical or irresponsible, and their level of expertise will 
change. So we just feel that this will provide a much-needed 
way out of a possibly unsuitable situation.
    The draft legislation to ensure that VA medical facilities 
comply with requirements related to appointment scheduling and 
to improve the uniform application of directives, AMVETS feels 
strongly that there needs to be continuity across the VA health 
care system, and this bill should help to make that 
recommendation a reality.
    Finally, draft legislation on informed consent. This is a 
top issue for AMVETS, and we wholeheartedly support this 
legislation, because we believe that the health and welfare of 
our veterans needs to come first. This means that their 
interests come before any VA employees, including physicians. 
AMVETS believes that having the veterans buy-in and clear 
understanding of any proposed risky medications will not only 
provide much-needed peace of mind for the veteran and their 
family, but will be instrumental in the overall healing 
process. An informed patient is much more likely to fully 
comply with their doctor's instructions, and much less likely 
to complain or be dissatisfied with their treatment.
    Let me be clear that our intention in supporting this 
legislation is not to burden or disrespect VA doctors, but to 
provide veterans the opportunity to be more actively involved 
in their health care treatments. In order to minimize the 
burden on physicians, AMVETS suggests utilizing nationally 
standardized medical educational materials which could be 
adopted by the VA and made available, either digitally or in a 
preprinted format, such as a medication guide.
    All of the medications which would require informed consent 
would either be available in a database, whereby each 
medication with its additional information could be printed for 
each specific covered medication and provided to the patient. 
If utilizing the preprinted medication guide, each covered 
medication would be included with all of the same additional 
information as the database option, which is in the written 
testimony, so I am not repeating that. The physician would then 
merely have to check off the recommended medications and hand 
that information to the patient. In both cases, a consent form 
would be provided to the patient for his or her signature in 
either an electronic or paper format.
    The patient's signature, at this point, merely indicates 
that they have been provided with the information regarding any 
covered medications and should not yet be understood as an 
acceptance of the proposed treatment plan. At this point, the 
patient should be given the opportunity to ask any immediate 
questions of the physician, or the veteran could be referred to 
a pharmacist for further information. The patient then would be 
given 3 full business days from the issuance of the initial 
recommended prescription to either consider and internalize the 
information provided by the doctor, conduct any additional 
research, seek a second opinion, discuss with family, or get a 
legal opinion. At the end of the three-day period, the patient 
would then convey their approval or disapproval of a suggested 
medication or medications by a secure messaging, phone, email, 
or fax, directly to the prescribing physician or his or her 
office. The veteran's signature, along with the follow-up, 
whether it is oral or written at the end of the 3 days would 
jointly fulfill the informed consent signature requirement, so 
there would be no further reason for the veteran to return to 
the doctor's office on this matter, unless there were 
extenuating circumstances.
    It appears that I have gone over time, so I am going to 
leave it at that, and I would be happy to answer any questions. 
Thank you.

    [The prepared statement of Diane Zumatto appears in the 
Appendix]

    Mr. Benishek. Thank you very much. Ms. Love, you are 
recognized.

                 STATEMENT OF SHURHONDA Y. LOVE

    Ms. Love. Mr. Chairman, and Members of the Subcommittee, 
thank you for inviting DAV, Disabled American Veterans to 
testify at this legislative hearing. As you know, DAV is a 
nonprofit veterans service organization comprised of 1.3 
million service-disabled wartime veterans.
    I will provide comment on three of the bills before the 
Subcommittee. My written statement covers all bills and drafts 
relative to this hearing. DAV is pleased to support the intent 
of the discussion draft for increased informed consent. 
However, we recommend VA include pharmacy personnel on all PACT 
teams to lessen the burden on physicians.
    H.R. 2460, if enacted, would authorize the Secretary to 
enter into agreements with State veteran homes to provide adult 
day health care for veterans who are eligible for but not 
receiving skilled nursing home care. Eligible veterans are 
those who require such care due to service-connected 
disabilities, or who have a disability rating of 70 percent or 
more disabling, and are in need of such care. The payment to 
the State home under this program would be at the rate of 65 
percent of the amount that would be payable to the State home 
if the veteran were an inpatient receiving nursing care. 
Payment by the VA would then be considered payment in full.
    The adult day health care program is a program for veterans 
who need assistance with activities of daily living, nursing 
services, and case management. It is also beneficial for those 
veterans with caregivers who may be experiencing isolation from 
their own lives, and are in need of respite from the constant 
care of their loved ones. During the time spent at the adult 
day health care program, veterans receive the health care 
services they need in addition to peer support, companionship, 
recreation, and social activities. The health care services 
received would be based on their personal needs, and could 
range from a full or half day, two to three times per week.
    Veterans want to be independent for as long as they can 
without being burdensome to their families. In addition, they 
still want to remain an active part of the family unit. Adult 
day health care helps to accomplish this goal by allowing the 
caregiver respite to take care of their personal needs while 
the veteran has an opportunity to interact with their peers 
while obtaining the health services that they need.
    DAV is pleased to support H.R. 2460, which is in line with 
DAV Resolution No. 101 adopted at our most recent national 
convention calling for the support of State veteran home 
programs, recognizing State home care as the most cost-
effective care available for sick and disabled veterans with 
long-time health care needs outside of the VA health care 
system.
    H.R. 3989, if enacted, would establish an external review 
process in cases in which the VA has denied caregiver benefits, 
approved a level of benefits considered inadequate to the 
needs, or revoked benefits. A decision on this review, once 
requested by the caregiver, would be required by the bill to be 
completed within 120 days. DAV has continued to express the 
need for an independent mechanism through which a caregiver can 
appeal the clinical team's decision. That decision can be 
reviewed de novo, and an unwarranted decision can be reversed, 
altered, or sent back to the clinical team with instructions to 
reassess or consider additional factors.
    H.R. 3989 offers a review of VA decisions. However, it is 
unclear if the review will be binding on VA, or whether the 
recommendations from the contractor would be cause for VA to 
issue a new decision based on the review findings. For 
caregivers who feel they are unduly denied benefits, VA must 
establish a systematic recourse and provide a publicly 
accessible program handbook, or directive, outlining mandatory 
program policies, procedures, and operational requirements, 
which would serve to inform and educate those enrolled and 
seeking enrollment into the program.
    DAV is pleased to support H.R. 3989, as it is in line with 
DAV Resolution No. 106 calling for legislation to provide 
comprehensive support and services to caregivers of all 
veterans severely injured, and ill, from military service.
    DAV has no objection to the passage of the remainder of 
bills before the Subcommittee.
    Mr. Chairman, DAV appreciates the opportunity to provide 
testimony. I will be pleased to address any questions you or 
the Subcommittee Members may have on these bills.

    [The prepared statement of Shurhonda Love appears in the 
Appendix]

    Mr. Benishek. Thank you, Ms. Love. Mr. Sganga, you are 
recognized.

                  STATEMENT OF FRED S. SGANGA

    Mr. Sganga. Mr. Chairman, and Members of the Subcommittee, 
thank you for this opportunity to testify in support of H.R. 
2460, introduced by Congressman Lee Zeldin of New York, to 
provide severely disabled veterans with an enhanced option to 
receive adult day health care services from a State veterans 
home. I am Fred Sganga, the legislative officer and past 
president of the National Association of State Veterans Homes. 
I also have the high honor of serving as the executive director 
of the Long Island State Veterans Home at Stony Brook 
University, a 350-bed State veterans home that also operates a 
40-slot medical model adult day health care program.
    Mr. Chairman, a decade ago, Congress passed legislation to 
assist our most disabled veterans by allowing them to receive 
skilled nursing care in State veterans home under a new program 
where VA paid the full cost of care to the State veterans home 
with no cost charged to the veteran. Unfortunately, the law did 
not cover alternatives to traditional institutional care, such 
as medical model adult day health care, which is currently 
being provided at three State veterans homes in Stony Brook, 
New York; Minneapolis, Minnesota; and Hilo, Hawaii.
    H.R. 2460 would fix that. Adult day health care is designed 
to promote wellness, health maintenance, socialization, 
stimulation, and maximize the participant's independence while 
enhancing their quality of life. A medical model adult day 
health care program also provides comprehensive medical, 
nursing, and personal care services.
    As a licensed nursing home administrator, I would like to 
thank Congressman Zeldin for recognizing the need to offer 
noninstitutional alternatives to our veterans. The legislation 
would also be especially important to veterans like Jim 
Saladino and his wife, Noreen.
    Fifty years ago Jim answered the call of his country and 
served in the United States Army during the Vietnam War. Today 
Jim suffers from the ravages of Agent Orange exposure, 
including diabetes and Parkinson's disease. He also recently 
suffered a stroke. The Saladino family could have easily 
decided to put Jim into my nursing home because he is a 100 
percent service-connected veteran, and his nursing home care 
would have been fully paid for by the VA, but this is not their 
choice.
    They would like their loved one to continue enjoying the 
comforts of his own home for as long as he can, and our medical 
model adult day health care program does just that. Three days 
a week, we pick up Jim and bring him to our home. Working 
closely with his personal physician, we provide services to 
help maintain his wellness and keep him out of the emergency 
room, and even avoid unnecessary hospitalizations. During his 
6-hour day with us, Jim receives a nutritious breakfast and 
lunch. He receives comprehensive nursing care. He also receives 
physical therapy, occupational theory, and speech theory. He 
can get his eyes checked by an optometrist, his teeth cleaned 
and examined by our dentist, his hearing checked by our 
audiologist. If required and his physician orders it, we can 
get him a blood test, or even an X-ray. We can have his vital 
signs monitored, and we can even bathe and groom him while he 
is on site. For Jim's wife, Noreen, his primary caregiver, this 
program gives her peace of mind knowing that he is in a safe 
and comfortable environment, and allowing her to get a break.
    However, because of the way the law is currently 
structured, despite Jim's eligibility for no-cost skilled 
nursing care, the Saladinos are required to pay out of pocket 
for a portion of Jim's adult day health care. Mr. Chairman, 
H.R. 2460 will fix this disparity by authorizing the VA to 
enter into agreements with State veterans homes to provide 
adult day health care for veterans who are eligible for but do 
not receive skilled nursing home care under the current full 
cost of care program. The payment to the State veterans home 
under this program would be at a rate of 65 percent of the full 
amount paid for skilled nursing care, the full cost of care 
program. This will save the VA money while keeping veterans 
like Jim Saladino in their own home.
    For the Saladino family, receiving no cost medical model 
adult day care would relieve a huge financial burden they 
currently incur. Even though Jim's service ended 50 years ago, 
he is still paying the price for his valor related to his 
service in Vietnam.
    Passing H.R. 2460 would send a strong message to all those 
who have worn the uniform to protect our freedoms that they 
will never be forgotten. H.R. 2460 has bipartisan support in 
the House, and has also been supported by the DAV, VFW, 
American Legion, AMVETS. I would also ask that the Legion's 
letter of support be made part of the record.
    On behalf of the National Association of State Veterans 
Homes, I urge you to approve H.R. 2460 for Jim and Noreen 
Saladino and for thousands of others across the country just 
like them.
    Mr. Chairman, that concludes my testimony, and I would be 
happy to answer any questions you or Members of the 
Subcommittee may have, and thank you again for this 
opportunity.

    [The prepared statement of Fred S. Sganga appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Sganga. I am going to yield 
myself 5 minutes for questioning. I just have a couple 
questions that relate to the bill of Mr. Zeldin.
    Mr. Sganga, the VA is going to testify because of the level 
of services for adult day care and nursing home care are 
different, and the period of time in which services are 
furnished are different, they believe that the payment rate 
proposed for 2460 was inappropriate.
    So, would you please respond to that assertion and explain 
what, if any, the monetary benefit is available to veterans or 
to State veterans homes through the VA through adult day health 
care, and why the provisions and the rate in H.R. 2460 are 
appropriate and necessary in your opinion?
    Mr. Sganga. Well, in my opinion, back in 2006 when Congress 
had said any veteran who is 70 percent or more service-
connected disabled is entitled to skilled nursing care, it 
didn't include adult day health care. Currently in my home, I 
am being paid $489 a day to care for that veteran who falls 
into that category. At 65 percent of that rate, I would be paid 
about $318 a day. That includes, Chairman Benishek, 
transportation to and from the home. Clearly $318 a day is less 
than $489 a day and it would allow the veteran to live in the 
comfort of his or her own home.
    I think what we used as a model was recognized by CMS. In 
the State of New York, if you receive nursing home care, the 
State of New York will reimburse that same nursing home who 
provides adult day health care at a rate of about 65 percent. 
So that 65 percent number is a highly recognized number within 
CMS.
    Mr. Benishek. So the services that you described in your 
testimony, the veteran gets a bed then for the day, and then he 
may get his bath--
    Mr. Sganga. That is a great question. Let me give you an 
example. We had an 85-year old Marine who was going to be 
admitted into the home. His wife could feed him. She could put 
his clothes on. She could even assist him with toileting. But 
what puts people in nursing homes is their ability to deal with 
their activities of daily living. For this spouse, she couldn't 
bathe this gentleman, and for that reason, he qualified for the 
nursing home. We provided her with the alternative of adult day 
health care, and now he comes to program 3 days a week, and now 
when he comes to the program, we bathe him in the program, put 
him in a clean set of clothes, and send him home at the end of 
the day. This couple got to enjoy their 65th wedding 
anniversary in their own home living together. So it is those 
kinds of stories that we want to help our vets with.
    Mr. Benishek. Let me get this straight now. So these are 
veterans that are actually eligible for nursing home care?
    Mr. Sganga. Yes. And the VA pays for it.
    Mr. Benishek. So this would keep somebody out of a nursing 
home--
    Mr. Sganga. Correct. At lesser cost.
    Mr. Benishek [continued].--and cost the VA less than if 
they had applied to go to a nursing home?
    Mr. Sganga. That is correct.
    Mr. Benishek. That makes a lot of sense then. I will yield 
back. Ms. Brownley, do you have any questions?
    Ms. Brownley. Yes, just briefly. And first, I wanted to 
thank Ms. Zumatto for helping and working with our staff in 
terms of drafting the legislation in my draft bill, so thank 
you very much for that.
    I think I just wanted to ask all three of you, really, you 
know, I think the goal of this bill is to really kind of reach 
a level of excellence in terms of, you know, the appropriate 
communication between the doctor and the patient, particularly 
when a drug may be prescribed that could have serious side 
effects, like addiction and other kinds of things, because that 
is what we have heard so much about in this Committee.
    So I guess, you know, if you could all comment in terms of, 
you know, feedback from your veterans on how well the current 
system is working and, you know, why you believe, you know, 
that this bill, taking it to kind of another level, to a level, 
in my opinion, of excellence, is important. Ms. Zumatto.
    Ms. Zumatto. Thank you for the question, Ms. Brownley. 
There are so many veterans that their quality of life has been 
compromised because of some of these medications. And many 
times--I mean, since most of us are not doctors, if a doctor 
tells us, you need to take this, or you need to do this, we 
often don't question them because we don't feel qualified. And 
so we just tend to do whatever the doctor says, which may be 
the appropriate thing to do. But what we would like to do is 
ensure that the veteran understands any of the risks that are 
going to be involved, or if there may be perhaps a less 
invasive procedure, medication, that could be tried, before 
perhaps moving to this more dangerous medication.
    And to your question, Dr. Roe, or your comment about not 
having the time as a physician, we do appreciate the short 
amount of time that doctors have, although I would say that VA 
doctors have a much lower panel of patients that they are 
expected to see on a daily basis than non-VA physicians. But I 
think by having this automated in a system, or in a piece of 
material that can be preprinted and just handed to the patient, 
and then it is up to the patient at that point to do any 
further research or read whatever is in there. We don't expect 
the doctor to spend 30 minutes or more talking about a list of 
medications and its side effects. We are expecting them to 
provide the information that is already created by the VA or 
whomever, and then the onus is on the patient and his family to 
do the research if they want to.
    Ms. Brownley. And I think, you know, that just leads into 
the current system in terms of the informed consent form. I 
don't think, and I am looking for confirmation from you, that 
the current system is not really generating that sort of more 
robust conversation between a doctor and patient so that they 
can go home. They want to talk to a pharmacist, they can do 
that; they can discuss it with their family members; they can 
do the research that they need to do. And I am just concerned, 
and I am looking for confirmation from you that you feel the 
same, is that, yes, they are going through and checking off and 
getting the patient to sign to say, you know, I have given you 
this information, you might not have read it, but I have given 
you the information, that that is not getting to where we want 
to get to in terms of having a more robust conversation.
    Ms. Zumatto. I would definitely agree. There are very few 
medications right now that require a signed form within the VA. 
They do require it for certain things, but generally, 
medications are not included.
    And I just had surgery last week at the VA, and when they 
gave me prescriptions to send me home, nobody told me anything 
about it, and one of them is an opioid. So that is the type of 
thing that we are trying to prevent.
    Ms. Brownley. Thank you. And my time is up, so I yield 
back.
    Mr. Benishek. Dr. Roe, you are recognized.
    Mr. Roe. I would like to comment. Look, handing somebody a 
piece of paper is not health care in the same degree. You have 
to have a doctor and patient or a nurse practitioner or a nurse 
sit down and discuss the medication, what its risks and 
benefits and side effects. I did that for 30 years. And signing 
a piece of paper that is just checking a box is not going to 
accomplish what we want to accomplish.
    I think what Ms. Brownley wants to accomplish, we all on 
this Committee want to accomplish. We have an opioid epidemic 
in the United States. We have, in the State of Tennessee, more 
people dying of overdose of prescription drugs than car wrecks. 
So it is a huge--and it is not just Tennessee. It is a huge 
problem.
    And so I think one way to do it, and obviously, it is 
training the medical personnel better, training patients 
better, but I don't want to put another barrier. We are 
complaining now about not enough access for care for our 
veterans, and I think we are adding another layer of 
bureaucracy here that may not get the benefit that you desire 
and I desire, and that is the adequate use of prescription that 
is written. I think that is what you really want at the end of 
the day.
    So those are my comments, and, certainly, we can work on 
this. I would like to. But I would say in its current form, I 
can't support it like it is.
    The other thing I didn't--not with this panel, but that 
Mrs. Walorski brought up that I didn't bring up a minute ago 
was on the scheduling issue, I think it is fine to do these 
things. But once again, there is no teeth, there is no penalty 
if you don't do it. That is what I was listening to her 
legislation.
    In other words, we are going to--I have been sitting here 
now for 7-1/2 years, and we find the VA doesn't comply or do 
something, there are no teeth in it, there is no penalty that 
if you don't comply. Okay, so they didn't comply.
    I think we have got to look and have some teeth in this 
bill that she has, and I would like to work with her on that. 
She is not here right now, but I think we need to do that.
    I have seen that over and over and over again here. I yield 
back.
    Mr. Benishek. Thank you, Dr. Roe.
    Mr. Takano, do you have any questions?
    Mr. Takano. Yeah. Thank you, Mr. Chairman.
    My question relates to H.R. 3956, the VA Health Center 
Management Stability and Improvement Act. And you are in 
medical centers every day. How important is it to have a full-
time medical center director in the facility and making day-to-
day decisions and strategic decisions about care for veterans?
    Ms. Love. Mr. Takano, DAV has not received a resolution to 
the hiring of VA medical center directors. However, we 
recognize the importance of VA being fully staffed with enough 
personnel to take care of veterans. Leadership would be part of 
that process.
    Mr. Takano. Can you comment on how having the leadership, 
having a permanent full-time director instead of acting 
directors, what effect that has on the morale of VA employees 
who go to work every day in a particular facility?
    Ms. Love. Not from an organization standpoint, but from a 
veteran standpoint, being an employee and having my leader 
present to direct the operations of the establishment would 
always be a plus.
    Mr. Takano. And related to H.R. 2460, Adult daycare in 
State Veterans' Homes, what concerns do you have for the VA to 
contract some of its services to the State veteran home?
    Mr. Sganga. Well, unfortunately, back in 2006, when 
Congress passed a bill to provide no cost skilled nursing care, 
it took the VA to implement that. It took about 3 years to 
implement the reimbursement process. It was very painful to a 
lot of veterans who truly deserved the care, and they did work 
with us to go retrospective--retroactive, I mean, to get the 
care paid for.
    What I am concerned about now is the fact that a lot of 
Members of this Committee understand that the VA is going to 
establish new regulations for adult day health care and for 
domiciliary care. Back in 2008, 8 years ago, I was part of a 
team that worked on Vermont Avenue with the VA to try to update 
the adult day health care regulations, which hadn't been done 
for years; and it is now 8 years later, and we are still 
waiting for that regulation.
    My nursing home on Long Island in Stony Brook serves as a 
model for adult day health care. I think it is a wonderful 
program. We have had visits from about 16 different States over 
the past 3 years, and I can tell you assuredly that there are 
many State veterans' homes that want to get into the game.
    Two things have to happen: We need the new regulations 
published. We have been told for 8 years that any minute now, 
they are coming out. And secondly, this bill for us, 70 percent 
population will help, with the proper funding, to keep those 
veterans out of the nursing home side and back into their 
communities while accessing the services they truly deserve.
    Mr. Takano. Thank you. Thank you for your response. On H.R. 
3989, the Support our Military Veterans' Caregivers Act, have 
you heard any concerns with the caregiver program as currently 
managed by the VA?
    Ms. Love. Some of the--Representative Takano, some of the 
concerns that we have is that the--there is not clear guidance 
with the current directive that VA has. Some of the issues will 
be a medical determination versus a clinical determination. 
These things are not clear for veterans to understand and 
decipher through.
    Another issue that we have would be, should a VISN director 
decide to request an external review, the key word there is 
``should,'' so that process should be automatic if the veteran 
is requesting a review.
    Mr. Takano. Well, is it necessary to set up an independent 
appeals process?
    Ms. Love. Can you rephrase that question?
    Mr. Takano. Well, is it necessary to set up an independent 
appeals process that is conceived in this bill?
    Ms. Love. Absolutely. It is necessary to set up some 
process in which the veteran has an opportunity to have a 
decision reviewed, and it should be a clear process to where 
all steps in the process are known to the veteran throughout 
the entire process.
    Mr. Takano. Well, what I am trying to get is, are there 
changes that could be implemented instead to improve the 
existing appeals process we have of VA, instead of setting up 
an entirely new separate independent process?
    Ms. Love. Well, the process needs to be made clear. It is 
not clear at all. It is not clear in the steps that the veteran 
is to take. It's not clear as far as the language that is used 
in the terminology of the directive that is currently before 
us.
    Mr. Takano. Okay. Well, Mr. Chairman, I think, you know, 
this has been a long problem for us, and it is a subject of 
much further examination, but anyway, I yield back.
    Mr. Benishek. I agree with you, Mr. Takano.
    Dr. Wenstrup.
    Mr. Wenstrup. Thank you, Mr. Chairman. Thank you all for 
being here today.
    You know, I think on Mr. Zeldin's bill, you know, as a 
practicing physician, the more you can do on an outpatient 
basis, keep people in their home, in their own home is 
typically better, or, at least, as an option for them. And it 
is otherwise helpful for the patient overall towards their 
quality of life. For some, it may be better to not be in their 
own home. And so, to me, that seems like a very viable option, 
as long as the care that is necessary is rendered.
    As far as the opioids, you know, I always felt an 
obligation, and still do, when I prescribe, to make sure that I 
am informing patients of side effects. I make sure that I am 
not doing something that is contraindicated with their other 
medications. I make sure that they don't have any allergies to 
medications that I am prescribing. These are the things that 
doctors normally do.
    Now, we know there is a problem not only in the VA, but 
outside the VA where people were overprescribing, and so, to 
me, a lot of that onus falls on the physician and patient 
relationship. But there was also always the double-check, if 
you will, from the pharmacy. And you get a prescription today, 
and you do get handed that information, and you have got 
stickers all over your prescription that are giving you the 
warning.
    So I think we really need to look at what really needs to 
be done to be effective to make sure that patients are aware of 
the risk, and in this case, of dependency and addiction, and 
maybe make sure that we are doing that.
    But I agree with Dr. Roe, some of it can be too time 
consuming, and the doctors here would probably agree that 
sometimes one of the worst things the patient could have is 
access to too much information because they find out that 1 in 
10 million has some side effect that suddenly they are paranoid 
about and they don't want to take the antibiotic that is 
supposed to help them and will help them.
    So, we have to be a little careful about how we do that, 
but I think there is an obligation, obviously, to make sure 
that you are doing the right thing informing patients properly, 
so I would like to work with you on that.
    I yield back. Thank you.
    Mr. Benishek. All right. Dr. Abraham.
    Mr. Abraham. Thank you, Mr. Chairman. A couple of comments 
on Mr. Zeldin's bill, 2460 and Mr. Sganga. They have certainly 
a civilian side of that also, and being a family practice doc, 
it does work. So I am much in support of that. The thing that 
nursing homes do, I think, as good a job as they can with the 
patient load that they have, but if that patient is in an adult 
daycare 6 hours a day, you are providing OTPT, you are moving 
the patient, you are grooming the patient. That patient is 
being mobile as much as possible, and I understand the 
significant impairment that some of those patients 
unfortunately have.
    But that increases joint mobility, it increases tissue 
oxygenation, just a better outcome for the patient. And if you 
look at objective data, which certainly I think most of us on 
the panel here have done so, either ones that are physicians, 
facilities such as yours at Stony Brook, compared to 24-hour, 
around-the-clock in a nursing home, less infection rate, less 
resistance to antibiotics, such as the MRSA epidemic that we 
are having now. So you know, I think it is a great thing, and 
hopefully, we can get this done.
    In response to Ms. Brownley's bill, again, you know, again, 
I, like Dr. Wenstrup, we certainly, hopefully, provide the 
patient with information that he or she can make an informed 
decision, but it is like Dr. Roe said, opioid, the epidemic is 
not only in Tennessee, Dr. Roe, it is--there are more patients 
dying from opioid dependence all over the Nation than car 
accidents. So it is a huge problem. We have got to figure this 
out
    So I think it is great. I mean, we can tweak this, and we 
can certainly work with Ms. Brownley and make this--and we, you 
know, we, I think, smart enough to figure this out, but just 
the mere fact that we are having the discussion, I think, is 
important and we keep moving this legislation forward in some 
form or fashion.
    And like my colleagues here, Dr. Roe and Dr. Wenstrup, you 
know, we want to make this work, and we are happy to work with 
you to find the right solution.
    And I yield back, Mr. Chairman.
    Mr. Benishek. I thank you, Dr. Abraham.
    Well, I want to thank the Members of the panel for being 
here today, and I encourage you to continue to keep us informed 
as to changes that occur with you, we want to get your input on 
all the pieces of legislation that have been put forth today. 
So thank you very much for being here. You are now excused.
    At this point, I welcome the third and final panel to the 
witness table. Joining us from the Department of Veterans 
Affairs is Dr. Maureen McCarthy, the Assistant Deputy Under 
Secretary for Health for Patient Care Services. And she is 
accompanied by Susan Blauert, the Chief Counsel for the Health 
Care Law Group of the Office of General Counsel.
    Dr. McCarthy, you may begin your testimony when you are 
ready.

               STATEMENT OF MAUREEN MCCARTHY M.D.

    Dr. McCarthy. Thank you, sir. Good after---good morning, 
rather, Chairman Benishek, Ranking Member Brownley, and Members 
of the Committee. Thank you for the opportunity to be here 
today to present our views on several bills that would affect 
VA health care programs and services. Joining me today is Susan 
Blauert, Chief Counsel for General Counsel's Health Care Law 
Group.
    First, I want to convey my gratitude and appreciation for 
the commitment of the Members of the Committee who seek to 
improve and provide these authorities to the VA. Though the 
Department, in writing, opposed a majority of the bills, we do 
so for purposes of resources, operations, and, in some cases, 
duplication of existing programs. We look forward to continued 
collaboration with the Committee and its Members to ensure we 
are providing the services and care our veterans deserve.
    Regarding H.R. 4977. VA policies already require directors 
to certify compliance with the scheduling directors and explain 
gaps in compliance based on data collected at the facility. We 
also know veterans aren't required to schedule hospital care. 
They can walk into the emergency department or be admitted 
directly by primary care.
    VA needs the flexibility to set scheduling standards that 
are clinically appropriate, and that can adapt to changes in 
the way veterans access health care, and I will be happy to 
explain some of the structures we have in place at this point 
to monitor that.
    Regarding H.R. 2460, VA supports growing adult day health 
care programs, because we definitely want to rebalance how we 
use home- and community-based services versus institutional 
services.
    Veterans and their families are supportive of initiatives 
that permit them to age in place and avoid nursing home care. 
However, H.R. 2460 would base payment rates for these programs 
on nursing home care rates, which are much higher, given the 
needed level of care.
    Whereas nursing home residents live at the facility and 
receive 24-hour nursing home care, these adult day health care 
participants live at home, and they use the program for say 6 
to 8 hours. Thus, this bill would require VA to pay two-thirds 
of the rate that VA pays for a higher level of care for 
furnishing a lower level of care for about a third of the time.
    Additionally, VA believes that shifting payments from a 
grant to a contract mechanism would place additional 
requirements on State homes that have been proven burdensome 
and difficult to implement.
    With regard to H.R. 3989, VA believes that the current 
process regarding review of eligibility determinations for the 
comprehensive program of support to caregivers effectively 
furthers VHA's policy to provide access to fair and impartial 
review of disputes.
    Currently, when an individual appeals the treatment 
decision of the care team about eligibility for participation, 
decisions are made by VHA leadership who have direct oversight 
of the clinical team that has been more intimately involved in 
the veteran's care. In contrast, the proposed external clinical 
review would be provided to an independent contractor who, in 
turn, would employ a panel of health care professionals not 
necessarily familiar with the case. We also emphasize that our 
caregiver program was designed by Congress to be a clinical 
treatment program and not a benefit program.
    Next, VA agrees that employment of physician assistants, a 
top five mission critical position within VA should be 
prioritized. Thus, VA supports the pilot program in section 2 
of H.R. 3974. The pilot program is a win-win for VA and the 
scholarship recipients as VA will reduce future recruitment 
costs while scholarship recipients fulfill their service 
agreements. That being said, VA recommends removing certain 
prerequisites described in the bill, and also a relook at the 
timeline of the expected numbers of participants.
    VA also supports section 4, including the PA occupation 
being included in the locality pay system in VA. We feel that 
would be an important element in addressing recruitment and 
retention difficulties associated with the pay disparity 
between private sector market pay and VA pay schedules.
    While VA supports sections 2 and 4, VA believes that 
section 3 would not be the best tool to address the current PA 
shortage. As some facilities do not report issues recruiting 
PAs, requiring all facilities to advertise education debt 
reduction program for PA positions would deny some facilities 
the ability and flexibility to make these awards for other 
critical positions for them.
    Next, VA is appreciative of your efforts to address 
challenges with recruiting and filling VA medical center 
director positions with H.R. 3956. VA has taken several steps 
to reduce the number of vacant positions. For example, VA 
anticipates having nominees identified for about 20 of the 34 
vacancies by the end of April.
    In addition, VA submitted a legislative proposal requesting 
the ability to transition all medical center directors from 
title 5 to title 38, which will provide additional compensation 
and staffing flexibilities, thereby relieving some of the 
current challenges with attracting highly qualified candidates 
to serve in these leadership roles. VA seeks your support of 
that proposal to ensure the resolution of the medical center 
director staffing challenges.
    With regard to the draft bill to establish a list of drugs 
requiring an increased level of informed consent, VA believes 
that we have met these terms in what we have going at this 
point. I am happy to share a list of medications for which VA 
already requires informed consent. VA feels the draft bill 
would burden veterans and their care providers by introducing 
some unnecessary steps and delays in what is standard informed 
consent process for high risk medications. We list several 
other concerns in the written statement.
    That being said, we were, at the time, unaware of the 
problem the legislation was supposed to remedy, but acknowledge 
indeed, Ranking Member Brownley's statement about the opioids 
and the purpose of this to address that. So we request an 
opportunity to meet with the Committee to ascertain the 
Members' concerns and work together.
    Thank you, Mr. Chairman and Ranking Member, for the 
opportunity to testify before you today. My colleague and I 
would be pleased to respond to questions that you or other 
Members may have at this time. Thank you.

    [The prepared statement of Dr. Maureen McCarthy appears in 
the Appendix]

    Mr. Benishek. Thank you, Dr. McCarthy, for your testimony. 
I will yield myself 5 minutes for some questions.
    So you think this medical center thing, this director 
program is primarily the fact that they don't pay them enough? 
Is that what we are getting at, you are changing the section to 
section 38? I don't remember the numbers.
    Dr. McCarthy. I think the pay is part of the problem. A 
typical VA medical center director compared to someone running 
a similar hospital in the private sector makes a fraction of 
what the private sector person makes. Some of the challenges 
are where our medical centers are located and people's ability 
to move to those locations, but salaries are a big piece of it.
    You may have noticed we have had some negative media 
attention over the last few years, and in particular, the sense 
of people who may, in the past, have considered becoming a 
director are feeling a lack of personal safety in assuming the 
role with the increased number of requirements placed on them. 
So I think it is multifactorial, but I do think salary would 
help.
    I also think a greater sense of appreciation for what they 
are doing and the challenges they face would help. And I have 
personally reached out to numbers of individuals that might be 
in acting roles and talked with them about why they are not 
stepping up to apply, and a number of them are talking about 
really the challenges and the pressures that are on our medical 
center directors right now with the intense level of oversight. 
That said, that is not to say that we shouldn't have oversight, 
but it is very, very challenging for all of them right now.
    Mr. Benishek. Thank you for that. I don't know if you are 
familiar, but I worked at a VA for 20 years as a physician, one 
of the challenges we had there was that the VA directors turned 
over every 2 years in many cases, and even with that 2-year 
tenure, things didn't get done. And with a 120-day tenure, you 
realize that these folks are not making the critical decisions 
that need to be made because they are worried about 
consequences of any decision they make as a temporary person.
    I am willing to work to make this happen, and are there 
changes in the law that need to be done to get the medical 
director to get this changed to this other section? Do we need 
to change the law to do that?
    Dr. McCarthy. Sir, there was a proposed--a legislative 
proposal VA submitted on changing it, those positions from 
title 5 to title 38, which would give more salary flexibility.
    Mr. Benishek. All right. Okay. I might want to go on to 
this, the stay-at-home home issue. You heard the testimony that 
these veterans that we are talking about, they are eligible for 
nursing home care now. So an effort to cut the cost of that and 
still provide them with the care they need seems like a no-
brainer to me. Why do you object to that?
    Dr. McCarthy. Sir, we definitely support veterans and their 
families as they make these decisions to age in place and want 
to do what we can to help them. We have a number of services in 
place already to support that.
    Our concern is--
    Mr. Benishek. We are not talking about people that aren't 
eligible for nursing home, we are talking about these are 
people that are eligible for nursing home care.
    Dr. McCarthy. Right.
    Mr. Benishek. And, either they go to a nursing home or they 
get this. You are saving money, aren't you? Or you want to 
provide the care a different way? I am not sure that that is 
actually happening, though.
    Dr. McCarthy. So as we move, shifting that balance I was 
talking about between institutionalization and the care- and 
community-based services that help people stay in their home, 
we definitely are trying to shift that balance for sure. Our 
concern was with the actual dollar number and was it, indeed, a 
fair calculation to pay two-thirds of the cost of a nursing 
home for them to be there for 6 to 8 hours. We have--
    Mr. Benishek. I think, to tell you the truth, if you had to 
pay somebody to go to the home for 6 to 8 hours, it would cost 
you more than $300. And Dr. McCarthy, you understand what I am 
talking about? To get a nurse to go to the home for 6 to 8 
hours and to do what they are going to do, you can't get one 
nurse to do that. They can't cut the hair more than one person 
needs to be doing it in the patient's home.
    So I have a little bit of trouble trying to figure out that 
argument.
    Dr. McCarthy. So just so you know, we have been working 
with the State Veterans Homes and have talked with them about 
two kinds of adult day health care models. One, which is a 
medical model, I think the classic example would be a post-
stroke patient, for instance, that needs a lot of direct 
nursing care and a comprehensive health care team, and the 
other is the social model.
    Mr. Benishek. I understand. I understand where you are 
going. I am just telling you this is not like respite care 
where you are just babysitting the patient and then the 
alternative is full care. You are talking about apples and 
oranges here. So to me, this--do you want to deny--you mean, it 
is cheaper to deny the patient the care, that is for sure.
    Dr. McCarthy. Not in the long run, I don't think.
    Mr. Benishek. Nobody--I don't think you are talking about 
that, but it kind of gives me the idea that that might be 
happening.
    Dr. McCarthy. So if I could--could I just--
    Mr. Benishek. It is definitely cheaper to deny the care.
    Dr. McCarthy. Right.
    Mr. Benishek. So I just want to--
    Dr. McCarthy. I agree with you. I was about to say that 
there are two models, and one is a more medical model, and one 
is a more social model, and so the way it is written is that 
this would apply to both models, and what we feel is that if it 
were a more social model, then the compensation wouldn't be 
justified. So we do have a regulation that was out for comment, 
and we are addressing the comments at this point, but it is 
really to look at two different models and--
    Mr. Benishek. I think we are talking about two different 
patient sets, though. We are talking about a patient set that 
the patient is 70 percent disabled and eligible for nursing 
home placement, as I understand it. So that is a different--
that is different than what you are talking about.
    Dr. McCarthy. Actually, that 70--
    Mr. Benishek. I am out of time, though. I appreciate it, 
but I would like to have you follow-up so I understand this 
better.
    Dr. McCarthy. I would be happy to do that.
    Mr. Benishek. Mr. Takano, do you have any questions?
    Mr. Takano. Yes, Mr. Chairman.
    You know, regarding draft scheduling compliance. This 
Committee heard just yesterday about the continued challenges 
veterans face when scheduling access to care, and part of the 
inconsistency stems from the fact that schedulers are working 
under an interim scheduling directive. Once a comprehensive 
scheduling directive is finalized, it would seem to me that 
ensuring greater compliance will help improve wait times and 
get veterans the care they need.
    Does the VAMC director currently have to comply with VA 
regulations and law?
    Dr. McCarthy. Yes. We believe so, yes. There is an 
expectation, if we could talk about scheduling, in particular, 
that the medical center director and the network director would 
visit the frontline staff that are involved in scheduling 
periodically. And in addition, there has been a tool developed 
to look at scheduling and the process, to look for any kind of 
irregularities. It looks at a total of five measures of 
compliance and practice to help figure out if anybody is 
manipulating data in any particular way.
    And if that is apparent, it will be apparent to the medical 
center, it will be apparent to the VISN, it would be apparent 
to leadership in VA central office. So there is a tool that 
people are using to help and verify, in addition to the 
expectations of the visits and the certifications.
    Mr. Takano. And how does the central office verify the 
compliance?
    Dr. McCarthy. So what is used as a database, and I have had 
this explained to me, what--what they use is a measure of five 
things. They look at the average new patient wait time, the 
cancel-by-patient rate, the established patient zero-day wait, 
and then in terms of practice, what is going on with the 
electronic wait list and the established patient measures, and 
based on outlier status on any of those, it is a warning sign 
that things may not be accurately followed in terms of the 
scheduling directive and the scheduling processes in place. 
That is the warning sign. And then there is a review that 
happens that is triggered by those kinds of events.
    But in addition, people are following all the time the wait 
lists, and in particular, the need for urgent care and so 
forth.
    Mr. Takano. Well, do you think that this--that effective 
compliance, verification of compliance through the central 
office, would this lead to enhanced veterans' access to care?
    Dr. McCarthy. So compliance and access are likely related, 
yes. But I think, in my mind, some of that is separate. I think 
we are all about improving access, and compliance is more 
asking are we doing it right and are we doing the right thing? 
But obviously, if we are compliant, we would get access. I just 
think about those in two parallel spheres. I am sorry.
    Mr. Takano. Okay. I want to move on to the H.R. 3989, 
Support Our Military Caregivers Act. Can you quick--briefly 
explain the current process to determine if a family is 
eligible for caregiver assistance, and what recourse does a 
family have if they disagree with the decision?
    Dr. McCarthy. So the way Congress wrote this for VA is 
different how it is written for DoD. For DoD, it is a benefit. 
For VA, it is part of the treatment plan. So the treatment team 
makes a recommendation for a veteran to have the caregiver 
based on the current needs of the veteran at the time the 
assessment is made.
    There includes a series of events, including home visits 
and so forth. Typically, it is a 90-day process of evaluation, 
and so all of the kinds of things that are determined are if 
the veteran needs this care, what kind of level is needed, and 
then an assessment of how best to accomplish this and the 
support that the family member would need, there is training 
that goes in to what the family member gets. So there is a tier 
assigned for the level which corresponds to the compensation 
level that the family member receives.
    Mr. Takano. If I could interrupt or add onto that. If the 
servicemember's health situation changes, will the family have 
to begin the process all over again of, you know, evaluating 
the caregiver assistance?
    Dr. McCarthy. Yes, because it is considered a treatment and 
not a benefit, and I think that is where there is a lot of 
misunderstanding. So when someone is assigned a benefit, it is 
an ongoing payment; whereas, as part of the treatment plan, the 
veteran may or may not need the ongoing support of a caregiver. 
And initially, say after transitioning from a polytrauma 
facility, they may need a lot more support, but as time goes 
on, they may not need the assistance at the same level, the 
same tier, or they may even not need the assistance of the 
caregiver, which is a clinical decision.
    Mr. Takano. All right. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Benishek. Dr. Roe.
    Mr. Roe. Just a couple of brief questions. You know, 
yesterday, the VA has 32,000 schedulers for their VA system, 
and that is half the population of the city I live in, which is 
the largest city in the 1st Congressional District of 
Tennessee. So there are only about three or four towns in the 
whole district that are bigger than the number of schedulers 
the VA has.
    And you know, yesterday, we were sitting in this same room, 
and we heard two very different stories about scheduling. And I 
think that it is important for us to get that straight. And I 
would support her bill, and the reason is because we can't get 
information that we can understand up here about wait times. We 
hear the Secretary say it is 4 days, you go home, and you hear 
everybody you talk about it, nobody is getting in in 4 days. So 
I think that is a problem we have here is it is a definition.
    And I know yesterday, when I went over it, it is like when 
a veteran calls in and they say, Well, we don't have an 
appointment for 6 weeks; would that be okay? When they would 
really like to be seen in about 2 weeks. And then that is 
considered the day that they actually agreed to, so there is no 
wait time, even though in reality there is a month's wait time 
or maybe longer than that.
    So I think we do need to look at that and be--and first of 
all, I told the Secretary yesterday--I mean, the Under 
Secretary of Health, Dr. Shulkin, yesterday. We need just to 
define what that is, and whatever it is, it is, so we are all, 
you know, singing off the same song page.
    The second thing. Dr. Benishek was drilling down this, and 
I just did some numbers. I can't understand your VA estimated 
cost on Mr. Zeldin's bill. And you look here and you say that 
the estimated cost is 1.7 million in the first year. I just did 
some simple arithmetic. If somebody goes 5 days a week to the 
adult daycare center we just heard about at $318, that is 
$76,000 a year. That means for 1.7 million, you can take care 
of 25 people. So how did you come up with that number?
    And then it says, 2.1 million in the second year. It makes 
no sense to me. If you multiply 318 times 5 and multiply it 
times however many weeks, 52 weeks a year, how many you go, 
that is a--and if you--at $450, it is--at his institution, it 
is $164,000 into Dr. Benishek's point. That is a lot cheaper, 
almost $100,000 a year less expensive. And I agree with you 
that you should look at medical and social because all patients 
are not the same.
    Dr. McCarthy. Right.
    Mr. Roe. That is totally correct on that.
    Dr. McCarthy. Right. So sir, I would be happy to kind of do 
a breakdown of the cost, but I believe part of the issue is 
that many of the people that go to the adult day health care 
centers go 3 days a week and not 5.
    Mr. Roe. Well, it is still--then it is 50,000 a year.
    Dr. McCarthy. Okay.
    Mr. Roe. I can do that math in my head pretty quick.
    Dr. McCarthy. All right. If you wouldn't mind, I would like 
to get back with you with the description of the numbers.
    Mr. Roe. You see where I am concerned, though. 1.7 million 
is 50,000, and 30 people is a 1.5 million a year, so I don't 
know how in the world the VA came up with that small of a 
number.
    Dr. McCarthy. All right. I will rework that, and I promise 
we will get back to you.
    Mr. Roe. Okay. Thanks. I yield back.
    Mr. Benishek. Dr. Abraham.
    Mr. Abraham. Thank you, Mr. Chairman. Just a couple of 
things on Dr. Benishek's and Dr. Roe's, just comments on the 
adult daycare living. I think I can arguably make the argument 
that with adult daycare, the way it is now, and the way it is 
perceived in Mr. Zeldin's bill, that you need both the social 
and medical input there. So yeah, I think you are getting more 
bang for your buck than certainly, you know, in the nursing 
home situation.
    I mean, I have known both. I have treated outpatients in 
both, and you know, they both do a great job. And I think when 
you are talking just strictly dollars with the adult daycare, I 
mean, you are certainly getting a little more bang for your 
buck, and the patient, more importantly, is getting maybe some 
improved therapy on joint mobility and that type of deal.
    The other issue on the--you said you have got a list of 
drugs there that require--and I will just ask you if you will 
give me a copy to my office, I would appreciate it. But I am 
assuming that one of those already are the opioids. Is that a 
correct statement?
    Dr. McCarthy. The long-term opioid.
    Mr. Abraham. Right. Okay. And you know, like Dr. Roe said, 
and the docs up here know, you know, it is burdensome, but Ms. 
Zumatto had some good alternatives as to how we get that 
patient to, I guess, become more informed.
    So again, I think it is a good conversation, but I guess, 
again, let's go back to the objective data. We have already got 
informed consent for the long-term opioids, but we still have 
an increasing opioid epidemic. So the question bodes, well, is 
the informed consent model working as it is.
    Evidently not. And again, my previous statement, I think we 
are smart enough to work with Ms. Brownley and to figure this 
out and get it right with Ms. Zumatto and the VSOs to get their 
input where we can hopefully get the right combination of what 
it does take to start chipping away at this opioid addiction 
stuff.
    The question I have for you. You made the comment in your 
statement that in the bill of the PAs, that you--that the VA 
was somewhat opposed to some of the prerequisites required. Can 
you list those prerequisites that--I mean, I heard Ms. Kuster. 
I was listening very acutely to what the prerequisites are. 
Which ones are the VA opposed to knocking out of the box?
    Dr. McCarthy. So it is just a few. There is a requirement 
for hiring executive director of one program and another 
position, and it requires that the person be currently employed 
by VA at the time of the passage of the legislation and that 
the person be a veteran. And there--that limits who would be 
eligible to apply for those positions.
    Mr. Abraham. Would the VA be okay with or be in favor of 
giving the veteran the priority of that slot of the PA slot? I 
mean, we all know we need more health care providers in the 
system, and if we have got a combat veteran, either he or she, 
that has been on the frontline serving as a medic or in some 
health care job already, they are far ahead of the game as to 
as far as somebody coming off the street literally and just 
starting the program anew. So they bring so much knowledge base 
already, and that is what it requires in a PA and an NP 
position to have that knowledge base, and they have already got 
that.
    So the question is, is VA okay with the VA getting 
preference or the--
    Dr. McCarthy. The veteran preference--
    Mr. Abraham. Yeah.
    Dr. McCarthy [continued].--would--just changing that would 
help, that exact wording.
    Mr. Abraham. All right. Thank you, Mr. Chairman. I yield 
back.
    Mr. Benishek. Thank you, Dr. Abraham.
    Does anyone have any further questions?
    Mr. Takano. Could you submit a list of the medications or 
drugs for the record?
    Dr. McCarthy. I would be happy to do that, and I brought 
some copies with me.
    Mr. Takano. Thank you. That is what I wanted. That is it.
    Dr. McCarthy. And just so you know, this was derived from 
our list of informed consents, so it lists particular drugs, 
and you will see a lot of chemotherapy drugs and so forth. But 
in addition, it talks about, like, the spinal injections and so 
forth for anesthesia, but it does have--it certainly has all 
the other drugs. And under anesthesia and pain management, 
about the 10th one down is consent for long-term opioid therapy 
for pain. Okay.
    Mr. Takano. All right. Thank you, Dr. McCarthy. Thank you.
    Mr. Benishek. Thank you.
    Mr. Takano. I yield back.
    Mr. Benishek. There are no further questions. The third 
panel is now excused.
    Dr. McCarthy. Thank you very much.
    Mr. Benishek. I ask unanimous consent that all Members have 
5 legislative days to revise and extend their remarks and 
include extraneous material.
    Without objection, so ordered.
    I would like to once again thank all our witnesses and 
audience members today for joining us this morning. The hearing 
is now adjourned.

    [Whereupon, at 11:43 a.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

             Prepared Statement of Honorable Elise Stefanik
    Chairman Benishek, Ranking Member Brownley - thank you for the 
invitation to testify on this important legislation. I look forward to 
discussing this key issue moving forward.
    As a member of the House Armed Services Committee with a critical 
Army base in my district, I am dedicated to providing support to 
servicemembers, veterans and their families. Since September 11th, 
2001, the Army's 10th Mountain Division at Fort Drum has been the most 
actively forward deployed division in the Global War on Terror.
    We have asked our servicemembers and their families to sacrifice an 
immeasurable amount over the last 14 years, so it is vital that we do 
not leave them behind - this is especially true for our military 
caregivers, the selfless group that cares for our heroes behind the 
scenes. These men and women are often left out when discussing 
veterans' issues.
    Military caregivers are an essential component of the communal and 
family support system for our disabled veterans. Military caregivers 
are usually spouses and other family members who spend their days 
taking care of disabled veterans in order to provide an environment 
that enhances their everyday lives.
    In 2010, Congress passed a law implementing the Family Caregiver 
Program. This was an important piece of legislation that made veterans 
who sustained injuries in the line of duty eligible for a package of 
benefits that includes access to a primary caregiver. These benefits 
would ensure that the family members who dedicate their lives as 
caregivers receive access to health care, caregiver training, and 
stipends for additional costs associated with their disabled veteran.
    Unfortunately, the Department of Veterans Affairs (VA) has had a 
difficult time managing the high demand of Family Caregiver enrollees, 
which is much larger than originally accounted for during 
implementation. According to the Government Accountability Office 
(GAO), VA officials estimated that they would receive 4,000 enrollees 
and staffed the program based on this estimate. However, in the first 
few months of implementation there were over 15,000 enrollees to the 
Family Caregiver Program. VA medical centers lack sufficient caregiver 
support coordinators and the necessary clinical staff to carry out 
medical assessments for eligibility. \1\
---------------------------------------------------------------------------
    \1\ Government Accountability Office (GAO). 2014. Actions Needed to 
Address Higher-Than-Expected Demand for the Family Caregiver Program. 
Informational, Washington, D.C. : GAO.
---------------------------------------------------------------------------
    These implementation issues have led to a delay in both the 
application and the appeals process. Application deadlines are not 
being met by their own internal standards and the staff is still 
shorthanded. These issues are not only unacceptable, but I believe they 
are preventable.
    This is why I introduced H.R. 3989, Support Our Military Caregivers 
Act after meeting with a constituent who is a caregiver facing the 
burden of the VA backlog.
    This bill would use pre-existing funds currently appropriated for 
the review and appeals process for an objective, independent party to 
conduct external, clinical reviews. This bill would ensure that new or 
modified processes are veteran-centric, outcomes-based and continually 
improved through the use of best practices. We can accomplish this by 
permitting a third party to work within the Department of Veterans 
Affairs to streamline claims and reduce the caregiver backlog through a 
more clinical analysis rather than benefits adjudication. The VA would 
maintain the third party until the overage of appeals is streamlined 
and the backlog is down to an acceptable rate in accordance with 
recommendations from the Government Accountability Office.
    Military caregivers are silent heroes in our communities and 
deserve the respect and benefits proportionate to their significant 
contributions. I look forward to discussing this issue further in order 
to implement a solution and get our military caregivers the benefits 
they have earned.

                                 --------
               Prepared Statement of Honorable Mike Bost
    Chairman Benishek and Ranking Member Brownley, thank you for 
holding this hearing on pending legislation which is critical to better 
oversight of the Department of Veterans' Affairs. Careful consideration 
of how the VA should be reformed is needed to ensure better health care 
access and medical treatment for our nation's veterans.
    As a Marine and the father of a Marine, I recognize the selfless 
sacrifice that so many Americans have made in defense of our freedoms. 
There is no doubt that we must fight for the brave men and women who 
have fought for us. I know my colleagues on both sides of the aisle 
feel the same way.
    Winning any battle requires steadfast and capable leadership. No 
organization can operate under a revolving door of interim leaders -and 
certainly not one tasked with caring for America's heroes. 
Unfortunately, that revolving door of leadership is exactly what is 
occurring at VA medical facilities across the country. This situation 
is simply unacceptable, as it may undermine the quality, consistency, 
and speed of care that our veterans receive.
    Our nation's warfighters deserve better, and that is why I 
introduced H.R. 3956, the VA Health Center Management Stability and 
Improvement Act. This common sense bipartisan bill requires the 
Secretary of the Department of Veterans Affairs to submit a plan to 
Congress within 120 days of passage for finding and hiring a permanent, 
highly-qualified director at each VA Medical Center (VAMC) that is 
currently under temporary leadership. This legislation is endorsed by 
the American Legion, Vietnam Veterans of America, Paralyzed Veterans of 
America, AMVETS, Disabled Veterans of America, and the Association of 
the United States Navy.
    The ``interim leadership'' problem happening at Department of 
Veterans Affairs Medical Centers across the country first came to my 
attention in my own backyard. I am proud to represent the Twelfth 
Congressional District of Illinois in Congress, and many Southern 
Illinois veterans access health care through the St. Louis Department 
of Veterans Affairs Health Care System. The St. Louis VA Medical Center 
provides health care to over 45,000 veterans annually, and I remain 
very concerned about the lack of stability in leadership there and how 
it may impact system operations.
    Over the last several years, the St. Louis VA has been managed by 
more than seven different acting directors. According to the VA's 
hiring policies, there is no time limit for Senior Executive Service or 
Medical Center Directors to serve on a detail in an acting capacity, 
yet these details must be approved in increments not to exceed 120 
days, with a possible extension to 240 days.
    Consequently, the St. Louis VAMC has experienced a revolving door 
of interim directors. This short term leadership negatively impacts the 
ability to engage in long-term planning and other functions necessary 
to provide and improve health care for the veterans it serves.
    After I began looking into the local issue at the St. Louis VA 
Medical Center, it came to my attention that this problem isn't just a 
problem in our area. Upon further investigation, I found that a large 
number of VA Medical Centers have lacked a permanent director for quite 
some time. This problem is due to Office of Personnel Management (OPM) 
requirements which stipulate that temporary directors can serve for no 
more than 120 days, with a 240 day maximum total if their tenure is 
extended. The lack of stable, permanent leadership is no doubt one of 
the reasons the Department of Veterans Affairs has struggled to provide 
appropriate health care to those it serves.
    H.R. 3956 seeks to fix this problem by requiring the VA Secretary 
to develop and implement a plan to fill these vacancies.
    Specifically, my bill requires the Secretary of the Department of 
Veterans' Affairs to:

      Report to the House and Senate Committees on Veterans' 
Affairs the status of any unfilled vacancies.
      To develop and submit to Congress a plan hire highly 
qualified medical directors for each VA Medical Center which lacks a 
permanent director. This plan must be submitted within 120 days after 
enactment of the bill.
      Identify possible impediments to staffing VA Medical 
Centers with permanent directors.
      Assess the possibility of promoting and training 
qualified candidates from within the Department of Veterans' Affairs 
for promotion to these Senior Executive Service (SES) positions.

    I have reached out to my local Congressional colleagues on the 
issue and sent letters to the Department regarding the lack of 
leadership at the St. Louis VAMC. Last week, I received a reply from 
the Department of Veterans Affairs Under Secretary of Health, Dr. David 
Shulkin, giving me an update on the issue. According to the timeline 
chart he provided, the St. Louis position has been vacant since July 
14, 2013 and is still vacant thirty-three months later. I have enclosed 
a copy of the St. Louis VA Medical Center director timeline with my 
formal statement to illustrate just how long this process has been and 
how long this critical leadership position has been vacant.
    This problem doesn't end in St. Louis. Unfortunately, similar 
scenarios can be found at Department of Veterans Affairs Medical 
Centers across the county. As of July 2015, the VA reported that over 
39 VAMCs were without a permanent director. H.R. 3956 would help 
correct this lack of permanent leadership at the health care centers 
that so many of our nation's veterans rely on.
    I thank the Chairman, Ranking Member, and this Subcommittee for 
consideration of H.R. 3956 and look forward to working with my 
colleagues and the Committee to further this legislation. Thank you and 
I yield back the balance of my time.

                                 --------
               Prepared Statement of Honorable Ann Kuster
    Chairman Benishek, Ranking Member Brownley, and Members of the 
Subcommittee, thank you for the opportunity to discuss H.R. 3974, the 
Grow Our Own Directive: Physician Assistant Employment and Education 
Act of 2015. Our full committee has worked hard to improve veteran 
access to health care, and to create opportunities for veteran 
education and employment. This legislation would allow us to merge 
those efforts and allow veterans to continue serving their country 
while in service to their fellow veterans.
    In the 14 and a half years since September 11th, and the 13 years 
since the invasion of Iraq, the men and women of the United States 
military have repeatedly demonstrated their skill, valor, and 
professionalism. They have repeatedly placed their lives on the line, 
been separated from their families, and deferred their own personal 
life goals in order to serve this country.
    As many in this room recognize, that service on our behalf creates 
an obligation on our part to ensure veterans have the opportunity to 
succeed and have access to the medical care they may require.
    Veterans today often leave the service with an incredible skill 
set. Our corpsmen and medics have proven medical experience in high 
pressure training and real world environments. They have also 
demonstrated an interest in public service by volunteering to serve in 
the military, and many hope to continue in service to the public after 
they leave active duty. Meanwhile, as this subcommittee in particular 
knows all too well, veterans often face many challenges in accessing 
care. As we discussed last week, sometimes this is due to IT and 
scheduling challenges. Other times it is due to the lack of providers 
available.
    In a time of shortages for primary care providers both in the 
private sector and in the VA, and with the Office of Inspector General 
listing physician assistants as one of the VA's top five occupations 
with the largest staffing shortages, creating a pathway of opportunity 
for our veterans to fill that gap and continue to serve their country 
seems to me like an excellent opportunity.
    H.R. 3974 would accomplish that objective by creating a pilot 
program to provide educational assistance to qualifying veterans for 
education and training as VA physician assistants. A veteran would 
qualify for this program who has medical or military health experience 
gained while serving in the Armed Forces; has received a certificate, 
associate degree, baccalaureate degree, master's degree, or post-
baccalaureate training in a science relating to health care; has 
participated in the delivery of health care services or related medical 
services; and does not have a doctorate in medicine, osteopathy, or 
dentistry.
    Eligible veterans would be able to apply during the five year pilot 
program to receive one of 35 scholarships available each year to cover 
the costs of obtaining a master's degree in physician assistant studies 
or a similar master's degree.
    Selection would be prioritized for those veterans that participated 
in an earlier veteran recruitment program known as the Intermediate 
Care Technician Pilot Program and those veterans agreeing to be 
employed by the VHA in a community that is medically underserved and in 
a state with a significant veteran population.
    Those veterans that use the program would then owe the VHA a period 
of obligated service based either on the scholarship program used, or 
three years.
    To ensure that veterans are prepared to succeed, participants will 
be paired with a mentor at their facility, and the VA shall partner 
with institutions of higher learning to guarantee physician assistant 
educational seats.
    As it is currently written, the bill would also establish standards 
to improve the education and hiring of VA physician assistants and 
enhance retention and recruitment through competitive pay standards.
    As this bill moves through the House and the Senate, there have 
already been several discussions to find ways to improve the bill, 
increase its chances at passage, and create this opportunity for our 
veterans. I am happy to continue those conversations in the coming days 
and weeks based on feedback from this hearing.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or our fellow members of the Subcommittee may 
have.

                                 --------
            Prepared Statement of Honorable Jackie Walorski
    Good morning Chairman Benishek, Ranking Member Brownley and members 
of the Committee. I appreciate being given the opportunity to discuss 
the VA Scheduling Accountability Act.
    First, I would like to thank Chairman Benishek and Ranking Member 
Brownley for holding this hearing and allowing me to testify on this 
important legislation. In 2014, news reports uncovering gross 
mismanagement and scheduling manipulation at a Department of Veterans 
Affairs (VA) hospital in Phoenix shook us to the core. Through hearings 
held in this committee and investigations by the VA Office of Inspector 
General (OIG) and Government Accountability Office (GAO), we 
substantiated many of the allegations of manipulated schedules and 
falsified wait-time data at the Phoenix facility. The manipulation of 
appointment schedules and data in Phoenix led to at least 40 veterans 
dying while they were waiting for care. However, as we took a closer 
look, we discovered that, sadly, this was not an issue unique to 
Phoenix. It was systemic. Here we sit two years later, digging deeper 
still into some of the root causes to ensure that no veteran ever dies 
again waiting for care. I introduced legislation this week, the VA 
Scheduling Accountability Act, that gets at one of the key drivers of 
wait time manipulation.
    VA Directive 2010-027 is VA's implementation processes and 
procedures policy for scheduling at their facilities and contains 19 
different items on the checklist. The directive requires an annual 
certification of full compliance with all items on the list. For 
instance, facilities are required to ensure completion, using Veterans 
Integrated Service Network (VISN)-approved processes and procedures, of 
a standardized yearly scheduler audit of the timeliness and 
appropriateness of scheduling actions and of the accuracy of desired 
dates. They are also required to ensure that deficiencies in competency 
or performance that are identified by the annual scheduler audit are 
effectively addressed.
    An August 2014 OIG report uncovered that in May 2013, the then-
Deputy Under Secretary for Health for Operations Management waived the 
FY 2013 annual requirement for facility directors to certify compliance 
with the VHA scheduling directive. Allowing facilities to only self-
certify reduced oversight over wait time data integrity and compliance 
with appropriate scheduling practices. This, in turn, allowed VA's data 
to be easily manipulated, contributing to the wait time scandal. There 
was a noticeable, substantial improvement in VHA's appointment 
scheduling after VA waived the directive, but as we now know, that 
improvement was an illusion. While the VA has reinstated the 
certification requirement, there is nothing stopping them from waiving 
it again.
    The VA Scheduling Accountability Act would require each facility 
director to annually certify compliance with the scheduling directive, 
or any successor directive that replaces it, and prohibits any waivers 
in the future. Should a director be unable to certify compliance, 
either because the facility is not in compliance or the director 
refuses to sign the certification for some other reason, the director 
must submit a report to the Secretary explaining why the facility is 
out of compliance. The Secretary will then report yearly to the House 
and Senate VA Committees with a list of facilities in compliance and 
those that are not, with an accompanying explanation as to why they 
were not in compliance. Lastly, the legislation requires that anytime 
VA waives or allows noncompliance with requirements in any other 
directive or policy beyond scheduling, VA must provide a written 
explanation for the decision to the House and Senate Veterans' Affairs 
Committees. This will provide more oversight of the Department and 
ensure Congress is aware when VA is waiving these policies.
    Waiving compliance requirements was a key driver in the wait time 
scandal, which continues to be an issue at the Department. This 
legislation will end this reckless practice once and for all, while 
increasing accountability and transparency at the VA as we work on ways 
to ensure that those who risked their lives for their country receive 
the prompt, quality care they have earned. I look forward to working 
with the members of this Committee, Veteran Services Organizations, and 
the VA in addressing this critical issue. I thank you again for this 
opportunity to speak today.

                                 --------
               Prepared Statement of Honorable Lee Zeldin
    Good Morning Chairman Benishek, and thank you for the opportunity 
to testify on behalf of my bill, H.R. 2460, which provides no-cost 
medical model adult day health care services for our 70% or more 
service connected disabled veterans.
    It must always be a top priority of Congress to ensure that all 
veterans receive the proper treatment and care they deserve after 
fighting for our country. While overseas, these brave men and women are 
exposed to significant hardships and trauma, and when they come home, 
many return with the physical and mental wounds of war. Despite various 
care options for veterans, their choices are often limited, and can 
come at a great expense. Service members who are 70% or more disabled 
from a service connected injury often require significant assistance 
from others in order to carry out basic everyday tasks. In many 
instances, veterans must rely on family members for assistance, 
creating many financial and emotional hardships for both the veteran 
and his or her family. Alternatively, some veterans, without the proper 
support system, may even be forced to rely on the assistance of trained 
medical professionals and reside in institutionalized facilities for 
daily assistance. Veterans in these facilities often spend significant 
sums of money each day just to be enrolled, and these expenses can be 
expected to span the remainder of the veteran's life in many cases.
    While alternative options currently exist, accessing these 
services, however, can often be very difficult. One such program that 
is currently available is Medical Model Adult Day Health Care; a daily 
program for disabled veterans who need extra assistance and special 
attention in their day to day lives. Adult Day Health Care programs 
provide disabled veterans and their families with a high quality 
alternative to nursing home care, providing quality outpatient services 
for those suffering from debilitating illnesses or disabilities. These 
programs provide a range of services from daily activities, such as 
bathing, to full medical services, like physical therapy. Adult Day 
Health Care, however, is only offered currently at three facilities in 
the United States. Long Island is fortunate to be one of the three 
locations, with a facility right in the heart of my district in Stony 
Brook, New York, the Long Island State Veterans Home. There are 
however, 152 other State Veterans Homes across the country, and this 
program could easily be offered at any of the 153 total State Veterans 
Homes. Unfortunately, however, the Department of Veterans Affairs does 
not currently cover the cost of participation in this program at state 
veteran homes and the expense of the program is put directly on the 
veteran and their family, which significantly limits the number of 
veterans who can enroll.
    In order to address this issue and expand access to care for our 
heroes, I introduced bipartisan legislation in Congress, H.R. 2460, 
which would ensure that 70% or more service connected disabled veterans 
are able to receive Adult Day Health Care at no cost to the veteran and 
their family by defining the program as a reimbursable treatment option 
through the VA. My bill would guarantee that all severely disabled 
veterans are able to access Adult Day Health Care. By providing 
disabled veterans with access to Adult Day Health Care programs, we can 
ensure that all veterans receive the best and most efficient outpatient 
services to provide them with the assistance and special attention that 
they need in their day to day lives, while still allowing them to 
maintain their independence.
    Adult Day Health Care also helps keep families together and strong. 
With the inclusion of Adult Day Health Care services as a covered VA 
expense, family members and caregivers can rest easier knowing that 
their loves ones are receiving top notch care during the day, while 
being treated with the same respect and dignity that they would receive 
at home. Not only does the Adult day Health Care model care for the 
medical needs of a veteran, but it also addresses their social and 
emotional needs as well. Adult Day Health Care allows veterans to 
interact and socialize with their peers and other individuals enrolled 
in the program. Rather than sitting home alone all day, participants in 
the adult day health care program receive one-on-one attention from 
medical and support staff while also maintaining an active social 
schedule through planned events and activities. Family members and 
caregivers can go about their day without the worry that their loved 
ones are unattended, and the veteran can continue to remain as active 
members of their community.
    It is a top priority of mine to ensure that all veterans on Long 
Island and across the country receive the proper treatment and care 
they deserve, which is why I fully support the adult day health care 
program. I will continue working every day to spread awareness of this 
bill, so that we pass this bill as soon as possible to expand Adult Day 
Health Care for our disabled veterans, and I thank you for considering 
this essential piece of legislation.

                                 --------
                 Prepared Statement of Diane M. Zumatto
    Distinguished members of the Subcommittee on Health, it is my 
pleasure, on behalf of AMVETS, to offer this testimony concerning the 
following pending legislation:

      HR 2460, to improve the provision of adult day health 
care services for veterans;
      HR 3956, the VA Health Center Management Stability and 
Improvement act;
      HR 3974, the Grow Our Own Directive: Physician Assistant 
Employment & Education Act of 2015;
      HR 3989, the Support our Military Caregivers Act of 2015;
      Draft legislation regarding informed consent; and
      Draft legislation regarding the scheduling of veteran 
appointments & to improve the uniform application of VA directives

    Though I plan to focus the bulk of my remarks on Representative 
Brownley's ``Informed Consent'' bill, I would like to begin today's 
statement with the following introductory remarks prior to turning to 
each specific piece of legislation. I ask that this committee ensures 
that the health care obligations imposed by the sacrifices of our 
veterans are met in a timely, professional and compassionate manner and 
I urge you to reject any plan to eliminate the VA from the hands-on 
care of our veterans.
    I know that each of you is aware of, and appreciates the numerous 
issues of importance facing our military members, veterans and 
retirees; therefore this testimony will be, following these 
introductory remarks limited to the specific pending health care 
legislation being considered today.
    I would also like to highlight several general issues that AMVETS 
would like the committee to monitor and enforce as it goes about its 
work, followed by specific recommendations related to the VA.

General Recommendations:

      ensure that the VA provides a continuity of health care 
for all individuals who were wounded or injured in the line of duty 
including those who were exposed to toxic chemicals;
      ensure that all eligible veterans not only have adequate 
access, but timely and appropriate treatment, for all of their physical 
and mental healthcare needs;
      continue the strictest oversight to ensure the safety, 
physical and mental health and confidentiality of victims of military 
sexual trauma;
      ensure that the VA continues to provide competent, 
compassionate, high quality health care to all eligible veterans; and
      ensure that the VA continues to receive sufficient, 
timely and predictable funding.

Specific Recommendations:

      Ensure that both advanced appropriations and 
discretionary funding for VA keeps pace with medical care inflation and 
healthcare demand so that all veterans healthcare needs can be 
adequately met;
      Maximize the use of non-physician medical personnel, when 
appropriate, as a way to mitigate physician shortages and reduce 
patient wait times especially while utilization of the VA system 
continues to rise;
      Ensure that VA makes more realistic third-party medical 
care collection estimates so that Congress doesn't end up under-
appropriating funds based on false expectations which in turn 
negatively impact veteran care. Additionally, VA needs to redouble its 
efforts to increase its medical care collections efforts, because taken 
together, the cumulative effects of overestimating and under-collecting 
only degrade the care available to our veterans. Furthermore, VA needs 
to establish both first- and third-party copayment accuracy performance 
measures which would help minimize wasted collection efforts and 
veteran dissatisfaction;
      VA needs to incorporate civilian healthcare management 
best practices and include a pathway to VA hospital/clinic management 
for civilians as part of their succession plan requirements, so that VA 
will be able to attract the best and the brightest healthcare managers 
in the industry;
      VA could immediately increase its doctor/patient (d/p) 
ratio to a more realistic and productive levels in order to cut wait 
times for veterans needing treatment and/or referrals. While the 
current VA (d/p) ratio is only 1:1200, the (d/p) ratio for non-VA 
physicians is close to 1:4200. Instituting this one change would 
drastically improve our veterans access to needed healthcare;
      VA needs to improve its patient management system so that 
veterans have more appointment setting options available to them, which 
could reduce staffing errors and requirements. VA should also consider 
utilizing a hybrid system whereby half the day might consist of 
scheduled appointment and the other half would be for walk in or same-
day appointment. The elimination of the need for non-specialty 
appointments would allow veterans quicker access to their primary care 
providers;
      The current VA healthcare system appears to be top-heavy 
with administrative staff and short-handed when it comes to patient-
focused clinical staff. This imbalance can only lead to noticeable 
veteran wait times;
      The VA needs to thoroughly review its entire 
organizational structure in order to take advantage of system 
efficiencies and to maximize both human and financial resources, while 
also minimizing waste and redundancies;
      VA must immediately improve its recruitment, hiring and 
retention policies to ensure the timely delivery of high quality 
healthcare to our veterans. VA currently utilizes a cumbersome and 
overly-lengthy hiring process which reduces its ability to deliver 
critical services. VA need to consider adopting a more expedient 
hiring/approval process which could include some form of provisional 
employment;
      VA needs to have, and utilize, the option to terminate 
non-performing employees at all levels of the organization so that only 
dedicated, accurate, motivated employees will remain in service to our 
veterans; and
      Finally, VA needs to reform their incentive programs so 
that only high-performing employees receive appropriate bonuses for 
their excellence in serving our veterans.

Pending Health Care Legislation

    HR 2460, to improve the provision of adult day health care services 
for veterans - AMVETS supports this legislation, which seems like the 
best of both worlds, in that it provides the appropriate and necessary 
care for veterans, in a more cost effective manner while also providing 
an improved quality of life. This legislation directs the Secretary of 
Veterans Affairs to enter into an agreement or a contract with each 
state home to pay for adult day health care for a veteran eligible for, 
but not receiving, nursing home care.
    The veteran must need such care either specifically for a service-
connected disability or the veteran must have a service-connected 
disability rated 70% or more.
    Payment under each agreement or contract between the Secretary and 
a state home must equal 65% of the payment that the Secretary would 
otherwise pay to the state home if the veteran were receiving nursing 
home care.
    HR 3956, the VA Health Center Management Stability & Improvement 
Act - AMVETS supports this legislation which seems to be a bit of a no-
brainer. Medical centers without directors will most likely not perform 
as well as or as consistently as, those that do. Specifically, the bill 
directs the VA to develop and implement a plan to hire a director for 
each VA medical center without a permanent director, giving the highest 
priority to medical centers that have not had a permanent director for 
the longest periods.
    HR 3974, the Grow Our Own Directive: Physician Assistant Employment 
& Education Act of 2015 - AMVETS supports this legislation which builds 
upon and leverages the training and experience of former military 
members. This bill directs the VA to carry out the Grow Our Own 
Directive or G.O.O.D. pilot program to provide educational assistance 
to certain former members of the Armed Forces for education and 
training as VA physician assistants.
    An individual is eligible to participate in the program if the 
individual:

      has medical or military health experience gained while 
serving in the Armed Forces;
      has received a certificate, associate degree, 
baccalaureate degree, master's degree, or post baccalaureate training 
in a science relating to health care;
      has participated in the delivery of health care services 
or related medical services; and
      does not have a degree of doctor of medicine, doctor of 
osteopathy, or doctor of dentistry.

    The VA shall:

      provide educational assistance to program participants 
for the costs of obtaining a master's degree in physician assistant 
studies or a similar master's degree;
      ensure that mentors are available for program 
participants at each VA facility at which a participant is employed;
      seek to partner with specified government programs and 
with appropriate educational institutions that offer degrees in 
physician assistant studies;
      establish specified standards to improve the education 
and hiring of VA physician assistants, and
      implement a national plan for the retention and 
recruitment of VA physician assistants that includes the adoption of 
competitive pay standards.

    HR 3989, the Support Our Military Caregivers Act - AMVETS is very 
supportive of this bill which permits an individual to elect to have an 
independent contractor perform an external clinical review of any of 
the following:

      a VA denial of an individual's application to be a 
caregiver or family caregiver eligible for VA benefits;
      with respect to an approved application, a VA 
determination of the level or amount of personal care services that a 
veteran requires;
      a request by a caregiver or family caregiver for a 
reconsideration of the level or amount of personal care services that a 
veteran requires based on post-application changes; and
      a revocation of benefits by the VA.

    The VA shall ensure that each external clinical review is completed 
and the individual is notified in writing of the results within 120 
days of the election.
    Draft Legislation, to ensure that VA medical facilities comply with 
requirements related to appointment scheduling for veterans and to 
improve the uniform application of directives - AMVETS feels strongly 
that there needs to be continuity across the VA healthcare system and 
this bill should help to make that recommendation a reality.
    Draft Legislation, to establish a list of drugs that require an 
increased level of informed consent - this is a top issue for AMVETS 
and we whole-heartedly support this legislation because we believe that 
the health and welfare of veterans needs to come first. This means 
their interests come before any VA employees, including physicians.
    AMVETS believes that having the veteran's `buy-in' and clear 
understanding of any proposed risky medications, will not only provide 
much needed `peace of mind' for the veteran and their family, but will 
be instrumental in the overall healing process. An informed patient is 
much more likely to fully comply with their doctor's instructions and 
much less likely to complain or be dissatisfied with their treatment.
    Let me be clear that our intention in supporting this legislation 
is not to `burden' or disrespect VA doctors, but to provide veterans 
the opportunity to be more actively involved in their health care 
treatments.
    In order to minimize the burden on physicians, AMVETS suggests 
utilizing nationally standardized medical educational material which 
could be adopted by the VA and made available either digitally or in a 
preprinted format (medication guide). All of the medications which 
would require informed consent would either be available in a database 
whereby each medication, with its additional information including, but 
not limited to:

      all the names of any drugs being offered to the patient, 
including any other trade or generic name for such drug;
      side effects, if any, including dependency;
      any alternative methods of treatment or therapy not 
involving a covered drug;
      whether the drug is being offered for a non-Food & Drug 
Administration (FDA) approved use;
      whether the drug is being given in a dosage that exceeds 
the dosages approved or tested by the FDA;
      any potential dangers of mixing drugs and dosages in 
sizes and combinations that have not been approved or tested by the 
FDA;
      any known interactions between a covered drug and other 
drugs or substances, including alcohol;
      any and all other appropriate warnings or information 
that a patient in similar circumstances would reasonably want to know

    could be printed for each specific covered medication and provided 
to the patient.

    If utilizing the pre-printed medication guide, the format of which 
is yet to be determined, each covered medication would be included with 
all of the same additional information as the database option, the 
physician would then merely `check off' the recommended medications and 
hand the information to the patient. In both cases a `consent form' 
would be provided to the patient for his/her signature, in either an 
electronic or paper format.
    The patient's signature, at this point, merely indicates that they 
have been provided with the information regarding any covered 
medications and should not yet be understood as an acceptance of the 
proposed treatment plan. At this point the patient should be given the 
opportunity to ask any immediate questions of the physician or the 
veteran could be referred to a pharmacist for further information.
    The patient would then be given three full business days from the 
initial prescription recommendation to:

      consider and internalize the information provided by the 
clinician;
      conduct any additional research;
      seek a second opinion, discuss with family or get a legal 
opinion

    At the end of the three day period, the patient would then convey 
their approval/disapproval of the suggested medication(s) via secure 
messaging (My HealtheVet), phone, email or fax directly to the 
prescribing physician or his/her office.
    The veteran's signature along with the follow up (oral or written) 
at the end of the three days would jointly fulfill the informed consent 
signature requirement, so there would be no further reason for the 
veteran to return to the doctor's office on this matter unless there 
were extenuating circumstances. (This process could be even further 
streamlined by not requiring the veteran to do any follow up, unless 
they disagree with the proposed treatment plan. In which case, their 
previous signature plus their lack of disagreement with the proposed 
treatment plan could be taken as their complicit consent.)
    An additional point of clarification I would like to make is that 
the VHA Handbook already mandates that side effects and alternative 
treatments be explained to a veteran prior to deciding on a treatment 
plan. This proposed legislation then is not asking for something 
entirely alien to the VA, it is merely asking for an increased 
`Informed Consent' requirement.
    Remember this added requirement would only be utilized when a 
physician prescribes a medication from the limited list of covered 
medications which carry `black-box' warnings, have substantial risks or 
undesirable side effects, etc.
    This type of information is especially critical for veterans who 
may have additional physical and/or mental health concerns and may 
already be taking or require a number of dangerous medications.
    The need for this type of medical disclosure is also a concern in 
the non-veteran health care community as evidenced by the FDA's recent 
announcement that immediate-release opioid painkillers such as 
oxycodone will now have to carry a ``black box'' warning about the risk 
of abuse, addiction, overdose and death. (``Black box'' warnings are 
the FDA's strongest, and they're meant to help educate doctors as 
they're prescribing medications to patients. See article below)
    This completes my statement at this time and I thank you again for 
the opportunity to offer our comments on pending legislation. I will be 
happy to answer any questions the committee may have.
Additional Information:
    VHA Handbook on Informed Consent - sent as a separate attachment

                                 --------
                Prepared Statement of Shurhonda Y. Love
    Mr. Chairman and Members of the Subcommittee:

    Thank you for inviting DAV (Disabled American Veterans) to testify 
at this legislative hearing of the Subcommittee on Health. As you know, 
DAV is a non-profit veterans service organization comprised of 1.3 
million wartime service-disabled veterans that is dedicated to a single 
purpose: empowering veterans to lead high-quality lives with respect 
and dignity.
    DAV is pleased to be here to present our views on the bills under 
consideration by the Subcommittee, and we appreciate your invitation.
                               H.R. 2460
    H.R. 2460, if enacted, would authorize the Secretary to enter into 
agreements with state veterans homes to provide adult day health care 
for veterans who are eligible for, but do not receive, skilled nursing 
home care under section 1745(a) of title 38, United States Code. 
Eligible veterans are those who require such care due to a service-
connected disability, or who have a VA disability rating of 70 percent 
or greater and are in need of such care. The payment to a state home 
under this program would be at the rate of 65 percent of the amount 
payable to the state home if the veteran were an inpatient for skilled 
nursing care and payment by VA would be considered payment in full to 
the state home.
    Adult day health care is an alternative to traditional skilled 
nursing care that can allow some veterans requiring long-term service 
and supports to remain in their homes near family and friends, rather 
than be institutionalized in nursing homes. This program is designed to 
promote socialization, stimulation, and maximize independence while 
enhancing quality of life as well as providing comprehensive medical, 
nursing, and personal care services for veterans.
    DAV is pleased to support H.R. 2460, which is in line with DAV 
Resolution No. 101, adopted at our most recent National Convention, 
calling for support for the state veteran home program, recognizing 
state home care as the most cost-effective care available for sick and 
disabled veterans with long-term care needs outside the VA health care 
system.
 H.R. 3956, the VA Health Center Management Stability and Improvement 
                                  Act
    If enacted, this bill would require VA to develop and implement a 
plan to hire a director for each VA medical center without a permanent 
director at the time of enactment. It would place the priority for 
hiring at facilities that have gone without a director for the greatest 
length of time. In the Secretary's plan, a deadline for hiring would be 
set at the Secretary's discretion.
    This bill would also direct the Secretary to identify impediments 
to the hiring of directors, and identify candidates from within VA who 
could be promoted to fill these key positions. At the 120th day after 
enactment of this bill, it would require the Secretary to submit a 
report to Congress. Every 180 days after, the Secretary would be 
required to submit a report to Congress on facilities still lacking 
permanent directors.
    Currently, 23 medical centers are without permanent directors. 
Prior to VA's adopting this more assertive approach, 35 vacancies were 
reported. We understand that VA is taking steps to hire medical center 
directors by posting national vacancy announcements in multiple 
locations across the system, and by leveraging social media outlets and 
other venues to increase public awareness of these leadership 
opportunities.
    DAV has not received a resolution specific to the hiring of VA 
medical center directors, but DAV Resolution No. 126 calls for the 
support of modernization of VA's human resources management system to 
enable VA to compete for, recruit and retain the types and quality of 
VA employees needed to provide comprehensive health care services to 
sick and disabled veterans. Directors of VA medical centers are key 
officials in this respect; therefore, DAV would not object to the 
enactment of this bill.
 H.R. 3974, the Grow Our Own Directive: Physician Assistant Employment 
                       and Education Act of 2015
    If enacted, this bill would direct VA to carry out a pilot program 
to provide educational assistance to certain veterans with the goal of 
employment as VA physician assistants.
    Under this bill, the pilot program would target veterans with 
experience gained in medical or military health care while serving, and 
who had received a certificate, associate degree, baccalaureate degree, 
master's degree, or post-baccalaureate training in a science related to 
health care, and had participated in the delivery of health care 
services or related medical services.
    The bill would require VA to provide educational assistance, 
including scholarships, to no fewer than 250 participants, 35 of whom 
would be employed each year of the pilot program. VA would be required 
to reimburse their costs of obtaining master's degrees in physician 
assistant studies or similar master's degrees, consistent with VA's 
existing health professions scholarship program authorized in Chapter 
76 of title 38, United States Code. The bill would require VA to make 
available mentors for participants at each VA facility and would 
require VA to establish partnerships with other government programs and 
with a specific number of educational institutions that offer degrees 
in physician assistant studies. It would also require selectees to 
agree to an obligated work period in VA facilities in specified 
geographic areas, including areas of medically underserved populations, 
but also in states with per capita veteran populations of more than 
nine percent.
    The bill also would require VA to establish standards to improve 
the education and hiring of VA physician assistants, and implement a 
national plan for the retention and recruitment of VA physician 
assistants.
    The bill would establish a series of new, mandatory positions in 
VA's national Office of Physician Assistant Services in VA Central 
Office, including a Deputy Director for Education and Career 
Development, a Deputy Director for Recruitment and Retention, a 
designated recruiter of physician assistants, and an administrative 
assistant to support these functions. The bill would outline their 
major duties.
    The bill would re-designate not less than $8 million in funds 
appropriated prior to the passage of this bill to carry out its 
purposes. The bill is silent on sources of additional funding that 
might be needed to meet its mandates.
    Finally, the bill would align VA physician assistant pay grades 
equivalent to the pay grades of VA registered nurses.
    DAV has not received a resolution from our membership dealing with 
VA recruitment, training or employment of physician assistants as a 
single employment category, but we recognize the value of this bill in 
improving health manpower in the VA, and especially in addressing 
shortages being observed today in VA's primary care provider workforce. 
On this basis DAV would not object to enactment of this bill.
           H.R. 3989, the Support Our Military Caregivers Act
    This bill would establish an external review process in cases in 
which VA denied caregiver benefits for veterans, approved a level of 
benefits that was considered inadequate to a veteran's needs, or 
revoked these benefits. A decision on this review, once requested by a 
caregiver, would be required by the bill to be completed within 120 
days.
    Our concerns regarding the VA Comprehensive Caregiver Support 
Program continue to include the apparent lack of due process and 
transparency in the decision and appeal process for veteran and 
caregiver program applicants. DAV identified early on the need for an 
independent mechanism through which (1) a caregiver can appeal a 
clinical team's decision; (2) that decision can be carefully reviewed 
``de novo;'' and (3) an unwarranted decision can be reversed, altered, 
or sent back to the clinical team with instructions to reassess or 
consider additional factors. Accordingly, DAV is pleased to support 
H.R. 3989 because it is in line with DAV Resolution No. 106, which 
calls for legislation to provide comprehensive support and services to 
caregivers of all veterans severely injured, wounded or ill from 
military service.
    We note the intent of this bill would be to offer program 
applicants a review of VHA decisions; however, it is not clear if the 
external clinical review would be binding on VA, and whether the 
recommendations of the contractor would be cause for VHA to issue a new 
decision based on the findings of the review. We also bring to the 
Subcommittee's attention there is still no publicly accessible program 
handbook or directive outlining mandatory program policies, procedures 
and operational requirements, which would serve to inform and educate 
those enrolled or those seeking enrollment in the program.
    Moreover, we believe VA's Caregiver Support Program office should 
have ready access to the types of data that would allow it to monitor 
and manage the program's workload due to the limited capabilities of 
VA's data system, which was designed to manage a much smaller workload. 
Veterans Integrated Service Network (VISN) officials and VA medical 
centers officials have reported that there are too few Care Support 
Coordinators (CSC) to handle the program's workload effectively. 
Specifically, at some medical centers, CSCs have been unable to perform 
all of the routine administrative tasks associated with their approved 
caregivers. Irrespective of inadequate staffing for the caregiver 
support program from VA Central Office, or not possessing the right 
tools or sufficient resources or support to properly manage, evaluate 
and improve the program, caregivers of, and injured veterans 
themselves, are being adversely affected and are not receiving the full 
benefits intended by Congress. In addition to passage of this bill, we 
urge VA and Congress to address these problems.
Discussion Draft, requirement of increased informed consent for certain 
                                 drugs
    If enacted, this bill would require VA to establish a panel of 
specialists that would reside within the Office of Specialty Care 
Services of VHA to establish and maintain a list of drugs to include 
psychotropic drugs that would require an increased level of informed 
consent. Under the bill, such drugs would only be prescribed to an 
enrolled veteran with written, informed consent of the veteran or 
appropriate representative of the veteran.
    We understand that VA maintains an oral informed consent process 
covering the types of drugs contemplated by this bill. According to VA, 
at the point that a VA physician prescribes psychotropic medications to 
patients, an automatic process commences to gain a patient's informed 
consent. In addition, some medical centers have assigned pharmacists to 
Patient Aligned Care Teams (PACT), where the use of certain drugs is 
explained and patients gain the opportunity to speak directly with 
pharmacy staff about possible side effects and contraindications. 
Finally, prescribed medications are received with accompanying 
information sheets, and some medications are issued with both drug 
information sheets as well as FDA medication guidelines. However, we 
understand VA has not implemented a nationwide directive requiring the 
presence of pharmacy counselors within PACTs. To ensure VA physicians 
can continue to provide timely care it may be beneficial to require VA 
to include pharmacy personnel on all PACT teams systems to ensure 
patients have adequate time to gain a meaningful understanding of the 
medications prescribed and alternative treatments available.
    DAV is pleased to support this draft measure which is consistent 
with DAV Resolution No. 126, and urges VA to promote and ensure health 
care quality and value, and to protect veterans' safety in the VA 
health care system.
     Draft Bill, to ensure VHA medical facilities are uniformly in 
   compliance with VHA appointment scheduling directives and policies
    This bill would require that each VHA medical center certify that 
it is in compliance with current VHA directives and policies applicable 
to scheduling veterans' appointments for health care. In the event the 
facility was not in compliance, the facility director would be required 
to provide an explanation of why the facility was not in compliance, 
and what steps were being taken to achieve compliance. The Secretary 
would be required to submit an annual report to Congress regarding the 
status of medical centers in meeting this requirement. In addition, the 
Secretary would be required to ensure all facilities are uniformly in 
compliance with VHA directives and policies on scheduling. In the event 
of a medical center's having been waived from uniform compliance, the 
Secretary would be required to notify Congress of such waiver, and 
provide explanation.
    DAV has received no specific resolution from our membership 
addressing the issue of VA certification of appointment scheduling, but 
we would not oppose passage of this bill.
    Mr. Chairman, DAV appreciates the opportunity to provide testimony. 
I would be pleased to address any questions you, or members of the 
Subcommittee may have on the topics covered in this statement.

                                 --------
                  Prepared Statement of Fred S. Sganga
    Mr. Chairman and Members of the Subcommittee, thank you for this 
opportunity to provide testimony regarding H.R. 2460, legislation 
introduced by Congressman Lee Zeldin of New York, to provide severely 
disabled veterans with an enhanced option to receive adult day health 
care services from State Veterans Homes.
    I am Fred Sganga, the Legislative Officer of the National 
Association of State Veterans Homes (NASVH). I also have the high honor 
of serving as the Executive Director of the Long Island State Veterans 
Home (LISVH) at Stony Brook University, a 350 bed State Veterans Home 
that also operates a 40 slot medical model Adult Day Health Care (ADHC) 
program.
    The State Veterans Home program was established by a Congressional 
Act on August 27, 1888, and for more than 125 years State Homes have 
been in a partnership with the federal government to provide long term 
care services to honorably discharged veterans; in some states, widows 
and spouses as well as Gold Star Parents are also eligible for 
admission. 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 (NASVH) was 
conceived at a New England organizational meeting in 1952 because of 
the mutual need of State Homes to promote strong federal policies and 
to share experience and knowledge among State Home administrators to 
address common problems. NASVH is committed to caring for our nation's 
heroes with the dignity and 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. Current 
services provided by State Homes include skilled nursing care, 
domiciliary care and adult day health care. The Department of Veterans 
Affairs (VA) provides State Homes with construction grants to build, 
renovate and maintain the Homes, with States required to provide at 
least 35 percent of the cost for such projects in matching funds. State 
Veterans Homes also receive per diem payments for basic skilled nursing 
home care, domiciliary care and ADHC from the federal government which 
covers about one third of the daily cost of care.
    Mr. Chairman, a decade ago, NASVH led the effort on Capitol Hill to 
assist our most disabled veterans by allowing them to receive skilled 
nursing care in State Veterans Homes under a new program that would 
provide the ``full cost of care'' to the State Home and thereby expand 
the options available to these deserving veterans at no cost to them. 
In 2006, Congress passed and the President signed Public Law 109-461 
which guaranteed ``no cost'' skilled nursing care to any honorably 
discharged veteran who has a 70% or higher service connected disabled 
rating. Unfortunately, the bill did not extend the same ``no cost'' 
program to cover alternatives to traditional institutional care, such 
as the medical model Adult Day Health Care currently provided at three 
State Veterans Homes in Stony Brook, New York, Minneapolis, Minnesota 
and Hilo, Hawaii. H.R. 2460 would fix that.
    Adult Day Health Care at the LISVH is designed to promote wellness, 
health maintenance, socialization, stimulation and maximize the 
participant's independence while enhancing quality of life. A medical 
model Adult Day Health Care program provides comprehensive medical, 
nursing and personal care services combined with engaging social 
activities for physically or cognitively impaired adults. These 
programs are staffed by a caring and compassionate team of multi-
disciplinary healthcare professionals who evaluate each participant and 
customize an individualized plan of care specific to their health and 
social needs.
    As a licensed nursing home administrator, I would like to thank 
Congressman Zeldin for recognizing the need to offer non-institutional 
alternatives to our veterans. Giving our veterans and families choices 
in how they can receive care is just the right thing to do. Making sure 
that there are no financial barriers to care is important to our most 
medically compromised veterans.
    It would be especially important to veterans like Jim Saladino and 
his wife Noreen. Fifty years ago, Jim answered the call of his country 
and served in the United States Army during the Vietnam War. Today, he 
suffers from the ravages of Agent Orange exposure. Specifically, he 
suffers from chronic illnesses including diabetes and Parkinson's 
disease and he also recently suffered a stroke.
    Although the Saladino family could have decided to put Jim into our 
State Veterans Home because he is a 100% service connected veteran so 
it would have been fully paid for by VA, but that is not their choice. 
They would like their loved one to continue enjoying the comforts of 
his own home - for as long as he can. By providing him the benefits of 
our medical model Adult Day Health Care program, Jim is able to keep 
living at home.
    Jim's wife, Noreen, serves as his primary caregiver. She has 
publicly stated that the medical model Adult Day Health Care Program 
has been a true blessing for her. Jim comes to the ADHC program three 
days a week and we work closely with his personal physician to provide 
services that will maintain his wellness and keep him out of the 
emergency room. During his six hour day with us, Jim receives a 
nutritious breakfast and lunch. He receives comprehensive nursing care. 
He also receives physical therapy, occupational therapy and speech 
therapy. He can get his eyes checked by an optometrist, his teeth 
cleaned and examined by our dentist, and his hearing checked by an 
audiologist. If required, he can get a blood test or an x-ray, have his 
vital signs monitored and receive bathing and grooming services while 
on site.
    For Jim's wife, having him come to our program allows her the peace 
of mind knowing that he is in a safe and comfortable environment. She 
can then get a break as caregiver and tend to those issues that allow 
her to run her household. However, because of the way the law is 
currently structured, despite Jim's eligibility for ``no cost'' skilled 
nursing care, they are required to pay out of pocket for a portion of 
his Adult Day Health Care.
    Mr. Chairman, H.R. 2460 will fix this disparity that prevents some 
of the most deserving and severely disabled veterans from taking 
advantage of this valuable program to help keep living in their own 
homes. This legislation would authorize VA to enter into agreements 
with State Veterans Homes to provide Adult Day Health Care for veterans 
who are eligible for, but do not receive, skilled nursing home care 
under section 1745(a) of Title 38, the ``full cost of care'' program. 
Veterans who have a VA disability rating of 70 percent or greater or 
who require ADHC services due to a service-connected disability would 
be eligible for this program. The payment to a State Home under this 
program would be at the rate of 65 percent of the amount that would be 
payable for skilled nursing home care under the same ``full cost of 
care'' program. This legislation would not only offer a lower cost 
alternative (ADHC) for severely disabled veterans who might otherwise 
require full time skilled nursing care, but it would also allow them to 
continue living in their own homes.
    The VA has been stressing the need to provide essential long-term 
care services in non-institutional settings for our most frail, elderly 
disabled veterans. Medical model Adult Day Health Care is a tremendous 
solution to this challenge being faced by the VA, one that can keep 
veterans living in their homes while allowing them to receive skilled 
nursing services and supports. There are a number of State Homes across 
the country interested in providing medical model ADHC services, 
however the current basic ADHC per diem is not nearly sufficient for 
most State Homes to be cover the costs of this program. Enactment of 
H.R. 2460 would provide a higher ADHC per diem rate for severely 
disabled veterans in medical model ADHC programs and thereby allow 
additional State Homes across the country to offer this service.
    For the Saladino family, receiving ``no cost'' medical model Adult 
Day Health Care for their loved one would relieve a huge financial 
burden that they currently incur. Even though Jim's service ended 50 
years ago, he is still paying a price for his valor related to his 
service in Vietnam. Passing H.R. 2460 would send a strong message to 
all those who have worn the uniform to protect our freedoms that they 
will never be forgotten.
    H.R. 2460 has bipartisan support in the House and has also been 
supported by a number of veterans service organizations, including The 
American Legion and the Veterans of Foreign Wars. I would ask that The 
American Legion's letter of support for this legislation be made a part 
of the record.
    On behalf of the National Association of State Veterans Homes, I 
urge you to favorably consider and pass H.R. 2460 for Jim and Noreen 
Saladino, and for thousands of others across the country just like 
them. Mr. Chairman, that concludes my testimony and I would be happy to 
answer any questions you and members of the Subcommittee may have. 
Thank you.

                                 --------
                 Prepared Statement of Maureen Mccarthy
    Good morning Chairman Benishek, Ranking Member Brownley, and 
Members of the Committee. Thank you for inviting us here today to 
present our views on several bills that would affect VA health programs 
and services. Joining me today is Susan Blauert, Chief Counsel for 
General Counsel's Health Care Law Group.

    Draft Bill: To ensure that each VA medical facility complies with 
requirements relating to scheduling veterans for health care 
appointments and to improve the uniform application of VA directives

    The proposed draft bill would require each VA medical facility to 
comply with requirements relating to scheduling Veterans for health 
care appointments and to ensure the uniform application of VA 
directives.
    Section 1 would require the director of each VA medical facility to 
annually certify to the Secretary that the medical facility is in full 
compliance with all provisions of law, regulations, and VA directives 
relating to scheduling appointments for Veterans to receive hospital 
care and medical services. VA does not support section 1 of this bill 
because it is unnecessary. Existing policies already require directors 
to certify compliance with the scheduling directive and explain gaps in 
compliance based on scheduling data collected at the facility level. 
This bill would not increase the amount or quality of information 
available regarding scheduling or meaningfully improve existing 
processes for certifying compliance.
    The bill also over-prioritizes scheduling to a great extent. 
Scheduling, while important, is not the only way Veterans access care 
in VA. As a technical matter, we note this bill would provide that each 
VA medical facility Director must certify compliance with all laws and 
regulations relating to ``scheduling appointments for Veterans to 
receive hospital care.'' Veterans are not required to be scheduled for 
hospital care; they can walk in the door and be admitted through the 
emergency room, if clinically appropriate, or their primary care 
provider may admit them directly. Within VA, the term ``scheduling'' 
typically is used in the context of outpatient care.
    The bill also prohibits the Secretary from waiving any provision of 
law or regulation relating to scheduling. This provision would not 
benefit Veterans. VA is actively working with Members of Congress on a 
consolidated care in the community program and other efforts to improve 
access to health care. In this dynamic environment, particularly with 
the increased use of community care, VA needs the flexibility to set 
scheduling standards that are clinically appropriate and can change and 
improve over time in step with other changes in the way Veterans access 
health care.
    Section 2 of the bill would require VA to ensure that its policies 
apply uniformly to each office or facility of the Department. VA does 
not support section 2 of the bill because it is unnecessary and, if 
interpreted broadly, unduly rigid. VA national policies already apply 
uniformly across the Department. At the same time, these policies 
provide some flexibility so that facilities can develop and pilot 
innovative ideas, or implement policies and procedures that are 
specific to the needs of the local Veteran community and consistent 
with the principles and procedures established in national policy. 
Section 2 could potentially limit VA facilities' ability to implement 
policies and procedures needed to tackle local challenges and address 
Veterans' needs.
    We do not have costs for this bill at this time.

H.R. 2460: To Improve the provision of adult day health care services 
    for veterans

    H.R. 2460 would amend 38 United States Code (U.S.C.) Sec.  1745 to 
require the Secretary to enter into an agreement under 38 U.S.C. Sec.  
1720(c)(1) or a contract with each State home for payment by VA for 
adult day health care (ADHC) provided to an eligible Veteran. Payments 
would be made at a rate that is 65 percent of the payment VA would make 
if the Veteran received nursing home care, and payment by VA would 
constitute payment in full for such care. Currently, under a grant 
mechanism, VA pays States not more than half the cost of care of 
providing ADHC. States may currently obtain reimbursement for this care 
from other sources in addition to VA's per diem payments.
    VA does not support this bill for the following reasons. 
Substantively, we note that the bill would base payment rates for ADHC 
on nursing home care rates, even though these are two distinctly 
different levels of care and are furnished for different periods of 
time. VA pays per diem for three levels of care at State Veterans Homes 
(SVH): nursing home care, domiciliary care, and adult day health care. 
The prevailing nursing home rate is calculated based on the cost of 
providing nursing home care. Nursing home residents live at the 
facility and receive 24-hour skilled nursing care. ADHC, however, is a 
much lower level of care where participants live at home and only use 
ADHC services for a portion of time during the day, normally about 8 
hours, or one third of the length of time that skilled care is 
provided. A per diem payment is made only if the participant is under 
the care of the facility for at least 6 hours. Because the level of 
services for ADHC and nursing home care are different, and the period 
of time in which services are furnished are different, we believe the 
payment rate proposed in the bill is inappropriate. The bill, in 
essence, would pay two thirds of the rate that VA pays for a higher 
level of care for furnishing a lesser level of care for only one third 
of the time.
    VA also has logistical concerns with the legislation. First, we 
note that the language in the bill directing VA to ``enter into an 
agreement under Sec.  1720(c)(1) of this title or a contract'' with 
each State home is inadequate. VA does not have independent agreement 
authority under Sec.  1720, and all agreements reached under this 
provision are contracts. The fact that these agreements are contracts 
places additional requirements on State homes that have proved 
burdensome and difficult to implement. To address this and similar 
situations, VA has requested congressional action to enact the 
Purchased Health Care Streamlining and Modernization Act that we 
submitted to Congress last year. This legislation would allow VA to 
enter into agreements that are not subject to certain provisions of law 
governing Federal contracts with providers on an individual basis in 
the community. Already, we have seen certain private nursing homes not 
renew their contracts, requiring Veterans to find new facilities for 
residence. We recommend Congress enact this new authority before 
requiring VA to transition payments to States for some ADHC 
participants from a grant to a contract mechanism.
    Additionally, in June 2015, VA published a proposed rule, ``Per 
Diem Paid to States for Care of Eligible Veterans in State Homes,'' RIN 
2900-AO88, along with a clarifying and correcting rule one week later. 
VA proposed these amendments to its regulations regarding payments for 
ADHC care in SVHs so that States may establish diverse programs that 
better meet participants' needs for socialization and maximize their 
independence. Currently, VA requires States to operate these programs 
using a medical supervision model exclusively. We expect that the 
proposed changes to our regulations will offer a socialized model that 
would result in an increase in the number of States that have ADHC 
programs. Currently, the SVH ADHC program is underutilized, as only 
three SVHs operate ADHC programs. We do not know at this time how many 
SVHs will adopt this new model, nor how the new model's use will affect 
costs. Until we have such information, we recommend against codifying a 
payment rate, as such a limitation could result in VA overpaying or 
underpaying States in the future.
    VA has other technical comments and recommendations we would be 
happy to provide at your request.
    VA supports growing ADHC programs in general because they are a 
part of VA's home and community-based programs included in the medical 
benefits package available to enrolled Veterans. VA operates ADHC 
programs, pays for ADHC in the community, and pays per diem to SVHs for 
ADHC. Those who are able to utilize the ADHC program are able to avoid 
nursing home care, maximizing their independence to support their 
choices, while reducing costs to VA. Projections for the Long-Term 
Services and Supports Model demonstrate that VA utilization for ADHC in 
the community will increase. VA recommends forbearing any action at 
this time until we have clear authority to enter into agreements other 
than contracts for such services and until VA is able to finalize 
changes to its regulations allowing for the new social model of care.
    VA estimates H.R. 2460 would cost $1.7 million in the first year, 
$2.1 million in the second year, and $12.6 million over five years.

H.R. 3989: Support Our Military Caregivers Act

    H.R. 3989 would add a new subsection (d) to 38 U.S.C. Sec.  1720G 
that would set forth a process for external clinical reviews of certain 
determinations under VA's Program of Comprehensive Assistance for 
Family Caregivers (PCAFC) and Program of General Caregiver Support 
Services, as established in Public Law (P.L.) 111-163. Under the new 
subsection (d), ``an individual may elect to have an independent 
contractor . . . perform an external clinical review'' of: a denial of 
a caregiver's application for benefits under Sec.  1720G, a 
determination or reconsideration of ``the level or amount of personal 
care services that a veteran requires,'' or a revocation of benefits 
pursuant to Sec.  1720G. The bill specifies that such reviews would be 
performed by an ``independent contractor'' as described in the bill, 
``[u]sing amounts otherwise appropriated'' to carry out Sec.  1720G.''
    VA does not support this bill because VA already has an existing 
mechanism in place to review eligibility determinations under Sec.  
1720G, including, where appropriate, consideration of recommendations 
from an external clinical review.
    VA implemented Caregiver Support Programs under Sec.  1720G in May 
2011. Since then, more than 30,000 caregivers have received services 
and support through PCAFC. These additional services and support are 
essential aspects of a Veteran's treatment plan as VA provides Veteran-
centered and family-centered care to Veterans.
    As provided in 38 U.S.C. Sec.  1720G(c), all decisions by the 
Secretary under Sec.  1720G affecting the furnishing of assistance or 
support shall be considered medical determinations. Accordingly, when 
there are disagreements with or clinical disputes over a decision under 
Sec.  1720G that are not resolved at the clinical team level, VHA 
follows the VHA Clinical Appeals policy and procedures that govern the 
appeals process for all VHA clinical programming (VHA Directive 2006-
057, VHA Clinical Appeals). This policy sets forth the mechanism in VHA 
for both internal and external clinical appeals. As provided in VHA 
Directive 2006-057, ``[i]t is VHA policy that patients or their 
representatives must have access to a fair and impartial review of 
disputes regarding clinical determinations or services that are not 
resolved at the facility level.''
    Providing a separate process for external clinical reviews, as set 
forth in H.R. 3989, would significantly impact the current process for 
reviewing eligibility determinations under PCAFC, in particular, as the 
program is currently operated. For example, when a Veteran (or eligible 
Servicemember) applies for the PCAFC, the individual's primary care 
team makes a series of clinical eligibility determinations. Once 
approved, the primary care team continues to remain involved by 
maintaining the individual's treatment plan and collaborating with 
clinical staff making home visits to monitor the individual's well-
being, supporting both the Veteran (or eligible Servicemember) and 
family caregiver(s). The existing VHA Clinical Appeals policy ensures 
that, in the event of an appeal, decisions are made by VHA leadership 
with direct oversight of the clinical team involved with the 
individual's care.
    In contrast, the external clinical review under H.R. 3989 would be 
conducted by an independent contractor who ``employs a panel of 
physicians or other appropriate health care professionals'' and who 
does not provide health care to the individual. The independent 
contractor would need to be educated about PCAFC, applicable 
eligibility requirements, existing assessment and revocation 
procedures, as well as required assessment tools. This new process 
would require management and quality assurance oversight and Veteran-
facing customer service and satisfaction supports that would require 
additional staffing or contract support.
    Moreover, using an ``independent contractor'' to perform external 
clinical reviews, as provided in H.R. 3989, could not be achieved with 
existing funding. Additional funding for this new requirement would be 
necessary, to include funding for education and customer service and 
satisfaction supports.
    VA is unable to provide a cost estimate on this bill as data 
required to construct costing is not readily available.

H.R. 3974: The Grow Our Own Directive: Physician Assistant Employment 
    and Education Act of 2015

    VA supports section 2 of H.R. 3974, subject to the availability of 
funds, which would require VA to carry out a pilot program to provide 
educational assistance to certain former members of the Armed Forces 
for education and training as physician assistants (PA). Having a pilot 
program will help alleviate the health care workforce shortages in VA 
by requiring scholarship recipients to complete a service obligation at 
a VA health care facility after graduation and licensure/certification. 
Additionally, scholarships will enable students to gain academic 
credentials without additional debt burdens from student loans. Future 
benefits are gained in reduced recruitment costs as scholarship 
recipients will have obligated service agreements to fulfill. These 
service agreement obligations secure the graduates' services for up to 
3 years, which reduces turnover, and costs typically associated with 
the first 2 years of employment.
    While VA supports H.R. 3947, we believe that the Congress should 
provide more flexibility in implementation. The bill is very specific, 
including in areas such as directing new pay levels, and the exact 
criteria for participant eligibility. VA should be afforded the 
flexibility to implement such a program in a manner that can minimize 
any unintended consequences, such as consistency across Title 38 
programs in other Federal agencies.
    While VA supports section 2, we recommend removing language in 
paragraph (j) that would require these positions to be filled by a 
Veteran and a current employee. While requiring a position be filled by 
a Veteran could be challenging, requiring that the individual be 
``employed by [VA] as of the date of enactment of the Act'' would be 
legally problematic. In addition, the limitation of filling the 
proposed Deputy Director positions with Veterans only (as opposed to 
employing Veteran preference) would significantly limit the pool of 
applicants with the necessary experience and skill sets necessary to 
successfully carry out the responsibilities of the positions.
    The total cost of section 2 of the Health Professional Scholarship 
Program (HPSP) with HPSP Stipend cost for 250 awards over 5 years would 
be $19,812,531. This amount includes $11,700,000 for scholarship 
assistance, $7,652,584 for stipend costs, as well as additional costs 
for administration, information technology, and travel.
    Section 3 would establish standards for the Department for using 
educational assistance programs to educate and hire PAs. VA does not 
support this section because Educational Debt Reduction Program (EDRP) 
assistance is targeted for specific positions that are designated as 
difficult to recruit and retain. In order to meet local Veteran 
population needs, local medical centers have the flexibility to 
determine the positions that have the most critical need for EDRP 
awards and advertise accordingly. Loan repayment awards are an 
attractive tool; however, EDRP is a limited resource and offering EDRP 
to an entire occupational series is contrary to the statutory mission 
of the program and sets a precedent for other occupations to seek 
similar authority.
    The PA occupation is recognized as a top 5 mission-critical 
occupation within VA, ranking fourth and tied with physical therapy, 
according to the January 2015 VA Office of Inspector General (OIG) 
report after medical officer (physician), nurse, and psychologist.
    Over the last several fiscal years (FY), the number of new PA hires 
has fluctuated between 250-350 annually. The number of EDRP awards made 
for newly hired PAs has gradually increased from 26 to 45 (62 percent 
increase) from FY 2014 to FY 2015, and currently comprises 13 percent 
of all new PA hires. In the FY 2015 EDRP award cycle, the average EDRP 
award for PAs was $63,000. Current projections estimate similar awards 
for the PA occupation based on qualifying student loan debt. Overall, 
the OIG top 5 occupations represented 82 percent of all EDRP awards 
made in FY 2015.
    EDRP awards are typically 5-year awards. If EDRP was offered to 
every new PA hire, nearly $4.6M would be needed each year for new 
awards, and additional funding would be required to sustain current 
participants. Furthermore, it can be expected that PAs currently 
employed within the VA network not receiving EDRP would expect to 
receive a similar award, or consider moving to a position elsewhere 
that authorized EDRP. Since EDRP may be awarded as a retention tool, 
additional funding would be required for current PAs as well.
    Including EDRP in all announcements would also give interested 
candidates for hire the impression that EDRP would be available. EDRP 
awards are not made until after qualifying student loan debt can be 
confirmed with education institutions and lenders, which can take 
several months and occurs after employees are onboard. Without 
significantly increasing EDRP funding, including EDRP in all PA vacancy 
announcements will prevent facilities from offering the award to other 
positions that are more difficult for recruitment and retention 
locally. Advertising EDRP in all PA announcements, without 
significantly increasing funding, is misleading and likely to 
disenfranchise new employees early in their VA career.
    Advertising EDRP for an entire occupation sets a precedent that 
will likely encourage other occupations to seek the same. Such costs 
are not only unsustainable, but in conflict with the statutory mission. 
PAs are nationally ranked as a mission-critical occupation; however, 
certain facilities report no issues recruiting PAs (i.e., Michael E 
DeBakey VA Medical Center in Houston, TX, has a strong PA program with 
academic affiliates and reports no issues hiring PAs). Requiring all 
facilities to advertise EDRP for positions would deny the facility the 
ability to make awards for positions that are the most critical.
    Alternative approaches may be better suited for strengthening the 
PA occupation within VA. If compensation of PAs is the primary driver, 
rather than include EDRP in all vacancy announcements, VA supports the 
legislation in Section 4, which seeks to eliminate the pay disparity 
between VA and the private sector.
    The cost to include EDRP in all PA vacancy announcements for 5,350 
new awards over 5 years would be $45,500,000. Salary costs and 
development costs are estimated at an additional $659,037, bringing the 
total cost of this proposal to $46,159,037.
    The PA occupation has been a difficult to recruit and retain 
occupation for several years. A major barrier to recruitment and 
retention of PAs is the significant pay disparity between private 
sector market pay and VA pay schedules for PAs. Special Pay rate 
authority exists at the medical center level to address these 
disparities. Salary surveys performed during FY 2015 by several VA 
medical facilities have resulted in establishment or adjustment in 
local special salary rates for the PA occupation resulting in 
significant increases in salaries. This is an indication of the 
existing salary disparity overall. Including the PA occupation as a 
covered occupation under the nurse locality pay system in VA would be 
an important element in addressing recruitment and retention 
difficulties.
    The total cost associated with this proposed legislation over 5 
years would be $135,149,625. This amount includes $19,812,531 in 
Scholarship Support Costs, $2,580,541 in Program Administration Costs, 
$220,016 in Operational Costs, and $112,536,537 associated with 
competitive pay for physician assistants.

H.R. 3956: The VA Health Center Management Stability and Improvement 
    Act

    Although the bill addresses the Department's challenges with 
recruiting and filling Medical Center Director positions, it does not 
offer any substantive solutions to address the challenges. Instead, it 
proposes legislation to develop and implement a hiring plan within 120 
days of the legislation going into effect. By the time this draft 
language might become legislation, VA anticipates having significantly 
reduced the number of vacant Medical Center Director positions, such 
that the legislation would no longer be needed, but would impose 
another congressional reporting requirement on VA. Therefore, we do not 
support this bill. As an alternative to creating new reporting 
requirements, the Congress should consider options that would allow VA 
to achieve the same result through existing reports, such as the 
Agency's human capital plan. In fact, many of the topics under 
consideration should already be covered in the succession management 
and recruitment sections of the existing human capital plan.
    Since the beginning of FY 2016, VA has been working hard to shorten 
the time to hire for these executive positions. In October 2015, we 
began using nationwide announcements to identify and secure larger 
pools of qualified candidates, both internal and external to VA. This 
enterprise approach allows us to best match the candidate's skills and 
abilities with one of the vacant positions and do so in close to 120 
days. Based on current recruitment efforts, we anticipate having 
nominees identified for approximately 20 of the more than 30 vacancies 
by the end of April 2016.
    In addition, VA recently submitted a legislative proposal 
requesting the ability to transition all Medical Center Directors from 
Title 5 to Title 38, which will provide additional compensation and 
staffing flexibilities, thereby relieving some of the current 
challenges with attracting highly qualified candidates to serve in 
these leadership roles. Support of this proposal would be more 
beneficial to VA and ultimate resolution of the current staffing 
challenges rather than what is proposed in H.R. 3956.

    Draft Bill: To direct the Secretary of Veterans Affairs to 
establish a list of drugs that require an increased level of informed 
consent

    The draft bill would add new section 7335 to Title 38, U.S.C., to 
require VA to establish, within VHA's Office of Specialty Care 
Services, a panel to create and maintain a list of drugs (including 
psychotropic drugs) that may only be furnished with the ``increased 
informed consent'' of the patient or, in appropriate cases, a 
representative thereof. Such term would refer to full and informed 
consent that provides the patient with a meaningful understanding of 
the treatment to be provided based on such consent, an opportunity to 
ask questions and receive information regarding such treatment, and is 
acknowledged in written form.
    The Secretary would be responsible for determining the composition, 
membership, and functions of the panel. VA medical professionals who 
then prescribe any drug on this list would need to prepare and present 
to the patient (or patient representative) a written form that meets a 
number of detailed criteria specified in the bill, (e.g., the names of 
any drugs being offered to the patient) including any other trade or 
the generic name for such drug, each side effect, alternative methods 
of treatment or therapy not involving that drug, etc. Before such form 
is used, however, the provider, except in emergency situations, would 
first need to: (1) ensure that the patient signs an initial form 
acknowledging that the patient has received information regarding the 
recommended treatment and any other possible treatments; (2) refer the 
patient to an appropriate pharmacy of the Department if the patient has 
additional questions about the drug in question; and (3) provide the 
patient with the opportunity to review the information.
    Thereafter, the patient would have the opportunity to sign the form 
reflecting the mandated requirements, to call or email the medical 
professional to provide consent, or to schedule a follow-up appointment 
with the medical professional to discuss the recommended treatment 
during the 3-day period beginning on the date on which the patient 
requests the appointment. The form would also need to provide for 
acknowledgement by the patient that he or she has received the required 
information, as described in brief above, and has had adequate time to 
understand the information and consider alternative treatments, 
including, as appropriate, the opportunity to leave the medical 
facility.
    VA does not support the draft bill. The terms of 38 U.S.C. Sec.  
7331, as implemented by 38 CFR Sec.  17.32, VHA Handbook 1004.01, 
Informed Consent for Clinical Treatments and Procedures; VHA Handbook 
1004.05, iMedConsent; and VHA Directive 1005, Informed Consent for 
Long-Term Opioid Therapy for Pain, already meet the objectives of the 
proposed measure and are aligned with professional best practice 
standards.
    No medical treatment or procedure can be provided in VHA to any 
patient without the patient's full and informed consent first having 
been obtained and documented. Providers are required to appropriately 
document the informed consent in the patients' electronic health 
records. In addition, through its implementing regulations and 
policies, VA has already identified classes of treatment and procedures 
that, because of their inherent risk for significant pain, discomfort, 
complication, or morbidity, require signed informed consent, that is, a 
patient's (or surrogate's) and practitioner's signature on a VA-
authorized consent form. These forms are developed by an established 
clinical expert process to include information about the treatment's 
risks, benefits, and alternatives at the appropriate reading level for 
the VA population. VA also provides written information about 
prescribed drugs each time the drug is dispensed to the patient. VA 
care is Veteran-centered, and the discussions described in the bill are 
already available to our patients.
    Experts in law, ethics, and clinical implementation of informed 
consent in VA have also implemented appropriate means for seeking and 
documenting informed consent by patients and surrogates, including 
situations where the individual providing consent on behalf of the 
patient is not physically present, for example mechanisms for 
asynchronous signature. However, VA does not allow signed consent forms 
to be transmitted through commercial e-mail services. Until secure 
email is available, this prohibition in policy helps to ensure patient 
privacy and the security of patient information, and it also ensures 
the authenticity of the signed informed consent form confirming the 
identity of the sender.
    The steps described in the proposed measure could significantly 
impede VA's ability to provide prompt care. The proposed legislation 
would add an undue time burden on Veterans and their care providers, by 
introducing unnecessary steps and delays in what is standard informed 
consent practice for high-risk medications. Of particular concern, the 
bill would apply the ``increased informed consent'' requirements to 
involuntarily committed inpatients in need of psychotropic drugs 
(because they have been found by the appropriate officials to be a 
danger to themselves or others). VA regulation and policy currently 
afford due process protections in these situations, while balancing the 
need for prompt medical intervention as defined by generally accepted 
standards of medical practice. Waiting on the completion of all the 
actions required by ``increased informed consent'' could well result in 
these clinical cases becoming exacerbated, with greater safety risks 
being posed, as a result, to the patients themselves, their surrogates, 
other patients, and/or VA staff.
    Finally, it is unclear what problem this draft legislation purports 
to correct or remedy. For this reason, we request the Committee forbear 
in its consideration of this draft bill until we have a chance to meet 
with the Committee to ascertain the Members' concerns and together 
consider less formal and more flexible ways of satisfactorily 
addressing them.
    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to appear before you today. We would be pleased to respond 
to questions you or other Members may have.

                                 --------
                       Statements For The Record

                          THE AMERICAN LEGION
    Chairman Benishek, Ranking Member Brownley, and distinguished 
members of the Subcommittee on Health, on behalf of National Commander 
Dale Barnett and The American Legion; the country's largest patriotic 
wartime service organization for veterans, comprising over 2 million 
members and serving every man and woman who has worn the uniform for 
this country; we thank you for the opportunity to testify regarding The 
American Legion's position on the pending and draft legislation.
                                H.R.2460
    To amend title 38, United States Code, to improve the provision of 
adult day health care services for veterans.

    State Veterans Homes are facilities that provide nursing home and 
domiciliary care. They are owned, operated and managed by state 
governments. They date back to the post-Civil War era when many states 
created them to provide shelter to homeless and disabled veterans. 
Currently, there are only two Adult Day Health Care programs at State 
Veterans Homes in the United States. Both are located on Long Island, 
New York. However, these programs could easily be offered at the other 
151 State Veterans Homes located throughout the country.
    H.R. 2460 would provide no cost medical model Adult Day Health Care 
at State Veterans Homes who are 70% or more service-connected. This 
bill is an extension of Public Law (P.L.) 109-461, Veterans Benefits 
Health Care, and Information Technology Act of 2006, which currently 
provides no cost nursing home care at any State Veterans Home to 
veterans who are 70% or more for their service-connected disability and 
who require significant assistance from others to carry out daily 
tasks.
    VA pays State Veterans Homes a per diem that covers merely one-
third of the cost of providing this service. This bill will expand 
disabled veterans' access to services such as Adult Day Health Care; a 
daily program for disabled veterans who need extra assistance and 
special attention in their day to day lives.
    Resolution Number 21 entitled State Veteran Home Per Diem 
Reimbursement supports an increase in the per-diem rates for veterans 
in need of such care that State Veterans Homes provide. \1\
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    \1\ American legion Resolution No. 21 (Aug 2014): State Veteran 
Home Per Diem Reimbursement

    The American Legion Supports H.R. 2460.
  H.R. 3956: VA Health Center Management Stability and Improvement Act
    To direct the Secretary of Veterans Affairs to develop and 
implement a plan to hire directors of the medical centers of the 
Department of Veterans Affairs.

    For years, The American Legion has consistently been concerned with 
the Department of Veterans Affairs (VA) leadership, physicians, and 
medical specialist staffing shortages within the Veterans Health 
Administration. Since, the inception of The American Legion's System 
Worth Saving (SWS) Program in 2003, we have tracked and reported 
staffing shortages at every VA medical facility across the country. The 
American Legion's SWS 2014 executive summary found that several VA 
medical centers continue to struggle to fill critical leadership 
positions across multiple departments resulting in communication 
breakdowns between medical center leadership and staff that work at the 
medical center.
    This bill would address the growing problems of VA medical centers 
operating without permanent directors creating an instability that puts 
the care of those who have served at risk. The VA Health Center 
Management Stability and Improvement Act would require the Secretary of 
VA to develop and implement a plan to hire directors of the medical 
centers of the VA who are under temporary leadership. No later than 120 
days after the date of the enactment of this Act, the Secretary of VA 
shall develop and implement a plan to hire highly qualified directors 
for each medical center of the VA that lacks a permanent director. The 
Secretary shall prioritize the hiring of such directors for the medical 
centers that have not had a permanent director for the longest periods 
of time.
    The American Legion supports legislation addressing the recruitment 
and retention challenges faced by the Department of Veterans Affairs 
(VA) and encourage VHA to develop and implement staffing models for 
critical need occupations. \2\
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    \2\ American Legion Resolution No. 101 (Sept. 2015): Department of 
Veterans Affairs Recruitment & Retention

    The American Legion supports H.R. 3956.
 H.R. 3974: Grow Our Own Directive: Physician Assistant Employment and 
                         Education Act of 2015
    To require the Secretary of Veterans Affairs to carry out a pilot 
program to provide educational assistance to certain former members of 
the Armed Forces for education and training as physician assistants of 
the Department of Veterans Affairs, to establish pay grades and require 
competitive pay for physician assistants of the Department, and for 
other purposes.

    This bill directs the Department of Veterans Affairs (VA) to carry 
out the Grow Our Own Directive (G.O.O.D.) pilot program that is 
designed to create a pathway for veterans who want to go to school to 
become a physician assistant in exchange for a three-year commitment to 
work within the VA healthcare system. H.R. 3974 proposes to reduce wait 
times at VA medical centers, while increasing the supply of physician's 
assistants within the VA healthcare system for the purpose of treating 
veterans.
    The American Legion endorses the Grow Our Own Directive (GOOD): 
Physician Assistant Employment and Education Act of 2015 for the 
following reasons:

      Enhances opportunities for veterans seeking employment 
within the healthcare field - these are Careers, not jobs, which equal 
quality pay and benefits, along with mobility;
      Addresses employment issues for underserved areas. VA has 
been in dire need of these type of positions for rural and other 
underserved areas;
      Assists veterans who have experience in the healthcare 
field with education costs, which reduces debt and other financial 
barriers for gainful employment within this high growth industry; and
      Ultimately, this pilot program gives the VA a chance to 
properly fill these positions in order to fully maximize the veteran's 
experience, while providing excellent care at the Veterans Affairs 
Medical Centers (VAMCs) or other VA healthcare facilities.

    The American Legion supports legislative and administrative 
measures that seek to encourage and recognize organizations that hire 
veterans, particular the Department of Veterans Affairs. \3\
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    \3\ American Legion Resolution No. 95 (Sept. 2015): Support 
Employment of Veterans in the Public and Private Workforce

    The American Legion supports H.R. 3974.
             H.R. 3989: Support Our Military Caregivers Act
    To amend title 38, United States Code, to improve the process for 
determining the eligibility of caregivers of veterans to certain 
benefits administered by the Secretary of Veterans Affairs.

    A caregiver is an unpaid or paid person who helps another 
individual with an impairment with his or her activities of daily 
living. Any person with a health impairment might use caregiving 
services to address their difficulties. A military caregiver is a 
family member, friend, or acquaintance who provides a broad range of 
care and assistance for, or manages the care of, a current or former 
military servicemember with a disabling physical or mental injury or 
illness.
    Typical duties of a caregiver might include taking care of someone 
who has a chronic illness or disease; managing medications or talking 
to doctors and nurses on someone's behalf; helping to bathe or dress 
someone who is frail or disabled; or taking care of household chores, 
meals, or bills for someone who cannot do these things alone.
    The Support Our Military Caregivers Act, would reform the current 
VA's Caregiver Program to help better assist family members who are 
caring for seriously wounded veterans. The VA's Caregiver Program is 
currently experiencing delays in the approval process for family 
members to receive this benefit. This bill would establish an external 
clinical review process that would allow for the review of the veterans 
applications or when the application for caregiver benefits is denied, 
allowing for an independent contractor to review the case.

    The American Legion does not have an official position on H.R. 
3989, and are unable to comment at this time.
                            Discussion Draft
    To direct the Secretary of Veterans Affairs to ensure that each 
medical facility of the Department of Veterans Affairs complies with 
requirements relating to scheduling veterans for health care 
appointments, to improve the uniform application of directives of the 
Department, and for other purposes.
    This draft legislation as written, requires that the director of 
each VA health care facility annually certifies to the Secretary that 
their medical facility is in full compliance with all provisions of the 
law and regulations relating to scheduling appointments for veterans to 
receive hospital care and medical services that are listed under 
Veterans Health Administration Directive 2010-027, entitled VHA 
Outpatient Scheduling Processes and Procedures, or any successor 
directive.
    The Secretary of VA on a yearly basis will report to both the House 
Veterans Affairs' Committee (HVAC) and the Senate Veterans' Affairs 
Committee (SVAC) with a list of medical centers that have certified 
compliance and a list of facilities that are not in compliance and to 
provide an explanation of why those facilities did not meet the 
requirements set forth within the VHA Outpatient Scheduling Processes 
and Procedures directive.
    Requiring VA to adhere to the law, regulations and VA policies 
governing scheduling is common sense. However, this bill fails to spell 
out any consequences if VA medical center directors fail to comply with 
the proposed legislation.

    The American Legion would only support this draft legislation if it 
includes an accountability statement holding medical center and 
Veterans Integrated Service Network (VISN) directors accountable when 
they have failed to comply with the intent of the discussion draft.
                            Discussion Draft
    To amend title 38, United States Code, to direct the Secretary of 
Veterans Affairs to establish a list of drugs that require an increased 
level of informed consent.

    Informed consent is a process for getting permission before 
conducting a healthcare intervention on a person. A health care 
provider may ask a patient to consent to receive therapy before 
providing it, or a clinical researcher may ask a research participant 
before enrolling that person into a clinical trial.
    This discussion draft, as written, directs the Secretary of VA to 
establish a list of drugs that require an increased level of informed 
consent. This bill would require the Secretary of VA to establish 
within the Office of Specialty Care Service of the Veterans Health 
Administration a panel to establish and maintain a list of drugs, 
including psychotropic drugs that may only be furnished under this 
title to a patient with increased informed consent of the patient or, 
in appropriate cases, a representative thereof.
    Informed Consent has either become non-existent or hurried by 
health care providers. It is standard medical procedure to ensure that 
our veterans are fully informed of the side effects and other 
liabilities of drugs they are administered prior to their 
administration. As part of the Informed Consent process, doctors should 
be required to provide a list of alternative treatments and therapies 
to the veterans they serve. When providers utilize informed consent, 
veterans and their families can make informed decisions of what is in 
their best interest. Finally, this process needs to be a deliberative 
process, where the understanding of the veteran is consulted and is 
assured.
    The American Legion calls for Congress to exercise oversight over 
DOD/VA to ensure servicemembers and veterans are only prescribed 
evidence-based treatments for TBI/PTSD and not prescribed off-label and 
non-Federal Drug Administration approved medications or treatments for 
TBI/PTSD. \4\
---------------------------------------------------------------------------
    \4\ The American Legion Resolution 292 (Aug. 2014): Traumatic Brain 
and Post Traumatic Stress Disorder Programs

    The American Legion supports the discussion draft.
                               Conclusion
    As always, The American Legion thanks this subcommittee for the 
opportunity to explain the position of the over 2 million veteran 
members of this organization. Questions concerning this testimony can 
be directed to Warren J. Goldstein in The American Legion's Legislative 
Division at (202) 861-2700 or [email protected].

                                 --------
                    AMERICAN PSYCHIATRIC ASSOCIATION
    The American Psychiatric Association (APA), the national medical 
specialty society representing over 36,500 psychiatric physicians and 
their patients, is pleased to submit this statement for the 
Subcommittee's hearing that includes legislation designed to establish 
an informed consent protocol within the Department of Veterans Affairs 
(VA), as part of an effort to improve the overall clinical care of our 
nation's veterans.
    Nearly two years after the incident surrounding delayed access to 
mental health services at the Veterans Health Administration (VHA), the 
matter of ensuring that veterans receive quality and timely care has 
been a priority for our nation. These issues are receiving considerable 
attention from Congress, and the APA is hopeful that attention will be 
translated into action. Towards that end, APA thanks Subcommittee 
Chairman Benishek and Ranking Member Brownley for holding this hearing.
    United States veterans are a multifaceted population requiring a 
culturally competent approach to medical treatment and care. Veterans 
experience mental health disorders, substance use disorders, post-
traumatic stress, and traumatic brain injury at disproportionate rates 
compared to their civilian counterparts. Often in combination with 
military-related diseases, many veterans develop substance use 
disorders and a large number ultimately complete suicide. Approximately 
1.9 million OEF/OIF/OND veterans have become eligible for VHA health 
care services since 2002. \1\ While a relatively small percentage of 
veterans utilize the health care services offered, the VHA has seen a 
63 percent increase in the number of veterans receiving mental health 
care between 2005 and 2013. As of March 2015, 57.6% (685,540) of the 
veterans seeking care at VHA facilities received at least one 
provisional mental health diagnosis, with the most common conditions 
being post-traumatic stress disorder, depressive disorders, and other 
anxiety disorders. \2\ Through the expansion of the Choice Program 
under the Veterans Access, Choice, and Accountability Act of 2014, the 
VA anticipates the number of veterans seeking mental health services to 
rise.
---------------------------------------------------------------------------
    \1\ U.S. Department of Veterans Affairs. VHA Office of Public 
Health. Analysis of VA Health Care Utilization among Operation Enduring 
Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn 
(OND) Veterans. Sept. 2015.
    \2\ U.S. Department of Veterans Affairs. Office of Informatics & 
Analytics. VA Mental Health Services Public Report. Nov. 2014.
---------------------------------------------------------------------------
    The VHA operates the nation's largest integrated health care 
delivery system, providing care to nearly 6 million veteran patients, 
and employing more than 270,000 full-time staff. In 2015 the Government 
Accountability Office audited the VHA, and identified two key barriers 
to accessing quality and timely care: 1) the lack of scheduled medical 
appointment slots, and; 2) the acute shortage of physicians. Health 
care professionals play a central role in ensuring the well-being of 
our nation's veterans. The providers working with the veteran 
population must be able to address the patient's particular physical 
and mental health demands. Physicians, in particular, play a critical 
role to this distinct population in providing quality care by engaging 
the patient, being aware of the patients' military history, and 
recognizing risk factors.
    With respect to the vital function of medical professionals at VHA, 
APA would like to convey a number of items that inadvertently create 
barriers to accessing mental health services and ensuring high quality 
care. The APA stands ready to assist the Subcommittee in advancing 
legislation that improves the overall care our veterans receive, and we 
ask that the Subcommittee take the following items under close 
consideration.
    The APA believes that any legislative initiative should not 
segregate mental health from other medical care, such as segregating 
psychotropic medications as posing certain risks. Psychotropic 
medications are in a class of pharmaceuticals along with other classes 
of medications that contain potential adverse effects, including 
cardiac, hematologic, oncologic, rheumatologic, steroids, as well as 
most commonly prescribed antibiotics. The APA believes that all 
providers should have an open dialogue and participate in shared 
decision making with patients about any pharmacological treatment that 
may have potential adverse effects to their lifestyle.
    The APA understands that the Subcommittee is entertaining the 
possibility of requiring a physician-patient dialogue concerning the 
warnings associated with psychotropic medications. The vast increase in 
the number of new psychopharmacologic agents over the last 20 years has 
made more therapeutic options available, but has also made treating 
patients more complicated. Prescribing practices, inclusive of the 
concurrent administration of a variety of psychotropic medications, 
have made the awareness of pharmaceutical interactions key for meeting 
the treatment needs of each individual patients. To date, the Food and 
Drug Administration has few indications on combination use with 
psychotropic drugs. To engage in a physician-patient discussion as 
entertained by the Subcommittee, the APA believes that the FDA must 
provide comprehensive data that would allow for informed decisions on 
complex treatment.
    Frequently, veterans will utilize primary care office visits to 
seek care for mental disorders. In these incidents, antidepressants are 
more often prescribed by primary care providers than psychiatric 
physicians. Any additional steps for increased informed consent may 
unintentionally reduce a primary care provider's receptivity to 
prescribe psychotropic drugs. Regrettably, the patient will likely not 
receive the medical treatment needed to aid in their mental wellness.
    The APA understands that the Subcommittee is entertaining a new way 
of measuring standards of care for informed consent for psychotropic 
drugs. Providers who do not comply with completing the required steps 
of increased inform consent would be vulnerable to a claim of 
negligence against them. The APA recommends establishing guidelines 
that would safeguard providers.
    The military culture promotes inner strength and self-reliance, 
contributing heavily to a stigma associated with mental disorders and 
to seeking treatment. Where stigma creates barriers to care, the 
additional measures required may generate unintended consequence of 
over emphasizing risks to an extent that some patients would view 
psychotropic drugs as more dangerous and decide not to take them.
    The Veterans Health Administration has multiple clinical practice 
guidelines and evidence-based tools to assist clinicians in identifying 
risk factors and measures to improve health outcomes. Physician and 
patient dialogue is a significant element in a patient's treatment, 
providing a platform for an informed discussion. The practice of 
medicine is a serious responsibility that encompasses providing a 
comprehensive understanding of treatment to the patient. The APA 
concurs a physician-patient dialogue may positively impact the decision 
of the patient's treatment. The APA asks that all classes of 
medications that pose adverse effects be included in the process of 
increased informed consent. This would eliminate an inherently 
discriminatory approach to mental health treatment, and further 
encourage a stigma associated behavior towards mental health services.
    Thank you again for the opportunity to offer our expertise on the 
consideration of establishing an increased level of informed consent 
for the record. We look forward to continuing our work with members of 
the Subcommittee. If you have any questions, or if we can be of further 
assistance, please contact Jeffrey P. Regan, Chief of Department of 
Government Relations at [email protected].

                                 --------
                              EASTER SEALS
  WRITTEN STATEMENT OF KATY NEAS, EXUCUTIVE VICE PRESIDENT FOR PUBLIC 
                                AFFAIRS
    Dear Chairman Benishek, Ranking Member Brownley, and Members of the 
Subcommittee:
    Thank you for holding this hearing on proposed legislation to 
improve Veterans' access to health care and other benefits administered 
by the U.S. Department of Veterans Affairs (VA). Easter Seals 
especially applauds the Subcommittee's focus on adult day health care 
(ADHC) and how this community-based service can improve a Veteran's 
health and well-being while also meeting the Veteran's goal of 
remaining at home and in their community.
    Easter Seals is changing the way the world defines and views 
disabilities by making profound, positive differences in people's lives 
every day. Through a network of 74-community-based affiliates, Easter 
Seals is a leading nonprofit provider that assists Veterans, military 
families, and others to reach their potential and succeed in their 
communities by providing and connecting them to local services and 
supports. Founded in 1919, Easter Seals began serving Veterans after 
World War II to help address the unmet needs of service members 
returning home with service-connected disabilities. Through our 
national network and Easter Seals Dixon Center for Military and 
Veterans Services, Easter Seals continues to fill the gap between the 
services Veterans need and the services currently available through 
government or other entities. Adult day health care is one of the 
community-based services that Easter Seals offers through more than 50 
programs in 14 states. Through the program, Easter Seals affiliates 
offer a menu of person-directed care and social and recreational 
activities to older adults, including Veterans, and individuals with 
disabilities. Easter Seals partners with the VA at the local level and 
nationally as the contractor to develop and administer the National 
Veteran Caregiver Training Program, which falls under the jurisdiction 
of this Subcommittee. Easter Seals is proud of its record and service 
for and on behalf of America's Veterans and their families.

    It is because of our long-term care expertise and Veterans' 
experience that we lend our support for the twin goals behind H.R. 
2460: to expand local adult day health care options for eligible 
Veterans and to ensure the VA's reimbursement rate better reflects the 
true cost and Veteran need of skilled adult day health care.

Expansion of Local Adult Day Health Care Options:

    The VA described ADHC as ``a key component in the continuum of 
long-term care'' that helps Veterans remain in their homes and provides 
needed care in the ``least restrictive environment that is safe for 
Veterans.'' \1\ The VA also noted that non-institutional extended care 
programs, such as adult day health care, have resulted in substantial 
reductions in nursing home placement, facilitates greater independence, 
and promotes enhanced quality of life for Veterans receiving the 
service. \2\ With the passage of the Veterans Millennium Healthcare and 
Benefits Act of 1999 (P.L. 106-117), Congress recognized the importance 
of adult day services for Veterans and authorized the VA to furnish 
ADHC to Veterans who would otherwise require nursing home care. The VA 
can provide ADHS directly or by contracting with State Veterans Homes 
or community organizations ``through non-VA care mechanisms such as 
sharing agreements, national or local contracts, and individual 
authorizations to the extent that the Veteran is eligible.'' Some 
Easter Seals affiliates currently contract with the VA to provide ADHC 
for Veterans living in their communities.
---------------------------------------------------------------------------
    \1\ Adult Day Health Care, VHA Handbook 1141.03, September 29, 
2009, http://www.va.gov/vhapublications/ViewPublication.asp?pub--
ID=2086
    \2\ Uniform Geriatrics and Extended Care Services in VA Medical 
Centers and Clinics, VHA Handbook 1140.11, November 4, 2015, http://
www.va.gov/vhapublications/ViewPublication.asp?pub--ID=2086
---------------------------------------------------------------------------
    H.R. 2460 would expand community-based options by directing the VA 
Secretary to partner with State Veteran Homes in each state to pay for 
adult day health care for a Veteran eligible for, but not receiving, 
nursing home care. While the VA is currently authorized to pay for ADHC 
at State Veterans Homes (SVH), only two of the 153 SVH currently offer 
ADHC at its facilities. \3\ Easter Seals supports efforts to expand 
long-term care options, including adult day health care, for eligible 
Veterans. Easter Seals believes the most effective approach in meeting 
the needs of eligible Veterans is to utilize the existing national 
network of more than 5,000 community-based adult day centers, \4\ which 
can include new and existing State Veteran Homes. This recommendation 
also recognizes the limited coverage of the 153 State Veteran Homes. 
Fourteen states, including large geographic states such as North Dakota 
and Alaska, are served by a single SVH. \5\ Expansion of ADHC in State 
Veteran Homes alone would not meet the needs of all eligible Veterans 
in a state. For example, there is a SVH in Marquette, Michigan, which 
is located in the Chairman's 1st Congressional District. However, the 
Marquette SVH is more than 4 hours from Alpena, Michigan, also in the 
Chairman's District. Michigan's only other SVH is located in Grand 
Rapids, also several hours away from Alpena. So while SVH expansion 
would benefit some Veterans it would not make sense for all eligible 
Veterans looking for ADHC.
---------------------------------------------------------------------------
    \3\ Caring for our Disabled Veterans Op-ed, Congressman Lee Zeldin, 
April 4, 2016, https://zeldin.house.gov/media-center/press-releases/
caring-our-disabled-veterans-fight-expand-adult-day-care
    \4\ National Adult Day Services Association, Research, http://
www.nadsa.org/research/
    \5\ National Association of State Veteran Homes, Directory of State 
Homes, http://www.nasvh.org/StateHomes/statedir.cfm

    Easter Seals Recommendation: As H.R. 2460 advances, Easter Seals 
encourages the Subcommittee to add ``or eligible non-Department 
extended care providers'' after every ``State home'' reference in the 
bill to ensure that other non-VA providers are included in the bill's 
---------------------------------------------------------------------------
other improvements.

Support for Adult Day Health Care Reimbursement That Reflects Costs:
    Easter Seals fully supports H.R. 2460's effort to ensure that the 
VA's reimbursement rate for ADHC better reflects the true costs 
associated with providing this highly skilled service. Specialized 
adult day health care available through community providers could cost 
approximately $90 per day or more, which is significantly less than the 
estimated $250 per day associated with nursing home care. Current VA 
reimbursement for ADHC is under $75 per day, which does not meet 
current costs.
    H.R. 2460 would tie the VA's adult day health care reimbursement 
rate to 65 percent of the payment the VA pays for State home nursing 
home care, a provision that Easter Seals strongly supports. In 
addition, the VA typically only authorizes up to two days of adult day 
health care despite the fact that some Veterans require additional 
care. For example, Easter Seals Serving DC, MD, VA provides adult day 
health care for about 30 Veterans through its Baltimore program. Some 
of the Baltimore-area Veterans that are covered through the VA's ADHC 
program require more than the two days that the VA currently covers. 
These Veterans are paying out-of-pocket for the remaining days.

    Easter Seals Recommendation: Easter Seals applauds efforts to more 
accurately reflect the cost of adult day health care and urges the 
Subcommittee to maintain the 65 percent rate provision. In addition, 
Easter Seals asks the Subcommittee to include report language urging 
the VA to increase the number of days a Veteran can receive VA-
reimbursed ADHC, as long as the Veteran requires the additional care 
and is already eligible for the more comprehensive nursing home care.

    Adult day health care is a critical long-term, extended care 
support that should be available to all eligible Veterans, no matter 
where they live. H.R. 2460 makes significant improvements to the 
provision of ADHC service at the VA. Easter Seals urges the 
Subcommittee to advance this important legislation with our recommended 
changes to ensure Veterans can maintain their health and independence 
by staying in their home and community through adult day health care.
    Thank you for the opportunity to share Easter Seals' views with the 
Subcommittee.

                                 --------
                 NATIONAL ASSOCIATION OF MENTAL ILLNESS
          STATEMENT OF MARY GILIBERTI, CHIEF EXECUTIVE OFFICER
    Chairman Benishek and members of the Subcommittee, I am Mary 
Giliberti, Chief Executive Officer of NAMI (the National Alliance on 
Mental Illness). I am pleased to offer NAMI's views on the draft bill 
before the Subcommittee directing the Secretary to establish a list of 
drugs that would require a new set of informed consent protocols.
    NAMI is the nation's largest grassroots advocacy organization 
dedicated to building better lives for the millions of Americans 
affected by mental illness. NAMI State Organizations and over 900 NAMI 
Affiliates across the country raise awareness and provide support, 
education and advocacy on behalf of people living with mental health 
conditions and their families.
    Through our NAMI Veterans and Military Council, our state and local 
NAMI organizations are engaged with VA Medical Centers in working with 
veterans and their families. The VA recently renewed a Memorandum of 
Understanding (MOU) with NAMI that allows us to continue to offer 
NAMI's ``Family-to-Family'' and ``Homefront'' classes to veterans and 
their families.
    NAMI would like to thank the Subcommittee on the important 
bipartisan work it has done in recent years to improve treatment and 
services for veterans living with mental health conditions. While 
enormous challenges still confront the VA in lowering wait times and 
expanding access to evidence-based practices such as Assertive 
Community Treatment (ACT) and crisis intervention, progress has been 
made in reaching veterans earlier. We encourage the Subcommittee to 
build on these accomplishments by continuing its oversight activities 
and supporting investments in evidence-based practices for treatment 
and services for mental illness.
    NAMI, however, would like to raise a number of concerns regarding 
the draft bill before the Subcommittee.

    1)The proposal unfairly singles out mental health conditions and 
the medications used to treat them as part of a new mandatory protocol 
that stigmatizes both these disorders and their treatment - NAMI 
believes that this proposal sets forth a dangerous precedent by 
singling out a category of medications, ``psychotropic drugs'' 
(referenced in Section 7335), as part of a separate informed consent 
protocol. While NAMI supports the goal of improving clinical care in 
the VA through appropriate informed consent, any new requirement 
designed to achieve this laudable goal should apply across all 
therapeutic areas: orthopedics, endocrinology, pulmonary medicine, 
neurology, nephrology, etc. Mental health medications should NOT be 
singled out in federal policy for different or separate treatment 
protocols.

    2)The proposed mandatory informed consent requirement has enormous 
potential to limit access to psychiatric treatment in the VA - NAMI is 
extremely concerned that this mandatory, inflexible informed consent 
protocol would serve as a significant barrier to veterans engaging in 
needed mental health treatment. Forcing clinicians to go through a 
multi-step mandatory checklist which, as currently drafted in this 
legislation, informs a veteran only about negative risks is exactly the 
wrong way to engage individuals in treatment. Effective practice 
dictates that engagement in mental health treatment needs to be done 
carefully and on the patient's terms. Imposing a government-mandated 
protocol would be enormously disruptive to the process of engagement.

    3)The proposed requirements in the draft legislation for disclosure 
contain a number of inaccurate statements regarding the FDA market 
approval process and authority over labeling of products - Page 5, line 
4 of the draft legislation requires prescribers to state that ``the FDA 
has not approved any psychiatric drugs to be used in combination with 
other psychiatric drugs.'' In fact, the FDA never approves medications 
to be used in combination with other therapies. Instead, in the pre-
market approval process, the FDA reviews data from randomized 
controlled trials submitted by sponsors to ensure safety and efficacy 
of individual products. Further, page 4, line 15 of the current draft 
sets forth a requirement for the disclosure of ``unknown dangers of 
mixing drugs and dosages in sizes and combinations that have not been 
approved or tested by the FDA.'' NAMI is concerned about any 
requirement dictating that prescribing physicians talk to their 
patients about ``unknown dangers.'' Instead, NAMI feels strongly that 
physicians should be guided by evidence-based practice and peer 
reviewed treatment guidelines to tailor treatment and services to the 
unique person they are working with.

    4)Use of the term ``psychotropic'' medications in the draft 
legislation lacks precision - It is unclear from the text of the 
legislation what the term ``psychotropic medications'' actually means. 
In fact, there are a broad range of therapeutic classes that are 
utilized for on-label treatment for mental health conditions. These 
include antipsychotics, antidepressants, anticonvulsants, 
benzodiazepines and others. Within these therapeutic classes, there are 
many other conditions for which there are FDA on-label indications. 
Does the legislation intend to apply these new disclosure mandates on 
this broad range of disorders and indications?

    5)Discussion of alternative treatment should be grounded in 
evidence-based services - NAMI supports physicians discussing with 
their patients the broad range of available therapies and options 
throughout the course of treatment. This is especially important with 
mental health conditions where individuals often experience periodic 
acute episodes of symptoms such as mania, psychosis or suicidal 
ideation. However, in discussing therapeutic interventions and 
alternative therapies, it is critical that the options being discussed 
be limited to and grounded in evidence-based practice. Physicians in 
the VA, and any other health care setting, should not be forced to 
disclose treatment options for which there is no scientific basis for 
safety and efficacy.

Better Education and Training of Prescribing Physicians in the VA Will 
    Improve Care

    NAMI supports the goal of this draft legislation in promoting 
enhanced communication to veterans about diagnosis, treatment, outcomes 
and alternatives. A mandatory, inflexible informed consent protocol 
will not achieve this common goal. In order to achieve the goal of 
better-informed and engaged patients in the VA, Congress should require 
the VHA to develop training and consultation programs that promote 
communication and engagement with individual patients. Such a training 
program should apply across all areas of clinical practice in the VA, 
not just the prescribing of medications to treat mental health 
conditions.
    As an organization that embraces veterans living with mental 
illness, NAMI is eager to assist the VA in developing a program of best 
practices for patient engagement. This would include developing a 
curriculum for primary care physicians and specialists in internal 
medicine as these clinicians write the majority of prescriptions for 
psychotropic medications in the VA.
    Despite the progress that has been made in recent decades, there is 
still stigma associated with mental health conditions. Particularly 
among veterans, there is often reluctance to acknowledge symptoms such 
as depression, anxiety, mania and delusional thoughts associated with 
conditions such as schizophrenia, bipolar disorder, depression and 
PTSD. Engaging veterans in treatment is a careful and nuanced process, 
one that can only occur effectively on the individual veteran's terms. 
A mandatory, inflexible informed consent protocol will not achieve this 
goal. Education and training of prescribing physicians is the answer.
    This Subcommittee has made significant progress in expanding access 
to mental health care in the VA. This record of accomplishment can be 
improved through training and education, not new government-mandated 
protocols that interfere with engagement and treatment.
    Thank you for the opportunity to offer NAMI's views on this 
legislation.

                                 --------
            VETERANS AFFAIRS PHYSICIAN ASSISTANT ASSOCIATION
                            President VAPAA
                          Rubina DaSilva PA-C
    Chairman Benishek, Ranking member Brownley, and other members of 
the House Veterans Affairs Subcommittee on Health, on behalf of the 
entire membership of the Veterans Affairs Physician Assistant 
Association (VAPAA) we appreciate the invitation to submit this 
testimony for the record. We thank members of this committee for 
critical, bipartisan legislation on Physician Assistant (PA) Workforce 
issues in the VA.We are very appreciative of H.R. 3974, The `Grow Our 
Own Directive: Physician Assistant Employment and Education Act of 
2015,'' ) and we thank Congresswoman Ann Kuster for her leadership on 
this bill.

    As committee members are aware, Public Law 113-146, the Veterans 
Access, Choice, and Accountability Act of 2014, directs the Secretary, 
under the VA's Health Professionals Education Assistance program, to 
give scholarship priority to applicants pursing education or training 
towards a career in a health care occupation that represents one of the 
five largest staffing shortages. However, despite the PA profession 
being ranked on 1/2015 and 9/2015 as 3rd and 4th on the OIG 
Determination of Veterans Health Administration's Occupational Staffing 
Shortages, the VHA has not created a dedicated PA scholarship program 
for any prospective students wishing to become a PA.
    When congressional leaders ask VHA about the availability of 
scholarship money for PA scholarships; Healthcare Talent Management 
(HTM) will state that scholarship money for PA students is available 
through the Employee Incentive Scholarship Program (EISP). 
Unfortunately, despite this assertion, the VAPAA has found that these 
programs are not applied for PA recruiting scholarships or educational 
support.'

    For Example:

    Congressional Question: What is the amount of scholarship monies 
that is currently available for Intermediate Care Technicians (ICT)?

    VHA Response: The annual budgets for the following two Health 
Talent Management programs for which all VA staff including Physician 
Assistants (PA) and ICTs can apply are the following:

      The Employee Incentive Scholarship Program (EISP) - 
$2,000,000 (Provides educational funding, i.e., tuition, books, fees)
      The VA National Education for Employees Program (VANEEP) 
- $14,573,000 (Provides educational funding and replacement salary

    A report from the Government Accountability Office in September 
2015, shows that EISP has allocated from FY 2010 through FY 2014 - 
$128,832,503.00 in funding for nursing and $11,842,919.00 in support of 
NPs and NP programs, with only $319,074.00 for PAs. Only 6 employees 
received scholarships to become PAs and 40 PAs who were mastered 
prepared but received a bachelor's degree, completed additional course 
work to earn their Master's degree from University of Nebraska bridge 
program.
    As of April 20, 2016, it appears that VHA is in violation of Public 
Law 113-146 as VHA has not created a scholarship program or given 
scholarship priority to PAs pursing education or training towards a 
career in a health care occupation that represents one of the five 
largest staffing shortages.
    In fact, the Health Professional Scholarship Program (HPSP) is a 
subcomponent of the Health Professionals Educational Assistance Program 
(HPEAP). The original authorization for HPSP expired in 1998. On May 
10, 2010, Public Law 111-163, Section 603 of The Caregivers and 
Veterans Omnibus Health Services Act of 2010, eliminated the 1998 
sunset date and re-authorized the use of HPSP through December 14, 
2014. The final rule for reinstatement of HPSP was published in the 
Federal Register and became effective on September 19, 2013. This 
timeframe allowed approximately one year during which the scholarship 
program would be operative. On August 7, 2014, as a result of Section 
302 of Public Law 113-146, VACAA extended the authorization for HPSP 
through December 31, 2019. In accordance with Section 301 of VACAA, 
annual HPSP awards will be based on the top five healthcare occupations 
for which there are the largest staffing shortages throughout VA.
    However, the (Office of Nursing Services) ONS and the Office of 
Academic Affiliation (OAA) included HPSP to fund VA Nursing Academic 
Partnerships - Graduate Education. 1.2 million dollars in funding 
earmarked for this program to pay for Acute Care Nurse Practitioner, 
Adult-Gerontology Nurse Practitioner, or Psychiatric Mental Health 
Nurse Practitioner. In addition HPSP funding will be used for 
appointments to the affiliated School of Nursing to pay for non-VA 
staff instead of providing support for our veterans.
    To maintain a PA workforce, the VA must invest in its PA workforce. 
By FY 2022 48.7% of PAs will be eligible to retire. PAs have a Total 
Loss Rate of 10.92% (1.) which is the second highest total loss rate of 
any of the Mission Critical Occupation 2015. PAs have 1 year quit rate 
of 9.6% and a 5yr quit rate of 32.3%. PAs current vacancy rate is 23% 
which is well above the overall VHA vacancy rate of 16%. Despite being 
on the Workforce Succession Planning MCO for several years, and being 
on the OIG top 5, PAs only netted a mere 129 new PAs for FY 2015.
    The PA profession has a unique relationship with veterans. The very 
first classes of physician assistants to graduate from PA educational 
programs were all former Navy corpsmen and army medics who served in 
the Vietnam War and wanted to apply their knowledge and experience in a 
civilian role in 1967. Today, there are 210 accredited PA educational 
university programs across the United States and approximately 2,020 
PAs are employed by the Department of Veterans Affairs (VA), making the 
VA the largest single federal employer of PAs. These PAs provide high 
quality, cost effective quality health care working in hundreds of VA 
medical centers and outpatient clinics, providing medical care to 
thousands of veterans each year in their clinics. PAs work in both 
ambulatory care clinics, emergency medicine, CBOC's in rural health, 
and in wide variety of other medical, mental health, and surgical 
subspecialties. \1\ In the VA system about a quarter of all primary 
care patients treated are seen by a PA. Approximately 32% of PAs today 
employed by VHA are veterans, retired military, or currently serving in 
the National Guard and Reserves.
---------------------------------------------------------------------------
    \1\ Total loss rate Workforce Succession Planning 2016 reported 
10.3, however, Workforce Analysis Dashboard 4.11.2016 shows PA total 
loss rate at 10.92%
---------------------------------------------------------------------------
    The Veterans Affairs Physician Assistant Association (VAPAA) 
maintains that Physician Assistants are a critical component of 
improving VA health-care delivery, and have consistently recommended 
that VHA include them in all health-care national strategy staffing 
policy plans. However, since January 1993 when VA added the Title 38 
GS-13, Chief Grade more than 22 years ago, little else has been done 
for this critical workforce and hope that as these committees review 
changes to improve access to care for veterans and oversight on VHA 
strategy for its healthcare workforce that changes will be included to 
address these PA problems.

Continued Delays in Hiring PA Employees

    VAPAA has found since last May's HVAC hearing that whenever a PA 
employee leaves the VA, VA acknowledges that it can take still six 
months to a year to fill one vacant position-assuming a viable pool of 
candidates is interested and available. When the VA seeks to replace 
health care professionals, VA cannot compete with nimble private health 
care systems. The lengthy process VA requires for candidates to receive 
employment commitments and boarding continues to hinder the VA ability 
to recruit and officially appoint new employees.
    Private health care systems can easily fill PA vacancies in a 
matter of days or weeks. While PA applicants may have noble intentions 
of working for VA and serving veterans, many will forgo what could be a 
4 to 6 month long waiting period and pursue timely employment 
opportunities elsewhere. For these reasons, we ask Congress to 
carefully review VA appointment authorities, internal credentialing 
processes, and common human-resources practices to identify ways to 
streamline the hiring process. If VA takes months to fill its health 
care vacancies with top talent, VA will continue to fail the delivery 
of timely, quality care to our nations' veterans.
    Members of HVAC and SVAC both introduced bipartisan legislation 
last October, providing for specific plans for Grow Our Own, asking 
that VA utilizing VHA provisions (Titles III and VIII of the newly 
enacted Veterans Access, Choice, and Accountability Act of 2014) to 
include the national VHA plans for expanding recruiting for new FTEE PA 
positions and for retaining an optimal PA workforce utilizing our 
recommendations below.

    Department of Veterans Affairs ``Independent Care Technician'' 
(ICT) Program, One Solution to Support Transitioning Medics and 
Corpsmen OIF OEF OND into ``Grow Our Own'' to Physician Assistant 
Occupation

    VAPAA points to another solution for meeting the healthcare 
workforce challenges in a recent pilot program. On October 26, 2011, 
the Administration announced its commitment to providing support to 
unemployed Post 9/11 combat veterans and it highlighted the PA 
profession as a prominent targeted career path for new returning 
veterans who had served as medics and corpsmen with combat medical 
skills similar to the history of returning Vietnam War veterans with 
these skills within the ICT pilot VA program at 19 VA sites. Medics and 
corpsmen receive extensive and valuable health care training while on 
active duty. They represent a large workforce - 74,000 medics and 
corpsmen, including Guard/Reserve, with 10,400 separating (FY 2011). 
According to a 2011 Army HR report, more than 20,000 medics were 
unemployed. Combat medics were the third largest military specialty 
drawing unemployment funds in 2011 from the Army.
    Under this initiative, the Administration promoted incentives to 
create training, education, and certifications of medic and corpsmen in 
need of transitioning of their military medical skills, being hired to 
work inside VA emergency departments, and has expanded into primary 
care, mental health, and surgery clinic positions.
    The VA has an excellent opportunity to facilitate and coordinate 
``Grow Our Own'' combat medics, Corpsmen, or Air Force paramedics to 
transition to the physician assistant occupation. However the (ICT's) 
currently in the Grow Our Own VA program are being frustrated by 
statements they should not expect scholarships from VA, and there is 
lack of VHA policy language directing VAMC's to ensure educational 
support of these combat veteran PA program candidates, assisting them 
in admission to accredited PA university Masters programs with targeted 
scholarships for PA Education. Ten former OIF OEF combat veterans 
already enrolled in University PA program in Tennessee are told they 
will not be eligible for scholarships.
    VAPAA is concerned over this ICT program that started in 2012 as it 
is being reported to be expanding to more full time ICTs. The continued 
lack of use of recruitment educational incentives within VHA and having 
it left at the discretion of the local hiring facility is setting up 
further frustration across the VA system with the lack of VHA 
scholarships for the critical PA occupation. The Office of VA 
Healthcare Retention and Recruitment and the VAMC's participating in 
the pilot ICT program have no dedicated VHA support to transition them 
into PAs The barriers to PA recruitment and retention will continue 
unless congressional members provide oversight, VHA must ensure that 
employee incentive programs, such as the EISP and the VA Employee Debt 
Reduction Program are made consistently available to all critical 
healthcare workforce PA vacancy announcements and utilized in ICT the 
program. VISN and VA medical center directors they must be held 
accountable for the failure to utilize these recruiting tools.
    The ICT Program establishment and expansion was authorized by the 
Under Secretary of the VA in March 2015. The program expansion will 
increase ICTs in the VA from the original 45 by hiring 234 more ICTs. 
Hiring the additional 234 ICTs has been left to the discretion of the 
Facility Directors of individual VAMC's.
    Between March 2015 when the ICT expansion was approved and March 
2016, less than 6 of the additional 234 ICTs have actually been hired 
by the VA. So VHA was supposed to develop a national VA veteran 
employment program targeting OIF OEF combat medics and corpsmen but it 
is being managed by local VAMCs with little oversight from VHA or VISN 
Directors.

Critical Workforce Occupations:

    VA's mission statement for human resources is to recruit, develop, 
and retain a competent, committed, and diverse workforce that provides 
high quality service to veterans and their families. VA identifies 
specific occupations as ``critical occupations'' based on the degree of 
need and the difficulty in recruitment and retention. There are 3 types 
of primary care clinical providers within the VA that provide direct 
patient care - Physicians, Physician Assistants and Nurse 
Practitioners. Physicians have mandated yearly market pay survey. Nurse 
Practitioners, by virtue of being a nurse, are under the mandated 
yearly RN LPS.
    PAs in a few facilities fall under Special Salary Rates; however, 
this is NOT mandated yearly. Some facilities have not performed a 
special salary survey for 11 years, resulting in the reporting in the 
VISN 2014-15 Workforce Succession Plan - 12 out of the 21 VISNs (88 VA 
main facilities) reported the reason that their VISN cannot hire PA's 
is because they cannot compete with the private sector pay. VA has 
refused to pursue steps to solve the current retention problems for 
PA's.

    Recommendations: We ask that both committees recognize the need to 
invest in the Recruitment and Retention of the PA Workforce in the VA 
System by supporting enactment and supported by the veteran service 
organizations at the November 18, 2015 hearing on S. 2134 and call 
attention the VHA witness Dr. Carolyn McCarthy testified in favor of 
this legislation `Grow Our Own Directive: Physician Assistant 
Employment and Education Act of 2015.'' (H.R. 3974). Additionally, we 
recommend the following--

    A.Restructure VHA Handbook 1020 - Employee Incentive Scholarship 
Program (EISP).
    B.Include PAs at all facility level to reflect Workforce Succession 
Planning and the OIG Top 5 as a hard to recruit occupation as this is 
the qualifying factor for EISP funding.
    C.Include Education Debt Reduction Plan in all PA job postings.
    D.Include targeted scholarships for the ICT program OIF OEF Grow 
Our Own returning veterans, and mandate VHA shall appoint PA ICT 
National director to coordinate the educational assistance necessary 
and be liaison with PA university programs.
    E.H.R. 3974 would direct new Physician Assistant director position 
to work within the National Healthcare Recruiter, Workforce Management 
& Consulting VHA Healthcare Recruitment & Marketing Office.
    a.This position then can develop targeted recruiting plans with 187 
PA programs, working in a way that the local Human Resource Officer 
(HRO) often will not; due to lack of staffing.
    F.The VA employed PA national Healthcare Recruiter would develop 
improvements in finding qualified candidate in a matter of days not 
months.
    G.VHA must incorporate new PA consultant manager into this National 
Healthcare Workforce program office.
    H.Health Professional Scholarship Program.-The Health Professional 
Scholarship Program (HPSP) provides scholarships to students receiving 
education or training in a direct or indirect health care services 
discipline. Awards are offered on a competitive basis and are exempt 
from Federal taxation. In exchange for the award, scholarship program 
participants agree to a service obligation in a VA health care 
facility. The Committee continues to support this program and is 
concerned that VA is limiting HPSP awards to only nursing students in 
fiscal year 2016. The Committee believes strongly that ample resources 
exist within the Department to ensure that hard to fill Top 5 OIG 
occupations are not excluded from participation. The Committee directs 
the VA to report to the Committee on Appropriations of both Houses of 
Congress no later than October 30, 2016, each profession that is 
eligible to receive the scholarship and any limitation that the 
Department is placing on awards
    I. Establish PA Pay Grades I-V, to continue be competitive with the 
civilian job market

Conclusion:

    Chairman Benishek, Ranking member Brownley, and other members of 
the HVAC Subcommittee on Health; as you strive to ensure that all 
veterans receive timely access to quality healthcare and as you build 
increased capacity for delivery of accessible high quality health care, 
and demand more accountability into the VA health care system, I 
strongly urge the full Committee to review the important critical role 
of the PA profession and to ensure legislatively that VHA takes 
immediate steps to address these longstanding problems and continue to 
work with us in supporting our Nation's veterans.

DISCLOSURE OF FEDERAL GRANTS OR CONTRACTS

    Veterans Affairs Physician Assistant Association
    The Veterans Affairs Physician Assistant Association (VAPAA) does 
not currently receive any money from a federal contract or grants. 
During the past six years, VAPAA has not entered into any federal 
contracts or grants for any federal services or governmental programs.
    VAPAA is a 501c (3) nonprofit membership organization.

                                 --------
             VETERANS OF FOREIGN WARS OF THE UNITED STATES
       STATEMENT OF CARLOS FUENTES, SENIOR LEGISLATIVE ASSOCIATE
                      NATIONAL LEGISLATIVE SERVICE
    MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:

    On behalf of the men and women of the Veterans of Foreign Wars of 
the United States (VFW) and our Auxiliaries, thank you for the 
opportunity to offer our thoughts on today's pending legislation.

H.R. 2460, To improve the provision of adult day care services for 
    veterans

    The VFW supports this legislation, which would expand adult day 
health care for veterans.
    Currently, veterans who are at least 70 percent service connected 
are eligible to receive cost free nursing home or domiciliary care at 
any of the more than 150 state veterans homes throughout the country. 
While nursing home care is a necessity for veterans who can no longer 
live in the comfort of their home, the VFW strongly believes veterans 
should remain in their homes as long as possible before turning to 
inpatient, long term care options. Adult day care is vital to ensuring 
such veterans are able to remain in their homes as long as possible.
    However, veterans who are eligible for cost-free nursing home care 
at state veterans homes are largely denied the option to receive cost-
free adult day care services at these facilities. Due to VA's delay in 
publishing regulations for adult day care, only three state veterans 
homes currently provide adult day care services. This legislation would 
rightfully ensure VA and state veterans homes have the authority to 
provide nursing home eligible veterans the ability to delay 
institutional care and remain in their homes with their loved ones.

H.R. 3956, VA Health Center Management Stability and Improvement Act

    This legislation would require VA to develop and implement a plan 
to hire highly qualified directors for each VA medical center (VAMC). 
The VFW agrees with the intent of this legislation and has 
recommendations to improve it.
    The VFW agrees that VA must urgently address the high volume of 
interim and acting directors throughout the VA health care system. 
According to recent VA data, more than 20 percent of VAMC and Veterans 
Integrated System Network (VISN) director positions are currently 
vacant. It is critical for VA to install permanent leadership at its 
medical centers to ensure it addresses the access crisis and is able to 
restore veterans' faith and confidence in their health care system.
    However, the VFW does not believe a plan to hire permanent 
directors would be successful if VA is not given the authority to 
properly compensate VAMC and VISN directors. Director positions are 
difficult to fill because they are responsible for overseeing hundreds 
of employees, who deliver care and services to thousands of veterans. 
That is why the VFW recommends the Subcommittee authorize market-based 
compensation for VA medical directors.
    VA must also have the leeway to quickly hire a qualified candidate 
when one is identified. The best qualified person for a medical center 
position may not be searching for a job on USA Jobs, and if VA 
identifies a qualified candidate it should not be required to have that 
candidate apply for an opening through USA Jobs. That is why the VFW 
urges the Subcommittee to authorize VA to directly hire VAMC and VISN 
directors.
    Furthermore, VA will not be able to quickly fill vacancies amongst 
VAMC and VISN directors if it lacks the human resources staff needed to 
identify qualified candidates and process their employment 
applications. Recent VA data shows VA has 633 vacancies in human 
resources throughout the Department. The VFW urges the Subcommittee to 
work with VA to ensure it has the authority to recruit, employ and 
retain the human resources employees it needs to quickly fill vacancies 
and develop succession planning processes to prevent high vacancy 
rates.

H.R. 3974, Grow Our Own Directive: Physician Employment and Education 
    Act of 2015

    This legislation would build on the success of the Intermediate 
Care Technician (ICT) Pilot Program. Launched in December 2012, the ICT 
pilot program recruited transitioning veterans who served as medics or 
corpsmen in the military to work in VA emergency departments as 
intermediate care technicians. The ICT program offered transitioning 
medics and corpsmen, who have extensive combat medicine experience and 
training, the opportunity to provide clinical support for VA health 
care providers without requiring them to undergo additional academic 
preparation.
    This legislation would go a step further by affording transitioning 
medics and corpsmen the opportunity to become physician assistants. 
With the end of the wars in Iraq and Afghanistan, and the continued 
drawdown of military personnel, more medics and corpsmen will be 
leaving military service and transitioning into the civilian workforce. 
The VFW strongly supports efforts to leverage their medical knowledge 
and experience to meet the health care needs of our nation's veterans.

H.R. 3989, Supporting Our Military Caregivers Act

    This legislation would require VA to contract with an independent 
entity to review appeals regarding eligibility determinations for the 
program of Comprehensive Assistance for Family Caregivers, commonly 
known as the Caregivers Program. While the VFW agrees with the intent 
of this legislation, we cannot support it as written.
    The VFW has heard too many instances of inconsistent implementation 
of the Caregivers Program. This is largely due to the fact that 
Caregivers Program eligibility is determined at the local VAMC level by 
a veteran's treatment team without proper guidance on how to make such 
a determination. The VFW has urged VA to establish a handbook for VA 
physicians to use as a reference when making a determination on whether 
a veteran is able to live independently without the assistance of 
others.
    VA physicians must also have the proper guidance on how to conduct 
a clinical evaluation to determine the degree to which a veteran is 
unable to perform activities of daily living and how many hours of care 
a veteran requires per week. To this date, VA has failed to provide 
such guidance to the field and has allowed VAMC personnel to continue 
to make inconsistent eligibility determinations. VA has informed the 
VFW it is working diligently on a directive to address inconsistent 
implementation of this important program. The VFW looks forward to such 
directive and will monitor progress to ensure VA medical facilities 
comply with the directive.
    The most common concern we hear from veterans regarding the 
Caregivers Program is that they were considered to be in the highest 
tier (requiring at least 40 hours of care per week), but were 
downgraded or discontinued from the program when they relocated to a 
different VAMC or VISN. The VFW has found that this is caused by an 
automatic re-evaluation that is triggered when a veteran moves from one 
VISN or VAMC to another.
    For example, a veteran who is service connected for numerous severe 
mental health conditions from Tennessee, where he was determined to 
require at least 40 hours a week of caregiver support, moved to 
Colorado. When the veteran received a re-evaluation at his new VAMC, it 
was determined the veteran no longer needed the assistance of a 
caregiver and was discontinued from the program, despite needing the 
aid of his wife to perform activities of daily living. Furthermore, the 
determination to discontinue the veteran from the program was made 
without a VA health care professional from his new VAMC conducting a 
site visit.
    The VFW strongly believes veterans who are determined to be 
eligible for the Caregivers Program should not be required to undergo a 
re-evaluation simply because they move to a different state or VISN 
catchment area. That is why we have urged VA to end such practice and 
ensure a qualified health care professional conduct a site visit to 
review a veteran's level of dependency before such veteran is 
discontinued from this important program.
    Veterans who disagree with a clinical determination made by their 
treatment team are not given appropriate recourse for appealing such 
decisions. This legislation seeks to correct this issue by authorizing 
veterans to seek a second opinion from an independent entity. While the 
VFW strongly believes veterans who disagree with a decision made by 
their treatment team must be afforded a fair and expedient opportunity 
to appeal such decision, we do not believe an independent contractor 
would have the experience in diagnosing and treating the unique health 
care conditions veterans face. Furthermore, this legislation fails to 
address the larger issue that limits a veteran's ability to appeal an 
eligibility decision regarding the Caregivers Program - VA's inadequate 
clinical appeals process.
    VA's current clinical appeals process does not afford veterans the 
ability to have their decision reviewed beyond the VISN level. Veterans 
who disagree with a clinical review conducted by the VAMC chief medical 
officer are given the opportunity to have the decision reviewed by the 
VISN director, who rarely overturns the VAMC decision. Moreover, the 
VISN level appeal is final, unless a veteran appeals to the Board of 
Veterans Appeal, which is not a viable option for veterans who require 
time sensitive medical treatments. That is why the VFW strongly urges 
this Subcommittee to review and reform the VA clinical appeals process.

Draft legislation to ensure each medical facility of the Department of 
    Veterans Affairs complies with requirements relating to scheduling 
    veterans for health care appointments

    The VFW supports the intent of this legislation, which would 
require all VA medical facilities to certify compliance with scheduling 
laws and directives. However, the VFW does not believe this legislation 
would resolve the underlying issue with scheduling at VA medical 
facilities.
    In the VFW's two reports on the Veterans Choice Program, which can 
be found at www.vfw.org/vawatch, we found VA's wait time metric is 
flawed and susceptible to data manipulation. For example, VA's 
preferred date metric does not properly measure how long a veteran 
waits for an appointment. A recent Government Accountability Office 
(GAO) report entitled ``Actions Needed to Improve Newly Enrolled 
Veterans' Access to Primary Care'' also highlights how a veteran who 
waited 20 days to see a primary care provider from the time he 
requested an appointment is recorded into the scheduling system as 
waiting 4 days for his appointment.
    The VFW recognizes that using the request date as the starting 
point is also flawed because VA has established an arbitrary wait time 
goal of 30 days for all appointments, which does not represent how the 
health care industry measures wait times. In a recent report, the RAND 
Corporation found the best practices in the private sector for 
measuring timeliness of appointments are generally based on the 
clinical need of the health care requested and in consultation with the 
patient and their family. That is why the VFW has urged VA and Congress 
to move away from using arbitrary standards to measure whether an 
appointment was delivered in a timely manner and adopt industry best 
practices by basing the timeliness of appointment scheduling on a 
clinical decision made by health care providers and their patients.
    The VFW does not believe this legislation can be successful if VA's 
wait time metric remains flawed and susceptible to data manipulation. 
Compliance with flawed metrics does not lead to better health care 
outcomes for veterans.

Discussion draft to direct the Secretary of Veterans Affairs to 
    establish a list of drugs that require increased level of informed 
    consent

    This discussion legislation would ensure veterans are properly 
informed of the possible side effects and dangers of certain 
prescription drugs before beginning a treatment regimen. The VFW 
supports this draft legislation and has several recommendations to 
improve it.
    The VFW has heard from veterans time and time again that they want 
to be incorporated in decisions regarding their health care. In 
particular, veterans who have been prescribed high dose medications to 
treat their health conditions would like to know whether they have 
alternatives to pharmacotherapy that are effective and lead to similar 
or better health care outcomes. This draft legislation would rightfully 
require increased informed consent before VA health care professionals 
prescribe potentially harmful drugs.
    While informed consent is important to ensure veterans are 
incorporated in decisions regarding their health care, such consent 
cannot be used to waive a VA provider's liability if veterans are 
adversely impacted by such medications. The VFW recommends the 
Subcommittee include a provision to ensure informed consent, as 
detailed in this legislation, does not release VA from liability if an 
adverse action were to occur as the result of such treatment.
    This legislation would also require VA to inform veterans of the 
potential danger of mixing drugs and dosages in sizes and combinations 
that have not been approved by the Food and Drug Administration. While 
general information on drug interactions is important, the VFW believes 
it would be more beneficial to give veterans an explanation of how the 
suggested prescription drug would affect the patient in accordance with 
all of the patients currently prescribed pharmaceuticals. By doing this 
veterans will be able make a personalized informed decision.
 Information Required by Rule XI2(g)(4) of the House of Representatives
    Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW 
has not received any federal grants in Fiscal Year 2016, nor has it 
received any federal grants in the two previous Fiscal Years.
    The VFW has not received payments or contracts from any foreign 
governments in the current year or preceding two calendar years.

                                 [all]
```