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25–155 2017

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 

( 

Available via the World Wide Web: http://www.fdsys.gov 

Leonard.horne on VACREP0180 with DISTILLER

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

RALPH ABRAHAM, Louisiana 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

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. 

Leonard.horne on VACREP0180 with DISTILLER

(III) 

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 

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IV 

National Association of Mental Illness .................................................................. 58 

Veterans Affairs Physician Assistant Association ................................................ 59 

Veterans of Foreign Wars of the United States .................................................... 63 

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(1) 

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 comLeonard.horne on VACREP0180 with DISTILLER

2 

plies 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 

Leonard.horne on VACREP0180 with DISTILLER

3 

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. 

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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 

Leonard.horne on VACREP0180 with DISTILLER

5 

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. 

Leonard.horne on VACREP0180 with DISTILLER

6 

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 AP- PENDIX]

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 

Leonard.horne on VACREP0180 with DISTILLER

7 

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 conLeonard.horne on VACREP0180 with DISTILLER

8 

versations 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 VISNapproved 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 sucLeonard.horne on VACREP0180 with DISTILLER

9 

cessor 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 waittime 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 

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10 

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 

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11 

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 

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12 

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. 

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13 

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]

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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 

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15 

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 

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16 

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. 

Leonard.horne on VACREP0180 with DISTILLER

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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. 

Leonard.horne on VACREP0180 with DISTILLER

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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 

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19 

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. 

Leonard.horne on VACREP0180 with DISTILLER

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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 

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21 

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 inforLeonard.horne on VACREP0180 with DISTILLER

22 

mation, 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. 

Leonard.horne on VACREP0180 with DISTILLER

23 

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. 

Leonard.horne on VACREP0180 with DISTILLER

24 

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 

Leonard.horne on VACREP0180 with DISTILLER

25 

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 

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26 

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. 

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27 

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 cancelby-patient rate, the established patient zero-day wait, and then in 

Leonard.horne on VACREP0180 with DISTILLER

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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 

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29 

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. 

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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 

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31 

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.] 

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1Government Accountability Office (GAO). 2014. Actions Needed to Address Higher-Than-Expected Demand for the Family Caregiver Program. Informational, Washington, D.C. : GAO. 

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

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. 

Leonard.horne on VACREP0180 with DISTILLER

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33 

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. 

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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. 

f 

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. 

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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. 

f 

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. 

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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. 

f 

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 

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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. 

f 

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 measLeonard.horne on VACREP0180 with DISTILLER

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ures 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; 

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• 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; 

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• 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 ‘blackbox’ 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 

f 

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. 

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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, conLeonard.horne on VACREP0180 with DISTILLER

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sistent 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. 

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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. 

f 

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. 

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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 

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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. 

f 

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 hosLeonard.horne on VACREP0180 with DISTILLER

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pital 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.) § 1745 to require the Secretary to enter into an agreement under 38 U.S.C. § 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 § 1720(c)(1) of this 

title or a contract’’ with each State home is inadequate. VA does not have independent agreement authority under § 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 

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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. § 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 § 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 § 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 § 1720G.’’ 

VA does not support this bill because VA already has an existing mechanism in 

place to review eligibility determinations under § 1720G, including, where appropriate, consideration of recommendations from an external clinical review. 

VA implemented Caregiver Support Programs under § 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. § 1720G(c), all decisions by the Secretary under § 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 § 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 

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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 

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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 missioncritical 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 

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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. § 7331, as implemented 

by 38 CFR § 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 proLeonard.horne on VACREP0180 with DISTILLER

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viding 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. 

f 

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. 

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1 American legion Resolution No. 21 (Aug 2014): State Veteran Home Per Diem Reimbursement 2 American Legion Resolution No. 101 (Sept. 2015): Department of Veterans Affairs Recruitment & Retention 

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

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

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 excelLeonard.horne on VACREP0180 with DISTILLER

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3 American Legion Resolution No. 95 (Sept. 2015): Support Employment of Veterans in the 

Public and Private Workforce 

lent 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

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. 

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4The American Legion Resolution 292 (Aug. 2014): Traumatic Brain and Post Traumatic 

Stress Disorder Programs 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. 

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

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 

f 

wgoldstein@legion.org. 

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 disLeonard.horne on VACREP0180 with DISTILLER

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2 U.S. Department of Veterans Affairs. Office of Informatics & Analytics. VA Mental Health 

Services Public Report. Nov. 2014. 

order, 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. 

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 

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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 

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 jregan@psych.org. 

f 

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 

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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-adultday-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 

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. 

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 communitybased 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. 

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-ofpocket 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. 

f 

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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. 

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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 evidencebased 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. 

f 

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 

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cants 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), 

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1Total loss rate Workforce Succession Planning 2016 reported 10.3, however, Workforce Analysis Dashboard 4.11.2016 shows PA total loss rate at 10.92% 

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. 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 

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cational 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. 

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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. 

f 

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 

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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 

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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. 

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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. 

Æ 

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