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S. HRG. 115–8 

NOMINATION OF HON. DAVID J. SHULKIN, M.D., 

TO BE SECRETARY, U.S. DEPARTMENT OF 

VETERANS AFFAIRS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

FEBRUARY 1, 2017 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

JON TESTER, Montana, Ranking Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

RICHARD BLUMENTHAL, Connecticut 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

TOM BOWMAN, Staff Director 

TONY MCCLAIN, Democratic Staff Director 

(III) 

C O N T E N T S 

FEBRUARY 1, 2017 

SENATORS 

Page 

Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia ............................ 1,3 

Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana ...................... 4 

Sullivan, Hon. Dan, U.S. Senator from Alaska ..................................................... 169 

Rounds, Hon. Mike, U.S. Senator from South Dakota ......................................... 173 

Sanders, Hon. Bernard, U.S. Senator from Vermont ........................................... 176 

Tillis, Hon. Thom, U.S. Senator from North Carolina .......................................... 179 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 181 

Brown, Hon. Sherrod, U.S. Senator from Ohio ..................................................... 183 

Manchin, Hon. Joe, III, U.S. Senator from West Virginia ................................... 187 

Cassidy, Hon. Bill, U.S. Senator from Louisiana .................................................. 189 

Blumenthal, Hon. Richard, U.S. Senator from Connecticut ................................ 191 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 195 

Heller, Hon. Dean, U.S. Senator from Nevada ..................................................... 198 

Hirono, Hon. Mazie K., U.S. Senator from Hawaii ............................................... 200 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 201 

WITNESSES 

Toomey, Hon. Patrick J., U.S. Senator from Pennsylvania ................................. 1 

Shulkin, Hon, David J., M.D., Nominee, Secretary, U.S. Department of Veterans Affairs ......................................................................................................... 6 

Prepared statement .......................................................................................... 8 

Response to prehearing questions submitted by: 

Hon. Johnny Isakson .................................................................................... 10 

Hon. Jon Tester ............................................................................................. 16,32 

Hon. Jerry Moran ......................................................................................... 33 

Hon. Patty Murray ........................................................................................ 39 

Hon. Bernard Sanders .................................................................................. 43 

Hon. Richard Blumenthal ............................................................................ 45 

Hon. Sherrod Brown ..................................................................................... 47 

Response to posthearing questions submitted by: 

Hon. Jon Tester ............................................................................................. 49,55 

Hon. Jerry Moran ......................................................................................... 55 

Hon. John Boozman ...................................................................................... 67 

Hon. Bill Cassidy .......................................................................................... 69 

Hon. Thom Tillis ........................................................................................... 70 

Hon. Mike Rounds ........................................................................................ 72 

Hon. Dan Sullivan ........................................................................................ 73 

Hon. Patty Murray ........................................................................................ 81 

Hon. Sherrod Brown ..................................................................................... 91 

Hon. Richard Blumenthal ............................................................................ 95 

Hon. Mazie K. Hirono ................................................................................... 100 

Hon. Joe Manchin III ................................................................................... 101 

Questionnaire for Presidential nominees ....................................................... 108 

Letters from the Office of Government Ethics ............................................... 163 

Letter from the nominee to the Office of General Counsel, U.S. Department of Veterans Affairs .............................................................................. 166 

APPENDIX 

Casey, Hon. Robert P., Jr., U.S. Senator from Pennsylvania; letter ................... 215 

Page

IV 

Walz, Rep. Tim, Ranking Member, U.S. House Committee on Veterans’ Affairs; prepared statement .................................................................................... 216 

Thevenot, Laura, Chief Executive Officer, American Society for Radiation 

Oncology (ASTRO); letter .................................................................................... 219 

Rausch, William J., Executive Director, Got Your 6; letter ................................. 221 

Reeves, Randy, President, The National Association of State Directors of 

Veterans Affairs, Inc. (NASDVA); letter ............................................................ 222 

(1) 

NOMINATION OF HON. DAVID J. SHULKIN, 

M.D., TO BE SECRETARY, U.S. DEPARTMENT 

OF VETERANS AFFAIRS 

WEDNESDAY, FEBRUARY 1, 2017 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 2:50 p.m., in room 

106, Dirksen Senate Office Building, Hon. Johnny Isakson, Chairman of the Committee, presiding. 

Present: Senators Isakson, Moran, Boozman, Heller, Cassidy, 

Rounds, Tillis, Sullivan, Tester, Murray, Sanders, Brown, Blumenthal, Hirono, and Manchin. 

HON. JOHNNY ISAKSON, CHAIRMAN, 

U.S. SENATOR FROM GEORGIA 

Chairman ISAKSON. We are in the midst of what may be as many 

as five votes on the floor, and in order to keep the Committee moving quickly and have this hearing over with as expeditiously but 

as thoroughly as possible, we are going to start off in a little bit 

different order. I will introduce Senator Toomey from Pennsylvania 

to make an introduction of Dr. Shulkin. Then we will have an 

opening statement by the Ranking Member, an opening statement 

by myself, and then we will begin to go to the hearing with the 

Members present. 

Is that satisfactory with everybody? Is that OK with you, Jon? 

Senator TESTER. You bet. 

Chairman ISAKSON. With that being the case, I introduce the distinguished Senator from Pennsylvania for the purposes of remarks 

about the Secretary-to-be. 

STATEMENT OF HON. PATRICK J. TOOMEY, 

U.S. SENATOR FROM PENNSYLVANIA 

Senator TOOMEY. Thank you very much Chairman Isakson, 

Ranking Member, Tester, Members of the Committee. I appreciate 

this opportunity to briefly introduce Dr. Shulkin before the 

Committee. 

You know, Washington, D.C., has long been a city that focuses 

a lot on titles. When Dr. Shulkin arrived in Washington to help 

take charge and reform a troubled Veterans Health Administration, he got a new 8title. He was ‘‘Honorable’’ Under Secretary of 

the Veterans Administration. Yet there is another title which I 

2 

think is more important to him, and by which he is very wellknown in Pennsylvania, and that is doctor. 

Despite the challenges which he has faced, and with which he 

has been entrusted, he has never forgotten his focus on medicine 

and his focus on serving others. As a fellow Pennsylvanian, it is an 

honor for me to be able to introduce him to this Committee today. 

You know, Pennsylvania has a very large number of veterans, 

nearly a million across our commonwealth. We have eight VA medical centers, 31 VA community-based outreach clinics. I have said 

many times, our veterans should be first in line for the best quality 

health care in America. 

In Pennsylvania and across our country in recent years, that has 

not always been the case, but in recent years the VA and Congress 

have worked to address some of the challenges and issues, and we 

have made progress. 

There is more work to be done. It is my hope that after confirmation, Dr. Shulkin will be leading that charge. I think he is the right 

man for this moment. 

He has got a very, very impressive and distinguished background. He is a graduate of the Medical College of Pennsylvania, 

now part of Drexel. He did his residency and fellowship at the University of Pittsburgh. He ended up back in Philadelphia at the University of Pennsylvania, where he played numerous roles, working 

his way up to become Chief Medical Officer and Chief Quality Officer for the University of Pennsylvania Health System. Dr. Shulkin 

then went on to Temple, then Drexel, managing those schools’ hospitals in various capacities. He then left for New York and became 

the President of the Beth Israel Medical Center. He later became 

President of the Morristown Medical Center, which is part of the 

Atlantic Health System. 

In 2015, Dr. Shulkin got the call that the VA needed his experience to help address some of the problems that we were facing 

there, and as the Committee knows, in 2014 the VA was embroiled 

in major scandals. Well, despite the difficult circumstances, Dr. 

Shulkin agreed to accept the position, accept the challenges, and he 

was confirmed by the Senate without objection. He then began to 

fix the implementation of the Choice Act, which had significant 

problems. 

Last week, Dr. Shulkin and I met and had a very constructive, 

great conversation about many things, including the ongoing implementation challenges of the Choice Act. I was very, very impressed 

with his extensive knowledge and his insights. I think those—that 

knowledge and insights have been forged by a career as a top administration in some of the Nation’s largest hospital systems, but 

it is also informed by his personal experience as a physician, which 

I think is invaluable. 

I look forward to continuing our work together to help our Nation’s veterans. It is an honor for me to be able to introduce Dr. 

David Shulkin to the Veterans’ Affairs Committee today. He is a 

great Pennsylvanian. I believe he will be a great leader of this essential organization. 

I thank you very much Mr. Chairman and Ranking Member 

Tester. 

3 

Chairman ISAKSON. Senator Toomey, thank you very much for 

being here. I know your time is tight and I appreciate your remarks about Dr. Shulkin. I appreciate all the work you have done 

to help the Veterans’ Affairs Committee. You will be excused. We 

will not hold it against you because you have got to vote; so do we. 

Senator TOOMEY. Thank you very much. 

Chairman ISAKSON. Thank you. 

Dr. Shulkin, we are going to have brief remarks by me, then the 

Ranking Member, then it will be your turn at the microphone. 

OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 

U.S. SENATOR FROM GEORGIA 

Chairman ISAKSON. I want to tell everybody about the first time 

I met Dr. Shulkin. It was on a Delta airplane, flying to Washington, DC, where I have met most of the people I know in my life, 

it seems like, between Georgia while coming to Washington, DC. I 

had just come from a meeting in my office with an anesthesiologist 

in Georgia, who had a concern and a question about the VA and 

anesthesiology and nurse anesthetists and all those types of 

things—a complicated issue, which is not the most important part. 

The important part is that Dr. Shulkin recognized me and came 

over and gave me his card and said, ‘‘I am David Shulkin.’’ I said, 

‘‘Well, I know who you are. We are going to have you before the 

Committee pretty soon.’’ He said, ‘‘Yeah. On Tuesday.’’ That is 

when we had his confirmation hearing as Under Secretary. 

I said, ‘‘Well, I will tell you what. Let me give you this card that 

I just received in my office from this anesthesiologist who has a 

concern with VA and anesthesia. Would you call him if you get a 

chance?’’ 

I got to the office the next morning. Dr. Shulkin had not only 

called him but he had called him and spent about 3 hours on the 

phone with him, and when I got to the office I had a call from Dr. 

Shulkin to let me know he had talked to him, plus a call from the 

doctor to tell me how satisfied he was that Dr. Shulkin cared 

enough to call him. 

That is what I look for. That is the tender, loving care that we 

look for in all executives that is rarely ever there, and in a job like 

veterans’ health care, that type of service and attitude is important. I also want to remind Dr. Shulkin of what he did that day, 

and that was my first day I knew if I could cast a good vote for 

him, I would. 

Now, let me just make these remarks, because all of the Members are going to have a lot of questions later on, and I know Sen. 

Tester is going to make remarks after I do. 

It is very important that we complete the task of getting open 

accessibility to our veterans to health care, but we make everybody 

understand we are not about privatizing health care for veterans. 

We are about making health care more available to veterans 

through implementation of the private sector with the Veterans 

Administration. We do not want to privatize it; we want to empower it. 

Further, we know that we still have wait times far too long on 

appeals. If we have one goal after getting Choice fixed, if we have 

one goal we have got to have, that is to get the wait time on apVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6601 Z:\ACTIVE\020117.TXT PAULIN
4 

peals down, and I mean way down. I think it is doable if we, on 

the Committee, do our job, working with the appropriators, and if 

the VA does its job in telling us what it really needs to do to speed 

up that process, whatever it might be. I am committed to accomplishing those two things in this 2-year term on the Committee. 

With that said, I am really lucky, as a Chairman, to have had 

a great Ranking Member in Richard Blumenthal the last 2 years. 

He helped the whole Committee unanimously pass through the 

U.S. Senate the Jeff Miller and Richard Blumenthal Veterans 

Health Care and Benefits Improvement Act last year, the last day 

of the session before Christmas. We made a lot of steps forward, 

but we did not make the ones we needed to, we did not make all 

of them. 

Now Jon Tester will replace Richard Blumenthal as Ranking 

Member, so I still am blessed to have the best Ranking Member I 

could possibly have. He is a good friend. He cares about veterans. 

I enjoy working with him a lot. With that said I will introduce Sen. 

Jon Tester of Montana. 

OPENING STATEMENT OF HON. JON TESTER, RANKING 

MEMBER, U.S. SENATOR FROM MONTANA 

Senator TESTER. Well, thank you, Chairman Isakson. I look forward to working with you, too. You are very kind. Thank you. 

Dr. Shulkin, welcome to this Committee. 

Dr. SHULKIN. Thank you. 

Senator TESTER. As you may have noticed, you are operating on 

a little bigger stage than what you operated on before, in more 

ways than one. 

I appreciate you accepting the responsibility that comes with the 

duties of the Secretary of the Department of Veterans Affairs. It is 

my hope, and I believe the hope of this Committee, that you are 

up to this task. The way in which you answer our questions today 

will help many of us make that final determination. 

Amidst an impressive career as a health care executive in the 

private sector, you were brought into the VA about 18 months ago 

to help transform the administration and delivery of veterans’ 

health care. The wait time scandals that arose from Phoenix, back 

in 2014, were something that none of us could tolerate. 

After Secretary Robert McDonald took the helm of the Department, a number of senior leaders were replaced and a number of 

transformational reforms were initiated, many of which you were 

a part of. Meanwhile, Congress, in a rare demonstration of bipartisanship, enacted the Veterans Access, Choice and Accountability 

Act of 2014. This legislation sought to bolster the capacity of the 

VA to better directly serve veterans, and to expand veterans’ access 

to community care when the VA was incapable of providing that 

care in a timely manner. Now, 21⁄2 years later, the VA is confronted 

with looming and dramatic funding shortfalls and a so-called 

Choice Program that, at least in Montana, has only left veterans 

with the choice of waiting longer for care or not getting it at all. 

Just a couple of weeks ago, a veteran from Helena, MT, wrote 

me: ‘‘Trying to get a cardiologist and working with the Choice Program was one of the most stressful parts of my heart attack incident. It took 19 days from the time the Choice Program was conVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6601 Z:\ACTIVE\020117.TXT PAULIN
5 

tacted with my urgent case for me to get to the specialist. I was 

concerned the entire time that I was going to have a heart attack 

while I was waiting.’’ 

This is unacceptable. I can share dozens of similar stories, from 

frustrated veterans, family members, and even front-line VA employees in Montana, not to mention community providers in my 

State and across the country that continue to drop out of the 

Choice Program because of the bureaucracy involved and the time 

it takes to get reimbursed through this program. 

Look, I get it. Some of it is how that law was written, and 

some—actually, a lot in my State—is on the part of the third-party 

administrator. But, a lot also has to fall on the VA, and as the 

head of the Veterans Health Administration for the last 2 years, 

a lot of that responsibility falls directly with you. 

We often look at the numbers and the statistics up here, to try 

to determine whether a program or an agency is effective, but behind every statistic, behind every number is a person and a story. 

And the story I hear every time I go back to Montana, which is almost every weekend, is that the Choice Program is making a difficult problem even worse. 

The VA has endorsed an effort to simply extend the life of that 

program, but I will tell you, if anyone wants to extend the life of 

that program, without also taking the steps needed to make it 

work better for veterans, you are going to have to go through me. 

And I will oppose you every step of the way. I relayed that message 

to you during our last conversation in my office. It is my understanding that we are on the same page. I appreciate you being upfront about that. 

I also know that you will be fighting a war on multiple fronts. 

While trying to carry out the Department’s mission, you will have 

to deal with a Congress that has not proven itself to be the most 

productive or cooperative partner. You will have to deal with the 

new President, who has taken some public positions on everything 

from privatization to personal opinions about the VA workforce 

that are in stark contrast to the positions that you have taken. 

Sooner then later you will come to a crossroads. You will have 

to choose whether to pursue what you think is best for veterans or 

what the President tells you is best for veterans. I want you to succeed. It is critically important. But, there was a reason it took so 

long to find someone to sit in your chair here today. 

In a conversation with VSO representatives a couple of weeks 

ago, Bob Wallace, the VFW Executive Director, described Bob 

McDonald’s job, your predecessor, as trying to turn around the Titanic in a bathtub, in as little time as possible. 

Under Secretary McDonald’s leadership there is no question that 

VA has made some meaningful and tangible progress on critical 

priorities like connecting more veterans to care, ending veterans’ 

homelessness, and getting the disability claims backlogged under 

control. Though the overall veteran population has decreased in recent years, more and more veterans are enrolled in VA health care 

and are receiving critical benefits like disability compensation or 

educational benefits. 

As we move forward, more veterans will come out of the shadows. The veteran population will age, and their already complex 

6 

medical conditions will become even more complex. These folks will 

turn to the VA and it is critical that you earn their trust by demonstrating that you can meet their needs in not only a timely but 

a thorough manner. 

So, the question of the day is whether you can build upon VA’s 

successes and continue delivering for veterans and their families, 

while also taking steps to address the systemic and chronic challenges that impede the Department’s ability to carry out its 

mission. 

In short, I hope you are up for the job. We need to know that 

you are the right person to lead this department at a critical time, 

because there is far too much at stake. 

I look forward to this discussion today and I want to thank you 

again for your willingness to serve on behalf of our Nation’s veterans and their families. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Tester. I appreciate your 

service and I appreciate your thorough opening statement. 

Now we are getting ready to see what a Congressional shuffle is 

all about. We had our second vote called. You saw a couple of Members leave to go over. They will come back so I can go over and replace them. We are going to go back and forth and play ping pong 

for about an hour and one-half. That is not to diminish a single 

question that we need to ask, and if we have to pause for a minute 

to get everybody back, we will do that, Dr. Shulkin. 

Dr. Shulkin, would you please stand and raise your right hand? 

Do you solemnly swear or affirm that the testimony you are 

about to give before the Senate Veterans’ Affairs Committee is the 

truth, will be the truth, the whole truth, and nothing but the truth, 

so help you God? 

Dr. SHULKIN. I do. 

Chairman ISAKSON. Thank you. You may be seated. 

You are welcome to have the floor for 5 minutes or so, a little 

more if you want it, and if you have got any family members or 

anyone you want to introduce in the audience, please do so. 

STATEMENT OF HON. DAVID J. SHULKIN, M.D., NOMINEE TO 

BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Dr. SHULKIN. OK. Well, Chairman Isakson, thank you for your 

remarks, and Ranking Member Tester, thank you for your remarks, and to all the distinguished Members of the Committee, 

and everyone here who joined us who cares deeply about veterans, 

I want to thank you for being here today. 

I have gotten to know all of you over the past 18 months, and 

I have a great respect for this Committee and the work you do. I 

happen to think it is the best committee in the Senate. It works 

in a bipartisan way on the behalf of veterans. 

It has been a privilege to serve as the Under Secretary for 

Health for the past 18 months, and it is my highest professional 

honor to be considered for the Secretary of Veterans Affairs. 

I am also grateful to my wife, who is here today, Dr. Merle Bari, 

somewhere—that way. OK. We met in medical school. We have 

been married for 29 years. It has been her continuous support and 

encouragement during my first confirmation process, and now, alVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6601 Z:\ACTIVE\020117.TXT PAULIN
7 

most 2 years later, when we started that, her commitment to veterans that has really inspired me. My two children, Danny and 

Jenny, are probably watching too, and I think all of you know our 

jobs are really family affairs. 

Our country’s sacred obligation to fully honor our commitments 

to our veterans is deeply personal to me. I was born on an Army 

base. My father was an Army psychiatrist—he is probably watching too. Both grandfathers were Army veterans, and my paternal 

grandfather served as the Chief Pharmacist at the VA hospital in 

Madison, WI. 

As a young doctor I trained in several VA hospitals. I view my 

service at VA as a duty to give back to the men and women who 

secured the uniquely American freedoms and opportunities we all 

enjoy because of the sacrifices they made. 

I came to VA at a time of crisis, when it was clear that veterans 

were not getting timely access to high-quality health care they deserved. I soon discovered that it was years of ineffective systems 

and deficiencies in workplace culture that led to these problems. I 

concluded it would take years to fix these problems, but because 

veterans’ lives were at stake, there was no time to waste. That is 

why I focused on meeting the most urgent health care needs of our 

veterans first, and reorganized our approach to reflect that. 

As a result, we have dramatically reduced the number of people 

waiting for urgent care. The VA now has same-day services in primary care and mental health at all of our medical centers, to make 

sure veterans get the urgent care they need, when they need it 

most. 

Over the past 18 months, I have had the opportunity to travel 

across the country to hear directly from veterans, their service organizations, and stakeholders about their concerns with VA. I appreciate both the candor of these conversations and the overwhelming support and commitment I have received from so many 

in improving VA. The opportunity to spend with and learn about 

the needs of the veterans we serve was the best preparation I could 

have had for this nomination. 

VA has been working hard to act more as an integrated enterprise, and toward that end I have worked closely with my colleagues in Veterans Benefit Administration and the National Cemetery Administration. I understand that veterans see us as one VA 

and not as three separate administrations. Creating a seamless experience for veterans accessing benefits and services is critical to 

fulfilling our mission. If confirmed, I would build upon my 

foundational understanding of these issues to accelerate change 

across all three administrations. 

VA is a unique national resource that is worth saving, and I am 

committed to doing just that. One thing I want to be especially 

clear on is that VA has many dedicated employees across the country, and our veterans tell us just that every day. It is unfortunate 

that a few employees who have deviated from the values we hold 

so dear have been able to tarnish the reputation of so many who 

have dedicated their lives to serving those who have served. 

There should be no doubt that if confirmed as Secretary, I will 

seek major reform and a transformation of VA. There will be far 

greater accountability, dramatically improved access, responsiveVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6601 Z:\ACTIVE\020117.TXT PAULIN
8 

ness and expanded care options, but the Department of Veterans 

Affairs will not be privatized under my watch. If confirmed, I intend to build a system that puts veterans first and allows them to 

get the best possible health care wherever it may be, in VA or in 

the community. 

I have demonstrated my commitment to moving care into the 

community where it makes sense for the veteran. When I began my 

tenure as Under Secretary for Health, 21 percent of care was delivered in the community, but today that figure stands at 31 percent. 

But, veterans tell us that even with the ability to seek care in the 

community, they want VA services. Of the more than 1 million veterans who took advantage of the Choice Program, only 5,000 have 

sought care solely in the community. The rest used both VA and 

the community. 

Should I be confirmed, I intend to build an integrated system of 

care that would strengthen services within VA that are essential 

for veteran well-being, and use services in the community that can 

serve veterans with better outcomes and value to the taxpayer. We 

will need to work closely together to extend and reform the Choice 

Program to ensure veterans are able to seek the care in the community they need. 

We have made significant progress in suicide prevention, including hiring more mental health professionals, implementing a predictive tool to identify those at the greatest risk, and fixing the 

Veterans Crisis Line so it better serves our veterans. We must also 

continue our progress in addressing the unique needs of women 

veterans by expanding women’s health services and ensuring our 

facilities are welcoming to women. I also want to recognize the importance of supporting the efforts of families and caregivers who 

are involved in the care of our veterans. 

We have to continue our work to eliminate the disability claims 

backlog, and we need legislation that would allow us to reform the 

outdated appeals process. We must continue the progress we have 

made in reducing veterans’ homelessness, and modernize our IT 

systems to improve our services and efficiencies. We have to address infrastructure issues and take a closer look at facilities that 

no longer serve a useful purpose. We must explore expansion of 

public-private partnerships rather than continue to build medical 

centers that have large cost overruns and take too long to build. 

With the support of the Members of this Committee and others 

in Congress, veterans and their service organizations, the dedicated 

employees of VA, and the American people, we can fulfill President 

Lincoln’s promise and our sacred mission ‘‘to care for him’’—and 

now for her—‘‘who shall have borne the battle.’’ There is no nobler 

mission or higher calling for me, and it would be my distinct honor 

and privilege to lead this effort. Our veterans deserve the very 

best, and with your support, I am confident we will succeed. 

Thank you and I look forward to your questions. 

[The prepared statement of Dr. Shulkin follows:] 

PREPARED STATEMENT OF DR. DAVID SHULKIN, NOMINEE TO BE SECRETARY, U.S. 

DEPARTMENT OF VETERANS AFFAIRS

Chairman Isakson, Ranking Member Tester, Distinguished Members of the Committee on Veterans’ Affairs, and everyone here today who cares deeply about our 

Veterans: Thank you for the opportunity to address you. I have gotten to know 

9 

many of you over the past 18 months, and I have great respect for this Committee 

and the work you do. It has been a privilege to serve as Under Secretary for Health 

over the past 18 months. It is my highest professional honor to be nominated for 

consideration as the next Secretary of Veterans Affairs. 

I’m grateful to have my wife, Dr. Merle Bari, with me here today. We met in medical school and have been married for 29 years. Her continuous encouragement and 

support since my first confirmation process almost two years ago, as well as her 

commitment to our Veterans, have inspired me. 

Our country’s sacred obligation to fully honor our commitments to our Veterans 

is deeply personal to me. I was born on an Army base. My father was an Army psychiatrist, both grandfathers were Army Veterans, and my paternal grandfather 

served as Chief Pharmacist at the VA hospital in Madison, Wisconsin. As a young 

doctor, I trained in VA hospitals. I view my VA service as a duty to give back to 

the men and women who secured the uniquely American freedoms and opportunities 

we all enjoy because of the sacrifices they made. I came to VA during a time of crisis, when it was clear Veterans were not getting the timely access to high-quality 

health care they deserved. I soon discovered that years of ineffective systems and 

deficiencies in workplace culture had led to these problems. I concluded it would 

take years to fix the problems, but because Veterans’ lives were at stake, there was 

no time to waste. That is why I focused on meeting the most urgent health care 

needs of our Veterans first, and reorganized our approach to reflect that. As a result, we’ve dramatically reduced the number of people waiting for urgent care. The 

VA now has same-day services in primary care and mental health at all our medical 

centers to make sure our Veterans get the urgent care they need, when they need 

it most. 

Over the past 18 months, I have had the opportunity to travel across the country 

hearing directly from Veterans, service organizations, and stakeholders about their 

concerns with VA. I appreciate both the candor of these conversations and the overwhelming support and commitment I have received from so many for improving VA. 

The opportunity to spend time with and learn about the needs of the Veterans we 

serve was the best preparation I could have had for this nomination. 

VA has been working hard to act more as an integrated enterprise, and toward 

that end, I have worked closely with my colleagues in VBA and NCA. I understand 

that Veterans see us as one VA and not three separate administrations. Creating 

a seamless experience for Veterans accessing benefits and services is critical to fulfilling our mission. If confirmed, I would build on my foundational understanding 

of these issues to accelerate change across all three administrations. 

VA is a unique national resource that is worth saving, and I am committed to 

doing just that. One thing I want to be especially clear on is that VA has many dedicated employees across the country, and our Veterans tell us that every day. It is 

unfortunate that a few employees who deviated from the values we hold so dear 

have been able to tarnish the reputation of so many who have dedicated their lives 

to serving those who have served. 

But, there should be no doubt that if confirmed as Secretary, I will seek major 

reform and a transformation of VA. There will be far greater accountability, dramatically improved access, responsiveness and expanded care options, but the Department of Veterans Affairs will not be privatized under my watch. If confirmed, 

I intend to build a system that puts Veterans first and allows them to get the best 

possible health care wherever it may be—in VA or with community care. 

I’ve demonstrated my commitment to moving care into the community where it 

makes sense for the Veteran. When I began my tenure as Under Secretary for 

Health, 21 percent of care was delivered in the community, today that figure stands 

at 31 percent. But, Veterans still tell us that even with the ability to seek care in 

the community, they want VA services. Of the more than 1 million Veterans who 

have taken advantage of the Choice program, only about 5,000 have sought care 

solely in the community. The rest used both VA and community services. 

Should I be confirmed, I intend to build an integrated system of care that would 

strengthen services within VA that are essential for Veteran well-being, and use 

services in the community that can serve Veterans with better outcomes and greater 

value to the taxpayer. We will need to work closely together to extend and reform 

the Choice program to ensure Veterans are able to seek the care in the community 

they need. 

We have made significant progress in suicide prevention, including hiring more 

mental health professionals, implementing a predictive tool to identify those at 

greatest risk, and fixing the Veterans Crisis Line so it better serves our Veterans. 

We also must continue our progress in addressing the unique needs of our women 

Veterans by expanding women’s health services and ensuring our facilities are welVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
10 

coming to women. I also want to recognize the importance of supporting the efforts 

of families and caregivers who are involved in the care of our Veterans. 

We have to continue our work to eliminate the disability claims backlog, and we 

need legislation that would allow us to reform the outdated appeals process. We 

must continue the progress we have made in reducing Veteran homelessness, and 

modernize our IT systems to improve our services and efficiencies. We also have to 

address infrastructure issues and take a closer look at facilities that no longer serve 

a useful purpose. We must explore expansion of public-private partnerships rather 

than continue building medical centers that have large cost overruns and take too 

long to build. 

With the support of the Members of this Committee and others in Congress, Veterans and their service organizations, the dedicated employees of VA, and the American people, we can fulfill President Lincoln’s promise and our sacred mission ‘‘to 

care for him who shall have borne the battle.’’ There is no nobler mission or higher 

calling for me, and it would be my distinct honor and privilege to lead this effort. 

Our Veterans deserve the very best, and with your support, I am confident we will 

succeed. Thank you and I look forward to your questions. 

RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON TO

HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 1. Dr. Shulkin, after serving at the Department of Veterans Affairs (VA) 

for about 20 months, what do you see as the most significant challenges facing VA 

and what would be your highest priorities if confirmed as Secretary? 

Response. Our most significant challenge will be to address the systemic challenges that face VA. Over the past 18 months that I have served as USH we have 

been focused on addressing the acute issues that VA inexperienced with the crisis 

in access and the erosion of confidence with the American people. We have made 

real progress, and have turned the corner in numerous areas. However, it is now 

time to address the systemic issues that are required in business transformation. 

My highest priority would be to work with the Administration and Congress to 

develop a sustainable plan for VA’s transformation. This would involve working together to create a true integrated network of care, a system supported by an engaged workforce and modern technology solutions,and accountable for improving 

outcomes and efficiencies. 

Specifically, I would target improvements to ease of the use of our services by decreasing non value added rules and regulations, implement industry best practices 

that lead to improved quality and efficiencies. I also want to accelerate our efforts 

in suicide prevention, homelessness, women’s healthcare, continue to decrease the 

claims backlog and work on appeals modernization. 

Question 2. Dr. Shulkin, would you please detail what experiences you have had 

while serving as Under Secretary for Health that you believe have helped prepare 

you for this broader role at VA? 

Response. Most significant in preparing for the role of SECVA has been the opportunity to visit, spend time listening and learning about the needs of the veterans 

we serve. During my 18 months as USH I have seen firsthand the unique services 

and programs that VA offers to Veterans. As a practicing VA physician, I have been 

able to use and see the systems our clinician rely upon to treat Veterans. With this 

opportunity, I have learned what works and what needs to be changed. I have also 

seen all too often where we have fallen short of the trust and confidence that veterans has placed in us 

VA has been working hard to act more as an integrated enterprise and in doing 

so I have worked closely with my colleagues in VBA, NCA and the Board of Veterans Appeals. I understand that veterans see us all as one VA and not separate 

administrations and therefore having a seamless experience is critical to us fulfilling 

our mission. During my time as USH, I have been able to contribute to efforts that 

improve services to veterans who utilize VBA and NCA. If confirmed, I would 

buildupon my foundational understanding of these issues to accelerate change in all 

three administrations. 

Question 3. Since 2010, veteran homelessness has decreased by 47 percent. If confirmed, how do you intend to continue to prioritize efforts to prevent and end veteran homelessness? 

Response. While these statistics indicate tremendous progress in ending Veteran 

homelessness and that the efforts of VA and its partners are producing successful 

outcomes for many Veterans, more must be done to accelerate progress. No one entity can end homelessness among Veterans alone. To achieve this goal, we need conVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
11 

tinued urgency and commitment from leaders in every community. There has been 

unprecedented support from the Administration, Congress, and state and local leaders to provide both the funding and human resources needed to end Veteran homelessness and much of our progress has come from the VA’s collaboration with community leaders focusing efforts on the implementation of evidence based proven 

practices that are reducing homelessness among Veterans. But we know that ending 

Veteran homelessness is not a single event in time; rather, it is a deliberate effort 

made to achieve the goal, and continued follow-up efforts to make sure that progress 

toward achieving the goal is maintained. 

We must continue our commitment to our efforts around rapid rehousing and permanent supportive housing for Veterans who fall into homelessness so that their 

homelessness is rare, brief, and nonrecurring. The ultimate goal is to make sure 

that every Veteran has permanent, sustainable housing with access to high-quality 

health care and other supportive services and that Veteran homelessness in the future is prevented whenever possible. 

But housing Veterans is not the end of the journey. These Veterans, especially 

Veterans who have experienced chronic homelessness, need ongoing intervention 

and case management. Therefore, we must commit to continue to fully support our 

homeless programs such as HUD-VASH and Supportive Services for Veteran Families (SSVF) and the current efforts to transform our homeless Grant and Per Diem 

(GPD) program. These programs provide data driven essential services designed to 

support Veterans with obtaining and maintaining housing stability. With our full 

commitment to stay the course that has proven successful to date, we can and will 

end Veteran homelessness and provide the blueprint for solving all homelessness. 

Question 4. Legislation was enacted last fall to authorize VA to implement its 

master plan for the West Los Angeles campus. This new model for the campus, with 

a focus on housing and supportive services for veterans, could become a model for 

future VA campuses. If confirmed, how would you safeguard against mismanagement, which has occurred in the past, and ensure the master plan is implemented 

in a transparent, responsible way that best serves veterans and that will be an example for other VA campuses? 

Response. In September 2016, Congress passed the West Los Angeles Leasing Act 

of 2016, which is historic legislation essential to VA’s ongoing effort to revitalize the 

West Los Angeles campus. Through such legislation, VA envisions providing approximately 1,200 permanent supportive housing units and Veteran focused services 

on the campus, particularly for homeless, severely disabled, aging, and female Veteran populations. Within the next 30 days, we plan to execute the first EnhancedUse Lease agreement for the campus, which will provide approximately 55 new 

housing units for Veterans. 

Enactment of this legislation was based on unprecedented collaboration and cooperation between the Department, Congress, Veteran Service Organizations, the 

community, and other stakeholders. Our ultimate goal is to fully revitalize the campus, so that it is both a 21st Century facility that provides convenient healthcare, 

benefits, and services, and serves a home for our Veterans and their families. As 

noted in the framework Draft Master Plan that Secretary Bob McDonald publicly 

announced in January 2016, VA is working to ensure that future third-party landuse agreements are Veteran focused and provide fair market value, from both a 

monetary and in-kind consideration standpoint. 

Currently, the West Los Angeles Leasing Act of 2016 requires VA to notify Congress 45 days before entering or renewing any leases or sharing agreement on the 

campus. The bill also requires VA to provide annual reports to Congress for the 

leases and sharing agreements carried out at West LA. In that regard, we have instituted a process where all proposed land-use agreements undergo thorough review 

of subject matter experts at both the medical center and VA headquarters, before 

approval and execution. And as required under the legislation, any revenues generated from such agreements will remain on campus, to maintain and renovate facilities to serve Veterans of greater Los Angeles. Additionally, the legislation expressly prohibits VA from disposing of any of the land at West LA. We are also required to submit annual audits to Congress, for any leases and Sharing Agreements 

executed on the campus. 

Through this process, VA has recently executed new agreements with our local 

medical affiliate, the University of California at Los Angeles, as well as the Brentwood School, and the city of Los Angeles. These agreements are part of our overall 

intent, to create irreversible momentum in a collaborative and transparent manner, 

where the campus is used consistent with the principles of the 1888 deed, which 

conveyed the property to the United States. 

We have established a new Community Veteran Engagement Board for the campus, where pertinent Veteran organizations and representatives will meet regularly, 

12 

to discuss any and all matters of interest regarding our mission and operation of 

serving Veterans on the campus; to include the framework Master Plan and campus 

development. 

A number of efforts are underway to support the implementation of the framework Draft Master Plan. In October, 2016, VA hired Concourse Federal Group 

(CFG) to assist with project management. CFG and their team of subject matter experts provide daily, on the ground support to VA for campus optimization and utilization, land use matters, and external communications. In December 2016, we also 

formed a VA Integrated Project Team, to begin the next phase of working to finalize 

the master plan for the campus. Experts from pertinent offices such as VHA; VA’s 

Office Of Construction And Facilities Management; Office Of Asset Enterprise Management, Office of General Counsel, and the Office of the Secretary, will be working 

in unison, to ensure that the next steps such as environmental, historic, traffic, and 

utilities due diligence, occurs in an open and inclusive process. VA will continue to 

hold town hall and public hearing events, to enable us to receive valuable input 

from Veterans, Veteran service organizations, our community partners, and local 

neighbors. Through this process, we envision a campus that includes not just permanent supportive housing units for Veterans and their families, but complimentary 

services to promote Veteran wellness, education, vocational training, rehabilitation, 

and peer interaction. 

We are also working with local philanthropists, specifically a 501(c)(3) entity 

known as the ‘‘1887 Fund,’’ to allow them to raise funds and provide donated expertise to restore the historic Wadsworth Chapel, and other landmark historic facilities 

on the campus. 

In coordination with the Los Angeles National Cemetery, we are working to commence the planned columbarium expansion project at the campus, to provide up to 

10,000 new niches for Veterans wishing for the campus to serve as their final resting place. 

We are also pleased to advise that the campus is under new leadership. In February 2016, Ann Brown was appointed to serve as the Medical Center Director at 

West LA. Before coming to the campus, she served as the Director at the Jesse 

Brown VA Medical Center in Chicago, Illinois. Before that, she was the Director in 

Martinsburg, West Virginia; the Acting Deputy Network Director for VISN 9; the 

Associate Director for Operations in Nashville, Tennessee, and the VISN 23 Business Office Manager in Lincoln, Nebraska. Through her leadership and during her 

brief tenure, the West LA campus now has a new Acting Associate Director, a Chief 

of Staff, an Associate Director for Patient Care Services, and an Assistant Director. 

We look forward to Ann continuing to build her team at the campus, to successfully 

carry out the charge we have for her and other VA personnel, which is to continue 

to put Veterans at the center of everything we do. 

Our sustained focus, commitment, and collaboration with the Department of 

Housing & Urban Development, the Department of Labor, local housing authorities, 

the former plaintiffs to the West LA litigation, local philanthropists, Veteran stakeholders, and the local community, has resulted in a 57% decline in Veteran homelessness in greater Los Angeles, since 2011. We know that in order to end Veteran 

homelessness nationwide, we must end it in Greater LA. Through our continued and 

collective efforts, I am confident that West LA will become a 21st-century, state-ofthe-art model for other campuses nationwide, and make us all proud as we continue 

to serve and honor our nations Veterans. 

Question 5. Women constitute an ever-growing segment of the Armed Forces and, 

consequently, the overall veteran population. What do you see as the primary challenges to appropriately treating and serving women veterans in VA facilities? 

Response. The primary challenges to caring for women Veterans in VA facilities 

include: ensuring providers are well-trained to provide women’s health services, ensuring an open and welcoming culture, including environment of care/facility issues, 

and outreaching to women Veterans prevent suicide. 

Access 

• Since 2014, VA has made tremendous strides in providing enhanced services 

and access for women. 

– 100% of medical centers and 90% of Community Based Outpatient Clinics 

have Designated Women’s Health Providers 

– 130 VA medical centers have gynecology services on-site 

– VA tracks quality by gender and has reduced or eliminated several key disparities 

o On some important quality measures, VA is better than the private sector (breast and cervical cancer screening) 

13 

• To meet increasing demand, VA needs to hire and train additional Designated 

Women’s Health Providers per year. 

– Convincing VA providers to train in Womens Health is difficult due to: 

(1) increased provider workload; 

(2) few incentives for those who have been seeing only men for decades. 

– Recruiting external providers is difficult due to: 

(1) shrinking national workforce of Primary Care physicians; 

(2) persistent perception of limited opportunity to care for women in VA settings. 

Culture 

• VA is now engaged in an enterprise-wide effort to ensure its language, practice, 

and culture is inclusive of women Veterans. 

• A 2015 national survey of women Veterans showed high satisfaction for those 

in VA care, perceived lack of Womens Health services among those not in VA care. 

• VA has launched multiple campaigns aimed at inclusivity and recognition for 

women Veterans. 

Suicide Among Women Veterans 

In 2014, an average of 20 Veterans died by suicide each day. Six of the 20 were 

users of VHA services. 

• Between 2001 and 2014: 

– The age-adjusted rate of suicide climbed much more rapidly for women Veterans than for women in the civilian population. 

– The rate of suicide for women Veterans in VA care, however, climbed more 

slowly than did the rate for those not using VA services. 

VA’s Office for Suicide Prevention partners with organizations to target services to 

women Veterans and ensures all outreach materials are inclusive. 

Question 6. In response to the mismanagement and cost overruns at the new Denver VA Medical Center, Congress mandated that all major construction projects over 

$100 million be managed by the US Army Corps of Engineers. Additionally, VA 

made numerous changes to its policies and procedures for major construction 

projects. If confirmed, would you make it a priority to continue these and additional 

reform efforts to ensure that VA major construction projects are on budget and on 

schedule? 

Response. VA’s Office of Construction & Facilities Management (CFM) is responsible planning, designing, constructing and acquiring major facilities, and setting design and construction standards. VA recognizes that there is a need for continued 

improvement in the management of its major construction program and for adopting 

best practices to avoid cost overruns and lengthy delays encountered on some recent 

major projects. 

Since 2014, VA has put in place sound construction management processes based 

on best practices from private industry and other Federal agencies including recommendations from the Government Accountability Office, VA’s Office of Inspector 

General, and the US Army Corps of Engineers (USACE). VA has also partnered 

with, and embarked on process improvements based on recommendations from construction industry partners such as the National Institute of Building Sciences and 

the Associated General Contractors of America. The following improvements were 

put in place to ensure future success in the major construction program: 

• Incorporating integrated master planning to ensure projects address gaps and 

meet agency goals; 

• Requiring major medical construction projects to achieve at least 35% design 

prior to establishing cost and schedule estimates or requesting funds; 

• Implementing rigorous requirements control and change management processes, and structured decisionmaking at key acquisition milestones; 

• Using a Project Management Plan for delivery—from planning to activation— 

to ensure clear communication throughout the life of every project; 

• Conducting pre-construction reviews of major construction projects throughout 

the design, to evaluate design and engineering factors and ensure constructability 

within given budget and schedule parameters; 

• Integrating Medical Equipment Planners into construction project teams from 

concept through activation; and 

• Putting in place metrics tools that will help monitor and manage performance 

and identify and mitigate emerging risks on large projects. 

By accepting and incorporating best practices and recommendations from these 

organizations, CFM has been on a path of continuous improvement with the goal 

of achieving successful execution of our major construction projects. 

14 

Additionally, VA and USACE have a long history of working together to advance 

VA’s facility construction program and share best practices. VA has engaged USACE 

to support our non-recurring maintenance and minor construction programs at more 

than 70 of our medical centers and national cemeteries across the enterprise. In December 2014, VA entered into an agreement to transition the Denver project to 

USACE for completion. Since then, VA has entered into agreements with USACE 

that now include VA utilizing USACE as Construction Agent on several major construction projects. This partnership continues to develop and mature, and the two 

agencies are working together to ensure the success of those partnered projects. 

VA continues to address concerns from Congress and other entities and will continue to work to ensure the VA construction program is delivering quality, sustainable facilities on-time and on-budget into the future. VA is also interested in improving the planning and execution of its entire capital program to better address 

its aging infrastructure and meet the needs of Veterans with state-of-the art facilities and services 

Question 7. What do you see as the role of this Committee in conducting oversight 

regarding VA and what steps would you take to ensure that the Committee is 

promptly notified of any emerging trends, issues, or developments at VA? 

Response. The Committee’s responsibility to the American public is to provide 

oversight of the Veterans Administration on all Veterans affairs issues to include 

budget, health care, benefits and cemetery affairs. If confirmed, I would seek to increase communication and collaboration with the Committee and its members and 

reduce the internal barriers that delay our responses and partnership with SVAC. 

I would also seek to make available my senior leaders and subject matter experts 

to answer your questions and be a resource that you need to do your job. 

Since joining the VA as Under Secretary, I have worked to provide quality and 

timely responses that meets the needs of the Committee. I will ensure that we notify your committee of concerning issues, trends and developments in a timely manner. We will continue our work on decreasing case work response time and ensure 

that you have the information you need to provide oversight necessary. 

Question 8. The National Cemetery Administration (NCA) has repeatedly earned 

the highest customer satisfaction score among the private or public sectors, yet the 

American Customer Satisfaction Index ranked the Department of Veterans Affairs 

third last in customer satisfaction among Federal agencies for 2015. What factors 

set NCA so far apart from the rest of VA and how would you leverage their best 

practices to improve customer satisfaction across the rest of the department? 

Response. NCA continues to perform at a high level and builds its customer service culture around VA’s core values, ICARE-Integrity, Commitment, Advocacy, Respect, and Excellence. In 2016, NCA received the highest ranking for any organization-public or private-on the American Customer Satisfaction Index (ACSI). With an 

index score of 96, NCA scored 28 points higher than the aggregate Federal Government score of 68.The following is a brief overview of the key processes underlying 

NCA’s high customer satisfaction ratings. 

1. Commitment from top leadership to be the best. 

2. Define Excellence using input from all levels of the organization. 

a. NCA has established a formal Organization and Assessment (OAI) program to assess performance and the overall organizational health of National 

Cemeteries, Memorial Service Networks (MSNs), and Central Office components. Using Malcolm Baldrige National Quality Award criteria as a management framework, it enables NCA to document, track, monitor, and report 

progress toward successful achievement of NCA Operational Standards and 

Measures in the key cemetery operational areas of interments, grounds maintenance, headstone/marker operations, equipment maintenance, facility, maintenance, and safety. 

b. NCA applies OAI to each organizational entity annually and records performance as a scorecard. 

c. Long Range Plan (FY 2016–2021) developed which focuses on five specific 

goals that will enhance service to Veterans and their families. 

3. Train employees on how excellence is defined and provide tools to succeed. 

a. Conduct front-line training at NCA’s National Training Center in St. Louis 

i. 48-week Cemetery Director intern program 

ii. Cemetery Caretaker training 

4. Hold employees and management accountable. 

a. Cascade performance expectations in performance plans. 

5. Establish continuous customer feedback loop and adjust OAI surveys. 

a. Quarterly Customer Satisfaction Surveys 

b. Refresh operational standards and measures based on feedback 

15 

i. Annual Lessons Learned Conference 

ii. Communities of Practice website 

6. Commitment to employing Veterans. 

a. Workforce embodies the culture of Veterans serving Veterans 

i. Almost 75% of NCA employees are Veterans 

ii. Over 28% are disabled Veterans 

The Veterans Health Administration (VHA) does, in fact, utilize the American Customer Satisfaction Index (ACSI) to understand how Veterans who have used VA 

healthcare services rate their customer experience, and compares that experience 

with that of private sector hospitals. For over a decade, VHA ACSI scores have outpaced that of the private sector (see Table 1 below). Many factors undoubtedly influence those scores—but certainly the high quality of VHA services along with their 

affordably are powerful drivers. But VHA is not content to rely solely on the ACSI 

to judge its performance, and we believe that the best way to compare ourselves is 

not with other Federal agencies, but rather, the U.S. health care system at large. 

Across private hospitals, physician groups, and plans in this Nation, the principal 

measure of patient experience is the Consumer Assessment of Health Providers and 

Systems (CAHPS) survey, which VA administers using an outside contractor. Our 

CAHPS surveys indicate VHA does have more work to do in the area of Access, although other areas, such as Comprehensiveness of Care, i.e., care for Veterans that 

focuses on all of their needs and preferences are, in fact, superior. 

Regarding best practices, while I was Under Secretary, I commissioned the Diffusion of Excellence initiative as an endeavor that focuses on achieving consistency 

of best practices throughout the VHA. During my first few months in office, I visited 

a number of facilities that had very unique ways of engaging both veterans and the 

employees who served them—even in sites that struggled to perform overall. I knew 

that if we identified the practices that worked best for veterans—both clinical and 

business-related—that we would be able to improve customer satisfaction throughout the system. 

The Diffusion model has not only identified over 100 best practices within VHA 

alone for improving the veteran experience—it actually provides a framework that 

allows us to replicate those change efforts in other areas throughout the system. 

As of today, these best practices have been replicated over 300 times across different sites in the system. The Diffusion model has gained traction, and is featured 

in an article that I wrote for the Journal of the American Medical Association, published just a couple of weeks ago. 

In addition, a major enabler of establishing and spreading these best practices is 

an electronic platform (called the Diffusion Hub) that not only helps with implementing methodologies—it also provides a library of tool kits for specific solutions 

that we would like to see everywhere. This platform not only includes projects within VHA—but projects that originated out of NCA and VBA, for spread in other administrations as appropriate. As of now, there are already several best practices in 

customer engagement that NCA has contributed to this platform through Secretary 

McDonald’s Leaders Developing Leaders (LDL) initiative. 

Table 1: VHA Trends in the American Customer Satisfaction Index 

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 

VHA Inpatients ...................................... 83 84 83 85 84 85 85 84 84 81 86 

VHA Outpatients ................................... 80 82 83 81 83 82 83 82 82 79 80 

Private Sector Hospitals ....................... 71 74 77 75 77 73 76 76 78 76 74 

Table 2: VA comparisons on Consumer Assessment of Health Providers and Systems 

(adjusted for differences in age, education, and health status) 

CAHPS Composite VA vs. Private Sector 

Access (based on % always getting carewhen needed) ............................................ 6 points lower than private sector 

Communication ............................................................................................................ About the same 

Provider Discusses Medical Decisions ......................................................................... About the same 

Self-Management Support ........................................................................................... About the same 

Comprehensiveness (attending to mental and emotional health as well as phys Comprehensiveness (attending to mental and emotional health as well as physical health) ical health).

6 points higher than private sector 

Office Staff .................................................................................................................. About the same 

Question 9. The Veterans Choice Program, created by section 101 of Public Law 

113–146, the Veterans Access, Choice and Accountability Act of 2014, would expire 

16 

August 7, 2017, without Congressional action. Going forward, how do you envision 

expanding veterans’ access to non-VA care while preserving within the Veterans 

Health Administration (VHA) the care and services VHA performs well? 

Response. One of the most critical needs facing our Veterans is access to community care. VA’s long-term vision for the future state is delivering timely, high-quality 

community care. It will make it easier for Veterans to access community care and 

easier for community providers to work with VA. 

Our goal is to deliver community care that is easy to understand, simple to administer, and meets the needs of Veterans and their families, community providers, 

and VA Staff. VA has developed a long-term strategy as a starting point that allows 

for a balance between community care and care in the VA, purchasing community 

care when VA does not provide the service or cannot provide it when clinically needed. VA needs local market assessments to determine the availability of care both 

in the VA and in the community to ensure the appropriate mix of care. 

We are making immediate improvements today, while seeking longer-term solutions. Together with Congress’s support and funding, VA will continue working to 

streamline and transform VA Community Care to improve the community care experience. 

RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VET- ERANS AFFAIRS

Question 10. Dr. Shulkin, what is your view on the role of the Secretary of Veterans Affairs? If confirmed, would you seek to be an independent advocate for veterans or would you be the executor of the Administration’s policies relating to 

veterans? 

Response. The Secretary of VA is responsible to ensure that our Nation’s veterans 

receive the highest level of service and care that we can provide. The Secretary also 

serves to ensure that the President and Congress’ policies and laws are carried out 

to the best of their ability. If confirmed, as Secretary, I would work tirelessly to see 

that these objectives are fulfilled. As Secretary, if confirmed, I would be a strong 

and independent advocate for veterans and for policies that would support the interests of veterans. Once laws and policies are put in place, the Secretary should serve 

to ensure that these are carried out to the best of his or her ability 

Question 11. Dr. Shulkin, what are your top three goals as Secretary of Veterans 

Affairs? 

Response. If confirmed, my top goals as Secretary would be: 

1) To ensure that the right people are in place to serve veterans, whether that 

be senior management or front line staff. 

2) To ensure that the right resources, tools, and systems are in place to deliver 

these services to our veterans 

3) To ensure that veterans are receiving the highest quality and character of services that they have earned and deserve. 

Question 12. Dr. Shulkin, after serving nearly two years as Under Secretary for 

Health, how will you broaden your focus for VHA to the entire organization? What 

do you foresee as your biggest challenge in that endeavor? 

Response. If confirmed, my goal for VA is to work as a seamless organization to 

meet the needs of our veterans. From a veterans perspective, they do not care if 

their services come from VHA, VBA, or NCA, but rather they care their issues are 

being addressed. The real strength of VA comes from the ability to meet physical, 

social, economic, and the holistic needs of the veteran. 

VA has been working hard to act more as an integrated enterprise and in doing 

so I have worked closely with my colleagues in VBA, NCA and the Board of Appeals. 

I understand that veterans see us all as one VA and not separate administrations 

and therefore having a seamless experience is critical to us fulfilling our mission. 

During my time as USH I have been able to contribute to efforts that improve services to veterans who utilize VBA and NCA. If confirmed, I would buildupon my 

foundational understanding of critical issues to accelerate changes in all three administrations and implement a singular veteran centric service model for VA. 

The largest challenge to working as an integrated enterprise is the ability to accelerate our journey to be a veteran centric organization and to challenge the status 

quo. 

Question 13. Dr. Shulkin, one of the Secretary’s major roles on an annual basis 

is developing and then defending VA’s budget for a given year. Please explain your 

role in this endeavor under Secretary McDonald. 

17 

Response. My role was to develop, submit and defend the budget for VA’s Medical 

Care appropriations—the Medical Services, Medical Community Care, Medical Support and Compliance, and Medical Facilities accounts, as well as for the Medical and 

Prosthetic Research appropriation. 

The VA Medical Care budget is largely driven by the VA Enrollee Health Care 

Model, an actuarial model that estimates demand for health care services for the 

more than nine million Veterans enrolled with VA. 

One of our challenges in developing this budget is that many Veterans have multiple options for health care, including Medicare, TRICARE, and employer health insurance. 

We estimate that enrolled Veterans get a little more than one third of their total 

health care from the VA; however, this demand level can change rapidly based on 

economic conditions and availability of VA services. 

We have seen steady growth in Veteran reliance on VA health care over the last 

several years, and anticipate that trend will continue in the future. 

In addition to the modeled amounts, we developed estimates for other significant 

requirements, including: 

• State Home programs 

• Homeless prevention programs 

• Readjustment Counseling Services (Vet Centers) 

• Non-Recurring Maintenance for VA’s aging health care facilities 

• Activation of new health care facilities (initial outfitting of equipment, furniture 

and supplies, and new staff when applicable) 

• Medical information technology support requirements, including VistA Evolution 

• CHAMPVA and related programs (Spina Bifida, Foreign Medical Program, and 

Children of Women Vietnam Veterans) 

• Caregivers support programs 

• Indian Health Service agreements 

• Health care services for Veterans exposed to toxic water at Camp Lejeune 

• Medical and Prosthetic Research programs 

a. Do you anticipate working within the limits established by the Office of Management and Budget or going to the President to advocate for the level of funding 

that is needed to fully fund the Department in the coming year? 

Response. It is essential that the Secretary be a strong advocate for the resources 

that are required to do the job of serving our country’s veterans. It is also essential 

that the Secretary ensure that those resources that are allocated are spent in an 

efficient and effective manner. 

As I know you understand, the Office of Management and Budget must balance 

the needs of all Federal Government agencies against the total annual budgetary 

resources established by Congress. Therefore, increases in the VA budget may need 

to come at the expense of other agencies. 

Question 14. Dr. Shulkin, if confirmed, what will be your plan to work with employee unions? Do you believe they play an important role in bridging communication between VA employees and management? 

Response. As the USH, I have seen the value in working to engage with the employee unions and there have also been challenges The five national unions within 

the VA represent approximately 285,000 VA employees. VA has also negotiated 

master collective bargaining agreements with four of the national unions. Therefore, 

engaging with the unions, including bargaining on some policies that change employees’ conditions of employment, is not only a statutory or contractual requirement, but when done effectively it creates a labor-management environment that 

enhances VA’s ability to communicate our policies and initiatives to our employees. 

Question 15. Dr. Shulkin, what is your view on the role of whistleblowers? If confirmed, will you encourage whistleblowing by the Department’s employees? 

Response. I support the Whistleblower Protection Act of 1989. VA has established 

a Whistleblower Protection Program that ensures employees, contractors, and grantees who disclose allegations of serious wrongdoing or gross mismanagement are free 

from fear of reprisal for their disclosures. If confirmed, will you encourage whistleblowing by the Department’s employees? Yes. Leaders are responsible for establishing a workplace atmosphere in which employees are comfortable highlighting 

and sharing their successes—as well as identifying areas in which we can improve. 

Whether that means notifying managers and supervisors of isolated gaps or bringing attention to larger, systemic issues that impede excellence, it is important that 

all employees are encouraged to report deficiencies in care or services we provide 

to Veterans. Relatively simple issues that front-line staff may be aware of can grow 

18 

into significantly larger problems if left unresolved. In the most serious cases, these 

problems can lead to and encourage improper and unethical actions. 

Across VA, I expect workplace environments that enable full participation of employees. I expect employees to bring to the attention of their managers and supervisors shortcomings in the delivery of our services to Veterans or any perceived violations of law or official wrongdoing—including gross waste, fraud, or abuse of authority. And I will make clear that intimidation or retaliation against whistleblowers—or any employee who raises a hand to identify a legitimate problem, make 

a suggestion, or report what may be a violation of law—is absolutely unacceptable. 

I will not tolerate it. Protecting employees from reprisal is a moral obligation of VA 

leaders, a statutory obligation, and a priority for this Department. We will take 

prompt action to hold accountable those engaged in conduct identified as reprisal 

for whistleblowing, and that action includes appropriate disciplinary action. 

Question 16. Last Congress, this Committee considered a number of legislative 

proposals that would have provided the Department with authority to sanction employees—both general schedule and Senior Executives—that is not available to other 

Federal agencies. Do you believe that, in order to best manage the Department’s 

workforce, it needs expedited firing authority that would reduce an employee’s right 

to appeal? 

Response. What we need is an employee discipline and appeal process that provides enough due process to pass constitutional muster but allows us to take action 

faster than we can under the current process and affords more deference to the 

Agency’s decisions than Merit Systems Protection Board judges often do. Ideally 

we’d like to see an overall reform of employee discipline and appeals rules throughout the Federal Government, not something that singles out VA employees for 

harsher treatment than their peers in other agencies, because we want to be able 

to attract and retain good people from all over rather than lose them to other agencies. We’d like to see a change in the agency’s burden of proof on appeal to the 

MSPB, so we can sustain our actions based on substantial evidence rather than the 

higher and harder-to-prove preponderant evidence standard that applies today. That 

small change would allow us to take discipline more expeditiously and sustain our 

well-founded actions on appeal. 

Question 17. Dr. Shulkin, have you spoken to the President-elect about your vision 

for the rest of the leadership team at VA? What is that vision? 

Response. Yes, I have spoken to President Trump about my vision for the leadership team at VA. We seek to fill our leadership positions with people that have outstanding values and ethics, people that are passionate about serving veterans, people with superb experience and competence, and people who understand the needs 

of veterans. 

Question 18. Dr. Shulkin, will you commit to quarterly meetings to update this 

Committee on progress the Department has made on recommendations from OIG, 

GAO, OSC, and other investigative reports? Who is responsible within VA for tracking and ensuring that these recommendations are implemented? 

Response. Yes, I will commit to these quarterly updates. Each Administration is 

responsible for tracking and ensuring recommendations are implemented. If confirmed I would ask that the Office of Congressional and Legislative Affairs be responsible for communicating the recommendations from these reports and the resulting actions taken by VA to comply with these recommendations. 

Question 19. Dr. Shulkin, the President-elect’s vision to reform VA included the 

following statement, ‘‘Ensure our veterans get the care they need wherever and 

whenever they need it. No more long drives. No more waiting backlogs. No more 

excessive red tape. Just the care and support they earned with their service to our 

country.’’ If confirmed, how will you achieve this vision—do you have more specifics 

on the President’s 10-Point plan for reforming and modernizing VA for the 21st 

Century? 

Response. If confirmed, I will immediately begin working to define the options 

that would work toward the improvements in VA that the President, Congress, and 

the American public seeks. In terms of the 10 point plan, I am still studying the 

various proposals and options that have been laid out by the President. 

Question 20. Secretary McDonald has been lauded by Veterans Service Organizations and military service organizations for his attentiveness to their concerns. 

a. Please describe your past VSO and MSO interactions. 

Response. My interactions with Veteran Service Organizations (VSOs) and Military Service Organizations (MSOs) have been very positive and collaborative in nature. I have met with the Big 6 VSOs (Disabled American Veterans, The American 

Legion, Veterans of Foreign Wars, Paralyzed Veterans of America, AMVETS and 

Vietnam Veterans of America) as well as Iraq and Afghanistan Veterans of America 

19 

(IAVA) on a monthly basis to share best practices and proactively address major 

VSO issues. Senior VA leaders have also met with the Post-9/11 VSO Groups: Got 

Your Six, Team Rubicon, Team Red, White and Blue (RWB), Student Veterans of 

America, Travis Manion Foundation and many MSOs such as Military Officers Association of America (MOAA) and Fleet Reserve Association (FRA) to build coalitions 

and address Veteran issues as well. VA Leaders have traveled to the major conventions and annual meetings and met individually with each of the VSO groups on 

a routine and reoccurring basis to solicit feedback and opportunities that VA can 

take to improve services for Veterans. On the local level, VA medical center facilities 

meet with our VSO partners on a monthly basis to capture feedback and improve 

the care and delivery of health care services to Veterans in the community. 

Some of the initiatives that we have worked closely with MSOs/VSOs included 

MyVA Transformation, MyVA Access and Suicide Prevention. A direct measure of 

the improvement that we have made with our MSO/VSO partners is with rebuilding 

trust. Nearly 60 percent of Veterans surveyed in June 2016 ‘‘trust VA to fulfill our 

country’s commitment to Veterans’’ which is up from 47 percent in December 2015. 

b. Please give specific examples of how you anticipate involving the VSOs and 

MSOs. 

Response. We expect the same level of partnership and engagement with our 

VSOs/MSOs colleagues to continue as we work to continue the progress/momentum 

that we have gained with MyVA Transformation. 

Question 21. Dr. Shulkin, will you commit to making data public, including the 

Monday morning workload report and wait times by medical facility? 

Response. I am a strong believer of transparency of data. I am committed to making public our wait times by medical facility and our patient satisfaction scores related to access by facility. I am not familiar with the workload report, but if confirmed would be willing to consider looking at this suggestion. 

Question 22. Dr. Shulkin, if confirmed, will you direct your agency to timely and 

fully respond to all reasonable Freedom of Information Act requests submitted by 

the American people? 

Response. Yes, as stated earlier I believe in transparency. 

Question 23. Dr. Shulkin, will you commit to sharing with committee staff VA organizational charts, for the administrations and staff offices, which include names 

and contact information, so that staff can get timely answers to concerns? 

Response. Yes 

Question 24. Dr. Shulkin, as you know, RAND recently reported that VA health 

care is as good or better than health care provided by the private sector. After nearly two years as Under Secretary of Health at VA, do you agree with this finding? 

Please explain. 

Response. Statements related to the comparison of quality between VA and the 

private sector has been studied by numerous independent research groups. These 

research finding speak for themselves. My interpretation of these studies is that 

clearly in some areas, VA outperforms the private sector. Areas of superior performance generally include the comprehensive nature of VA care and include measures 

related to health screening, primary care, outpatient measures, safety and behavioral health. However, there are other areas of healthcare performance where VHA 

lags. If confirmed as Secretary, I would continue to focus my efforts on improving 

the quality and safety of VA healthcare, and continue to pursue improvement efforts 

utilizing private sector benchmarks. 

Question 25. Many veterans, especially those with complicated health issues, rely 

upon the specialized services of the VHA. Many of these services, like spinal cord 

injury, blind rehabilitation, and prosthetics, are not widely available in the private 

sector. In an era of declining budgets and decentralization of funds, please describe 

your views on VA’s responsibility to maintain capacity in these programs. What is 

your perspective on the future of VA specialized services (spinal cord injury, polytrauma, blinded rehabilitation, mental health)? 

Response. With regard to mental health care, VA comprises an unparalleled system of comprehensive treatments and integrated services to meet the needs of each 

Veteran and the family members who support the Veteran’s care. These services 

support Veteran resilience, identify and treat mental health conditions at their earliest onset, address acute mental health crises, and provide recovery-oriented treatments. VA provides a continuum of forward-looking outpatient, residential, and inpatient mental health services across the country. In FY 2016, more than 1.6 million 

Veterans received specialized mental health treatment from VA; This number has 

risen each year from over 900,000 in FY 2006. VHA provides mental health care 

integrated within its Primary Care clinics at VHA medical centers and large and 

very large community clinics with 15% more Veterans receiving Primary Care MenVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00023 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
20 

tal Health Integration services in 2016 than in 2014. The integration of mental 

health services into primary care settings is designed in part to help overcome some 

Veterans’ reservations about seeking mental health services. It also provides an opportunity to deliver mental health services to those who may otherwise not seek 

them and to identify, prevent, and treat mental health conditions at the earliest opportunity. Through the Measurement Based Care in Mental Health Initiative, VA 

is working toward the nationwide implementation of measurement based care 

(MBC). Fifty-eight champion sites, representing 18 Veterans Integrated Service Networks, have been selected to help develop and refine the infrastructure for this implementation. With MBC, Veterans assess their wellness through a standardized set 

of questions, with the resulting data then used to individualize and enhance their 

mental health care. To our knowledge VA is the largest mental health system implementing MBC. 

A key VHA strategic principle is to ensure access, continuity, and quality for special emphasis and vulnerable populations in VHA, such as Veterans with spinal cord 

injuries and disorders (SCI/D), where VHA has expertise not found in the community. VA provides world class care to Veterans with SCI/D so they can achieve the 

highest possible health, independence, quality of life, and productivity throughout 

life. 

A unique strength of the VA SCI/D System of Care, not found elsewhere in the 

private sector, is that the full continuum of care is provided to Veterans with SCI/ 

D throughout life. This includes rehabilitation, acute care, ongoing primary care, 

preventive care (including comprehensive annual evaluations), lifelong medical management, outpatient care, home care, telehealth, respite care, long-term care, and 

end of life care. That care is coordinated through a hub and spokes model; similar 

coordination is not available outside of the VA. 

There is no better place for Veterans with an SCI/D to get care than one of the 

24 regional VA SCI/D Centers, where care is provided through highly dedicated and 

committed teams of knowledgeable and skilled professionals from different disciplines. In addition, VA facilities without an SCI Center have trained SCI/D teams 

that work closely with SCI Centers to deliver primary and limited specialty care. 

This hub and spoke model of care provides integrated and coordinated regional and 

local care throughout the US. Geographical access is further enhanced by dedicated 

SCI/D home care and telehealth programs. There are unique dedicated SCI/D longterm care units in VA that are not available anywhere else in the country. There 

are superior critical services provided in VA, such as prosthetics, bowel and bladder 

care, ventilator care, Home Improvement and Structural Modifications (HISA) 

grants, and travel. 

In 2000, a report ‘‘VA Spinal Cord Injury and Disorders: A Comparison of Program Data Collected Across Four Modes of Care’’ demonstrated that the VA SCI/ 

D System of Care was more comprehensive and offered superior resources, care, and 

training as compared with other large SCI Systems of Care in the U.S. and in Europe. Analyses of outcome data collected since then show that VA provides care that 

meets or exceeds internal and external benchmarks in all areas, including outcomes 

related to quality of life. Over the past 20 years, studies, surveys, anecdotal evidence, and behavior have demonstrated that Veterans with SCI/D highly value VA 

care. • A will maintain our commitment to ensure these Veterans receive the specialized services they need. Such services are not widely available in the private sector—if at all. • VA has established programs and systems of care to maintain and ensure the 

provision of lifelong specialized care and services for these severely disabled Veterans • VA’s systems of care for Polytrauma/Traumatic Brain Injury (TBI), Amputation, 

Spinal Cord Injury and Disorders, and Blind Rehabilitation are strong: 

– Specialized services are provided across tiered networks of specialty rehabilitation centers that serve as regional referral centers for acute inpatient rehabilitation for severe injuries. 

– Ongoing care and services are provided for Veterans in VA facilities with specialized interdisciplinary teams closer to the Veteran’s home community. • These VA programs uphold the highest standards of rehabilitation, such as 

CARF (Commission on Accreditation of Rehabilitation Facilities) accreditation for 

inpatient rehabilitation facilities, and participating in HHS ‘Model Systems’ for VA’s 

TBI and SCI programs (consortium of premiere private and academic rehabilitation 

centers). 

• VA is further committed to ensuring Veterans continue to receive the prosthetic 

items and services they need. In FY 2016, VA expended $2.8 Billion to provide 20 

million medical items, prosthetic devices and items to 3.3 million Veterans. 

21 

• With regard to mental health care, VA comprises an unparalleled system of 

comprehensive treatments and integrated services to meet the needs of each Veteran and the family members who support the Veteran’s care. 

• These services support Veteran resilience, identify and treat mental health conditions at their earliest onset, address acute mental health crises, and provide recovery-oriented treatments. 

• VA is committed to ensuring continuing access to a full spectrum of mental 

health care for our Veterans. 

Question 26. VHA has made undeniable progress over the past two years in integrating more community care into the VA health care system. Do you believe that 

a veteran’s primary care clinician should continue to be part of the VA system or 

can s/he be any clinician a veteran chooses? 

Response: VA has developed a model of personalized, proactive, primary care for 

Veterans. It provides a comprehensive approach to caring for the Veteran. Every 

Veteran is assigned to a primary care provider when they begin participating in VA 

health care to ensure their care is coordinated. This approach is critical to ensuring 

the Veterans health. However, in many parts of the country, Veterans live too far 

or face other obstacles in getting to the VA for their primary care. If Veterans receives primary care in the community, VA needs to ensure that all of the care is 

coordinated and the provider quality is the same or better than the VA. 

Question 27. As we have discussed on numerous occasions, the roll-out and execution of the Veterans Choice Program in Montana and many other states has been 

nothing short of a disaster. In fact, the same issues have remained largely unresolved for two years and have left veterans, community providers and VA employees 

frustrated and angry. As many of these issues remain the responsibility of the Third 

Party Administrators in Choice, what are you going to do to hold them accountable 

for a continued failure to meet the terms of their contract, and to meet the basic 

expectations of veterans? Do you continue to believe that VA becoming the primary 

payer of Choice for all veterans and community care spending flexibility are critical 

to ensuring that the Choice program operates as intended? 

Response. The VA uses several strategies to evaluate contractor performance and 

imposes penalties on contractors when they fail to meet the terms of their contracts. 

The Quality Assurance Surveillance Plan (QASP) is a recurring assessment of contractor performance throughout the term of the contract. When contractors fail to 

meet the metrics established in the QASPs, letters of correction and financial penalties, also called equitable adjustments, are assessed against the contractor. Equitable adjustments have been, and will continue to be, used to move the contractor 

toward meeting the metrics outlined in the contract. 

Congress can assist in simplifying the claims processes through a change in the 

law that makes the VA the primary payer. This change would lead to greater efficiencies in claims submission by our community providers and subsequent payment 

by our contracting partners. This change would also eliminate the labor intensive 

process of identifying and communicating other insurance coverage on the front end. 

A transition back to VA being primary payer should be a relatively smooth transition since the original framework of our Consolidated Patient Account Centers 

(CPAC) was built upon this premise. This change will allow our CPACs to operate 

as originally designed by recouping costs from third-party payers after care has been 

rendered. 

Question 28. Dr. Shulkin, the Commission on Care rejected the idea of granting 

veterans who use the VA unfettered choice in seeking care outside of the VA. Do 

you agree with this position, or do you believe that a veteran who is eligible for VA 

health care ought to be provided with a voucher to seek care wherever s/he chooses, 

with VA footing the bill? 

Response. My belief is that every veteran that relies upon VHA for their 

healthcare must have access to the best quality healthcare in a timeframe that 

meets their clinical needs. We must utilize care within the VA and outside the VA 

to meet this objective. In terms of total unfettered access, I think given the models 

considered by the Commission and the subsequent economic modeling done by their 

economists, that the Commission came up with the reasonable conclusions. However, if confirmed, I would plan to explore different options that would allow veterans greater choice while maintaining the unique character and services of VHA. 

These proposals will require additional analysis before they can be fully considered. 

Question 29. Dr. Shulkin, are you in favor of the Commission on Care recommendation that would grant veterans with other-than-honorable administrative discharges eligibility to access VA health care on at least a temporary basis? 

22 

Response. If confirmed, I would take a serious look at such a proposal and confer 

with both the White House and Congress about ways that we might address this 

population. 

a. Have you spoken to President-elect Trump about how he intends to handle 

services for veterans in need who have bad paper discharges? 

Response. No 

Question 30. President-elect Trump’s plan for veterans talks about embedding satellite VA clinics within other health care facilities in rural and other underserved 

areas. With existing government acquisition, leasing, and contracting laws, how do 

you intend to make this happen quickly? 

Response. The Department has various means for providing care or embedding 

‘‘clinics’’ in affiliates or other healthcare facilities to provide healthcare for Veterans 

in rural and other underserved areas: 

VA providers only—VA provides healthcare out of non-VA’s healthcare sites 

through the sharing of staff/resources, not real property. This is a similar model to 

how VA partnered with the Department of Defense (DOD) to do exit exams. A VA 

doctor would perform exams in a DOD facility, but VA would not have real property 

interest in the site, it would be purely resource sharing. 

Real Estate Solutions—VA could utilize tools such as revocable licenses and permits as quick, short-term real estate agreements to occupy third-party space for VA 

providers. Such agreements do not have to be competitively sourced but can only 

provide a interim solution—up to 5 years in certain circumstances but typically 

much shorter. For any type of long-term, presence, VA would acquire space from a 

third party through leasing. With current competitive requirements, it may take 

longer to go through the process. VA would lease a portion of space and staff it with 

VA personnel as a standard clinic. The competitive procurement process would dictate the final location from within a VA specified geographic area, but requirements 

could be written to help narrow down the scope. This issue could be streamlined 

with legislative changes to allow sole source leasing with affiliates and state and 

local governments. In that case, it would still be a lease, but could be non-competitive if it were with an affiliate location or applicable local government. 

Question 31. Dr. Shulkin, do you intend to modify Secretary McDonald’s MyVA 

priorities or ‘‘breakthrough initiatives?’’ 

Response. The MyVA priorities were established through consultations with VA 

management and staff, veterans service organizations, community groups and The 

MyVA advisory Committee. Progress has been made in many of these areas and in 

some cases the goals have been achieved. If confirmed as Secretary, I would continue progress in those areas where progress is still needed, establish new and bold 

goals for other priority areas, and continue to consult with veterans and the organizations that represent their interest to modify and evolve these initiatives. 

Question 32. In your opinion, what more do you believe needs to be done to improve personnel recruitment and retention at VA health care facilities? 

Response. VHA is continually striving to improve personnel recruitment and retention at VA health care facilities, and has a robust and multi-pronged approach 

to recruitment. Local facilities have in-house human resources departments, as well 

as nurse recruiters, who reach out to and coordinate with applicants on a local level, 

including outreach to nearby training programs and hosting open houses when 

needed to facilitate hiring. Facilities also produce job advertisements in local, state 

and national publications, journals, newspapers, radio advertisements, hold local career/job fairs, and attend local and regional job fairs. VHA also has a National Recruitment Program (NRP), 100 percent staffed by Veterans, that employs private 

sector best practices to fill VHA’s top five most critical clinical and executive positions. 

Our major challenge is the unnecessary hiring complexity caused by VA having 

three different hiring authorities. As Secretary, I’d like to continue to explore with 

the Congress establishing an Alternative Human Resources (HR) System for VA, 

converting VA to Title 38. Additionally, for our clinicians, a single Federal credentialing system, coupled with national reciprocity for credentialing, would greatly improve our ability to hire and retain clinicians, improve the hiring process from the 

applicant’s perspective, and allow us to more easily deploy our clinicians to meet 

surge needs as the may arise across VHA. 

Finally, the prudent use of recruitment, retention and relocation incentives has 

been an important tool for VHA hiring and retention. Removing these incentives 

from the CARA award caps would restore our ability to appropriately deploy these 

important flexibilities to improve our ability to compete with the private sector. 

Question 33. There has been increasing pressure in recent years for VA to contract for services in local—especially rural—communities where VA facilities are not 

23 

easily accessible. Mental health is one area of particular emphasis in this regard. 

What do you believe is VA’s responsibility for meeting the needs, including mental 

health needs, of rural veterans? If confirmed, what emphasis would you place on 

this issue? 

Response. 

• VHA is committed to meeting the health care needs, including mental health, 

of all Veterans, regardless of where they live. • Rural Veterans deserve a special focus as they have a higher risk of suicide 

than Veterans in urban areas. • Other challenges of rural Veterans include: 

– Provider shortages 

– Geographic barriers 

– Lack of transportation options 

– Rural community hospital closures • VHA is taking steps to address mental health provider shortages in rural areas 

by establishing regional telemental health hubs • In 2016 VHA established four regional telemental health (TMH) hubs to enhance Veteran access to mental health care for Veterans residing in rural areas 

– The four hubs are in South Carolina, Utah, Pennsylvania, and WashingtonOregon area. 

– Six additional hubs are planned to come online in 2017. 

– This will extend mental health services to up to 200 sites of care where more 

mental health capacity is needed. • VHA has also expanded capacity to serve rural Veterans at home, issuing tablets for the delivery of care, including mental health, to nearly 3,000 Veterans. • Standardized training on suicide prevention guidelines in face-to-face clinical 

settings and during telephone contacts specifically for clinicians who work with 

rural Veterans • Integrating evidence-based practices and existing VA programs (e.g., suicide 

risk management in primary care, crisis support, firearm safety, and the HomeBased Mental Health Evaluation program) into a comprehensive portfolio of best 

practices to prevent rural Veteran suicides. • We recognize there are workforce shortages in rural areas and will continue to 

pursue strategies to meet these workforce gaps, including: 

– Expanded scope of practice for advanced practice registered nurses 

– Expanding workforce training programs in rural VA locations 

– Leveraging the VA ECHO (Extension for Community Health 

Outcomes) program to ensure primary care providers in rural sites can access specialty training and consultation 

– Hiring of highly trained Veteran combat medics and corpsmen 

Question 34. What is the appropriate level of oversight and responsibility that VA 

has for the care veterans receive from community providers? 

Response. VA needs to ensure we provide a full network of care, including appropriate quality in the network. The Request for Proposal (RFP) that was released on 

December 28, 2015 includes requirements for the networks to be accredited and for 

providers to be credentialed. The contractor must establish a variety of quality, network adequacy, patient experience and operational efficiency plans. There are over 

20 in total that will be required as part of the contract. In addition, VA will establish certain quality measures to be included based on industry standards. A Quality 

and Patient Safety Model and Framework was created to establish the baseline for 

moving to a value-based model of care, based on the Institute of Medicine (IOM). 

These measures will move the VA forward in ensuring appropriate quality when 

community care is provided. 

Question 35. Female veterans are the fastest growing population in the VA today 

and will continue to grow over the next several years. The President-elect has stated 

his intent to better meet the needs of female veterans, which I support. 

a. During your time at VA, what have you done to improve the physical and mental health care access, quality of care, and address privacy, security, as well as the 

transition for female veterans? 

Response. 

Physical and Mental Health Care Access 

• Since 2014, VA has made tremendous strides in providing enhanced services 

and access for women. 

– 100% of medical centers and 90% of Community Based Outpatient Clinics 

have Designated Women’s Health Providers 

– 130 VA medical centers have gynecology services on-site 

24 

– VA offers a full continuum of gender-sensitive mental health services to 

women Veterans 

– VA has deployed large scale initiatives to train current VA physicians on 

Women’s Health core curricula and priority topics, including Mental Health 

– All Primary Care and Mental Health providers are also trained in the care 

of Veterans who have experienced Military Sexual Trauma 

Quality of Care 

• VA tracks quality by gender and has reduced or eliminated several key disparities 

• On some important quality measures, VA is better than the private sector 

(breast and cervical cancer screening) 

Privacy and Security 

• VHA has committed to ensuring all facilities meet Privacy Standards—to include physical and auditory privacy—and to increasing the accountability of facilities to follow these standards. 

• By policy, all Veterans’ personalized health information is protected with the 

same level of privacy and security regardless of gender. 

• VA’s focus also goes beyond physical security to ensure the entire experience of 

women Veterans is positive. 

• VA has launched multiple campaigns aimed at recognizing the service of women 

Veterans and is now launching an even more direct effort to increase civility and 

respect through the ‘‘End Harassment’’ campaign. 

b. Will the President-elect’s desire to ‘‘fully equip’’ every VA hospital with women’s 

health services bump other projects for the SCIP list to achieve this goal? 

Response. For the past several years, one of VHA’s goals has been to incorporate 

women’s health into various aspects of our capital initiatives. Just a few of our numerous examples include dedicating a women’s health exam room into the PACT 

design model; converting existing multi-bed inpatient rooms to single bed inpatient 

rooms; updating VA’s Women’s Health Design Standard and Guide for separate 

women’s clinics; and including a women’s health sub-criteria in the Strategic Capital 

Investment Planning (SCIP) scoring process to increase points for any capital initiative focusing on women’s health. 

In addition, in the SCIP 2018 cycle, VHA narrowed the first year capital initiative 

focus to only include leases and projects under the following umbrellas: Women’s 

Health, Inpatient Medical/Surgical Bed Conversion to Single Beds, Primary Care 

and Outpatient Mental Health, Safety, and Infrastructure. The impact of this focus 

for first year projects and leases resulted in approximately a 1/3 reduction in capital 

initiatives compared between the SCIP 2017 cycle final list and SCIP 2018’s preliminary list. This allowed women’s health type projects and leases to better compete 

for limited construction and leasing funding. 

VHA plans to continue this narrowed focus with the same categories for the SCIP 

2019 cycle in an effort to continue to support VHA’s goals, which includes converting 

existing deficient space and/or adding more space, resulting in state-of-the-art, modern environments for VA to provide women’s health. 

Question 36. During your time at VA, what have you specifically done to reduce 

the number of veteran suicides? What do you still hope to accomplish if confirmed 

as Secretary? 

Response. Accomplished: 

• Convened a Call to Action on Preventing Veteran Suicide in February 2016— 

included Congressional members, Federal partners, non-profits, VSOs, survivors of 

suicide prevention; led to recommendations that have been implemented throughout 

VA and communities 

• Completed most comprehensive analysis of Veteran suicide to date: ‘‘Suicide 

Among Veterans and Other Americans’’—examining more than 55 million Veteran 

records from 1979 to 2014 from all 50 states and 4 territories. 

• Convened several public-private partnership strategic planning sessions to seek 

input and dialog about our partnership strategy. 

• Signed Memoranda of Agreement with Johnson & Johnson, Give an Hour, Bristol Myers Squibb Foundation, IBM, Wounded Warrior Project, Psych Armor, and 

Project Hero expanding the reach of VA mental health programing. 

• Developed and implemented REACH VET (Recovery Engagement and Coordination for Health—Veterans Enhanced Treatment), to identify and intervene with Veterans who are at a statistically elevated risk for suicide and other adverse outcomes. 

• Designated the month of September for Suicide Prevention Awareness and led 

‘‘Be There’’ campaign across Federal, VSO, and corporate partners. 

25 

• Elevated VA’s suicide prevention efforts and redirected resources, and personnel 

to create a new Office for Suicide Prevention to reach across entire department and 

lead a comprehensive strategy on suicide prevention 

In Progress 

• Implement state-of-the-art best practices for risk assessment, treatment, crisis 

management and quality improvement for VHA users in all clinics that treat Veterans at elevated risk. • Continue to deploy comprehensive solutions, including targeted screening, risk 

assessment, predictive analytics, outreach, and innovative programming to identify 

Veterans at elevated risk and offer care as appropriate. • Enhance enterprise-wide awareness and training of all staff (clinical and nonclinical) in recognition and intervention for Veterans at risk for suicide. • Ensure ease of Veteran experience and quality of clinical care in VCL-Suicide 

Prevention Coordinator care continuum. Expand programming of Suicide Prevention 

Coordinators (SPCs) based on identified areas of need. • Execute a public-private partnership program to increase coordination of available suicide prevention resources for Veterans not enrolled in VA. • Expand existing outreach campaigns to target highest-risk Veterans and increase overall reach. • Create new and update existing IT infrastructure to provide rapid access to 

data that inform suicide prevention effort • Develop data-sharing strategies specific to Veteran suicides to engage our Federal, non-profit, and corporate partners to work together on better understanding 

Veteran suicide 

Question 37. Veteran homelessness decreased by 47 percent between 2010 and 

2016, largely due to funding from Congress and the hard work of local communities, 

yet on any given night, nearly 40,000 veterans remain homeless. Ensuring veterans 

have permanent housing is incredibly important. 

Response. While there has been tremendous progress in ending Veteran homelessness and the efforts of VA and its partners are producing successful outcomes for 

many Veterans, there is still work to be done to ensure that no Veteran is without 

a place to call home. We know that ending Veteran homelessness is not a single 

event in time; rather, it is a deliberate effort made to achieve the goal, and continued follow-up efforts to make sure that progress toward achieving the goal is maintained. We must continue our commitment to our efforts around rapid rehousing 

and permanent supportive housing for Veterans who fall into homelessness so that 

their homelessness is rare, brief, and nonrecurring. The ultimate goal is to make 

sure that every Veteran has permanent, sustainable housing with access to highquality health care and other supportive services and that Veteran homelessness in 

the future is prevented whenever possible. 

While several states and nearly 40 communities have met the Federal benchmarks and criteria for ending veteran homelessness, I have heard from communities 

that have reached the goal earlier that maintaining a system that can rapidly house 

newly homeless veterans takes nearly the same level of effort and resources as 

housing unsheltered veterans to meet the goals. Even as the number of unsheltered 

veterans decreases, will you commit to evaluating resource needs based on existing 

populations and projections as you consider budget proposals for these programs? 

a. If confirmed, will you commit to ensuring that this work remains a priority at 

VA? 

Response. I am committed to ending Veteran homelessness and if confirmed it 

will remain a priority at the VA. 

Question 38. According to the VA’s National Center on Homelessness Among Veterans, the fastest growing subpopulations of homeless veterans are female veterans 

and those who have deployed to Afghanistan and Iraq under OEF/OIF/OND in the 

last decade and a half. What will you do to ensure that VA homelessness programs 

address the needs of these specific groups? 

Response. Last year, the National Center on Homelessness Among Veterans conducted a study to look at population projections of Veterans likely to either be a risk 

of or actually become homeless and access VA care over the next 10 years. Women 

Veterans and Veterans who had served in the OEF/OIF era were identified as two 

subpopulations projected to grow in number while those older than age 55 were projected to decline. It should be noted that even with this growth, the majority of 

homeless Veterans is still projected to be predominantly single and male (85–90% 

in 2025). The National Center has commissioned two subsequent studies to map 

both current need profiles of homeless women Veterans served within VA and outcomes associated with different program utilization patterns. We expect to have results from these studies within the next six months which will be essential to accuVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00029 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
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rately mapping where we need to strategically direct resources to address this projected demand. At this time, we do feel that current VHA program capacity, particularly in the Supportive Services for Veterans and Families (SSVF) and HUD-VASH 

programs which provide the bulk of services for women Veterans who are homeless 

or at-risk for homelessness, is sufficient to support these projections for at least the 

near term. 

Question 39. Over the last 15 years, Congress has worked to improve health care, 

benefits, and care coordination for our most seriously wounded, ill and injured servicemembers, veterans, and their caregivers/family members to ensure a seamless 

transition between the DOD and VA systems and to provide continuity in care and 

services. How do you plan to strengthen collaboration and cooperation between 

these two agencies and improve upon the existing health and benefit systems? 

Response. 

• VA, in partnership with DOD, has taken significant steps to address the transition of seriously wounded, ill and injured Servicemembers and Veterans. We will 

continue to build on this work by: 

– Leveraging the VA/DOD Interagency Care Coordination Committee (IC3), a 

subcommittee under the VA/DOD Joint Executive Committee, was formed to 

improve care coordination and reduce transition gaps. 

– Enhancing care coordination through the Lead Coordinator role who serves 

as the primary point of contact for Servicemembers and Veterans and their 

caregivers during recovery and transition between DOD and VA; 

– Community of Practice—connecting the DOD and VA clinical and non-clinical 

case managers of recovering Servicemembers and Veterans enabling collaboration and best practices to be shared; 

– Implementing Interagency Comprehensive Care Plans—serves as a single, 

interoperable, individualized plan that assists managing the patient’s goals thus 

reducing the need to retell their story as they transition and relocate. We will 

work to establish an IT solution for the Interagency Comprehensive Plan. 

– Enhancing health information exchange: 

• A Veteran’s complete health history is critical to providing seamless, high-quality integrated care and benefits. • Today, more than 220,000 VA health care and benefits professionals have access 

to Joint Legacy Viewer, which VA and DOD clinicians can use to access the health 

records of Veterans and Active Duty and Reserve Servicemembers • We are currently deploying EHMP (Electronic Health Management Platform) 

which will integrate health data from VA, DOD, and community care partners into 

a customizable interface that provides a holistic view of each Veteran’s health 

records. 

– Disability claim filing pathways: (not sure this is the right place, but including here just in case) 

• VA and DOD are dedicated to improving the processes for individuals in the 

IDES and Separating Servicemember (SSM) disability claim filing pathways. 

• The Service Treatment Record (STR) is the common data information source 

critical to support both claimant groups. 

• Efforts are actively underway to ensure the STR can be electronically transferred from the DOD to VA systems, relieving the need for the Servicemember to 

hand-carry their records to VBA for claim support. 

• VA and DOD have re-engineered the Separating Servicemember claims 

workflow and it will be piloted by DOD and VA facilities in the National Capital 

area starting in March 2017. 

Question 40. Accurate forecasting of usage of veterans benefits is essential in 

planning for resources to administer those benefits. If confirmed, what would you 

do to ensure that VA provides accurate and timely forecasts of the need for additional staffing resources so that Congress is able to appropriate resources in a timely manner? 

Response. A workforce analysis is the foundation of any good workforce plan as 

it directly aligns the organization’s needs with outcomes. VBA’s workforce analysis 

is an ongoing effort, and as new data becomes available (such as the Veterans Benefits Management System (VBMS) transactional-level data and National Work Queue 

(NWQ) post-implementation data), it is incorporated in VBA’s Resource Allocation 

Model (RAM) which is a systematic approach to distributing field resources each fiscal year. 

The RAM utilizes a weighted model to assign compensation and pension Full 

Time Equivalent (FTE) resources based on regional office (RO) workload, including 

rating inventory; and rating, non-rating, and appeal receipts. The RAM incorporates 

several variables to accurately align with VBA’s transformation to a paperless, elecVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
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tronic environment, where receipts can be assigned and managed at the national 

level. These variables include station efficiency (claims completed per FTE), quality, 

and RO capacity. 

VBA leaders use the model as a guide, making adjustments for special circumstances or missions performed by individual ROs. Special missions include: 

• the Appeals Management Office (AMO), 

• Benefits Delivery at Discharge (BDD) sites, 

• Integrated Disability Evaluation System (IDES) processing sites, 

• Quick Start processing locations, 

• National Call Centers (NCCs), 

• foreign claims processing locations, 

• radiation processing locations, 

• Camp Lejeune Contaminated Water (CLCW) processing locations, and 

• Pension Management Centers (PMCs). 

With the exploration and analysis of future workload management functionality, 

VBA will work closely with DOD to collaborate on drawdown estimates and aggregate demographics of forces so VA has an early picture of the Veteran population 

profile. Data will be assessed at a more granular level to understand employee production and prioritize the integration of additional enhancements in the NWQ. VBA 

submits its annual Staffing Levels report to Congress in late March, detailing the 

staffing levels at each RO. 

Question 41. The current appeals process for veterans benefits is broken. More 

than 450,000 appeals are pending. The current appeals process is complex, inefficient, and confusing. Most importantly, it no longer serves veterans and their families. In 2016, VA worked with eleven VSO and non-VSO stakeholders to create a 

framework to reform the appeals process. Do you support reforming the current appeals process? If confirmed, will you prioritize reforming the current appeals process? Do you support the 2016 framework as described above? 

Response. I fully support reforming the current appeals process. Comprehensive 

reform is necessary to replace the current lengthy, complex, confusing VA appeals 

process with a new appeals framework that makes sense for Veterans, their advocates, VA, and stakeholders. This reform is crucial to enable VA to provide the best 

service to Veterans and, if confirmed, I will prioritize reforming the current appeals 

process. 

I support the framework developed collaboratively by VA and a wide spectrum of 

stakeholder groups in 2016. I believe that the engagement of the organizations that 

participated in development of the new framework ultimately led to a stronger proposal, as we were able to incorporate their feedback and experience having helped 

Veterans through the complex appeals process. 

The current VA appeals process takes too long. Appeals have no defined endpoint 

or timeframe and require continuous evidence gathering and re-adjudication. On average Veterans are waiting 3 years for a resolution on their appeal. For cases that 

reach the Board of Veteran’s Appeals (Board), Veterans are waiting on average 6 

years and thousands of Veterans are waiting much longer. The current appeals 

process is also too complex. Veterans do not understand the process, it contains too 

many steps and it is very challenging to explain to Veterans. Additionally, accountability does not rest with one appellate body; rather, jurisdiction over appeals is 

split between the Veterans Benefits Administration (VBA) and the Board. 

The new framework, which I fully support, steps away from an appeals process 

that tries to do many unrelated things inside a single process and replaces it with 

differentiated lanes, which give Veterans clear options after receiving an initial decision on a claim. For a claim decision originating in VBA, for example, one lane 

would be for review of the same evidence by a higher-level claims adjudicator in 

VBA; one lane would be for submitting new and relevant evidence with a supplemental claim to VBA; and one lane would be the appeals lane for seeking review 

by a Veterans Law Judge at the Board. In this last lane, intermediate and duplicative steps currently required by statute to receive Board review, such as the Statement of the Case and the Substantive Appeal, would be eliminated. Furthermore, 

hearing and non-hearing options at the Board would be handled on separate dockets 

so these distinctly different types of work can be better managed. As a result of this 

new design, the agency of original jurisdiction (AOJ), such as VBA, would be the 

claims adjudication agency within VA, and the Board would be the appeals agency. 

This new design would contain a mechanism to correct any duty to assist errors 

by the AOJ. If the higher-level claims adjudicator or Board discovers an error in 

the duty to assist that occurred before the AOJ decision being reviewed, the claim 

would be returned to the AOJ for correction unless the claim could be granted in 

full. However, the Secretary’s duty to assist would not apply to the lane in which 

28 

a Veteran requests higher-level review by the AOJ or review on appeal to the Board. 

The duty to assist would, however, continue to apply whenever the Veteran initiated 

a new claim or supplemental claim. 

This disentanglement of process would be enabled by one crucial innovation. In 

order to make sure that no lane becomes a trap for any Veteran who misunderstands the process or experiences changed circumstances, a Veteran who is not fully 

satisfied with the result of any lane would have 1 year to seek further review while 

preserving an effective date for benefits based upon the original filing date of the 

claim. For example, a Veteran could go straight from an initial AOJ decision on a 

claim to an appeal to the Board. If the Board decision was not favorable, but it 

helped the Veteran understand what evidence was needed to support the claim, 

then the Veteran would have 1 year to submit new and relevant evidence to the 

AOJ in a supplemental claim without fearing an effective-date penalty for choosing 

to go to the Board first. 

To fully enable this process and provide the appeals experience that Veterans deserve, VBA, which receives the vast majority of appeals, would modify its claims decisions notices to ensure they are clearer and more detailed. This information would 

allow Veterans and their representatives to make informed choices about whether 

to file a supplemental claim with the AOJ, seek a higher-level review of the initial 

decision within the AOJ, or appeal to the Board. 

The new framework would not only improve the experience of Veterans and deliver more timely results, but it would also improve quality. By having a higherlevel review lane within the VBA claims process and a non-hearing option lane at 

the Board, both reviewing only the record considered by the initial claims adjudicator, the output of those reviews would provide a feedback mechanism for targeted 

training and improved quality in VBA. 

The legislation should be enacted now. It has wide stakeholder support and the 

longer we wait to enact the Appeals Reform legislation more and more appeals will 

enter the current, broken system. The status quo is not acceptable for our Nation’s 

Veterans and taxpayers. The new framework will provide much needed comprehensive reform to modernize the VA appeals process and provide Veterans a decision 

on their appeal that is timely, transparent, and fair. 

Question 42. There was a recent Congressional Budget Office report released that 

suggested that significant savings could be realized in VA compensation expenditures by streamlining who is considered service-connected. Of particular note, the 

report suggests that a number of presumptive conditions, such as Multiple Sclerosis, 

should not in fact be presumptively considered for service-connection. Do you support the recommendations offered by CBO targeting service-connected disabled veterans compensation? 

Response. This recommendation would alter the fundamental principles of the VA 

disability compensation program, specifically the definition of ‘‘line of duty’’ as it relates to determing service-connection for diseases or injuries related to military 

service. While this principle has been debated and studied over the years, VA still 

believes and Congress has historically maintained support for the current definition 

of line of duty. That is, servicemembers who contract any injury or illness while on 

duty or on authorized leave, that is not the result of willful misconduct or drug and 

alcohol abuse, are entitled to service-connection for such conditions. The basic 

premise is that Servicemembers are on duty 24 hours a day, seven days a week and 

such individuals are subject to the Uniform Code of Military Justice at all times and 

in all places, including while on leave. VA believes that the government should continue to support those who have made enormous sacrifices and answered the call 

to defend their country by maintaining the current definition of line of duty. 

Additionally, VA does not support eliminating the presumption of service-connection for certain conditions such as Multiple Sclerosis. The establishment of presumptive disabilities is based on extensive medical evidence and sound scientific research 

which identifies certain medical conditions that manifest years after the Veteran’s 

exposure. VA believes these individuals are justly considered for service-connected 

benefits as it relates to these conditions. 

Question 43. VA’s FY 2017 budget request for major and minor construction of 

$1.025 billion is a significant decrease from FY 2016 request of $1.675 billion. The 

Department testified that it was taking a ‘‘strategic pause’’ regarding construction 

awaiting the report by the Commission on Care. Now that the report has been published, what do you think the Department should do to modernize and replace its 

aging and substandard facilities? 

Response. In FY 2017 the Department did not request funding for any new construction projects. Instead, VA’s FY 2017 budget request focused on fixing what we 

have by directing resources to fund the continuation or completion of minor conVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
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struction and non-recurring maintenance (NRM) projects initiated in prior fiscal 

years. 

The reason for not funding any new projects was because VA was waiting to receive the recommendations from the Commission on Care (which we received in July 

to determine if resources would need to be reallocated or requested to implement 

infrastructure strategies accordingly. In addition, VA wanted to ensure maximum 

future flexibility by not committing to a long term solution prior to the release of 

the report. 

In August 2016, the President and VA responded to the Commission’s report. The 

Department agreed that the Commission’s facilities recommendations were critical 

to enable a successful transformation of VA’s healthcare system to an integrated 

network to serve Veterans. VA stated that a strong suite of capital planning programs, tools, and resources would be needed to be able to fully realize the benefits 

and Veteran outcomes expected from implementing an integrated healthcare network. 

Currently, VA is working toward the goal of high performing networks that take 

into account current and expected future services by developing a structure to integrate community care and VA-provided healthcare on a market by market basis. 

The Department kicked-off an effort with private sector healthcare experts to design 

an approach for integrated healthcare delivery decisions based on Veteran population, demand, internal capacity, and external public and private sector health care 

resources and capacity. Once the approach is validated, tested, piloted, and deployed 

nationwide, a national infrastructure realignment strategy will be developed accordingly to establish an objective process to appropriately realign VA’s capital infrastructure. Through this process, VA will also identify the resources, tools, and authorities that are needed to enable the divestiture of assets and to streamline capital project execution. VA is committed to pursuing the appropriate capital resources 

to serve Veterans and ensure that a successful realignment strategy is implemented. 

Question 44. VA’s vocational rehabilitation and employment program is one of the 

smallest, yet most important, programs within the Department. It is the linchpin 

for helping veterans who incur service-connected disabilities achieve a fulfilling and 

gainful future. I am deeply committed to making sure that this program lives up 

to its full potential, especially when individuals who have sustained serious injuries 

in combat are concerned. 

What are your thoughts on the role that vocational rehabilitation plays in terms 

of the total rehabilitation of an individual recovering from severe combat-related injuries and on how VA’s current efforts might be improved? 

Response. ‘‘What are your thoughts on the role that vocational rehabilitation plays 

in terms of the total rehabilitation of an individual recovering from severe combatrelated injuries’’: 

– The Vocational Rehabilitation and Employment (VR&E) program provides comprehensive services and assistance to enable Veterans and Servicemembers with 

service-connected disabilities to include physical, cognitive, mental, and emotional 

disabilities as well as an employment handicap to prepare for, find, and maintain 

suitable employment. For Veterans with service-connected disabilities so severe that 

they cannot immediately consider work, the VR&E program offers services to improve their ability to live as independently as possible in their homes and communities Nearly one quarter or more of VR&E participants recently studied, by cohort, 

have a primary rating for Post-Traumatic Stress Disorder (PTSD). (VR&E Longitudinal Study Annual Report 2016, 2015). VR&E participants in the longitudinal 

study also reflect an average disability rating of 60%; participants have a range of 

physical and emotional barriers and disabilities. 

– VR&E’s service delivery model works to best support Veterans where Veterans 

are located. VR&E employs over 1,000 professional Vocational Rehabilitation Counselors (VRCs) and Employment Coordinators (EC). These personnel provide services 

to Veterans and transitioning Servicemembers through a network of over 350 locations. VR&E’s service delivery model include operations at 56 regional offices (ROs); 

the National Capital Region Benefits Office; approximately 142 out-based offices; 71 

Integrated Disability Evaluation System (IDES) installations and 94 VetSuccess on 

Campus (VSOC) schools/sites. VR&E is also able to provide individualized services 

based on the Veteran or Servicemember’s unique individualized needs. 

– VR&E has two special missions focused on reaching critical populations via targeted outreach and support—IDES and VSOC. VR&E actively collaborates with the 

Department of Defense to provide VR&E services to Servicemembers through the 

IDES program. Vocational Rehabilitation Counselors are located on 71 military installations and work directly with transitioning Servicemembers to provide VR&E 

services. VR&E is committed to ensuring that the needs of seriously injured VetVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
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erans and Servicemembers are met in a timely manner by providing priority processing of applications for these populations. Automatic entitlement to VR&E services for wounded, ill and injured Servicemembers, a provision of Public Law 110– 

181(NDAA; Congress has renewed annually), allows for streamlined support and assistance for this critical population. Veteran Success on Campus (VSOC) Counselors 

provide on-campus access to VA benefits and services/support for 78,000 Veteran 

students on 94 campuses across the country. 

Response. ‘‘How could VA’s current efforts be improved’’ 

– As part of ongoing VR&E Transformation, VR&E has several initiatives currently in development to improve service delivery to Veteran clients. VR&E Service 

is currently developing a new case management system and process that will be 

fully electronic and paperless, with planned pilot/deployment in FY 2017. VR&E 

also deployed tele-counseling Nation-wide in 2015, and continues to work to increase 

the use of this enabling technology to better serve both Veterans and their counselors. VR&E is also working on initiatives to streamline administrative processing 

and support for VR&E in the VR&E program. 

– To continue to better understand the VR&E population, VR&E continues to 

execute the congressionally mandated 20-year VR&E Longitudinal Study of Veterans who began their VR&E programs in 2010, 2012, and 2014. Reports are submitted to Congress annually on the long-term benefits of participating in the VR&E 

program. The study allows VR&E to continuously analyze trends among participants receiving services, and respond with initiatives that improve and adapt services to their changing needs. 

Question 45. VA granted the presumption of service-connection for conditions associated with exposure to Agent Orange to recipients of the Vietnam Service Medal 

until 2002 when criteria was restricted to those who had ‘‘boots on the ground.’’ 

What are your views on granting the presumption of service-connection to veterans 

who served in the bays, harbors, and territorial seas? 

Response. VA honors the service and dedication of U.S. Navy and Coast Guard 

Veterans who served aboard ships on the offshore waters of Vietnam. However, current laws are intended to compensate Veterans for Agent Orange exposure related 

diseases when there was an actual potential for such exposure. That potential existed for Veterans who served within the land boundaries of Vietnam, including its 

inland waterways, where Agent Orange use occurred. 

The United States Court of Appeals for the Federal Circuit upheld this definition 

in Haas v. Peake (2008). Available evidence does not support such potential exposure existed for service aboard ships operating on Vietnam’s open water bays, harbors, and territorial seas. The distinction is based on the fact that aerial spraying 

of Agent Orange and other tactical herbicides over Vietnam was used to destroy 

enemy food crops, reveal enemy positions by defoliating jungle and riverbank cover, 

and create vegetation-free security zones around military bases. No such use of 

Agent Orange occurred over the offshore waters of Vietnam. 

To better understand possible Agent Orange exposure among Navy Vietnam Veterans, VA tasked the National Academies of Science (NAS) with investigating and 

determining whether there were any potential routes of exposure, such as through 

aerial spray drift or sea water contamination from river water runoff. The NAS report, Blue Water Navy Vietnam Veterans and Agent Orange Exposure (2011), determined that there was insufficient evidence to confirm that these potential routes resulted in any significant exposure. U.S. Navy and Coast Guard activity during the 

Vietnam War involved large open water ships conducting operations off the coast 

of Vietnam [often referred to as the ‘‘Blue Water Navy’’] and smaller vessels conducting operations on the inland bays and river system of Vietnam [often referred 

to as the ‘‘Brown Water Navy’’]. Some Blue Water ships temporarily entered Vietnam’s inland waterways to conduct naval gunfire support of ground operations or 

to deliver supplies. 

Although there is insufficient scientific evidence to grant a blanket presumption 

of Agent Orange exposure for all U.S. Navy Vietnam Veterans, VA has a liberal policy of presuming exposure for all Veterans who served aboard Brown Water vessels 

operating on Vietnam’s inland waterways and for those Veterans serving aboard 

Blue Water ships that temporarily entered the inland waterways. Additionally, if 

evidence shows that a Blue Water ship off the Vietnam coast sent crew members 

ashore for duty or visitation, any Veteran on the ship at that time will receive the 

presumption of exposure if they state that they personally went ashore. The Veterans Benefits Administration (VBA) maintains a list of ships that entered Vietnam’s inland waterways or otherwise sent crew members ashore for duty or visitation. This list is based on evidence found in ship histories or deck logs, which are 

received from the Department of Defense’s Army and Joint Services Records Research Center (JSRRC) or other credible sources. The list is available online and can 

31 

be quickly updated by VBA’s Compensation Service to reflect the most up-to-date 

research. 

Question 46. VA currently uses the criteria of 170,000 un-served veterans within 

a 75-mile radius for purposes of establishing new national cemeteries. In the past, 

the Senate has supported this standard and has authorized new cemeteries based 

upon VA’s recommendations. Do you believe this should continue to be the standard 

practice? In the absence of a VA recommendation, do you believe Congress should 

legislate the location of new national cemeteries? 

Do you believe this should continue to be the standard practice? 

Response. VA changed the criteria used to establish new national cemeteries in 

FY 2011. The current standard, which was approved by Congress, reduced the Veteran population threshold required to build a new national cemetery from 170,000 

to 80,000 within a 75-mile radius. As a result of this change, VA will construct 5 

new national cemeteries designed to serve over 550,000 Veterans. 

In addition, VA established burial access policies in 2011 and 2013 that will allow 

for construction of five Columbarium-only national cemeteries in certain urban locations where time and distance barriers make it difficult for Veterans to use the existing national cemeteries. VA will also establish a national cemetery presence in 

eight rural areas where the Veteran population is less than 25,000 within a 75-mile 

service area. The proposal targets those states in which: 1) there is no open national 

cemetery within the state; and 2) areas within the state are not currently served 

by a state Veterans cemetery or a national cemetery in another state. 

In the absence of a VA recommendation, do you believe Congress should legislate 

the location of new national cemeteries? 

Response. VA opposes any legislative action that would direct the location of a national cemetery. The placement of national cemeteries is based on objective criteria 

that address the maximum number of unserved Veterans in a given area. This approach has been very successful. To date, 91.7% of the total Veteran population— 

approximately 20 million Veterans—has convenient access to a burial option. When 

all planned national and state Veteran cemeteries currently in queue are opened, 

95% of the Veteran population will be served. 

Question 47. What is the future of VHA’s electronic health record? 

Response. The future of VHA’s electronic health record (EHR) is a modern system 

that improves health outcomes for Veterans on a platform that can seamlessly adopt 

technological advances. 

VA is carefully considering the future of VistA. In the context of current budgetary constraints, we are evaluating all options from adopting a commercial off the 

shelf (COTS) EHR to retaining an enhanced and standardized VistA. We are actively gathering key information and expert feedback, and recruiting a Chief Health 

Informatics Officer with extensive commercial EHR experience to help VHA craft an 

informed EHR strategy within the first 100 days of the new Administration. The 

goal is to make a decision that will best serve Veteran’s needs. 

OI&T has been working in partnership with VHA to develop the foundation for 

a modern health platform—the Digital Health Platform (DHP). This new initiative 

successfully completed a proof-of-concept. Over time, this approach will address the 

interoperability and integration challenges for Veterans by integrating information 

gathered from mobile applications, devices, wearable technology, along with data 

from Veterans’ VA, military and commercial electronic health records in real-time. 

We are not waiting for a decision to enhance the care Veterans are receiving 

today. Interoperability between VA and DOD is better today than at any point in 

the history of the Departments with the deployment of the Joint Legacy Viewer 

(JLV). JLV is not a vision for the future or a plan on paper. JLV is available to 

all clinicians in every VA facility in the country. It is a web based user interface 

that provides the clinician an intuitive interface to display DOD and VA healthcare 

data on a single screen. Providers from a variety of specialties have provided positive feedback and user stories are proving that we are successfully sharing information seamlessly between the departments. We have also invested in a longer term 

interoperability solution known as the Enterprise Health Management Platform 

(eHMP). 

eHMP builds on the interoperability success of JLV, and is a modern web based 

user-interface that will improve access to health information by integrating health 

data from VA, DOD, and community care partners into a customizable interface 

that provides a holistic view of each Veteran’s health records. A version of eHMP 

has been installed at 130 sites. 

32 

ADDITIONAL PREHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 48. In response to question 11, you note that you are still studying the 

various proposals and options that have been laid out by the President. At this 

point, how would you recommend fleshing out his plan? 

Response. If confirmed as Secretary, I would immediately engage with the Administration to discuss ways to implement the President’s plan. It is my understanding 

that the transition team has formulated some approaches already, but these have 

not yet been shared with me, as I have not yet been confirmed. If confirmed, I would 

then engage with both the Senate and House as well as others such as Veteran 

Service Organizations to gain their perspectives and suggestions for improving 

healthcare to veterans. I have gone on record about my belief that we must develop 

an integrated system of care, utilizing what is best about VA and best from the private sector. My commitment in this process is to be open to new ideas and approaches as long as they improve access and quality of care for veterans. I would 

ensure that any solutions that I would recommend for consideration would be consistent with my values to support policy that is in the best interest of our veterans 

and advances our system toward higher levels of performance. 

Question 49. In response to question 12, you note that VA will expect the same 

level of partnership and engagement with the VSOs and MSOs to continue the 

progress/momentum that VA has gained with the MyVA Transformation. Can you 

please provide specific examples of the partnership and engagement you anticipate 

having with the VSOs and MSOs? For example, will you continue to have monthly 

meetings with the groups outlined in your response? 

Response. I am committed to full transparency, cooperation and coordination with 

our MSO/VSO partners to maximize input from the widest range of appropriate 

stakeholders and to facilitate an open exchange of opinion from diverse groups to 

improve our programs to assist Veterans. During my tenure as USH, I engaged and 

solicited input and feedback from MSOs/VSOs on key issues, best practices or opportunities to improve policies, programs, service quality and meet Veteran needs. 

We host monthly VSO breakfast meetings with our senior leadership team, have 

participation and representation of VSOs on our workgroups and planning teams 

within our VA Program offices and also meet with VSOs on a frequent basis as specific issues or needs arise. In addition, I personally traveled to each of their national 

conventions and meetings last year. All of these engagements are necessary and will 

continue as VSOs are an important partner in helping us understand what improvements we can make to better deliver care and services to our Nation’s Veterans. 

Question 50. With regard to question 20, can you please clarify what options you 

are considering in order to provide veterans with greater choice than they have 

now? 

Response. The Choice program has been essential for VA to have made improvements in access to care. However, we have learned that the program as it currently 

exists is too complex and as a result is not working well enough for many veterans. 

We must fix this. Furthermore, in designing a healthcare system, it would not be 

my recommendation to use mileage and wait times as the criteria for determining 

eligibility. My goal is to design a system that is both easier to use and supports 

greater choice for our veterans. However, we must do this in a way that ensures 

that veterans are receiving high quality care and that is affordable to the taxpayer. 

If confirmed, I would present several specific options on how to achieve these goals 

by improving upon the design of our current Choice system and in recommending 

alternative eligibility criteria to mileage and wait times. I would not want to prematurely offer specifics on these proposals at this time as I believe they must first 

be studied and modeled and appropriate input from stakeholders must be obtained 

before these are discussed in a public forum. 

Question 51. With regard to question 25, can you please provide what emphasis 

you would place on meeting the needs, including mental health needs, of rural 

veterans? 

Response. I am committed to meeting the health care needs of all Veterans, regardless of where they live. Rural Veterans face unique challenges in accessing care 

and it would be my priority to refine telehealth, community care, and home health 

options as a means of providing these Veterans access to health care when and 

where they need it. 

Question 52. With regard to question 27, can you please reference what you have 

done, during your tenure at VA, to improve the physical and mental health care acVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
33 

cess, quality of care, and address privacy, security, as well as the transition for female veterans? 

Response. During my tenure as Undersecretary for Health, VHA committed to ensuring all facilities met Privacy Standards—to include physical and auditory privacy—and to increasing the accountability of facilities to follow these standards. 

VHA created a policy to ensure that personalized health information is protected 

with the same level of privacy and security regardless of gender. We also launched 

multiple campaigns aimed at recognizing the service of women Veterans and will 

be soon launching an even more direct effort to increase civility and respect through 

the ‘‘End Harassment’’ campaign. 

Question 53. In response to question 34, can you please clarify your personal 

belief? 

Response. My read of the statutory language at title 38 U.S.C. section 105 leads 

me to the conclusion that any disability resulting from injury incurred in or aggravated by service shall be service-connected. There is no requirement of causation. 

This conclusion has been reviewed by Federal courts and found to be accurate. 

At times, both the Congress and VA have established presumptions of service connection for certain disabilities and diseases that are shown by sound scientific and/ 

or medical evidence to have resulted from exposure to a contaminant while in service or, in the case of amyotrophic lateral sclerosis (ALS), service itself. All such disabilities are covered unless it is a result of willful misconduct or an abuse of alcohol 

or drugs. Multiple sclerosis is one example of this type of disease. 

Question 54. In response to question 35, please describe what you believe the Department should do to modernize and replace its aging and substandard facilities. 

Response. As stated in VA’s FY 2017 Budget Request, based on the current mission, the Department has an identified need of approximately $41 to $50 billion to 

close critical performance gaps in the areas of safety, security, utilization, access, 

seismic safety, facility condition, space, parking, and energy. Once the Department 

develops and implements its integrated healthcare delivery model, a national infrastructure realignment strategy will be developed to align VA’s infrastructure to 

match the approach to provide care to Veterans. At that time, VA will determine 

what inpatient and outpatient facilities are needed, as well as what renovation/construction is needed to implement the realignment. Depending on the realignment, 

a significant portion of the $41 to $50 billion infrastructure gap will still need to 

be addressed through renovation or replacement. This effort will require a combination of substantial investment in VA-owned and operated infrastructure and disposal/reuse of unneeded facilities. This effort will require a combination of substantial investment in VA-owned and operated infrastructure and disposal/reuse of 

unneeded facilities and continued reliance on care in the community. 

Question 55. In your response to question 39, you note that VA is actively ‘‘gathering key information and expert feedback‘‘ to help VHA craft an informed EHR 

strategy within the first 100 days of the Administration. You note that you are recruiting a Chief Health Informatics Officer to help in this effort. How will the hiring 

freeze impact the recruitment of the Chief Health Informatics Officer? 

Response. I have had discussions with the White House on the hiring freeze, at 

this time those discussions have centered on ensuring that we are able to hire for 

positions that require direct patient care. If confirmed, I will evaluate other positions to see if others would require a request an exception to the freeze. 

Question 56. With regard to question 13, given the level of depth provided in other 

areas of this questionnaire on issues and items not currently within your direct purview of Under Secretary of Health, can you please review the tracking mechanism 

of disability claims production widely-known as the Monday Morning Workload Report and respond to whether under your leadership you would continue to make 

public this report? 

Response. Yes, The Monday Morning Workload Report is a public report. It is our 

transparent communication to share with the public how VA is performing in our 

mission to deliver benefits to our Nation’s Veterans. 

RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. JERRY MORAN TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 57. Dr. Shulkin, how would you describe the culture and functionality 

of the highest echelon in the VA Central Office? What changes would you make in 

the VA Central Office? Please be specific and candid. 

34 

Response. Over the past 18 months as Under Secretary of Health, I have come 

to understand the issues involving VA management and organization of our Central 

Office. While I have made several important organizational changes, I made a deliberate decision not to undergo large scale organizational changes, I wanted the organization to focus on addressing our wait time issues and other organizational priorities that I had established. Organizational change in important, but it can also be 

very distracting, and I wanted the organization to know our top priority was to address the clinical needs of our veterans. Also during my tenure as Under Secretary, 

I named 20 new senior leaders to my top 22 management positions. Each leader has 

been instructed to assess their organization and to present their assessments. We 

have begun a formal organizational review and assessment. If confirmed, I am prepared to make the necessary changes at VACO and the field to ensure more efficient 

and effective operations. Specifically I plan to address the separation between policy 

and operations at VACO which has resulted in duplicative and sometimes confusing 

direction to the field. 

Question 58. Dr. Shulkin, what distinguishes you from the current VA leadership 

team? Do you plan to lead and manage the VA differently than the current VA leadership team? What are the differences? Please be specific. 

Response. The Secretary of VA is responsible for ensuring that our nations veterans receive the highest level of service and care that we can provide. The Secretary also serves to ensure that the President and Congress’ policies and laws are 

carried out as intended to the best of their abilityIf confirmed, as Secretary, I would 

work tirelessly to see that these objectives are fulfilled. 

With a new Administration and Congress, we have the opportunity to address systemic issues that have not been fully addressed in the last Administration. If confirmed, I would seek to work collaboratively with the new Administration, Congress, 

and Veteran organizations to implement systemic changes for VA that would improve service, quality and value. Given that there will be new leadership in place 

at the White House, Congress, and VA, this will be different than the last Administration. The mandate from the country to do better for our veterans is clear and 

now is the time to take on the tough issues and propose bold solutions. I am ready 

for this opportunity and challenge. 

Question 59. Dr. Shulkin, once the replacement for a new Undersecretary of the 

Veterans Health Administration (VHA) has been identified, what are the top three 

priorities that individual should consider in this position overseeing the VHA? What 

are the biggest challenges facing the VHA? 

Response. As Under Secretary for Health, I established five priorities for VHA. 

I firmly believe that these priorities are critical to the continued improvement of 

VHA. These five priorities were 1) Improve Access to Care, 2) Improve employee engagement and filling VA management vacancies, 3) Implementing industry best 

practices, 4) Developing a integrated network of care between VA and community 

care, and 5) Enhancing trust among veterans. 

My instructions to a new Under Secretary for Health will be to prioritize Quality. 

Quality involves three important components of care: access, clinical outcomes, and 

service levels. Specifically with the focus on quality, we want to accelerate efforts 

in suicide prevention and treatment of behavioral health conditions, and women’s 

healthcare. 

Question 60. How many rural VA facilities have you visited? Please identify the 

locations. 

Response I have visited a number of rural facilities: Dublin, Georgia; Augusta 

Maine; Bangor Maine, Caribou Maine, and Lebanon, Pennsylvania. In addition I 

conducted a number of listening sessions in Alaska during my visit there in 2015. 

I also practice internal medicine, via telehealth, in Grants Pass Oregon, which is 

a rural area that has a shortage of primary care physicians. 

Question 61. How many VA employees are currently on administrative leave? Of 

those currently on administrative leave, how much has the VA exhausted on their 

salaries while they have been on administrative leave and unable to fulfill the duties for which they were hired? 

Response. Attached for your review are the personnel actions as of 12/16/2016. 

[Privileged and Confidential for use by US Government only, which cannot be 

printed in the public record.] 

Question 62. Dr. Shulkin, in your experience in the VA Central Office, are there 

VA employees you believe are toxic, corrosive or indifferent to VA culture reform? 

If so, would you remove some or none of these individuals from the VA? If so, what 

authorities do you possess and would utilize to remove these individuals from the 

VA? If you believe you do not have the authority to remove them, explain why. If 

35 

you believe you need additional authority to remove them, explain in detail the authority you believe is required. 

Response. Yes, I believe that there are employees that have deviated from the values that are essential for us to serve veterans. As Secretary, I would work to remove 

these employees from our workforce. The process to remove employees is currently 

too long and too cumbersome. While it is essential that there is due process, I would 

seek the authority to remove these individuals in a more expedited manner. 

Question 63. Please provide information regarding the Office of General Counsel, 

to include: FY09-FY 2017 funding levels, full-time personnel and their duty station, 

and job descriptions for the positions within the Office of General Counsel. Please 

also describe and explain the breadth of the Office of General Counsel’s work and 

advisement. If the Office of General Counsel advises you take a position or make 

a decision that is counter to President-elect Trump’s positions and commitments to 

reform the VA, will you follow the advisement of the Office of General Counsel? Is 

the Secretary of the VA required by law to execute the position or decision advised 

by the Office of General Counsel? Explain options available to the Secretary of the 

VA to take a position or make a decision counter to the advisement of the Office 

of General Counsel. 

Response. OGC’s annual budget of approximately $114M ($94M BA, $20M RA) 

supports +/- 700 FTE. Roughly 400 of OGC’s personnel work in the District Chief 

Counsel Offices that provide legal support to VA’s Medical Centers, Regional Offices, 

National Cemeteries, and other field operations; approximately 85 represent the Department in litigation before the US Court of Appeals for Veterans Claims; and the 

balance are assigned to VA Central Office and provide subject-matter-specific legal 

support to VA leadership on all issues arising from VA policies and programs, including information law, personnel law, procurement law, real estate law, Veterans’ 

benefits law, torts and administrative law. The OGC workforce includes approximately 480 attorneys and 220 non-attorneys, including paralegals, legal assistants, 

and other administrative staff. 

OGC’s authorizing statute, 38 U.S.C. § 311, provides for the appointment of a 

General Counsel by the President, with the advice and consent of the Senate, to 

serve as the chief legal officer of the Department and to provide legal assistance to 

the Secretary concerning the programs and policies of the Department. OGC’s authorizing regulations, provided in 38 CFR Part 14, provide that the General Counsel 

is responsible to the Secretary for the following: 

(a) All litigation arising in, or out of, the activities of the Department of Veterans 

Affairs or involving any employee thereof in his or her official capacity. 

(b) All interpretative legal advice involving construction or application of laws, including statutes, regulations, and decisional as well as common law. 

(c) All legal services, advice and assistance required to implement any law administered by the Department of Veterans Affairs. 

(d) All delegations of authority and professional guidance required to meet these 

responsibilities. 

(e) Maintenance of a system of field offices capable of providing legal advice and 

assistance to all Department of Veterans Affairs field installations and acting for 

the General Counsel as provided by Department of Veterans Affairs Regulations and 

instructions, or as directed by the General Counsel in special cases. This includes 

cooperation with U.S. Attorneys in all civil and criminal cases pertaining to the Department of Veterans Affairs and reporting to the U.S. Attorneys, as authorized, or 

to the General Counsel, or both, criminal matters coming to the attention of the Regional Counsel. 

(f) Other matters assigned. 

OGC provides advice and counsel to the Secretary and other VA officials regarding the legal framework within which those officials may act. Because actions taken 

in contravention of applicable laws may put the Department at unnecessary risk of 

litigation or other adverse outcomes, OGC endeavors to provide an analysis of available options rather than to simply advise for or against a single course of action. 

OGC strives to give useful, practical advice, couched in terms of ‘‘yes, if . . .’’ rather 

than ‘‘no, because.’’ This approach generally avoids putting the Secretary in the position of having to choose between carrying out the President’s agenda and complying with the law. As Secretary, I intend to work with my General Counsel to 

identify legally defensible means of accomplishing the reforms to which the President-elect has committed for the benefit of Veterans and taxpayers. 

Question 64. If the VA Inspector General (IG) provides a report with findings of 

wrongdoing and criminal action, do you intend to notify Congress prior to or in tandem with the disclosure of the IG’s report? In detail, please explain the authorities 

and actions you will execute to hold accountable the employees identified in the IG’s 

36 

report. Regarding similar instances under the leadership of Secretary McDonald, he 

refused to execute and utilize authorities provided to him. Do you intend to break 

with this precedent and use the authorities granted to the Secretary of Veterans 

Affairs? 

Response. With respect to utilizing the statutory authorities for employee accountability that are at my disposal, I am aware that the expedited Senior Executive removal authority contained within the Veterans’ Access, Choice, and Accountability 

Act of 2014 has come under question in the courts and may be found to be unconstitutional. Because the Choice Act authority supplemented rather than replaced 

other, more defensible authorities for holding employees accountable, Secretary 

McDonald chose to use the other authorities rather than the Choice Act once the 

constitutional issue became clear. We do still have a number of options for holding 

employees accountable, including traditional processes under Title 5 and Title 38 

and the expedited process that came with the Choice Act. As frustrating as it is for 

me as a leader and for Congress as an authorizing body to see that authority challenged, it really doesn’t serve Veterans or taxpayers well if we take an action that 

we know we’ll have trouble defending in court. So while I will consider all of the 

authorities at my disposal to hold misbehaving and under-performing employees accountable, I will approach each case with an eye toward ensuring that the action 

taken will withstand appeal. 

Question 65. In July 2015, the VA requested authorities from Congress to transfer 

$3.5 billion from the Choice Program to fund a shortfall in non-VA health care. Despite knowledge of such a debt as early as February 2015, VA officials waited until 

July to disclose the situation, providing a one-month notice of the potential lapse 

in health care for veterans due to insufficient funds. Do you agree with the VA’s 

strategy to leave Congress little time to assess and address the $3.5 billion shortfall? If not, please explain how this situation should have been handled? If a shortfall scenario were to occur again as some have insinuated, what can we expect you 

to do differently from previous VA leadership? 

Response. 

• VA’s budget plan early in FY 2015 was based on the Choice Program being 

operational more quickly than what was ultimately possible and a higher anticipated use by Veterans of Choice Program funds. VA pushed forward with plans for 

providing Care in the Community as part of the effort to improve Veterans access 

to care. The planned increase in workload was not able to be supported within the 

Choice Program operations established at that time. As a result, VA’s non-Choice 

Care in the Community program’s increased execution was at a rate that exceeded 

the 2015 plan. Program execution visibility was hampered by limitations of the financial management systems as well as the uncertainty of the program’s cost in 

2015 from both unreported obligations and over-obligations associated with medical 

authorizations. 

• Regrettably, the process to clearly define the specific shortfall required more 

time than would have been preferred and significantly shortened the response time 

made available to the Congress. Secretary McDonald was made aware of the shortfall in May 2015 when VA staff confirmed there would be funding shortfalls in Care 

in the Community. Congress was informed in briefings in June and July that the 

non-Choice Care in the Community account was executing at a rate well beyond the 

2015 funded plan. 

• In June 23, 2015 letters to the Committees on Veterans Affairs and the Appropriations Committees and subcommittees, VA requested authority to use available 

Choice Act funding and to transfer existing funds from other medical programs to 

address the shortfall in non-Choice Community Care requirements. 

• VA requested Congressional flexibility to use section 802 funds on a limited authority basis in the amount of $2.5 billion as the estimated cost exceeding the Care 

in the Community 2015 budget and use $500 million for Hepatitis C treatments. VA 

could also make a $348.5 million transfer from Medical Facilities to the Medical 

Services account for Community Care, all totaling $3.48 billion. 

• Congressional action provided VA the authority to use up to $3.3485 billion of 

Choice Act funds to meet the shortfall in the non-Choice Care in the Community 

FY 2015 budget. 

What is different now? 

• Significant advancements have been made in refining processes for the utilization of Choice Program funds. 

• VHA is completing monthly Financial Management System—Fee Basis Claims 

System (FMS-FBCS) reconciliations that are certified by VISN directors and Chief 

Financial Officers. 

37 

• For FY 2017, VA requested and received a separate appropriation for Community Care which will improve transparency and Congressional oversight. 

• The FY 2017 appropriation provided VA with new authority to transfer funds 

to the Medical Community Care account from other VA discretionary accounts. 

• VA is in the process of modernizing the Financial Management System, which 

along with improvements in methods and processes in the various automation systems that feed into the financial management system, will give VA senior management the ability to more easily identify this type of problem in the future. 

• A congressional action that would assist VA is legislative language allowing VA 

to record the costs of Care in the Community at the time of payment, like some 

other Federal agencies, as opposed to the current practice requiring funds to be obligated at the time of authorization for care. 

The planning and budget execution review processes that are now in place, will 

provide the necessary early warning of any similar funding issues and will allow 

for possible internal corrections. Additionally, I will be provided with the necessary 

information regarding the development of such an issue and will inform the Congress of it in a much more responsive manner. 

Question 66. If the Senate Veterans’ Affairs Committee requests the presence of 

VA employees to testify regarding a matter that was investigated by the Inspector 

General, will you make those personnel available to testify? Would you refuse to 

make VA employees available and advise they invoke their Fifth Amendment right 

against self-incrimination as Deputy Secretary Sloan Gibson did with several VA 

employees that the IG found were manipulating the VA system regarding relocation 

and financially benefited. Would you have made these employees available to testify 

before the House Veterans’ Affairs Committee? What would you have done in this 

specific situation? 

Response. I am committed to sharing information about VA policies, programs 

and activities with the oversight committees. The issue sometimes is one of timing: 

would testimony before the Committee during an active IG investigation potentially 

compromise a criminal proceeding, or violate an individual witness’s Constitutional 

right against self-incrimination? We have to balance those competing interests in an 

effort to do the right thing in each case. 

In the VBA relocation cases, it is my understanding that those employees retained 

private attorneys who advised them to invoke their Fifth Amendment rights. The 

Fifth Amendment right against self-incrimination is personal to individuals, not 

subject to invocation or waiver by one’s employer, including the Deputy Secretary. 

The problem in that case was timing. At the time that the employees’ testimony 

was requested, the IG had referred the case to the Department of Justice for possible criminal prosecution, and DOJ had not yet determined whether it would take 

the case. As a result, HVAC’s demand for those employees’ testimony on the same 

issues that had been referred for potential criminal prosecution posed a real—not 

hypothetical—threat to their constitutional right against self-incrimination. In the 

interest of providing the Committee the information it needed, the Deputy Secretary 

asked the Committee to defer the hearing until after DOJ disposed of the case so 

the employees’ Fifth Amendment rights would not be implicated. When the Committee declined to postpone the hearing, the employees invoked their right against 

self-incrimination. 

Question 67. How do you define unusual and excessive burden as it relates to the 

clause within the Choice Act? Do you consider it is an unusual and/or excessive burden for an 80 year old veteran without a vehicle to arrange transportation for a 200 

mile drive to receive a shingles shot at a VA hospital facility? In this specific case, 

would you permit this veteran access to a shingles shot in his community by utilizing the unusual and excessive burden clause in Choice? 

Response. As defined in the Veterans Access, Choice and Accountability Act 

(VACAA), the Unusual or Excessive burden provision is for a Veteran who resides 

40 miles or less from the closest VA medical facility and the Veteran faces an unusual or excessive burden in accessing such a facility. If the Veteran lives 200 miles 

from the closest VA medical facility, they would be able to use the Choice program 

for all of their care under the distance provision of VACAA. If the Veteran lived 40 

miles or less from the closest VA medical facility and has a medical condition that 

impacts his ability to travel to that facility, the Veteran would be eligible to receive 

all of their care through VACAA. The Unusual or Excessive burden provision did 

not account for transportation issues in making a determination regarding eligibility. The Unusual and Excessive burden provision does not take into account the 

availability of services in local market. VA believes that eligibility requirements 

should allow for the use of community care in instances where clinicians have determined there is need and VA cannot provide the service or provide the service timely. 

38 

Question 68. Do you believe the Choice Program should be extended? Should the 

criteria for eligibility be altered? Do you have recommendations to improve Choice? 

If so, please provide a summary. 

Response. Yes, VA would recommend that the Choice Act be amended to make 

full expenditure of the Choice Fund the sole basis for the expiration of the Veterans 

Choice Program (VCP) while utilizing existing eligibility criteria. This change would 

serve as an interim measure while Congress continues to consider VA’s long term 

plans as well as the recommendations of the Commission on Care. 

VA’s long term plan would consolidate all of its community care programs (both 

VCP and other programs, since VCP is only about 25% of total community care) into 

a single program that meets the needs of Veterans, their families, and community 

providers. This new program would clarify eligibility requirements, build on existing 

infrastructure to develop a high-performing network, streamline clinical and business processes, and implement continuum of care coordination services. This new 

program will provide enrolled Veterans increased flexibility, greater choice and faster access to health care in the community. 

VA has also identified several shorter-term legislative measures that offer immediate improvement for VCP. Those proposals include making VA the primary payer 

for VCP. We urge Congress to enact those changes, as well as adjust the termination provisions in the Choice Act. Addressing the sunset date issue in the coming 

weeks will accomplish three significant objectives that VA believes all stakeholders 

can agree on: 1) allowing Veterans to benefit from every dollar already appropriated 

by Congress to improve Veterans’ access to care; 2) providing the new 115th Congress, the new incoming Administration, and Veteran stakeholders more time to 

chart the course for the future of community care, including ensuring the financial 

resources are available to carry out that course; and 3) time for VA to work with 

Congress and stakeholders to ensure a smooth transition with minimal disruption 

for Veterans moving from VCP to VA’s new consolidated community care program. 

Question 69. Do you consider front-line medical facility positions, including direct 

patient care positions, to be positions that are low risk and do not require a heightened sensitivity level to conduct an investigation and/or criminal background check? 

Do you believe the policies within 5 CFR 731 that govern suitability of covered positions in the VA provides sufficient guidance and specific direction to determine 

whether an individual is ‘‘favorable’’ to hire and should be in contact with veterans? 

What would you change in the VA credentialing process, please be specific, to better 

protect veterans from individuals who may cause them harm 

Response. Provision of high-quality, safe patient care is the foremost mission of 

the VA. A critical component of providing safe care is the hiring and appointing of 

qualified healthcare providers. This begins before the provider is offered a position 

through the intense onboarding process. 

The onboarding process is comprised of many steps which are all in place to ensure the applicants have the qualifications to meet VA standards and perform the 

duties for which they are being hired. The onboarding process includes the Human 

Resource process of investigating background to reveal criminal convictions, civil 

judgments, and exclusions from participation in Federal and State Health Care Programs, qualifications and basic eligibility determination, interviews, reference 

checks, and at minimum, a National Agency Check with Written Inquiry (NACI) 

level background investigation. 

Another distinct and separate component of the onboarding process is the credentialing and privileging of the provider. This is an extensive process in which the 

training, education, work history, clinical references, and licensure are primary 

source verified. During the credentialing process the National Practitioner Data 

Bank (NPDB) is queried as well as the Federation of State Medical Boards (FSMB) 

(for physicians) to identify any licensure actions, medical malpractice payments, adverse clinical privileges actions, health care-related criminal convictions and civil 

judgments and exclusions from participation in Federal or state health care programs. Licensed Independent Practitioners, such as physicians and dentists, are 

also enrolled in the NPDB’s continuous query program and FSMB’s Disciplinary 

Alert Service so that the facility is instantly notified if any report is made by any 

entity (VA or non-VA) to either organization so that immediate action can be taken 

as necessary. 

VA utilizes an electronic credentialing software platform, VetPro, in which the 

primary source verified credentials for over 300,000 licensed, registered, or certified 

healthcare provider are stored and maintained. These files are easily shared and 

transferred between VA facilities to expedite the credentialing process for providers 

who move within the agency. The sharing of these files also assists in ensuring providers who have had substantiated clinical care concerns do not easily move 

39 

throughout the system as their VA clinical history is available to anyone with access 

to their file. 

The selecting official at the facility level has all of this information to review and 

consider when making a decision of whether or not to hire the provider and if they 

are a good fit for the patient care needs of the facility. 

Once hired, all Licensed Independent Practitioners are continuously monitored 

through a Focused Professional Practice Evaluation process and then through an 

Ongoing Professional Practice Evaluation process. These are screening tools (required for any Joint Commission Accredited facility) used to evaluate all providers 

who have been granted privileges and to proactively identify quality of care issues. 

VA is committed to the thorough vetting of all providers who will treat our patients and we will continue to provide education, guidance, and tools to help the 

leaders at the VHA facilities make informed hiring decisions. VA meets and exceeds 

the Joint Commission accreditation standards for credentialing of healthcare providers that are utilized by healthcare organizations throughout the country. 

RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 70. What steps will you take to establish a fully interoperable recordsharing system between the Department of Defense and the Department of Veterans Affairs, and to move beyond the use of the Joint Legacy Viewer to trade 

screenshots of records? 

Response. In accordance with requirements in the FY 2014 National Defense Authorization Act, DOD and VA were required to be interoperable by December 2016. 

This was certified ahead of schedule on April 8, 2016. 

• The DOD/VA Joint Legacy Viewer (JLV) is a clinical application that provides 

an integrated, chronological display of the complete longitudinal health record from 

DOD, VA, and Community Care providers in a customizable viewer. 

• JLV is not a ‘‘screenshot’’ sharing technology. It uses and displays (near realtime) computable data that can be organized as each user requires for their current 

and future workflow needs. 

• JLV shows all patient data, regardless of the source (VA, DOD, community 

partners) in one place. 

• Veterans Benefits Administration (VBA) offices use JLV to expedite benefit 

claim processing, and other staff from Office of Inspector General (OIG), Office of 

Medical Legal Affairs (OMLA), and Office of General Counsel (OGC). 

Today, more than 228,000 VA health care and benefits professionals have access 

to JLV and have used it to view more than 2 Million Veteran records. A preliminary 

VHA review found that patients reported 14% higher customer satisfaction when 

providers were using JLV because they were more familiar with their medical history. 

Next steps in interoperability—eHMP: 

• JLV has been a critical first step in connecting VA and DOD health systems 

with a read-only application, however, it is limited in its functionality. 

• VA has developed Enterprise Health Management Platform (eHMP) which will 

deliver urgently-needed clinical functionality, while incorporating all of the data 

interoperability achieved with JLV. 

• Through eHMP (which is a platform and not an EHR), clinicians will have a 

powerful Google-type record search that encompasses VA, DOD, and Community 

partners, as well as the ability to write notes, order laboratory tests, and communicate with improved tracking to ensure follow through on tasks. 

• VA has deployed the initial version of eHMP (version 1.2) across the entire VHA 

enterprise. 

• By ‘‘sitting’’ on top of the VA’s 130 separate VistA EHR’s, eHMP can maintain 

a consistent user interface while the supporting EHR systems underneath are modernized and/or changed. 

Question 71. Do you support overturning the decades-old ban on allowing VA to 

cover the costs associated with in vitro fertilization and other assisted reproductive 

technology services? 

Response. VA’s goal is to restore and improve the quality of life for Veterans in 

accordance with evidence based medical standards and to the greatest extent the 

law will permit. 

• In the past, IVF has been legislatively excluded from the medical benefits package. 

40 

• Recent passage of Pub. L. 114–223 enables VA to provide counseling and treatment using Assisted Reproductive Technologies (ART), including IVF to Veterans 

(and their respective spouse) with a service-connected (SC) condition that renders 

them unable to have children without the use of fertility treatment. 

• VA subsequently amended its regulation with publication of an interim final 

rule on January 19, 2017 that authorizes the same. VA will provide ART treatment, 

including IVF, to these affected Veterans and spouses. 

• VA estimates that nearly 400 total Veterans will be provided ART (including 

IVF) treatment over the remainder of this fiscal year and FY 2017. 

Note: The most common single cause of battle injuries is explosive devices 

(36.3%). Such trauma frequently results in genito-urinary injuries. For example, 1 

in 5 warriors were evacuated from Operation Enduring Freedom combat in October 2011 with a genito-urinary injury. 

Question 72. What is your assessment of VA’s protections against retaliation for 

reporting sexual assault within the VA system? 

Response. VA’s protections against retaliation for reporting sexual assault within 

the VA system is deeply rooted in its commitment to creating a culture, embedded 

in our mission and core values, which engages and inspires employees to their highest possible level of performance and conduct. 

Sexual harassment in the workplace is prohibited by law, and sexual assault is 

a serious form of sexual harassment. Reporting sexual harassment (or harassment 

on the basis of race, color, religion, national origin or age) is an activity that is protected by law. Retaliation against any individual for reporting such conduct is prohibited. VA managers at the highest and lowest level and employees are prohibited 

by law from retaliating against any employee for reporting sexual assault. There are 

consequences for engaging in such behavior. 

In VA’s Office of Resolution Management, there is an enterprise-wide Anti-Harassment Office (AHO), which provides centralized tracking, monitoring and reporting to proactively respond to all allegations of harassment. The AHO ensures that 

all harassment allegations are reported to VA leadership. Such a report outlines 

prompt corrective measures taken to decrease harassing behavior in the workplace. 

The AHO is committed to establishing transparency and accountability at every 

level of employment. 

VA has also established enterprise-wide anti-harassment policies and procedures 

to ensure that an allegation of harassment, including sexual assault and retaliation 

for reporting sexual assault, receives a prompt, thorough and impartial investigation; and that VA takes immediate and appropriate corrective action when it determines that harassment has occurred. 

By doing this, VA can proactively prevent harassing conduct before it becomes severe or pervasive. The EEO complaint process is also designed to make individuals 

whole for discrimination, that has already occurred, through damage awards and equitable relief, and to prevent the recurrence of the unlawful discriminatory conduct. 

While the EEO complaint process does not require an agency to discipline its employees, VA through the AHO, requires that immediate and appropriate corrective 

actions are taken to eliminate harassing conduct regardless of whether the conduct 

violates the law or whether an employee pursues an EEO complaint. The AHO focuses solely on whatever action is necessary to promptly bring the harassment to 

an end or to prevent it from occurring at all. 

An employee who believes that he or she has been subjected to harassing conduct, 

for reporting sexual assault or for any other reason, can report the matter to his 

or her immediate supervisor (or second-line supervisor if the immediate supervisor 

is the alleged harasser); to the Anti-Harassment Coordinator (AHC) for his or her 

specific office; or to the AHO. Employees who witness potential harassment are encouraged to report it. Supervisors or managers who are notified of harassment or 

witness potential harassment are required to report it immediately, and also to assess the situation immediately in consultation with the AHO or AHC. 

All reports of hostile or abusive conduct and related information is maintained on 

a confidential basis to the greatest extent possible. The identity of the employee alleging violations of the Anti-Harassment Policy will be kept confidential except as 

necessary to conduct an appropriate inquiry into the alleged violations or when otherwise required by law. Anonymous allegations of harassment will also be investigated and monitored to the fullest extent possible. 

VA is dedicated to protecting its employees from retaliation for reporting sexual 

assault and all other unlawful discrimination, and VA has in place an effective 

mechanism and policy to ensure that our employees are protected. For the sake of 

everyone, including the Veterans we serve, we want to provide a safe working environment for every VA employee. 

41 

Question 73. Do you support expanding the caregivers program to cover caregivers 

of veterans from all eras? What is your assessment of the program as it stands and 

how can it be further streamlined and improved? 

Response. 

• The Caregivers and Veterans Omnibus Healthcare Services Act of 2010 allows 

VA to provide services to qualified family caregivers of eligible Post-9/11 Veterans 

who incurred or aggravated a serious injury in the line of duty, including a monthly 

stipend paid directly to designated primary family caregiver, and coverage under 

CHAMPVA if eligible. 

• VA has developed multiple public/private partnerships in support of family 

caregivers of Veterans to provide training, education, and support to caregivers of 

Veterans of all eras. 

• The Caregiver Support Program is currently involved in program review and 

evaluation with VA researchers to evaluate the short-term impacts of the Program 

of Comprehensive Assistance for Family Caregivers (PCAFC) and the Program of 

General Caregiver Support Services by assessing the impact of current programming on the health and well-being of Veterans and caregivers. This work is ongoing 

and will impact current as well as future programming. 

• According to RAND’s report ‘‘Hidden Heroes,’’ the needs of family caregivers of 

Pre 9/11 Veterans are different than the Program of Comprehensive Assistance for 

Family Caregivers provides. 

• Based on current budget models, VA estimates the annual cost of expansion to 

be approximately $3 billion annually. 

• I would support providing equitable programming for caregivers of Veterans, regardless of the Veteran’s era of service or the reason why the Veteran requires assistance from a family caregiver. I would welcomes collaboration with Congress to 

make enhancements, including legislative changes, to the current program which 

may allow for expansion to caregivers of Veterans from eras. 

Question 74. What is your assessment of the program as it stands and how can 

it be further streamlined and improved? 

• As it stands, the Program of Comprehensive Assistance has provided services 

to more than 30,000 family caregivers of Veterans, far exceeding the original vision. 

• Despite the attention focused on the Post-9/11 Program, VA has very successfully implemented many other services and supports to family caregivers who do not 

qualify for the Comprehensive Assistance Program, including multiple trainings, 

peer support, and a very active telephone support line. 

– 350 Full Time Caregiver Support Coordinators at medical centers across 

country 

– 4,000 caregivers of Veterans of all eras have completed self-care training 

– Active peer support mentoring program, telephone education groups, on-line 

trainings 

– Caregiver Support Line has received more than 276,000 calls, continuing to 

average more than 250 calls per day 

• The legislation could be improved. One specific example is the use of the word 

‘‘injured,’’ in the Law, which excludes caregivers of Veterans with ALS, MS, and 

other debilitating illnesses. 

• Another idea for improvement may be focusing the caregiver support for aging 

Veterans in need of home-based care which may help delay long-term institutional 

care. 

Question 75. With the policy change last year to open all military professions to 

women and to allow transgender individuals to serve, what steps must VA undertake to ensure the system is prepared to handle an increasingly diverse veteran population? 

Response. 

• VA must continue education and training of providers 

• VHA’s LGBT (LGBT), Health Program, Women’s Health, Center for Women 

Veterans, Center for Minority Veterans, and Office of Health Equity have led national campaigns to raise awareness about the healthcare needs of lesbian, gay, bisexual and transgender women, African Americans, and rural Veterans. 

– The VHA LGBT Health Program has developed fact sheets for Veterans and 

providers on LGBT Veteran health care available here: (http:// 

www.patientcare.va.gov/LGBT/VA_LGBT_Outreach.asp) 

• VHA strongly supports training for providers so they can have tools to deliver 

clinically and culturally competent care for our diverse group of Veterans. 

– The VHA LGBT Health Program has developed and promoted several clinical 

trainings for providers in sexual health, transgender healthcare, as well as lesVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00045 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
42 

bian, gay, and bisexual Veteran healthcare (http://www.patientcare.va.gov/ 

LGBT/LGBT_Veteran_Training.asp). 

– A national transgender e-consultation program and a transgender SCANECHO program has been implemented. To date, 55 interdisciplinary healthcare 

teams encompassing nearly 400 providers have been trained 

– The VHA LGBT Health Program has been working with Pentagon officials 

about training military healthcare providers in transgender care utilizing the 

VA model. 

• In 2016, VA established an LGBT Veteran Care Coordinator at every facility. 

These Coordinators help train local staff and ensure that the facility provides appropriate clinical services for LGBT Veterans. 

• A demographic field for Self-Identified Gender Identity (expected Feb 2017) in 

the electronic health record will help providers and staff better communicate with 

a diverse veteran population. 

Question 76. What benefits has VA seen from its Child Care Pilot Program and 

what steps could be taken to permanently establish this program at VA facilities 

around the country? 

Response. The Caregivers Act of 2010 required a Child Care Pilot program be established in at least three VISNs over two years. The VHA sites selected were: 

• Buffalo, New York; opened 10/2011 

• Northport, NY; opened 4/2012 

• American Lake-Puget Sound (American Lake), Washington; (9/2012) 

• Dallas, TX became an additional pilot site in 3/2013 

The four pilots have continued to provide child care services with congressional 

authority extensions, most recently the Department of Veterans Affairs Expiring 

Authorities Act of 2016, authorizing services through December 31, 2017. 

• VHA is not able to conclusively demonstrate a relationship between use of the 

child care pilot sites and impact on no-show rates 

– However, despite limited data, Veterans did voice this service improved access to their appointments. 

– The pilot program is highly successful based on Veteran satisfaction with 

child care provided and allowed Veterans greater access to appointments. 

– While women Veterans are the most frequent users, it is notable that male 

Veterans users also use the service. 

• VA is on record as asking for permissive authority legislation. There is no legal 

authority to expand the pilots or to add additional childcare in VA. 

• In order to expand the program, Congress would need to enact legislation granting permanent discretionary authority to the Secretary to provide child care assistance for Veterans accessing health care at facilities. The Secretary’s authority 

should include the ability to establish the types of child care providers to participate 

in this program, the scope of child care assistance, and the location of child care 

services. 

Question 77. The Integrated Disability Evaluation System (IDES) integrates the 

Department of Defense (DOD) and Department of Veterans Affairs (VA) disability 

systems to improve and expedite processing of servicemembers through the disability evaluation system. 

a. What is your assessment of the need to further streamline and improve the 

IDES? 

Response. The Integrated Disability Evaluation System (IDES) is a joint DOD/VA 

Program that can certainly be presented as a success story of integrated, inter departmental cooperation. This program is designed to assist the DOD in determining 

whether wounded, ill, or injured Servicemembers (SMs) are fit for continued military service or if found unfit by the DOD, separate or retire the SM for their serviceconnected disability. IDES further showcases the unified efforts of DOD and VA 

working together to ensure all medically required evaluations, medical supportive 

services and full VA entitlements are made available to SMs found to be unfit. From 

the Program’s Initial Operating Capabilities (IOC) to date, over 190,061 Servicemembers have been processed via the IDES Program. In FY 2016, the IDES program averaged approximately 2453 cases per month. By continuing to provide this 

expeditious, yet comprehensive level of service to our SMs participating in the IDES 

Program, potential opportunities for continued improvement and streamlining include: 

– Ongoing early identification and thorough evaluation by DOD of SMs that 

may not meet the retention standards established by their specific military 

service. 

43 

– Offering enrollment in VA Healthcare to all IDES Program participants as 

a mechanism for maintaining uninterrupted access/healthcare coverage post 

separation from military service. 

SMs approaching normal separations/discharge or retirement from the service 

may also be eligible for VA benefits. These SMs may apply for VA benefits and compensation after they have separated from the service or may file a claim for VA compensation and benefits while still in the service by participating in the VA’s Benefits 

Delivery at Discharge (BDD) or the Quick Start Program. 

BDD allows a Servicemember to submit a claim for disability compensation 60 to 

180 days prior to separation, retirement, or release from active duty or demobilization. BDD can help the SM receive VA disability benefits sooner, with a goal of 

within 60 days after release or discharge 

• Separation Health Assessment (SHA) Initiative. Although part of the BDD Program, VA and DOD commenced an initiative in 2013 that further assists SMs by 

allowing them to choose which Department (DOD or the VA) will conduct their final 

separation from service examination. If a SM chooses to have their SHA examination performed by the VA, they must file a claim for benefits no later than 90 days 

prior to their scheduled separation. Once completed, the examination results are 

provided to the DOD, who in turn will review and accept the examination results 

as the final separation from service examination. The goal of this initiative is to provide VA disability benefits to the SM within 60 days after release or discharge. 

– Quick Start allows a Servicemember to submit a claim for disability compensation 1 to 59 days prior to separation, retirement, or release from active 

duty or demobilization. By submitting a disability compensation claim before 

discharge makes it possible to receive VA disability benefits as soon as possible 

after separation, retirement, or demobilization. SMs with 1–59 days remaining 

on active duty or full time Reserve or National Guard service, or SMs who do 

not meet the Benefits Delivery at Discharge (BDD) criteria requiring availability for all examinations prior to discharge, may apply through Quick Start. 

b. If confirmed, how would you work with the DOD Secretary to ensure both DOD 

and VA ensure that veterans move smoothly through the multi-step disability evaluation process? 

Response. Our approach would include continued holistic reviews of the IDES program, specifically focusing on a more robust feedback process from current and 

former participants of IDES and their families to ascertain: 

– Transition improvements that can be made to the Program. Conduct a comprehensive review of all phases of the program and re-evaluate the challenges 

faced by both the SMs and their supporting chain of commands to remove or 

modify administrative processes identified as ‘‘very challenging’’ by Program 

participants and commanders alike. 

– Review current services, programs and assistance provided by both the VA 

and DOD with a specific focus on the families of separating SMs, to better prepare them for their spouse’s transition from military service. 

RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 78. Dr. Shulkin, as Under Secretary for Health, you stated to Virginia’s 

Daily Press that privatization ‘‘would be a terrible mistake, a terrible direction for 

veterans and for the country, to essentially systematically implement recommendations that would lead to the end of the VA health-care system,’’ As Secretary of the 

Department of Veterans Affairs, would you continue to oppose efforts to reduce the 

Federal role in providing health care services to veterans? 

Response. I have consistently stated my support for an integrated system of care 

for veterans. I wrote about this in my New England Journal of Medicine article in 

2016. This integrated network would support and enhance services that are essential to veterans within the VA that either cannot be readily found in the private 

sector. The integrated system would also utilize care in the community that may 

be more accessible or higher quality of care than found in the VA. It is my firm 

belief that this integrated system of care will provide the best outcome for our veterans and the best value for taxpayers. Each community has different needs and 

capabilities and therefore such a system will require local needs assessments. Nationally, VA currently utilizes 31% of its’ care in the community, demonstrating that 

we are able to both support a strong VA and work effectively with community providers. 

44 

I also believe that the VA health care system is essential to fulfilling our commitment to our Nation’s veterans. All of my efforts would be directed to making our 

system work better on behalf of our veterans. I do believe that with thoughtful and 

proactive planning we can enhance and strengthen services, and eliminate waste 

and duplication by accelerating our efforts through an integrated system of care 

that serves veterans. 

Question 79. In respect to the Choice Program, I hear two main concerns from 

Vermont veterans. First, is that there are delays in third party administrator (TPA) 

authorizations for care, which have led to critical medical appointments being delayed or missed entirely. Second, miscommunications between VA and the TPA on 

authorizations and billing have led to multiple Vermont veterans being sent to collections by local health care providers. As Secretary, how would you address these 

issues to ensure veterans get the care they need when they need it, without their 

credit being adversely impacted? 

Response. VHA is committed to ensuring that all Veterans have timely access to 

care. In June 2016, the Office of Community Care implemented a contract modification to improve the appointing requirements and processes for Veterans 

Choice Program services. In accordance with the modification, the initial appointment for an episode of care must be scheduled within five (5) business days of the 

contractor’s receipt of a 10–0386 ‘‘VHA Choice Approval for Medical Care’’ form (or 

similar VA-generated request), all applicable clinical documentation, and the Veteran has opted in for VCP. The appointment must take place within 30 calendar 

days of the initial scheduling unless the desired appointment date is otherwise 

noted on the referral. 

VHA continues to work with the contractors and VA staff to ensure clear and concise communication is the utmost importance to for our Veterans to have timely access to care. The Office of Community Care has worked on the development and 

modifications of the VHA form 10–0386 to make the request for care clear and concise for our Veterans. The form has several mandated fields that require VA staff 

members to ensure the request has all the pertinent information needed for the contractors to provide the best care to our Veterans. 

VA understands that any situation resulting in delayed payments or accumulation 

of debt due to inappropriately billed claims is stressful for Veterans and unacceptable. We are working hard to correct these errors and offer assistance to our Veterans immediately. 

We were able to pull the following data specific to VISN 1 and Vermont: In the 

past 90 days (Oct-Dec 2016), Community Care received a total of 139 Adverse Credit 

Reporting (ACR) requests for VISN 1. 

Question 80. Treatment courts can play an important role in ensuring veterans 

with histories of substance misuse get a second chance. What do you see as VA’s 

role in ensuring veterans can benefit from these programs? 

Response. Incarceration as an adult male is the most powerful predictor of homelessness. VA services for justice-involved Veterans are therefore provided through 

two dedicated national programs, both prevention-oriented components of VA’s 

Homeless Programs: Health Care for Reentry Veterans (HCRV) and Veterans Justice Outreach (VJO). Known collectively as the Veterans Justice Programs (VJP), 

HCRV and VJO facilitate access to needed VA health care and other services for 

Veterans at all stages of the criminal justice process, from initial contact with law 

enforcement through community reentry following extended incarceration. 

VJO Specialists serve Veterans at earlier stages of the criminal justice process, 

with a three-pronged focus on outreach to community law enforcement, jails, and 

courts. All VJO Specialists must be licensed independent clinicians, and the vast 

majority are social workers. Differences (in size, structure, openness to outside partnerships and to treatment-based criminal justice interventions, etc.) between local 

criminal justice systems, as well as the partnership-driven nature of the work, mean 

that the VJO program can look significantly different from one location to the next. 

VJO Specialists at each VAMC work with Veterans in the local criminal courts (including but not limited to the Veterans Treatment Courts, or VTCs), conduct outreach in local jails, and engage with local law enforcement by delivering VA-focused 

training sessions and other informational presentations. 

VA supports VTCs through the participation of its VJO Specialists as members 

of VTC treatment teams, and through the health care services it provides to Veteran 

defendants, most of whom would otherwise receive care at county expense. The Specialists assess Veteran defendants’ treatment needs, assist as needed with the VA 

eligibility and enrollment process, link Veterans with appropriate VA treatment 

services, and (with the Veterans’ permission) provide regular updates to the court 

on their progress in treatment. The VJO Specialists’ (and VA’s) role in a VTC is limVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00048 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
45 

ited to the treatment-related aspects of the court process; although VA eligibility 

may be a court-imposed requirement for admission, VA does not decide which Veteran defendants should be admitted to a VTC or define the level of offenses (e.g., 

misdemeanor vs. felony) that a VTC will accept. VJO Specialists work closely with 

justice system partners as they plan new VTCs, informing the partners about VA 

services that would be available to Veterans defendants locally or regionally. However, as with all VJO-related services, the Specialists do not advocate specifically 

for the use a particular model or set numerical targets for desired VTC growth, but 

instead encourage communities to plan proactively to meet the needs of justice involved Veterans using approaches that best fit local circumstances. VA also does not 

provide grant funding or other financial support to VTCs or other Veteran-focused 

courts. 

Question 81. It can sometimes be challenging for rural veterans, like those in my 

home state of Vermont, to have all their health care needs met. Under your leadership, how would VA maximize its telehealth capabilities to ensure rural veterans 

can assess quality VA-provided care closer to—or even in—their home? 

Response. Telehealth is a key component of the strategy to address access issues, 

especially in rural areas where it can be difficult to hire providers. • VA is expanding services through enterprise-wide initiatives, including by the 

expansion of Primary Care, Tele-Mental Health, and specialty care hubs that each 

service many sites of care. • In Fiscal Year 2016, VA provided more than 2 million Telehealth visits to over 

700,000 Veterans across more than 50 specialties. 

– Approximately 315,000 of these Veterans were located in rural areas, including approximately 1,500 in rural areas of Vermont. • While most Veterans currently access Telehealth services in their local VA 

Community-Based Outpatient Clinic, VA’s Veteran-centric approach has led the Department to pursue expansion of services directly into Veterans’ homes. 

– VA Video Connect, VA’s home Telehealth program, provided more than 

39,000 encounters direct to Veterans’ homes last year, of which over 40% were 

rural. 

– For Veterans without an Internet-connected device at home, VA has implemented a system to provide tablets for home Telehealth use. 

• As VA works to expand established Telehealth services, the Office of Rural 

Health and Office of Connected Care also partner with clinical program offices to 

foster innovative Telehealth programs that specifically increase access for rural Veterans. 

– In FY 2016, rural Telehealth programs provided care to over 85,000 Veterans 

in remote areas across the country. This number is expected to increase to the 

hundreds of thousands in FY 2017. 

RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT

OF VETERANS AFFAIRS

Question 82. As of December 31, 2016, there were over 450,000 cases pending in 

VA’s appeals system. Last year, Secretary McDonald convened a group of stakeholders including VSOs to attend a multi-day event to collaborate on how to fix the 

VA appeals system. Department of Veterans Affairs Appeals Modernization Act of 

2016, which I introduced last Congress put the results of that collaboration into legislation and the Disabled American Veterans, the American Legion, the Veterans of 

Foreign Wars, the Paralyzed Veterans of America, AMVETS, the Military Officers 

Association of America, the National Association of County Veterans Service Officers, and the National Association of State Directors of Veterans Affairs supported 

the legislation. 

Do you support the reforms contained in that legislation as a path forward for 

improving the appeals process, if not, why not, and how would you reform the 

process? 

Response. I fully support reforming the current appeals process. Comprehensive 

reform is necessary to replace the current lengthy, complex, confusing VA appeals 

process with a new appeals framework that makes sense for Veterans, their advocates, VA, and stakeholders. This reform is crucial to enable VA to provide the best 

service to Veterans and, if confirmed, I will prioritize reforming the current appeals 

process. 

I support the framework developed collaboratively by VA and a wide spectrum of 

stakeholder groups in 2016. I believe that the engagement of the organizations that 

participated in development of the new framework ultimately led to a stronger proVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00049 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
46 

posal, as we were able to incorporate their feedback and experience having helped 

Veterans through the complex appeals process. 

The current VA appeals process takes too long. Appeals have no defined endpoint 

or timeframe and require continuous evidence gathering and re-adjudication. On average Veterans are waiting 3 years for a resolution on their appeal. For cases that 

reach the Board of Veteran’s Appeals (Board), Veterans are waiting on average 6 

years and thousands of Veterans are waiting much longer. The current appeals 

process is also too complex. Veterans do not understand the process, it contains too 

many steps and it is very challenging to explain to Veterans. Additionally, accountability does not rest with one appellate body; rather, jurisdiction over appeals is 

split between the Veterans Benefits Administration (VBA) and the Board. 

The new framework, which I fully support, steps away from an appeals process 

that tries to do many unrelated things inside a single process and replaces it with 

differentiated lanes, which give Veterans clear options after receiving an initial decision on a claim. For a claim decision originating in VBA, for example, one lane 

would be for review of the same evidence by a higher-level claims adjudicator in 

VBA; one lane would be for submitting new and relevant evidence with a supplemental claim to VBA; and one lane would be the appeals lane for seeking review 

by a Veterans Law Judge at the Board. In this last lane, intermediate and duplicative steps currently required by statute to receive Board review, such as the Statement of the Case and the Substantive Appeal, would be eliminated. Furthermore, 

hearing and non-hearing options at the Board would be handled on separate dockets 

so these distinctly different types of work can be better managed. As a result of this 

new design, the agency of original jurisdiction (AOJ), such as VBA, would be the 

claims adjudication agency within VA, and the Board would be the appeals agency. 

This new design would contain a mechanism to correct any duty to assist errors 

by the AOJ. If the higher-level claims adjudicator or Board discovers an error in 

the duty to assist that occurred before the AOJ decision being reviewed, the claim 

would be returned to the AOJ for correction unless the claim could be granted in 

full. However, the Secretary’s duty to assist would not apply to the lane in which 

a Veteran requests higher-level review by the AOJ or review on appeal to the Board. 

The duty to assist would, however, continue to apply whenever the Veteran initiated 

a new claim or supplemental claim. 

This disentanglement of process would be enabled by one crucial innovation. In 

order to make sure that no lane becomes a trap for any Veteran who misunderstands the process or experiences changed circumstances, a Veteran who is not fully 

satisfied with the result of any lane would have 1 year to seek further review while 

preserving an effective date for benefits based upon the original filing date of the 

claim. For example, a Veteran could go straight from an initial AOJ decision on a 

claim to an appeal to the Board. If the Board decision was not favorable, but it 

helped the Veteran understand what evidence was needed to support the claim, 

then the Veteran would have 1 year to submit new and relevant evidence to the 

AOJ in a supplemental claim without fearing an effective-date penalty for choosing 

to go to the Board first. 

To fully enable this process and provide the appeals experience that Veterans deserve, VBA, which receives the vast majority of appeals, would modify its claims decisions notices to ensure they are clearer and more detailed. This information would 

allow Veterans and their representatives to make informed choices about whether 

to file a supplemental claim with the AOJ, seek a higher-level review of the initial 

decision within the AOJ, or appeal to the Board. 

The new framework would not only improve the experience of Veterans and deliver more timely results, but it would also improve quality. By having a higherlevel review lane within the VBA claims process and a non-hearing option lane at 

the Board, both reviewing only the record considered by the initial claims adjudicator, the output of those reviews would provide a feedback mechanism for targeted 

training and improved quality in VBA. 

The legislation should be enacted now. It has wide stakeholder support and the 

longer we wait to enact the Appeals Reform legislation more and more appeals will 

enter the current, broken system. The status quo is not acceptable for our Nation’s 

Veterans and taxpayers. The new framework will provide much needed comprehensive reform to modernize the VA appeals process and provide Veterans a decision 

on their appeal that is timely, transparent, and fair. 

47 

RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. SHERROD BROWN TO

HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 83. As a result of the Veterans Access, Choice and Accountability Act 

of 2014, veterans have been charged fees for seeking care in the community through 

the Choice Program. In some cases these fees have been turned over to collection 

agencies, putting the veteran’s credit score and sometimes livelihood at risk. Under 

your direction what steps will the VA take to ensure that veterans have a clean financial bill of health? 

Response. The Choice Act requires VA to be secondary payer when a Veteran receives community care for a non-service-connected condition and has other health 

insurance (OHI). In these cases Veterans are responsible for their co-pay or deductible as part of their participation with their OHI. 

There have been cases when the delayed payment to the community care provider 

is inappropriately billed to the Veteran directly. The Choice contracts clearly identify billing timeframes for the Choice contractors and VA. The contractors have 30 

days to pay a submitted claim or to deny the claim with an explanation of additional 

information needed to process. VA has 14 days to pay the contractors—this is a new 

addition to the contract in order to address the backlog of payments. 

VA understands that any situation resulting in delayed payments or accumulation 

of debt due to inappropriately billed claims is stressful for Veterans and unacceptable. We are working hard to correct these errors and offer assistance to our Veterans immediately. 

a. Additionally, I hear concerns from medical providers who have had reimbursements delayed by the VA for months. This has caused providers to stop taking veterans, many of whom live in rural areas and are in need of care. Under your direction, what steps will the VA take to improve reimbursements rates for care in the 

community? 

Response. Currently there are no reports of providers refusing to see Veterans as 

a result of non-payment from VA. We have however received reports of providers 

who are refusing to see Veterans because of non-payment from the third party contractors. We are 100% current with Choice payments to the TPAs and have been 

for over 4 weeks. 

In February 2016, the Office of Community Care created the Provider Rapid response Team. The purpose of this team is to quickly respond to any issue with provider payment or anything else that might affect Veteran’s access to care in the 

community. This team liaises directly with leadership with the contractors to quickly and effectively solve provider issues. 

Question 84. The Diffusion of Best Practices initiative has shown promise in 

standardizing veterans’ care and experience at VA medical facilities. If confirmed as 

VA Secretary, what is your vision for continuing to build on that process? 

Response. Diffusion of Excellence is an initiative that carried out one of my major 

priorities as Under Secretary: achieving consistency of best practices across the system. In your home state, Cleveland has a simple but impactful best practice that 

involves non-clinical employees spending time with veterans throughout their journey through the hospital: with this program, employees not only witness the experience of veterans firsthand, but they also get to know the veterans more closely and 

hear their stories throughout their service. 

If confirmed I would ask Dr. Elnahal and his team to build the Diffusion of Excellence initiative out for the entirety of VA. This is an easier endeavor than it might 

seem: throughout the last 18 months, hundreds of best practices have been compiled 

with an online information sharing tool called the Diffusion Hub, which included 

many projects commissioned over the last year at VBA and NCA during a major 

leadership development initiative. We will establish a similar performance improvement and governance framework for the entirety of VA, and strategically target 

areas where we need the most improvement. 

Appendix: Diffusion Activities occurring in Ohio: 

48 

Question 85. In your current role, you continue to hold medical appointments with 

veterans. Why is that important to you and what have you learned from that experience that would enhance your ability to lead VA? 

Response. During my career as a healthcare executive I have always maintained 

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remain connected to the mission of helping those in need and in learning how systems of care actually work. Being a practicing physician also allows me to understand and communicate better with our staff and to understand how the system allows them, or fails them in their job to care for veterans. Practicing medicine at the 

VA, in both New York City and via telehealth in Grants Pass Oregon, has allowed 

me to better understand the needs of the veterans that we serve and how our system of care is different than what I have experienced in the private sector. It has 

given me firsthand knowledge of the integrated nature of our system, that provides 

not just physical care, but also addresses the social, psychological and economic 

needs of our veterans. I’ve also come to appreciate the specialized services offered 

by VA such as prosthetics and adaptive sports programs that are essential to the 

well being of many of the veterans that we have the honor of serving. 

Question 86. With each new generation of warfighters confronts issues of exposure 

to toxic and hazardous materials during service. Will you commit to addressing the 

full scope of health issues faced by veterans and their families as the result of exposure to things like Agent Orange, burn pits, or nuclear material? 

Response. The Department of Veterans Affairs (VA) honors the national service 

and sacrifice of our Veterans and is committed to providing compensation and 

health care benefits for disabilities that were incurred or aggravated by that service. 

This includes any disability resulting from exposure to environmental toxins or hazardous materials. 

VA regulations and policies have long addressed environmental exposure issues 

that include World War II-era radiation from atomic bomb use and testing; Vietnam-era Agent Orange herbicide use; Gulf War desert particulate matter and burn 

pit toxins; and Camp Lejeune contaminated water during the 1950s–1980s. 

Specifically, these regulations govern and address benefits for: 

(1) Radiation exposure-related disabilities and for participation in radiation-risk 

activities and exposure to ionizing radiation; 

(2) Diseases associated with exposure to Agent Orange herbicide for those Veterans who served in or visited Vietnam, or on its inland waterways, between January 9, 1962 and May 7, 1975; for service in a military unit operating on the Korean 

demilitarized zone between April 1, 1968 and August 31, 1971; for regular and repeated contact with a post-Vietnam C-123 aircraft used for aerial spraying of Agent 

Orange in Vietnam; and for involvement with testing, storage, transport, or other 

use of Agent Orange; 

(3) Disability patterns associated with service in the Southwest Asian Persian 

Gulf War theater. These include undiagnosed illnesses and diagnosable medically 

unexplained chronic multi-symptom illnesses, as well as certain infectious diseases. 

In addition, our regulations also provide benefits for other diagnosable conditions 

associated with burn pit and Southwest Asia desert hazards; and 

(4) Disabilities associated with service at the US Marine Corps’ Camp Lejeune, 

NC, based on evidence of exposure to contaminated water from the mid-1950s to the 

mid-1980s. Free health care is already available for certain associated diseases and 

a VA regulation is pending that would provide presumptive service connection for 

eight diseases. 

VA will continue to work with the Department of Defense to monitor and respond 

to any indication of toxic or hazardous environmental exposures experienced by Veterans during their military service and provide benefits for any resulting disabilities. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VET- ERANS AFFAIRS

Question 1. During your nomination hearing, you stated with regard to President 

Trump’s Hiring Freeze, that the most important factor was having the resources to 

hire the people you need to take care of our veterans. You added that you felt very 

comfortable about where VA is after receiving all of the hiring freeze exemptions 

you requested from the White House. What would it take for you to ask for exemptions for the Veterans Benefits Administration and the Board of Veterans’ Appeals? 

What metrics would you use to determine whether hiring exemptions are necessary 

for VBA and BVA? 

Response. There is no doubt that if the hiring freeze were to continue for an indefinite period of time that we would begin to see a real degradation of service levels of Veterans I would be specifically concerned that if there was a delay in new 

enrollments for benefits that access to healthcare may be impacted, which would be 

50 

unacceptable. As I mentioned in my hearing I have spoken to the Acting Under Secretary for Benefits, Thomas Murphy. He is prioritizing new enrollments and will inform the Secretary if significant changes occur as a result of attrition that may be 

impacting service levels. If there is a significant change in the number of days that 

Veterans are waiting for benefits the Acting Secretary of VA would address this 

with the White House and request an exemption from the hiring freeze. Currently, 

VBA is in the process of submitting an exemption request to permit the hiring of 

direct labor occupations to ensure reduced impact on VBA’s ability to serve Veterans. Regarding appeals, while staffing is important we will not significantly impact the 

pending inventory without appeals modernization legislation that discontinues the 

flow of appeals into the current broken process and a temporary surge of additional 

resources. During the 114th Congress, VA worked with VSOs and other stakeholders to design a new appeals process that is fair, transparent, and timely. This 

new framework for appeals was introduced in several bills in the 114th Congress 

and has been reintroduced in the 115th Congress. VA intends to address its need 

for a temporary surge of additional resources to eliminate its current inventory of 

appeals in the annual budget process. 

Question 2. How hands-on of a leader have you been in problem solving on controversial issues that VA has faced since your arrival—for instance, high-profile suicide incidents, Veterans Crisis Line issues, or the aftermath of the Tomah opioid 

crisis. What was your personal role in resolving these challenges? 

Response. My management style is one that leads by example. In response to the 

access crisis I began seeing patients in the walk in access clinic in New York and 

by telehealth in Grants Pass, Oregon. In our homeless programs I participated in 

our midnight point in time counts in LA and in both years I have been here at our 

homeless stand-down’s in DC. I personally called for and led our urgent call to action to prevent suicides among Veterans that we help with Members of Congress 

in 2016. In issues such as VA’s response to the opioid crisis I led public forums with 

our elected Members of Congress and the Surgeon General to address the issue and 

then wrote up our approach to opioid reduction for publication in a major medical 

journal. These are just examples, but I believe they demonstrate my belief that leaders must get personally involved in issues that matter and it is essential that leaders be seen as having personal involvement in areas that they want the organization 

and the community to effectively address. 

Question 3. VA has been criticized for how it distributed medical staff hired under 

the Veterans Access, Choice and Accountability Act of 2014. Please discuss your role 

in these decisions and if you had no role, what you would have done differently? 

Response. I did not arrive at VA until July 2015. However, in September 2014, 

VHA completed a Nation-wide data call to identify staffing needs for clinical and 

medical support staff, with a special emphasis on Primary Care, Mental Health, and 

Specialty Care. After further analysis, VHA identified the need for 10,682 additional 

Full-Time Equivalent Employee (FTEE) to be hired by September 2016. VHA directed a prioritization of the VACAA 801 funds distribution to 33 VAMCs experiencing the greatest challenges with Veterans access. Since access remained a critical 

priority across the entire VA Health Care System, the remaining funds were distributed proportionally across all sites, based upon the Veterans population to be 

served. This decision was made by the Acting Under Sectary for Health, Dr. Carolyn 

Clancy. By December 31, 2015, VHA had achieved 102% of the VACAA target, having hired 10,854 FTEE. Primary Care, Mental Health, and Specialty Care areas 

were VHA’s most urgent needs at the time and were appropriate for prioritization 

of the VACAA staffing allocations. 

Question 4. It seems to me that technology is the underpinning of success at VA 

and things are pretty far behind—there still is no new scheduling system, no decision on EHR, no consistency of systems between processing of initial claims and appeals on those claims. With respect to the various important and pressing IT needs 

facing the Department, how do you intend to prioritize? Where do you stand on 

VISTA Evolution vs. DOD and VA simply using the same system? 

Response. The goals of the VistA Evolution program are improving the efficiency 

and quality of Veterans’ health care by modernizing VA’s health information systems; increasing data interoperability with DOD and private sector care partners; 

reducing the time it takes to deploy new health information management capabilities; and continuing to provide safe, efficient health care IT tools to VA medical providers so they can continue to deliver Veteran-centric, team-based, and quality-driven care. The VistA Evolution Program manages the development of what is known 

as VistA 4 which is a collection of approximately 60 projects and initiatives focused 

on VA’s interoperability efforts with DOD and the private sector; the flagship EnterVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
51 

prise Health Management Platform (eHMP) and Joint Legacy Viewer (JLV) projects 

and other projects. Among many achievements, the work of the VistA Evolution Program has enabled VA to certify to Congress, together with Department of Defense 

(DOD), that VA had met the FY 2014 National Defense Authorization Act (NDAA) 

interoperability standards. 

As of January 2017, the VistA Evolution Program had completed approximately 

27 projects and 31 remain to be finished by the end of FY 2018. The investments 

and work of the VistA Evolution Program have and continue to deliver value for 

Veterans and VA providers regardless of whether VA’s path forward is to continue 

with VistA, shift to a commercial EHR platform as DOD is doing, some combination 

of both or other alternatives. VA is currently reviewing options regarding long-term 

EHR modernization courses of action. 

Question 5. Same Day Access has been one of your initiatives. What is your definition of Same Day Access? 

Response. In primary care, when a Veteran contacts a VA about a healthcare 

need, VA will either address that need the same day or schedule appropriate follow 

up care. Veterans with urgent issues will be provided care the same day. VA may 

address the needs of Veterans by providing a face to face visit at a VA medical center, returning a phone call, arranging a telehealth or video care visit, responding 

by secure email or scheduling a future appointment. For mental health, if the Veteran is in crisis or has another need for care right away, the Veteran will receive 

immediate attention from a health care professional at the VA medical center. 

Question 6. Are you satisfied with the level of communication between VA central 

office and the field? If yes, how quickly did you find out about problems in the field, 

and if no, what have you done to improve communication? 

Response. As one of my first steps as Under Secretary I sought candid feedback 

about the adequacy of communication with the field. What I consistently heard was 

that the communication was unidirectional, in that the field would get directives 

from central office but they did not feel that their input into directives and other 

policies was being adequately considered. I sought to improve these communications, and to make the discussions bi-directional by having more forums in which 

to communicate with the field. This has included quarterly town hall meetings, the 

use of an intranet communications tool (called Pulse) that has close to 100,000 users 

from the field, regular and frequent calls with the field and Central office where 

I participate in many of these, and regular videos and emails that I send to the field 

to communicate important priorities, events, and milestones. In addition, our leaders developing leaders program has helped to improve communication with the field 

among thousands of our field staff and central office staff. Having detailed some of 

the progress we have made, we have much more work to do to close the deficits that 

have long existed between central office and the field. We have prioritized our efforts in internal communications and will continue to work on this as a priority. I 

can commit that if confirmed as Secretary that improved communications will be a 

vital element for my leadership team. 

Question 7. Do you share my belief that Bob McDonald was an effective and successful VA Secretary? In your testimony, you said you would seek ‘‘major reform and 

a transformation of VA.’’ How does your vision of ‘‘transformation and reform’’ differ 

from Bob McDonald’s? 

Response. Secretary McDonald entered VA in 2014 at a time of crisis. His leadership allowed VA to begin a path of recovery and he was able to lay the foundation 

for the transformation of VA. As such, yes I believe that Secretary McDonald was 

both effective and successful. My vision of transformation and reform can buildupon 

the good work that Secretary McDonald began. I do believe that for VA to be successful we must now begin to address some of the long term systems problems that 

VA faces. First is our need to act as an integrated enterprise both within our three 

separate administrations and across the country. This will allow us to take advantage of VA’s economies of scale and also begin to deliver a more consistent experience for our Veterans. We must also modernize many of our systems that have been 

long neglected. We must address the need for greater integration of our services between VA and the private sector and other Federal entities, whether this relates to 

healthcare or to building and maintaining our current infrastructure and facilities. 

This action will take dedicated focus by our leadership but I believe can be accomplished and will result in meaningful improvements for our Veterans. 

Question 8. As VA Secretary, what are you going to do to make VA a more attractive place to work—whether we’re talking about Montana or Georgia? 

Response. VA is undergoing one of the most ambitious Department-wide initiatives to transform its workplace culture in its history, known as MyVA. The MyVA 

initiative is predicated on five foundational strategies, one of which is Improving the 

52 

Employee Experience. This core strategy is aimed at fundamentally changing the 

VA culture to focus on two key and inextricably linked goals: improving leadership 

and increasing employee engagement in every corner of the Department. To that 

end, we have implemented a new ILEAD campaign that promotes leadership development for leaders at every level, characterized by principle-based leadership and 

demonstrated though ‘‘servant leader’’ behavior. These two powerful concepts shift 

the emphasis from self-serving behaviors and blindly following bureaucratic rules, 

to behaving in ways that put principles first, and service to others as the driving 

force. With respect to employee engagement, I will reply on feedback from our employees through the OPM Federal Employees Viewpoint Survey and the VA All Employee Survey. As a result of these surveys I am committed to: 

• Moving pay setting for our healthcare employees to a market-based pay system • Working with the Committee to establish an alternate personnel system for all 

VHA personnel, and proposals that will allow VA to offer more competitive pay (special rate increase, elimination of dual compensation waiver, and changes to Physician and Dentist Pay) • Implementing changes to the Title 38 leave system for Physicians and other 

‘‘24/7’’ providers, creating more flexible work schedules that will address critical 

staffing needs while being more desirable to Physicians. 

In addition, I need the ability to use all recruitment and retention tools and flexibilities; however the CARA Act has significantly reduced VA’s ability to offer recruitment, relocation, and retention incentives. 

Question 9. What are you going to do differently than your predecessor to make 

the Choice program work better in states like mine? 

Response. VA has worked to make many changes and improvements to the Veterans Choice Program and will continue to do. We now have completed over 60 contract modifications with Health Net and TriWest to improve the program from the 

original implementation. VA has improved communications with the contractors by 

developing a standardized referral form for care. The referral form, VHA 10–0386 

‘‘VHA Choice Approval for Medical Care,’’ provides a set format for VA facilities to 

request needed care, and helps to avoid any miscommunication and misdirected to 

inappropriate specialties. VA has embedded contractor staff in facilities to assist in 

resolving questions and issues timely. In addition, VA implemented Provider Agreements to assist Veterans in receiving timely care. Provider Agreements have been 

utilized in to provide care to Veterans, when the contractors were unable to schedule such care timely. The Provider Agreements are initiated at the VA medical center level, and allow Community Care providers to work directly with VAMC to 

schedule care for referrals that have been returned in certain circumstances from 

the contractors. These agreements have augmented the care provided under contractors to ensure Veterans receive timely community care. 

Question 10. In response to question 6 of my pre-hearing questions, you raised 

VA’s Whistleblower Protection Program. As you may know, section 247 of the Continuing Appropriations and Military Construction, Veterans Affairs, and Related 

Agencies Appropriations Act of 2017 (P.L. 114–223) directs VA to establish a new 

process for VA employees to file whistleblower complaints. Section 247 of Public 

Law 114–223 is based on legislation, the VA Patient Protection Act of 2016, which 

was considered before the Senate Veterans’ Affairs Committee in November 2015. 

According to testimony from VA, VAOIG, and the U.S. Office of the Special Counsel, 

the new process established by section 247 is unworkable, unnecessary, and may 

undermine current whistleblower protections. What are your views on section 247? 

If confirmed, will you work with the Senate Veterans’ Affairs Committee to ensure 

that whistleblower protections in the Department are effective? 

Response. I have several concerns about section 247. 

First, I believe strongly that VA employees should be entitled to the same whistleblower protections as other Federal employees, to include an easy-to-access and easily understood process for disclosing concerns about safety or about fraud, waste, or 

abuse in the workplace and about retaliation they may encounter after making a 

disclosure. Section 247 imposes on VA, alone among Federal agencies, an additional 

set of rules and requirements around disclosures and retaliation complaints that are 

frankly confusing for employees, duplicative of existing processes, and expensive to 

carry out from a manpower perspective. It also imposes on VA supervisors, alone 

among Federal supervisors, a more draconian set of penalties for retaliation. 

I would prefer to see the whistleblower protection rules apply equally across the 

entire government. Rather than impose this unfunded mandate on VA to handle 

these matters differently than anyone else does, I’d prefer to see Congress properly 

resource the Office of Special Counsel, which is in essence the Central Whistleblower Office for all Federal employees, and VA’s Inspector General, which has the 

53 

mandate and the expertise to investigate many of the concerns that VA whistleblowers raise. 

Another concern I have about section 247 is the burden in places on VA’s firstline supervisors—many of whom are doctors or nurses who supervise in addition to 

caring for Veteran patients, or are claims processors or cemetery workers who serve 

Veterans directly while also supervising. Section 247 says that when an employee 

submits a whistleblower claim under this new process, the supervisor has to stop 

what he or she is doing in support of Veterans to carry out this complicated process 

of determining whether the claim meets the legal definition of whistleblowing and, 

if it does, to provide a formal written response back to the employee within four 

days. That is not the best use of our supervisory health care providers or claims 

representatives or cemetery staff, and I think it will create an unhelpful formal or 

even adversarial dynamic between our supervisors and their employees. 

Question 11. VA’s fiscal year (FY) 2017 budget request states that there is a direct 

and proportional correlation between the number of employees at the Board of Veterans’ Appeals (Board) and the resolution of claims for VA benefits that reach the 

Board. As you acknowledged in your confirmation hearing, today there are over 

450,000 appeals pending. To address the appeals inventory, VA’s FY 2017 budget 

called for an increase of full-time equivalent (FTE) employees in fiscal years 2017 

and 2018. For FY 2017, the Board received funds from Congress to hire 242 FTEs. 

I fought to get VA these funds.If confirmed, will you ensure that the President’s 

across-the-board hiring freeze does not negatively impact VA’s ability to meaningfully address the over 450,000 appeals that are pending? 

Response. I am committed to addressing VA’s pending appeals inventory. As of 

January 31, 2017, there are over 469,000 appeals pending in the Department, with 

over 135,000 pending with the Board. VA is grateful for the additional funds received in FY 2017, enabling the Board to hire 242 FTEs, for a total of 922 cumulative FTE. The Board has been aggressively hiring and onboarding staff to a current level of 738 cumulative FTE, but has many more FTE to hire and onboard to 

reach its FY 2017 FTE goal. While a hiring freeze would negatively impact the 

Board’s ability to provide appeals decisions to Veterans regarding appeals, VA cannot significantly impact its pending inventory without appeals modernization legislation that discontinues the flow of appeals into the current broken process and a 

temporary surge of additional resources. I would note, for clarification, that although the Board projected continued FTE growth in FY 2018 as part of its workload projections in VA’s FY 2017 budget, we are aware that any increase in resources above the FY 2017 baseline will be contingent on annual budget appropriations. 

Question 12. In the 2016 Commission on Care report, the Commission projected 

that by 2034, 60 percent of veteran users could be using private care. Under your 

vision for the future of VA health care, would this be acceptable? Are you concerned 

about the impact on specialized services such as spinal cord injury, prosthetics, 

Traumatic Brain Injury, Post Traumatic Stress Disorder, and other mental health 

needs, given the more costly private sector is not as equipped to provide these services to veterans? Please discuss. 

Response. Under my vision for the future of VA health care, I would project that 

although 100 percent of enrolled Veterans could be using either VA or Community 

care, because they would have a real choice, that we would still see a majority of 

enrolled Veterans choosing to use VA for integrated primary care and mental health 

services, along with most of the specialized services designed for people who served 

in the military. We would use community care often for specialty care that does not 

require tailoring for the military, like obstetrical care, optometric services and care 

for management of chronic disease for veterans who live where it would not be convenient to reach VA care. 

You make an excellent point in your question that many of these services tailored 

to the needs of prior servicemembers are simply not available in most communities, 

but are quite costly when they are. For those reasons, and because so many Veterans prefer to receive these services alongside comrades who served, I am not too 

concerned that use of an integrated VA/community care network will erode our ability to provide these specialized services to America’s heroes. 

Question 13. What is your plan to support VA’s Office of Tribal Government Relations, in their efforts of continued collaboration and outreach to Native American 

Veterans in their communities? 

Response. I will rely on the support and counsel of our Office of Tribal Government Relations (OTGR) to coordinate the agency’s tribal consultation efforts, and to 

ensure both the Secretary and other senior VA leadership are engaged in communicating and working with tribal leaders as part of the enduring government to govVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00057 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
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ernment relationship that exists between the United States and Indian tribes. We 

also rely on OTGR to assist the VA enterprise with cultivating informed, trusting 

relationships with tribal leaders, national intertribal organizations and service providers to identify opportunities for sharing of resources and pursuing partnerships 

that ensure access to care for our Veterans living within or near tribal communities. 

It is our expectation that OTGR will play a key role in leading VA’s efforts to connect VA, other members of the Federal family, state governmental organizations, 

private and non-profit organizations, with tribal communities. Additionally, I will 

rely on OTGR to coordinate the agency’s response to the identified priorities which 

include access to medical care, addressing housing and homelessness, treatment for 

PTSD and mental health, understanding benefits, including benefits for families and 

transportation. By recognizing and adhering to these culturally specific requests, VA 

will be informed, demonstrate trustworthiness and continue to understand the nuances of working within Indian Country. An organization that understands the people and population it serves has the best odds of success. 

Question 14. What are your thoughts on the proposed consolidation of the Indian 

Health Service and Tribal Reimbursement Program into one standard program? 

Response. Consolidation of the agreements with the IHS and Tribal Health Programs into one program could make the program more straightforward to administer; however, given VA values its relationships with these partners, we would recommend consultation with these stakeholders be initiated to determine what tribes’ 

concerns and recommendations may be regarding the potential impact of a consolidation with Indian Health Service.. This could also have implications for tribal 

health programs who opt to serve as community care providers that deliver care to 

non-native Veterans because IHS is fairly limited to delivering care to IHS-eligible 

patients. This would also continue to multiply the different ways VA purchases community care rather than consolidating and streamlining into one overall program for 

the VA. 

Question 15. What is your plan to ensure the Department of Housing and Urban 

Development-Veterans Affairs Supportive Housing program, Tribal HUD-VASH, is 

permanently funded in order to combat homelessness of Native American Veterans 

who live on tribal lands? 

Response. Tribal HUD-VASH is an important and necessary joint effort between 

HUD and VA, with HUD providing the housing vouchers and VA providing the necessary case management. To date, Tribal HUD-VASH has 26 tribal grantees and 

each tribal grantee is funded for one case manager. VA includes case management 

funding in its overall budget requests for HUD-VASH and it is included in our FY 

2017 appropriation, and we expect to continue to fund the positions in subsequent 

years. For the continued support of the Tribal HUD-VASH program, HUD has requested $7 million in its FY 2017 Budget, a request both the House and Senate 

Committees on Appropriations supported in their draft fiscal year 2017 appropriations bills. In a similar show of support, Congress included a Tribal HUD-VASH 

funding anomaly for HUD in the second FY 2017 Continuing Resolution (CR) to ensure program continuity of operations during the CR period. 

Question 16. How do you intend to work with the National Association of State 

Departments of Veterans Affairs? 

Response. I will continue to prioritize working closely with our state partners and 

with NASDVA. NASDVA President Randy Reeves and I have already been in frequent contact and I look forward to building upon the great relationship between 

VA and NASDVA that my predecessors have forged before me. Additionally, I also 

intend to reaffirm VA’s commitment to partnering with the states by signing a new 

Memorandum of Agreement between VA and NASDVA at their winter conference 

later in February. 

Question 17. Please describe your plan to address national physician assistant recruitment and retention issues. 

Response. The National Recruitment Program (NRP) provides a centralized inhouse team of skilled professional recruiters employing private sector best practices 

to fill the agency’s most critical clinical and executive positions. The national recruiters, all of whom are Veterans, work directly with executives, clinical leaders, 

and local human resources departments in the development of comprehensive, client-centered recruitment strategies that address both current and future critical 

needs. At facility request, NRP targets hard-to-fill recruitments in their regions. 

VHA markets directly to direct patient care providers through partnerships such 

as National Rural Recruitment & Retention Network (3RNet), a national network 

of non-profit organizations devoted to health care recruitment and retention for underserved and rural locations, as just one example. Through these partnerships, 

VHA has access to a robust database of candidates interested in working for VHA. 

55 

National Recruiters routinely post VHA practice opportunities on career sites such 

as www.vacareers.gov. 

Question 18. At your hearing, you said that colleges that engage in deceptive and 

misleading recruiting practices would ‘‘not be tolerable.’’ In May 2016, 23 major national veterans and military organizations wrote a letter to the VA Secretary requesting action on this critical issue. Would you commit to reporting back to this 

Committee within three months with your recommendation for practical and realistic steps VA can take to ensure student veterans are protected from predatory and 

deceptive practices and given the information they need to make an informed choice 

about their college? 

Response. Yes 

Question 19. On behalf of the National Alliance on Mental Illness, Montana, I 

submit the following question: According to a March 2016 report prepared by the 

Veterans Legal Clinical at Harvard Law School, approximately 125,000 post-9/11 

veterans cannot access basic VA services, such as mental health care because of 

Other Than Honorable or ‘‘Bad Paper’’ discharges. The report details that VA has 

never evaluated the service of 90 percent of the veterans in this category, many having sought healthcare or housing services from VA, only to be turned away without 

any Character of Discharge review. Even more alarming, about 22,000 veterans 

with service-connected mental illness have received Other Than Honorable discharges since 2009. If confirmed, will you commit to thoroughly reviewing each of 

these cases, and where necessary allow veterans to receive the VA services, including mental health care, they deserve? 

Response. Yes I will, Veterans with OTH discharges can potentially receive VA 

care, including MST-related care, upon review of their discharge by the Veterans 

Benefits Administration (VBA). Following this review, VBA issues a decision as to 

whether or not the Veteran’s discharge is a bar to receipt of health care benefits. 

VA has taken steps to ensure staff are aware that Veterans with OTH discharges 

are potentially eligible for some services and that there have been no shifts in policy 

to tighten eligibility requirements. 

RESPONSE TO ADDITIONAL POSTHEARING QUESTIONS SUBMITTED BY HON. JON TEST- ER TO HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPART- MENT OF VETERANS AFFAIRS

Question 20. Many individuals that participate in the VA Caregivers Program for 

severely wounded veterans are working dramatically reduced hours outside the 

home or have left the workforce completely. This reduction in outside earnings can 

result in significant difficulties meeting financial obligations, including student loan 

debt held by the caregiver. How do you plan to identify and assist such caregivers 

facing financial hardship due to student loan debt? 

Response. Family Caregivers participating in VA’s Program of Comprehensive Assistance for Family Caregivers (PCAFC) receive an average stipend amount ranging 

from $624.84 to $2,372.22 in December 2016, based on the Veteran’s level of required assistance and geographic location. Eligibility for PCAFC is based on the 

Veteran’s required level of assistance and not on financial need. VA does not have 

the authority to request or monitor this type of personal financial caregiver information for participation in PCAFC or any of VA’s Caregiver Support Programs. Because there is no requirement for Caregivers to report financial status, I anticipate 

that family Caregivers will oppose providing information to VA about their student 

loan debt. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JERRY MORAN TO HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VET- ERANS AFFAIRS

Question 21. What role do you see the VSO community playing under your leadership? Please give at least five (5) specific examples of how you anticipate involving 

the VSOs. 

Response. Veterans Service Organizations (VSOs) will play an integral role under 

my leadership. I am committed to transparency, cooperation and coordination with 

our VSO partners to maximize input from the widest range of appropriate stakeholders and to facilitate an open exchange of opinion from diverse groups to improve 

our programs to assist Veterans. During my tenure as USH, I engaged and solicited 

input and feedback from VSOs on key issues, best practices or opportunities to improve policies, programs, service quality and meet Veteran needs. 

56 

I host monthly VSO breakfast meetings with our senior leadership team, have 

participation and representation of VSOs on our workgroups and planning teams 

within our VA Program offices and also meet with VSOs on a frequent basis as specific issues or needs arise. In addition, I personally traveled to many of their national conventions and meetings last year. All of these engagements are necessary 

and will continue as VSOs are an important partner in helping us understand what 

improvements we can make to better deliver care and services to our Nation’s Veterans. There are several areas of planned collaboration and ongoing communication between VA and the VSO community going forward to include Appeals Modernization, 

MyVA Access, Care in the Community, Patient Experience and partnering on communications at the national, regional and local level to share success stories/best 

practices as well to address opportunities for improvement. 

Question 22. What are your top three goals as Secretary of Veterans Affairs? 

Response. 

(1) Getting the right people in place in management positions at VA in order to 

have the biggest impact across the organization. These positions include the Secretary’s direct reports, VISN Directors, Medical Center Directors and clinical leaders. This then cascades down throughout their respective organizations to get the 

right employees who are serving our Veterans. 

(2) Addressing the critical access issues in the system. While we have made real 

progress in improving access for the urgent care needs of our Veterans, much work 

still needs to be done. We must have a system that fully addresses the needs of Veterans at the time that they need those services. 

(3) Restoring the trust of Veterans in VA through creating a Veteran centric organization. Everything we do must be focused on serving our Veterans and as we 

begin to move in this direction I believe we will see that our Veterans will increasingly have confidence and trust in VA. 

Question 23. The Veterans Health Administration has made undeniable progress 

over the past two years in integrating more community care into the VA healthcare 

system. Do you believe that a veteran’s primary care clinician should continue to 

be part of the VA system or can s/he be any clinician a veteran chooses? 

Response. Our goal is to provide all eligible Veterans with access to an integrated, 

high-performing network that allows Veterans to achieve the best health outcomes 

and patient experiences possible. This network takes the best of VA and the best 

of the private sector and combines them together. VA wants to ensure that all Veterans have a primary care provider to coordinate their care in the high performing 

network. In those cases where VA cannot provide a primary care provider, than Veterans should be able to select a primary care provider from the high performing network. 

Question 24. The Commission on Care rejected the idea of granting veterans who 

use the VA unfettered choice in seeking care outside of the VA. Do you agree with 

this position, or do you believe that a veteran who is eligible for VA health care 

ought to be provided with a voucher to seek care wherever s/he chooses, with the 

VA footing the bill? 

Response. Our goal is to provide all eligible Veterans with access to an integrated, 

high-performing network that allows Veterans to achieve the best health outcomes 

and patient experiences possible. This network takes the best of VA and the best 

of the private sector and combines them together. Today, 80% of Veterans already 

have a choice between VA and private sector care as they have other health insurance options. Last year 1/3 of all of our appointments were in the community, up 

from 20% less than two years ago. The Commission on Care considered a few options and rejected the idea of unfettered choice. Given what they were considering 

I do agree with their decisionmaking. However, if confirmed as Secretary I would 

consider a number of new alternatives to a system restricting care based upon wait 

times and mileage. I believe that there are new models that need to be considered 

that are clinically based and that maximizes the strengths of VA and the privatesector, is mindful of taxpayer dollars, and puts the Veteran at the center of decisionmaking. I would welcome the opportunity to work with you further to ensure that 

we consider all of the options available to us to ensure that Veterans are getting 

the care that they need. 

Question 25. Are you in favor of or are you opposed to Recommendation 17 of the 

Commission on Care, which would grant veterans with other-than-honorable administrative discharges eligibility to access VA health care on at least a temporary 

basis? VBA 

Response. If confirmed, I would commit to using the regulatory authority available to the Secretary to ensure that Veterans with other than honorable discharges 

57 

are getting access to care. In the situation where we need legislative change I would 

work with both the White House and Congress about ways that we can address this 

population. 

Question 26. What specific plans can you offer to reduce the number of veteran 

suicides, which are unacceptably high? 

Response. VA’s comprehensive, integrated, data-driven approach to preventing 

Veteran suicide connects Veterans to an array of resources and support in order to 

reach Veterans before challenges become crises. VA’s Office for Suicide Prevention 

(OSP) is using findings from completion of the most comprehensive analysis of Veteran suicide data to date examining more than 55 million Veteran records from 

1979 to 2014 from all 50 states and 4 territories to inform suicide prevention activities: 

• Providing immediate outreach and enhanced care to Veterans found to be at 

highest risk for suicide (top 0.1%) through predictive analytics; rapidly expanding 

this program to include outreach to Veterans who are at moderate risk for suicide • Increasing staffing and resources for Suicide Prevention Coordinators integrated at every VAMC and large CBOC (over 300 nationwide who solely work on 

Veteran suicide prevention efforts) • Training every VA employee to specifically respond to Veterans at risk for suicide and crisis, including staff at VBA, NCA, VACO, and Vet Centers • Rapidly disseminating evidence-based treatments (Dialectical Behavioral Therapy, Collaborative Assessment and Management of Suicide, Cognitive Behavioral 

Therapy) for Veterans experiencing suicidal ideation across VA’s healthcare system 

• Engaging all U.S. Governors to prioritize combatting Veteran suicide in every 

state; immediately coordinating with 5 states with highest rates of Veteran suicide 

to develop suicide prevention initiatives to include strategic partnerships, targeted 

outreach, and enhanced care for all Veterans who may be at risk for suicide 

• Distributing gun locks, gun safes, and other safe storage resources to at-risk 

Veterans and their families 

• Disseminating nationally community toolkits for safe firearm storage in partnership with National Shooting Sports Foundation (NSSF) and other firearms 

stakeholders 

• Developing comprehensive OSP-DOD Transition program to identify and follow 

all Servicemembers who may be at risk for suicide upon separation 

• Establishing partnerships to train employers of large concentrations of Veterans 

(e.g. IBM, Johnson & Johnson, Homeland Security, etc.) in recognizing and responding to suicide risk and help employers understand specific assets and needs of Veterans to retain them in the workforce 

• Improving the performance and capacity of the Veterans Crisis Line by opening 

a second call center and reducing calls that go to backup centers to nearly 0%. Over 

2.6 million calls have been answered since VCL opened in 2007 

• Immediately convening a VA Secretary Advisory Board on Suicide Prevention 

to include Congressional members, Veteran Service Organizations, Federal Partners, Non-profit Partners, Family Members, Veteran Suicide Attempt Survivors, and 

others to inform and enhance VA’s suicide prevention initiatives. 

Question 27. What specific recruitment and retention plans can you offer to increase the organizational capacity of VA mental health clinicians and support personnel? 

Response. VHA has added 3,946 additional mental health providers over the past 

5 years and has increased the number of patients provided mental health treatment 

by 355,500 (28%). VHA offers education loan assistance via the Education Debt Reduction Program (EDRP) to mental health providers in hard to recruit/retain positions and locations. 26% of physicians receiving EDRP are psychiatrists. In the 

EDRP pilot program established by the Clay Hunt Act, the amount of the annual 

award will be increased and the program will be extended to psychiatrists in their 

final year of their residency training. VHA is helping to build a pipeline of highlytrained mental health professionals. VHA’s Office of Academic Affiliations trains 

roughly 6,400 trainees in mental health occupations per year, and roughly 70 percent of VA psychiatrists and psychologists received some of their clinical training 

at a VA facility. VHA’s Mental Health Education Expansion Initiative, a new fiveyear commitment, will increase clinical education in mental health professions. In 

the first year, Academic Year 2013–2014, over 200 training positions were added. 

In the second year, Academic Year 2014–2015, 126 positions at 45 different sites 

were added. VHA has increased mental health training opportunities for several 

years through increases in mental health training positions and approval of new 

sites for training. For example, as of July 2014, VHA psychology internships are 

present in 49 states, Puerto Rico, and the District of Columbia. There has been 

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some targeted expansion in training in rural and highly rural facilities. VA had the 

first accredited Psychology residency program in the state of Alaska. In FY 2016, 

VA awarded eighteen pre-degree Licensed Professional Mental Health Counselor internship positions to seven VA medical centers. For FY 2017, VA awarded 3 predegree Marriage and Family Therapist internship positions at one site. 

Question 28. During the 114th Congress, I was proud to sponsor the Veterans Mobility Safety Act (PL: 114–256) (hereinafter ‘‘the Act’’). The purpose of the Act is to 

require certain safety and quality standards of providers of automobile adaptive and 

special adaptive equipment so that disabled veterans, and the driving public, are 

safer on the roads. Providing quality care for disabled veterans is something that 

I have taken very seriously as both a member of the U.S. Senate Committee on Veterans’ Affairs, and the Chairman of the U.S. Senate Appropriations Subcommittee 

on Military Construction, Veterans Affairs, and Related Agencies. 

In your new role as the Secretary of the U.S. Department of Veterans Affairs 

(hereinafter ‘‘VA’’), will you commit to providing disabled veterans with the highest 

quality of care that you, and the VA, can possibly provide? 

Response. Yes, absolutely. VA will maintain our commitment to ensure disabled 

Veterans receive the specialized services they need. In addition to the longstanding 

Automobile Adaptive Equipment benefit, and VA Driver’s Training Program, VA has 

established programs and systems of care to maintain and ensure the provision of 

lifelong specialized care and services for these severely disabled Veterans. VA’s systems of care for Polytrauma/Traumatic Brain Injury (TBI), Amputation, Spinal Cord 

Injury and Disorders, and Blind Rehabilitation are well established. Specialized care 

and services are provided across tiered networks of specialty rehabilitation centers 

that serve as regional referral centers for acute inpatient rehabilitation for severe 

injuries. Ongoing care and services are provided for these Veterans in VA facilities 

with specialized interdisciplinary teams closer to the Veteran’s home community. 

These VA programs uphold the highest standards of rehabilitation, such as CARF 

(Commission on Accreditation of Rehabilitation Facilities) accreditation for inpatient 

rehabilitation facilities, and participating in Department of Health and Human 

Services ‘Model Systems’ for VA’s TBI and SCI programs (consortium of premiere 

private and academic rehabilitation centers). VA is further committed to ensuring 

Veterans continue to receive the prosthetic items and services they need. In FY 

2016, VA expended $2.8 Billion to provide 20 million medical items, prosthetic devices and items to 3.3 million Veterans. Finally, VA maintains its priority and visibility for these Veterans in partnership with our Federal Advisory Committee for 

Prosthetics and Special Disabilities—the longest standing Federal advisory committee serving the VA. Established by Congress in 1992, this Committee advises the 

Secretary on VA prosthetic and special disabilities programs that serve Veterans 

with spinal cord injury, blindness or visual impairment, amputation, deafness or 

hearing impairment, and other serious disabilities. An annual report is also provided to Congress regarding this Committee’s recommendations and VA’s actions 

taken in response to those recommendations. Finally, the Office of Quality, Safety, 

and Value will ensure that these veterans are receiving the highest quality medical 

care with our multiple mechanisms for tracking safety and quality metrics for these 

complex patients. 

Question 29. On February 2, 2017, the VA filed a ‘‘Notice of Inquiry’’ in the Federal Register to ‘‘request information and comments from interested parties to help 

inform VA’s development’’ of a quality and safety policy for providers of modification 

services under the Automobile Adaptive Equipment program. However, the Act requires that the Secretary develop this comprehensive policy in ‘‘consultation’’ with 

different stakeholders, including the National Highway Transportation Safety Administration, and industry representatives. 

Unfortunately, in VA’s Notice of Inquiry, VA confirms that it is going to use this 

notice as the platform to receive the aforementioned required consultation. This is 

entirely unacceptable, as the law requires consultation, and should not be misinterpreted as merely a comment period for the Notice. Moreover, I believe that a robust 

consultation with different stakeholders will provide superior safety and quality 

standards. If you do indeed believe that disabled veterans deserve a high quality 

of care, in your new role as Secretary of the VA, will you follow the clear language 

of the statute and require consultation with specific stakeholders? 

Response. Yes, VA fully intends to comply with establishing this program in consultation with stakeholders and AAE entities across the national and state level, 

and public sector. VA has already been in contact with many of these stakeholders, 

and in doing so has discovered a number of entities with established quality and 

safety programs related to automobile adaptive equipment. Given the short suspense to implement this comprehensive program and supporting policy, and in order 

59 

to be as broadly inclusive as possible, VA issued this public notice to expeditiously 

gather information from across all entities. Once this information is coalesced, VA 

will be fully informed about, and will have identified, all stakeholders for subsequent extensive consultation. This plan will then be presented in proposed regulation to all for review/public comment. 

Question 30. Will the major Information Technology (IT) modernization projects 

and programs currently underway at the VA lead to improvements in VA vendor 

reimbursement? More specifically, will the aforementioned IT projects produce a reliable system for ensuring the prompt and accurate payment of VA vendor invoices? 

Response. Yes, the Community Care Reimbursements Systems (CCRS) Project 

align with industry standard claim reimbursements to fully automate and integrate 

with other business systems including Referral and Authorization, Revenue, Fraud, 

Waste, and Abuse (FWA), data analytics and financial systems. This system will 

align with the future state, highly-integrated Community Care model, supporting 

both contracted Community Care Networks and Out of Network claims processing. 

Question 31. During a July 2016 hearing, the need for VA IT modernization and 

pursuit of a commercial off-the-shelf (COTS) HER was discussed and you stated ‘‘We 

reached consensus...that looking at a commercial product is the way to go. It has 

to be done recognizing the unique needs of our community and providers.’’ 

Can you provide an update in pursuing a COTS solution, please describe in detail 

and include projected timing on this effort? 

Response. VistA was one of the first broadly used Electronic Health Records 

(EHR) in the country. It has been recognized for effectiveness and is still a high 

quality EHR used as the primary tool across the country. VA is proud of VistA, but 

we recognize the need for improvements. 

We will complete the next iteration of the VistA Evolution Program—VistA 4— 

in fiscal year (FY) 2018, in accordance with the VistA Roadmap and VistA Lifecycle 

Cost Estimate. VistA 4 will bring improvements in efficiency and interoperability, 

and will continue VistA’s award-winning legacy of providing a safe, efficient health 

care platform for providers and Veterans. 

We have made substantial progress in delivering new capabilities leveraging 

VistA, while also strategizing for our future needs. VA is considering the future of 

VistA and VA’s EHR as one component of a Digital Health Platform (DHP). The previous Administration delivered a Business Case for DHP, which included 3 options 

for the EHR component. This Business Case needs to be evaluated and a decision 

will be made on our path forward with respect to DHP and our EHR modernization 

efforts. However, the success of the digital health platform is not dependent on any 

particular EHR. 

The issue of moving away from VistA to a commercial EMR has been a subject 

of discussion at VA for years. VA has not always been clear on the future direction 

with regards to a COTS solution. I believe it is time that we make a firm decision 

and once a decision is made we will need to work closely with the Administration 

and Congress to define the path toward a successful outcome. If confirmed as Secretary I will commit to a decision on the COTS vs. Vista upgrade by July 1, 2017. 

The time leading up to July will be required to do a full assessment of the options 

in the context of the Digital Health Platform and work that is still required to make 

an informed decision. 

Question 32. The Commission on Care’s Final Report included a recommendation 

to ‘‘modernize VA’s IT systems and infrastructure to improve veterans’ health and 

well-being and provide the foundation needed to transform VHA’s clinical and business processes.’’ (Recommendation #7). Further recommending, ‘‘the VHA procure 

and implement a comprehensive, commercial off-the-shelf (COTS) information technology solution to include clinical, operational and financial systems that can support the transformation of VHA as described in this report.’’ Former Secretary 

McDonald, recommended to former President Obama that the VA found this recommendation feasible and advisable. 

Do you agree with this recommendation? What are the barriers to implementing 

this recommendation? 

Response. Yes. Approximately 90% of OI&T’s budget goes toward sustaining our 

aging infrastructure and applications, compared to around 60% in the private sector. 

OI&T has sacrificed modernizing these legacy systems and turning off older applications in exchange for adding incremental improvements and new capabilities. OI&T 

has developed a comprehensive strategy to substantially decrease its legacy system 

footprint and sustainment costs moving forward. A cornerstone of that strategy is 

VA’s cloud implementation, which will improve efficiency and reduce costs. Implementing new functions like cloud will decrease sustainment costs because it requires 

significantly less maintenance. 

60 

Question 33. Although DOD has just begun its implementation of a new COTS 

solution, they reportedly carried out a successful procurement and testing process. 

How closely have you worked with DOD to learn from their experiences and processes? Will you pursue working with the DOD to capitalize on the COTS experience? 

Response. Yes, I have been told that VA has been working with DOD throughout 

the entire process and is learning from DOD’s experiences while also helping to continue to advance on our Interoperability efforts. O I and T was did not report to 

me directly as Under Secretary, although we worked closely together on many 

projects. If confirmed as Secretary, I would work directly with DOD to determine 

how we might work closer together to leverage their work in this area. 

Question 34. Do you believe that VISTA can manage the business and clinical 

commitments of Care in the Community or the idea and concepts embedded in the 

VA Choice Program? Does the VHA currently have the ability to create an electronic 

longitudinal health record that veterans simultaneously incorporates the care of veterans at the VA and in the community? 

Response. Yes. The VistA Evolution Program manages the development of a collection of approximately 60 projects and initiatives. Many of these are focused on 

VA’s interoperability efforts with DOD and the private sector. 

The VistA 4 work managed by the VistA Evolution Program was first funded in 

FY 2014 and is scheduled to be completed by the end of FY 2018 (September 30, 

2018). However, just because I believe VistA is capable of performing these functions, does not mean that the best ultimate decision is to stay with VistA. As stated 

above we will have a decision on a COTS product vs. VistA by July 1, 2017. 

Question 35. In the 114th Congress, provisions from the Toxic Exposure Research 

Act were signed into law as subtitle C of H.R. 6416. Simultaneously, the VA entered 

into a contract with the National Academy of Medicine to conduct a study on the 

health conditions of descendants of veterans exposed to toxins during the Gulf War. 

This is an important step forward, however, the aforementioned legislation that is 

now law requires a broader application and does not stipulate a certain conflict, 

time periods, group of veterans or type of exposure. The law requires the VA to contract with the National Academy of Medicine to conduct a review of health conditions potentially related to the toxic exposure of veterans who may have been exposed during their military service, which is intended to address veterans from any 

or all conflicts where they may have been exposed regardless of timeframe and locale. As Secretary, will you incorporate this statute into the currently contracted 

National Academy of Medicine study? It would seem redundant and duplicative to 

execute this statute at a later date when the VA has contracted with the National 

Academy of Medicine to conduct similar but limited work. 

Response. At the time VA contracted with the National Academy of Medicine 

(NAM) for both Gulf War & Health, Volume 11 and Veterans & Agent Orange, Volume 11, VA subject matter experts (SMEs) were well aware of Congress’ upcoming 

legislative requirement and wrote the two contracts accordingly—to have major 

focus on intergenerational health effects. With the final passage and signing into 

law of the Toxic Exposure Research Act, VA SMEs took further steps to discuss with 

NAM staff each of these two contracts and the exact language of the Act to ensure 

that NAM would be able to deliver reports which met the explicit requirements of 

Congress. On 12 January, 2017 VA SMEs took the additional step of discussing with 

the seated NAM ad hoc committee for Gulf War & Health, Volume 11 both the 

charge to the Committee (from the contract) and the language from the Act. VA 

SMEs will do the same with the NAM ad hoc committee for Veterans & Agent Orange, Volume 11 in March 2017. Both of these NAM reports are due to be completed 

in early 2019. Both of these reports, but especially Gulf War & Health, Volume 11, 

will have broad applicability to all Veteran cohorts and their descendants. 

VA does oppose additional legislation on this matter as we feel that we have this 

legislative requirement covered. The NAM has already empaneled ‘‘top scientists, 

epidemiologists, clinicians, and investigators to research the literature on health 

conditions’’ for the Committee preparing the Gulf War & Health, Volume 11 report. 

Question 36. Would you favor or oppose legislation that would require the VA to 

extend its contract with the National Academy of Medicine (formerly the Institute 

of Medicine) to empanel top scientists, epidemiologists, clinicians, and investigators 

to research the literature on health conditions associated with exposure not only to 

Agent Orange but to other toxic agents as well? 

Response. VA does oppose additional legislation on this matter as we feel that we 

have this legislative requirement covered. The NAM has already empaneled ‘‘top scientists, epidemiologists, clinicians, and investigators to research the literature on 

health conditions’’ for the Committee preparing the Gulf War & Health, Volume 11 

report, and NAM will soon do so for the Veterans & Agent Orange, Volume 11 comVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00064 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
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mittee. Both committees will address the key elements of the Toxic Exposure Research Act. 

Question 37. How do you plan to address improving the quality of benefits claims 

decisions and appeals? With public pressure to decrease the backlog of both claims 

and appeals, there is an increasing preference for adjudicating claims speedily at 

the expense of the quality and thoroughness of decisions. What are your specific 

ideas for how you expect to improve the quality of claims decisions that will ensure 

that veterans are provided all the due process and duty to assist rights afforded 

them under the law? 

Response. VBA has emphasized the importance of completing claims decisions in 

a timely and accurate manner. Quality is a critical performance element for all 

claims processors as is productivity. VBA has developed a multi-faceted approach 

to continuous quality improvement. Quality reviews completed on a national level 

provide data for error correction and tracking, targeted employee training, and station performance metrics. Consistency studies are regularly administered to claims 

processing employees to assess consistency of decisionmaking and provide training 

and feedback on any targeted areas of concern identified. Local offices complete systematic quality reviews on individual employees and quality checks on cases during 

the adjudication process. The results of these reviews are used for error trend analysis, targeted training and individual employee performance evaluations. 

With regard to appeals, a critical flaw in the current appeals process is that 

VBA’s initial claim adjudicators do not receive effective quality feedback from VBA 

appeal decisions or from Board of Veterans’ Appeals decisions. This is because the 

appeals process features an open record and continuous duty to assist and it generally takes several years to finally decide an appeal. As a result, a resolved appeal 

is based on a record that is different than the record considered by the initial VBA 

adjudicator. To address this concern, VA worked with VSOs and other stakeholders 

to design a new appeals process that features two quality feedback loops based upon 

a review of the same record, one in VBA and one from the Board. In addition, under 

the new framework, appeals to the Board will feature a more concise record that 

is easier to review. VA expects that this design will improve the quality of its initial 

decisions and reduce appeals. This new appeals framework was introduced in several bills in the 114th Congress and reintroduced in the 115th Congress. In addition, VBA has realigned all of its appeals operations and policy under a new organization, its Appeals Management Office, for improved oversight and quality assurance. The Board has also changed its quality assurance process to focus on known 

areas of concern and expanded the scope of its review to allow for identification and 

improvement of issues in all parts of the appeals system. 

Question 38. Do you endorse or oppose the creation of a fourth entity within the 

VA, a Veterans Economic Opportunity Administration? 

Response. While VA appreciates the focus on improving employment services for 

Veterans by consolidating various programs, we do not support the creation of a separate Veterans Economic Opportunities Administration (VEOA). The current Veterans Benefits Administration (VBA) structure reflects the Under Secretary for Benefits’ overall responsibility for Veterans benefit programs, including compensation, 

pension, survivors’ benefits, VR&E, educational assistance, home loan guaranty, and 

insurance. A separate Administration for economic opportunity programs would negatively impact Veterans and would result in a redundancy of management support 

services. Additional staff would be required to support the administrative and management functions for the new administration which would be at the expense of direct FTE associated with the delivery of benefits, which would reduce support to 

Veterans. In 2011, the Office of Economic Opportunity (OEO) was established in 

VBA under the authority of the Under Secretary of Benefits to directly oversee Education Service, VR&E Service, Loan Guaranty Service, and Economic and Employment Initiatives. We believe there is currently an appropriate management structure in which there is internal collaboration among these program offices to oversee 

Veteran programs related to economic opportunities. We are concerned that dividing 

the benefit programs between two Administrations will result in a redundancy of 

management support services and add an administrative burden. 

Question 39. The Choice Act authorized the Secretary of the VA to seek the removal or transfer of Senior Executives based on poor performance or misconduct. 

To date, the VA has used its authority to fire only six senior executives. Last year, 

the VA and the Justice Department informed Congress that it would no longer enforce the removal provisions of the Choice Act. In addition, previous VA leadership 

vigorously opposed congressional efforts to enact additional accountability measures 

on non-senior executive VA employees: 

62 

a. Do you agree with the previous administration’s refusal to enforce the removal 

provisions of the Choice Act? 

b. If confirmed, will you use your powers Congress has given you under the Choice 

Act to remove Senor Executives who fail to serve our Nation’s veterans? 

c. If confirmed, will you work with Congress to enact additional accountability 

measures to hold all VA employees accountable? 

Response. The Department of Justice is frankly in a much better position than 

I am to determine whether a particular statute is or is not consistent with the U.S. 

Constitution. The issue DOJ has flagged in this case is a fairly nuanced legal issue, 

and it’s not really up to me to say whether their analysis is right or wrong. That 

said, I want to be sure that we can sustain through the appeal process any action 

we take against an executive who failed to serve Veterans well or who has acted 

inconsistent with our values. If that means we need to amend the Choice Act to correct the issue DOJ flagged, I am supportive of that. At the same time, we should 

consider adding language to the statute that directs the Merit Systems Protection 

Board to defer to VA’s actions unless our actions are arbitrary or illegal in some 

way. Ideally Congress would look at ways to improve the accountability and appeals 

processes for all Federal employees rather than singling VA employees out for different treatment. I look forward to working with Congress to identify and implement whatever solutions we need get this critical process right. If confirmed I would 

use my full powers as Secretary to remove Senior Executives that have failed in 

their responsibility to care for our veterans. 

Question 40. Your predecessor frequently claimed that 90 percent of VA medical 

centers have ‘‘new leadership teams.’’ Please provide detailed analysis that justifies 

this figure. If analysis does not exist to justify this statistic, please provide your 

own, personal assessment of how many ‘‘new leadership teams’’ exist. However, 

those who have engaged in misconduct and are transferred from one VA facility to 

another do not factor in this equation. Most of these senior employees have appeared to avoid any accountability for their actions: 

Response. Unfortunately, the 91% was an erroneous estimate that was mistakenly 

included in VA’s March 2015 Accountability Fact Sheet. The correct fact at that time 

should have read as follows: 

Since June 2014, 84% of our medical facilities and VISNs have newly placed leaders or leadership team members onboard. This percentage is inclusive of both newly 

placed and permanent leaders. The leadership team is defined as the Medical Center Director, Chief of Staff, Associate Director, Assistant Director, Nurse Executive, 

and Deputy Medical Center Director, Network Director, Chief Medical Officer, and 

Deputy Network Director. (Source: VHA Executive Recruitment Quad Report as of 

12/3/2015; Timeframe: June 2014 to February 2015). 

I have not quoted statistics like this as I am not sure it is the most meaningful 

way to determine if we are getting the right management teams on board. What 

is more important to me is to make sure that our searches for medical center leadership are bringing us the best candidates. I am not in favor of continuing with the 

same ways that we have recruited leaders in the past. I have publicly stated on numerous occasions that I am looking for a mix of leaders that come from VA who 

are promoted for the right reasons into management positions but to also bring in 

outside leaders who are familiar with private sector practices. I believe that the selection of new leaders for our organization is among the highest priorities for the 

Secretary. 

• If confirmed, will you commit to ending the practice of merely transferring VA 

leaders when they engage in misconduct and instead ensure they are really held accountable for their actions? 

Response. Beginning in 2014, allegations of misconduct or poor performance by a 

Medical Center Director or other senior VA leader have been referred to the Office 

of Accountability Review, an independent investigative body aligned within VA’s Office of General Counsel but with dotted-line reporting to the Secretary through the 

Deputy Secretary and Chief of Staff. When OAR substantiates that a Director has 

engaged in misconduct or failed to act in accordance with our values, OAR has made 

recommendations for appropriate action to the Chief of Staff and Deputy Secretary. 

We do not move bad actors around—we take whatever action is warranted, up to 

and including removal. If confirmed as Secretary, I will make sure that several 

things are done. I would be seeking faster decisions on disciplinary actions of senior 

executives to either clear them of the allegations or to remove them from service. 

Of course, anything we do must be consistent with the current law and uphold the 

employee’s due process. I am not in favor of routinely transferring employees to 

other positions (detailing) or in using paid administrative leave. 

63 

Question 41. For fiscal year 2015, the Office of Special Counsel (OSC) processed 

2,165 cases from the VA. The agency with the next highest case load was the Department of Defense (DOD), with 1,322 cases—despite the fact that the DOD has 

twice as many civilian employees as the VA. Last Congress, OSC testified that the 

overwhelming volume of VA complaints presented numerous challenges to the agency charged with investigating and enforcing our Nation’s whistleblower protection 

statutes. 

a. Do you agree that the VA has a cultural problem with respect to reprisal on 

whistleblower? 

b. How will you improve the culture of the VA with respect to whistleblowing? 

c. If confirmed, how will you work with the Office of Special Counsel to investigate 

whistleblower claims and ensure that VA whistleblowers are protected? 

d. If confirmed, will you commit to holding managers that engage in whistleblower 

retaliation accountable? 

Response. We have made a lot of progress since Fiscal Year 2015 in the way we 

approach whistleblower disclosures and whistleblower retaliation claims. We’ve been 

working with OSC in closer collaboration than I think any other Federal agency 

does, working jointly with them to train our supervisors and managers on the whistleblower laws, to expedite relief to employees who may be experiencing retaliation, 

and to improve the sense of psychological safety that we need our employees to have 

so they feel comfortable speaking up when some aspect of our service to Veterans 

is in some way flawed. We’ve also reorganized the functions within VA that investigate whistleblower disclosures and retaliation claims, as well as the functions that 

track referrals we receive from OSC and from our Inspector General’s office, to provide greater visibility over these issues and ensure we are thorough and consistent 

in our approach. 

With respect to the volume of disclosures and retaliation complaints that OSC receives from VA employees, I do think we need to be mindful that only a small percentage are substantiated, but of course OSC needs to review all of them to be sure 

VA’s programs are being conducted properly and our employees are being treated 

fairly. I am hopeful that Congress will continue to properly resource OSC to do this 

critical work. If confirmed, I would hold mangers accountable for whistleblower retaliation. 

Question 42. If confirmed, how will you work with the VA Office of Inspector General to investigate whistleblower claims and ensure that VA whistleblowers are protected? 

Response. I would refer any whistleblowers claims of serious misconduct to the 

OIG and would implement any recommendations that result from that review. As 

well as ensure any disciplinary actions are taken by any misconduct identified by 

the OIG. Also, I will take the necessary steps to ensure the whistleblowers identity 

is kept confidential, if so requested. 

Question 43. There have been several instances when VA employees who are also 

veterans blow the whistle on wrongdoing at their facilities, they have had their private medical records improperly accessed by coworkers and used to discredit their 

claims. 

a. Do you believe that HIPPA provides enough protections for VA employees that 

encounter these experiences? If not, will you work with us to enact additional protections into law? 

Response. Yes, I believe that HIPPA provides the necessary protections. I would 

be willing to consider and work with you on additional protections if they are necessary. 

b. Will you commit to ensuring that employees that VA employees who improperly 

access VA whistleblowers’ medical records as a means of retaliation are held accountable? 

Response. Working collaboratively with OSC and the Privacy officer here within 

VHA, we have developed a new process to investigate and deal with issues of this 

type. I don’t think we need any additional statutory protections to address this 

issue; we just need to keep enforcing the statutes and other legal authorities we already have. I will of course commit to ensuring that whistleblowers are protected 

from all manner of retaliation, including improper access to their medical records, 

and to holding accountable anyone who engages in retaliatory conduct. 

Question 44. In August 2016, the VA released its comprehensive report on veteran 

suicides after analyzing 3 million records in only 20 states, with the result being 

20 veterans a day taking their life. Another study commissioned by the Senate VA 

committee in 2013 directly linked the prescription of psychiatric drugs to an increase in the veteran suicide rate, and it cited a report that Health and Human 

Services and Centers for Medicare and Medicaid Services published in August 2013, 

64 

stating, ‘‘Antidepressant medications have been shown to increase the risk of suicidal thinking and behavior.’’ 

In the 114th Congress, I was visited by a veteran and his service dog, who informed me of the training his dog received to help with his specific symptoms of 

PTSD. He prvided a peer-reviewed study from researchers at Purdue University and 

the Human Animal Bond Research Initiative on the efficacy of service dogs for suicidal veterans with positive results. Shortly after the meeting, I cosponsored the 

PAWS Act, which would provide VA-supervised service dogs to our nations veterans 

as a complementary or alternative method of treatment. Will you commit to exploring this option during your tenure as Secretary, and more broadly commit to research involving other alternative methods of treatment in an effort to continue reducing the tragically high rate of veteran suicides?’’ 

Response. VA is aware of the interest in the potential therapeutic value of service 

dogs in the treatment of PTSD and other mental health disorders. That is why, on 

my initiative, VA’s Center for Compassionate Innovation has launched a pilot program pairing Veterans with Mental Health Mobility Service Dogs. At the same time, 

VA is in the process of completing a landmark study on service dogs in the treatment of PTSD. We are also continuing to work with your office on the PAWS Act 

and look forward to coordinating with you on next steps in this direction. I will gladly commit to further research involving this and other alternative methods of treatment during my tenure as Secretary. 

We are committed to evaluating the impact of service dogs on the quality of life 

for Veterans with mental health conditions in the following three ways: 

• Animal Assisted Therapy programs where Veterans are part of the training 

process for service dogs, particularly around socialization of the service dogs in different settings 

– Socialization of the dog in crowds, on elevators, in public places, etc. necessitates the Veteran involved in the training to be in these settings 

– Allow the Veteran to apply coping strategies learned in therapy to real-life 

situations while training the dog 

– Gives the Veteran a sense of purpose and ‘giving back’ to others since the 

dogs are ultimately paired with another Veteran with a physical disability 

– Several programs across the country; program at Palo Alto has been in place 

almost 9 years with many success stories 

• Mental Health Mobility Impairment Service Dog Initiative where Veterans with 

substantial mobility limitation secondary to a mental health condition are eligible 

for the veterinary health benefit 

– Evaluation by a multidisciplinary team, including a mental health clinician, 

determines that a service dog is the optimum intervention to overcome or mitigate the mobility limitation 

– Mobility limitation may include difficulty navigating public spaces, completing the activities of daily life such as shopping in a grocery store, and coming into the clinic for appointments 

– Center for Compassionate Innovation, Mental Health, and Prosthetics and 

Sensory Aid Services are teaming up to evaluate quality of life and satisfaction 

outcomes from 100 Veterans under this initiative 

– 7 Veterans have been approved for the veterinary benefit, 4 have dogs and 

3 are in the process of being paired with a service dog, and 20 are going through 

the evaluation process with their multidisciplinary teams 

• PTSD Service Dog Study 

– Recruitment is at greater than 80%; recruitment anticipated to be completed 

by spring 

– Fully staffed with all dog trainers (on board). Two per study site at three 

study sites equal six (6) trainers. A seventh trainer serves as the supervisor 

VA supports a range of studies on post-deployment mental health concerns such 

as PTSD, depression, anxiety, substance abuse, and suicide. Research aims to: 

• describe the incidence and prevalence of mental health disorders, 

• identify their risk factors, including pre- and post-deployment assessments, 

• quantify effect of deployment on future health outcomes 

• understand the basic mechanisms underlying disorders, 

• identify new effective treatments, and 

• develop models of care that will deliver effective treatments more quickly, widely, and reliably to Veterans in need. 

During the last 18 months, VA and other Federal research funding agencies have 

worked together to address the mental health needs of Veterans through the National Research Action Plan (NRAP), developed in response to President Obama’s 

65 

Executive Order 13625. The plan outlines the vision for PTSD, TBI, and suicide prevention research and describes requirements intended to help the agencies successfully reach important research goals over the next few years. 

VA also participates in developing cross-agency priority goals for Veterans’ mental 

health. These goals, coordinated by the Office of Management and Budget 

(www.performance.gov), will establish common data elements for PTSD and suicide 

prevention, which will improve the coordination of research efforts across Federal 

agencies. Earlier efforts produced common data elements for TBI and substance use. 

VA is also implementing a randomized program implementation: Block randomization or step-wedge design techniques, is a method by which one can assess the 

efficacy of a program during and after implementation, which is the strength of randomized clinical trials. This technique, if it can be made to work on a large scale, 

is much more reliable as a program assessment tool than the use of historical controls or pilot projects. This research work stream will attempt to use randomizedprogram implementation in several program rollouts to determine feasibility and 

barriers to implementation of this approach in the VA healthcare system. The function of assessment tools will depend upon the output of the Measurement Science 

work stream; and the rollout strategy employed may benefit from output of the Operations Research work stream. Current randomized program implementation initiatives have been launched to determine effective approaches for suicide prevention, opioid prescribing, telehealth, and home-based geriatric services. 

VA is also studying the use of service dogs for Veterans with PTSD. A multisite 

study will provide eligible Veterans with either an emotional support dog or a service dog that has been specifically trained to perform tasks that mitigate PTSD. Researchers will look for improvements in participants’ PTSD symptoms, quality of 

life, participation in society, and employment status. 

As of the second week in December 2016, 180 of 220 Veterans (82%) have been 

recruited and assigned to receive either a service dog or an emotional support dog. 

At the current rate of recruitment, the remaining 40 Veterans should be enrolled 

by May 2017. 

Question 45. Do you believe the VA can benefit from public/private partnerships, 

specifically with existing healthcare facilities and new construction? 

Response. Yes. Public private partnerships can support the right sizing and adaptation of VA’s owned infrastructure that could realize a better return on investment 

for Veterans and taxpayers. Partnerships can take various forms and should be 

evaluated against VA’s needs and on a lifecycle cost basis compared to a traditional 

public sector project. 

VA is presently exploring up to five infrastructure partnerships pursuant to the 

Communities Helping Invest through Property and Improvements Needed for Veterans (CHIP IN) Act that passed in late December 2016. VA enjoys collaborations 

with numerous healthcare affiliates, universities and community hospitals, which 

could be enhanced with the ability to share space and facilities that is limited by 

current laws and regulations. VA has also had success through its enhanced use 

lease (EUL) partnership program to leverage private investment with little or no 

government funding. Further flexibility, including expanding EUL legislation and a 

broader authority for public private partnerships will provide VA the potential partnerships to build or lease new or renovate/reuse existing facilities. 

Question 46. The VHA has been attempting to address the issues of interoperability with other departments, including Defense and HHS along with the general 

healthcare community. With the growth of the Choice Act, what is your plan to 

achieve interoperability with these diverse entities? 

Response. One of the goals of VA Community Care is to establish a clear process 

for Veterans to seamlessly transition between VA, DOD, HHS and community providers. In order to improve the coordination of care and reduce administrative burden, VA will implement integrated administrative systems for eligibility, referral, 

authorizations, provider payments and customer service. To that end, we will leverage technology to: 

(1) Provide easy to understand eligibility information to Veterans, community 

providers and VA staff 

(2) Provide Veterans timely access to a community provider by automating referral and authorization process 

(3) Provide tools to ensure access to high-quality care inside and outside VA 

(4) Coordinate care through seamless health information exchange 

(5) Increase automation to support accurate and timely payment of community 

providers 

(6) Provide tools for quick resolution of questions and issues for Veterans, community provider and staff. 

66 

These improvements will be implemented through a system of systems approach 

which involves the design, deployment, and integration of systems. Implementation 

of this approach will be executed through rapid cycle deployment using agile methodologies. This will allow VA to fix the most pressing issues with community care 

today, while making continuous updates to promote a learning health system that 

evolves with the needs of the Veteran population. 

Question 47. The Choice Act has shown the need for outside providers to service 

veterans, at least those geographically removed from department operated sites. 

How do you envision creating a better system for coordinating care and services of 

veterans utilizing the choice program and monitoring the outcomes of choice providers and ensuring all veterans receive the same excellent level of care and services 

wherever they go? 

Response. VA’s high performing network will have preferred providers that meet 

quality, safety and reliability metrics to ensure excellent level of care for all Veterans. Our contracted network TPAs will work collaboratively with the VA provider 

relations office, and local VAMCs to ensure local and regional community care partners join the network to meet the unique needs in a Veteran’s community. We will 

also have regional quality and peer review committees with membership from both 

our contractors and the VA. We will match as closely as possible community standard quality metrics and VA metrics to ensure Veterans receive excellent quality of 

care within our integrated network which includes VA and our community partners. 

VA is also creating tools for the secure and seamless exchange a vital health information. These tools are currently being tested in the field at several VAMCs and 

their community partners. 

Question 48. The private sector has made many advances in both technology and 

procedures in the medical field. How do you implement these advances into the department? Will you implement these through pilot projects to better evaluate their 

applicability to the Veteran environment? How will you encourage private entities 

to bring their innovations to the department in a timely manner? 

Response. VA must take advantage of technology advances in the private sector 

to improve care and services for Veterans. OI&T has shifted its mindset from complex customized acquisitions to leveraging the best of private sector existing technology and innovative mechanisms like public private partnerships. This not only 

improves speed to market, but allocates resources efficiently, and ensures VA is 

using the best technology available. Our strategic sourcing approach consolidates 

VA’s IT purchasing power to obtain and deliver the best solutions to our Veterans 

from the best industry talent at the best price. Strategic Sourcing will provide access to best-in-class suppliers; ensure strong contractual performance through continuous monitoring; improve our speed to market, product compliance, and quality; 

ensure our compliance with Federal Information Technology Acquisition Reform Act 

(FITARA); provide greater technical capabilities for VA and our Veterans; and foster 

the most responsible allocation of taxpayer dollars. 

Initiatives like this have been proven successful in efforts such as the Digital 

Health Platform (DHP) proof of concept, which utilized the public private partnership construct with an academic partner. DHP is a first-of-its-kind public-private 

partnership that will redefine the concept of ‘‘interoperability.’’ DHP is a cloud-based 

platform. It is not hampered by software updates and changing technology. It is 

flexible and open. DHP already works with existing health platforms such as VistA, 

Cerner, Epic, and more. Future developments can be sourced industry wide. 

Additionally, we are utilizing private sector solutions through VA’s Center for Innovation (VACI). The work of VACI is driven by a strong commitment to a Veterancentered approach to service delivery, and dedication to data-drive decisionmaking, 

design thinking, and agile development. We do this through competitions, special 

projects, human centered design, innovators network, open innovation, and fellowships. 

Question 49. I request specific data regarding the number of VA employees who 

are currently or were held on administrative leave due to offenses of misconduct. 

Of those, how much has the VA exhausted on their salaries while on administrative 

leave and unable to fulfill the duties for which they were hired? 

I requested this information as an advance question prior to your hearing but it 

was not answered. Your response was a 29-page spreadsheet listing individuals with 

‘‘proposed actions’’ and ‘‘actions taken’’ regarding their ‘‘sustained offenses.’’ There 

is no data regarding the number of days each individual was on administrative 

leave due to the ‘‘sustained offenses’’ and just as important the dollar amount exhausted on administrative leave during the time period when the individual was put 

on administrative leave and when they were reinstated, if at all. The response also 

does not include a summary clearly explaining the total number of VA individuals 

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and total cost incurred by the Federal Government. Please furnish this data and if 

there is no method by which the VA has tracked and collected this data, please explain why and how intend to furnish this data. 

Response. In response to your request for specific data regarding the number of 

VA employees placed on administrative leave related to misconduct, and the salary 

costs associated with such administrative leave, the attached table lists 25 employees who are/have been placed on administrative leave during the current Fiscal 

Year. The table lists the total number of days each employee was on administrative 

leave, the salary dollar value of the administrative leave, and date the administrative leave period ended. 

I am aware of a newspaper article that recently quoted a much higher number 

of VA employees that have been placed on administrative leave. I have not been 

able to have this data confirmed by the VA Department of Human Resources. I will 

continue to ask VA to provide me with the comprehensive data that would substantiate this number. The issue that I am told is difficult to do is that administrative 

leaves are recorded for many reasons other than disciplinary issues. Regardless of 

the difficulty in reporting this data, if confirmed as Secretary I would use my office 

to ensure that the practice of paid administrative leave is used as little as possible 

and only when absolutely required. 

Finally, by way of context, at VA, as at other Federal agencies, administrative 

leave may be used to take an employee out of the workplace while agency management or another entity (such as the Office of Inspector General) investigates to determine whether the employee has engaged in misconduct warranting adverse action. Employees may also be placed on administrative leave during the time period 

between the delivery of a proposed removal or other adverse action and the issuance 

of a final decision on the proposal. 

Factors Mitigation Plan 

Increasing Demand/Lack of 

Providers and Clinic Staff.

• Active recruitment of health care providers and clinic 

staff—VA increased provider and nursing staffing by approximately 12% over the past two years 

• Granting full practice authority for Advanced Practice 

Nurses 

• Increase use of telehealth for Primary Care and Mental 

Health 

• Use of community care resources when unable to recruit 

providers 

• Increased use of extended clinic hours 

Inefficiencies in clinic practices.• Implemented Clinic Practice Management Program across 

VA—in this program all facilities have at least one group 

practice manager to oversee and optimize administrative 

clinic activities 

• Validating clinic grids to achieve optimal clinic capacity 

• Focus on improving productivity—increased productivity 

by 16% over past two years 

• Developed strategies for reducing ‘‘no show’’ rates, and redesigning clinic space 

• Implemented standardized face to face Clinic Clerk Training for optimal scheduling of patients 

• The above efforts have resulted in an increase in 12,000 

appointments daily in 2016 when compared to 2014 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHN BOOZMAN TO

HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 50. Dr. Shulkin, you have rightly stated that the VA should stop doing 

the things the VA doesn’t do well. I think many would agree that the VA does not 

have the strongest track record when it comes to VA led IT solutions, to include 

software development. Countless iterations of VISTA and a currently disjointed 

scheduling system are cases in point. 

Yet, the VA is again pursuing what appears to be a VA solution to scheduling 

software with VSE. This is concerning, when there are many commercially available, proven and affordable off-the-shelf solutions. Even more concerning is at the 

68 

hearing yesterday you also referenced an additional VA scheduling tool, called 

MASS. I am very concerned the VA is moving forward with multiple scheduling 

tools, at great cost, without giving adequate thought to commercially available solutions, interoperability and effectiveness. An even greater, overarching concern is the 

scheduling solutions you describe did not mention how they would integrate into an 

even larger EHR transition. Lack of preparation and the absence of a coordinated 

strategy are what led to the disjointed IT architecture VA has now. 

a. Please describe how you have arrived at multiple software solutions, the respective capabilities and objectives of VSE and MASS, anticipated costs, as well as what 

consideration has been given to ensuring interoperability with existing platforms 

and needs. 

Response. Improving the tools to support accurate and timely scheduling is a top 

priority for VA and critical to our ongoing efforts to expand and improve access. 

VA’s current legacy scheduling application successfully schedules millions of appointments, but it is cumbersome to use, does not have a modern look-and-feel, and 

does not include functions that can drive improved operational efficiencies. VA is focused on providing our workforce with modern scheduling tools. Please find additional details below. 

VSE

VistA Scheduling Enhancements (VSE) is a cost-effective, interim solution to 

bring an urgently needed modern interface to the antiquated VistA scheduling package. VSE is currently being piloted in multiple clinical settings at five VA facilities. 

If the pilot is successful, VSE will be implemented nationally until a permanent and 

complete solution is available. The ‘‘go /no go’’ decision related to VSE is anticipated 

by February 10, 2017 after feedback from the pilot sites. The costs for the pilot sites 

are less than 10 million. The anticipated spending on VSE through FY 2019 is $36 

million, which includes development, enhancement and national deployment costs. 

MASS

In addition to VSE, VA awarded a contract for the Medical Appointment Scheduling System (MASS). The Medical Appointment Scheduling Solution (MASS)is a 

best-in-class Commercial off the shelf (COTS) resource-based scheduling tool. MASS 

is being piloted in 

Boise, Idaho as a potential long term solution to VA’s scheduling needs. The future potential deployment costs and approach will be clarified through this MASS 

pilot. As you note in your question, scheduling decisions must be made as part of 

a broader view of Health IT strategy at VA. The anticipated spending on MASS 

through FY 2017 is $19.5 million, with the total spending to be determined after 

completion of the pilot. However, if VSE is determined to meet the needs of our 

schedulers and a decision is made to proceed with a national rollout then the Mass 

pilot could be stopped and the cost of the pilot would be significantly less. 

b. Please explain how these tools affect the self-scheduling pilot project required 

by the Faster Care for Veterans Act. 

Response. The Faster Care for Veterans Act requires a full and open competition 

for a Commercial Off-the-Shelf Solution (COTS) self-scheduling application for use 

by Veterans. The Request for Proposal (RFP) to acquire that application is on-track 

for release by February 14, 2017 with an anticipated contract award date of 

April 17, 2017, as required by the Act. The Act stipulates that these self-scheduling 

solutions must integrate with VA’s current scheduling platform, VistA, or any future 

scheduling platform. 

Prior to the Faster Care for Veterans Act, VA developed the Veteran Appointment 

Request (VAR) self-scheduling application through a contract. VAR allows Veterans 

to self-schedule Primary Care appointments with their Patient-Aligned Care Team 

and to request assistance in booking both Primary Cary and Mental Health appointments at VA facilities where they receive care. As of February 3, 2017, VAR is operating in 42 VA medical centers and expansion to additional sites is planned. 

c. Please provide specific details regarding the RFI that was recently issued regarding the Faster Care for Veterans Act pilot, to include justification as to why 

the VA has imposed such restrictive requirements which exceed congressional intent 

and may impede full consideration of available, commercial off-the-shelf solutions. 

Response. The intent of the RFI is to conduct market research and ensure that 

VA is in a position to gather the best information on commercial-off-the-shelf 

(COTS) solutions that will meet the requirements specified in the legislation. In addition, the RFI provides VA with the information to determine if the procurement 

must be set aside for competition among Veteran-owned-small-businesses (VOSB) in 

69 

compliance with the June 16, 2016, U.S. Supreme Court decision regarding 

Kingdomware Technologies, Inc. v. United States (Kingdomware) case. 

In order to ensure the solution is scalable, reliable, and sustainable, the RFI questions sought to determine the range of options available. In addition, the RFI included questions that provided additional information to determine the stability of 

the recommended solution. 

The questions on case studies allowed the supplier to demonstrate that the proposed solution is fully operational, and supports the intent of the legislation. It 

should be noted, that the VA has received 8 responses, several of which are not current VA contractors. This will provide excellent input to the next phase—the release 

of the RFP by February 14, 2017. 

d. Will you ensure, as the Faster Care for Veterans Act requires, that the RFP 

is free and open and not limited to existing VA contractors? How will you ensure 

that a pilot is launched quickly and safely without unreasonable customization? 

Response. Yes, we fully expect it will be a full and open competition as required 

by the Act. We expect the RFI market research will demonstrate that VA is not required to restrict the competition to SDVOSB or VOSB vendors in accordance with 

Public Law 109–461 (38 U.S.C. 8127 and 8128) ‘‘Kingdomware decision.’’ There have 

been eight respondents to the RFI; several of which were not current VA contractors. It is in both VA’s and the taxpayer’s interest to select a partner that can offer 

a product that does not require extensive customization in order to meet the criteria 

set out in the law. 

The RFP is not restricted to those who responded to the RFI, and VA expects 

many more suppliers can provide their solutions during the RFP solicitation process. 

The requirements included in the RFP are being reviewed to ensure they are sufficient to meet critical VA needs, including security, privacy, VistA integration, and 

identification of patient eligibility without exceeding the capabilities specified in the 

Act. VA is prepared to move forward once a successful award is made, and the pilot 

is planned to begin shortly after contract award (on-target for April 17, 2017). 

e. Finally, please describe how you are standardizing functions across the entire 

VA enterprise and leveraging other large EHR implementations to prepare for such 

a large transition to a fully functioning electronic health record. 

Response. VA is currently reviewing options regarding long-term EHR modernization which include continuing to upgrade VistA, shift to a commercial EHR platform, some combination of both, among other alternatives. 

In order to enhance our clinical practice standardization, VA will leverage the Enterprise Health Management Platform (eHMP), which is now deployed and in pilot 

testing throughout the VA system. It provides a structured interface for standardization of clinical processes and can be utilized with our current legacy systems or 

a commercial EHR. 

In addition, the VA has developed a Digital Health Platform concept that has a 

goal of standardizing functions across the entire VA, and provide a comprehensive 

end-to-end model for integrating healthcare across an individual’s lifespan enabling 

interoperability among systems much more efficiently than traditional system integration efforts. VA is actively reviewing all of the above technology approaches and 

frameworks so as to make future-looking Health IT modernization decisions that 

provide cutting edge technology to VA medical providers serving Veterans in the 

most cost-effective manner. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BILL CASSIDY TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

TOXIC EXPOSURE

Question 51. Dr Shulkin, in 2002 the VA stopped granting the presumption of 

Agent Orange exposure to those veterans who served in the bays, harbors and territorial seas of the Republic of Vietnam despite the fact that there is strong evidence 

of infiltration of toxins into those harbors and bays. In 2015, the Court of Appeals 

for Veterans Claims (GRAY v. McDonald) found that the VA had excluded the bays 

and harbors from the definition of ‘‘inland waters,’’ and ordered that the VA rewrite 

the regulation based upon the probability of exposure due to river discharge. 

The VA currently continues to exclude these bays and harbors from the definition 

of inland waters. We all agree the rivers were contaminated and rivers run into the 

harbors and bays. Maritime traffic and anchoring kept that area in a state of flux 

and the Institute of Medicine has also confirmed a plausible pathway for the dioxin 

to have entered the shipboard potable water system via the shipboard distillation 

70 

system, which actually enriheds the dioxin. Will you be taking action to restore benefits to these veterans?’’ 

Response. This case (GRAY v. Acting Secretary) remains under litigation. VA believes its revised policy, in response to this litigation, is consistent and fair, as it 

clearly delineates between inland waterways and offshore waters. In addition, this 

policy is consistent with evidence concerning the spraying of Agent Orange in Vietnam. VA previously extended the presumption of exposure to herbicides to Veterans 

serving aboard U.S. Navy and other vessels that entered Qui Nhon Bay Harbor or 

Ganh Rai Bay. In the interest of maintaining equitable claim outcomes among shipmates, VA will continue to extend the presumption of exposure to Veterans who 

served aboard vessels that entered Qui Nhon Bay Harbor or Ganh Rai Bay during 

specified periods that are already on VA’s ‘‘ships list.’’ VA will no longer add new 

vessels to the ships list, or new dates for vessels currently on the list, based on entering Qui Nhon Bay Harbor or Ganh Rai Bay or any other offshore waters. 

VA will continue to look at additional evidence and adjust policy as appropriate. 

TELEMEDICINE

Question 52. Dr. Shulkin, do you view telemedicine as a platform that could improve access and quality for the critical health care needs of our Veterans? If so 

could you please elaborate on the role telemedicine might play in the future of the 

VA and care in the community. 

Response. Telemedicine represents a key component of VA’s strategy to enhance 

access to the highest quality medical services for our Telemedicine represents a key 

component of VA’s strategy to enhance access to the highest quality medical services 

for our Veterans. VA completed 2.1 million telemedicine visits across 50 specialties 

last year, providing service to more than 700,000 Veterans. VA will continue to leverage and expand Telemedicine programs to share valuable clinical resources 

across the healthcare system, facilitating support from large and academically affiliated VA facilities to Veterans in rural and underserved areas. VA has initiated or 

expanded projects for 8 Primary Care and 10 tele-mental health hubs to serve Veterans in regions where demand exceeds capacity, and 45% of telemedicine visits last 

year were delivered to Veterans in rural areas. VA is also building its capacity to 

support Veteran access to specialized care that is in short supply in some areas of 

the country, including tele-genomics, tele-ICU, tele-dermatology and tele-rehabilitation services. In addition, VA delivered more than 39,000 clinical video visits to Veterans’ homes last year, and home telehealth programs have produced a reduction 

in hospital admissions. Continued expansion of mobile and home telehealth programs is planned. 

Currently, telemedicine in Community Care is only in San Diego. VA hopes to expand in other markets once we get it up and going. VA completed 2.1 million telemedicine visits across 50 specialties last year, providing service to more than 

700,000 Veterans. VA will continue to leverage and expand Telemedicine programs 

to share valuable clinical resources across the healthcare system, facilitating support from large and academically affiliated VA facilities to Veterans in rural and 

underserved areas. VA has initiated or expanded projects for 8 Primary Care and 

10 tele-mental health hubs to serve Veterans in regions where demand exceeds capacity, and 45% of telemedicine visits last year were delivered to Veterans in rural 

areas. VA is also building its capacity to support Veteran access to specialized care 

that is in short supply in some areas of the country, including tele-genomics, teleICU, tele-dermatology and tele-rehabilitation services. In addition, VA delivered 

more than 39,000 clinical video visits to Veterans’ homes last year, and home telehealth programs have produced a reduction in hospital admissions. Continued expansion of mobile and home telehealth programs is planned. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. THOM TILLIS TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

VA LEASES

Question 53. As you know, Congress has not, through a regular process, authorized Department of Veterans Affairs (VA) major medical facility leases since a 2012 

change in budgetary scoring of these leases by the Congressional Budget Office 

(CBO). This change in budgetary scoring has resulted in VA major medical facility 

leases receiving large, up-front spending scores, despite the fact that actual spending would not increase. This issue has prevented Congress from authorizing two 

71 

dozen major medical facility leases in 15 states, including in Virginia and North 

Carolina, states with some of the fastest growing populations in the Nation. If confirmed as Secretary of Veterans Affairs, what are your plans to address this problem? How can we, as elected officials, better assist VA in finding a solution to the 

lease authorization issue? 

Response. If confirmed, I will work diligently with the Congressional Budget Office (CBO) and Congress to come to a resolution in order to move the 24 pending 

leases forward. These leases are critical to providing care to Veterans and represent 

2.7 million annual clinic visits. Specifically, I will work with CBO to highlight the 

key changes VA is currently implementing to standardize our leasing process and 

requirements to further demonstrate that the leases are not similar to government 

purchases of facilities built specifically for VA’s use. It is paramount that we all 

work together to find a solution. 

COMMUNITY CARE NETWORK RFP

Question 54. When the VA put together its plan for the community care network, 

did the Department consider the disruption to veterans from these changes—including in the urgent and emergent pharmacy program? If so, what methodology did you 

use and most importantly, what are you planning to do to ensure veterans do not 

see a disruption in their access to critical medicines? 

Response. Changes to prescription fulfillment processes for the Community Care 

Network (CCN) combine existing requirements for the PC3 program, the Choice program and the approximately 75 regional and local ‘‘first fill’’ pharmacy contracts. 

The changes were made considering the impact on Veterans and were specifically 

designed to improve services by: 

a. Expanding the number of urgent/emergent drugs available. 

b. In comparison to approximately 75 existing regional and local first fill contracts, the urgent/emergent drugs available under the CCN is in some cases a reduction but in many cases it is an expansion. 

c. Eliminating the out-of-pocket costs Veterans must now pay for their PC3 and 

Choice urgent/emergent prescriptions. 

d. Eliminating the need for Veterans to seek reimbursement from VA for PC3 and 

Choice urgent/emergent prescriptions. 

e. Ensuring continuity of care by making urgently needed medications not listed 

on the CCN drug list to be available via a prior authorization process. 

f. This feature is not currently available uniformly across the VA system. 

g. The changes to non-VA prescription fulfillment processes were developed with 

significant input from field-based VA pharmacists who were charged with improving 

access, patient safety and the customer experience. VA’s formulary management 

process is dynamic, updated continuously to meet the needs of Veterans and the 

evolving health system. In the unlikely event the changes result in disruption of 

services to Veterans, VA has the ability to modify the process to avoid the disruptions. 

FASTER CARE FOR VETERANS ACT

Question 55. Late last year, the Faster Care for Veterans Act was signed into law 

by President Obama. As you may know, the legislation directs the VA to establish 

a pilot program to test commercial off-the-shelf scheduling solutions, such as cloudbased applications and services, to allow veterans to book their own appointments 

online or on a mobile device, in real-time, 24–7. The goal is to help the VA rebook 

the 18 percent of appointments that are generally wasted due to last minute cancellations, scheduling changes, and no-shows, enabling more veterans to access 

timely care. 

As you know, the VA has a long history of trying to build scheduling solutions 

in-house. Will you prioritize solutions that are already proven to work at scale in 

the private sector? 

Response. Yes, VA’s OI&T has implemented a buy-first strategy, which is utilized 

whenever possible. 

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RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MIKE ROUNDS TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

THE VA AND CERTIFIED REGISTERED NURSE ANESTHETISTS

As you know, on December 14, 2016, VA issued the final rule providing full practice authority for advanced practice registered nurses with an effective date of Jan. 

13, 2017, which excluded Certified Registered Nurse Anesthetists (CRNAs). 

Question 56. What is the VA’s rationale for excluding Certified Registered Nurse 

Anesthetists (CRNAs) in the final rule? 

Response. Amending this regulation increases VA’s capacity to provide timely, efficient, and effective primary care services, as well as other services. This increases 

Veteran access to needed VA health care, particularly in medically-underserved 

areas and decreases the amount of time Veterans spend waiting for patient appointments. 

CRNAs play a critical role in providing care for our Veterans. We did not find that 

VA had immediate and broad access challenges in the area of anesthesia that would 

require including CRNAs in the final rule. If VA learns of access problems in the 

area of anesthesia care in specific facilities or more generally that would benefit 

from FPA, now or in the future, or if other relevant circumstances change, we will 

consider a follow-up rulemaking to address granting FPA to CRNAs. VA CRNAs 

that are granted full practice authority by their state license will continue to practice in VA in accordance with their state license and subject to credentialing and 

privileging by their VA medical facility’s medical executive committee. VA will not 

restrict or eliminate these CRNAs’ full practice authority. 

Question 57. Would the VA experience cost savings by hiring CRNAs and thereby 

increasing the capacity of the VA to administer anesthesia instead of using non-VA 

anesthesia practitioners in some cases? 

Response. VA believes a team-based approach to anesthesia care provides the best 

outcomes to Veterans. Cost is not the primary driver in making decisions on behalf 

of Veterans. We do employee CRNA’s as part of the team and believe we are cost 

effective. Contracting cost is not necessarily more expensive than having VA paid 

Full-Time Employee Equivalents. This is complex and involves the use of anesthesia 

residents (allowed to work for 80 hours/week) in many locations, and is considerably 

cheaper than Physician Assistants and Nurse Practitioners in the ICUs, as an example. Additionally, some contracting is for specialty services that are not needed 

on a full-time basis (e.g., coverage of evoked potential surgery, coverage of liver 

transplants). Because of this complexity, it is very difficult to estimate the systemwide effect. 

Question 58. Despite the VA assessing no anesthesia workforce shortage overall, 

would a local VA facility potentially benefit from more hiring flexibility to fill anesthesia workforce positions? 

Response. There could always be some benefit in more hiring flexibility in order 

to improve access to care for Veterans. If VA learns of access problems in the area 

of anesthesia care in specific facilities or more generally in VHA facilities that would 

benefit from advanced practice authority, now or in the future, or if other relevant 

circumstances change, VA will consider a follow-up rulemaking to address granting 

FPA to CRNAs. 

TRAUMATIC BRAIN INJURY AND POST-TRAUMATIC STRESS

Question 59. If confirmed, how will you work to prioritize research and the development of new treatments for PTS and TBI, two devastating and life-threatening 

conditions that disproportionately affect veterans long after they are in combat? 

Response. If confirmed as Secretary, I would work toward advancing VA’s core research mission. While there is much more to learn, VA is already a world leader 

in research on PTSD and TBI. VA was, in fact, established to take on the mission 

of studying and treating the health consequences of military service. No other 

health system has the mandate, the research portfolio or the clinical expertise to 

carry out this mission. VA researchers developed and fielded the gold standard tools 

in PTSD research and are pioneering new diagnostic and treatment approaches to 

TBI. As demonstrated in our recent Brain Trust Conference, VA knows that, as good 

as we are we cannot accomplish the mission alone. VA is highly focused in our research program to test, confirm and implement new treatments for PTSD and TBI, 

working closely with partners in other research agencies. A specific highlighted new 

activity is concentrating on launching studies of new medications and other therapies for PTSD where we will be establishing public private partners (PTSD 

73 

Psychopharmacology Initiative). I stand committed to work with the best within VA 

and synergize our efforts with researchers across the country and around the world 

to meet the health needs of our Nation’s Veterans. 

Question 60. With public and private partners, studies on post-mortem brain tissue from the VA’s National Center for PTSD Brain Bank, have improved our understanding of how TBI and PTS affect the brain and helped discover potential targets 

for new treatments. How can the VA continue to support these successful efforts 

and work to close research gaps? 

Response. As you note, VA’s National Center for PTSD Brain Bank, the first of 

its kind, was established to significantly advance our understanding of how the 

health effects of military service affect the brain and to develop new treatments to 

improve the lives of Veterans. I am committed to supporting the efforts of VA’s 

world-class research and clinical teams and of integrating their efforts with those 

of public and private partnerships to identify and tackle the next breakthroughs in 

research and treatment. We will maintain VA’s new Office of Public Private Partnerships and participate in engagement programs such as Stand Down on Suicide 

Prevention, VA Brain Trust Conference and meet with leaders of major pharmaceutical companies to ensure that the right people and the right teams are closing 

those gaps and identifying the next research horizons. VA Research has a long history of working in partnership to move evidence for new treatments forward. We 

are currently launching new treatment trials under our PTSD Psychopharmacology 

Initiative, however, efforts are ongoing to continue to improve understanding and 

advance treatment for TBI and PTSD in a robust portfolio of clinical trials, epidemiology, and health services. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. DAN SULLIVAN TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 61. Do you believe the current hiring process within the VA is as timely 

and efficient as it could be? If not, what do you believe should done in order to improve the current system so that hiring high-quality personnel occurs as expeditiously as possible? 

Response. There are a number of efforts that will need to continue in order to improve the hiring processes and lessening the time to fill jobs. The hiring metric established by the Office of Personnel Management for filling jobs open to the general 

public is 80 days. The VA hiring metric for filling jobs open to the current Federal 

workforce is more aggressive and is 60 days; I support this goal. VA’s hiring managers and human resources offices take every opportunity to fill jobs quickly by 

using noncompetitive hiring authorities when there are qualified and eligible applicants, such as Veterans. In addition, I believe we will improve the timeliness and 

efficiency of the hiring process by: 

• Ensuring better collaboration between the H.R. professional and the Hiring 

Manager when developing the position’s requirements and the skills needs for the 

job that is to be filled; 

• Sharing selection certificates between H.R. offices within VA and with other 

Federal agencies that may have posted job ads with similar job skills which minimizes the need to continually post jobs; and 

• Establishing standing applicant files for mission critical occupations. 

Question 62. I am asking this question on behalf of my constituent, Ross Bieling: 

‘‘Dr. Shulkin, as Under Secretary to the VA during the Obama administration, during your tenure, please provide examples where you have implemented meaningful 

ideas resulting in positive change within the VA system that have directly or indirectly benefited all veterans. And if not, why not?’’ 

Response. Mr. Bieling, thank you for your question. I would be glad to share several examples that started as ideas and moved into meaningful benefits for our Veterans. I will share four ideas here that all relate to improving access to care. They 

are: 1) reorganizing our approach to wait times to a clinically meaningful approach 

toward urgent care; 2) access stand downs; 3) same day services; and 4) best practice adoption. 

When I came to VA 18 months ago, the biggest issue I believe we faced was access 

to care for our Veterans. However, from the way that VA was approaching access 

I did not believe that we could develop an effective solution to the problems we 

faced. I, therefore, instructed our team to reduce our clinicians’ way of ordering 

consults from 31 different ways to just 2 ways: either routine or urgent. That allowed us to see which Veterans needed care the most. It also allowed us to focus 

74 

our efforts on these urgent health care needs. Once we did that, we went to our second idea—that is to have national access stand downs. This was a mandatory event 

that occurred in every single medical center to focus the entire staff on reducing urgent care needs. This effort is described in an article I wrote, http://catalyst 

.nejm.org/va-stand-down-resolved-56000-plus-urgent-care-consults/. 

After we reduced our urgent consults, we then implemented the next idea—same 

day access. We have implemented same day services for primary care and mental 

health in every one of our medical centers in the country. The final idea implemented is our Diffusion of Excellence initiative. In this initiative, we are taking the 

best practices in access from around the country and sharing them to adopt these 

practices. All of these ideas have led to a significant improvement in access for our 

Veterans. 

Question 63. I am asking this question on behalf of my constituent, Capt. Bob 

Pawlowski: ‘‘Given the effort to revamp the VA and the important focus on health 

care and services for our veterans, what do you propose to improve the perception 

in our veterans minds that this is a ‘new VA’ and you are ‘here to serve?’ ’’ 

Response. Captain Pawlowski—thank you for your question. The design of the 

‘‘new VA’’ as you stated is already underway. Since my arrival 18 months ago, we 

have been working to define a Veteran-centric experience. This is about changing 

the culture of VA, and setting new expectations for our employees. Our ICARE values define the ‘‘new VA:’’ Integrity, Commitment, Advocacy, Respect, and Excellence 

(ICARE). 

We have asked all employees to sign a commitment pledge to upholding these values and we have now trained over 100,000 of our leaders in how to manage to these 

values. We are teaching a ‘‘principle’’ based management style rather than a ‘‘rules’’ 

based style that had begun to characterize much of VA in the past. If confirmed as 

Secretary, I will continue to lead through these values and make sure that all employees are working to honor our Veterans through the adoption of these principles. 

The ultimate judge of our success will be our Veterans. 

Question 64. I am asking this question on behalf of my constituent, Charles Wilson: ‘‘I was told my entire military career that if I stay in and retire, I would be 

given medical benefits at no cost. I was actually shocked, when I retired, to learn 

that I had to pay for that benefit. Why? Is there any relief in sight to this tragedy, 

or are we going to be asked to suck it up once again?’’ 

Response. Mr. Wilson, let me start by thanking you for your service. I am aware 

of a 2003 decision by the United States Court of Appeals for the Federal District 

held that promises of lifetime health care made decades ago by recruiters to entice 

people to serve in the military for at least 20 years were not valid and we have also 

learned that the recruiters did not have the authority to make them. I would also 

encourage you to call the following number to determine your eligibility for VA services 1–877–222–8387. 

Question 65. I am asking this question on behalf of my constituent, Bejean Page: 

‘‘Will you [as VA Secretary] seek out veterans and ask them what they need?’’ 

Response. Mr. Page, if confirmed as Secretary I will absolutely do this. In fact, 

as Under Secretary for Health I can assure you that we have begun to do this now. 

We seek direct Veteran feedback about what they need in several ways.Let me 

name four of these ways. First, we speak to our Veterans all of the time. Whenever 

I do visits to our medical centers around the country I make sure I meet with Veterans to get their candid feedback. In addition, I actually practice medicine in the 

VA system and care for patients (who do not know I am the Under Secretary) so 

I hear it straight from them. Second, we ask our Veterans directly all the time. We 

do hundreds of thousands of satisfaction questionnaires and we pay attention to 

what we hear and we also ask our patients on our kiosks (we call it Vetlink) about 

their experience and how we can do better. Third, Veterans contact us every day 

with their issues and we not only listen, but we respond. I get dozens of these 

emails myself directly from Veterans and I can assure you I pay attention to what 

I am hearing. And remember, 33% of our employees are Veterans and many use our 

services so we listen to our employees as well. Finally, we have established a formal 

Veteran insights panel of a few thousand Veterans that we run ideas by and ask 

their thoughts. We also use our Veteran Service Organizations in a similar way and 

ask them what they think. As you know they represent collectively millions of Veterans. 

Question 66. I am asking these questions on behalf of my constituent, D.A. Anderson: ‘‘What is your vision for the VA in going forward? How can the VA be run more 

like a business that has accountability for its actions and treats the veterans of this 

country with fairness and respect?’’ 

75 

Response. I have a background in business and in running leading healthcare organizations.My approach to running VA is similar to running these other organizations. Successful businesses must be responsive to their customers or they fail. My 

vision for VA is to be the system of choice in the country and to have healthcare 

and services that are second to none anywhere. VA must not only be responsive to 

Veterans (and their families and caregivers) but also be responsible to taxpayers. 

This means that both the quality of the services and the efficiency of the services 

must be competitive with private sector options. Accountability in my opinion is set 

by having clear expectation, clear metrics and feedback, and clear consequences. I 

am committed to do just this. 

Question 67. I am asking this question on behalf of my constituent, Jason 

Nesslage: ‘‘There is discussion in our veterans ranks regarding concurrent receipt 

of retired pay and disability pay. There is not one veteran that wants this to return 

to the past, where a retired servicemember chose whether he/she wanted the VA 

offset pay or their retirement pay. These are clearly two different entitlements that 

should never be up for discussion again. What are your thoughts?’’ 

Response. Mr. Nesslage, while I agree that Servicemembers and Veterans should 

be entitled to the maximum benefits allowable as established under law, by statute, 

VA is not able to pay both disability compensation benefits and military retirement 

payments in certain instances. Congress recently expanded entitlement to receive 

concurrent payment for individuals who have a disability rating of 50 percent or 

more. We will continue to implement any future legislation on this issue. 

Question 68. I am asking this question on behalf of my constituent, Ross Bieling: 

‘‘Do you believe that the current VA structure for purchasing, ensures that new 

products and equipment are considered for purchasing at the lowest competitive 

price possible ensuring that budget dollars are spent wisely and effectively? Please 

describe in detail the current system utilized within the VA for purchasing and if 

or how you would restructure it under your leadership ensuring that veterans will 

ultimately benefit within these important areas.’’ 

Response. Mr. Bieling, we need to look at all of our support systems and structures to ensure that what we are doing is actually supporting our Veterans while 

providing value for taxpayers. There is a current initiative underway to improve our 

supply chain which would not only leverage spending with the input of clinicians, 

but will also improve inventory management and business processes. 

Five initiatives were set in place for the supply chain and purchasing modernization effort: standardize processes and data to establish enterprise-wide management 

practices; centralize purchasing for cost avoidance; establish a life-cycle management system to ensure consistent availability and correct usage of supplies and 

equipment; create a national supply chain formulary for improved ordering and recordkeeping; and standardize positions and work responsibilities of acquisition and 

logistics staff. 

Central to the effort was establishing a new list of medical supplies and equipment to be purchased through a centralized system, using one of four regional 

‘‘prime vendors.’’ This list, or formulary, includes over seven thousand items and 

continues to expand, as have the number of facilities using this list. The modernization effort centralizes purchasing authority, streamlines ordering, tracking and procurement of equipment and supplies by providing an efficient, just-in-time distribution process. It also enables VA to leverage its scale to order items at a negotiated 

rate to avoid costs. 

By modernizing these processes, VA’s supply chain is successfully reducing excess 

inventories and leveraging purchasing power, guaranteeing medical facilities have 

the right supplies, in the right amounts, at the right place, right when they are 

needed for Veterans’ care. 

Question 69. I am asking this question on behalf of my constituent, Tony Molina: 

‘‘Would the VA consider establishing a special help desk for VSO’s and Tribal Veteran Representatives, so when a family member asks for a copy of their DD214, we 

can receive it as quickly as possible? I have been given many answers but there is 

still no quick way for us to attain a DD214 with one phone call and online takes 

forever.’’ 

Response. Mr. Molina, currently, we allow authenticated VSOs to request DD 

Form 214s through our general benefits line without a written request, thus allowing the VSO to obtain the document as quickly as possible. Additionally, this service 

is also provided by chat agents to properly authenticated VSOs. Agents can provide 

the requested document via U.S. Mail or by fax. Additionally, on February 21, 2017, 

a new rule will take effect under 38 CFR 14.628 that will allow tribal nations to 

apply for VSO status in the same manner as if they were a state and once they 

76 

are properly accredited, VA will be able to provide this same service to their organizations as well. 

Question 70. I am asking this question on behalf of my constituents, Mike and 

Sandy Coons. ‘‘Why is it that retired veterans who have served 20+ years for our 

Nation are required to put up with waiting for an authorization for medical care 

for weeks, much less days? Retired military or vets with 100% disability have the 

retired military ID card. We have earned our free medical and dental that was 

promised to us, yet we have to pay into TRICARE, we have to get a ‘mother may 

I?’ for physical therapy, lab tests, radiological testing when all we should be doing 

is showing our ID to the doctor’s office and the doctor’s office bills the VA. All we 

want is for the government to honor the promises made that we fulfilled on our 

end!’’ 

Response. For many of the VA community care programs, especially Choice, VA 

is following the criteria Congress set out in law. I recognize that it is not always 

easy for Veterans to move between programs or access certain types of care. This 

is exactly the reason why in the future streamlining is necessary to eliminate some 

of the bureaucracy. Veterans eligible for enrollment in VA’s Health Care System are 

eligible to receive all medically necessary care available through VA health care programs. Veterans, who are eligible for health care from both VA and TRICARE, are 

free to choose whether they want to receive care from VA or TRICARE. 

Question 71. I am asking this question on behalf of my constituents, Mike and 

Sandy Coons. ‘‘Why can’t vets with 20+ years or 100% disability, get full dental coverage for all needs, routine cleanings, fillings, crowns, dentures, partials, etc.?’’ 

Response. Veterans who have service-connected disabilities rated 100% disabled, 

or are unemployable and paid at the 100% rate due to service-connected conditions, 

are eligible for comprehensive dental care. 

Question 72. I am asking this question on behalf a constituent. ‘‘My niece is a retired veteran with lupus and has to wait months for an appointment. In addition, 

the VA is not as familiar with this specific disease as other doctors. Therefore, I believe my niece does not receive the best care, even after serving our country. If a 

patient cannot receive prompt attention and appropriate care, will the VA pay for 

a doctor outside of the network?’’ 

Response. If an enrolled Veteran is not able to receive care in a timely manner 

or requires specific care that is not available at VA, the Veteran can be seen in the 

community through the Veterans Choice Program (VCP) or other community care 

programs. The Veteran can speak with the Choice Champion at the facility she attends if she wants to talk someone in person to explain her options. She can also 

call the Choice Call Center at 1–866–606–8198, or visit the VCP internet site at: 

http://www.va.gov/opa/choiceact/. 

Question 73. I am asking this question on behalf of my constituent, Ric Davidge. 

‘‘The demand for mental health professionals in Alaska has been long and well 

known. We just need more. A suggestion is that the VA through the US Public 

Health Service focus on this highly needed professional group and then put them 

in Alaska for two years.’’ 

Response. Thank you for the suggestion. VA and HHS are exploring any and all 

possible avenues to fully staff our hospitals and clinics with an emphasis on Veterans Access. VA and HHS leadership are developing a partnership between our 

agencies for Public Health Service medical officers to serve as clinicians in VHA 

medical facilities, to include mental health professionals. The mental health needs 

of our Veterans are a priority and we will take your suggestion into consideration. 

Question 74. I am asking this question on behalf a constituent. ‘‘I have observed 

three instances of what could be determined as HIPAA violations since 2014. My 

husband and I have received two pieces of unrelated medical correspondence for veterans who live somewhere else: one, a faxed a prescription for a VA pharmacy for 

a veteran who lives elsewhere, the second was a piece of correspondence pertaining 

to a medical appointment for a veteran who lives in Texas, (the appointment was 

set for a provider in Texas.) I made the VA and the Choice Program aware of these 

two instances. 

‘‘The third instance was revealed to have impacted my husbands’ benefits claim 

directly. We received a copy of his Disability Benefits Questionnaires which contained medical history of another veteran that had been erroneously inserted into 

my husband’s claim. This other veteran is older and had been seen at a VA for dizziness which my husband now suffers from as well. However, this medical appointment date was 1986 when my husband was just a freshman in high-school and did 

not suffer dizziness until his Traumatic Brain Injury (TBI) sustained while performing USAF work duties in Plattsburgh, NY in 1990. This 1986 VA visit was cited 

as the reason for denying his C & P rating increase claim in 2014. An appeal was 

77 

filed in a timely manner and the second rating doctor reviewed this rating file and 

used the original rating doctor’s decision as the reason to also deny the benefit rating increase claim. Neither of these doctors referred James for follow up evaluation 

of TBI related issues.’’ 

‘‘How will the workflow processes be improved to end these potentially life-altering mistakes? Would Dr. Shulkin be open to having an audit of workflow processes 

in an effort to identify gaps and unnecessary duplicitous steps in order to streamline 

the process?’’ 

Response. Yes, I am open to any improvements that could mitigate risks as well 

as streamline workflow processes. The inappropriate access of patient health records 

is unacceptable and in violation of privacy laws and regulations, VA policies and 

procedures, and our principles. We recognize that access to current health information is critical in order to support care coordination and delivery of high-quality 

care. Currently, each VAMC has unique processes and procedures for requesting, retrieving, and processing returned documentation as well as general workflows related to handling and uploading returned documentation and closing consults. Establishing standardized processes and responsibilities will improve the availability 

of clinical documentation for providers, enhance continuity of care, and streamline 

the approach to manage incoming documentation. We are committed to keeping our 

Veterans health information secure. 

Question 75. I am asking this question on behalf a constituent. ‘‘I currently have 

a claim for service-connected Hepatitis C that has been denied twice at the local 

level and now it is under review at the national level. Will the VA acknowledge the 

transmission of HCV by jet injector?’’ 

Response. We have heard feedback from Veterans regarding a possible relationship between the hepatitis C virus infection and immunization with jet injectors. Although we currently do not have a documented case of hepatitis C transmitted by 

a jet injector, it is biologically plausible. Any Veteran enrolled in the VA health care 

system who has concerns about hepatitis C infection, because of jet injectors or any 

other potential blood exposure during military service, is welcome and encouraged 

to request testing and evaluation for hepatitis C at the nearest VA hospital. 

Question 76. I am asking this question on behalf a constituent. ‘‘My husband tried 

to get just medical assistance from the VA in 2004 for Hepatitis C. He believed he 

got HCV at boot camp, or Korea during the war from air guns. The VA turned him 

down for medical treatment and he died in 2008. He did not know much about it, 

like everyone else. I’ve have had an appeal since 2008. I have HCV that I believe 

I got from [XXXXX]. I’m pretty healthy, except I need treatment, like he did. He 

was proud to be in the Army. I am trying to get DIC benefits, but the VA is fighting 

it. I have letters from friends, doctors, etc. I have been fighting since 2008.’’ 

Response. Mrs. [XYZ]—After looking into your case, I was advised that the regional office did grant you entitlement to DIC benefits in September 2016. The regional office is in the process of awarding benefits pending recoupment of a previous 

overpayment and payment of attorney fees. 

Question 77. I am asking these questions on behalf of my constituent, D.A. Anderson. ‘‘Because you have been a part of the VA system in the last administration, 

would you consider that a liability or an asset and why? Do you think that being 

a non-veteran will affect your effectiveness in any way?’’ 

Response. I have been at VA for 18 months. I consider this an asset. Since I was 

new to the VA system, it took me several months to learn about the system, identify 

the ways of getting management initiatives accomplished, and developing relationships and trust with employees, Veteran groups, and community organizations. 

Eighteen months, however, is not long enough to have become engrained in the system about doing things the same way as we always have.My current knowledge of 

the system allows me, if confirmed, to have the ability to move the system forward 

without a new learning curve and with the ability to know how to implement these 

changes. 

In terms of being a non-Veteran, I have spoken to dozens and dozens of Veterans 

about what they want in a new Secretary. What I have consistently heard is that 

the most important thing they want is a Secretary who knows how and who will 

make the system work better for them. I believe my experience will allow me to do 

this. Since I have worked in the system for the past 18 months, I do believe that 

I have developed a good understanding of the Veteran perspective. However, by not 

being a Veteran, I know that I will need to try even harder to make sure I am including the Veteran perspective in everything I do. I plan to accomplish this by 

building a strong management team that has strong representation from Veterans, 

and in constantly asking for feedback and input from Veterans. 

78 

Question 78. I am asking this question on behalf of my constituent, Carol [XYZ]. 

‘‘When is the VA going to pay their bills? I had to find another podiatrist due to 

the VA being behind on paying the bills.’’ 

Response. As the relationship between VHA and the network contractors continues to mature, the timeliness and effectiveness of payments to community providers improves. The most recent reports indicate that over 90% of clean claims are 

processed within 30 days; a great step forward since program inception. 

Simultaneously in traditional community care, claims staff members have worked 

tirelessly to reduce the overall backlog of overdue claims within the past 18 months. 

In July 2015, there was an overall claims inventory of nearly two million claims 

with prompt payment rate of 67%. These numbers have steadily been reduced to 

a total inventory of 660,000 with a prompt payment rate of nearly 80%. 

We are keenly aware of some providers threatening to leave the Network. There 

is no more critical service we provide then to ensure timely and consistent care for 

our Veterans. To that end, in February 2016, the VHA Office of Community Care 

Provider Rapid Response Team (PRRT) was created to facilitate the expedited resolution of ongoing individual billing and payment cases. Since its creation, the PRRT 

has received a total of 263 cases, resolving 236. The average time to resolve an individual case is between 7 and 10 days. 

Despite these successes, tremendous room for improvement still exists. VHA leaders engage in weekly meetings with Health Net and TriWest leadership reviewing 

key areas of performance. The Request for Proposal (RFP) for the new Community 

Care Network addresses incentives to encourage prompt payment by contractors to 

providers. This RFP was released on December 28, 2016, and will provide stronger 

oversight in ensuring timely payment to providers. 

Question 79. I am asking this question on behalf a constituent. ‘‘Since those of 

us who qualify for boots on the ground, why do we have to go through so many 

hoops to share a buddy letter or to show through our experiences that we do have 

PTSD, no matter what our MOS was?’’ 

Response. VA no longer requires that an in-service stressor be documented in personnel records—rather, if the stressor is related to combat or fear of hostile military 

or terrorist activity, then the stressor can be proved merely by lay testimony (a Veteran’s statement) that the event occurred. Veterans may still submit buddy statements to show the current severity or existence of a disability and the statements 

can be considered in assigning an evaluation. For military sexual trauma (MST) 

leading to a diagnosis of PTSD, only corroborating evidence (‘‘markers’’) is needed. 

For stressors that do not fall under an exception to the evidentiary standard (i.e., 

they must be proven by the facts of the case) a buddy statement can be used to help 

show that the stressor occurred. However, even in those situations, a buddy statement is only one piece of evidence that can be submitted to prove that a stressor 

occurred. 

Question 80. I am asking this question on behalf of my constituent, Capt. Trevor 

Sayer. ‘‘I am a USMC Captain retiring this summer. I am retiring from a joint command in Arizona, and begin my terminal leave in March. The VA pre-discharge 

claims enrollment program (BDD) allows active duty to submit claims 120 days out. 

However, if you are leaving the state in which you file before the claim is processed 

and your appointment for your initial medical exams are not made in time then the 

claim has to start over in the new state. Now in my case, I am in Arizona and going 

home to Ketchikan. I could start my claim now in Arizona but I am told it could 

delay processing by months because the claim would need to be transferred to Alaska then arrangements for me to fly from Ketchikan to a VA med center in Anchorage would need to be made in order to do initial medical screenings. There simply 

isn’t time within this 120 day window to do all the evaluations in AZ before I depart. The alternative being to forego terminal leave in order to do medical screening 

prior to going to Alaska or wait till I get home to Ketchikan and submit a fully developed claim once my retirement is effective thus eliminating the benefit of the predischarge program. What if the VA had a mobile outreach program in Alaska?’’ 

Response. Servicemembers are highly encouraged to initiate their claims during 

the pre-discharge stage to afford the earliest effective date possible for any award 

of benefits. Currently, participation in the Benefits Delivery at Discharge (BDD) 

program requires being available for examination at the Servicemember’s last duty 

station. However, if the Servicemember is not available for examination at their last 

duty station, the claim is transitioned to the Quick Start program. Quick Start 

claims are also considered priority VA claims. The VA examination for the claim 

would then be completed near the post-separation site where the Servicemember/ 

Veteran resides and is available for examination. 

79 

Based on your specific scenario, it is recommended for you to file your claim as 

soon as possible and we can expedite the scheduling of your examination at the 

most appropriate location convenient to you. 

Question 81. I am asking this question on behalf of a constituent. ‘‘We called one 

of the VA phone numbers and they said on the recording that if there was someone 

who was feeling suicidal, to call a hotline number or call 911. So why is it that the 

VA phone systems cannot give an immediate option to press a number to go immediately to the hotline or to the 911 services?’’ 

Response. Earlier this year we implemented a feature that allows callers to VA 

medical centers to ‘‘press 7’’ to be directly connected to the Veterans Crisis Line. 

We are exploring expanding that feature to other VA entities. The option of direct 

connection to 911 services is more complex and we are studying it now. Due to its 

complexity, we do not have a timeline for when, or if, it will be implemented. 

Question 82. I am asking this question on behalf of constituents. ‘‘Issues like the 

flu, sinus infections, migraines and items like that it is much easier for us to go 

to a local hospital and use our TriWest in the urgent care department and pay the 

co-pays. As far as we know, we can’t go to urgent care at the local hospital and use 

our VA. Is this where Choice would come in? Also, going in for urgent care or emergency care in a regular hospital could they streamline the VA Choice like it is with 

the TRICARE (TriWest) so we don’t have to call prior to treatment for authorizations?’’ 

Response. The Veterans Choice Act expanded VA’s ability to provide timely access 

to care for Veterans from sources in the community. While this much-welcomed expansion of authority provides VA with another means with which to provide routine 

care for Veterans who cannot otherwise be seen within a VA facility, the requirement for VA pre-authorization of care under this program does not lend itself to 

being an effective tool for management of medical care during instances of urgently 

or immediately-required medical attention. VA is seeking additional authority from 

Congress to consolidate its community care programs and to provide expanded urgent/emergency care coverage to eligible Veterans. 

Question 83. I am asking this question on behalf of my constituents. ‘‘We travel 

out of Alaska to Florida for our winter time for three months. So when we arrive 

in Florida, we can use the urgent care or the emergency room at Bay Pines VA Medical Center in Seminole, Florida and those services are really pretty good. However, 

we have to go into module A and wait because we do not have a VA primary doctor 

down here in Florida. We have noticed that our records and annotations from Alaska and records and annotations here in Florida do not always make it into the same 

record files on My Health in a timely manner. Why is that? One example is the 

echocardiogram my husband had at the Bay Pines VA medical center on Friday a 

week later, it is still not on the My Health records. This was a specialist referral 

that was requested in Anchorage that we asked to be conducted in the VA Gainesville thoracic surgeon’s office so we would be close to family in case a surgery was 

needed.’’ 

Response. For some data from the Electronic Health Record (e.g., lab test results), 

information becomes available within My HealtheVet three calendar days after is 

has been verified. This delay enables the provider to communicate with the patient 

if needed, for example to discuss an abnormal test result. The example you provided 

of an echocardiogram is something that is not currently sent to My HealtheVet, but 

is something we are working on for the future. 

Question 84. I am asking this question on behalf of my constituents. ‘‘We think 

every VA center, especially in Alaska, needs to have an emergency room or agreements need to be worked out with local hospitals to service-disabled veterans by 

using the VA Choice for emergency services at local hospitals.’’ 

Response. The Veterans Choice program was designed and implemented to expedite access to care for those Veterans who do not have a VA facility reasonably 

available to provide required treatment in a primary care or urgent care environment. Because of the nature of the administrative requirements included in the 

Choice Act, utilization of it as a means to provide emergency care is not feasible 

and would add confusion or delay to Veterans in seeking or receiving care during 

an emergency. As it pertains to emergency care, the primary consideration of VA 

is the safety and well-being of the Veteran. 

As such, VA provides emergency treatment to Veterans via Community Care programs that remove administrative prerequisites, such as calling a third-party administrator or VA, and encourages Veterans to proceed directly to a source where 

they can receive the care and services required. VA agrees that all Veterans should 

be aware of actions to take during an emergency as well as the benefits available 

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to them. As part of plan to improve and consolidate community care programs, the 

variation in emergency care would also be addressed. 

Question 85. I am asking this question on behalf of my constituents. ‘‘It is extremely difficult to see the VA primary care doctors more than once a year face-toface. A lot of our interaction takes place on phone calls with nursing staff. When 

dealing with specialized health issues, that once a year face-to-face is not sufficient. 

We need to be able to go into our primary care when we’re dealing with being moved 

from specialty clinic to specialty clinic in order to discuss the next course of action.’’ 

Response. Primary care plays an important coordinating role for patient care, particularly for the patient with complex medical issues requiring involvement of one 

or more specialists. These Veterans may require frequent interactions with the primary care provider in addition to other health care team members. The kind of 

interaction will vary depending upon both the medical needs and preferences of the 

patient, and includes face-to-face visits as well as telephone care and secure messaging. Primary Care policy (VHA Handbook 1101.10, Patient Aligned Care Team 

(PACT) Handbook) provides flexibility for the team to decide with the patient both 

the type and frequency of these interactions. Patients are encouraged to discuss 

their preferences with their Patient Aligned Care Team (PACT) to ensure that they 

are accommodated in the treatment plan. In occasional instances, these discussions 

can be facilitated by the patient advocate if specific concerns of the patient remain 

unaddressed. 

Question 86. I am asking this question on behalf of my constituents. ‘‘We have 

both have talked to several dependent wives whose spouses are suffering from PTSD 

that served in the war zone and that they are not able to get help while they’re 

serving at their current assignment. They feel like they have to get out of the service and they need to cope with it on their own, as the upper supervision has impressed upon them that they don’t have a problem and they don’t need to go get 

help for it. There is still a high need for more treatment and education in the upper 

management levels for them to understand and to help their troops suffering with 

PTSD without taking away peoples jobs or the stigma of this. Especially special ops 

or infantry. Our military and our veterans have served well, they have fought well, 

but they are struggling because they’re being told that they should not identify 

themselves with PTSD issues because they might lose their jobs. Also, a lot of the 

dependent wives are having to cope with PTSD with their husbands that they don’t 

fully understand how they can handle it, how they can walk through it with them, 

and how they can encourage them. We suggest that there needs to be a PTSD assistance and education program for spouses of military members/veterans to help 

the families as well. Also, recommend offering co-counseling services for dependent 

spouses that have walk-through documented PTSD incidences with their veteran 

husbands or their wives.’’ 

Response. I agree that PTSD or any mental health issue is best addressed within 

the context of the family. Since 1979, VA’s Readjustment Counseling Service (also 

known as the Vet Center Program) has been offering couples and family interventions as a core service. Unfortunately, there are currently legislative obstacles to involving family members in VA mental health services. If confirmed as Secretary, I 

will seek Congress’ action in updating legislation in order to allow VA clinicians to 

provide robust involvement of family members in the care of all Veterans seeking 

VA care. 

Vet Centers provide readjustment counseling to any Veteran, active duty Servicemember, and those in the National Guard and Reserve Forces who served in a combat zone or area of hostility. The family members of these individuals are also eligible to receive counseling when it is found to aid in the readjustment of their loved 

one or to help the family cope with a deployment in the absence of their Servicemember. Services to family members can consist of individual, group, and family 

counseling and focus on psycho-education, reducing the symptoms associated with 

PTSD, or any other goal the Veteran or Servicemember has identified. All Vet Center services are provided regardless of the character of discharge, to include dishonorable discharge. 

To help reduce the stigma associated with receiving counseling, Vet Centers maintain the highest levels of confidentiality. Vet Center Counseling Records are released only through the signed consent of the eligible individual or to avert a crisis 

such as serious suicide ideation or attempt. 

Question 87. I am asking this question on behalf of my constituents. ‘‘There appears to be some pretty significant delays in the referral management office to get 

referral appointments. We believe that part of the problem is a lack of sufficient 

personal for referral management offices to handle and swiftly process those referrals outside of the VA to a specialist. If a specialist is seen (like a pulmonary doctor) 

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and refers to another specialist (thoracic surgeon), we have to go back to the VA 

referral process system again into a holding pattern to get the request from the specialist that requested we see another specialist or series of tests that results in further delays. And we have to wait for the primary nurse practitioner to approve it 

before we can even get to the other specialist who is a doctor. We also find that 

we have to make routine phone calls to follow up on those actions, like the ‘squeaky 

wheel gets greased first.’ ’’ 

Response. We developed an operating model that improves efficiency in the referral process including direct communication with our community providers via our 

portal, the creation of standard episodes of care (EOC). This model is currently 

being rolled out and is now in use in Alaska. Many of these include the authority 

for a Veteran to see several providers or receive several tests as part of a complete 

EOC. For example, a complete EOC for a Veteran with a pulmonary nodule could 

allow a community pulmonologist to see the Veteran, diagnose a lung cancer and 

then send that veteran to a thoracic surgeon to perform a partial lobectomy. This 

should assist in getting Veterans access to specialty care more timely. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO HON. 

DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

VA PUGET SOUND HEALTH CARE SYSTEM

Question 88. As you know, many Seattle area veterans receive their care through 

the VA Puget Sound Health Care System—specifically at the Seattle campus. Unfortunately, in meetings with individual veterans as well as Veteran Service Organizations in Washington state, we regularly hear of obstacles that veterans face in accessing care. My colleagues and I have worked to identify some of the root causes 

of these issues, which seem largely to stem from unfilled management positions, an 

overreliance on ‘‘acting’’ roles that lack decisionmaking authority, and frequent turnover in leadership. 

On October 26, 2016, you spoke with my colleague Congressman Adam Smith, 

whose district includes the VA Puget Sound Healthcare Center in Seattle. During 

that call, Mr. Smith specifically noted the multiple leadership issues that plague the 

Seattle VA facility, including ongoing problems with open, unfilled positions. It is 

my understanding that both you and Congressman Smith agreed that sending a 

management improvement team was warranted, and would be beneficial to Seattle 

area veterans. Your staff in Washington, DC, confirmed this in an October 28, 2016 

message. 

Unfortunately, on November 14 last year, Congressman Smith’s office was informed that this commitment was being rescinded, and VA officials have so far refused to explain why. The leadership problems continue, and have only worsened 

with President Trump’s recent Executive Order directing a Federal hiring freeze. 

Clearly, the need for assistance remains. 

• To that end, will you commit to sending a management improvement team to 

the VA Puget Sound Health Care System? 

Response. I am disappointed to hear this and I was not aware of any decision to 

rescind a team from going to VA Puget Sound. I will commit that a team of Human 

Resources experts will be on site within 60 days to assist VA Puget Sound Health 

Care System hiring efforts and further instruct the team that no one but me would 

be allowed to rescind this commitment. 

IMPACT OF HIRING FREEZE

Question 89. Dr. Shulkin, you said in your nomination hearing, ‘‘the most important thing to me is that we have the resources to hire the people that we need to 

take care of our veterans. We have requested that from the White House and we 

have gotten that.’’ You further claimed that there are 45,000 positions open within 

VA, of which 37,000 are exempt, but that still leaves 7,000 positions vacant. Additionally, those numbers only apply to positions in the Veterans Health Administration. There are another 688 vacancies within the Veterans Benefits Administration, 

none of which are exempt. So the hiring freeze will clearly have a very real impact 

on veterans’ access to services and care. 

For example, data from VA Portland Health Care System, which provides benefits 

and treatment to veterans in Washington State, shows that on average they processed more than 500 claims for beneficiary travel program every business day in 

2016. As a result of this high volume, the travel reimbursement claims processing 

time is backlogged to about six weeks for most claims and up to eight weeks or more 

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for complex claims. Portland VA had hoped to address this backlog by hiring additional staff for their Veterans Transportation Program. Unfortunately, although the 

authorized number of staff for the VTP was raised to nine employees, the hiring 

freeze has blocked this VA from hiring the staff it needs to quickly provide this important benefit to our veterans. • How can you say that you have received all the resources you need to take care 

of our veterans when close to 700 positions related to providing our veterans with 

benefits remain vacant and how are you going to address the delays in processing 

veterans’ benefits with so many open positions at VBA? 

Response. If confirmed as Secretary my focus would be to address any barrier that 

prevents us from delivering the services needed to our Veterans. At this point in 

time, my primary concern is to ensure the health and safety of our Veterans. I believe we have the exemption for hiring that allows us to do that. VBA continues to 

offer overtime on an optional basis to employees processing compensation rating 

claims. Additionally, VBA has authorized overtime for specific pension and non-rating work. VBA is considering all options, to include mandatory overtime, to ensure 

that Veterans are getting the best care and services possible while the hiring freeze 

is in effect. 

• If confirmed, will you exempt VBA positions from the hiring freeze? 

Response. I stated in my testimony that I had spoken to the current Acting Under 

Secretary for Benefits and asked him to closely monitor the situation with clear 

metrics to make sure that we are not seeing a significant deterioration of service 

levels. It is my understanding that VBA is in the process of submitting an exemption request to permit the hiring of direct labor occupations to ensure reduced impact on VBA’s ability to serve Veterans. If I am confirmed as Secretary I would give 

full consideration to this request. 

Question 90. As VA Secretary, it will be your job to advocate on behalf of all policies that affect veterans. That means that you must advocate not just for access to 

health care but also for veterans’ ability to access all the benefits that have been 

provided to them in return for their service. One of those benefits is the hiring preference veterans receive when applying for Federal positions. I am very concerned 

that President Trump’s hiring freeze will impact these veterans, who apply for Federal positions in disproportionate numbers compared to non-veterans. 

• If confirmed, what work will you do with the Administration to make sure that 

veterans are not disadvantaged in their effort to seek Federal employment? 

Response. VA provides first consideration to all qualified preference eligible Veterans when filling jobs open to the general public. When filling jobs that are only 

open to current Federal employees, VA also accepts applications from Veterans who 

are currently not part of the Federal workforce, but are eligible for hire using special hiring authorities. A large percentage of the Veteran workforce at VA, 32.57%, 

was hired using a variety of special hiring flexibilities, such as the Veterans Recruitment Act, Veterans Employment Opportunity Act, Schedule A Authority for 

People With Severe Physical Disabilities, Psychiatric Disabilities, and Intellectual 

Disabilities, and the 30% or More Disabled Veteran Public Law. To the maximum 

extent possible, if confirmed as Secretary, VA will continue to fill jobs with qualified 

Veterans. 

The VA also has an established Veterans Employment Services Office to monitor 

our progress with regard to employment of Veterans and to advise me on Veteran 

recruiting and retention strategies. I am proud of the work we’ve done to assist Veterans seeking Federal employment, and I remain committed to those efforts. Over 

120,000 of our employees are Veterans, including over 50,000 of whom are Disabled 

Veterans. 

I look forward to the opportunity to serve as co-chair, with the Secretary of Labor, 

of the Veteran’s Employment Council to ensure the Federal Government maintains 

its momentum in providing employment opportunities for Veterans both in the Federal Government and in the private sector. 

UNDER OTHER THAN HONORABLE DISCHARGES

Question 91. I am concerned about the increasing number of servicemembers who 

leave the service not knowing their VA eligibility status. A 2016 report from Swords 

to Plowshares showed that under other than honorable (UOTH) discharges often result from minor infractions that relate to PTSD or other conditions that prevent 

them serving as expected. The report noted that Post-9/11 veterans in particular are 

three times more likely than Vietnam Era veterans to receive an under other than 

honorable discharge, and that veterans with an under other than honorable discharge are twice as likely to commit suicide, twice as likely to be homeless, and 50 

percent more likely to get caught up in the criminal justice system. 

83 

The brave men and women who volunteer to serve in our military should not be 

left without healthcare or basic workers’ compensation for injuries in service. 

Thankfully, the issues surrounding UOTH discharges have gained public and media 

attention, and increasing attention from this Committee, including a media event 

that the Chairman hosted last month. 

Current law allows former servicemembers to get basic veteran services if their 

conduct was not dishonorable. However, it is often up to VA discretion when it 

comes to providing services to a veteran with an UOTH discharge. Over the past 

several years, VA has taken steps to address this problem, including preserving 

homeless housing eligibility while corrective legislation was prepared; improving the 

internal processes for deciding eligibility in these cases; improving internal communication to VA staff to make sure every veteran has an opportunity to access services; and making a commitment to this Committee last year that it would revise its 

regulations to better take mental health and other factors into account. These are 

great first steps, but there is much more that must be done to properly care for veterans with an UOTH discharge. 

If confirmed, what specific steps do you plan to undertake to provide services and 

care to eligible veterans with UOTH discharges? 

• In particular, will VA follow through on its commitment to issue new regulations this fiscal year amending the criteria for ‘‘under other than dishonorable’’ service, regardless of President Trump’s executive order that would require agencies to 

revoke two regulations for every new rule they want to issue? 

• If confirmed, will VHA revise its military sexual trauma program instructions 

to ensure that no veteran is denied access to military sexual trauma care, regardless 

of circumstances of discharge? 

Response. If confirmed as Secretary, I would work to use the full regulatory authority available at VA to serve as many Veterans as possible including those with 

other than honorable (OTH) discharges. If there are statutory requirements that 

prevent us from doing this, I would come to you to ask for your assistance. Currently, an OTH discharge is not necessarily a bar to receiving MST-related health 

care. It is my understanding that Veterans with OTH discharges can currently receive VA care, including MST-related care, upon review of their discharge by the 

Veterans Benefits Administration (VBA). Following this review, VBA issues a decision as to whether or not the Veteran’s discharge is a bar to receipt of health care 

benefits. VA has taken steps to ensure staff are aware that Veterans with OTH discharges are potentially eligible for MST-related services and that there have been 

no shifts in policy to tighten eligibility requirements. I am committed that no Veteran with MST would be denied access to care. 

PAIN MANAGEMENT

Question 92. The VA, with Committee oversight and support, has taken important 

steps to improve pain management throughout the VA system. These include implementation of a ‘‘step care’’ model that matches appropriate therapies to the unique 

needs of individual patients, particularly for veterans with complex chronic pain 

problems of long, sometimes lifelong, duration. There has also been collaboration 

with the Department of Defense to allow servicemembers transitioning to VA care 

to have their pain management coordinated across the systems. Furthermore, VA 

researchers have worked with the National Institute of Health and other research 

partners on new treatments, particularly those that could be alternatives to the use 

of opioids for chronic pain. Despite progress, a lot remains to be done. 

a. What is your position on alternative methods of pain management? 

Response. I have always been a strong believer in the importance of complementary and alternative methods in pain management. As the CEO of Beth Israel Medical Center in NYC we developed one of the largest private sector Complimentary 

Care Programs in the country.At VA, we have an extensive commitment to complementary care under the leadership of Dr. Tracy Gaudet. Dr. Gaudet prior to coming to VA led Duke University’s programs in Complimentary Care. 

b. If confirmed, how specifically will you continue prioritizing these efforts? 

Response. In response to Section 932 of the Comprehensive Addiction and Recovery Act (CARA), passed in July 2016, the VHA has developed an ambitious plan to 

expand research, education, and clinical delivery of complementary and integrative 

health approaches for pain management as well as mental health and overall wellbeing over the coming three years. On the clinical side, the Integrative Health Coordinating Center in the Office of Patient Centered Care & Cultural Transformation 

is working to make the evidence-based CIH approaches—including acupuncture, 

chiropractic, yoga, tai chi, meditation, and massage—more widely available to Veterans nationally. Our commitment is that every medical center will offer at least 

84 

two of these therapies routinely for Veterans with pain, and one ‘‘flagship’’ site in 

each VISN will offer the entire range of therapies. Our new Community Care contract will also make these complementary therapies available to Veterans in the 

community if they are not available through the medical center. 

To support this increased access to CIH therapies for pain we are actively working 

to revise VA medical policies and regulations to facilitate delivery and evaluation 

of CIH approaches as part of the VA medical benefits package. We are also rolling 

out a large scale educational initiative through our Employee Education Service to 

increase awareness among clinical staff of the role of evidence-based CIH approaches for pain, so that our clinicians will begin to utilize these approaches more 

actively with Veterans. Finally, our Office of Research Development is collaborating 

with the National Center of Complementary and Integrative Health at NIH and the 

DOD to fund a large research initiative supporting demonstration projects developing the most effective ways to deliver CIH for pain in our military populations. 

VETERANS ABILITY TO RAISE CONCERNS

Question 93. I have heard from many veterans in Washington state that it is very 

difficult to get a concern or complaint addressed that is not specifically related to 

an appeal or claim. I have also heard that former Secretary McDonald’s open door 

policy, including the establishment of town halls, was well received by veterans. I 

understand that veteran advocates are intended to help veterans with complaints, 

but my office continues to receive complaints from veterans who do not feel their 

advocates are actually addressing their concerns, perhaps a consequence of the 

structure in which veterans advocates work with local VA but do not raise the concerns to the Department in D.C. • If confirmed, can you assure me that you will continue the open-door policy established by former Secretary McDonald, and that you will create an avenue 

through which veterans can raise their concerns and complaints higher than a veterans advocate if they feel the complaint has not been addressed? 

Response. Secretary McDonald and I share many of the same values in how to 

run organizations, but of course our styles are not identical. My record at VA shows 

that I have also been accessible to Veterans and many organizations as well. I hold 

town hall meetings, speak at numerous events where I interact with Veterans and 

organizations that represent them, and take advantage of as much interaction as 

I can. My career has been focused on allowing the voice of the patient to be heard 

as a primary means for improving healthcare. I’ve started companies that allow patients to be more empowered and I’ve written a book called ‘‘Questions Patients 

Need to Ask’’ to allow patients to be more informed about being a knowledgeable 

consumer of services. I would plan to continue with this philosophy of patient empowerment if confirmed as Secretary. 

Question 94. While I have heard support for the VA town hall program, I have 

also received complaints from veterans in rural communities who have not been able 

to attend these meetings because they only take place in the greater Seattle area. 

• If confirmed, can you assure me that you will keep the VA town hall program 

going, and that you will expand it to reach parts of the country outside major metropolitan cities? 

Response. Yes. 

BREMERTON CBOC

Question 95. I wanted to follow up on the conversation we had regarding the 

Bremerton CBOC. As I mentioned, for the last decade, my office has been working 

with VA, the local community, and the Navy to find an appropriate relocation site 

for the CBOC in Bremerton, Washington, which is significantly undersized. In your 

written response to questions you cited multiple tools to solve real estate problems, 

some of which were not effective in resolving the Bremerton CBOC issue. This facility has experienced two failed relocation efforts, the last of which means a new facility won’t open until 2019 at the earliest. I understand it is VA’s opinion that this 

location is not opening as a result of the building not being renovated in compliance 

with seismic regulations. However, this community has been without adequate care 

capacity for ten years, so I am less interested in what has gone wrong than how 

you intend to fix it. 

a. What immediate steps will you take to provide additional outpatient resources 

to the growing veteran population in Bremerton? 

Response. The VISN 20 Network Director during an update call with your staff 

on February 2, 2017, committed to seeking clinical space in a non-VHA healthcare 

facility into which could be placed an additional PACT Team to increase primary 

care while work to relocate the Bremerton CBOC is completed. VA has already idenVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00088 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
85 

tified two possible locations: one at the new Harrison Hospital in Silverdale; a second in the Franciscan Medical Building in Port Orchard. Opening an additional 

PACT team at a satellite location in the Bremerton area is contingent on our ability 

to timely recruit the PACT medical team professionals required to provide this service. In the meantime, all new Veterans seeking enrollment for Primary Care Services in the Kitsap County area are offered the option to enroll with a Choice primary 

care provider. There are approximately 153 Primary Care Choice providers in 

Kitsap County—sufficient to provide the primary care needs of our Veterans in the 

Bremerton area. 

b. What changes will you make to prevent this from happening again? 

Response. The delays associated with moving the Bremerton CBOC to a new and 

larger location were related to the contractor that was selected for this project. This 

raises the issue of Federal contracting law and the ability to select the best contractor for the job to ensure that this type of issue does not arise again. If confirmed 

as Secretary I would undertake a review of our contracting rules and make recommendations on how we can improve and prevent issues like this from recurring. In 

the meantime, please be assured that the Bremerton CBOC relocation project has 

the personal attention of the VISN 20 Network Director and VA Deputy Under Secretary for Health for Operations and Management. 

ACCESS TO WOMEN’S HEALTH IN RURAL AREAS

Question 96. Dr. Shulkin, women make up the fastest growing veterans population in the United States. In response to pre-hearing questions, you noted that 

since 2014, 100 percent of medical centers and 90 percent of CBOCs have Designated Women’s Health Providers (DWHP). Those are commendable numbers, but 

I would like to see 100 percent of CBOCs have a DWHP, especially since so many 

veterans live in rural areas where their only access to VA care is through their local 

CBOC. In fact, a report released this January by the U.S. Census Bureau found that 

roughly half of all veterans live in rural areas. In my home state of Washington, 

more veterans lived in rural areas than non-veterans. 

a. With VA projections showing that the number of women veterans is expected 

to rise to 15 percent of the entire living veteran population, how will you, if confirmed, ensure that 100 percent of CBOC’s have a Designated Women’s Health Provider? 

Response. VA recognizes that the population of women Veterans has grown dramatically and will continue to rapidly expand. For FY 2017, VA has set a Secretary’s Management Initiative focus on women Veterans’ access, trust and satisfaction. Specifically with regard to access in CBOC’s we will conduct additional 

trainings this year gaining an additional 500 providers through our Mini Residency 

trainings. The attendees are selected specifically targeted to gaps in providers, particularly for CBOCs. In addition, we are launching a new traveling education for 

rural sites to deliver the curriculum to CBOC providers. VA has identified where 

the gaps in providers exist, we strive to have Designated Women’s health Providers 

at every facility and CBOC.VA, just as for all of health care, continues to be challenged in hiring Primary Care Providers. To assist with recruitment, Workforce 

Management and Consulting (WMC) is developing new recruitment tools to entice 

more women’s health providers into VA employment. 

b. What else will you do, specifically, to care for the growing population of women 

veterans? 

Response. With regard to ongoing access, VA Office of Community Care has recently added analysis of referrals for women and provider availability. Approximately 33% of women go out into community care each year, thus an important 

focus had been adequacy of referral networks. In house, we have expanded Mammography to 52 sites and will continue to add locations that reach the critical minimum number of women at that site. VA Office of Women’s Veterans Health has 

developed IT tools for management of breast cancer cases. Also added is a tracking 

system that allows follow up of tests ordered for women, whether seen in the VA 

or in the community. 

VA recognizes ongoing challenges for women Veterans using VA care and benefits. 

Despite many gains in culture change, women Veterans report feeling less welcome 

at VA than men, and overall do not report high trust in VA. We have launched a 

new campaign to enhance respect of Veterans and to end harassment of women Veterans by other Veterans. The full campaign will roll out it waves throughout this 

year. 

86 

CAREGIVERS

Question 97. As I have long believe, you stated in your meeting with me on Tuesday that the Caregivers program may actually be cost effective. However, you also 

stated that it would cost $3 billion annually in your answer to my pre-hearing questions. When we discussed this further you said that you would be interested in 

doing a cost-benefit analysis of the Caregivers program, or something similar, to determine if it is a cost effective program for VA to utilize, which could result in the 

actual cost of the program being much less than $3 billion. 

• Do I have your assurance that you will conduct a cost benefit analysis of the 

Caregivers program to determine if it is actually cost effect? Once this analysis is 

complete will you work with CBO to update the estimated costs associated with the 

Caregivers program? 

Response. You have captured our conversation correctly. I do believe that support 

of additional Caregivers, particularly to older Veterans, may be cost-effective. This 

may be especially true in the area of cost avoidance of institutional care. I would 

be very interested in seeing the results of a study that would allow us to make a 

decision regarding the value of expanding the program. Rather than committing to 

a study right now, I would first want to make sure that such a study has not already been done for us to learn from. If not, I would want to speak to our researchers in VA to see if we have the ability to do such a study and if not I would want 

to speak to an outside group to determine the cost, time required and scope of such 

a study. Finally, I would want to confer first with CBO to make sure that we are 

asking the right questions up front to ensure that the results of the study would 

be meaningful to them. 

IMPACT OF INCREASED MILITARY

Question 98. President Trump has said he wants to substantially increase the size 

of the U.S. military, with an addition of 60,000 active duty soldiers, an unspecified 

number of additional sailors to man the 78 naval vessels he would like to build, another 12,000 Marines, and additional personnel to man at least another 100 combat 

aircraft for the Air Force. These servicemembers will one day become veterans who 

will rely on VA to provide them timely access to the benefits and care they earned 

through their military services. A Brown University study showed that the cost of 

caring for veterans peaks 30 to 40 years after a conflict has ended, and that future 

costs associated with the Iraq and Afghanistan veterans will likely be between $600 

billion and $1 trillion. If President Trump is serious about increasing the size of our 

military, he must also be serious about providing resource to VA to ensure that all 

veterans can access the services and benefits they have earned in a timely matter. 

a. How are you preparing VA so it can afford the impending influx of veterans 

from the Iraq and Afghanistan wars? 

Response. As Secretary McDonald stated in testimony from FY 2017 budget hearings, forty years after the Vietnam War ended, the number of Vietnam Era Veterans 

receiving disability compensation has not yet peaked. VA anticipates a similar trend 

for Gulf War Era Veterans, only 27 percent of whom have been awarded disability 

compensation. As the demand for benefits and services from Veterans of all eras 

continues to increase, VA will ensure budget requests to Congress reflect the necessary resources to handle influxes in workload and benefit payments. 

b. Have you had conversation with President Trump about the possibility of increased funding for VA concurrent with the increase in the number of servicemembers? If not, do I have your assurance that you will have periodic conversations 

with President Trump if funding shortfalls continue to impact VA’s ability to provide benefits? 

Response. I have not had this conversation with President Trump. VA will continue to coordinate with the White House as well as DOD leadership to ensure 

workload forecasts and funding requests reflect the latest information available regarding separating Servicemembers. This ongoing coordination will ensure VA and 

Veterans are not impacted by a funding shortfall. If confirmed as Secretary, I would 

commit to raising issues to the President that impact on our ability to deliver necessary services to our veterans. 

HOMELESSNESS

Question 99. You stated in your response to a pre-hearing question that you believe the current spending levels for key programs that combat homelessness among 

our veterans, particularly HUD-VASH and Supportive Services for Veterans and 

Families, are sufficient to address this serious issue. 

87 

However, the Department of Housing and Urban Development estimates that 

nearly 40,000 veterans are homeless on any given night. • Can you please explain how there is no need for additional resources to address 

veteran homelessness with so many of our veterans sleeping in the streets each 

night? Response. The 2017 President’s Budget includes $1.6 billion for VA programs that 

prevent or end homelessness among Veterans including funding for case management support for the nearly 80,000 existing Housing and Urban Development-VA 

Supportive Housing (HUD-VASH) vouchers, grant funding for community-based prevention and rapid rehousing services provided through the Supportive Services for 

Veteran Families (SSVF) program, clinical outreach and treatment services through 

Health Care for Homeless Veterans (HCHV), service intensive transitional housing 

through the Grant and Per Diem (GPD) and prevention services to justice involved 

Veterans in the Veteran Justice Program (VJP); and employment supports in Homeless Veterans Community Employment Services (HVCES). 

We believe that through prevention and housing retention efforts that our current 

capacity allows us to provide we will be able to continue to reduce the inflow of veterans becoming homeless or returning to homelessness. Those Veterans who are 

currently homeless often require enhanced efforts at engagement and support to 

help them achieve housing. The reduction in the overall number of homeless Veterans allows us to re-direct the services and programming to those more complex 

Veterans with greater needs. We believe we have the capacity to do this within our 

current programming while continuing to decrease the number of Veterans identified in our PIT counts. We do, however, need to ensure that funding levels are sustained so that communities can meet the goal of ending Veterans homelessness, and 

once there, they will be able to sustain it and not jeopardize the progress to date 

or recreate the levels of homelessness among Veterans prior to the investment. 

EDUCATION

Question 100. Throughout my time in the Senate, protecting our servicemembers 

and veterans enrolled in higher education has been one of my top priorities. Unfortunately, our military students and their families have not always been treated well 

by their colleges and student loan servicers. One such company was ITT Educational Services, Inc., (‘‘ITT’’) which closed last September after enforcement actions by the Department of Education. ITT had been subject to investigations by numerous state attorneys general, the Securities and Exchange Commission, the Department of Justice, and the Consumer Financial Protection Bureau for illegal recruitment practices, scamming students into taking out expensive private loans, and 

other misconduct. According to data provided to my office by the Workforce Training 

& Education Coordinating Board, there were approximately 215 veteran students in 

Washington State enrolled in ITT programs at the time the school abruptly closed. 

I want to make sure that we do everything we can to avoid putting our veterans 

at risk for future abuses by unscrupulous actors. Do you commit to withdrawing 

program approval for GI Bill Benefits when an institution of higher education is 

found by any other Federal or state entity to have committed fraud, including deceptive or misleading recruitment? 

• If confirmed, will you commit to working with other Federal agencies to crack 

down on ‘‘bad actor’’ colleges that deceive veterans? 

Response. Yes. We have already forged and continue to strengthen relationships 

focused on enforcement with the FTC, DOD, Dept of Education, Consumer Financial 

Protection Bureau, and DoJ. Additionally we are collaborating on these issues with 

the State Approving Agencies. 

Question 101. As you may know, our financial aid rules permit for-profit colleges 

to receive up to 90 percent of their total revenue from Federal aid, which is known 

as the ‘‘90/10’’ rule. However, a loophole in Federal law does not technically ‘‘count’’ 

educational programs for veterans and servicemembers, including Post-9/11 GI Bill 

benefits and Military Tuition Assistance, as ‘‘Federal aid.’’ These benefits are therefore excluded from the 90 percent cap. I am very concerned that this loophole drives 

unnecessarily aggressive marketing and recruitment of our military students and 

their families. But regardless of whether you share my opinion on whether Congress 

should close this loophole, I hope we can agree on the facts. 

• Do you consider Department of Veterans Affairs Post-9/11 GI Bill, and Department of Defense Tuition Assistance benefits, both of which are paid for by American 

taxpayers, to be Federal aid? 

Response. Yes 

Question 102. Last year, the Department of Education worked with the Department of Veterans Affairs to publish full estimates on the amount and percentage 

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of VA and DOD funding that is received by institutions of higher education from 

each Federal educational program, including Post-9/11 GI Bill benefits and Military 

Tuition Assistance. I had been pressing for some time for this data to become publicly available as a useful tool to know which institutions have a healthy level of 

outside, non-Federal investment. • Do you believe this is important consumer information for the U.S. Department 

of Education to continue making available to our veterans and servicemembers? 

Response. Yes as it provides quantifiable impact of any proposed changes to the 

90/10 rule. 

Question 103. I believe it is essential to ensure that student veterans have the 

resources they need to succeed in their educational pursuits. 

a. Do you believe that veterans who were attending a school that closed before 

they could complete their education deserve to have their eligibility for GI Bill benefits restored, just like students who receive Pell Grants and student loans? 

Response. VA has supported proposed legislation (S. 2253) that would reduce the 

negative impact on student Veterans and their dependents of abrupt school closure 

to include some amount of entitlement restoral. 

b. Additionally, do you believe that student veterans who are using their GI Bill 

benefits when their school closes should see their living stipends extended for at 

least a short period? 

Response. VA has supported legislation (S. 2253) that would provide a limited continuation of the housing stipend in cases of abrupt school closure. 

Question 104. The conflicts in Iraq and Afghanistan have led to a tremendous 

number of veterans returning home to get an education using their Post-9/11 GI Bill 

benefits. But unfortunately, as noted by former Consumer Financial Protection Bureau official Holly Petraeus, many colleges see these veterans as nothing more than 

a ‘‘dollar sign in uniform.’’ 

In the last few years, the Department of Veterans Affairs, Defense, Education, 

and the Consumer Financial Protection Bureau have begun to implement Executive 

Order 13607, Establishing Principles of Excellence for Educational Institutions 

Serving Servicemembers, Veterans, Spouses, and Other Family Members. The 

‘‘Principles of Excellence’’ allow the VA to make law enforcement referrals to crack 

down on bad actors, particularly for-profit colleges, like Corinthian and ITT. • If confirmed as VA Secretary, will you support the law enforcement community 

by following the Principles of Excellence and actively making referrals to other 

agencies in order to protect veterans and curb waste and abuse of education benefits 

provided by taxpayers? 

Response. Yes, VA already has and will continue to refer schools and incidents 

to other Federal agencies to ensure compliance with all applicable laws and regulations. 

LGBTQ

Question 105. When Vice President Mike Pence was running for Congress in 2000, 

his website included multiple statements that are shamefully discriminatory against 

the LGBTQ community. In addition to opposing gay marriage and anti-discrimination laws that protect LGBTQ individuals, a section of his website included a statement that has been interpreted as an endorsement of conversion therapy, a discredited practice that falsely purports to change a person’s sexual orientation or gender 

identity. While Vice President Pence has denied this accusation, I remain deeply 

concerned about this Administration’s treatment of LGBTQ individuals. • If confirmed as VA Secretary, can you assure me that you will never deny care 

to any veteran on the basis of his or her sexual orientation or gender identity? 

• Can you further assure me that you will continue to protect LGBTQ employees 

from discrimination based on their sexual orientation or gender identity? 

Response. I am committed to diversity and inclusion in both patient care and the 

VA workforce. In fact, VA is among the leaders in the Federal Government in the 

area of LGBT protections. With respect to Veteran patient care, on July 1, 2014, 

VHA issued a policy memorandum ensuring that all our LGBT Veteran patients receive quality and respectful patient care, ‘‘in an environment and culture that is informed, welcoming, and empowering for the LGBT Veterans and families whom we 

serve.’’ The specific guidance on care for transgender Veterans can be found in VHA 

Directive 2013–003: Providing Health Care for Transgender and Intersex Veterans. 

VHA also established an Office of Health Equity to address the different and specific health care needs of diverse populations, including the LGBT community. To 

ensure that these services are delivered by culturally competent health care providers, VA has had a longstanding commitment and explicit policy protecting all of 

its employees from discrimination and harassment on the basis of gender identity 

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and sexual orientation, long before these protections became embedded in Federal 

policy or law. We complement these policy protections with mandatory and elective 

EEO, cultural competency and unconscious bias training in the area of LGBT 

awareness for all our employees, including health care providers and supervisors. 

The VA is close to issuing a Transgender Employee Workplace Transition Guidance 

as a resource for our employees to address these issues appropriately and sensitively 

in the VA workplace; I will ensure this gets published. I commit to you that VA will 

continue to support these and other protections for our LGBTQ Veterans and employees. 

ACA 

Question 106. Dr. Shulkin, I am deeply concerned about the impact that dismantling the Affordable Care Act may have on our veterans. A study released last September by the Urban Institute found that the ACA’s combined coverage expansions 

reduced the uninsured rate among non-elderly veterans by 42 percent. The number 

of non-elderly veterans without health insurance has declined from 12 percent in 

2013 to 8.6 percent in 2014 as a result of the ACA. If ACA is repealed without a 

comprehensive replacement plan the most likely scenario at this time is that many 

veterans currently insured through the ACA will turn to VA for health care. 

• As Republicans rush to rip apart the civilian healthcare system by repeal, increase uncompensated care at rural hospitals, threaten to gut Medicaid and take 

away the guarantee of full coverage under Medicare, what conversations have you 

been a part of to ensure no veterans lose health insurance? 

• During your confirmation hearing you said that VA will do all it can to care 

for all veterans; could you provide specific answers to how, if confirmed, you will 

handle a possible increase in the number of veterans seeking VA care if they lose 

coverage through ACA repeal? 

Response. The Urban Institute’s analysis of 2011–2015 American Community Survey data that noted a decline in the number of uninsured Veterans between 2013 

and 2014 is encouraging news for efforts to promote Veteran’s access to care. Within 

this context, it is possible that both the ACA and VA’s outreach to encourage enrollment in the VA health care system contributed to this reported decline in uninsured 

Veterans. Regardless of future national health reform policies, the VA will continue 

to plan for providing high quality health care to our Nation’s Veterans that are eligible for VA health care services. If more Veterans seek care in VHA as a result 

of an ACA repeal or any other reason, as Secretary I would seek the resources necessary to make sure we honor our commitment to serve these Veterans. 

SEXUAL ASSAULT

Question 107. Sexual assault continues to be a pervasive issue in our military. Reports suggest that as many as 1 in 10 servicemembers experience sexual assault or 

harassment. In 2014, 62 percent of those who reported they were assaulted also said 

they experienced retaliation. While the Department of Defense has undergone commendable efforts to tackle this distressing problem, we have a long way to go to ensure that the brave men and women in our military are provided the resources they 

need, and VA plays an integral role in supporting survivors of sexual assault. 

• If confirmed as VA Secretary, what specific steps will you take to ensure that 

survivors of sexual assault and harassment receive the specialized care they need 

and are entitled to? 

Response. All Veterans seen for health care services are screened for experiences 

of MST (sexual assault or repeated threatening sexual harassment). This is an important way to ensure that Veterans are aware of and offered the free MST-related 

care available through VHA. Every VA medical center provides MST-related services including evidence-based psychotherapies that target the mental health diagnoses that are associated with MST. MST is an experience, not a diagnosis or a condition in and of itself. Every VA medical center has a designated MST Coordinator 

who can assist Veterans with accessing MST-related health care. Beginning in FY 

2012, VHA mental health and physical care providers must complete a one-time 

mandatory training that is accredited for continuing education. The MST Support 

Team in Mental Health Services coordinates a wide range of other national specialized MST-related training initiatives for VHA clinicians. 

Question 108. During your time as President of Morristown Medical Center you 

withdrew counselors from Morris County Sexual Assault Center, which provided important resources to survivors. In an Op-Ed concerning this decision you suggested 

that ER services would be adequate. 

• If confirmed, will you commit to putting all the resources necessary to support 

survivors of sexual assault in the military, including ensuring that survivors have 

access to counseling services to treat long-term trauma? 

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Response. Your statement about what happened at Morristown is not accurate. 

I would be glad to discuss the specific circumstances with you at the appropriate 

time, but the facts show that when I learned about this I restored these services. 

In regards to your question, the MST Support Team in Mental Health Services completes an annual report to determine whether each VA health care system (HCS) 

has adequate capacity to provide MST-related care. The most recent report found 

that 100 percent of VA HCS were at or above the established benchmark for MSTrelated mental health staffing capacity. All Veterans seen for health care services 

are screened for experiences of MST (sexual assault or repeated threatening sexual 

harassment). This is an important way to ensure that Veterans are aware of and 

offered the free MST-related care available through VHA. Every VA medical center 

provides MST-related services including evidence-based psychotherapies that target 

the mental health diagnoses that are associated with MST. The VA offers a continuum of MST-related care that ranges from outpatient to mental health rehabilitation and treatment programs (MH RRTPs) and inpatient programs for Veterans who 

need more intense treatment and support. 

MEDICAL LEGAL PARTNERSHIPS

Question 109. Research indicates that genetics, medical care, and personal choices 

account for 40 percent of an individual’s health outcomes while 60 percent of health 

outcomes are determined by social and environmental factors. This is particularly 

true for veterans who often face barriers to safe housing, benefits appeals, and employment that negatively affect their health. The VA’s annual CHALENG survey of 

homeless veterans has shown that four of homeless veteran’s top 10 unmet needs 

are legal needs including eviction and foreclosure issues, child support and family 

law, outstanding warranties and fines, and restoring drivers’ licenses. Medical-legal 

partnerships (‘‘MLPs’’) between legal services and medical providers can help to address these issues by integrating legal solutions into medical settings. 

• In recognition of the importance of MLPs, the VA recently launched the MLP 

Expansion Initiative to expand the number of MLPs in VA sites in order to identify 

and identify veterans’ legal needs that effect health outcomes and to improve physician quality of care. If confirmed as VA Secretary, will you commit to continuing 

the MLP Expansion Initiative to increase veterans’ access to legal services in VA 

facilities? 

Response. Medical-legal partnerships (MLPs) allow VA to help Veterans address 

not only their health-related needs but also their health-harming legal needs, by 

providing access to legal services that VA itself cannot offer. There are now 13 

MLPs in VA facilities, and I am committed to fostering such partnerships elsewhere 

in our health care system. The VA MLP Expansion Initiative will therefore continue 

its work on this important issue. 

• VHA Directive 2011–034 encourages VA medical centers to make space available for legal services providers to assist veterans. Approximately 120 legal pro bono 

clinics staffed by outside legal providers are currently given space to operate in VA 

centers. Do you commit to keeping VHA Directive 2011–034 in place? What additional steps will you take to ensure veterans have access to legal services, to support 

existing MLPs, and to create new partnerships between health facilities and legal 

service providers? 

Response. VHA will soon issue a new directive to replace the expiring VHA Directive 2011–034. This new directive will restate VHA’s commitment to facilitating Veterans’ access to legal services, and provide expanded operational guidance to VA facilities. It is in the final stages of pre-publication review in VHA, and once released 

it will guide VHA’s continued efforts to assist Veterans with unmet legal needs. Although VA does not have the authority to provide or fund legal services, we will 

continue to seek out and develop new partnerships to improve Veterans’ access to 

needed legal services. 

CERTIFIED REGISTERED NURSE ANESTHETISTS

Question 110. In your response to pre-hearing questions, you recognized workforce 

shortages at VA and promised to continue pursuing strategies to meet such gaps, 

which included expanding the scope of practice for advanced practice registered 

nurses. On December 14, 2016, VA issued the final rule providing full practice authority for advanced practice registered nurses with an effective date of January 13, 

2017. However, the final rule excluded Certified Registered Nurse Anesthetists 

(CRNAs) from receiving full practice authority, which the draft rule did not. This 

is despite supportive evidence in favor of full practice authority for CRNAs in research journals and recommendations from numerous independent entities, including the Commission on Care. Additionally, the exclusion of CRNAs from the VA 

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final rule is inconsistent with the full practice authorities that exist in other Federal 

health care systems in the military and the Indian Health Service. I understand 

that VA’s rationale behind excluding CRNAs from the final rule was that there is 

no shortage of anesthesia providers in the VA system. However, a RAND study commissioned by this Committee published in 2015 found that a lack of anesthesia services and support directly affects VA’s ability to provide care. It seems like the research evidence, recommendations from independent entities, and policies of Federal 

health systems outside VA should have been sufficient to include CRNAs in the 

final rule, which I fully support. • Can you please provide a comprehensive explanation as to how you came to the 

conclusion you did, including fully identifying and explaining the criteria you used 

for providing APRN full practice authority and how this criteria was applied equitably across the four APRN categories? • Will you commit to revisiting VA’s rule on nursing full practice authority to further assess whether CRNAs should be included if confirmed? 

Response. I appreciate your point of view on this issue. VA first began to look at 

changing its’ policy on advanced practice nurses over 9 years ago. As Under Secretary I committed to making a decision and I did so. We have received hundreds 

of thousands of comments and I have personally taken dozens of meetings and sessions to hear people thoughts and input on this topic. I tried to make the best decision I could at the time, with the information I had available. 

The truth is that I believe CRNAs play a critical role in providing care for our 

Veterans. In fact we hire at VA many more CRNA’s than we do anesthesiologists. 

We also believe that it is a team based approach to anesthesia care that serves our 

Veterans best, with the best outcomes. A team based approach to care includes 

CRNA’s working with anesthesiologists. In making our final rule, we did not find 

that VA had immediate and broad access challenges in the area of anesthesia that 

would require a change to our current approach to anesthesia care, that is a team 

based approach. If VA learns of access problems in the area of anesthesia care in 

specific facilities or more generally that would benefit from FPA for CRNA’s, now 

or in the future, or if other relevant circumstances change, we will consider a followup rulemaking to address granting FPA to CRNAs. VA CRNAs that are granted full 

practice authority by their state license will continue to practice in VA in accordance 

with their state license and subject to credentialing and privileging by their VA 

medical facility’s medical executive committee. VA will not restrict or eliminate 

these CRNAs’ full practice authority. Amending this regulation increases VA’s capacity to provide timely, efficient, and effective primary care services, as well as 

other services. This increases Veteran access to needed VA health care, particularly 

in medically-underserved areas and decreases the amount of time Veterans spend 

waiting for patient appointments. 

SMOKING

Question 111. As a physician, I’m sure you know that smoking poses a significant 

threat to the health of our veterans, in addition to costing the VA healthcare system 

billions of dollars every year. You may also be aware that over half of current smokers (57%) report that they had tried quitting within the past year and, according 

to the Centers for Disease Control and Prevention, as of 2010 nearly 70% of adult 

smokers wanted to quit. 

• If confirmed as VA Secretary, what policies and practices will you put in place 

to ensure that all veterans have affordable and comprehensive access to the help 

they need when they want to quit? 

Response. VA is a leader in smoking and tobacco use cessation treatment with a 

range of evidence-based interventions. Today, the smoking rate of Veterans in VA 

care is 16.8%, the lowest ever and a 49% decrease from fiscal year 1999. VA is committed to maintaining current programs and to build on their success through the 

development and implementation of new innovative treatment models that will ensure that any Veterans who want assistance with quitting smoking will receive comprehensive and effective care. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. SHERROD BROWN TO

HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 112. For-profit colleges are able to leverage the Higher Education Act’s 

90/10 loophole to go after veterans with GI Bill benefits, using those funds to compensate for the gap these institutions face due to a lack of Federal fund. 

a. Do you support closing the 90/10 loophole? 

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Response. While VA defers to the Department of Education on the 90/10 calculation, I am supportive of including the Post-9/11 GI Bill in the 90 percent limit on 

Federal funding or related proposals. Under the present structure, some institutions 

may be targeting Veterans because the Federal education benefits they receive are 

treated the same way as private funds in the 90/10 calculation. 

Modifications to the 90/10 rule could provide additional tools to assist in this area. 

However, it is understood that such a change could cause some schools to exceed 

the 90 percent threshold and be at risk of losing eligibility to receive Federal student aid. Therefore, in order to ensure that Veterans are not adversely affected, the 

manner in which such a change would be implemented is important. VA would welcome the opportunity to work collaboratively with the Department of Education and 

Congress as it considers changes in this area. 

b. What actions are you prepared to take to ensure VA’s compliance with 38 

U.S.C. 3969? 

Response. The VA Education Service is postured to formally request the Secretary 

to leverage his authorities outlined in the public law when an institute of higher 

learning (IHL) is in violation of the law.VA has recently made two referrals to FTC 

for potential violations of section 3696. 

c. What is your plan to hold colleges accountable to properly using the GI Bill benefits veterans sacrificed for? 

Response. VA will continue to work with all State Approving Agencies and our 

Federal partners to ensure compliance and enforcement of all GI Bill statutory and 

regulatory requirements. 

d. What is your strategy for communicating to colleges the standards for compliance with the VA Advisory Committee on Education’s VA Principles of Excellence 

initiative? 

Response. Since the inception of the Principles of Excellence (POE) in 2012, the 

standards for compliance with POE are communicated to the institutes of higher 

learning via the VA GI Bill web site and reviewed during the over 5000 annual compliance visits with schools. 

e. Please outline your plan to collaborate with other Federal entities to address 

colleges that take advantage of veterans and their benefits. 

Response. We have developed strong relationships with the Department of Education, Federal Trade Commission, Department of Justice, Department of Defense, 

Consumer Financial Protection Bureau and VA’s Office of Inspector General. Regular meetings are ongoing and as needed virtual communications are leveraged as 

warranted. In 2017, VA will further strengthen these collaborations in order to ensure schools that engage in any activities that negatively impact our student veterans are addressed appropriately and in accordance with applicable laws and regulations. These include but are not limited to deceptive marketing, deceptive recruiting, and accreditation of IHL programs and schools. 

Question 113. How will you implement the Career Ready Student Veterans Act, 

legislation aimed at blocking GI Bill benefits going to programs that, due to lowquality or lack of accreditation, do not result in veteran-graduates earning state certifications and licenses? 

Response. The State Approving Agencies, who are charged with enforcing the requirements for initial and continued GI Bill program approval, will be at the forefront of the implementation effort, as they have expertise in GI Bill approval requirements and state licensure and certification requirements. VA has had a number of discussions with the State Approving Agencies (SAAs) on these new provisions and we are currently in the process of drafting guidance. Both VA and the 

SAAs strongly believe that vocational and occupational programs should meet the 

requirements in the state in which the educational institution is located so that GI 

Bill beneficiaries are well-prepared upon completion of these programs. 

Question 114. As Governor of Indiana, Vice President Pence wrote to VA officials, 

including Secretary McDonald, urging the Department to compensate student veterans for lost GI Bill benefits used at shuttered ITT Tech and Corinthian College 

locations. These student veterans were taken advantage of by institutions looking 

to profit from their sacrifice. 

a. How will you ensure that these veterans’ GI Bill benefits are restored? 

Response. Currently, VA does not have the statutory authority to restore a student’s GI Bill benefits due to a school closure. VA has provided technical assistance 

to Congress on draft legislative language that would allow for such benefit restoration and will continue to provide any additional assistance that may be needed. 

b. Do you believe that when VA and other Federal entities designate that an institution of higher education displays signs of instability? If so, what is your plan to 

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communicate to student veterans when an institution shows such potential, as ITT 

Tech and Corinthian Colleges did prior to their closing? 

Response. VA uses a web based Comparison Tool with an appropriate Caution 

Flag to make student Veterans aware of indicators VA or other Federal agencies 

have determined potential students should pay attention to and consider before enrolling in a program of education. The VA is also very proactive in sending emails 

to individual students attending such institutions which explain the potential impact to their education benefits. For example VA has sent six different email communications to ITT students providing information and resources to assist them. 

Question 115. Knowing the risks posed by colon cancer, the second-most common 

cause of death from cancer for men and women collectively, and the opportunities 

for patients through early screening and detection, will you ensure that all available 

colorectal cancer screening methods endorsed by the U.S. Preventative Services 

Task Force are employed to serve the healthcare needs of veterans? 

Response. Yes I will. The VHA is proud to have just received an achievement 

award from the National Colorectal Cancer Roundtable for surpassing an 80% 

screening rate for colorectal cancer (http://nccrt.org/tools/2017–80-by–2018-nationalachievement-awards/). However, we are continuing efforts to further expand screening and to ensure appropriate and rapid follow up of every Veteran. Specifically, we 

have developed and are deploying an IT tool to automate the reminder for the appropriate screening and tracking of every veteran. VA is currently updating its recommendations for colorectal cancer screening and is carefully considering the recommendations of the U.S. Preventive Services Task Force. 

Question 116. In your testimony you said that VA needs to be able to hold its employees accountable. What did you mean by that, and what metrics would you use 

to hold employees accountable? 

Response. I know that the vast majority of the VA workforce is highly professional 

and motivated to take care of our Veterans. There are times when employees get 

off track and need help in either getting back on track or moving out of the VA. 

While we already have and leverage existing laws to help move off track employees 

out of the workforce, additional legislation is needed. More specifically: 

• The Choice Act VA needs to be modified, specific to SES removal procedures, 

to ensure constitutionality. 

• The Merit Systems Protection Board needs to be directed to a lower burden of 

proof and deference to the agency’s choice of penalty. 

• We need the authority to use indefinite suspensions where there is reasonable 

cause to believe an employee has done something to harm or endanger a patient 

or a coworker. 

• 5 U.S.C. 7511(a)(1)(A), (B), and (C) and 5 CFR 752.401(2), (3) and (5) need to 

be modified to allow those individuals serving a probationary period or on a temporary appointment to be separated without full due process and appeal rights. 

Question 117. Last December, ProPublica and The Virginian-Pilot issued a report, 

based on data gathered from VA’s Agent Orange Registry, which assess that children born to servicemembers who had self-reported Agent Orange exposure during 

or after the Vietnam War were 34 percent more likely to have a birth defect than 

children born to servicemembers who had not self-reported exposure. 

a. On Tuesday I received a response from VA-that you signed and your letter said 

VA recommended to ProPublica that the report be peer reviewed, but my question 

to you is if VA had been collecting this information for over 40 years, why didn’t 

VA initiate its own study? 

Response. As was mentioned in the letter ‘‘a voluntary registry such as the Agent 

Orange Registry, may have bias, or a systematic deviation, that results if those who 

volunteer are not representative of the entire population of concern.’’ Any research 

based on or conclusions drawn from this flawed dataset are immediately suspect for 

this reason. Desiring quality data and study design, VA has initiated the Vietnam 

Era Health Retrospective Observational Study (VE-HEROeS). 

b. Why did it take a FOIA request to produce a study on data that VA already 

had at its finger tips? 

Response. As stated above, the voluntary Agent Orange Registry did not provide 

a quality data set for research. VA has initiated the Vietnam Era Health Retrospective Observational Study with the aim to aim to develop scientific, peer-reviewed 

evidence that will inform policy decisions. 

c. What is the timeline for VA’s Agent Orange working group to review whether 

to include bladder cancer, hypothyroidism, Parkinson’s-like symptoms, and hypertension to the list of presumptive conditions? 

94 

Response. A VA Technical Working Group has reviewed the National Academy of 

Medicine’s Veterans and Agent Orange, Update 2014 and is in the process of drafting recommendations for the Secretary of Veterans Affairs. 

d. I know VA has had the information from the Agent Orange Registry for years, 

yet VA says more research is needed, particularly from male servicemembers. These 

veterans and their families have waited too long for VA to do the right thing. Is 

the only reason VA isn’t acting because of funding? 

Response. VA relies on scientific, peer-reviewed evidence to inform policy decisions, and such evidence for transgenerational effects due to Agent Orange exposure 

does not currently exist, as reported in the most recent Veterans & Agent Orange 

Report issued by the National Academy of Medicine. However, VA continuously 

monitors the development of new scientific approaches that may provide additional 

insight. 

Question 118. Many of the issues veterans face as they transition from active duty 

into the community is because of a lack of connectivity and collaboration between 

the Department of Defense and VA. 

a. What steps would you take as Secretary to fix this? 

Response. The Departments of Veterans Affairs (VA) and Defense (DOD) partner 

with other agencies to administer the Transition Assistance Program. This interagency cooperation provides coordinated information, counseling, and support to 

transitioning Servicemembers. This includes one-on-one counseling with military 

service representatives experienced in the transition process, enhanced VA benefits 

briefings that are designed to provide individuals with information about education 

and employment programs; training vehicles on VA benefits and services that can 

improve a transitioning Servicemembers’ overall quality of life, as well as, overviews 

of other benefits to assist in building and maintaining a stable home environment. 

VA and DOD have developed a robust relationship to improve the experience for 

separating Servicemembers as they transition into civilian life. Under the auspices 

of the Joint Executive Committee, which provides senior leadership a forum for collaboration and resource sharing, both departments have worked closely to remove 

barriers and challenges that impede collaborative efforts, assert and support mutually beneficial opportunities to improve business practices, ensure high quality costeffective services for VA and DOD beneficiaries, and facilitate opportunities to improve resource utilization. As Secretary, I will work to strengthen the role of the 

Joint Executive Committee as it provides the strategic direction for the joint coordination and sharing efforts between the two Departments and oversees the implementation of those efforts. 

b. Will you make the single electronic health record from active duty to VA a priority? 

Response. Yes, we continue to make this a priority. We are actively exploring a 

few ways to accomplish this. The recent development of a prototype of the Digital 

Health record has created a new opportunity to make this a cost-effective mechanism to accomplish this. 

Question 119. In 2010, the Federal Government adopted Opening Doors: The Federal Strategic Plan to Prevent and End Homelessness. Opening Doors set out goals 

for ending homelessness for families and youth, the chronically homeless, and veterans. Through a combination of increased Federal investment—in both HUD-VASH 

vouchers and VA programs—and better practices, the Federal Government has 

made significant progress toward that goal. Since 2010, we’ve reduced homelessness 

among veterans by 47 percent. 

But more needs to be done to ensure that no veteran is homeless. Last year, Congress enacted key provisions from the Veterans Housing Stability Act of 2015, which 

I cosponsored, to keep moving us toward this goal. Among other things, the bill 

would increase veterans’ access to permanent housing options by increasing outreach to landlords to encourage renting to veterans and expand the definition of 

‘‘homeless veteran,’’ so more veterans, including those facing domestic abuse, can access housing assistance. 

If confirmed, will you work expeditiously to implement these provisions? 

Response. Yes. The Jeff Miller and Richard Blumenthal Veterans Health Care Act 

and Benefits Improvement Act of 2016, Public Law 114–315, was signed into law 

on December 16, 2016. Section 701 of this Act expands the eligibility to participate 

in the GPD program to persons fleeing domestic violence and interpersonal violence. 

VHA is working to incorporate the statutory changes as they relate to eligibility 

under the GPD program as quickly as possible following the standard agency protocols for inclusion of new statutory elements and notification to the field. Additionally, Our HUD-VASH regulations further define homeless as any individual or family who is fleeing or is attempting to flee domestic violence, dating violence, sexual 

95 

assault, stalking, or other dangerous or life-threatening conditions in the individual’s or family’s current housing situation, including where the health and safety 

of children is jeopardized and who have no other residence and lack the resources 

or support networks to obtain other permanent housing. 

Regarding outreach to landlords, VA in partnership with HUD and the United 

States Interagency Council on Homelessness (USICH) have embarked on a coordinated outreach effort to engage and recruit landlords, and the trade and professional associations to which they belong to provide affordable housing for Veterans 

exiting homelessness. The goal is an increased willingness to work with government 

and community providers to help these Veterans locate and maintain permanent 

and permanent supportive housing. 

Question 120. Are you familiar with Opening Doors? If confirmed, will you commit 

to requesting the resources and pursuing policies necessary to achieving the goal of 

ending veterans’ homelessness? 

Response. Yes, Opening Doors is the Federal Strategic Plan to Prevent and End 

Homelessness among all populations—Veterans being a priority sub-population. I 

am proud to say that since its inception in 2010, Veteran homelessness has decreased by nearly fifty percent—far more than any other sub-population. One reason 

for this significant decrease has been the targeted resources that have been appropriated to combat Veteran homelessness. The 2017 President’s Budget includes $1.6 

billion for VA programs that prevent or end homelessness among Veterans. These 

funds are critical to ensure that once communities meet the goal of ending Veterans 

homelessness they will be able to sustain it and not jeopardize the progress to date 

or recreate the levels of homelessness among Veterans prior to the investment. I 

will continue to request appropriate levels of funding to ensure that Veteran homelessness is rare, brief, and nonrecurring. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT

OF VETERANS AFFAIRS

Question 121. Improper Accreditation of schools and use of regulations in VA. 

During the hearing, I asked about implementation of the unanimously passed Career-Ready Student veterans Act and you committed to implementing that law. 

a. To the extent that such implementation requires the use of regulations, how 

will you comply with President Trump’s recent executive order requiring the elimination of two regulations for every new regulation that is promulgated? 

Response. The Career-Ready Student Veterans Act as enacted is now Section 409 

of the Jeff Miller and Richard Blumenthal Veterans Health Care and Benefits Improvement Act of 2016. There are many elements of this part of the law that can 

be implemented without regulations. However, where regulations are needed, we 

will work with the Director of the Office of Management and Budget to navigate 

the process. I am committed to implementing the Career Ready Student Veterans 

Act. 

b. Do you believe that Executive Order will impact your ability to run VA, which 

has used the regulatory process to provide care to veterans? 

Response. The Department of Veterans Affairs will certainly have to adjust the 

way we have historically managed our programs through the use of regulations. 

However, I am confident that the VA will continue to accomplish its mission. I also 

look forward to the opportunity to remove some of the outdated and unnecessary 

regulations that do not allow us to best target our resources to those areas that benefit Veterans most. 

Jerry Falwell Jr. has announced that President Trump has asked him to lead a 

White House Task Force on higher education reform. Falwell has been very critical 

of accreditation standards and gainful employment rules that have been required 

by the Obama Administration for schools receiving Federal dollars, including GI bill 

benefits. 

c. If confirmed, will you commit to ensuring GI Bill benefits are used to help veterans attend high-quality schools and then get good jobs or start their own businesses, consistent with recently passed legislation, regardless of what Falwell or 

others might recommend? 

Response. Yes. VA will continue to faithfully enforce the laws applicable to the 

GI Bill benefits. 

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PATIENT SAFETY

Question 122. The Veterans Health Administration has historically been a leader 

in patient safety making its current place on the U.S. Government Accountability 

Office (GAO) High Risk Report as a result of ‘‘risks to timeliness, cost-effectiveness, 

quality and safety of veterans’ health care’’ particularly concerning. Under previous 

leadership, the National Center of Patient Safety reported directly to the Undersecretary for Health, but now it resides in the Office of Quality, Safety and Value. I 

believe it is important that patient safety remains a top priority for the entire Department of Veterans Affairs. 

If confirmed, will you commit to aggressively working to get VA off of the High 

Risk List including resolving all of the issues regarding patient safety at VA that 

GAO identified? 

Response. Yes, as a former chief medical officer and an executive who has always 

focused on quality and safety, I have always prioritized patient safety as the foundation of health care delivery. I feel the same way about care for our Veterans. As 

you know, numerous external assessments, including a report by the RAND Corporation, have reported that VA care matches or exceeds patient safety and quality 

in the private sector. Regardless, patient safety is a pursuit that should always be 

prioritized, and you have my utmost commitment to this. 

One goal that I have in continuing to enhance patient safety is to create a system 

for quality and safety governance that ensures the right resources and policies are 

in place that directly impact front-line clinicians and improvement teams. Regarding 

the placement of the National Center for Patient Safety (NCPS)—which is a support 

structure for leadership and front line teams in facilities—I believe its effectiveness 

is enhanced under a structure that directly connects identified risks for preventable 

harm (the focus of NCPS) with parts of the organization that focus on quality improvement. The Office of Quality, Safety and Value does just that, and you have my 

commitment to support and enhance the structure of this office to meet our needs 

over time. This is consistent with the contemporary approach to patient safety and 

quality in private sector organizations. 

I am committed to addressing all underlying risks (ambiguous policies; fragmented oversight; inadequate information technology; siloed training; and the need 

to enhance allocation of resources to meet Veterans’ needs) identified by the GAO 

when they placed VA Health Care on the High Risk List because this work is imperative to complete the transformation of the Veterans Health Administration. You 

have my full commitment that we will continue our work to remove VHA from the 

high-risk list as quickly as possible. 

INFORMATION TECHNOLOGY AND INTEROPERABILITY

Question 123. If you are confirmed as VA Secretary, you will be responsible for 

both VHA and OI&T. Just yesterday, a VA Office of the Inspector General Report 

released a report on the $2 million that OI&T spent on a cloud brokerage service 

contract that was supposed to all VA employees to access computing resources over 

the Internet on a pay-for-use basis. 

The project, however, provided limited functionality for providing computing resources over the Internet for and the Inspector General also found that VA did not 

have adequate project management controls in place to ensure the contract met VA’s 

IT needs and provided an adequate return on investment. 

a. If confirmed, what will you do to improve return on investment for VA’s IT purchases? 

Response. I have not yet had a chance to review this IG report, but I would agree 

that this is concerning and if confirmed as Secretary I would be looking to see what 

recommendations the IG has made to ensure that issues like this do not occur 

again. It is important that we do better. 

OI&T, through its Strategic Sourcing function, has consolidated its IT purchasing 

power to obtain and deliver solutions to our Veterans from industry at the best 

price. Strategic Sourcing will provide access to best-in-class suppliers; ensure strong 

contractual performance through continuous monitoring; improve our speed to market, product compliance, and quality; ensure our compliance with Federal Information Technology Acquisition Reform Act (FITARA); provide greater technical capabilities for VA and our Veterans; and foster the most responsible allocation of taxpayer dollars. 

b. Do you believe that the Veterans Health Administration and the Office of Information and Technology have made adequate progress in addressing the IT challenges at VHA? 

Response. I believe that progress has been made but we need to do much better. 

The Veterans Health Administration and the Office of Information & Technology 

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continue to collaborate as partners in improving the Health Information Technology 

(HIT) at VA. Through this partnership, VHA has received a number of critical improvements to HIT at VA while recognizing that our work together is ongoing so 

as to keep pace with the needs of VA’s medical providers serving Veterans as well 

as putting modern HIT tools in the hands of Veterans. 

As Secretary, I would be looking for faster decisionmaking and more meaningful 

outcomes for our Veterans. The Commission on Care and the Independent Assessment have made a number of recommendations that require changes in the way 

that we currently operate. I would support an aggressive plan to ensure the necessary changes are implemented. 

c. Are you satisfied with the degree of health record interoperability between DOD 

and VA? 

Response. A Veteran’s complete health history is critical to providing seamless, 

high quality integrated care and benefits. Our interoperability work with DOD and 

the private sector has made great strides and we are working daily to expand on 

our capabilities. On April 2016, VA and DOD were proud to certify to Congress, including this Committee, that VA had met the FY 2014 National Defense Authorization Act (NDAA) interoperability standards. Using the VA/DOD Joint Legacy Viewer 

(JLV), more than 220,000 VA health care and benefits professionals have access to 

real-time electronic health record information on a single screen from all VA, DOD 

and VA external partner facilities where a patient has received care. More than 2.5 

Million records have been viewed in JLV by VA staff. Overall, 1.5 million data elements are currently being shared daily between the DOD and VA. These tools help 

those VA employees delivering health care and as well as those who process disability benefits claims who also need access to a patient’s health record. The VA’s 

Enterprise Health Management Platform (eHMP) incorporates JLV’s capabilities 

and provides even greater interoperability and clinical tools. 

While we did achieve interoperability and we are working on tools that will provide even better integration with DOD, today I am not fully satisfied. We have obtained a read only interoperability and that is not enough in my opinion. 

BAD PAPER DISCHARGES

Question 124. I am also concerned that the warm hand-off between DOD and VA 

that is essential for veterans to get off on the right foot is failing for too many individuals with so called ‘bad paper discharges.’ 

a. If confirmed, will you commit to working with Secretary Mattis to ensure that 

no Veteran falls through the cracks? 

Response. I agree this is very important and yes, I will meet with Secretary 

Mattis on this matter. 

VA has regularly met with the Department of Defense (DOD) to better understand each other’s processes and collaborate to make certain that any proposed 

changes will not have negative unintended consequences for DOD’s discharge process and will continue to do so moving forward. 

I also understand that there was a commitment last year by Sloan Gibson to conduct a rulemaking process regarding VBA’s processes and procedures for character 

of discharge determinations to update the definitions regarding ‘‘moral turpitude’’ 

and ‘‘willful and persistent misconduct.’’ I think taking this step will help things 

greatly for veterans who would otherwise be unable to access VA health care and 

benefits. 

b. Is VA still committed to updating that regulation and if confirmed, will you 

commit to updating the regulation as rapidly as possible? 

Response. VA remains committed to pursuing policy changes to character of discharge (COD) determinations. VA is actively working to update 38 CFR 3.12, the 

regulation governing determinations of former servicemembers’ COD for individuals 

with other than honorable (OTH) and punitive discharges. These changes will address ill-defined terms in the existing regulation, such as ‘‘moral turpitude’’ and 

‘‘willful and persistent misconduct,’’ as well as provide guidance on consideration of 

mitigating circumstances that relate to Veteran status. Given that this proposed 

regulatory update will impact basic eligibility requirements for Veterans benefits, 

VA wants to ensure any proposed rulemaking reflects adequate research and deliberation. VA has already met with the Department of Defense (DOD) to better understand each other’s processes and collaborate to make certain that any proposed 

changes will not have negative unintended consequences for DOD’s discharge process and will continue to do so moving forward. 

Pursuant to the Administrative Procedure Act, rulemaking requires time for public notice and comment, as well as Office of Management and Budget (OMB) review. 

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VA anticipates publishing a proposed rule to update 38 CFR 3.12 by the end of calendar year 2017. 

LONG-TERM CARE

Question 125. Recognizing that VA provides a continuum of care that is unmatched in the private sector, and an increasing number of older and disabled veterans are coming to VA for care. In Connecticut, VA projects the number of veterans 

age 65 or older will be nearly 100,000 this fiscal year. As you know Medicaid is the 

largest single payer of long-term care in the United States and almost half of all 

state Medicaid spending goes to home and community-based services. However, VA’s 

spending for home and community-based services has remained at about 30 percent 

and is perhaps reflective of an intuitional bias toward nursing home care. Aging 

Veterans want the option of living at home with appropriate supports and services. 

a. What will you do as VA Secretary to meet the increasing long-term care needs 

for veterans with serious chronic diseases and disabling conditions? 

Response. I will continue the Department’s focus on optimizing the health, function, and well-being of Veterans facing the challenges of aging, disability, or serious 

illness by honoring their preferences for care by increasing access to home and community based services (HCBS). Since FY 2010, VHA has grown total spending for 

HCBS by 190%, from $810 million in FY 2010 to $2.3 billion in FY 2015. Furthermore, total HCBS spending as a ratio of total Long Term Services and Supports 

(LTSS) spending has almost doubled from FY 2010–2015, from 16% in FY 2010 to 

31% in FY 2015, with commensurate decreases noted in the proportion of the LTSS 

budget spent on nursing home care going from 84% to 69%. 

VA’s efforts to provide long term care in home and community based settings will 

reduce nursing home admissions and preventable hospitalizations. However, we also 

want to ensure access to high quality nursing home care for Veterans when it is 

required through our community living centers, contract community nursing homes, 

and State Veteran Homes. In order to achieve these goals, VA needs Congressional 

support for VA authority to purchase care using provider agreements. 

VA is poised to lead the Nation in the care of older Americans. VHA will continue 

to use data to support efficient and effective growth for home and community based 

services. VHA has recently completed a study that found many additional VHA 

users would benefit from VA’s Home Based Primary Care (HBPC). This program 

has been shown to reduce total VA and Medicare costs by 12%. As a result, VHA 

has initiated efforts to expand HBPC access to meet the additional need for this program. VHA is also committed to expanding the Medical Foster Home Program as 

an alternative to institutional placement. Previous studies have shown that Medical 

Foster Homes can reduce Veteran total health care costs by 40%. In addition, VHA 

is conducting a national study to quantify long term care demand among Veterans, 

with an emphasis on measuring nursing home and HCBS demand and identifying 

rural and highly rural areas in most need of additional access. Findings from this 

study will be available in early 2018 and will be used to guide expansion of home 

and community based services to Veterans in most need of additional supports. 

VHA expanded access to the Veterans-Directed Home & Community Based Services (VD-HCBS) Program in FY 2016. The goal is to make the program available 

at every VA medical center within the next three years. Through VD-HCBS, the 

Veteran has the opportunity to manage a monthly budget based on functional and 

clinical need, hire family members or friends to provide personal care services in 

the home, and purchase goods and services that will allow him or her to remain 

in the home. VD-HCBS is administered through a partnership with Health and 

Human Services Administration for Community Living (ACL) and has proven to be 

a program that can meet the needs of some of VA’s most vulnerable populations, 

including many who would likely be placed in nursing home without this option. 

The number of Veterans served increased from 1,281 to 1,751 in FY 2016, a 37% 

increase. 

VHA’s ability to enhance and grow access to VD-HCBS has been greatly enhanced 

by changes in the Veterans Choice Program. In FY 2016, 81 VD-HCBS Providers 

have entered into VA Choice Provider Agreements with VAMCs offering VD-HCBS. 

Additionally, 30 new VD-HCBS Providers have been approved to deliver VD-HCBS 

services to Veterans, which has expanded access to HCBS for Veterans in over 130 

rural and highly rural counties. VHA plans to focus on increasing VD-HCBS access 

in rural and highly rural areas where there is limited supply of traditional home 

care agencies that meet VA requirements to participate in the Veterans Choice 

Program. 

VHA will continue to implement effective strategies based on measuring Veteran 

need for increased access to HCBS, creating an appropriate balance of HCBS and 

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nursing home care, ensuring Veterans needing long term care are able to stay in 

the own homes for as long as possible. VHA will monitor progress of VISNs toward 

meeting performance measures that focus on rebalancing long term care. VHA will 

also continue to increase access to HCBS, primarily through expansion of HBPC and 

VD-HCBS, while leveraging opportunities under the Veterans Choice Program. 

b. Have you considered how any efforts to restrict Medicaid, either through block 

granting or increasing requirements for eligibility, would impact veterans who may 

rely on Medicaid for long-term care or other health care needs? 

Response. It is unclear what impact any such changes would have on Veterans 

needing long term care or other health care needs. As reforms are pursued, VA will 

need to evaluate the implications carefully and keep Congress informed of our 

findings. 

c. Do you believe VA is prepared to step in and provide care that would not be 

available to veterans if Medicaid is block granted? If so, what is currently being 

done with that excess capacity? 

Response. If policy changes at the national level occur that result in a new influx 

of Veterans that seek care, VA would do its’ best to meet these needs. As has been 

our approach over the past 18 months, we would prioritize urgent care needs. However, if such a new influx of Veterans were to come to VA I would seek additional 

funding to be able to adequately care for all of our Veterans. I do not believe that 

VA has current significant unused capacity at this time. 

CAREGIVERS SUPPORTS

Question 126. All the VSOs are advocating for caregivers of severely ill and injured veterans of all eras to be eligible for comprehensive caregiver services and 

supports. I’m very supportive of Senator Murray’s bill to expand program for caregivers of veterans from all eras, but paying for that expansion proved problematic 

last Congress. I do hope that this Committee and Congress will find a way to get 

around the previous roadblocks to passing that bill in the very near future. 

In the meantime, one program that could help address part of this inequity is the 

Veteran Directed Care program that allows all severely ill and injured veterans to 

support their family caregiver and continue living in their community. However, 

this program is not available at all VA facilities. In Connecticut for example, this 

program is only available at one (West Haven) of the two VA medical centers. 

• What will you do to improve VA’s support for family caregivers of veterans from 

all eras in the absence of expansion legislation? 

Response. VSOs have been advocating for caregivers of severely ill and injured 

Veterans of all eras to be eligible for comprehensive caregiver services and supports. 

I’m supportive of Senator Murray’s bill to expand program for caregivers of Veterans 

from all eras, but paying for that expansion proved problematic last Congress. I do 

hope that this Committee and Congress will find a way to support that bill in the 

very near future. We are looking into further study that may help us gain a better 

understanding of the true costs associated with caregivers. 

In the meantime, one program that could help address part of this inequity is the 

Veteran Directed Care program that allows all severely ill and injured Veterans to 

support their family caregiver and continue living in their community. However, 

this program is not currently available at all VA facilities. 

APPEALS LEGISLATION

Question 127. You expressed support to reforming the appeals process and the 

new framework that was developed by VA and stakeholders in 2016. As you mentioned, there is a wide spectrum of support for the new framework among stakeholders. 

Do believe that the stand-alone appeals reform legislation that was introduced in 

the Senate in the 114th Congress (S. 3328) should be modified? If you do, please 

discuss your views. 

Response. No. Among the bills introduced in the 114th Congress, VA preferred 

S. 3328 because it was a standalone bill, contained an effective date provision that 

allowed for an 18-month implementation period, included our clarification of the options available to Veterans after an initial decision on a claim, and had the support 

of VSOs and other stakeholders. 

AGENT ORANGE AND THE DMZ

Question 128. In March 2016, I wrote to then Secretary Bob McDonald regarding 

the qualifying period for the presumption policy related to Agent Orange Exposure 

to all veterans who served in the Korean Demilitarized Zone (DMZ). In May 2016, 

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Secretary McDonald responded indicating that VA would consult with the Department of Defense (DOD) about whether veterans were exposed to a herbicide agent 

in or near the DMZ prior to April 1, 1968. 

If that consultation has not yet happened, will you commit to doing so if confirmed, and to following up with me as to whether VA will expand the qualifying 

period per my initial request? 

Response. VA has reached out to DOD to make sure there are no records of usage 

of Agent Orange (AO) before April 1, 1968. Current records available to VA indicate 

no AO was sprayed before that date. VA is committed to having the most accurate 

records possible. If as Secretary I was to learn of new information that is different 

from what we know now, then I would act upon this information to make the right 

decisions on behalf of Veterans. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MAZIE K. HIRONO TO

HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 129. Dr. Shulkin, the Veterans Choice and Accountability Act of 2014 

provided the VA with $2.5 billion to add critically needed physicians and other medical staff. However, there have been recent reports that there has been no bump in 

VA hiring that would indicate staffing had increased beyond normal hiring and 

there has been priority given to those VA hospitals with the largest wait times. 

Please answer the following questions: 

a. Has the $2.5 billion been used to increase staffing beyond normal hiring patterns? 

Response. Yes, the Choice Act funding increased staffing. Choice Act funding increased the rate of hiring in VHA and resulted in a 6.3% net increase of more than 

18,800 additional onboard staff. During the 17 months of the Choice Act hiring initiative (August 1, 2014–December 31, 2015), VHA hired 56,965 employees, of which 

11,287 (20%) were hired using Choice Act funding. The total hires in this timeframe 

represented a 13% increase over the level of hiring in the previous 17-month period 

(March 2013–July 2014). 

b. Was there any priority given to those VA facilities that had the longest wait 

times? 

Response. This decision predates my arrival at VA, it was shared with me that 

VHA requested input from that each of our Medical Center Directors. Medical Directors submitted their needs based upon wait times and need for personnel. VHA collected this information and matched it against data showing where need was greatest. The VACAA 801 funds were distributed to 33 VAMCs that were experiencing 

the greatest challenges with Veterans access. While this was not a direct match to 

wait times there was an attempt to try to make sure that the funds distributed were 

appropriate. Since access remained a critical priority across the entire VA Health 

Care System, the remaining funds were distributed proportionally across all sites, 

based upon the Veterans population to be served. 

c. Did the hiring reflect critical needs, for example in areas that had acute provider shortages in their Cardiology departments was there an emphasis on increasing cardiology staffing or was hiring done without consideration of targeted need? 

Response. There was a special emphasis on hiring Primary Care, Mental Health, 

and Specialty Care providers. In addition, each local facility targeted recruitment 

efforts toward their hardest to fill positions. 

d. What plans are there to hire in the VA in a way that reflects need-prioritizing 

not only locations with shortages but particular specialties that are the highest priority. 

Response. Each Medical Center is responsible to determining their needs for personnel that is required to meet the needs of the Veterans that they serve. This data 

is then reviewed by the VISN before being submitted for approval. Medical Centers 

must also consider the availability of services in the community as many Veterans 

are able to access care in the community when these specialties are not available 

at the VA. 

The National Recruitment Program (NRP) provides a centralized in-house team 

of skilled professional recruiters employing private sector best practices to fill the 

agency’s most critical clinical and executive positions. The national recruiters, all of 

whom are Veterans, work directly with executives, clinical leaders, and local human 

resources departments in the development of comprehensive, client-centered recruitment strategies that address both current and future critical needs. At facility request, NRP targets hard-to-fill recruitments in their regions. 

101 

VHA markets directly to direct patient care providers through partnerships such 

as National Rural Recruitment & Retention Network (3RNet), a national network 

of non-profit organizations devoted to health care recruitment and retention for underserved and rural locations, as just one example. Through these partnerships, 

VHA has access to a robust database of candidates interested in working for VHA. 

National Recruiters routinely post VHA practice opportunities on career sites such 

as www.vacareers.gov. 

e. How much of the $2.5 billion has been used and how has it been used? 

Response. The VACAA 801 Spending Plan, submitted to Congress on December 3, 

2014 provided the breakdown of funding for hiring, leases and other purposes. Of 

the $5B provided by VACAA, $2.213B was dedicated to the hiring of clinicians and 

medical support staff by the end of FY 2016. 

Question 130. Dr. Shulkin, following up from the question on the Palo Alto pilot 

which allows veterans to access care at pharmacy clinics, what is the timeline and 

path forward on expansion of the program? What additional requirements would improve the program’s accessibility for veterans? 

Response. The Veterans Health Information Exchange (VLER) is connected to all 

CVS Minute Clinics across the Nation for bidirectional exchange via the eHealth Exchange. The technical capability to roll this out nationally is in place. Further rollout for access to these clinics will be determined by the local need of each facility. 

Many VA medical centers now have same day access to primary care which would 

make the need for these services much less. However in areas where there is not 

a Medical Center nearby these clinics may be an important way to ensure timely 

access. The Office of Community Care is working with VA contracting partners to 

allow for access to care at community pharmacy clinics, with initiation of this pilot 

under the Choice program at the Phoenix VAMC in the next quarter. Different from 

the Palo Alto pilot which does not use Choice funding, the eligibility criteria under 

Choice does limit its usage; however with the assistance of triage nurses at the facility level, Veterans will be able to be directed to these clinics with wider hours of 

operation for their immediate needs and therefore allow for diversion of care from 

VAMC emergency rooms and primary care clinics. We expect the rollout beyond the 

Palo Alto and Phoenix pilot sites later this year. 

Question 131. Dr. Shulkin, telehealth services are an important part of the VA’s 

health care delivery system. What additional resources are required to expand the 

existing system and how can the program be used to fill the gaps in care for veterans who live in rural communities? 

Response. The VA is currently leveraging Telemedicine to share clinical resources 

across VA facilities and states, providing the opportunity for large or academically 

affiliated VA facilities to fill Veteran clinical service needs in rural and underserved 

areas. 

The development and maintenance of successful Telemedicine services rely on the 

coordinated efforts of information technology, telehealth, engineering, and clinical 

provider staff as well as the availability of a robust information technology network, 

modern equipment, and a supportive legal and policy environment. 

From a legislative perspective, express authority for a VA provider to care for a 

Veteran, using a state license, irrespective of the location of the provider or patient 

in would, itself, help accelerate Telehealth expansion. 

Expansion of Telemedicine is dependent on the investment in these key areas, 

with limits defined primarily by the level of investment. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOE MANCHIN, III TO

HON. DAVID J. SHULKIN, M.D., NOMINEE TO BE SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 132. As of February 1, 2017, per the VA’s website, there are 388,364 

pending claims in VA’s queue waiting for a decision. Of those, there are 97,119 

backlogged rating-related claims backlogged. Please elaborate on your plan to: 

a. Get these backlogged claims processed within the next 60 days, 

b. Reduce the backlog to zero? 

c. Ensure all new and pending claims are processed within 125 days? 

Response. VBA makes every effort to work claims in a timely manner. We recognize that some pending claims require additional time to process to ensure VA 

meets its legal obligations to assist Veterans in the development of their claims. 

Complex claims (involving multiple body systems or a high number of claimed contentions) do tend to take longer as VA considers additional evidence and/or new 

medical conditions throughout the claims process. Additionally, late evidence or new 

102 

contentions stop the momentum made in processing the claim, since they usually 

require a new round of evidence-gathering, medical examinations, and analysis, 

thus prolonging the determination of a decision. VBA is focused on resolving specific 

rating claims—our oldest claims, fully developed claims, and special interest claims 

(homeless, extreme financial hardship, former prisoners of war, terminally ill, etc.). 

Based on claim characteristics that make a claim more complex as well as VA’s responsibility to help Veterans develop their claims, VA expects some claims to take 

longer than 125 days. One of VBA’s published strategic targets is to reduce the disability rating claims backlog to less than 10 percent of the total rating inventory 

by FY 2021. 

Question 133. Mandatory overtime of Veterans Benefit Administration employees 

has previously been used to reduce claims. While the current ‘‘hiring freeze’’ executive order is in effect, is the Department allowed to institute mandatory overtime 

if the claims backlog reaches a certain threshold? Do you anticipate that you will 

need to require mandatory overtime in the next 90 days? 

Response. VBA continues to use overtime for employees processing compensation 

rating claims. Additionally, VBA has authorized overtime for specific pension and 

non-rating work. VBA is considering all options, to include mandatory overtime, to 

ensure that Veterans are getting the best care and services possible. 

Question 134. Is there ever a reason why a veteran would be taken off the Agent 

Orange Registry? If so, what are the parameters that the Department of Veterans 

Affairs uses to make such a judgment? 

Response. There is no reason that a Veteran should be taken off the Agent Orange Registry. 

Question 135. You have mentioned in previous public statements that eradicating 

veterans homelessness is not a single event; it requires a long term commitment. 

Now that the number of homeless veterans has diminished, how do you plan to 

reach the remaining population of homeless veterans who are so difficult to reach? 

Additionally, are there specific initiatives in place to handle female veteran homelessness? 

Response. VA will continue until the goal of all Veterans having permanent, sustainable housing with access to high quality health care and other supportive services is met. While significant advances have been made in reducing Veteran homelessness, there are sub-populations of homeless Veterans who are hard to reach and 

engage in services (e.g., chronically homeless, those with serious mental illness, and 

justice involved, and those not eligible for VHA health care services). The 2017 

President’s Budget includes $1.6 billion for VA programs that prevent or end homelessness among Veterans including funding for case management support for the 

nearly 80,000 existing Housing and Urban Development-VA Supportive Housing 

(HUD-VASH) vouchers, grant funding for community-based prevention and rapid rehousing services provided through the Supportive Services for Veteran Families 

(SSVF) program, clinical outreach and treatment services through Health Care for 

Homeless Veterans (HCHV), service intensive transitional housing through the 

Grant and Per Diem (GPD) and prevention services to justice involved Veterans in 

the Veteran Justice Program (VJP); and employment supports in Homeless Veterans Community Employment Services (HVCES). 

All of our homeless programs serve woman Veterans and we continue to evaluate 

additional service options for this important and growing population. Last year, the 

National Center on Homelessness Among Veterans conducted a study to look at population projections of Veterans likely to either be a risk of or actually become homeless and access VA care over the next 10 years. Women Veterans and Veterans who 

had served in the OEF/OIF era were identified as two subpopulations projected to 

grow in number while those older than age 55 were projected to decline. The National Center has commissioned two subsequent studies to map both current need 

profiles of homeless women Veteran served within VA and outcomes associated with 

different program utilization patterns. We expect to have results from these studies 

within the next six months which will be essential to accurately mapping where we 

need to strategically direct resources to address this projected demand. At this time, 

we believe that current VHA program capacity, particularly in the Supportive Services for Veterans and Families (SSVF) and HUD-VASH programs which provide the 

bulk of services for women Veterans who are homeless or at-risk for homelessness, 

is sufficient to support these projections for at least the near term. 

Question 136. The pernicious nature of post-traumatic stress is especially traumatic for rural veterans who do not always have access to high quality mental 

health and/or cannot receive care in a timely manner. Please elaborate on you plan 

to improve treatment, wait times, and increase options for rural Veterans with 

PTSD to ensure their safety and health. 

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Response. VA’s Office of Rural Health has collaborated with VA Connected Care 

and Mental Health to establish a regional telemental health hub network to enhance access to care for Veterans residing in rural areas and/or in areas with identified access challenges. These regional hubs leverage VA’s established and successful 

use of telemental health to provide staffing solutions to facilities that are particularly access challenged. Four hubs were initiated in June 2016 and are located in 

South Carolina, Utah, Pennsylvania, and the Washington-Oregon area. Six additional hubs were approved to come online in 2017. Regardless of their location, the 

hubs are available to provide services to Veterans and VA clinics throughout the 

country. The regional hubs provide a variety of services to include consistent, timely 

access to a full episode of treatment (e.g., evidence-based psychotherapy, pharmacotherapy, and primary care mental health integration services) for commonly seen 

conditions including Post Traumatic Stress Disorder, depression, and substance use 

disorders. 

VA’s National Center for PTSD also offers a variety of resources to improve the 

treatment of PTSD, including a Consultation Program to build competency for treating PTSD among Community Providers. Consultation is available free of charge, 

and it offers education, training, and other information to non-VA health professionals who treat Veterans with PTSD. The services are consistent with evidencebased practices for PTSD and VA consensus statements such as the VA/DOD Clinical Practice Guidelines for PTSD. The goal is to improve the care available to all 

Veterans with PTSD regardless of where they receive services. 

Question 137. How is the Department of Veterans Affairs currently differentiating 

treatment options, as well as facilities, for female victims of Military Sexual Trauma? Are there policy alternatives regarding treatment and facility structure being 

considered now that are different than the status quo? 

Response. VHA policy requires that mental health services be provided in a manner that recognizes that gender-sensitive issues can be important components of 

care. VA recognizes that some Veterans will benefit from treatment in an environment where all the Veterans are of one gender. This may help address a Veteran’s 

concern about safety and may improve a Veteran’s ability to disclose, address gender-specific concerns, and engage fully in treatment; however, VA also recognizes 

that mixed-gender programs have advantages. This may help Veterans challenge assumptions and confront fears about the opposite sex in a protected environment and 

may provide an emotionally corrective experience. Given these considerations, VA 

does not promote one model as universally appropriate for all Veterans; the needs 

of a specific Veteran dictates which model is clinically most appropriate. Gendersensitive mental health care contains these key components: 

• Comprehensiveness: Includes full continuum of service availability for women; • Choice: Considers treatment modality (e.g., mixed-gender, women-only service 

options); 

• Competency (of clinician): Addresses women’s unique treatment needs; and 

• Innovation: Provides creative options and settings for subgroups of women, especially when caseloads of women are small. 

Question 138. Will you continue to advance the MyVA concepts and programs put 

into place under Secretary McDonald’s leadership? Are there components of MyVA 

that you will differ from? 

Response. MyVA is an initiative to drive continuous improvement across the entire VA enterprise-as opposed to driving change from within each of the three administrations (Cemeteries, Benefits and Health). I believe this is important to continue as Veterans view VA as one organization and not three separate organizations. The MyVA initiative set organizational priorities, established metrics and 

timelines, and assigned accountable managers. With this approach, VA has improved numerous processes that have resulted in meaningful differences to Veterans. If confirmed as Secretary, I would continue with efforts for continuous improvement and accelerate our efforts to make meaningful changes on behalf of Veterans. Almost certainly VA’s organizational priorities will change and evolve under 

a new Secretary. It would be my hope that we would have goals that were bold and 

would be realized through our transformational change that we plan to undertake 

within VA. 

Question 139. You have previously stated that you do not and will not support 

a whole sale privatization of the Veterans Health Administration, and rather, you 

support an ‘‘integrated’’ model. Please elaborate on what you mean by ‘‘integrated’’ 

model. 

Response. By an ‘‘integrated’’ model, I am referring to a system that integrates 

the best of what the VA offers Veterans and the best of what the private sector can 

offer together. A successful VA system would be more than just the intersection of 

104 

VA and the private sector but it would have additional value added for Veterans. 

By using VA’s considerable capabilities in care coordination, case management, and 

quality oversight, VA can make sure that Veterans receive an integrated experience 

and do not have the gaps in care that too many Americans experience in the our 

health care system. I believe such an integrated model of care can provide our Veterans with healthcare outcomes that will be the best care available anywhere. 

Please see my article that I published in the New England Journal of Medicine 

where I described this model for the country. www. nejm.org.doi/full.10.1056/ 

NEJMp160 

Question 140. What statutory authorities do you need to remove employees who 

are low-performing and/or not working in the best interest of America’s veterans? 

Response. I know that the vast majority of the VA workforce is highly professional, motivated to taking care of our Veterans and the cream of the crop. There 

are times when employees get off track and need help in either getting back on 

track or moving out of the VA. While we already have and leverage existing laws 

to help move off track employees out of the workforce, additional legislation is needed. More specifically: 

• The Choice Act VA needs to be modified specific to SES removal procedures to 

ensure constitutionality. • The Merit Systems Protection Board need to be directed to a lower burden of 

proof and deference to the agency’s choice of penalty. • We need the authority to use indefinite suspensions where there is reasonable 

cause to believe an employee has done something to harm or endanger a patient 

or a coworker. • 5 U.S.C. 7511(a)(1)(A), (B), and (C) and 5 CFR 752.401(2), (3) and (5) need 

modified to allow those individuals serving a probationary period or on a temporary 

appointment to be separated without full due process and appeal rights. 

Question 141. The Veteran Success on Campus (VSOC) program has been widely 

successful and there are many campuses, like West Virginia University, that meet 

the requirements for VSOC, but still are on the wait list. Will you commit to supporting additional funding in The President’s FY 2018 budget that will make it so 

more of our Nation’s veterans have access to this program? 

Response. Vocational Rehabilitation and Employment (VR&E) Service currently 

maintains a list of 175 schools that have expressed an interest in becoming a 

VetSuccess on Campus (VSOC) site. We are looking at opportunities to fill select additional VSOC positions if this approved in the FY 2018 budget. 

Question 142. Both Healthnet and TriWest have a footprint in West Virginia and 

my office has received complaints about the inability to reach a representative by 

phone and the lengthy approval process. Lengthy approval times often lead to a financial burden on the veteran and their family. Please elaborate on what VA is currently doing and what you envision VA will do when contracting with third party 

administrators in the future? 

Response. VA recognizes that there have been issues with customer service and 

timeliness of authorizations for care into the community. VA is actively engaged 

with both Third Party Administrators (TPAs) to improve service and reach our 

united goal of providing the best health care experience for our Veterans and the 

providers who care for them. In October 2016, VA and Health Net agreed to an expedited payment plan to assure community providers can continue serving our Nation’s Veterans. VA has also formed a provider rapid response team to address provider issues brought to the attention of Community Care. The team’s goal is to respond to providers within 72 hours, and the team engages individually with each 

provider to resolve problems and works with the TPAs to complete payments where 

appropriate. VA is also offering more Provider education on how the billing and payment processes work to help reduce problems. Since late 2016, all correctly submitted/clean provider claims are being paid timely (within 30 days). Claims that are 

rejected and denied due to errors require additional interaction on both sides and 

result in delays and reprocessing of claims. 

VA has partnered with the TPAs to embed staff in over 40 VA medical centers 

to improve the communication and coordination of care for veterans. We continue 

to grow that number and we will certainly look into creating this type of service 

in West Virginia. 

Daily monitoring of the contract via VA contract officer representatives and the 

TPA operations staff occurs to resolve issue and ensure Veterans are receiving timely access to health services. VA representatives are engaging in weekly correspondence with each contractor on issues of performance not meeting contract specifications. VA will also continue to issue letters of corrections in areas where performance is subpar. 

105 

The future Community Care Network returns the Veteran communications, 

scheduling, customer service, and care coordination to the VAMCs. Based on lessons 

learned with the current contracts, VA will utilize the new contracted networks to 

assure that Veterans receive care in the community while not relying on other parties for these very important functions. 

Question 143. What do you believe are the factors that create appointment wait 

times and how do you plan on mitigating those factors to ensure timely, quality care 

for our Nation’s veterans? 

Response. Contributing factors to appointment wait times include increasing patient requirement for care, staffing levels of providers, nurses and schedulers unable 

to keep up with the demand for care, and inefficiencies in clinic practices. 

VA has been working mitigate these factors to ensure timely, quality care for the 

Veterans we serve. VA’s greatest effort is to focus on ensuring timely care for Veterans with the most urgent needs. In July 2015, when I joined the VA as Under 

Secretary of Health, I identified the first challenge to be the inability to identify patients with the highest and most urgent clinical needs. I tasked senior leadership 

to take on different tactics to simplify our clinical processes. This included consolidation of the over 30 different ways of scheduling a specialist consult to two ways, 

classifying the appointment as either stat or routine. This resulted in identifying 

around 57,000 urgent consult referrals to specialists waiting over 30 days for an appointment. VHA executed an emergent call to action with national Stand Downs in 

November 2015 and in February 2016. During these endeavors, staff from each medical center contacted targeted Veterans waiting for care, triaged them for clinical 

care needs and connected them with the appropriate services. Around the time of 

the stand-downs, VA also implemented a standardized process for facility staff to 

review in real-time, referrals to specialists with more urgent needs. These efforts 

have led to an ongoing reduction of Veterans waiting over 30 days to see a specialist 

from the 57,000 in November 2015 to about 200 as of February 2017. 

Other Elements in Mitigation Plan 

Factors Mitigation Plan 

Increasing Demand/Lack of 

Providers and Clinic Staff.

• Active recruitment of health care providers and clinic 

staff—VA increased provider and nursing staffing by approximately 12% over the past two years 

• Granting full practice authority for Advanced Practice 

Nurses 

• Increase use of telehealth for Primary Care and Mental 

Health 

• Use of community care resources when unable to recruit 

providers 

• Increased use of extended clinic hours 

Inefficiencies in clinic practices.• Implemented Clinic Practice Management Program across 

VA—in this program all facilities have at least one group 

practice manager to oversee and optimize administrative 

clinic activities 

• Validating clinic grids to achieve optimal clinic capacity 

• Focus on improving productivity—increased productivity 

by 16% over past two years 

• Developed strategies for reducing ‘‘no show’’ rates, and redesigning clinic space 

• Implemented standardized face to face Clinic Clerk Training for optimal scheduling of patients 

• The above efforts have resulted in an increase in 12,000 

appointments daily in 2016 when compared to 2014 

Question 144. Will you commit to ensuring that VA continues to invest in the veteran transportation program? 

Response. Yes, I commit to continuing the Veterans Transportation Service that 

transports Veterans to and from their appointments, especially, in rural areas 

where both community care and VA care are less available. This is an area in which 

we have been able to partner with our VSO groups. 

Question 145. With VA’s expertise on substance abuse and the Department’s robust Office of Research and Development, I believe that you are well equipped to 

be on the forefront of alterative pain therapy research for the entire country. Please 

106 

elaborate on how you will increase the number of alternative treatments for pain 

management. What investments will you make and are there authorities you need 

from Congress? 

Response. In response to Section 932 of the Comprehensive Addiction and Recovery Act (CARA), VA developed an ambitious plan to expand research, education, and 

clinical delivery of complementary and integrative health (CIH) approaches for pain 

management as well as mental health. The Integrative Health Coordinating Center 

in the Office of Patient Centered Care & Cultural Transformation is working to 

make the evidence-based CIH approaches—including acupuncture, chiropractic, 

yoga, tai chi, meditation, and massage—more widely available to veterans nationally. Our commitment is that every medical center will offer at least two of these 

therapies routinely for Veterans with pain. In addition, the Office of Research and 

Development is collaborating with the National Center of Complementary and Integrative Health at NIH and the DOD to fund a large research initiative supporting 

demonstration projects developing the most effective ways to deliver CIH for pain 

in our military populations. 

Question 146. The Department of Veterans Affairs is often charged with having 

a corrosive culture that breeds unethical, and sometimes unlawful, behavior that is 

not veteran-centric. While there have been improvements under Secretary McDonald’s leadership, there is still work to be done. What are specific actions that you 

will implement to ensure that the culture of VA will continue to improve? 

Response. Employees want to work in an environment where they have the tools 

and resources they need to be able to serve their patients. As a health care executive this is what the type of environment I strive to have for our staff and their 

patients. Employees want a place that has systems that work, co-workers that are 

well trained and supported, and a culture of respect. If confirmed as Secretary, I 

would work hard to have a work environment that supports our staff and allows 

them to do their best for our Veterans. Part of what is needed is to be able to support, retain, and recognize those employees that share the organization’s values and 

are high performers and to be able to remove those that have strayed from these 

values. When people are allowed to remain in the workplace, despite poor performance or bad behavior, it is demoralizing to all employees. 

Question 147. Please elaborate on specific ways the Department of Veterans Affairs and Congress can work together to improve the claims backlog. 

Response. We appreciate Congress’s ongoing support for our budget for staffing, 

and information technology advancements and sustainment. We fully expect that as 

the needs arise for legislative intervention that we will be able to collaborate with 

Members of Congress to ensure that the needs of our Nation’s Veterans and their 

families are met with the highest level of care and compassion. 

Question 148. Do you support an expansion of the Caregivers programs beyond 

post-9/11 veteran era? 

Response. I support programming for all caregivers of all Veterans, regardless of 

the Veteran’s era of service or the reason why the Veteran needs the assistance of 

a caregiver. I cannot, however, support the expansion of the current Program of 

Comprehensive Assistance for Family Caregivers without considerable concern for 

how the cost will impact other services and supports to Veterans. VA welcomes collaboration with Congress to establish a sustainable program that provides assistance and support to all caregivers. I am exploring the option of a study to determine 

the cost avoidance that may be seen with the expansion of Caregivers to give us 

a better understanding of the true costs involved in expanding the program. 

Question 149. Do you believe there are improvements or changes that need to be 

made in the way VA determines service-connected disabilities? Would you be open 

to reexamining the compensation and pension exam process? 

Response. VA agrees, in principle, that there is a need for revision of the 1945 

regulations that are found in 38 CFR Part 4, the VA Schedule for Rating Disabilities (VASRD). While VA has undertaken several changes, in the past, to update 

and clarify regulations for individual sections of 38 CFR Part 4, VA has not had 

major revision of VASRD that can be viewed as a complete modernization of its 

evaluative criteria. 

In 2009, the Veterans Benefits Administration (VBA) Under Secretary for Benefits 

(USB), on behalf of the Secretary for Veterans Affairs (VA), directed the revision 

and update of the 15 body systems that are contained in the VASRD, under the authority of 38 U.S.C. § 1155. To date, VA has published for notice and commented 

on six of the VASRD regulations, which are currently under review for final publication. VA is working to publish proposed updates to the Federal Register for the remaining body systems. VA plans to complete these regulations by the end of 2018. 

Additionally, VBA continues to work to modernize efforts related to the disability 

107 

evaluation process, to include accessibility to Veteran’s benefits and system and procedural enhancements to improve the timeliness and quality of rating decisions. 

We have consistently taken steps to improve the compensation and pension examination process. We now receive disability benefit questionnaires (DBQs) from Veterans seen by their private providers. We have increased the type of examinations 

that can be done by medical disability examination contract providers as well as by 

VHA clinicians. And we are working to implement system enhancements that more 

efficiently and quickly process evidence through automation. Finally, in FY 2016, 

VBA and VHA collaborated on a multi-prong Breakthrough Initiative to Improve the 

C&P Exam Process, and these efforts are ongoing. This included providing training 

to individuals involved in the C&P exam process in VBA and VHA as well as educating Veterans on what to expect before, during, and after their C&P examination. 

Question 150. The difficulty veterans face in scheduling appointments is a frequent complaint to my office. Please elaborate on ways to improve scheduling to 

make it easier both for VA scheduling staff and the veteran. 

Response. VistA Scheduling Enhancements (VSE) is a cost-effective, interim solution built in partnership with the private sector to bring an urgently needed modern 

interface to the antiquated VistA scheduling package. VSE makes it easier for 

schedulers to schedule and coordinate follow up appointments with other Veteran 

appointments, keep track of Veteran appointment preferences, and reduce scheduling errors all via a simplified point and click process. VSE is currently being piloted in multiple clinical settings at five VA facilities. If the pilot is successful, VSE 

will be implemented nationally until a permanent and complete solution is available. 

VA provides uniform face to face training that teaches all schedulers how to optimally meet all of the scheduling needs of Veterans. This training includes simulation using VA’s computerized system, working through real life challenge scenarios 

and focusing on optimization of customer service. 

Based upon Veteran feedback, VA is implementing ‘‘patient centered scheduling,’’ 

whereby Veterans are offered the option to schedule follow-up appointments upon 

leaving clinic even when appointment needs are a year or more into the future— 

this replaces the ‘‘recall system’’ that constrained Veterans to only schedule their 

appointment as it got closer to their appointment date. 

VA also implemented call centers for Veterans to more easily request and cancel 

appointments by phone. 

The Veteran Appointment Request (VAR) Mobile App enables Veterans to selfschedule appointments or request someone call them to make an appointment via 

either a smart phone or desktop computer. The system is currently being utilized 

at 21 sites and is being evaluated for possible expansion. 

Finally, VA has awarded a contract for a commercial scheduling package, called 

MASS. Mass is now being implemented in a pilot site within VA to determine how 

it functions and compares to the alternatives detailed above.A off the shelf system, 

while more costly, might be the best solution to VA’s long standing scheduling 

issues. 

Question 151. What are ways that you would like to see access to Mental Health 

improve? What is being done to help prevent the overprescribing of opioids and benzodiazepines? 

Response. Timely access to high-quality mental health care is an imperative for 

VHA. As of December 31, 2016, every VA Medical Center endorsed their capability 

to provide same-day mental health services to Veterans in urgent need. This represents a critical first step in our MH access plans but it is only the beginning. Veterans do not only need access to an appointment, they need access to a full episode 

of care which may require a succession of appointments over a short period of time. 

VHA is already the Nation’s leader in integrating mental health services in primary 

care teams, an effort we continue to expand. In addition, we are rapidly expanding 

telemental health care across the system to expand capacity as well as making improvements in the CHOICE program when community providers are the best match 

to a Veteran’s needs. Such demands can be a major obstacle to seeking care for 

many Veterans and can be overcome by delivering telemental health services directly to their homes, offices, or even to their parked cars. Finally, we are ensuring 

that expanded access means high quality, evidence-based, compassionate care which 

ensures a steady increase in trust, compliance, continuity, satisfaction and clinical 

outcomes. This will require additional hires, expansion of available Mental Health 

disciplines (including the current ‘mission critical occupations’ of psychologists and 

psychiatrists, as well as Licensed Professional Mental Health Counselors, Marriage 

and Family Therapists, Social Workers, Vocational Rehabilitation Specialists, Addictions Specialists, Advance Practice Mental Health Nurses, Psychiatric Physician AsVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00111 Fmt 6633 Sfmt 6621 Z:\ACTIVE\020117.TXT PAULIN
108 

sistants, and Clinical Pharmacists). Full staffing, a full array of services, and enhanced availability across the Nation are key components of VA’s Mental Health Access improvement plan. 

The Opioid Safety Initiative was instituted nationally in the VA in 2013. Since 

then there has been a decrease in patients receiving opioids (27% reduction), a decline in the use of long term opioids (33% reduction), an increase in the use of safe 

prescribing practices such as patient signed consents, prescription drug monitoring 

program (PDMP) checks, use of urine drug screens (increased 48%) , and avoidance 

of unsafe combination therapies. The combined use of opioids and benzodiazepines 

has decreased by 51% from 2012 to 2017. There is a need to treat Veterans with 

pain, and the VA is focused on using conventional and alternative therapies to address pain and enable a reduction in opioid use. 

Question 152. In the past, you have stated that you would not have used the ‘‘40 

mile’’ and ‘‘30 day’’ rule if you had designed the Choice program. Please elaborate 

on how you would like to see Choice fixed and what measures you would use in considering eligibility for referral to care in the community? 

Response. I know of no health system that has designed a system around mileage 

and wait times. The reason I believe we must look at alternatives to these criteria 

is that mileage and wait times do not differentiate between Veterans that need urgent care and Veterans that desire elective care. Such a system also does not differentiate between those that have other healthcare options available to them and 

those that have none. We are embarking upon an exploration of a number of different models that would propose alternative criteria and then we would need to get 

Veteran input into these models. We also need to do economic modeling of these 

models to determine the cost of new options. Once we have completed this initial 

work we would begin to socialize our ideas with Veterans, Veteran Service Organizations, Members of Congress and the Administration, and our staff. 

Question 153. A frustration that many veterans have is that even though there 

is a VA regional office in their community, they have to contact a call-center to get 

an update on the status of their claim or to ask questions. How can the Veterans 

Benefits Administration be more accessible to veterans directly? Furthermore, have 

you considered embedding VBA counselors in VA medical centers to help veterans 

and their families understand their benefits during a hospitalization? 

Response. Besides our national call centers; every regional office has a public contact team that can assist Veterans and claimants with submitting claims for benefits or getting a status on their claim. VA continues to look for ways to increase access to Veterans. Many of the VA medical centers do have VBA personnel onsite 

on an ad hoc basis to assist with claims related questions. Any expansion would require balancing of available resources. Finally, VA cultivates close partnerships with 

Veterans Service Organizations, which help Veterans and their families understand 

and navigate VA benefit programs. 

[The Committee questionnaire for Presidential nominees from 

David J. Shulkin, M.D., submitted twice, follows:] 


SHUqPt1.eps
109 


SHUqPt2.eps

Revised December 2016 

PART I: ALL OF THE INFORMATION IN THIS PART WILL BE MADE PUBLIC 

1. Basic Biographical Information 

Please provide the following information. 

Position to Which You Have Been Nominated 

N arne of Position Date of Nomination 

Secretary, Veterans Affairs January 11, 2017 

Current Legal Name 

First Name Middle Name Last Name Suffix 

David Jonathan Shulkin 

Addresses 

Office Address 

(include street address) 

Other Names Used 

~~~~ Name Used Name Used To From 

First Name Middle Name Last Name Suffix (Month/Year) (Month/Year) 

0~ (Check box if (Check box if 

:>' estimate) estimate) 

Est Est 

D D 

Est Est 

D D 
110 


SHUqPt3.eps

Birlh Year and Place 

Year of Birth Place of Birth 

(Do not include month and day) 

1959 Highland Park, IL 

Marital Status 

Check All That Describe Your Current Situation: 

Never Married 

D 

Married 

XXX 

Separated Annulled Divorced Widowed 

D D D D 

Spouse's Name 

(current spouse only) 

Snouse's First N arne Snouse's Middle Name Snouse's Last Name Spouse's 

Suffix 

Merle Mindy Shu! kin 

Spouse's Other Names Used 

(current spouse only) 

il11 

Name Used Name Used To From 

First Name Middle Name ~ fu!f!h (MonthlY ear) (MonthlY ear) 

u '03 (Check box if (Check box if 

:E estimate) estimate) 

Merle Mindy Bari X Est Est 

1960 0 present 0 

Est Est 

0 0 
111 


SHUqPt4.eps

Children's Names (if over 18) 

First Name Middle Name Last Name Suffix 

Daniel Bari Shulkin 

Jennifer Laurie Sbulkin 

2. Education 

List all post-secondary schools attended. 

Type of School Date Began Date Ended 

School (vocational/technical/trade school, School (month/year) (check Date Name of School college/university/military college, (month/year) Degree 

corre~'Pondenceldistance/extension/ (check box if box if estimate) Awarded 

(check "present" box online school) estimate) if still in school) 

Hampshire College College •.. Est Present BA January Septemberl977 January1982 " 1982 

Medical College of Medical School Est Est Present MD June 

Pennsylvania September1982 M.ay 1986 o 0 1986 

(Now Drexel 

School of 

Medicine) 

Yale University First Year of Residency ... Est Present 

School of Medicine Julyl986 c June 1987 0 0 

University of Internal Medicine Residency Est Est Present 

Pittsburgh, (years 2 and 3) July1987 c June 1989 D 0 

Presbyterian 

Medical Center 

University of General Medicine Fellowship ,July1989 Decemberl990 

Pittsburgh 

General Medicine 

Fellowship 

Robert Wood Fellow Julyl990 Decembcr1991 

Johnson 

Foundation 
112 


SHUqPt6.eps

3. Employment 

(A) List all of your employment activities, including unemployment and self-employment. 

If the employment activity was military duty, list separate employment activity periods to 

show each change of military duty station. Do not list employment before your 18th 

birthday unless to provide a minimum of two years of employment history. 

Tyf!e of EmJ!lo~ment 

(Active Military Duty Station, Date 

National Guard/Reserve, Emulol:ment 

USPHS Commissioned Corps, Date Ended Other federal employment, Name of Your Most Recent Location Employment (month/year) 

State Government (Non- Employer/ Position (City and Began (check box if 

federal Employment), Self- Assigned Dun: State (month/year) estimate) 

employment, Unemployment, Station Title/Rank only) (check box if (check 

Federal Contractor, Non- estimate) "present" box 

Government Employment if still 

(excluding self-employment), employed) 

Other 

Government US Department of Under Secretary Washing! E<t Est Present 

Veterans Affairs for Health on DC July2015 D P~ent 

Private- non Government Morristown President, Morristow Est Est 

Medical Center Morristown n, NJ January2010 o July 2015 o 

Medical Center 

President, 

Accountable 

Care 

Organization, 

Vice President 

Atlantic Health 

System 

Private- Non Government Kennedy Health Consulting Role Voorhees, Est Est 

System - Interim Chief NJ Apri12009 D January2010 o 

Medical Officer 

Private- Non Government Beth Israel President and New E•t Est 

Medical Center CEO York, July2005 n Apri12009 0 

New York 

Private- Non Government Temple Chief Medical Philadelph E<t E" 

University Officer ia,PA March2004 0 July2005 n 

Hospital 

Private - Non Government Drexel University Chief Quality Philadelph July2002 March2004 

School of Officer ia,PA 

Medicine 

Private- Non Government DoctorQuality, Chairman and Con._o;hoho Novcmberl999 July2002 

Inc CEO cken, PA 

Private- Non Government University of Chief Medical Philadelph Deccmbcr1998 December1999 

Pennsylvania/ Officer/Chief ia,PA 

University of Quality Officer/ 

Pennsylvania Senior Executive 

Health System Managed Care 

and Contracting 

and Operations - "-~~-
113 


SHUqPt7.eps

Private- Non Government University of Chief Medical Philadelph February 1996 ~ovember1998 

Pennsylvania/ Officer! Chief ia,PA 

University of Quality Officer 

Pennsylvania 

Health System 

Private- Non Government University of Chief Medical Philadelph February1993 Novemberl997 

Pennsylvania Officer ia,PA 

Hospitals 

Private- Non Government Hospital of the Direct of Clinical Philadelph January1992 Januar~ 1993 

University of Outcome ia,PA 

Pennsylvania Assessment and 

Quality 

Management 

Private- Non Government Robert Wood Fellow Washingt July1990 Decemberl991 

Johnson on, DC 

Foundation 

(B) List any advisory, consultative, honorary or other part-time service or positions with 

federal, state, or local governments, not listed elsewhere, 

Date Service Date Service Ended 

Name of Government Name of Position Began (month/year) (check box 

Entity (month/year) if estimate) (check 

(check box if "present" box if still 

estimat~l serving) 

Institute of Medicine Advisory Committee Member (Committee 1993 Est E•t Pre~ent 

to Advise HCF A Administrator on Peer 0 1994 n 0 

Review Evaluation Plan) 

Center for Medicare and Advisory Committee Member Est 2004 Est Present 

Medicaid Services (Committee on Quality) 2004 0 c 0 

Agency for Healthcare External Advisory Board Member- E•t E" Present 

Research and Quality University of Rochester- Safety in 2004 0 2004 0 0 

Neurologic Event Surveillance 

4. Honors and Awards 

List all scholarships, fellowships, honorary degrees, civilian service citations, military 

medals, academic or professional honors, honorary society memberships and any other 

special recognition for outstanding service or achievement. 

• Eugene Baum Memorial Prize for Scholastic Excellence, Medical College of 

Pennsylvania- 1986 

Medical Journal ism Award, awarded by Sandoz Pharmaceuticals for the 

Physicians for Research in Cost-Effectiveness (PRICE) Newsletter excellence in 

design and editorial content- 1989 

A MA/Burroughs Welcome Leadership Award for Community Services- 1988-

1989 
114 


SHUqPt8.eps

Top Philadelphians Under 40- Philadelphia Business Journal- 1994 

• Healthcare Hero's Award- Philadelphia Business Journal Awarded for 

Accomplishments in the Philadelphia Health care Community- 1 994 

I 00 People to Watch- Business Philadelphia- 1994 

• Quality Recognition Award- Philadelphia Chamber of Commerce -Awarded for 

Quality Improvement Efforts- 1995 

Quality Recognition Award- Philadelphia Chamber of Commerce- A warded for 

Quality Improvement Efforts- 1996 

PACE/Delaware Valley Quality Recognition Award- 1997 

Up and Corners Healthcare Leaders for the Next Century- Modern Healthcare1997 

Fellow- American College of Physicians- 1998 

Alfred Stengel Health System Champion A ward, University of Pennsylvania 

Health System- 1998 

AI pha Omega Alpha Honorary Society (Lifetime) - 1998 

What Works Award (for Disease Management) -Health Technology Magazine1998 

International Emerging Leaders Award- Healthcare Forurn/Korn Ferry- 1998 

Innovation Leadership Award- Temple University Health System- 2005 

Medical Humanitarian Leadership Award- Biku Cholirn- New York- 2006 18. 

Modern Health care, -Up and Corners-Ten Years Later- Star of the Class- 2007 

• Community Services Award- United Jewish Services Lower East Side NY 2007 

I 00 Most Powerful People in Healthcare in America- Modern Healthcare- 2008 

Latino Health Community Services Award- NY, NY 2008 

• Fifty Most Powerful Physician Executives- Modern Healthcare- 2008, 2009. 2011 
115 


SHUqPt9.eps

Rosef Joseph Community Medical Award- Council of Jewish Organizations. 

New York, NY, 2009 

Top Physician Leaders of Hospitals, Annual Listing, The Health Review- 2009 

Top Physician Leaders of Hospitals and Health Systems -Becker's Hospital 

Review- 2012-2103 

Maimonides Humanitarian Award- New Jersey Health Professionals Division 

Israel Bonds- 20 13 

Power Top 50 in Healthcare- New Jersey Biz- 20 14 

100 Physician Leaders in Healthcare- Becker" s Hospital Review- 2014 

American Cancer Society- Annual Honoree, 2014 

Digital Transformations, CEO of the Year, JiveWorld16, 2016 

50 Most Influential Physician Executives, Modern Healthcare, 2016 

Doctor of Humane Letters, Honorary Degree, Pace University, New York, NY 

Honorary Degree, Thomas Jefferson University School of Medicine, 

Philadelphia, PA 

• Distinguished Alumnus Award, Drexel University 

5. Memberships 

List all memberships that you have held in professional, social, business, fraternal, 

scholarly, civic, or charitable organizations in the last ten years. 

Unless relevant to your nomination, you do NOT need to include memberships in 

charitable organizations available to the public as a result of a tax deductible donation of 

$1,000 or less, Parent-Teacher Associations or other organizations connected to schools 

attended by your children, athletic clubs or teams, automobile support organizations (such 

as AAA), discounts clubs (such as Groupon or Sam's Club), or affmity 

memberships/consumer clubs (such as frequent flyer memberships). 

Name of Organization Dates of Your Membershin Position(s} Held (You may approximate) 

American Medical Association 19 8 8-1990, Resident Member Chair Resident Physicians Section of 

20 I 0 ~Present, Member Pennsylvania Medical Society and 

AMAmember 
116 


SHUqPt10.eps SHUqPt11.eps

American College of Physicians 1997- Present, Member Fellow and Member 

1998- Present, Fellow 

New Jersey Council of Teach 2013-2015 Chair of Board 

Hospitals 

Morris County Business Chamber 2012-2015 Executive Cabinet Member 

American Hospital Association 2009-2014 Regional Policy Committee Member 

NY Academy of Medicine 2008-2010 Member 

Northeast Business Group on Health 2008-2010 and 2013- March 2015 Member 

Patient Safety Officer Society 2002-2009 President 

Union Square Partnership 2005-2006 Board Member 

Vistage CEO Group 2007-2015 Member 

6. Political Activity 

(A) Have you ever been a candidate for or been elected or appointed to a political office? 

NO 

Year(s) Election 

N arne of Office Elected/AflflOinted/ Held or Term of Service 

Candidate Only A1mointment (if applicable) 

Made 

(B) List any offices held in or services rendered to a political party or election committee 

during the last ten years that you have not listed elsewhere. 

Name of ParJ:.Y/Election Office/Services Rendered ResJlonsibilities Dates of 

Committee Service 

None 
117 


SHUqPt12.eps

(C) Itemize all individual political contributions of $200 or more that you have made in the 

past five years to any individual, campaign organization, political party, political action 

committee, or similar entity. Please list each individual contribution and not the total 

amount contributed to the person or entity during the year. 

N arne of Reciuient Amount Year of Contribution 

Menendez for Senate $1000 2012 

Pallone for Congress $250 2014 

Assemblyman Singer ofNJ $300 2014 
118 


SHUqPt13.eps

7. Publications 

List the titles, publishers and dates of books, articles, reports or other published materials 

h d. . t at you have written, inclu mg articles published on the Internet. 

Title Publisher Date{s} of Publication I 

Shulkin D, Zuckerman B. Journal of the American Aging 1982;19:181 

Association 

Spectrotluorometric analysis of 

the effect of centrophenoxine on 

Lipofuscin accumulations in the 

Nematode, Caenorhabd it is 

elegans 

Shulkin D, Tripoli L, Abell T. Lues American Journal of Medicine 1988;85:425 

I 

Maligna in a patient with Human 

Immunodeficiency Virus Infection 

Shulkin D, ' Levey J. The American Journal of 1989;297:5;337 

Thyrotoxic periodic paralysis ! in a Medical Sciences I patient taking Acetazolamide. ! 

BariM,ShulkinD., E. Abell Journal of the American Academy 1989;266:3000-3003 

I 

of Dermatology Precocious Ulcerative Syphilis 

and Human Immunodeficiency 

Virus Infection 

Shulkin 0, EscarceJ, Journal of the American Medical 1991 ;266:3000-3003 I Enarson C, Eisenberg J Association 

I The Impact of the 

Medicare fee schedule on 

An academic department 

of medicine. 

Resenstein, A Health Care Strategic 1991;6: 14-16 

Management 

Shulkin, D 

Medical staff cooperation in 

controlling health care costs: the 

pros and cons of influencing 

physician behavior. 

Eisenberg, J Annals of Internal Medicine 1991 ; 1 15:493-494 

Shulkin, D 

Payment reform: what are the 

prospects for internal medicine. 
119 


SHUqPt14.eps

Shulkin, D Quality Review Bulletin 1992;18:477-479 

Fox, K 

Stadtmover, E 

Guidelines for Prophylactic 

platelet Transfusions: Need for a 

concurrent outcomes 

management System. 

Shulkin, D Academic Medicine 1992;67:266-70 

Kronhaus, A 

Nash, D 

Management training of 

physicians: the privately financed 

fellowship. 

Shulkin, D Journal of Research in 1992:4(2) :31 -42 

Pharmaceutical Economics 

Nash, D 

The Impact of Managed Care 

Formularies on the Cost and 

Quality of Care: a Survey of 

Physician Attitudes 

Shulkin, D Archives of Surgery 1993; 128:449-452 

Kinosian, B 

Blick, H 

Daly, J 

Eisenberg, J 

The economic impact of 

infections: an analysis of 

hospital costs and charges in 

surgical oncology patients. 
120 


SHUqPt15.eps

Shulkin, D American Journal of Cardiology 1993 ;7 1 ;749-750 

Lieverman, J 

Morganroth, J 

Schwartz, J.S. 

Use of Claims Data for 

Determining the Appropriateness 

of Ambulatory Cardiac Monitoring 

Shulkin, D Clinical Performance and High 1993; I (3); 134-1 37 

Quality Healthcare 

Kinosian, B 

Glick, H 

Puschett, C 

Daly, J 

Sirio,C 

Explaining Cost Variations in 

Clinical Trials Using Severity of 

Illness Measures 

Shulkin, D Academic Medicine 1993;68(9);688-692 

Rennie, D 

Goin, J 

Patterns of authorship among 

chairman of medicine 

Shulkin, D American Journal of Medical 1993;8(2)68-71 

Quality 

Otten, J 

The patient focus walk-through 

assessment tool; an instrument 

to supplement patient satisfaction 

data. 
121 


SHUqPt16.eps

Shulkin, D Annals of Internal Medicine 1993; 119:74-78 

Cooper, W 

Reasons for Rising 

Administrative Costs. 

Shulkin, D American Journal of Medical 1995:10( 1):14-1 7 

Quality The July phenomenon revisited: 

Are hospital complication 

Associated with new house staff? 

Shulkin, D Journal of Infection Control 1995;23(1 ): 1 -4 

Brennan P.J. 

The Cost of Caring for Patient 

with Tuberculosis 

Shulkin, D The Journal of Quality 1995;21 (8):376-393 

Improvement 

Black, F 

Weiss, K 

Erban, S 

Innovations in Patient Care; 

Changing Clinical Practice and 

Improving Quality 

Shulkin, D International Journal Technology 1995;32-37 

Management- Special Publication 

Brailer, D on the Role of Management of 

Technology in Clinical and 

Using Quality Indicators to Administrative Healthcare Delivery 

Develop and Automated 

Measure of Adverse Events 

Shulkin, D Journal of Cl inical Outcomes 1 996;(3):39-48 

Management 

Ratki, T 
122 


SHUqPt17.eps

Matuszewski, K 

Model Guidelines for the Preoperative Evaluation of Patients 

Undergoing Elective Surgery 

Shulkin, D Journal of Health and Social 1996;7(4):1-9 

Policy 

Hillman, A 

Care for Homeless: a Practical 

Solution to an Academic Problem 

Shulkin, D Quality Management in Health 1996:4(2):37-41 

Care 

Harris, M 

Coordinating Initiatives in Critical 

Pathways and Information 

System 

Shulkin, D American Journal of Medical 1996:11(1):43-45 

Quality 

Ferniany, W 

The Effect of Developing Patient 

Compendiums for Pathways on 

Patient Satisfaction 

Shulkin, D International Journal for Quality in 1997;9(3): 171-176. 

Health Care 

Quality Management in an 

Academic Integrated Delivery 

System: the Case of the 

University of Pennsylvania 

Health System. 

Shulkin, D Archives of Internal Medicine 1998;158:2109-21 1 1 

Bernard, D.B. 

The Media versus Managed 

Health Care: Are we Seeing a 
123 


SHUqPt18.eps

Full Court Press? 

Shulkin, D American Journal of Medical 2000: 1 5(2):49-53 

Quality 

Why Quality Improvement Efforts 

Fail and What You can Do About 

it. 

Shulkin, D American Journal of Managed 2000:1:13-15 

Care 

Vjota, D 

Maskantani, S 

The Health Partners PayerProvider Model Creating 

Accountabilityfor Implementing 

Best-Practices (Disease 

Management) 

Shulkin, D Joint Commission Journal of 2006: 17(6):291 -300 

Quality and Patient Safety 

King, ES 

Moyer, DV 

Courturie, MJ 

Gaughan, JP 

Getting Doctors to Report 

Errors: The DISCLOSE 

Study. 

Shulkin, D Journal of Hospital Medicine 2006;1 (5):296-305 

King, ES 

Moyer, DV 

Courturie, MJ 

Gaughan, JP 

Gettinr:~ Doctors to Report 
124 


SHUqPt19.eps

Errors: The DISCLOSE 

Study. 

Shulkin, D Joint Commission Journal of 2003 :29(3): 146-1 51 

Using a Market Model to Track 

Quality and Patient Safety 

Advances in Patient Safety 

Shulkin, D New England Journal of Medicine 2008:358:2091-2093 

Like Night and Day- Shedding 

Light on Off- Hours Care. 

Shulkin, D Journal of Patient Safety 2009 5(2):75-78 

Safety Assessing Hospital Safety 

on Nights and Weekends: The 

SWAN Tool 

Shulkin, D Journal of Hospital Medi::ine 201 0(59):50 1-507 

Leitman, IM 

Levin, R 

Slvarprasad, L 

Saralakulasingam, CJ 

Bernard, OS 

Friedmann, P 

Quality and Financial Outcomes 

from Gainsharing for Inpatient 

Admissions: A Three Year 

Experience. 

Shulkin, D Journal of Population Health 2011: 14(6):267-75 

Management 

Jewell, KE 

Alexandrov, AW 

Impact of Systems of Care and 

Blood Pressure Management on 
125 


SHUqPt20.eps

Stroke Outcomes 

Shulkin, D Disease Management 1999;2( 1 -2):43-50. 

Mashchak-Carey, B 

Schutta, MH 

Schwartz, S 

Joshi, M 

Bernard, D 

Successful Implementation of a 

Comprehensive Diabetes 

Disease Management Program 

in an Academic Health System 

Shulkin, D Disease Management 2001 ;4( 1 ):1 5-18 

Nash, D 

Comite, F 

Loepkee, R 

VanCleave, B 

Kane, B 

Christianson, J 

Pousma, D 

Measurement of the Impact of 

Winoma Health Online 

Shulkin, D Journal of Quality and Safety 2003 ;29(3): 146-51 

Using a Market Model to 

track Advances in Patient Safety 

Shulkin, D Journal of Population Health 2011;14:211-14. 

Management 

PRIDE in Accountable Care 
126 


SHUqPt21.eps

Shulkin, D Mayo Clinic Proceedings 2012;87(8):721 -722 

Building an Accountable Care 

Organization for All the Wrong 

Reasons. 

Shulkin, D Pharmacy and Therapeutics 2012 :37( 1 1 ):623-649 

Reinventing the Pharmacy and 

Therapeutics Committee 

Shulkin, D, T. O'Keefe, D. Journal of Healthcare Quality 2014;36(6):54-57 

Visconi, A. Robinson, AS Rooke, 

W. Neigher 

Eliminating Visiting Hour 

Restrictions in Hospitals 

Shulkin, D Virtual Mentor 2013:July I, 15(7):611-614 

Shulkin, MW 

Shulkin, OJ 

A Story of Three Generations in 

Healthcare 

Shulkin, D Annals of Allergy and July 15, 2013 

Immunology 

The Role of Allergists in AGO's. 

Shulkin D New England Journal of 2016:374(11):1003-5 

Beyond the VA Crisis- MedicineTransforming into a High 

Performance Network 

Shulkin D Federal Practitioner 2016 May Issue 

Why VA Healthcare is Different 

Shulkin D New England Journal of April14, 2016 

How the VA's Stand Down Medicine Catalyst Catalyst.nejm.com 

Resolved 56,000 Plus UrgentCare Consults 
127 


SHUqPt22.eps

Shulkin D New England Journal of 375(24):2395-2400 

Califf, RM Medicine 

Robb, MS December 15, 2016 

Bindman, AV 

Transforming Evidence 

Generation to Support Health 

and Healthcare Decisions 

Shulkin D Modern Healthcare January 2, 2016 

VA needs skilled healthcare 

leaders to speed system reforms 

Shulkin D Veterans' Choices 2016:64(1):2 

VA Voluntary Service Celebrates 

70 Years 

Shulkin D Omaha World-Herald October 10, 2016 

VA is Saving Lives Everyday 

Shulkin D Bloomberg News Blog 2016 

How VA's Million Veteran 

Program Will Advance the 

National Movement T award 

Precision Medicine 

Shulkin D Resident and Staff Physician 1988; ~:10-15 

From Resident to Patient 

Shulkin D Forum in Internal Medicine 1989;2:2-5 

Variation in Medical Care: 

Cookbook medicine for the 90s? 

Shulkin D Bulletin of the Delaware County 1990;1Qj_(70):1 0:17-22 

The high cost of health care: a Medical Society 

model of over-regulation 

Shulkin D Hospital Physician 1990;~(4):51-59 

Cost controversies: a patient 

with syncope 
128 


SHUqPt23.eps

8. Public Statements 

(A) List any testimony, official statements or other communications relating to matters of 

public policy that you have issued or provided or that others presented on your behalf 

to public bodies or officials. 

• Nomination Hearing of David Shu/kin 515115 

• Alaska Field Hearing 8125115 

• A Call for System-Wide Change: Evaluating the Independent Assessment of the 

Veterans Health Administration 1017115 (accompanied by Shu/kin) 

• Choice Consolidation: Assessing VA's Plan to Improve Care in the Community 11/18115 

(accompanied by Shu/kin) 

Senate - Consolidating Non-VA Care Programs - 1212115 (accompanied by Shu/kin) 

• Phoenix Field Hearing 12114/15 

• Senate - VA's Transformation Strategy: Examining the Plan to Modernize VA 1121116 

(accompanied by Shu/kin) 

• Lost Opportunities for Veterans: An Examination of VA 's Technology Transfer Program 

213116 

• U.S. Department of Veterans Affairs Budget Request for FY 17 2110116 (accompanied 

by Shu/kin) 

• Senate FY 17 and 18 Advance Appropriations Hearings 2123116 (accompanied by 

Shu/kin) 

• House Appropriations Committee 312116 

Senate Committee on Appropriations FY17 and 18 advance appropriations 313116 

• Senate Appropriations - 3110/16 

• Evaluating VA IT: Scheduling Modernization and Choice Consolidation 4114116 

• A Continued Assessment of Delays in Veterans' Access to Health Care 4119116 

Senate- VA Hearing on Information Technology 612212016 

Senate - The Future of the VA: Examining the Commission on Care Report and VA 's 

Response 9114116 (accompanied by Shu/kin) 

(B) List any speeches or talks delivered by you, including commencement speeches, 

remarks, lectures, panel discussions, conferences, political speeches, and question-andanswer sessions. Include the dates and places where such speeches or talks were given. 

See Attachment B 

(C) List all interviews you have given to newspapers, magazines or other publications, and 

radio or television stations (including the dates of such interviews). 

See Attachment C 
129 


SHUqB1.eps

David Shulkin M.D. 

Attachment B- Lectures, Speeches, 

Presentations 

Lectures by Invitation: 

1981 

1988 

1989 

1990 

1990 

1991 

1991 

1991 

1991 

1991 

1991 

1991 

Centrophenoxine and the Aging Nematode, American 

Aging Association Annual Meeting, New York, NY 

Ulcerative Syphilis and Acquired Immunodeficiency 

Syndrome, Regional Meeting of the American College of 

Physicians, Philadelphia, PA 

Variation in Medical Care. University of Pittsburgh School 

of Medicine. Pittsburgh, PA 

Medical Costs: Are Doctors Responding Appropriately'! 

Altoona Hospital, Grand Rounds, Altoona, P A 

Seeing the Way to Cost-EtTective Eye Care. Excel 

Foundation Conference on Eye Care, Delivery, New York, 

Ethical Issues Facing Medicine. The Philadelphia Center, 

Philadelphia, PA 

Economic Imperatives in an Ambulatory Care Program. 

Department of Enviromnental and Community Medicine, 

Robert Wood Johnson Medical School, New Brunswick, NJ 

Quality Care in a Cost-Conscious Environment. The 

Medical College of Pennsylvania, Philadelphia, PA 

Preparing Physicians for the 21st Century: Integrating 

Educational Approaches to Cost and Quality in Graduate 

Medical Education. York Hospital. York, PA 

Physician Opportunities Outside the Traditional Boundaries. 

The Medical College of Pennsylvania, Philadelphia, PA 

Efficient Utilization of the Hospital Laboratory. Grand 

Rounds, Children's Hospital of Philadelphia, Philadelphia 

Appropriate Use of Biotechnology. Health Dimensions, 

Washington, DC 
130 


SHUqB2.eps

1991 

1991 

1991 

1991 

1991 

1991 

1991 

1992 

1992 

1992 

1992 

1992 

1992 

1992 

Panel: Cost-Effective Workup of a Solitary Pulmonary 

Nodule. Cooper University Medical Center. Camden NJ 

The Medicare Fee Schedule, American Academic Medical 

Center Consortium Annual Meeting. Philadelphia 

Changes in Physician Payment Reforn1, Robert Wood 

Johnson Foundation Clinical Scholars Program National 

Meeting, Ft. Lauderdale. FL 

Cost-Effectiveness of an Enteral Feeding Product. Society 

of General Internal Medicine Annual Meeting, 

W ashin,r,ton, DC 

Medical Costs: A New Perspective- Issues in Medicine for 

the Primary Care Physician. St. Margaret's Hospital. 

Pittsburgh, P A 

Rising Costs: The Role of the Medical Practitioner. 

Healthcare Financial Management Educational Foundation, 

Washington, DC 

Impact of the Medicare Fee Schedule on an Academic 

Department of Medicine. Society of General Internal 

Medicine Annual Meeting, Washington, DC 

The Burden of Caring for the I Iomeless in Academic 

Medical Centers Armual Meeting. Society for General 

Internal Medicine, Washington DC 

Administrative Costs in Hospitals. American Federation 

of Clinical Research Arumal Meeting, Baltimore, MD 

Explaining Cost Variations Using Severity of illness 

Measures. Society of General Internal Medicine Armual 

Meeting, Washington, DC 

Financial Incentives and Physician Behavior. Senior 

Management Seminar. The Wharton School 

Economic Considerations of Smoking Cessation. New York. 

NY 

Ar1 Approach to Outcomes Management. American Society 

for Medical Quality. Hershey, PA 

Continuous Quality Improvement. American Society for 

Statistical Control, Philadelphia, PA 
131 


SHUqB3.eps

1992 

1992 

1992 

1992 

1992 

1993 

1993 

1993 

1993 

1993 

1993 

1993 

1993 

1993 

1993 

1993 

Implementing an Outcomes Management System. Taylor 

Hospital, Chester, P A 

Physician Participation in Quality Assessment and 

Measurement. Riddle Memorial Hospital, Media, PA 

Outcomes Management in the 90's. Grand Rounds, 

Medical College of Pennsylvania, Philadelphia. PA 

Upcoming Trends in Outcomes Measurement. Senior 

Management, Medicare/Blue Shield. Camp Hill, PA 

Comparing Quality Measurement in Industry and Health 

Care. American Society for Quality Control, Philadelphia 

General Internists and the Transition to Continuous Quality 

Improvement. Society of General Internal Medicine Annual 

Meeting, Washin1,>ton, DC 

Profiling Physician Behavior. Address to the Managed Care 

Congress, Regional Meeting, New York, NY 

External Monitoring of Quality Care, Council ofTeaching 

Hospitals, Emergency Medicine Directors, Philadelphia, PA 

Managed Care in the 1990's. Keynote Talk, Hospital 

Association of Pennsylvania Annual Meeting, Hershey, PA 

Health Care Reform: Impact on the Hospital Worker, 

American Society Healthcare Employees, Delaware Valley 

Chapter, Philadelphia, PA 

Physician Involvement in Continuous Quality Improvement, 

Riddle Hospital, Media, PA 

The Changing Face of Patient Education. Fifth Annual 

Directors Conference, Schering Managed Care, Charleston, 

Outcomes Management and Health Care Reform. 

Pennsylvania Society of Hospital Phannacists, Norristown, 

PA 

Physician Involvement in Quality of Care Assessment. 

Grand Rounds, Medical College Hospitals, Bucks County 

Campus, Bucks County. PA 

Quality Improvement in the Ambulatory Setting, Prudential 

Health Care Forum on Quality, Horsham, PA 

Quality Improvement and Outcomes Research in Infection 
132 


SHUqB4.eps

1993 

1993 

1993 

I993 

1993 

1993 

1993 

1993 

1993 

1993 

1993 

1993 

1993 

1994 

Control. Annual Meeting of the Association for 

Practitioners in Infection Control. Philadelphia, PA 

Using Clinical Outcomes Data to Improve Pharmaceutical 

Quality. Central Pennsylvania Association, Hospital 

Pharmacy, Philadelphia, PA 

Benchmarking Clinical Outcomes. Prudential Insurance 

Company of America, Corporate Headquarters, Horsham, 

PA 

Health Care Financing and Clinical Care. Medical College 

of Pennsylvania, Philadelphia, PA 

Outcomes Measurement and Management. The National 

Managed Health Care Congress, Washington DC 

The Physician's Role in Phannaceutical Cost Control. 

American Society of Hospital Pharmacists, Atlanta, GA 

The Impact of Outcomes Research on Medical Education. 

The Medical College of Pennsylvania, Philadelphia, PA 

Impact of Outcomes Research on the Phannaceutical 

Industry. Regional Conference, Philadelphia, PA 

Developing Agendas for Physicians in Quality Improvement. 

Delaware Valley Quality Assurance Professionals, 

Plymouth Meeting, PA 

How Physicians Will Respond to Cost Containment. 

Medical Data lntemational, Washington DC 

Phannacoeconomic Factors Involved in the Treatment of 

Acute Hypertension, American Society of Hospital 

Phannacists, Atlanta, GA 

Impact of Outcomes Management on Surgical Practice. 

American College of Surgeons, Eastem Chapter, 

Allentown, PA 

Managed Care: Visions for the 21st Century. Hospital 

Association of Pennsylvania, Hershey, PA 

Peer Ratings and Physician Perfonnance. Northeast 

Regional Managed Health Care Congress, New York, NY 

A Strategy to Improve Patient Satisfaction Using Clinical 

Pathways to Clarify Patient Expectations. Academy for 

Health Services Marketing, San Diego, CA 
133 


SHUqB5.eps

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

Comparison of Clinical Pharmacists and Infectious Disease 

Fellow Based Antibiotic Restriction Programs at a 

University HospitaL Infectious Disease Society of America, 

Orlando, FL 

Administrative Positions as a Career Option Society for 

Generallntemal Medicine, Washington, DC 

Developing Physician Leadership Skills in a Changing 

Environment. Pennsylvania Medical Society Education 

and Trust Corporation, Harrisburg, PA 

Incidence of Sepsis Syndrome in Academic Medical 

Centers. ICAAC Poster Presentation, Orlando, FL 

Innovations in Patient Care. Association Health Services 

Research, San Diego, CA 

Quality Management Initiatives. Council of Teaching 

Hospitals, Rochester, NY 

Applications of Critical Pathways. Academic Medical 

Center Consortium, Boston, MA 

Health Care Agenda for the 90's. Brigham and Women's 

HospitaL Boston, MA 

Public Accountability of Medicine. Children's Hospital of 

Pennsylvania, Philadelphia, PA 

Quality Assessment and Outcomes Management. Fourth 

Annual Critical Care Symposium, Lehigh Valley Medical 

Hospital, Allentown. PA 

Evaluating the Outcomes of Epilepsy. Pfizer, Inc., Chicago, 

IL 

The Impact of Outcomes Data on the Pham1aceutical 

Industry. Cytogen, Inc., Princeton, NJ 

Use of Outcomes Data in Cardiovascular Diseases. 

National Registry for Myocardial Infarcts. Naples, FL 

Critical Pathways and Case Management. Rose Medical 

Center, Park City. UT 

Improving Quality Assessment and Health Care Reform, 

Rose Medical Center, Park City, UT 

Health Refonn in American Medicine. Rotary Club of 

Whales, Medical College of Pennsylvania, Philadelphia, P A 
134 


SHUqB6.eps

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

1994 

Phanmcoeconomics a Quality of Life Studies. Institute 

for lntemational Research. Philadelphia, PA 

Clinical and Financial Outcomes: Important Concepts 

Applicable to Institutional Health Care. Hospital Phannacy 

Advisory Board. Chicago, IL 

Outcomes Assessment in Surgery. Surgical Grand Rounds, 

St. Lukes Hospital, Bethlehem, PA 

Outcomes Management in Medical Education. Grand 

Rounds, Fitzgerald Mercy Medical Center. Darby, PA 

The New Therapies: Who Will Foot the Bill in the New 

Health Care Climate0 Therapeutic Options in Neurology, 

Philadelphia, P A 

Developing Integrated Delivery Systems. Jersey Shore 

Medical Center, St. Simmons Island, GA 

Responses from the Phannaceuticallndustry in a 

Captiated Environment. Bristol-Myers Squibb 

Leadership, Absecon, NJ 

Strategic Planning for Managed Care Environments. St. 

Joseph's Hospital, Sea Isle, GA 

Use of Quality Measures. Academic Medical Center 

Consortium. Boston, MA 

Improving Cost-Effective Clinical Decision Making. The 

Institute for Physician Leadership. Hershey, PA 

Managing Information in a Managed Care Environment. 

Pennsylvania Medical Society, Pittsburgh, PA 

Paying for Quality in Managed Care. The Northeast 

Managed I-lealthcare Congress, New York. NY 

Challenges for Academic Medical Centers. Health Policy 

Institute, Thomas Jefferson University, Philadelphia, PA 

Clinical Outcomes and Pham1acoeconomics. Pennsylvania 

Society of Hospital Phannacists, Philadelphia, PA 

Disease Management for the Pham1aceutical Industry. 

Bristol-Myers Squibb Company, Tarrytown, NY 

Physician Leadership in the Quality Debate. President's 

Forum, American Medical Association, Washington DC 
135 


SHUqB7.eps

1994 

1995 

1995 

1995 

1995 

1995 

1995 

1995 

1995 

1995 

1995 

1995 

1995 

1995 

1995 

lnfonnation Management in Quality of Care. Pennsylvania 

Medical Society. West Conshohocken, PA 

Physician Involvement in Resource Management. Albert 

Einstein Medical Center, Montefiorc Medical Center. 

Bronx, NY 

Managing Health Care in the Rural Environment. 

Armstrong County Memorial Hospital. Kittanning, PA 

Outcomes Management. The Johnson and Johnson 

Wharton Fellows Program, Bryn Mawr, PA 

Quality Improvement Efforts, Philadelphia Chamber of 

Commerce Annual Banquet, Philadelphia, PA 

Quality Measurement and Providers, Regional Leadership 

Conference, Blue Cross ofWestem Pennsylvania, 

Pittsburgh, P A 

Case Management: The Link to Outcomes Management. 

National Case Management Conference, The Medical 

College of Pennsylvania, Philadelphia. PA 

Disease Management Systems. Scientific Advisory, 

Meeting Merck and Co. Plymouth Meeting, PA 

Models of Multi disciplinary Care. Annual Meeting of the 

Permsylvania Respiratory Care Society, Philadelphia, PA 

Improving Efficiency in a Managed Care Environment. 

Grand Rounds, Doylestown Hospital, Doylestown, PA 

Network Development in Managed Care Enviromnents. 

Wyoming Valley Health Care System, Grand Rounds, 

Wilkes-Barre, PA 

Clinical Benchmarking. University Hospital Consortium, 

Philadelphia. P A 

Improving Clinical Decision Making. American Medical 

Association Aimual Meeting. Chicago, IL 

Measuring Hospital Quality: Current Realities and Future 

Goals. Health Services Research in Radiology, Philadelphia, 

Physician Leadership in Guideline Development. National 

Conference Integrating Economics, Product Selection of 

Clinical Pathways, Boston. MA 
136 


SHUqB8.eps

1995 

1995 

1995 

1995 

1995 

1995 

1996 

1996 

1996 

1996 

1996 

I996 

1996 

1996 

Outcomes Measurement and Disease Management. 

Turner/White Communications, New York, l\Y 

Redesigning the Hospitals Approach to Quality 

Measurement. Brandywine Hospital, Brandywine, PA 

Open Versus Closed Fornmlaries. Phannaceutical 

Manufacturers Association Education and Research Institute, 

Philadelphia, PA 

Dealing with the Onslaught of Measures; lessons from a 

survivor. University of Massachusetts Medical Center, 

Westborough, MA 

Demonstrating Best Practices in Academic Medical Centers. 

Association of Academic Medical Centers Annual Meeting, 

Washinh>ion, D.C. 

Comparing the Length of Ventilation on C ABG Patients 

Pre/Post Weaning Pathway. Respiratory Care Association, 

Orlando, FL 

UPHS First Annual Disease Management Forum (Course 

Director), Philadelphia. PA 

Developing a Managed Care Curriculum for Physician 

Educators. Society for General Internal Medicine Annual 

Meeting, Washington, DC. 

Critical Pathways. Jersey Shore Medical Center, Abescon, 

NJ 

Partnership with Managed Care Organizations, Institute for 

International Research, Washington, DC 

Disease Management: New Research Realities. BIO 

Council of Biotechnology Centers Meeting, Philadelphia, 

PA 

Managed Care: Is the Boy Crying Wolf Again? Children's 

Hospital of Philadelphia. Philadelphia, P A 

Quality Care in Managed Care Medicine. Riddle Memorial 

Hospital, Media, P A 

Developing Integrated Delivery Systems. Advisory Hoard 

Company, Washington, DC 
137 


SHUqB9.eps

1996 

1997 

1997 

1997 

1997 

1997 

1997 

1997 

1997 

1997 

1997 

1997 

1997 

1997 

1997 

1998 

Automating Pathways to Analyze Variance. Third National 

Healthcare Conference on Perfonnance Improvement, 

Washington. DC 

Developing Quality Management Programs. York Hospital 

Board Retreat, Washington, DC 

Physician Leadership Skills in the Year 2000. York Hospital 

Medical Staff, York, PA 

Developing Integrated Healthcare. Palmetto General 

Hospital Retreat, Marco Island. FL 

Health Promotion and Disease Prevention. Bryn Mawr, PA 

Predictive Model for Resource Allocation. Academic 

Medicine and Managed Care Forum, Washington, DC 

Balancing Healthcare Costs, Quality and Access Center for 

Clinical Quality Evaluation. Vienna, VA. 

Information System Technology and Improving Healthcare, 

Scottsdale Institute. Scottsdale, AZ. 

Role of Phannacists in Leading Healthcare Systems -

Keynote Address. American Society of Health System 

Pharmacists. Washington, DC 

Merging Hospitals and Leading Change. Pennsylvania 

Hospital Leadership Retreat. Bryn Mawr, PA 

Managing Quality in Health Care: An international 

Comparison- Moderator. Insead, Fountainbleau, France 

Emerging Roles for Internists, Society for General Internal 

Medicine. Washington, DC. 

Outcomes in Obesity Management. Obesity Leadership 

Conference, Naples, FL 

Managing Care in a Integrated Delivery Systems, Annual 

Meeting of the American Medical College, Washington, DC. 

National Quality Award Presentation, National Committee 

for Quality Assurance, Washington DC. 

Cost-Effectiveness and the Community-Based Physician, 

Grand Rounds. Holy Redeemer Health System, Bucks 

County, PA. 
138 


SHUqB10.eps

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

1998 

Managed Care Principles in Practice. John Hopkins 

University, Baltimore, MD. 

Creating New Standards for Excellence. Robet1 Wood 

Johnson Medical School, New Brunswick, NJ. 

Going Beyond Competition in Medicine. Alpha Omega 

Alpha Honorary Society, Philadelphia, PA. 

Seven Trends that will Change American Healthcare. 

Carilion Health System, Roanoke, VA. 

Addressing the Needs of the Elderly American 

Geriatrics Society, Philadelphia, PA 

Managing Risk. The New Healthcare Marketplace 

Conference, University of Syracuse, Syracuse, NY. 

Corporate Partnerships-- Essential Principles for Success. 

Abbott Pham1accuticals, Philadelphia, P A. 

Preparing for the Future in Managing Patient Care: Keynote 

address. Louisiana State University Medical Center, Second 

Annual Disease Management Forum, Baton Rouge, LA 

Pursuing Excellence in Healthcare. Ministry Healthcare 

Leadership Conference, Kohler, WI. 

Partnerships between Academic Medicine and For-Profit 

Companies, Merck, Company. West Point, PA. 

Designing and Implementing Strategies for Improvement. 

National Physician Leadership Forum. YHA, Inc. Dallas, 

TX. 

Leadership Issues in Turbulent Times. Society for Chief 

Medical Officers, San Francisco, CA. 

Prioritizing Issues for Physician Leaders. The Chief Medical 

Officers Forum. The Wl1arton School, Philadelphia PA. 

Health System Development and Implementation. The 

Emest A. Codman Award. Joint Commission of Accrediting 

Organizations, Chicago, IL. 

Disease Management Programs for the Chronically Ill. 

Zeneca Managed Care Symposium, Palm Beach, FL. 

Leading Change in Academic Systems. Harvard School of 

Public Health, Boston, MA. 
139 


SHUqB11.eps

1998 Bringing Disease Management to a National Level. VHA 

Shareholders Forum, Dallas TX. 

1998 The State of the Chief Medical Oiticer Role. The Wharton 

School, Philadelphia, PA. 

1998 Preparing for the Future in Managing Patient Care. 

Louisiana State University Second AmlUal Disease 

Management Forum, Baton Rouge, LA. 

1998 Good Medicine Done Right: Improving Healthcare through 

Disease Management. Institute for llealthcare Improvement 

Annual Meeting, Orlando, FL. 

1999 Creating Economic Value in Hospitals. Hospital Council of 

Western Pennsylvania, Pittsburgh, PA. 

1999 Technology Assessment. Chief Medical Officer Forum. The 

Wharton School, Philadelphia, PA. 

1999 Technology, Costs, and quality. HBSI National Forum. 

Washington, DC. 

1999 Redesigning Clinical Care for Better Outcomes. Physician 

Leadership and Management Program. Chicago, IL. 

1999 Ushering in the New Age of Care Management and Medical 

Informatics. Sisters of Joseph's Physician Leadership 

Forum. Dearborn, MI. 

1999 Seven Trends That Will Change American Healthcare 

T Greater Philadelphia Chamber of Commerce, 

Philadelphia, P A 

1999 The VHA Leadership Award Awardee 

Presentation. VHA Ntl Meeting, Orlando, FL. 

1999 Redesigning Managed Care's Future in Academic 

Delivery Systems. Greater Phila Health Alliance, 

Philadelphia. P A 

1999 Revisiting the Role of Community and Academic Hospitals 

Grand Rounds., Holy Redeemer Health System, Huntin~o>ton, P A 

1999 The Role of Biotechnology in Managed Care. 

Amgen Leadership Conference, Los Angeles, CA 

1999 Delivering the Message About HealthCare. American 

Writers Association. Philadelphia. PA 
140 


SHUqB12.eps

1999 Conflict and Change: How Quality Enters the Coverage 

Decision ECRl, Plymouth Meeting, P A 

1999 Partnering for Profit Through Quality Management. 

American College of Medical Quality, Atlanta, Georgia 

2000 Will Quality Ever Drive the Healthcare Industry? 

APIDM, Philadelphia, P A 

2000 Entering the Intemet Era in Healthcare. Healthcare 

Management Program. The Wharton School. 

Philadelphia, P A 

2000 Understanding Economics of Quality Improvement. 

Institute of Medicine -EtTect of Financing 

Policies on Quality Improvement, Washington DC. 

2000 Patient Safety Issues and Reporting of Errors. Hospital 

Association of Pennsylvania, Harrisburgh, PA 

2000 Strategies to Conquer Quality. National Committee for 

Quality Assurance, Washington, DC 

2000 New Intemet Initiatives to Change the Medical 

Marketplace. KEPRO, Hanisburg, P A 

2000 Physician Leadership on the Net. York Hospital 

Strategic Board Retreat York, PA 

2000 Intemet Intemet Strategies for Quality. American College 

of Medical Quality. Annual Meeting. Dallas. TX 

2000 Enhancing Plan and Provider Relationships. 

Medical Alliance, Burlillb>ton, VT 

2000 Medical EITOr Reduction in a Changing Healthcare 

Environment Consortia Health Plans, Chicago, Ill. 

2000 Leadership in a Challenging Environment 

Borgess Health System, Grand Rapids, MI 

2001 Employee Choices in Health Care Selection Delaware 

Valley HealthCare Coalition, Bucks County P A 
141 


SHUqB13.eps

2001 

2001 

2001 

2001 

2001 

2001 

2001 

2001 

2001 

2001 

2001 

2001 

2001 

2001 

2001 

Clinical and Adminstrative Integration of Benefit Selection 

efirst Benefits Conference, Conshohoken, P A 

Where have all of the ehealth companies gone') 

Thomas Jefferson University, Philadelphia P A 

The Business Case for Quality, Pittsburgh Business Group 

on Health, Pittsburgh, PA 

What Matters to Consumers? Washin,gton Business 

Group on Health, Washington, DC 

Patient Safety- The Employers Role 

MidWest Business Group on Health, Chicago, IL 

Consumer Oriented Health Care- Cemer Corpoaration 

Kansas City, MO 

Patient Safety- What Managed Care and Providers Can 

Do Together? National Managed Care Con,b'Tess, 

Atlanta, GA 

What Patients Want- Consumers in Healthcare 

MidWest Business Group on Health, Chicago, IL 

Providers Reactions to Intention to Treat Quality Data. 

HCN, Milwaukee Wisconsin. 

Where have all of the Healthcare Leaders Gone? 

Greater Philadelphia Health Care Assembly, Medical 

College of Pennsylvania, Philadelphia, PA 

Will There Be a Marketplace for Quality? Frankford 

Health System Philadelphia, PA 

Keynote: Infom1ation Systems in Patient SafetyHospital Infonnation Management Regional MeetingLankenau Hospital, Wynnewood, PA 

Making Medicine Work. Mid Atlantic Venture Fair, 

Philadelphia, PA 

Economic Parameters in Health Services, WEMBA, 

Wharton School, Philadelphia. PA 

Technology and the Role of the Peer Review 
142 


SHUqB14.eps

2002 

2002 

2002 

2002 

2002 

2002 

2002 

2002 

2002 

2002 

2002 

2002 

Organization Third Annual KePRO Conference, 

Harrisburg, P A 

Retum on Investment of Quality Care. Robert Wood 

Johnson Foundation Clinical Scholars Program. Yale 

University School of Medicine, New Haven, CT 

Technology's Retum on Investment in Healthcare 

Widner University, West Chester, PA 

Defined Contributions in Health Care- The National 

Managed Care Congress- Baltimore, MD 

Regulations and Policy Changes. Evanston 

Northwestem Hospital Foundation. Chicago, Ill. 

Accountability and Safety. Maryland Hospital 

Association Keynote. Baltimore, MD 

Guidelines and Quality of Care- Main Line Health 

Cardiology Division, Conshohocken, P A 

lnfonnation Technology for Payers. Physicians, and 

Patients Health Insurers Association of America 

(HIAA), Chicago Ill. 

Making Healthcare Safer. American College of 

Healthcare Executives- Wilmington, DE 

Outcomes Workshop- Making Healthcare Better 

Second Annual Outcomes Management Seminar 

Northwestem Memorial Hospital, Chicago, IL 

Finding Successful Strategies to Change Physician 

Behavior. Phannaceutical Marketing Congress 

Philadelphia, I' A 

The Market Model for Patient Safety. 

The Wharton Healthcare Conference 

Philadelphia, P A 

Lessons for Quality Improvement Organizations 

Board Retreat, WVMI, Inc. Fannington, PA 
143 


SHUqB15.eps

2002 

2003 

2003 

2003 

2003 

2003 

2003 

2004 

2004 

2004 

2004 

2004 

2004 

Patient Safety Lessons for Providers, Employers, 

and Consumers- Wisconsin Health Care Forum, 

Madison, WI 

Patient Safety Officers Training, Harvard University, 

Boston, MA 

Quality of Care Perspectives- National Quality 

Colliquium, Boston, MA 

Organ Transplantation- Improving the Processes of 

Care, Gift of Life, Layfatette Hill, P A 

Organizational Dynamics in Health Organizations 

Traverse City, Michigan 

Where Rubber Meets the Road- Practical Applications 

of Patient Safety- West Virginia Medical Institute 

Board of Trustees, West Sulfur Springs, WV 

Leading Change for Patient Safety- American 

Board of Utilization Review and Quality Assurance 

Annual Meeting, Orlando, Florida 

Changing Physician Behavior: Lessons for the 

Phannaceutical Industry. Healthcare Marketing Council 

New York, NY 

Quality Improvement Organizations: Role of Managed 

Care Plans- Quality Insights of Pennsylvania, Keynote 

Harrisburg, P A 

Patient Safety Advances- Morristown Memorial 

Hospital Grand Rounds- Morristown. N.J. 

Quality Report Cards- Delaware Valley Hospital 

Council- Philadelphia, P A 

Reducing Infection Rates. Keynote- Infectious Disease 

Outcomes Congress, Harrisburgh, P A 

Evidence Based Patient Safety Practices- American 

College of Obstetrics and Gynecology Annual 

Conference, Philadelphia, P A 
144 


SHUqB16.eps

2004 

2004 

2004 

2004 

2004 

2004 

2004 

2004 

2004 

2005 

2005 

2005 

2005 

Ambulatory Patient Safety Practices, National Patient 

Safety Forum, Boston, MA 

Plans and Providers Collaboration Strategies for 

Improving Quality, National Managed Care Congress 

Washington, DC 

Recent Initiatives in Medical Error Reduction, Quality 

Colloquium, Harvard University, Boston. MA 

Physician Perfonnance Measurement: A National 

Perspective. Care Science Conference, Philadelphia, P A 

Healthcare Improvements In the Past Year. Board of 

Trustees Annual Meeting, West Virginia Medical 

Institute, Roanoke, VA 

Evidence Based Medicine: Reducing Variation in 

Clinical Practice- Third Annual Campaign in Quality 

St. Lukes Healthcare, Utica, NY 

Industrial Techniques to Improve Healthcare Efficiency 

Delaware Valley Healthcare Professional SocietyKeynote- Philadelphia, PA 

Patient Safety Innovations for Hospitals and Physicians 

West Virginia Hospital Association, Chareleston, WV 

Management Perspectives on Health Care. Temple 

University Health Care Alumni Association, 

Philadelphia, PA 

Team Work and Communication Strategies to Reduce 

Injury. School of Physical Therapy, Temple 

University 

Rapid Response Teams and Systems Approaches to 

Reducing Errors, New Jersey Hospital Association 

Princeton, NJ 

Disease Management in the Hospital Setting 

Disease Management Society, National Meeting 

Philadelphia, PA 

New Developments in Safety. Harvard Colloquim on 

Quality. Boston, MA 
145 


SHUqB17.eps

2006 

2006 

2007 

2007 

2007 

2008 

2008 

2009 

2009 

2009 

2009 

2009 

2009 

Rapid Response Teams- Greater New York Hospital 

Association Keynote Speaker- Pelham, NY 

Quality: A View from the CEO's Office FOJP 

Annual Conference, New York, NY 

Leadership and Diversity in Healthcarc. Greater New 

York Hospital Association. Baruch College. NY, NY 

Exploring Integrative Approaches to Hcalthcare. 

Urban Zen Initiative. Donna Karan Foundation, NY. 

NY 

Translating Best Practices from the Mainland. 

Keynote Speech- Schneider Regional Medical Center 

St. Thomas, US Virgin Islands 

Running a Hospital in the Big Apple 

Aish lntemational. New York, NY 

Leading Quality from the CEO's Office 

Quality Colloquium at Harvard, Boston, MA 

Challenges for Healthcare Leaders. Keynote 

New Jersey Hospital Association Annual Meeting 

Princeton, NJ 

Pay for Performance Systems- The State of the Union 

New York Business Group on Health, New York 

Health Care Payment Refonn in the US- American 

College of Physicians National Meeting- Meet the 

Professor Session- Philadelphia, PA 

Accountable Care Organizations. Kennedy Health 

System Board- Voorhees NJ 

Health Care Refonn: Implications for Providers 

Delaware Valley Health Executives- Thomas 

Jefferson University, Philadelphia, PA 

Physician Leadership Models in University Based 

Hospital Structures- UMDNJ-Kennedy System Board 

Retreat, Atlantic City, NJ 
146 


SHUqB18.eps

2009 

2009 

2010 

2010 

2010 

2009 

2011 

2010 

2011 

2012 

2012 

Changing Models of Health care Delivery- Federation 

Medical Executive I st Annual Lecture, Philadelphia, 

PA 

Economic Changes in the Hea!thcare Industry 

Gerson Lehman Executive Forum New York, NY 

Stroke and Blood Pressure Management (Moderator) 

Short Hills. NJ 

Implications of Health Refom1 for Health Care 

Leadership- Keynote Address to the l31

h Annual 

Institute for Clinical Systems Improvement and 

Institute for Healthcare Improvement Meeting 

St Paul, Minnesota 

Evidence Based Practice- Panel Discussion 

ICSI/IHI, St. Paul, MN 

Innovation in Healthcare, Farleigh Dickenson 

School of Business- Innovation Summit, Madison, NJ 

Impact of Health Refonn on Foundations 

Morristown, NJ 

Implications of Health Reform on Long Tenn Care 

Keynote Talk- Care One National Meeting 

Meadowlands, NJ 

Homeland Security Issues in Healthcare 

Summit on Resilience. PACE University 

New York, NY 

Contemporary Concepts in Health care Services 

Keynote Speaker- Bracco Diagnostics 

Princeton, NJ 

Implications of Health Care Refonn 

Kean University, Union NJ 
147 


SHUqB19.eps

2012 

2103 

2013 

2012 

2013 

2013 

2013 

2013 

2013 

2013 

2013 

2013 

Where Healthcare is Heading- Panel Presentation 

Quest Diagnostics, National Conference 

Parrsipinany, New Jersey 

Value Based Purchasing and Episodes of Care 

Rutgers University Bowers Conference 

New Brunswick, NJ 

Implications of Federal Health Refonn 

Northeast Business Group on Health, Annual 

Meeting, New York, New York 

The Future of Emergency Medicine 

American College of Emergency Physicians 

New Brunswick, NJ 

Accountable Care and the Vascular Surgeon 

New Jersey Society of Vascular Surgeons Belleville, 

NJ 

Advanced in Technology and Innovation 

ACG Conference, Boston, MA 

Technologic Advancements in Medicine 

Morgan Stanley Healthcare Conference 

New York, New York 

lntemational Lessons in Running Hospitals 

Lainaido Hospital, Netanya, Israel\ 

Innovations in Health care Models of Care 

Mid-Jersey Chamber of Commerce 

New Brunswick, NJ 

Accountable Care Models: Implications on 

Post Acute Care. Alvarez and Marsal Annual 

Conference Kiawah Island, SC 

:Lessons from an ACO Delivery System 

Princeton Club, New York, NY 

Value Based Purchasing in Oncology. 

Northeast Business Group on Health Symposium 

Jersey City, NJ 
148 


SHUqB20.eps

2013 Accountable Care Sustainability 

Marwood Lecture New York, NY 

2014 Eliminating Disparities in Vulnerable Populations 

Symposium on Population Health 

St. Elizabeths College, Madison NJ 

2014 Accountable Care Delivery Systems and Care 

Coordination- Rutgers University Pharmacy 

Conference Somerset, NJ 

2014 A CEO's Lessons from Running Hospitals 

Rutgers University, School of Social Science and 

Health, Newark NJ 

2015 Impact of Provider Reimbursement Systems on 

Phannaceutical Development: Panel Discussion 

Research and Development Summit- Miami, FL 

2015 Consumerism and Health Insurance: Panel Discussion 

Morris County Chamber of Commerce, Morristown NJ 

2015 

2016 

2016 

2016 

2016 

Impact of Provider Reimbursement Systems on 

Phannaceutical Development: Panel DiscussionR and D Summit- Miami, Florida 

Systemic Improvements in Healthcare 

Paralyzed Veterans of America 

Arlington, VA 

Innovations in Medicine 

Lake Nona Impact Forum 

Orlando, FL 

Quality of Care Keynote 

American College of Medical Quality Annual Meeting 

Washinf,rton DC 

Building the Big Data Economy. Panel 

Discussion Bloomberg News~ Newseum 

W ashin.r.,rton DC 
149 


SHUqB21.eps

2016 

2016 

2016 

2016 

2016 

2016 

2016 

2016 

2015 

2015 

2015 

2015 

2015 

Transforming VA Healthcare Using Telehealth 

Keynote: American Telehealth Association 

Minneapolis, MN 

Giving Back through Public Service 

Commencement Keynote, PACE University 

New York, NY 

Technology and Medical Advances 

New Jersey Tech Council Keynote 

Newark, NJ 

Decisions for Healthcare Leaders 

Commencement Keynote, Thomas Jefferson 

University School of Medicine, Philadelphia, P A 

Precision Medicine and Research for Veterans 

LaunchPad Milken Foundation 

National Press Club, Washington DC 

Adapt or Die- Invisible Wounds of War 

Bush lnstitute, Dallas Tx 

Interagency Innovation- Department of Defense 

Collaborations- National Defense University 

Washington DC 

Veteran Well Being: Preventing Suicide 

National Press Club Washington DC 

American Legion Annual Conference 

Future of Veterans Affairs, Baltimore MD 

Paralyzed Veterans of America 

Centers of Excellence, Jacksonville Fl 

Keynote: Ending Homelessness Among Veterans 

Congressional Black Caucus, Washington DC 

American Council for Technology and Industry Advisory 

Council- Working with the Private Sector, Washington, DC 

Using Infom1ation Technology to Advance America's 

Health care Priorities. Department of Defense!V A and 

liovcmment HIT Summit Alexandria, Virginia 
150 


SHUqB22.eps

2015 Academic Medicine and the Veterans Affairs: The 

Impact on American Medicine- AAMC Annual Meeting 

Council of Deans- Baltimore, MD 

2015 

2015 

2015 

2016 

2016 

2016 

2016 

2016 

2016 

2016 

2011 

2016 

Federal Healthcare and Implications for the Future 

Keynote: AM SUS- The Society for Federal Health 

Professionals. San Antonio, Texas 

Technology Applications to the Veterans Healthcare System 

Keynote: AFCEA International Bethesda, MD 

Ineroperability and Integrated Care. Federal Healthcare 

Executive Forum. Washington, DC 

Future Models of VA Care. Paralyzed Veterans of 

America Arlington, VA 

Addressing the Needs of Veterans, Disabled Veterans of 

America, Crystal City, VA 

Innovation in Government. Lake Nona Impact Forum 

Orlando, Florida 

Innovation in the VA Health System 

American College of Health care Executives Annual 

Session, Chicago, IL 

Federal Models of Caring for Patients National 

Association of Conununity Health Centers 

Washington, DC 

VA Healthcare. Commission on Care 

Washington, DC 

Research in Veterans Brain Health 

VA Brain Trust Summit, Wash DC 

Strategic Future of VA 

VA Strategic Summit 

Washington DC 

VA Care vs. Private Sector Care 

VA Heath care 2016, Pentagon City, VA 
151 


SHUqB23.eps

2016 VA's Role in Medical Education 

Resident Fellows Section 

2016 

2016 

2016 

2016 

2016 

2016 

2016 

2016 

2016 

2016 

American Medical Association, Chicago IL 

Advances in Mental Health 

White House Summit on Making Healthcare Better 

White House, Washington DC 

What's Next for VA? 

Keeping the Promise Conference 

Washington DC 

Addiction and Healing: Forum with 

Senators Booker and Menendez 

and the Surgeon General 

Livingston, NJ 

Re-inventing Veterans Health care 

Disabled American Veterans Annual Conference 

Atlanta, GA 

Progress at the Veterans Health Administration 

Veterans Foreign Wars, Annual Meeting 

Charlotte, NC 

Rehabilitation in Disabled Veterans. Paralyzed 

Veterans of America- Keynote Orlando, FL 

Best Practices in Veterans Care 

International Veterans Conference 

Seoul, South Korea 

Advances in Care of CNS Disorders 

Cohen Veterans Network 

Washington DC 

Advancing Veterans Health Care 

American Legion National Conference 

Cincinnati OH 

Blind Rehabilitation Care 

Blind Veterans of America National Meeting 

Milwaukee, WI 
152 


SHUqB24.eps

2016 

2016 

2016 

2016 

2016 

2016 

2016 

2016 

Developments in Veterans Healthcare 

Potomac Officers Society 

Tysons Comer, Virginia 

Phannaceutical Best Practices 

Wisconsin Society of Phannacists Keynote 

Wisconsin Dells, WI 

Suicide Prevention. White House Summit 

on Suicide. White House 

Caregiving in Home Settings 

Elizabeth Dole Foundation Hidden Heroes 

Washinhrton DC 

Precision Medicine 

Association of Academic Health Centers 

Washington DC 

Military Wellncss Initiative 

United State Congress Center 

Washington DC 

Predictive Analytics creating Breakthroughs 

US News and World Report Futures Conference 

Washington, DC 

lntemational Health Technology 

Presentation to the Crowne Prince 

and Piincess ofDemnark 

Washington, DC 

Lectures at University of Pennsylvania: 

1991 

1993 

Health Economics. Governors School of Business, 

University of Pennsylvania, Philadelphia, PA 

Measuling Quality Outcomes in Managed Care, 

University of Pennsylvania Center for Professional 

Development, Conshohocken, P A 
153 


SHUqB25.eps

1993 

1993 

1993 

1994 

1994 

1994 

1994 

1995 

1995 

1995 

1995 

Organizational Incentives fiJr Quality in the Hospital 

Environment. Sixth Annual Managed Care Health Care 

Senior Executive Education Program, The Wharton 

School, Philadelphia, PA 

International Implications of Outcomes Management. 

Leonard Davis Institute of health Economics, Helsinki 

Program in Health Economics, Philadelphia, P A 

Managed Care and Outcomes Assessment, University 

of Pennsylvania Continuing Education Series. 

Conshohocken, P A 

Improving Quality in Health Care. The Wharton 

Annual Healthcare Conference. The Wharton School, 

Philadelphia, P A 

Measuring Quality in Health Care. Grand Rounds, 

Hospital of the University of Pennsylvania, 

Philadelphia, P A 

Managing Cost and Quality in Health Care, \Vharton 

Executive Management Program, Philadelphia, PA 

Health Services Research in Radiology and Surgery. 

Department of Radiology, Sheraton Hotel, Philadelphia, 

PA 

Strategic Planning for Physician Executives, 

Management Development Pro6'fam, The Wharton 

School, Philadelphia, PA 

Rethinking Outcomes Management. Wyeth Ayerst 

Program in Management for Chairs of Medicine. The 

Wharton School, Philadelphia, PA 

Using Outcomes to Improve Efficiency in Drug 

Utilization: Management Program for Pharmacists. The 

Wharton School, Philadelphia, PA 

Outcomes Management. The Johnson and Johnson 

Wharton Fellows Program, Bryn Mawr, P A 
154 


SHUqB26.eps

1995 

1996 

1996 

1996 

1996 

1996 

1997 

1997 

1997 

1997 

1997 

1997 

Measuring Hospital Quality: Current Realities and 

Future Goals. Health Service Research in Radiology, 

Philadelphia, P A 

Re-engineering Health Care. University of 

Pennsylvania Health System Planning Group, Bryn 

Mawr, PA 

Quality Measurement at the University of 

Pennsylvania. American-France Summit in Health 

Economics. Leonard Davis Institute of Health 

Economics, Philadelphia, P A 

Getting Physicians Involved in Managed Care 

(moderator). Clinical Performance Improvement Round 

table. The Wharton School, Philadelphia, PA 

Pasmire Lecture- The Cycle of Life (moderator). 

Presbyterian Medical Center, Philadelphia, PA 

Outcomes Management. Association of Gynecologic 

Oncology Leadership Program. The Wharton School, 

Philadelphia, P A 

Impact of Managed Care of Plastic Surgery. Division 

of Plastic Surgery. University of Pennsylvania. 

Philadelphia, P A 

Leading Into the Future of Anesthesia. Department of 

Anesthesia. Hospital of the University of Pennsylvania, 

Philadelphia, P A 

The Future of Health Care. Penn Business Students in 

Medicine, Philadelphia, I' A 

Health Promotion and Disease Prevention, UPHS, Bryn 

Mawr. PA 

Financing Healthcare. Medical Management 

Conference, 

Presbyterian Medical Center, Philadelphia, P A 

Addressing Healthcare Productivity. Medical 

Management Conference, Hospital of the University of 

Pennsylvania, Philadelphia, P A 
155 


SHUqB27.eps

1997 

1997 

1998 

1998 

1998 

1998 

1999 

1999 

Disease Management under Managed Care. Institute on 

Aging, Philadelphia, PA 

Managing Risk, Grand Rounds Department of 

Medicine, Hospital of the University of Pennsylvania, 

Philadelphia. P A 

Managing Clinical Performance: Creating Competitive 

Advantage. The Wharton School Impact Conference, 

Philadelphia, PA 

Disease Management as an Industry., The Wharton 

School, Philadelphia, P A 

Health Care Management, Japan Quality Assurance 

Institute, Philadelphia, P A 

The Seven Trends That Will Change Healthcare. 

Keynote speaker: Pennsylvania Hospital Leadership 

Retreat, Bryn Mawr, P A 

Quality and Managed Care. Institute of Medicine, 

Healthcare Conference for Congressional Staff 

Philadelphia, P A 

Graduate Medical Education's Changing Face, Medical 

Management Conference, Presbyterian Medical Center, 

Philadelphia, P A 

Lectures at Drexel University School of Medicine 

2002 

2003 

2003 

Teaching Resident and Students about Quality 

Directors of Medical Education, Queen Lane 

Campus 

Best Practice Standards for Physicians 

Drexel University Physicians 

Preventing Medical Liability 11lrough Clinical 

Best Practices, Queen Lane Campus 
156 


SHUqB28.eps

Lectures at Temple University School of Medicine 

2004 

2004 

2004 

2004 

Innovations in Medicine- Medicine Grand Rounds 

Philadelphia, P A 

Improving Satety in Surgical Practices- Surgery Grand 

Rounds. Philadelphia, P A 

Pediatric Best Practices- Pediatric Grand Rounds 

Temple University Children's Hospital, Philadelphia 

PA 

Communication Practices Impacting Outcomes. 

Psychiatry Grand Rounds, Temple University 

Hospital, Philadelphia, PA 

Lectures at Beth Israel Medical Center 

2006 

2006 

2007 

2009 

2013 

2013 

Lectures at Atlantic Health 

Diabetes Disease Management 

Endocrinology Grand Rounds, NY ,NY 

Primary Care Practices in Urban Settings 

Family Medicine Grand Rounds, NY, NY 

Patient Centered Care-Progress in the Past 50 Years 

Medicine Grand Rounds, NY, NY 

Leaming trom China's Hea!thcare System 

Operations Forum, NY, NY 

Medical Best Practices. Medicine Grand Rounds, NY 

Clinical Practices for Medicine Grand Rounds, 

Obstetrics and Gynecology, New York, NY 

2010 Understanding Where Healthcare is Going 

Grand Rounds Medicine and Surgery~ Morristown, NJ 

201! Leadership Roles for Physician Executives- Physician 
157 


SHUqB29.eps SHUqC1.eps

2013 

2013 

The Affordable Care Act 

Surgery Grand Rounds, Morristown NJ 

Technology in the Changing Healthcare Environment 

Advanced Physician Leadership Academy 

David Shulkin M.D. 

Attachment C- Interviews, Radio, Magazines 

Press Quotes 

Diabetes Control in Aisle 3- Modern Healthcare April20, 1998 

Does Standardization Equal Quality? Physicians News Digest April1998 

UPHS Puts Quality Plan in Place: Will it Pay Off- Return on Quality Report- March 15, 

1998 

Preventive Measures- Penn Health August 1997 

Asthma Disease Management Program Links Health Professionals- Drug Topics 

Magazine August 18, 1997 

Health care Leaders for the Next Century- Modern Healthcare September 15, 1997 

Physicians Rate HUP Services- HUPdate- October 1997 

UPHS and Pharmacare Team up on Program for Asthma- Disease Management News 

October 10, 1997 

UPHS: 82.9% of Risk Members will be in DM programs- Disease Management News 

October 25, 1997 

Monitoring Asthma Patient Compliance- Healthcare Business Digest Volume 2(9) 

September 1997 

Mismanged Care? US News and World Report November 24, 1997 

Transplant Survival is greatly Improved- Philadelphia Inquirer December 13, 1997 

Managed Care gathers the power of data Philadelphia Inquirer December 14, 1997 

For Better Health Info on the Net- Philadelphia Business Journal March 17-23 2000 

Quality of Care and Coverage- ERCI Conference Spotlights- The American Journal of 

Managed Care January 2000 page 126-129 

Physician Advocates Quality Medicine as Best Path to Successful Practice- The Quality 

Indicator April 2001 pages 1-5. 

Recognizing Quality- Modern Healthcare February 2, 1998, page 31. 

Health System wins Major National Award- Daily Pennsylvanian February 4, 1998 

UPHS Develops DM Partnerships with CHI, Aetna. US Healthcare- Disease 

Management News January 25. 1998 

National Quality Award given to Penn System- Philadelphia Business Journal February 

13-19 1998 

Feds could pay HUP not to train residents- Daily Pennsylvanian October 8, 1997 

50 Most Influential Physician Executives- Modern Healthcare May 9, 2011 

• Atlantic Health System and Continuum Health Alliance Announce CollaborationAlternative Press September 7, 2011 

Aetna Considers Carving out Specialized Care Agreements- Philadelphia Business 

Journal February 20-26 1998 

TakingabigRisk.com Modern Health care February 21, 2000 page 37-41. 
158 


SHUqC2.eps

Shulkin, Bernard Start Internet OM Related Services Company- Disease Management 

News Volume 5( 4) 1999 page 1. 

Strategic Physician Recruiting- Health Leaders March 2012 

Hospitals, Docs are assuming leadership in majority of ACO Governance structuresACO Business News Volume 3(3) March 2012 

Up and Comers Yearbook- Class of 1997- Supplement to Modern Healthcare 

September 17, 2007 

Doctors and Health Plans: Can They Possibly Get Along? Medical Practice Bulletin 

Volume 1, 1999 

Payors expand quality incentives Physicians News Digest November 2003 

Health Experts Look Beyond HMOs for Better Approach- Wall Street Journal March 3, 

2003 

Quality Improvements needed in healthcare Observer Dispatch June 3, 1999 

Good news: The doctor really will see you now. Philadelphia Inquirer July 20, 1997 

University Program sets standards in care- Daily Pennsylvanian January 25, 1999 

Consultation about costs needed- Medical World News- June 26, 1989 

• After Dot-com experience, Doctor Returns to 1'' Love. Philadelphia Business Journal 

August 16-22 2002 

New professional society launches Patient Safety Officer Society- Formulary March 

2002 Volume 37 page 1 

Penn Health strikes online deal with VHA. Philadelphia Business Journal October 9-15 

1998 

Making the Grade- Wall Street Journal- October 19, 1998 

Physicians Wary of JCAHO Rules on Medical Errors- Physician Financial NewsVolume 19, September 15, 2001 

University of Pennsylvania Hospital Extends OM System- The Quality Letter December 

1998 

Taking the pulse of Medicine- Philadelphia Inquirer November 6, 2000 

Triple Crown Healthier- Pennsylvania Current February 25, 1999 

Technicality Costs Hospitals 20M- Philadelphia Business Journal May 15-21 1998. 

Medication Error cut in area- Philadelphia Inquirer January 6, 2005 

Voyage to the Web- Philly Tech October 2000 Cover Story 

HUP Ranked among nations best hospitals- July 15, 1999 

Financially Press UPHS seeks outside funding of OM programs- Disease Management 

News July 25, 1999 

Beeper users sent back to phone age. Philadelphia Inquirer May 21, 1998 

Bypass Mortality Rates Fall- Philadelphia Inquirer 

Karpas Center Celebrates 25 Years on First Ave- Town and Village October 5, 2006 

• Accountable Care Organizations- New Jersey Business 933:8214 2014 

ACO Pioneers- :Q and A with Leaders from the Nebraska Medical Center and Atlantic 

Health: Beckers Hospital Review- March 20, 2011 

A Long Legal Battle Looms as Hospitals Fight Closure- The New York Sun Mary 7, 2007 

The Quality Quagmire- Managed Healthcare News Volume 17(1):January 2001 
159 


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Charity care puts hospitals in need of a transfusion- Philadelphia Inquirer March 29, 

1998 

Affordable Care Act: Prescription for Change in NJ Healthcare NJ Spotlight June 18, 

2012 

Making the Grade- Wall Street Journal October 19, 1998 

A Hospital CEOs Secrets to Good Healthcare Prevention Magazine March 14, 2009 

How to Tell Your Doctor to Wash his Hands: The Nice Way for Patients to Get ToughBottom Line Personal Volume 30(15) August 1, 2009 

An AGO- What's That? Hospital and Health Networks Daily July 18, 2012 

Quote of the Day- AIS's Health Business Daily- April2, 2012 

A new tool to compare hospital performance- Philly.com November 4, 2011 

Readmissions up but deaths down- Philadelphia Inquirer- September 29, 2006 

Ailing Health Care System Finds Reform a Salve, Not Cure- All The Business Edge of 

Morris County February 2011 Issue 2 No 3. 

Finding a Way to Ask Doctors Tough Questions- Wall Street Journal March 4, 2009 

In Morristown, Changing the Industry's silo mentality- NJ Biz October 7 2013 

The high-deductible Trap Modern Healthcare June 22, 2013 

Shulkin to Chair Board of NJ Council of Teaching Hospitals- Morristown Patch January 

7, 2013 

Hosptials may take hit over cliff deal- Star Ledger January 4, 2013 

Accountable Care Organizations- MD Advisor Fall2012 

Schedules for Medicare fees are studied- Philadelphia Business Journal December 9-15 

1991 

Beth Israel Medical Center recruiting 50 bilingual Asian staff to enhance its services to 

the Chinese community- Sing Tal Newspaper August 11, 2005 

Beth Israel Kings Highway to welcome new President- Daily Bulletin of Brooklyn July 29 

2005 

Doctors at Teaching Hospitals face pay cuts, study says- Philadelphia Inquirer 

December 4, 1991 

ACOs and Market Share: Could care Coordination Drive Monopolization? Becker's 

Hospital Review- November 7, 2013 

Reform Update- AGO Executives say experience rocky, but informative , Modern 

Healthcare January 8, 2014 

Healthcare reform put into action- Star Ledger 933(7650) 2013 

24 hour Visitation? MRC Times 933(7743). 

Throwing Out a Net For Good Health Care. Philadelphia Inquirer Apri116, 2000 

Changing the State of Today's Health care Quality and Safety. FOJP Focus Volume 3 

Winter 2007 

Providers and Businesses Begin Addressing the Healthcare Elephant in the Room 

Morris County Chamber of Commerce Business Edge August 2012 

New Jersey Hospital Launches Storefront Modeled on Apple Genius Bar- Medcity News 

12/3/14 
160 


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New Jersey Hospital sets up an on-site Digital Health Store- MobiHealth News January 

15,2015 

Do Hospitals Need Genius Bar-Like Services - Hospitals and Health Networks January 

15,2015 

Technology Stores Added to Health System Offerings- Hospitals and Health Networks 

February 10, 2015 

Hospital Taps Mobile Tech to Connect with Patients- Daily Record 12/8/14 

Tech Support at the Hospital? Morristown Medical Center Says, "Why Not?"- Healthcare 

Design 1/29115 

New Jersey Hospital Launches Health Center Modeled on Apple's Genius Bar 

PSFK.com 12115/14 

Hospital opens Apple-Style Genius Bar for Healthcare - Advisory.com 12115/14 

What one hospital learned from the Apple Store. Healthioutcomes.com 12/11/14 

• Health Management? There's an APP for that and Morristown's Hospital Store Will 

Make it Work for You. NJBiz, 12117/14 

Media Interviews: 

Frankie Boyer Health Radio Show- Visiting Hours are Never Over- March 2014 

WL TW New York Radio interview with Nina Del Rio on visiting hours- March 2014 

How to Choose a Good Doctor- Radio Jim Bohannon show 

Market Watch Looking for a New Doctor? Its kind of like dating. WL TW New York 

Health Leaders Magazine (Philip Betbeze) 7-2-15 

The Year in VA and Military Medicine (John Gresham) 9/15 

New Executives at VA- Fed News Radio (Emily Kopp) 9/15 

USA Today interview for Veterans Day special edition supplemental published Nov 2015 

interviews took place in September 2015 

VA Vacancies -NBC News (Rich Gardella) 10/7115 

• Veterans Day Special Supplemental (Reporter- USA Today) 11/2015 

Interview with Pitt Med Alumni Magazine ( Nick Keppler) 11/2015 

Fed News Radio (Emily Kopp) November 2015 

Federal Practitioner (Q and A with no reporter listed) 

http://www.mdedge.com/fedprac/article/1 06300/new-view-va December 2015 

AZ Central, "VA Inspectors reject blame for delayed disciplining of Phoenix Executives 

(Dennis Wagner) 12/15 

Federal Practitioner Profile Dr. Shulkin' s January 2016 (no reporter listedhttp://www.mdedge.com/fedprac/article/1 05039/new-va-under-secretary-health-focusesaccess-employee-engagement 

• The Military Advantage Slog (Tom Philpott) March, 2016 

Bloomberg USH was a panel participant at this Newseum event: PUSHING THE 

BOUNDARIES OF HEALTHCARE INNOVATION: Personalized Care and Cancer 

Treatment In the Age of Big Data 04/2016 

• Advisory.com (Eric Larsen) 5/2016 

USA Today, access to care and wit times (Donovan Slack) 5/2016 
161 


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Philadelphia Inquirer (Sam Wood) 5/2016 

Washington Post and Bloomberg (Reporters: The Washington Post -Laurie McGinley 

and Bloomberg- Justin Sink, Forbes Mathew Herper). 06/2016 

White House Moonshot - Dr. Shulkin did a mini satellite media tour in which he did 6 

back to back telephone interviews on Moonshot . (Leo Shane- Military Times) 

USA Today and Associated Press (Multiple Reporters) 07/2016 

USA Today, NYT, Etc- Media Avail at roundtable discussion to announce results of 

largest analyses of Veteran Suicide - 07/2016 

Gannett News (Keith Ryzewicz) 07/2016 

Year in VA & Military Medicine Magazine (Charles Oldham) 8/29/16 

NPR interview on VACAA Hiring Initiative (Qui! Lawrence) 9/28/2016 

DC VA Medical Center site visit by Crowned Prince Fredrik of Denmark- USH 

interviewed by Danish TV on VA's future strategic vision. 9/29/16 

ReachMD/iHeart Radio Interview (Program hosts Mark Masselli and Margaret Flinter) 

10/6/16 

The Business of Government Hour (Michael J. Keegan, host) 10-6-16 

USA Today (Reporter Donovan Slack I Exclusive: VA shuffles managers, declares 'new 

leadership') 10-18-16 

U.S. News & World Report (Michael Schroeder) 12/16 

USA Today interview (Donovan Slack) Exclusive: Internal documents detail secret VA 

quality ratings, 12/16 

NPR on Choice Hiring (Qui! Lawrence) 12/16 
162 


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9. Agreements or Arrangements 

XX See OGE Fonn 278. (If, for your nomination, you have completed an OGE Fonn 278 

Executive Branch Personnel Public Financial Disclosure Report, you may check the box here to 

complete this section and then proceed to the next section.) 

As of the date of filing your OGE Form 278, report your agreements or arrangements for: 

(1) continuing participation in an employee benefit plan (e.g. pension, 401k, deferred 

compensation); (2) continuation of payment by a former employer (including severance 

payments); (3) leaves of absence; and (4) future employment. 

Provide information regarding any agreements or arrangements you have concerning (1) 

future employment; (2) a leave of absence during your period of Government service; (3) 

continuation of payments by a former employer other than the United States Government; 

and (4) continuing participation in an employee welfare or benefit plan maintained by a 

former employer other than United States Government retirement benefits. 

~itatus and Terms of Any Date A1~reement or Arrangement Parties (month/year) 

None 

10. Lobbying 

In the past ten years, have you registered as a lobbyist? If so, please indicate the state, 

federal, or local bodies with which you have registered (e.g., House, Senate, California 

Secretary of State). 

• None 

11. Testifying Before the Congress 

(A) Do you agree to appear and testify before any duly constituted committee of the 

Congress upon the request of such Committee? 

Yes 
163 

[Letters from the Office of Government Ethics follows:] 


SHUqGEltrX.eps

UNITED STATES OFFICE OF 

GOVERNMENT ETHICS 

The Honorable Johnny Isakson 

Chairman 

Committee on Veterans' Affairs 

United States Senate 

Washington, DC 20510 

Dear Mr. Chairman: 

In accordance with the Ethics in Government Act of 1978, I enclose a copy of the 

financial disclosure report filed by David J. Shulkin, who has been nominated by 

President Trump for the position of Secretary, Department of Veterans Affairs. 

We have reviewed the report and have obtained advice from the agency concerning any 

possible conflict in light of its functions and the nominee's proposed duties. Also enclosed is an 

ethics agreement outlining the actions that the nominee will undertake to avoid conflicts of 

interest. Unless a date for compliance is indicated in the ethics agreement, the nominee must 

fully comply within three months of confirmation with any action specified in the ethics 

agreement. 

Based thereon, we believe that this nominee is in compliance with applicable laws and 

regulations governing conflicts of interest. 

Enclosures 

1201 New York Avenue, NW, Suite 500 I Washington, DC 20005 

www.oge.gov 
164 


SHUqGEltrX1.eps

Walter M. Shaub, Jr. 

Director 

Office of Government Ethics 

Suite 500 

1201 New York Avenue, N.W. 

Washington, D.C. 20005-3917 

Dear Director Shaub: 

DEPARTMENT OF VETERANS AFFAIRS 

Designated Agency Ethics Official 

February 1, 2017 

I am enclosing a supplement to the ethics agreement that David J. Shulkin 

signed on January 27, 2017. Based on my review of the ethics commitment made in 

this supplement, it is my opinion that there will be no unresolved conflicts between his 

financial interests and the duties that he will be expected to perform as Secretary. 

Enclosure 

Mark 

~w Jaynes 

Alternate Designated Agency Ethics Official/ 

Deputy Chief Counsel 
165 


SHUqGEltrY.eps

UNITED STATES OFFICE OF 

GOVERNMENT ETHICS 

The Honorable Johnny Isakson 

Chairman 

Committee on Veterans' Affairs 

United States Senate 

Washington, DC 20510 

Dear Mr. Chairman: 

February 2, 2017 

By letter dated January 27,2017, the Office of Government Ethics (OGE) transmitted to 

the Committee the financial disclosure report and ethics agreement of David J. Shulkin in 

connection with his nomination for the position of Secretary, Department of Veterans Affairs. 

Enclosed are a letter from the Department of Veterans Affairs and a letter from Dr. Shulkin 

supplementing Dr. Shulkin's ethics agreement. 

We have reviewed this additional snbmission and have also obtained advice from the 

Department of Veterans Affairs conceming any possible cont1ict in light of its functions and 

Dr. Shulkin's proposed duties. Based on the infonmJtion provided, OGE continues to believe 

that Dr. Shulkin is in compliance with applicable laws and regulations goveming conflicts of 

interest. 

Enclosures 

Sincerely, 

WALTER 

SHAUB j 

Walter M. Shaub, Jr. 

Director 

1201 NEW YORK AVE NW•SUITE SOO·WASH1NGTON DC·20005 
166 

[Letters from David J. Shulkin, M.D., to the Office of General 

Counsel, U.S. Department of Veterans Affairs:] 


SHUqOGCltr1a.eps
167 


SHUqOGCltr1b.eps

Ms. Tammy Kennedy 

Page 2 

substantially in any particular matter that to my knowledge has a direct and predictable 

effect on the financial interests of the entity for as long as I own it, unless I first obtain a 

written waiver, pursuant to 18 U.S.C. § 208(b)(1 ), or qualify for a regulatory exemption, 

pursuant to 18 U.S.C. § 208(b)(2). 

I have an agreement with Hutchinson Biofilm Medical Solutions Ltd. that entitles 

me to receive a grant of stock options from the company if, at any time in the future, the 

company issues stock options. I will not participate personally and substantially in any 

particular matter that to my knowledge has a direct and predictable effect on the 

financial interests of Hutchinson Biofilm Medical Solutions Ltd., unless I first obtain a 

written waiver, pursuant to 18 U.S.C. § 208(b)(1 ), or qualify for a regulatory exemption, 

pursuant to 18 U.S.C. § 208(b)(2). 

I will divest my interests in the following entities within 90 days of my 

confirmation: Amazon, Bank of America, Citigroup Inc., JP Morgan Chase, Morgan 

Stanley, Wells Fargo, and M& T Bank Corp. With regard to each of these entities, I will 

not participate personally and substantially in any particular matter that to my 

knowledge has a direct and predictable effect on the financial interests of the entity until 

I have divested it, unless I first obtain a written waiver, pursuant to 18 U.S.C. 

§ 208(b )( 1 ), or qualify for a regulatory exemption, pursuant to 18 U.S. C. § 208(b)(2). 

I understand that I may be eligible to request a Certificate of Divestiture for 

qualifying assets and that a Certificate of Divestiture is effective only if obtained prior to 

divestiture. Regardless of whether I receive a Certificate of Divestiture, I will ensure that 

all divestitures discussed in this agreement occur within the agreed upon timeframes 

and that all proceeds are invested in non-conflicting assets. 

I have been advised that this ethics agreement will be posted publicly, consistent 

with 5 U.S.C. § 552, on the website of the U.S. Office of Government Ethics with ethics 

agreements of other Presidential nominees who file public financial disclosure reports. 

Sincerely, 

, 

I 

David Shulkin 
168 

Chairman ISAKSON. We appreciate your service and your 

testimony. 

For the Members’ purposes, we are going to have at least two 

rounds of questions. We are going to make sure everybody has 

plenty of time to ask. We have a little bit of a gymnastics that is 

going on right now, so we will make sure everybody has time. 

I would like for every member of the VSOs or the VSO representatives who are in the audience to please stand. The Veterans of 

Foreign Wars. [Applause.] 

I want you all to understand something. You are the reason we 

are here. We are not the reason you are here. You are the reason 

we are here, to make sure we get the VA working as well as we 

can, as efficient as we can, and we thank you for your service to 

the country. 

Now, I am going to ask Dr. Cassidy to come up and take my 

place in the chair until either Senator Moran gets back or I get 

back, and we will go back and forth, and my staff will tell you who 

to call on next. We will try our best to go Democrat, Republican, 

Democrat, Republican. 

If you all do not mind, I am going to turn it over to Dr. Cassidy. 

Senator CASSIDY [presiding]. OK. 

Senator Sullivan. 


SHUqOGCltr2.eps
169 

HON. DAN SULLIVAN, 

U.S. SENATOR FROM ALASKA 

Senator SULLIVAN. Thank you, Mr. Chairman and Dr. Shulkin. 

Welcome. Congratulations. I very much appreciate your service, 

your desire to continue to serve. I appreciate your family’s service. 

I know it is a team effort and thank you. 

You know, Alaska, my State, we have more vets per capita than 

any State in the country, and I appreciate very much your continued commitment, or your commitment as the Under Secretary, to 

come up to Alaska. I think you and I—it is safe to say we had a 

memorable trip up there. We met with hundreds of Alaskan veterans. I think you saw the deep patriotism that is embedded in the 

heart of every one of my constituents, the toughness, but also a lot 

of the unique challenges which you have been working with us on. 

I very much appreciate it. 

Let me begin by trying to get a few commitments that relate to 

that. You came up as part of your Under Secretary confirmation 

process to the State, but if confirmed, can I get a commitment from 

you to come back to Alaska, and for you and I to spend some time, 

not only in the urban areas but some of the more very, very rural 

parts of the State, where, again, we have veterans all over? 

Dr. SHULKIN. Senator, we had a very good trip and there is nothing I would enjoy more than doing it again with you. 

Senator SULLIVAN. Great. I take it that is a yes. 

Dr. SHULKIN. Yes. 

Senator SULLIVAN. Great. 

If confirmed, will you continue to work on the Alaska Pilot Program, which you initiated, in part, because of our trip together, 

which worked on addressing some of the unique challenges? I want 

to commend you for your focus on that, but as you know we still 

have work to do. Will you commit to me, if confirmed, to continue 

to work on those unique challenges that we have in the State? 

Dr. SHULKIN. Well, Senator, first of all, I want to thank you, because you have been tireless in insisting that we get the program 

working. So, many of the pilots that we began, that are now spread 

throughout the country, actually started in Alaska, and I think we 

have demonstrated that it is now working better because of many 

of the initiatives that you started. 

Senator SULLIVAN. Well, it is a team effort. 

Dr. SHULKIN. Yes. 

Senator SULLIVAN. I am glad that you and I worked together on 

these, and I want to continue to do that if you are confirmed. 

You know, speaking of a team effort, you and I have had the opportunity, particularly on a lot of plane flights and things in Alaska, and hearings and office visits, to talk about a lot of issues, 

Alaska-related, national-related. 

One of the things I did for this confirmation process was I 

reached out directly to the veterans in my State, and said, ‘‘Hey, 

what questions would you want to ask the incoming Secretary?’’ So, 

as you can imagine, we had dozens of responses, which I am going 

to relay a few here. The ones that we do not have time to discuss 

in the hearing we will submit for the record. 

The first one meant a lot to me. It is from an Alaska veteran by 

the name of Bob Thoms. Cajun Bob is his nickname. He lives in 

170 

the Mat-Su Valley. This is somebody who has bled for his country. 

This is a Marine who has received six Purple Hearts, Silver Star, 

he was on the cover of Life magazine during the Battle of Hue City, 

Vietnam veteran. He is a hero among us. 

I am sure a lot of the veterans in the audience can relate to this. 

He indicated, you know, an interest, certainly, in the issue, but still 

a deep distrust of VA. He is nervous that your appointment as Secretary is going to be more of the same, because, as you know, there 

has been promises and promises and promises, generations of 

promises. His focus has been where people are not held accountable 

and veterans are stuck in a system that works against them and 

not for them. 

His question regarding your nomination, and vets like him, is he 

said he was hoping for someone who—and forgive the language 

here; it is a Marine—would kick ass and take names with regard 

to being the Secretary. 

How can you assure veterans like Cajun Bob and others, not only 

in Alaska but throughout the country, that some of the big focuses 

that President Trump has talked about, on really shaking up the 

VA, are going to happen under your watch, when, to be honest, you 

have been part of the outgoing administration? This concern was 

a common theme from a lot of the questions we received. If you can 

answer that I would be very appreciative, and I know Cajun Bob 

would too. 

Dr. SHULKIN. Well, first of all, I think when you and I go back 

to Alaska we should go meet with Cajun Bob. I think he would love 

that. 

Senator SULLIVAN. You would love that. 

Dr. SHULKIN. Yes. 

Senator SULLIVAN. I would love that. 

Dr. SHULKIN. Yes, and we will ask him how we are doing. 

But, look. I think what Cajun Bob is saying is really important. 

If you do not have trust in the group that is empowered to take 

care of you and provide you services, you cannot do your job very 

well. So, —— 

Senator SULLIVAN. Do you think the VA has trust right now? 

Dr. SHULKIN. I think that trust was eroded, particularly with the 

wait time crisis in April 2014, and many people lost trust. We 

know, when we first began to measure this last year, our trust 

level with veterans was at 41 percent. Today it is at 61 percent. 

So, I think that we are slowly regaining trust, but we have a long 

way to go. 

What I would say to Cajun Bob is that, look, I approach things 

first as a doctor, and as a doctor I know no matter how smart I 

think I am, or if I, you know, did the best in my medical school 

class, if my patient does not trust me, they are not going to listen 

to what I have to say, then I am not going to be able to help them. 

So, I think that is very important. 

As a health care executive, I look at our system in VA and I say 

if we do not have a modern system that is responsive to our veterans’ needs, that we cannot perform our function. One of the 

things that I think most people would tell you about me is I do not 

have a lot of patience, and I am going to be serious about making 

171 

these changes and regaining that trust. If I do not do it, I should 

be held accountable and you should replace me. 

Senator SULLIVAN. Thank you. Thank you, Mr. Chairman. 

Senator CASSIDY. Ranking Member Tester. 

Senator TESTER. Yes. Thank you, Senator. 

When you interviewed for this job, and had to visit with the 

President, and you agreed to take the job, were there any conditions attached? 

Dr. SHULKIN. I did have a chance to speak to President Trump, 

President-Elect at that time, about this position, and what we 

spoke about, he asked me several questions. He said, ‘‘Tell me what 

is your view on what is happening in VA now—’’ 

Senator TESTER. OK. 

Dr. SHULKIN [continuing]. ‘‘What you think needs to be done and 

what are the things that have to essentially occur?’’ 

Senator TESTER. Yep. 

Dr. SHULKIN. We shared the common vision that we have to do 

a lot better for our veterans. 

Senator TESTER. Gotcha. 

Dr. SHULKIN. We did not have specific preconditions in this job, 

and he knows that I would follow my values and do what I think 

needs to be done. 

Senator TESTER. So, there were no conditions attached? 

Dr. SHULKIN. There were no conditions. 

Senator TESTER. Did you talk about privatization at all? 

Dr. SHULKIN. Yes, we did. 

Senator TESTER. What was his definition of privatization and 

what is yours? Are they the same? 

Dr. SHULKIN. Well, I did not ask him his definition. I told him 

what I thought needed to happen, and—— 

Senator TESTER. Tell me what that definition is. 

Dr. SHULKIN. What I told him is that I am a strong advocate for 

the VA, that the services that are available in VA are not available 

in the private sector, and that my view of where VA needs to go 

is an integrated system of care—— 

Senator TESTER. OK. 

Dr. SHULKIN [continuing]. Taking the best of VA and the best in 

the community, and that is what I would work toward. 

Senator TESTER. OK. You have mentioned before that the wait 

time or the mileage is what you would use. So, give me your definition. If I am a veteran and I have got a problem—say I have a 

cold—and I want to go to my local doc. Are you going to let me do 

that, or are you going to say, ‘‘No. Go to the nearest VA facility,’’ 

if there is one down the block? 

Dr. SHULKIN. Well, I think there are two parts to your question, 

because it is really the key issue. How do you design a health care 

system that works for veterans? I would not have designed it based 

upon mileage and on wait time. 

Senator TESTER. OK. That is fine. 

Dr. SHULKIN. OK? I would design it based upon clinical need. 

What we really want to do is make sure that the veteran can get 

to the services that they need in health care in a timely fashion. 

That is why I focused on urgent care issues. That is why there is 

172 

now primary care, same-day access and mental care—mental 

health same-day access in every VA across the country. 

For somebody who needs to see their doctor that day, they should 

be seen. If they cannot be seen in the VA, they should be seen in 

their community. 

Senator TESTER. That goes for any condition? If they cannot be 

seen that day—so of the docs in a hospital or a CBOC are booked 

up and somebody comes in and has the flu, if they cannot get in 

you send them to the doc—send them to local hospital or local 

clinic? 

Dr. SHULKIN. Senator, what I am talking about is a clinical definition of urgent care. 

Senator TESTER. OK. Gotcha. 

Dr. SHULKIN. I do not want any veteran in this country—— 

Senator TESTER. That is—the urgent care—— 

Dr. SHULKIN [continuing]. In harm. 

Senator TESTER. Yeah, I gotcha. 

Dr. SHULKIN. OK? For a cold, OK, now you are—— 

Senator TESTER. That is—— 

Dr. SHULKIN [continuing]. Getting a doctor’s advice—— 

Senator TESTER. Yeah, yeah. 

Dr. SHULKIN [continuing]. We may be able to help you over the 

telephone through telehealth, et cetera. 

Senator TESTER. OK. That is fine. 

So, can you talk a little bit about the Choice Program and what 

has—because, I mean, that has kind of been your baby, right? Can 

you tell me why a veteran, for example, in Plentywood, MT, would 

be on a telehealth screen to a doc within a clinic or CBOC, and 

that doc tells that veteran that he needs a chest x-ray, and then 

they have to go through the VA to get confirmation that that chest 

x-ray actually is going to be taken care of the by the VA, and 2 

weeks later that person gets a chest x-ray? 

Dr. SHULKIN. Yeah. I cannot tell you that that makes any sense. 

What we did in the Choice Program was we added a layer of additional administrative complexity, where instead of the VA being 

able to help the veteran, as they always did, you now had to go 

through a third-party administrator. That led to a delay in care, in 

many cases, too many cases. 

Senator TESTER. Yeah. 

Dr. SHULKIN. You have been describing a few already. 

Senator TESTER. Yeah. 

Dr. SHULKIN. We need to take that layer of complexity out. The 

VA needs to take back the customer service—— 

Senator TESTER. OK. 

Dr. SHULKIN [continuing]. And the scheduling. 

Senator TESTER. Excuse me, because I framed it wrong. I am not 

even talking about the ones who go to the Choice Program. I am 

talking about the ones that have VA care, where a VA doc looks 

at them and says, ‘‘You need an x-ray,’’ yet it takes 2 weeks to get 

that x-ray. This is in a private facility, by the way, that is contracted with the VA, and it takes 2 weeks to get the x-ray done. 

I mean, that makes no sense whatsoever. 

Dr. SHULKIN. It makes no sense whatsoever. 

Senator TESTER. What can we do to fix it? 

173 

Dr. SHULKIN. Well, what we have to do is, first of all, we do know 

the Choice Program has added complexity. If what you are saying 

is there is a delay in getting contracted care—right? 

Senator TESTER. Right. 

Dr. SHULKIN. When a doctor orders an x-ray, there should not be 

a lot of intermediary steps there. We should be able to go directly 

and be able to get that x-ray. 

Senator TESTER. I gotcha. What can be done to fix it, though? 

Then I will kick it off—— 

Dr. SHULKIN. Well—— 

Senator TESTER [continuing]. Because I am out of time. 

Dr. SHULKIN [continuing]. We are going to remove the bureaucracy in between, because there is no benefit to that 2-week delay. 

Senator TESTER. We will get to Choice on the next round. Thank 

you, Mr. Chairman. 

Senator CASSIDY. Yes. 

Next is Senator Rounds. 

HON. MIKE ROUNDS, 

U.S. SENATOR FROM SOUTH DAKOTA 

Senator ROUNDS. Thank you, Mr. Chairman. 

Dr. Shulkin, first let me begin by just saying that I appreciated 

the opportunity to visit with you in my office the other day. I 

shared with you then that I appreciated the way that you came 

into the VA. You are one of the guys that came in when—even in 

the campaigns they were not talking about Washington as a 

swamp yet. They were talking about the fact that—and on several 

occasions, with Mr. McDonald, Secretary McDonald, we talked 

about the fact that you two guys came in knowing that you were 

in the middle of something that you had to fix. It was at a time 

in which you had a billion-dollar overcost or an overrun on one single hospital in Colorado, yet you guys came in, and you came in 

with the intent of fixing and making things better for veterans, and 

I appreciate that. 

At the same time, I want to just touch on a couple of issues that 

you and I have talked about in the past, that I want to get into 

a little bit more today, as we said we would during that meeting 

in my office. 

First of all, the Black Hills VA system in Hot Springs, SD, 

where, as you know, there is a host of individuals there that 

have—for literally since that town was created—serviced veterans 

in in-treatment facilities. They have also made it very clear that 

they want to continue that. As a matter of fact, they are one of 

your five-star facilities in the United States. 

Secretary McDonald had suggested some significant changes 

there. In our meeting the other day, you indicated a willingness to 

take a look at finding something that will work for the community 

of Hot Springs in their desire to serve veterans. Would you expand 

on that a little bit, and once again just commit that you will take 

a second look at it and see what we can do to make this work, for 

the veterans, to make it better for them, in that whole area? It is 

not just South Dakota. It is Wyoming. It is Colorado. It is Nebraska as well. 

174 

Dr. SHULKIN. Yeah. I think it was the afternoon after we met, 

I already had a chance to get on the phone with the VISN director 

and the facilities director out in that area, and I had them go 

through their rationale about how they got to their decisionmaking. 

I had some additional questions, much like you, and I appreciate 

you bringing those to my attention. 

We are going to re-look at this. There were actually a couple of 

options on the table, all that I can understand how they got to 

where they got to, but I think that there are some additional questions. So, I have begun the process of looking at that and will get 

back to you and discuss with you about what some of those options 

are. I actually want to get your thoughts on how we can serve the 

veterans in that area best. 

Senator ROUNDS. Very good. I think the veterans in that area, 

and most certainly the community of Hot Springs, as I say, that 

community came into existence, really, to serve veterans, and it is 

one of the oldest in the United States. I appreciate that and your 

interest in working with us. 

The second item is one that I think is probably a little less comfortable in discussing, and that is the Emergency Care Fairness 

Act, that was passed by this Congress in 2009, and signed by the 

President in 2010. What this was, for the benefit of folks out there 

that may not understand it, this basically said that if a veteran 

ends up going to an emergency room, even if they wanted to go to 

a VA center, if the emergency care was delivered at a non-VA facility, the VA would pick up the cost of that emergency room 

treatment. 

Shortly after that occurred, rules were revised within VA that 

did exactly the opposite, indicating that they would act as a secondary payer only. Even with veterans who have Medicare, any 

deductibles or copays, the VA has said, ‘‘Sorry. That is a secondary 

payment and we are not responsible for it.’’ So, they have not made 

any of those payments. In fact, I think the total costs on that are 

into the billions of dollars now, which are on the backs of veterans. 

Now, Congress’ intent was pretty clear and, in fact, not only has 

there been one court case on it, which went in favor of the veterans, there has now been an appeals case, which ruled that VA 

is wrong. In fact, let me just quote this to you—— 

Dr. SHULKIN. Mm-hmm. 

Senator ROUNDS [continuing]. This is the way that it comes up. 

This is in the case of Staab v. McDonald which says, ‘‘And the VA 

needs to find a way to pay for it.’’ 

So, let me just lay this out for you. This particular product is one 

in which the court said the VA is wrong, and the VA needs to pay 

these copays and deductibles for those facilities that are outside of 

a VA facility, which was the direction from Congress. 

Now that is two court cases right in a row. My understanding is 

that you have had a chance to take a look at this. 

Dr. SHULKIN. Mm-hmm. 

Senator ROUNDS. The reason why it came to my attention is we 

had two different times in which there were requests to hotline 

bills in the Senate, suggesting unanimous consent items that would 

have reversed that law, which would have taken VA out of paying 

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literally billions of dollars, and it would have dumped it on the 

backs of veterans, after the fact. 

Now, we stopped both of them. 

Dr. SHULKIN. Mm-hmm. 

Senator ROUNDS. What I would like to know, sir, is your opinion 

on the bill and where you see us going from here, with getting that 

resolved. 

Dr. SHULKIN. Yeah. Well, right now my opinion does not matter 

because this is law. The judges have ruled, and you have accurately described the situation. I have instructed VA to start putting 

together—and they are doing this now—the regulations that it is 

going to take to be able to start paying these bills, these emergency 

room bills, and every day that we delay, veterans are being put in 

the middle, and that is really unfair to them. 

Senator ROUNDS. Dr. Shulkin, here is the reason why people get 

discouraged with this. This is exactly the conversation that you and 

I had, and that was my understanding. Yet just today, in my office, 

I received a letter. I was surprised to receive a letter from the VA, 

in reply to our letter, which we had sent in asking the VA to reconsider their position. In today’s letter it stated that the current status of the bill is still active, on appeal, and requires an opening 

brief to be submitted on February 6, 2017—— 

Dr. SHULKIN. Yes. 

Senator ROUNDS [continuing]. Indicating they continue to do battle on this in the courts. 

Dr. SHULKIN. Let me clarify our position. 

Senator ROUNDS. OK. 

Dr. SHULKIN. I have already said—your facts are correct. This is 

law and we are moving forward to start paying these bills. However, VA does not believe that the court interpreted the statute correctly. So, the Department of Justice—and this is since you and I 

had a chance to meet—has just decided to accept the appeal. So, 

the Department of Justice will appeal this, and we will see what 

happens. 

In the meantime, I am not going to allow veterans to be put in 

the middle, like we have been continuing to do. We are going to 

move forward and we will do it with speed, to make sure that we 

start paying these bills as soon as we possibly can. But, there will 

be—the Department of Justice has decided to take up this case. 

Senator ROUNDS. Just for the record, I understand—I know that 

I am going over my time, Mr. Chairman, but this is in terms of 

more than $3 billion, and in some cases estimated at more than 

$10 billion of debt which veterans will have if the VA does not pay 

it. Dr. Shulkin, you do not have the money in your budget. Are you 

prepared to ask this Congress for the appropriate funds to get the 

bill paid if—— 

Dr. SHULKIN. Well, I will try to be brief as well. The concern that 

VA has—having said we are moving in the direction that I think 

you are comfortable with—the concern is this is a new interpretation of a benefit for veterans who have other health insurance and 

who are not service-connected. If we do not get additional funds authorized, that money will come from the services that we provide 

today to veterans, and they will have less health care available. 

176 

So, yes, we will come to you and ask you to help support, with 

additional funding, this new benefit if it is not overturned in an appeal by the Department of Justice. 

Senator ROUNDS. Let me note that it was a benefit that was directed by Congress—— 

Dr. SHULKIN. Yes. 

Senator ROUNDS [continuing]. In 2009, and signed into law in 

2010. 

Dr. SHULKIN. You are correct, sir. 

Senator ROUNDS. Thank you, sir. 

Dr. SHULKIN. Yes. 

Senator ROUNDS. Appreciate it. 

Senator CASSIDY. Senator Sanders. 

HON. BERNARD SANDERS, U.S. SENATOR FROM VERMONT 

Senator SANDERS. Thank you, Mr. Chairman, and Dr. Shulkin, 

thanks for dropping in the other day and thanks for being here. 

Thanks for all the veterans and veterans’ organizations for being 

here. 

Let me just jump into a couple of issues. There is an effort, and 

probably being led by the Koch brothers, to privatize virtually 

every government agency. Will you oppose the privatization of the 

VA? 

Dr. SHULKIN. I have been clear. I am opposed to the privatization 

of the VA. 

Senator SANDERS. Let me pick up on a point that Senator 

Rounds just made a moment ago and broaden it a little bit. 

No agency of government can do its job unless it has an adequate 

budget. Will you be 100 percent honest in coming before this Committee and telling us what the needs are of the VA, in terms of 

making sure that every veteran in this country who goes to VA has 

the quality care that he or she needs? 

Dr. SHULKIN. Senator Sanders, I see that as one of the primary 

responsibilities of a Secretary. I absolutely will do that. 

Senator SANDERS. So, you do understand that there will be pressure on you; that, generally, administrations, no matter what they 

may be, try to tell heads of agencies to tamp down on their requests. But, what I think is needed is, speaking for, I hope, the 

whole Committee, is that we want you to ask for what you need. 

Dr. SHULKIN. Yeah. I have not been in Washington as long as 

you, but in my short time I have already figured out exactly what 

you are saying. Yes, I will commit to that. 

Senator SANDERS. Thank you. 

In our chat the other day, you told me something that I did not 

know—I did not know and I do not know that other Members of 

the Committee know, so, correct me if I am wrong. You told me 

that there are now 45,000 vacancies just in VA health, not to mention other parts of the system. Is that correct? 

Dr. SHULKIN. There are 47,230 vacancies now throughout VA. 

Senator SANDERS. Throughout VA. 

Dr. SHULKIN. Throughout VA. Most are in health. 

Senator SANDERS. OK. 

Dr. SHULKIN. Not all. 

177 

Senator SANDERS. I have to believe that with that number of vacancies that has an impact on the quality of care and the timeliness of care that veterans receive. 

Dr. SHULKIN. We believe it does. 

Senator SANDERS. Do you have the resources now to fill those 

vacancies? 

Dr. SHULKIN. Yes. Yes. Our budget—every position that we are 

recruiting for—those are active recruitments—has a budget associated with it. Yes, sir. 

Senator SANDERS. As I understand it, President Trump’s freeze 

on Federal hires will not impact you? 

Dr. SHULKIN. I have been very pleased that after the freeze 

memo came out we went immediately back to the White House and 

said that this would impact us, and we got an exception for all of 

the positions that are critical related to health and safety. I feel 

very comfortable with that. Of the 47,230 that we are actively recruiting for, about 37,000 right now are excepted. 

Senator SANDERS. OK. 

There is no question, I think primarily for political reasons, the 

VA has been beaten up a whole lot in recent years, by politicians, 

by the news agencies, and so forth. That is not to say that the VA 

does not have serious problems, but it does say that our entire 

health care system has serious problems, not just the VA. 

Now, when I was Chair of this Committee, we had a meeting 

right in this room, right at that table. We had the leadership of 

every major veterans’ organization in the country, where I asked 

a pretty simple question. It was, ‘‘If and when people get into the 

system, understanding there are unacceptable waits to get in, but 

once they get into the system, do you believe that the quality of 

care that veterans are receiving is good?’’ 

What I will not forget, and I want to ask you that same question, 

is, without exception, every leader of every major veterans’ organization, from The American Legion, VFW, DAV, on down, said once 

people get into the system, by and large the quality of care is good, 

very good, excellent. What do you think? 

Dr. SHULKIN. Well, even more important than what I think, 

there have been numerous independent studies by academic centers and other groups that have studied this, and consistently they 

have found that the quality of VA care, particularly when it relates 

to mental health, primary care measures, screening measures, safety measures, quality measures in general, is actually superior in 

the VA system to the average of the private health care system. I 

do want to add, though, that does not mean that we are perfect. 

About 5 to 6 percent of our hospitals in the VA system are actually 

below where they need to be. 

Senator SANDERS. That is a fair point. But, let me just reiterate 

that for the benefit of all three of us who are here—— 

[Laughter.] 

Senator SANDERS [continuing]. Which is, every person here wants 

the VA to do better. I do not think there is a partisan division on 

that. 

Dr. SHULKIN. Yes. 

Senator SANDERS. But, I think it is also important that before we 

go beating up VA every day, run to CNN or all the newspapers, 

178 

anyone, saying VA is terrible, that we understand—and you correct 

me if I am misreading this—there was a recent report that came 

out in RAND—— 

Dr. SHULKIN. Yes. 

Senator SANDERS [continuing]. Which is an independent think 

tank, which I think was actually commissioned by legislation that 

we passed. 

This is what it said; and tell me if you agree with the quote. ‘‘In 

a tally of 83 different measures, covering a variety of types of care, 

including safety and effectiveness of treatment, the quality of VA 

health care exceeded that of non-VA care.’’ End of quote. 

Do you think that is a valid—— 

Dr. SHULKIN. I read the same study you did and I think that has 

been shown by other groups as well. 

Senator SANDERS. Just on one issue, in terms of mental health, 

that I hope, Mr. Chairman, we can work on. Right now, if a veteran needs mental health care from VA, as I understand it, he or 

she can get that care, but amazingly enough, he cannot bring in 

his wife or girlfriend or spouse or whatever it may be. I am not 

quite sure how you treat an individual without bringing family 

members in. 

Is that something you think we should—I know that is the case 

by law now. Is that something we might want to look at? 

Dr. SHULKIN. Well, I think what we do know is when we send 

a soldier off to battle, we are sending the whole family off, and so 

often many of these issues that are so difficult to deal with have 

to be dealt with in the family unit, which is very important. I do 

think that if our goal is—and I know it is our shared goal, to be 

able to help treat and address this issue—we need to think about 

different ways of doing that, and including the family as part of 

that, I think, is going to be an important way to find solutions. 

Senator SANDERS. Mr. Chairman, I would hope that we could 

work together on that issue. 

Chairman ISAKSON [presiding]. We certainly will. And we are 

going to work at sticking to 5 minutes so we can have enough 

rounds to get everything in. 

Thank you, Senator Sanders. 

Before I rotate the turn, because Senator Tillis is going to be 

next, let me just ask this. Dr. Shulkin, do you know of any health 

care systems in the country that have more than 6.5 million patients and 314,000 personnel? 

Dr. SHULKIN. I am not aware of one, sir. 

Chairman ISAKSON. Is not that the right numbers for the VA? 

Dr. SHULKIN. Yes. 

Chairman ISAKSON. So, in answer to your question, we have got 

314,000 personnel delivering medical services to 6.5 million veterans. Those are the biggest numbers in the country. You are going 

to have a slip-up every now and then. 

Yet, there are good stories out there. We are going to do two 

things. We are going to fix the slip-ups—you know, no more terrible stories like finding maggots in somebody’s wound or things 

like that, which are sensationalized. Senator Tester and I have 

talked about making statements on the floor about every 2 weeks, 

telling the good stories of the VA, so you better be having some. 

179 

If there are bad stories, we want to tell those too, including how 

we have corrected them, so we dispel what is happening right now, 

where the media is just making a story out of anything that comes 

out of VA. 

With that said, Senator Tillis, you are in charge. 

Senator TILLIS. Well, thank you, Mr. Chair. 

Chairman ISAKSON. For 5 minutes. 

HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA 

Senator TILLIS. Oh. First off, just for those of you out here, all 

the Members on this VA Committee are interested in this hearing. 

They happen to be playing the dance that we are doing right now. 

I, for one, am missing a vote right now, and I have asked them to 

go ahead and call the vote so they can get to the next one, so that 

I could have this discussion. 

Dr. Shulkin, and Mr. Chair, I do not even know if this is allowed 

within the roles, so I will not do it, but I am just curious, with the 

number of VSOs who stood up here, I would be really curious if 

they were willing to do this without a request from me. How many 

of them would raise their hand to the idea of we want to completely and utterly privatize the VA? [Pause.] 

I did not break the rules but it seems to me that there are not 

a whole lot of people who are behind this. I know that you are not. 

Dr. SHULKIN. Right. 

Senator TILLIS. The reason that I mention that is I am tired of 

some of the suggestions by Members of Congress who say that 

there is some plot out there, or agenda, to do it. It is simply not 

true. 

We need to get Choice to work. We have had discussions about 

that. We have to recognize that 30 to 40 percent of all VA care 

comes from non-VA providers. Then, we just need to get it right, 

so the brick-and-mortar presence is exactly where it needs to be to 

provide the best care to the veteran. 

Anyone in this body who tells you that there is a movement afoot 

to privatize the VA has either been mislead or they are trying to 

mislead you, and I am not going to be a part of that, nor am I 

going to stand for it. 

I think you are great. I have already told you I am going to vote 

for your confirmation. You have done a great job in your current 

capacity. You have got about as many friends in Alaska as polar 

bears. I am glad to hear that. [Laughter.] 

You have been down to North Carolina. 

Dr. SHULKIN. Yes. 

Senator TILLIS. I like the idea that the Administration showed 

wisdom in bringing somebody in who has a bird’s-eye view of the 

transformation plan. A lot of what Secretary McDonald was trying 

to accomplish makes sense. Some of it we can make better. I know 

that I have your commitment to follow through and build on those 

12 breakthrough priorities, putting pressure on Congress to take 

action, which we have not yet, to enable you to actually execute 

those priorities. 

Are you going to come before this body and commit to me that 

you will be shooting straight with us, to say for us to get the work 

done so that you can fulfill a commitment to transform the VA? 

180 

Dr. SHULKIN. Yes. Absolutely. First of all, your involvement in 

helping us, and along with—— 

Senator TILLIS. Senator Tester. 

Dr. SHULKIN [continuing]. Senator Tester as well, we really appreciate. I could not agree with you more. There is a lot of very, 

very good work that has been done that we want to build upon, but 

as Secretary, it would be my job to make sure that you allow me 

to have the tools and the resources and the authority to be able to 

get this work done, to make the progress that we need to make. 

And I expect to be held accountable if you give me that authority 

and I am not getting the job done. 

Senator TILLIS. Thank you. I also meant to mention that I have 

thoroughly enjoyed having Senator Tester over in our office, talking 

with the VA over the last year. He has shown up every time. We 

have had great discussion and I look forward to, with the Chair’s 

indulgence, of allowing us to continue to do that with you all. 

Two things I want to get to very quickly. One, as close to a yesno answer would be great. The Community Care RFP, or request 

for proposal, that was issued in December—I think December 28— 

in some ways some people are viewing that as kind of a midnight 

rule that we would have liked to have spent some time talking 

under the new Administration about the priorities of that RFP. 

What are your plans, as Secretary, with this RFP? 

Dr. SHULKIN. We have instructed a group, in the next 2 weeks, 

to give us their assessment on whether this RFP has enough flexibility to allow us to do the types of transformation that we need 

to do or whether we need to take a pause. So, in 2 weeks we are 

going to have an answer to that. 

Senator TILLIS. We would like to get that report as soon as possible—— 

Dr. SHULKIN. Yes. 

Senator TILLIS [continuing]. Because, obviously, this may or may 

not fall under things that we could do with a resolution of disapproval. I do not think that is productive. We would make sure— 

I would like to make sure that our Members are consulted and 

those who may not be familiar with it know the implications of 

your assessment. 

The last thing that I want to talk about, we spoke about in my 

office earlier. We need to have you come back and tell the Congress 

when we are the main reason why you cannot do what you want 

to do. We need to have some frank discussions about limits that we 

are placing on you. I shared with you, in my office, a situation 

where the VA were making a good decision to consolidate a presence in very close proximity and you were not allowed to do something that would have improved the care and access in an area 

that I went to visit. 

I hope I have your commitment to come before this body and say, 

‘‘We will do this because you have told us to, but it is at the expense of an improved level of access and care,’’ wherever that may 

be. I think we cannot have it both ways. We cannot constrain what, 

in your best judgment, is the best way to serve veterans and then 

come up here and quietly prevent you from doing that. 

Do I have your commitment to have that open dialog with us? 

181 

Dr. SHULKIN. Absolutely. I think if we continue the status quo, 

that is not going to get us where we need to go. 

Senator TILLIS. Unless we want to put a mirror down there at 

the witness stand and blame us for suboptimizing what we can do 

for the veterans. 

Then, a part of that also has to be making the tough decisions 

about the inventory of brick-and-mortar presences that no longer 

make sense. We have got to make sure that the focus is on the veteran. It is not on a job or two here and there, which is important 

but it is not near as important as making sure that we have optimized our presence and our footprint in every State in the Nation. 

Thank you. I look forward to working with you. 

Dr. SHULKIN. Thank you, Senator. 

Chairman ISAKSON. I am sorry. We will go to Senator Boozman 

and then Senator Brown. 

Senator BROWN. No. We are not going back and forth, Mr. 

Chairman. 

Chairman ISAKSON. Well, I am trying to do, time-wise, the best 

I can, and some we are doubling up, in some cases. I will make 

sure you have plenty of time. 

Senator BROWN. Thank you, Mr. Chairman. 

HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN. Thank you, Mr. Chairman. 

The Choice has really been very effective in Arkansas. Alone, 

over 4,500 community providers are providing veterans with quality care, with close to 13,000 individual veterans being served between July 2015 and November 2016. That is really a good story 

and we really do appreciate the efforts, and I know you have been 

right in the middle of that. 

The IG report that came out, you know, talked about cumbersome authorization and scheduling. Can you talk a little bit 

about both of those things, and really, in particular, the scheduling 

aspect? That is something that I know, with your background, you 

are very, very familiar with—— 

Dr. SHULKIN. Mm-hmm. 

Senator BOOZMAN [continuing]. It is a solvable problem. Can you 

talk a little bit about how we do a better job of getting that done? 

Dr. SHULKIN. Senator, the two things on the IG report, on Choice 

and on scheduling. Is that correct? 

Senator BOOZMAN. Yes, sir. 

Dr. SHULKIN. OK. The IG report, which just recently came out 

on the Choice Program, covered a time period from November 2014 

to September 2015, and it described, I think accurately, a program 

that was in disarray. Since then, we have made, with your help, 

four changes to the law, 50 contract modifications. We have completely changed the ability, so now VA employees can make outbound calls. We have changed the episode from 60 days to a year. 

We have made this a much, much different program than it is 

today, and we can see the result. More veterans are able to schedule appointments. We now have over a million Choice appointments that have been scheduled by veterans, which is a good 

thing—or a million veterans have used the Choice Program; 6 million appointments. 

182 

In terms of scheduling, we still have not given our employees the 

right tools to be able to do their job well. They are using what I 

would call old blue DOS screens to schedule, and I do not know 

how they even do their job. Thank God they are so good at what 

they do. 

We need to give them new tools. I have asked, and we are moving forward with a commercial scheduling product for scheduling. 

It is called MASS. We also have an internal scheduling program. 

We call it—because everything has an acronym in VA—called VSE. 

That will be ready for a decision on February 10, whether it is a 

go, no-go. It is deployed to about 10 sites where it is being tested 

by our employees, and we are going to make a decision on that as 

well. 

So, the bottom line is we need a new scheduling system. We have 

known that for years. We are finally going to do it. 

Senator BOOZMAN. Good. Very good. 

One thing that has come up, I know that, you know, we have 

struggled forever with the process disability compensation claims, 

to try and get those done in a timely manner. I have been on the 

Committee now for—in the House and the Senate for 15 or 16 

years, and this is something that just has always been a problem. 

I know that you have worked on it really hard and the numbers 

have come down. That is a good thing. 

Particularly, the backlog to receive medical disability exams, and 

I think at one time it was 600,000. 

Dr. SHULKIN. Mm-hmm. 

Senator BOOZMAN. We are down now to closer to 60,000, and 

moving in the right direction. 

I guess recently we have redone the contracts and things? 

Dr. SHULKIN. Mm-hmm. 

Senator BOOZMAN. There is some concern that, you know, the 

people that did such a good job getting it in this situation. We have 

got new folks coming in and there is concern that they do not have 

the resources to actually, in a timely fashion, get set up and get 

the job done. 

What we do not want to do is get ourselves back in the situation 

of having the—can you just talk about that and kind of talk about 

the concerns? 

Dr. SHULKIN. I think you are correct. We have decided to take 

on a new contact, to outsource a contract to a vendor. We awarded 

that. That was protested by two companies that did not win the 

award. The GAO actually took a look at our process and said that 

VA did things correctly. But, this is now being considered through 

a court process, and we heard today that we are likely to hear back 

on that protest through the courts in June. 

Until then, we have a bridge contract. I spoke to our Acting 

Under Secretary today, our Acting Under Secretary of Benefits, 

who assures me that veterans are getting the C&P exams that they 

need, that we are not seeing a delay, because we are able to use 

the bridge contract as well as those clinicians who work in VHA. 

So, we have to wait until June and we will see what the resolution is through the courts. 

Senator BOOZMAN. Very good. One further thing, and then we 

are running out of time. 

183 

You are a private sector guy. You have run all kinds of operations, been very, very successful. You have had the ability, in 

those entities, to hold people accountable. Can you talk a little bit 

about what you need to do and what tools we need to give you? 

Marco Rubio has a bill. 

Dr. SHULKIN. Mm-hmm. 

Senator BOOZMAN. Others have bills. 

Dr. SHULKIN. Mm-hmm. 

Senator BOOZMAN. Tell us a little bit about that. That is just a 

basic component of running a—— 

Dr. SHULKIN. Absolutely. When I talk about the tools that a Secretary needs to do their job, a basic function of any chief executive 

is to be able to get the right people working in the organization, 

and those that do stray from the values that we hold have to leave 

the organization. We do not currently have that right on either 

side, so I see this as a dual-pronged process. 

For those employees that really do not belong in the organization, the Secretary needs the ability to be able to remove them. We 

have—we were given expedited authority to remove employees 

through the Choice Act, which you gave us. Unfortunately, it was 

determined to be unconstitutional, and now the Department of Justice did not choose to go and to defend that. 

So, we are going to need new tools, and I am going to need to 

come back to you, and we need to figure out a way that we can 

make what you wanted to happen work better and make it constitutional. 

On the other side, a Secretary also needs the ability to retain, 

reward, and recruit those types of employees that we all want serving veterans, and we have been hampered in our ability to use the 

tools that we once had to be able to retain and recruit the very, 

very best. And, fortunately, the vast majority of our employees are 

people that we are all proud of. I am proud to work with them, I 

am going to stand behind them as Secretary, and I want the tools 

that we can make sure that we have the very best people in this 

country serving our veterans. 

Senator BOOZMAN. Good. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Boozman. 

Senator Brown. 

HON. SHERROD BROWN, U.S. SENATOR FROM OHIO 

Senator BROWN. Thank you, Mr. Chairman. Thanks, Dr. Shulkin. 

It is nice to see you again. I enjoyed our conversation. 

First, Senator Tillis talked about the paranoia, it seems like, on 

their side of the aisle, that the people at the VA might want to privatize. Well, the fact is the President has talked about privatization. The fact is the President spoke out against changing Medicare: voucherizing, privatizing, raising the retirement age, the eligibility age; and then is trying to put a Secretary of Health and 

Human Services in who has devoted his Congressional career to 

privatizing, voucherizing, raising the eligibility age. 

So, I think it is important that all the VSOs here represented, 

all the people that care about veterans, all the people on both sides 

of the aisle here that think the VA should remain a public system 

with the Choice Act, understanding it not be privatized, continue 

184 

to speak out. That is why I am pleased that Dr. Shulkin has said 

that in response to Senator Tillis and that Dr. Shulkin has said to 

me, privately, and to many others, that he will absolutely resist 

privatization. 

I am also concerned because I know the President has advisors, 

paid and unpaid, who are pushing him hard on privatization of the 

VA, so it is important that we all be vigilant. 

That is, anyway, all I wanted to say there. 

The hiring freeze, you spoke about it yesterday. I am concerned 

about the hiring freeze, what it does to the 400,000 pending disability compensation and pension claims at the VBA. I wanted you 

to just answer yes or no, because of us getting back for votes and 

all. You are committed, I assume, to VBA processing claims quickly, speeding that up? Yes or no. 

Dr. SHULKIN. Yes. 

Senator BROWN. How many vacancies exist at VBA for claims 

processing? 

Dr. SHULKIN. I do not have the specific number. There are 47,230 

across VA. We have an exception for 37,000. VBA is not part of 

that exception, so I spoke to the Acting Under Secretary today, who 

has assured me he has metrics on what is happening to these 

claims. If we are seeing a big concern with that, I do plan on going 

back and addressing that. 

The problem is without getting your benefits you cannot get access to health care, so these two are connected. 

Senator BROWN. Well, they are connected, too, in the sense that 

the President’s freeze, while there are exemptions, the understanding is the exceptions do not include human resource specialists. I do not know how you hire enough medical professionals. I 

hope that you will go back to the White House and explain this, 

from fruits to nuts, so they understand what damage this is doing 

to processing those claims and elsewhere in the VA system. 

Dr. SHULKIN. I do plan on that. 

Senator BROWN. Thank you. 

I want to talk briefly about something. In Dayton, last December, 

the Secretary signed a memorandum of agreement with the city of 

Dayton, OH, and local organizations, to establish VA’s History, Research and National Heritage Center. You are familiar with this 

MOA? 

Dr. SHULKIN. Yes. 

Senator BROWN. I need your commitment to fully implement it. 

This project has taken longer than it should have, almost 7 years. 

Please review it and begin implementation as quickly as possible. 

Dr. SHULKIN. It is a terrific program. Yes, sir. 

Senator BROWN. Thank you. Thanks. It means a lot to that community. 

Last question. In my State, in Ohio, 11 million people, 25,000 

veterans, 12,000 of their family members gained coverage because 

of the Affordable Care Act, because of Obamacare, either the federally run exchange or Medicaid expansion. I want your support to 

guarantee health care for our Nation’s veterans and their families, 

including those that would be harmed by an ACA repeal. 

185 

Dr. SHULKIN. Well, that is why the VA is here, and that is our 

mission. So, we will do everything that we can, if there is an influx 

of veterans into our system. Yes, sir. 

Senator BROWN. Does that mean that you will use your seat in 

the Cabinet, as you sit around the table with perhaps Secretary 

Price and the President of the United States and the Vice President of the United States, all who have campaigned on repealing 

the Affordable Care Act? Does that mean you will use your seat at 

the Cabinet table to push back on the Administration’s attempts to 

limit access to care for all of them, including those 25,000 

veterans? 

Dr. SHULKIN. Senator, if I am confirmed, my sole focus is going 

to be on making sure that veterans’ needs are met and on veterans 

getting the services that they need. That is going to be my role in 

the Cabinet. I see that as a very important responsibility, and I am 

going to speak up on behalf of veterans. 

Senator BROWN. OK. Thank you for the way you said that. My 

fear is that if the Affordable Care Act is repealed, 22 million people 

lose their coverage. There is no plan that anybody has come up 

with yet to replace it. I care about all 22 million of those. I especially care, as I know you do, about the 25,000 veterans and 12,000 

family members who would also lose coverage if that is done. So, 

I ask you to speak out, as difficult as it might be when you may 

be the only one in the room speaking out, not just for primarily 

those veterans but how they will fall through the cracks if they do 

not really replace the repeal of the Affordable Care Act. 

Dr. SHULKIN. I appreciate that. 

Senator BROWN. Thank you. 

Chairman ISAKSON. Just for a clarification, the repeal of the Affordable Care Act would not affect a veteran, because the Veterans 

Administration is open for business and operated by the VA. 

Senator BROWN. Mr. Chairman, respectfully, the ACA did insure 

25,000 veterans and 12,000 family members that were not insured 

prior to the ACA, because they fell through the cracks at the VA. 

Chairman ISAKSON. But, we have made clear there is no privatization of the VA and there is no diminishing of the VA. We are 

not going to do that, nor are we going to take away any of their 

valuable current holders. [Pause.] 

We have a fourth vote and then a fifth vote, which is coming up, 

and I am going to make both of those votes. I am going to ask Senator Rounds to fill in for me as Chair. Senator Manchin—have you 

asked questions yet, Senator Manchin? 

Senator MANCHIN. No sir. 

Chairman ISAKSON. Well, what we will do, if that is OK with— 

are you ready? Do you want to ask yours now, Dan? 

Senator SULLIVAN. If that is OK, Mr. Chairman. 

Chairman ISAKSON. Dan has got to go back, and you have got— 

I will go with Dan and then you. [Pause.] 

OK. Well, I think we can get both of them in before the last vote 

is over. I will make sure—the cloakroom is looking for you, so we 

will hold it open. [Pause.] 

Senator Sullivan, come forward. Oh, go ahead, Senator Rounds. 

Senator SULLIVAN. Thank you, Mr. Chairman, and my good 

friend from West Virginia, thank you. 

186 

Dr. Shulkin, you know, you were talking about accountability, 

which you and I have had that discussion, and you have already 

had a lot of questions on that. The authority that was provided you 

in the Choice Act, you welcome that, do you not? 

Dr. SHULKIN. Yes. 

Senator SULLIVAN. So, you mentioned it was determined it was 

unconstitutional—just—I believe a court determined it was unconstitutional. Did not the Justice Department say it was unconstitutional? 

Dr. SHULKIN. My understanding of this, and I am not a lawyer— 

I know you are, so I am on dangerous grounds—— 

[Laughter.] 

Dr. SHULKIN [continuing]. My understanding is a court did determine—— 

Senator SULLIVAN. OK. 

Dr. SHULKIN [continuing]. That this was unconstitutional. The 

Department of Justice failed to accept our request to appeal that, 

so we were pretty much stuck and we were overturned. 

Senator SULLIVAN. OK. Well, we want to work with you because 

I think that is a bipartisan area of agreement that the trust that 

you were talking about, with regard to our veterans, is undermined 

when you have these stories. I am not saying—as you know, most 

of the VA officials do a great job and really care about the veterans 

community that they serve. But, there have been some reports, I 

think very legitimate reports, where there has been malfeasance 

and actions that deserved to be punished or relieved. When that 

does not happen, it undermines the trust from our veterans. 

I think that is a bipartisan commitment. We all want to work 

with you on that, to restore that authority, make it constitutional, 

of course. 

Dr. SHULKIN. Yes. 

Senator SULLIVAN. But, I had my doubts on where that was. 

Let me go back again to another veteran constituent asked about 

how will the VA increase its presence in isolated communities and 

communities that are very rural? What are your ideas for that? 

And a related question, in Alaska, do you see the Alaska Tribal 

Health System playing an important role in that area with regard 

to Alaska Native veterans, or non-Native veterans? 

Dr. SHULKIN. Yeah. I see our ability to address the health care 

professional shortage in rural areas in three ways. First, and most 

important, to work with the community providers, as we have been 

doing, particularly in rural areas. In the case of Alaska, working 

with the tribal consortiums and the Indian Health Service has been 

absolutely critical, and I am pleased to say we just signed a 2.5 

year extension to make sure that there is continuity of care for our 

veterans, and using them. 

Senator SULLIVAN. Thank you for that. I know that was a focus. 

Dr. SHULKIN. Right. So, that is number 1. 

Number 2 is, we have to use technology in areas where we are 

not able to recruit all the health care professionals we need. Most 

people do not realize, nobody in this country is using telehealth 

technology the way that the VA is. We did 2.1 million telehealth 

visits last year. That was 700,000 veterans. Nobody comes close, 

and we are doing it terrifically. 

187 

I actually practice medicine, from here in Washington to Grants 

Pass, OR, where I take care of patients using telehealth. I can tell 

you, I was skeptical, but it works well, and the patients like it, too. 

Third is, we do need these tools to recruit and to use, frankly, 

financial incentives to get health care professionals to areas that 

we need them to care for veterans, because we are competing 

against the community, like in Mat-Su Valley, which you and I 

were talking about, we have been 2 years without a primary care 

doctor, and that is just not acceptable. 

Senator SULLIVAN. We want to work with you. Again, I think 

that is an area of bipartisan concern. Getting a doctor out in the 

Mat-Su Valley in Alaska is going to be very important, and I appreciate your commitment on that. 

Let me ask my final question, the broader issue that, again, I 

know the Chairman talked about in his opening remarks. But, 

what is your plan to tackle the current backlog and the process as 

it relates to appeals, because as you know, that has been a big 

challenge. There are some appeals that have been hanging out 

there for years—5, 6, 7, 8, 9, 10 years. 

Dr. SHULKIN. Right. The appeals process is broken. The system 

was designed in 1933, and every now and then you have to update 

it, and we are way past that. We need an appeals modernization 

act, I think, that several people—I know Senator Blumenthal, Senator Rubio has proposed legislation. We will not fix this problem 

without legislation to fix it. 

Let me just update you on a few figures. The average appeal in 

the board is 6 years. We have one appeal that is now going on beyond 30 years, and the reason is you can constantly add new evidence at any point in the process and it starts over. 

So, this process needs to be fixed. We are really fortunate that 

Members of Congress, the VA, and our veteran service organizations lock themselves in a room until we came up with a solution 

that we think works, and that is now pending before you. We hope 

it is reintroduced into this Congress and we hope that you will pass 

it. 

Senator SULLIVAN. Thank you. Thank you, Mr. Chairman, and 

Dr. Shulkin, I look forward to your swift confirmation. 

Dr. SHULKIN. Thank you. 

Senator SULLIVAN. Thank you again for your willingness to 

serve. 

Senator ROUNDS [presiding]. Senator Manchin. 

HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA 

Senator MANCHIN. Thank you, Mr. Chairman, and thank you, 

Dr. Shulkin, for being here and also for being willing to serve. You 

have done a great job in the year and one-half you have been there 

and I appreciate very much your service. 

I want to thank you, basically, for working as you did, well, trying to make the changes we needed to make. I think we are on a 

positive role there and a positive movement. 

Second, I would like to invite you to come to West Virginia and 

see our facility. I do not know if people know this but, you know, 

we are one of the most patriotic States with more veterans than 

most any. Out of 1,800,000 people that live in my State, 9.2 percent 

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are veterans. Almost 10 percent of my population are veterans, 

which is unbelievable. 

With that, my concern, as you know, has been with opioid 

addiction. 

Dr. SHULKIN. Yes. 

Senator MANCHIN. Not just in my State, but nationwide there 

has been an epidemic. It is also within veterans. In my veteran 

corps it has been very detrimental to them. 

A story ran in the Wall Street Journal that said 66,000 veterans 

were treated for substance abuse disorder just in the last fiscal 

year—66,000. It detailed that there is a shortage of VA in-patient, 

residential rehab beds, and that the VA often relies on non-VA facilities to treat addicted veterans. To give you an example of how 

under-bedded we are, under-supplied for the needs that we have, 

there are only 906 VA in-patient drug rehab beds nationwide—only 

906 for a population which is in desperate need. 

With that, Congressman Price, who has been considered for 

DHHS, has not committed to the funding that would support these 

types of rehab centers, that would help people get off of these prescription and lethal drugs. I did not know what your thought was, 

because right now you do not have the ability to pick up without 

the private sector support. If the Affordable Care Act goes down, 

we are dead. If he does not make a commitment from DHHS, we 

are dead again, and then you do not have the ability or the funding 

mechanism to pick up the slack. 

So, I do not know how you feel about that, just to get your input. 

I am not trying to put you on the spot, but what do you make of 

this and how does this addiction—how are we doing on the addiction fight? 

Dr. SHULKIN. This is an area, opioid addiction, that I am very 

proud that VA recognized, frankly, before the rest of the country 

did; recognized it as a crisis and began to take action. In 2009, VA 

put a comprehensive program in place. It is why, while the rest of 

the country has seen opioid use go up, we have seen a 22 percent 

reduction since 2010. We are doing things that, quite frankly, we 

think are working and that the rest of the country can learn from. 

It does not mean, as you are suggesting, that we do not have to 

do more and that we should not do more. But, our work in making 

patients sign informed consents, our work in taking back medications that they are not using, in academic detailing, where we are 

teaching our doctors about the appropriate way, when to use 

opioids and when not to, our use of complementary care, so that 

we use alternatives to pain management—these are the things that 

are working, because what we know works best is to not start a 

patient, do not allow them to get addicted, which is going to help. 

But, for those that are there, we know that substance abuse is 

a big issue among veterans. We have to get them the right 

treatment. 

Senator MANCHIN. You and I have met now—I appreciate you 

coming to the office and the conversation we had was quite enlightening. We talked about something that I found out was a problem, 

I found out through the VAs, and especially with the addiction 

problem. A lot of the hospitals have told me that if an addicted person comes and they do not get what they ask for—and they usually 

189 

know exactly what they want, not what is prescribed for them but 

what they want—they will call their Congressman or Senator and 

complain about bad treatment they are receiving, which puts you 

all on alert that you are not getting satisfactory services from that 

clinic, whether it be one of my CBOCs or whether it is going to be 

one of my hospitals. 

What I have asked for—and I do not know how the other committees feel about this—but what I asked for is that when it comes 

to dispersing opiates, the addictive opiates that are killing people 

right and left, including our veterans, that the hospitals and dispensing from the VA should not be—should not be calculated in 

that chain of satisfaction, basically because they are not getting the 

pill they want. Everything else, yes, we know if they are not getting the service. But on that one there, that puts them, and puts 

our hospital systems basically in the position to where they get reimbursements, you know, basically cut and severed if they do not 

get good, high ratings from their patients. An addicted person is 

not going to give you a good, complimentary evaluation if they do 

not get what they want. It just makes common sense. You all, I 

hope, have the ability to do that, or I hope you would look into 

that. 

Dr. SHULKIN. Yeah. Look, even if we get scored poorly, we are 

going to do the right thing for the veteran, and that is most important. But, I do appreciate you bringing this up as an issue. 

I spoke this morning to Dr. Clancy, who heads up our quality 

area, who is responsible for this scoring, and she has said that we 

can actually calculate our scores without those questions in it, so 

we can do it with and without—— 

Senator MANCHIN. Right. 

Dr. SHULKIN [continuing]. And actually learn about what you are 

talking about. 

Senator MANCHIN. You would lead the charge nationwide and it 

would be a great help for the society. 

I want to thank you for the job you have done in the VA, because 

you all have turned it around. It is moving in the right direction. 

A lot more needs to be done, but my veterans appreciate it very 

much. Thank you, sir. 

Dr. SHULKIN. Thank you. 

Senator ROUNDS. Senator Cassidy. 

HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA 

Senator CASSIDY. Dr. Shulkin, nice to see you. 

Dr. SHULKIN. Nice to see you. 

Senator CASSIDY. Again, I have always—since you started I have 

admired the work you have done and the commitment you have 

made. 

I did not forget, you and I, in a private conversation, I mentioned 

a physician colleague in the VA who said that some of the research 

positions are not going to young clinician researchers. So, for the 

record, he did say I could connect you, give you his name. 

Dr. SHULKIN. Great. 

Senator CASSIDY. We will communicate that to your staff. 

Dr. SHULKIN. Excellent. Thank you. 

190 

Senator CASSIDY. Now, Senator Manchin just brought up the 

problem of opioid addiction. My concern is that we hide problems 

by speaking of a mean. You have decreased opioid addiction by 22 

percent. That is system-wide. You are a big system. I bet you there 

are some hospitals where it has actually increased—increased despite a recognition of the problem. 

Dr. SHULKIN. Mm-hmm. 

Senator CASSIDY. So, you are saying yes, which I take as an 

agreement. 

Dr. SHULKIN. Yes. 

Senator CASSIDY. How do we know which facilities are bad apples—— 

Dr. SHULKIN. Mm-hmm. 

Senator CASSIDY [continuing]. If, since 2010, despite the mean 

going down, we know, therefore, some going up are really going up, 

that their weighting, still, the mean goes down? What specific 

interventions are being done in those facilities, and how quickly do 

you identify—you see the set of questions I am going after? 

Dr. SHULKIN. We not only have the data by facility, like you are 

suggesting, we actually have it by prescriber, and that is one of the 

reasons why we have been able to drive down the use. Every prescriber gets their prescribing use compared to other prescribers in 

the VA system, and then we mandated—it is not a voluntary or optional process—academic detailing, which means that everybody 

needs to be able to sit down with their prescribing, with an advance teacher, and sit down and talk about what they could be 

doing better. 

Senator CASSIDY. Are there physicians, or prescribers, who have 

been outliers on the upside—they are not oncologists, they are not 

pain doctors, so we do not think they have a reason to be prescribing a lot—— 

Dr. SHULKIN. Yes. 

Senator CASSIDY [continuing]. Rather they are just—I am suspecting you have some that continue to be outliers on the upside. 

Dr. SHULKIN. We do. 

Senator CASSIDY. Now, if you can identify them, what is being 

done? 

Dr. SHULKIN. Well—— 

Senator CASSIDY. Since this has been going on since 2010—— 

Dr. SHULKIN. Yes. 

Senator CASSIDY [continuing]. You know, it is not so much we 

are going to detail them because clearly they continue to prescribe. 

Dr. SHULKIN. Right. Right. As you know, from being a practicing 

physician, when you get this type of data, there are processes on 

how to do that, and this is not bureaucratic. This is what happens 

in every hospital across the United States. We tend to use a peer 

review process, where you get to sit down with your colleagues, 

who also practice, and have to explain why you are continuing to 

practice that way. If the explanation is not good, they actually can 

be de-credentialed and de-privileged with their ability to see—— 

Senator CASSIDY. Now in the past year—— 

Dr. SHULKIN. Yeah. 

Senator CASSIDY [continuing]. How many physicians have been 

de-credentialed for overprescribing opioids? 

191 

Dr. SHULKIN. I am not aware of any, specifically. 

Senator CASSIDY. How many physicians would be two standard 

deviations above the mean, in terms of—not an oncologist, not a 

pain doctor—— 

Dr. SHULKIN. Yeah. 

Senator CASSIDY [continuing]. How many would be two standard 

deviations above the mean, in terms of prescribing? 

Dr. SHULKIN. I am not familiar enough that I want to start giving you wrong information, but I suspect, just because I think you 

and I have been doing this long enough, that there are some. I do 

think that addressing that issue, that the VA really has begun to 

do this, through its medical staff and its chiefs of staff, but I do 

not have specific numbers for you. 

Senator CASSIDY. Yeah, I get that, and there is a specificity here. 

On the other hand, you can hide a lot of stuff within speaking 

about the mean. 

Dr. SHULKIN. Absolutely. 

Senator CASSIDY. Now, I think, and I typically find that 5 percent of every group you ought to take out back and dispose of. 

Right? Not Senators, of course. [Laughter.] 

Not on this side of the aisle. [Laughter.] 

That said, I think I spoke to Dr. Clancy when I first joined the 

Senate, about the specificity, and was told, yes, you can go that 

specifically. 

Dr. SHULKIN. Yes. 

Senator CASSIDY. The fact that you still have those two standard 

deviations above suggests to me that this process of academic detailing and peer review is either too cumbersome, too fenced 

around with protections, or something, but there are still veterans 

getting addicted because of inappropriate prescribing. 

Dr. SHULKIN. I am sure—in everything that we are doing, I am 

sure we can do this better, and we will take this back and take a 

look at it. But overall—and you are right, we are talking about 

means, and I agree with your statistical analysis here—but overall, 

we are actually doing things that many in America have not begun 

to do. We have begun to write this up and speak about it at national conferences, and we think there is a lot to learn from it. 

That does not mean that we cannot do it better, and we will look 

at this. 

Senator CASSIDY. And although I am frustrated, I will return to 

where I started. I appreciate the good work you and many of the 

physicians have done. We wish to support you. But I will, when 

you come back, continue to ask about the specificity. 

Dr. SHULKIN. Right. 

Senator CASSIDY. To what degree are we using data analytics to 

specify those prescribers who really are outliers, and really probably should not be allowed to prescribe narcotics? 

Dr. SHULKIN. OK. Very good. Thank you. 

Senator ROUNDS. Senator Blumenthal. 

HON. RICHARD BLUMENTHAL, 

U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thank you, Senator Rounds. I want to 

begin where Senator Cassidy finished, first to thank you for your 

192 

service. You have done great work so far in your present position. 

You have brought new leadership and vision to an agency that 

needs it. I also look forward to your coming back here, as Senator 

Cassidy has alluded to. You have been extraordinarily accessible 

and responsive to all of us, I feel, and I want to thank you for that. 

Particularly for me, we had a productive conversation yesterday, 

and you committed to helping me with a number of issues in Connecticut, including getting us Wi-Fi in our facilities, most especially 

West Haven, where I have been working, and working, and working to accomplish that end, and billing problems in Connecticut 

that are impacting some veterans when the VA fails to pay a provider, and a number of other areas where you have been extremely 

responsive. So, I thank you for that very good beginning. 

I would like to ask you, first of all, on an issue that we discussed 

yesterday, the appeals reform. I think you and I agree that this 

measure is extraordinarily necessarily because claims have been 

delayed and backlogged and gridlocked for far too long, and the appeals process needs to be better strengthened with resources and 

streamlined. Would you agree? 

Dr. SHULKIN. Yeah, and, Senator, while you were probably doing 

your fourth or fifth vote, we recognized and thanked you for your 

leadership in introducing into the last Congress, and hope that you 

will reintroduce it. We desperately need appeals modernization and 

this issue will not get fixed without it. 

Senator BLUMENTHAL. I plan to champion it again. Thank you for 

your support. 

The American Legion included, in its legislative priorities—and 

I thank them for doing so—the need to protect student veterans 

from predatory schools. 

Dr. SHULKIN. Yes. 

Senator BLUMENTHAL. In 2016, the Yale Law School issued a report entitled ‘‘VA’s Failure to Protect Veterans From Deceptive Recruiting Practices,’’ which showed that the VA is not complying 

with 38 U.S. Code 3696, which requires the disapproval of GI Bill 

funding when the VA finds that colleges have engaged in deceptive 

and misleading college recruiting. 

This topic is very close to my heart, having two sons who have 

served, and knowing many, many student veterans. If confirmed, 

will you commit to cracking down on colleges that are essentially 

lying to our veterans, and cheating them and the taxpayers out of 

veterans’ hard-earned GI Bill support, including by using all resources and authorities available to you, as the head of the VA, as 

well as working with other Federal agencies to crack down on these 

abuses? 

Dr. SHULKIN. Yes, Senator. This situation that you described 

would not be tolerable to me, and absolutely, I would commit to 

that. 

Senator BLUMENTHAL. I would pledge to you my total and complete support, at whatever level, in whatever way that I can help. 

Dr. SHULKIN. Mm-hmm. 

Senator BLUMENTHAL. I want to second what I think is Senator 

Murray’s cause here. She has been such a champion of IVF treatment for veterans, and I hope that you will lend your complete support to that program as well. 

193 

Dr. SHULKIN. Yeah. On January 19th, this became a final interim rule, so we are moving ahead with coverage for service-connected IVF treatment. It is absolutely—it is long overdue. 

Senator BLUMENTHAL. Great. And in light of your own medical 

background, I am sure you appreciate the need and importance of 

this program. 

And finally, because my time is running out and we have one 

more vote, a 2015 report from the Veterans Education Success 

Fund found that 20 percent of 300 GI Bill-approved programs, in 

licensed occupations, left the graduates ineligible to work. 

In the last Congress we joined in a bipartisan, bicameral effort 

to unanimously pass the Miller and Blumenthal Veterans Health 

Care and Benefits Improvement Act. One component was the Career-Ready Student Veterans Act, which requires the VA to disapprove GI Bill benefits for programs that lack the appropriate accreditation for graduates to earn State licenses and certification. It 

sounds highly technical but in the real world can have a tremendous impact on enabling our veterans to get to work, and I hope 

that you will commit to rapidly implementing this important bill. 

Dr. SHULKIN. Yes. Thank you for your leadership on that. 

Senator BLUMENTHAL. Thank you. I very much appreciate your 

leadership and I look forward to working with you. 

Dr. SHULKIN. Thank you, Senator. 

Senator BLUMENTHAL. Thank you. 

Chairman ISAKSON [presiding]. Senator Blumenthal, you were 

not here at the beginning of the testimony and I wanted you to 

know I bragged about you and appreciated very much your leadership last year in co-chairing the Committee with me, leading to the 

stuff we passed at the end of the session. I just wanted to acknowledge that publicly. 

Senator BLUMENTHAL. Thank you. Well, I appreciate that, Mr. 

Chairman, and I was proud to be among your supporting cast. 

Thank you. 

Chairman ISAKSON. Well, any time the Committee can pass out 

a bill 15–0, something is going right, and we appreciate your help. 

Senator BLUMENTHAL. Thank you. 

Chairman ISAKSON. OK. Who is going to interpret these notes for 

me? Are you next, Mike? 

Senator Rounds, and thank you Senator Rounds for filling in for 

me. 

Senator ROUNDS. Thank you, Mr. Chairman. I would like to talk 

about the Choice Act, and just reconfirm your thoughts about some 

directions we have got to go. 

Last year, this Committee passed out an amendment to the 

Choice Act which would have made the VA the primary, rather 

than the secondary, payer in the Choice Act, which would clear up 

a whole lot of stuff out there. Would you commit, once again, your 

support to moving this from secondary payer to primary payer in 

the Veterans Choice Act? 

Dr. SHULKIN. Yeah. Senator, I think the way that we are using 

the term ‘‘primary payer,’’ absolutely. We want to take the veteran 

away from being caught in the middle and then being caught in 

this credit swap. I want to make sure that when we write this that 

we write it correctly, because we do not want to add to the expense 

194 

of the Choice Act. We want to use our funds most judiciously, and 

to the benefit of the taxpayers and veterans. 

So, yes, we think we need to do it differently. As you know, in 

Community Care, VA is the primary payer. In Choice, we are the 

secondary payer. It makes no sense to have two different ways of 

paying bills for the same veterans. So, we want to get it to one program that makes sense. I think you and I would describe that as 

primary payer, but there is some technical language in there I 

want to make sure is in the bill. 

Senator ROUNDS. But the idea would be that, under the Choice 

Program, when a VA goes to their physician, following the rules, 

that the VA would pick up the bill, and then if there was other insurance, the VA would then go back and—— 

Dr. SHULKIN. That is the exact idea. 

Senator ROUNDS. OK. 

Dr. SHULKIN. Yes. 

Senator ROUNDS. Second item. With regard to the costs involved, 

I just want to hear your thoughts on this. In some of the work that 

we have done, we find some rather disturbing costs involved in the 

administration, not just of the Choice Act, but really the cost of administering the claims process. 

Dr. SHULKIN. Yeah. 

Senator ROUNDS. Let me just lay out what we are finding. Now, 

the VA’s average cost to process one claim is approximately 10 

times the cost of a TRICARE claim—10 times. VA/VHA, not just 

the Veterans Choice Act but VA current programs, $15.91 per 

claim. Now compare that with TRICARE at $1.50 per claim for 

paper, or $0.40 per claim for electronic. Even Medicare, at $0.80 

per claim. 

We have got to have a better way of delivering that administrative service because that is money that, right now, rather than 

going into veterans’ care is going into administrative thing that is 

clearly out of date, and out of proportion with what the rest of the 

industry is going to. 

Would you like to share a little bit about—I mean, you have seen 

it now for a couple of years. 

Dr. SHULKIN. Yes. 

Senator ROUNDS. And I know you are aware of it. Can you talk 

a little about how you see your vision—— 

Dr. SHULKIN. Yeah. 

Senator ROUNDS [continuing]. And how we start to address this? 

Dr. SHULKIN. Certainly our goal is to get the administrative costs 

down to as low as possible. Our RFP that we had talked about earlier is redefining the way that a third-party administrator’s role 

would be, and the idea would be to get the administrative costs 

down. That is the objective. 

The numbers that you are talking about, when the Choice Program got stood up, and so we were just enrolling patients, the administrative costs were astronomical, because we were building a 

brand new administrative infrastructure and using third parties to 

do that, and so the administrative costs were sky high. Since May 

2016, our administrative costs in the Choice Program are now 10 

percent. That is not bad, compared to industry managed care 

standards. We think we can do better than that. 

195 

TRICARE, the comparison you made, has been up and running 

for years and years, so, you know, the comparisons were not exactly equal. Your observation about that any cost that goes to administration is not going to benefit directly a veteran, that is what 

we want to get as small as possible. 

Senator ROUNDS. Very good. Thank you, Mr. Chairman. I will 

yield back my time. 

Chairman ISAKSON. Thank you again for filling in while I was 

out. 

Before I introduce Senator Murray, for the benefit of everybody 

at the dais now, we are going to hold the record open until 6 p.m. 

tomorrow for you to submit any questions after the hearing you 

want to submit. Dr. Shulkin, we are going to ask you have them 

answered by 6 p.m. next Monday. We want to get you confirmed, 

unless you have a bad answer to any of those questions. 

Dr. SHULKIN. You do know it is Super Bowl Sunday, right? 

Chairman ISAKSON. I have got the Falcons pin on right here. OK. 

[Laughter.] 

But on Monday, it is Shulkin Monday. It may be the Falcons on 

Sunday but it is still—— 

[Laughter.] 

Chairman ISAKSON. OK. OK. Unless you plan on doing some celebrating that we did not want to know about. [Laughter.] 

I am aware, and since you asked, the Falcons are playing on 

Sunday at 6:30 p.m., Fox television. [Laughter.] 

It is going to be Tom Brady today. [Laughter.] 

We are finally going to get him one of these days. 

Senator Murray. 

HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you very much, Chairman Isakson, and 

to our Ranking Member, Senator Tester. 

I want to recognize all the VSOs here. It is an amazing turnout 

and it shows how much you care about this nomination and this 

department, and I appreciate that. 

Dr. Shulkin, welcome. We had a chance to talk yesterday about 

what I think needs to be done to provide better care for all of our 

military families, and you know where I stand on a lot of things, 

from privatization to the urgent need to improve access to care. 

You also know that I believe the problems at VA are not always 

about money, but about the need for strong leadership, so I want 

to get right to my questions, since I know my time is limited here, 

since I know the Chairman does want to go to a game on Sunday. 

Chairman ISAKSON. If Sunday is the deadline, it is Monday. 

[Laughter.] 

Senator MURRAY. Dr. Shulkin, I think Senator Blumenthal asked 

about this, but after a very long fight Congress finally passed a bipartisan provision to give the VA legal authority to cover IVF for 

veterans and their spouses through fiscal year 2018. Despite some 

technical holdups, I have been assured that the VA will implement 

this consistent with the intent of that law, but I am very concerned 

that the Trump Administration, in some reckless attempt to just 

reverse regulations, will prevent that from happening. 

196 

I wanted to ask you specifically, do I have your assurance, yes 

or no, that veterans and their spouses will have access to this service through fiscal year 2018? 

Dr. SHULKIN. Yes. It was an interim final rule on January 19. 

Done. 

Senator MURRAY. OK. And can I count on your continued support 

for access to IVF for those veterans? 

Dr. SHULKIN. Yes. 

Senator MURRAY. Great. Dr. Shulkin, President Trump last week 

issued a hiring freeze on Federal workers, which does affect the 

agency you may lead, as well as more than 800 positions at VA facilities in my home State of Washington. Now I know the VA has 

responded with some exemptions, to try and make sure care is not 

compromised, but there are still open positions. 

Do you agree with the President’s hiring freeze, which is now affecting those open positions at the VA? 

Dr. SHULKIN. Senator, the most important thing to me is that we 

have the resources to hire the people that we need to take care of 

our veterans, and we have requested that from the White House 

and we have gotten that. So, the openings, we have 37,000 positions exempted right now that we are actively recruiting for, and 

that we desperately want to fill. I am very comfortable with where 

we are at this point. 

Senator MURRAY. OK. Well, are you going to make sure the 

President understands that this freeze is actually counterproductive at the VA? 

Dr. SHULKIN. Everything that we have asked for from the administration right now has been granted, so I feel comfortable that we 

have what we need. I do commit that if confirmed as Secretary, I 

would be a tireless advocate to ask the President for everything 

that we need to make sure that our veterans are getting both the 

health care and services that they deserve and that I would be here 

to protect, because if I am Secretary I am going to have their back. 

Senator MURRAY. OK. We will hold you to that. 

Now, I have heard from a lot of veterans in my State and across 

the country who are actually outraged by President Trump’s executive order that unfairly banned refugees from Muslim-majority 

countries and created a religious test as to how Federal agencies 

treat Americans, their families, and those seeking a better life here 

in the United States. I stand with them, and I believe what Republicans and President Trump are doing is un-American and unconstitutional. 

Can you assure me that as VA Secretary under this administration that when pressed by President Trump to carry out an unconstitutional act, such as denying medical services and benefits, or 

making a hiring decision based on race, ethnicity, or religion, that 

you will never withhold care or treat a veteran different as a result 

of their ethnicity or religion? 

Dr. SHULKIN. Senator, look. I very, very much value the way that 

this Committee works, which is in a bipartisan way. Our total 

focus is on veterans. As Secretary of VA, if I am confirmed, my sole 

focus is going to be on making sure that every veteran who has 

earned the right to be cared for as a veteran, through VA, gets 

that, regardless of anything, and nothing will get in the way of givVerDate Mar 15 2010 15:59 Apr 04, 2017 Jkt 000000 PO 00000 Frm 00200 Fmt 6633 Sfmt 6601 Z:\ACTIVE\020117.TXT PAULIN
197 

ing a veteran the services that they deserve and the health care 

that they need, and the other services. So, that would be—— 

Senator MURRAY. Including ethnicity and religion? 

Dr. SHULKIN. Veterans are not religions and Democrats and Republicans, they all bleed red, and as far as I am concerned they are 

all the same. They all deserve the same exact access to services 

and health care. 

Senator MURRAY. OK. Well, President Trump also said that he 

is going to conduct a wide-scale investigation of voting issues pertaining to the recent Presidential election, despite the fact there is 

no evidence of voter fraud. And now, as you know, veterans and 

servicemembers are often registered in multiple States, which 

alone is, by the way, not a crime unless the individual actually 

votes in multiple States. 

I am very concerned that this misguided effort could lead to veterans and servicemembers being stripped from voter roles in every 

jurisdiction they are registered in, which is especially egregious 

given, of course, their service to our country. 

As Secretary, what are you going to do to make sure veterans, 

servicemembers, and their families do not have their rights robbed 

by this process? 

Dr. SHULKIN. I do not know that the issue related to voters’ 

rights and some of the things that you are describing are in the 

purview of the Secretary of the VA, but certainly everything that 

is in the purview of the Secretary of the VA that I can do to advocate on behalf of veterans, I am going to make sure that I do. 

Senator MURRAY. Well, I appreciate that. Well, I hope that when 

you hear the President make a wide-scale whatever, that he seems 

to be doing, that you remind him that veterans also are impacted 

by this. When he says that he is going to go after voter fraud 

across the country, as I said, many of our veterans and their families are registered, by virtue of their service in several States. They 

are not voting in two different States or three different States, but 

they are registered so they can participate as citizens. 

I expect you to stand up and remind the President, when he 

makes these broad, wide-range executive actions, that veterans 

have to be thought about in that process. 

Dr. SHULKIN. Yes. 

Senator MURRAY. Thank you. 

Chairman ISAKSON. I just want to inject, as kind of an after— 

not an afterthought but a primary thought, that we have so many 

foreign nationals who fight in our military. I think 15 percent of 

our military is made up of people who are foreign nationals who 

are here on permits. 

Diego Rincon of Colombia was the first lost Georgian who lost his 

life in Iraq. His portrait hangs over my desk in my office, and he 

volunteered for the United States military, to later become a citizen. And our military has had a great open policy for recruiting 

both domestic American citizens as well as overseas citizens of 

other countries who have come here to become U.S. citizens. 

We have a tremendous commitment to any of those people, regardless of where they are from or who they are. If they sign for 

us to fight and risk their lives, they deserve every benefit unfettered that we promise them when they sign up, and we are going 

198 

to always see to it that is the case. I am sure Dr. Shulkin will, and 

I will too. 

Dr. SHULKIN. Yes. 

Chairman ISAKSON. With that said—let us see, did Jerry come 

back? Have you asked any questions yet? 

Senator MORAN. I have not. 

Chairman ISAKSON. OK. Who—and we just had Patty. 

Have you asked any questions yet? Have you got time to wait for 

him? 

Senator MORAN. Mm-hmm. 

Chairman ISAKSON. Dean Heller. 

HON. DEAN HELLER, U.S. SENATOR FROM NEVADA 

Senator HELLER. Mr. Chairman, thank you, and to the new 

Ranking Member, I look forward to working with both of you. 

Dr. Shulkin, congratulations. 

Dr. SHULKIN. Thank you. 

Senator HELLER. I am pleased for you and your family and those 

that are perhaps watching today’s hearing. I appreciate the visit 

you made to my office yesterday, where we talked about some numbers and some statistics that were important to me. I told you I 

may bring them up in today’s hearing, so here we are. I want to 

thank all the VSOs and all those that are in attendance today for 

sharing and expressing your concern for this particular position, 

which is important to all of us. 

I want to compare some of the numbers of today when it comes 

to backlog claims, and I apologize if this has been a topic discussed 

prior to me getting in here, but the backlog claims today versus December 2013. 

Today, we have a 28 percent backlog, about 1,235 to be exact, 

versus December 2013 it was 67 percent. So, you can see that we 

have made some progress and I appreciate the men and women 

back in Nevada that are working for us and doing a great job back 

there to reduce this backlog. 

Today, the total pending claims is 4,416 versus in 2013, which 

was 6,622. The problem, of course, is in the appeals. We talked 

about this a little bit. Today, it is 2,731 versus 2013, where it was 

1,140. That is a 140 percent increase since 2013. 

As you know, as we have pushed on the—and staff back in Nevada have pushed on this backlog claims for pending claims. Obviously the problem is that we are now seeing these appeals balloon. 

Dr. SHULKIN. Yes. 

Senator HELLER. What process? What process do you see in the 

near future that will address these appeals? 

Dr. SHULKIN. Senator, first of all, thank you for recognizing the 

tremendous progress that the benefits team has done. This has 

been—— 

Senator HELLER. They have done a great job. 

Dr. SHULKIN [continuing]. An example of modernization of VA 

that has taken the numbers down dramatically—— 

Senator HELLER. Yes. 

Dr. SHULKIN [continuing]. Nationally from over 700,000 to today, 

about 80- or 90,000, and we are going to do better than that by the 

end of the year. 

199 

Senator HELLER. Good. Glad to hear that. 

Dr. SHULKIN. But, in the appeals process, we have no hopes without a modernization act being passed through Congress to fix the 

appeals process. It is a broken process. It will not get better without your help, and we certainly hope that you and your colleagues 

will pass a modernization act this year. 

Senator HELLER. The average days to complete now are 124 days 

versus where it was in 2013. In Nevada, at least, it was 433—— 

Dr. SHULKIN. Mm-hmm. 

Senator HELLER [continuing]. Almost 434 days. So, you can see 

that there is some real progress there. I just want our veterans to 

know, back in the State of Nevada, how hard that office is working, 

the men and women that are committed to our veterans to make 

sure that they do get these benefits and services that they need. 

I would like to talk about doctor shortages for just a moment. We 

have, in the State of Nevada, felt a real impact. Nevada ranks 47th 

in the Nation for physicians per capita, and 48th for nurses. And 

as you know, on top of that the VA is competing with the private 

sector for hiring. 

Given your experience, especially in running hospitals, what recruitment or retention efforts and initiatives will you be pushing to 

ensure that we get high-quality medical professionals joining and 

staying at the VA? 

Dr. SHULKIN. Well, recruitment is our key issue, and I want people to know that working at the VA is a tremendous privilege. I 

see patients in the VA and I am proud to work with the men and 

women that serve in the VA. People read about all the bad press 

and the media events, and they say, ‘‘Well, I may not want to work 

there,’’ but I can tell you, when they come they see an environment 

that really is an extraordinary place to work. I want people to 

come. 

When you have given us the tools, like the Choice Act, we have 

hired 18,800 net new staff because of the authorization that you 

gave us. I hope, as Secretary, if I am confirmed, that you give me 

the ability to recruit and retain even further. So, when the CARA 

legislation passed, inadvertently, I believe, or at least I hope, our 

recruitment dollars were put into the CARA performance awards. 

So, it actually removed a tool that we used in the past to recruit 

and retain the very, very best, and I would like to have the ability 

to have what we had before, which is the dollars available to do 

what you are talking about. 

Senator HELLER. Doctor, just—— 

Dr. SHULKIN. Yes. 

Senator HELLER [continuing]. Because I am short on time—— 

Dr. SHULKIN. Yep. 

Senator HELLER [continuing]. Can you give me your opinion on 

medical scribes, and do you believe that they will help these VA 

physicians and their workloads? 

Dr. SHULKIN. We are looking at the medical scribe issue. The private sector has used it very successfully and we are starting some 

pilots in that. That is something that I think has some promise. 

Senator HELLER. How about more doctors in rural areas? 

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Dr. SHULKIN. We need them, and we need to expand our graduate medical education programs in these rural areas. We would 

like to do that as well. 

Senator HELLER. Thank you. Mr. Chairman, my time is out. 

Chairman ISAKSON. Thank you, Senator Heller. We will go to Ms. 

Hirono and then to Jerry Moran. 

HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII 

Senator HIRONO. Thank you very much. It is good to see you 

again. I enjoyed the opportunity to talk with you and, in fact, just 

to reiterate, when I met with you I mentioned that three aspects 

of VA Administration that I am particularly interested in, and you 

committed to working with me on all of them, one is, of course, to 

improve access to health care for veterans and also to the various 

programs that support veterans. The second is to improve the communication between VA and the veterans, and the third is to 

smooth the transition from—for the veterans when they leave active service status. 

So, how we implement all of these areas are what we will be 

going forward on, should you be confirmed. 

I did have a question that I hope—a series of questions that I 

think should elicit very short answers from you. The first is that 

I was informed that there is a tool called the Blue Button—— 

Dr. SHULKIN. Yes. 

Senator HIRONO [continuing]. That was born out of a veterans’— 

VA to empower patients with direct access to their medical data 

contained in the My Health, whatever—— 

Dr. SHULKIN. My Healthy Vet. 

Senator HIRONO. Yes. OK—personal health record portal. Will 

you promise to support the ongoing development of the Blue Button 

tool and consider allowing more functions beyond viewing and 

downloading one’s records? 

Dr. SHULKIN. I will be brief. I think you are right. This was a 

success, the Blue Button, easily to download your EMR. We do 

have a digital services team that is looking at ways to be able to 

expand capabilities. 

Senator HIRONO. Great. I have a number of questions relating to 

the care that they should receive. I know that you are aware of the 

bill that Senator Joni Ernst and I introduced. She introduced it. I 

am the lead Democratic cosponsor on veteran e-health and telemedicine, and I would like you to reiterate, for the record, that you 

believe that this is a very good thing, it would provide more avenues for care for especially our veterans who live in rural areas, 

and that you will work very closely, particularly to overcome some 

objections by the American Medical Association. 

Dr. SHULKIN. Yeah. As I discussed with you, this bill is something that I strongly support, and we need this to take care of our 

veterans, particularly in our rural areas. I really hope that you will 

re-introduce that, and I will do everything possible to help support 

that bill. 

Senator HIRONO. And, of course, we would like the Chair to be 

on board also. 

Another care question. The VA is currently collaborating on a 

pilot basis with pharmacies to provide walk-in services for common 

201 

health care issues. The VA has a contract with CVS, which is everywhere, including in Hawaii. I think it would be a good thing if 

you would be willing to look at expanding the VA’s collaboration 

with pharmacies to provide walk-in services, which would be so 

much more convenient for our veterans than to have to go to a VA 

facility. 

Dr. SHULKIN. Yeah. This started with our Palo Alto VA and I 

would agree with you. It has been a successful pilot. We are looking at expanding but we will probably need to do that through an 

RFP to make sure that the process of giving out a contract is fair 

and complies with Federal rules. 

Senator HIRONO. Another—this has to do with survivor claims. 

In the Veterans Health Care and Benefits Improvement Act, there 

was a provision to automate the survivor claims process, to just 

speed up the process, and I just would want to make sure that the 

implementation of this provision is occurring, so that the claims— 

claimants can get what they should be getting without going 

through all kinds of unnecessary hoops. 

Dr. SHULKIN. Yeah. Senator, I agree, this is important to do. I 

do not have a specific timeline but I would be glad to get back to 

you with that. 

Senator HIRONO. Thank you. 

Well, this goes to construction of facilities, because we still—the 

CBOCs are very important and there are a number of these facilities that are in the pipeline, including one in Hawaii, the Advanced 

Leeward Outpatient Healthcare Access Clinic, and State Veterans 

Home on Oahu. I would want to work with you to make sure that 

these projects are moving along, because they are already on the 

list of projects to build. 

Dr. SHULKIN. I would be glad to do that. 

Senator HIRONO. Then very specifically, we passed the Filipino 

Veterans Equity Compensation Fund and there are still some 

claims being made to the fund, and some of these veterans are having a hard time with providing all of the kind of records that they 

need. Some of the records have been destroyed, et cetera, and we 

would really want to work with you as World War II Filipino veterans are dying on a daily basis, and I will want to work with you 

so you can facilitate the decisions to support these veterans with 

just claims. 

Dr. SHULKIN. Yes. You and I discussed that and I am supportive 

of doing what we can to get people who have earned the benefits 

the benefits that they deserve. 

Senator HIRONO. Thank you. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Hirono. I appreciate 

your input and your questions. 

We will go to Senator Moran, followed by Senator Tester, followed by Senator Boozman. 

Senator Moran. 

HON. JERRY MORAN, U.S. SENATOR FROM KANSAS 

Senator MORAN. Mr. Chairman, thank you very much. Dr. 

Shulkin, welcome to the Committee. Welcome back to the Committee. I congratulate you and your wife on your nomination and 

look forward to hearing your testimony today. 

202 

Let me start by saying that we had a fine conversation in our 

office. I am looking for assurance that the VA is going to be different than it has been, in a more—this may sound provincial, 

about Congress, but a couple of things that have troubled me about 

the VA. One is that the outreach to Members of Congress, responsiveness, our ability to get VA attention on case work and individual veterans problems, in my view, has been miserable, and you 

assured me that things are going to change, and I assume if I 

asked you that question you would be politically adept enough to 

say yes again today. But the reality is, in my view, the VA is failing not just Congress but veterans that we are elected to serve and 

try very hard to care for. 

Another example of the VA’s lack of concern for Congress is it 

seems to me, in way too many instances, perhaps all, in legislation 

that we passed, the VA then narrows the scope of that legislation, 

thwarting congressional intent. I just sat here listening to you testify and was thinking about three instances, just in the Choice Act. 

Remember the early days of 40 miles in which it was as the crow 

flies. That is a way to deny veterans benefits that Congress intended for them to have—ultimately corrected, that is a good thing, 

but interesting to me that is where the VA started. 

The full-time position. What is the definition of a facility, and 

particularly as a CBOC, we tried to redefine what a CBOC is, 

based upon a full-time position. The VA then narrows it—not 40 

hours as most of us would expect a full-time position to be, but 

something less than that. Again, thwarting the efforts of Congress, 

the intent of Congress to serve our veterans. 

The one that you and I talked most about in my office, which I 

am hoping that you have some good news, is the opportunity for 

us to correct this issue of unusual and excessive burden in which 

we indicated that you can go—you can have Choice, but then you 

narrowed it by—you, the VA—narrowed it by limiting the necessary procedures, the procedures that then qualified. Again, narrowing the opportunity for veterans to be served by Choice. And 

just three instances I thought, sitting here listening to your 

testimony. 

Any chance you can tell me good news, that you have looked at 

that and—— 

Dr. SHULKIN. Yeah. Senator, I can give you good news on that, 

that I believe—and I appreciate you and your staff pointing this 

out to us—those were meant to be examples. I think the field took 

them literally, that these are the only five conditions. So, we have 

gone out now, nationally, and clarified that, to give the flexibility 

that you need. 

But let me make the comment. This is complex business when 

we are making laws and implementing them. These examples are 

going to continue to come up. My commitment to you, if I am confirmed as Secretary, is we have to have these types of conversations and this type of communication, because you are hearing from 

constituents and you have information, and we need to get back to 

you in a timely fashion. That is why I am committed to that. Because we are going to continue to have these differences in interpretations. But in the end, we both want what is best for veterans, 

203 

and I believe we will come up with the right solutions, like in this 

example where I just gave you good news. 

Senator MORAN. That is good news, and I appreciate that, assuming that we then see a result. 

Dr. SHULKIN. Yes. 

Senator MORAN. In many instances in which the VA assures us 

that they have solved a problem, you get out to Kansas and nobody 

in the VISN or nobody in the hospital—— 

Dr. SHULKIN. Right. 

Senator MORAN [continuing]. Knows any change. Your work is 

fully cut out for you, even when you make a decision that is advantageous to veterans. 

I am thinking about what you just said. We are going to have 

these kind of discussions—that is true. You are going to implement 

laws, but it does seem to me that in too many instances the goal 

has been to narrow the scope. I mean, the VA ought to be looking 

for ways to expand the opportunities, not narrow them. So, I hope 

your attitude and approach changes from what I saw in the past. 

I also asked you—and I do not think this happened so I do not 

think you can deliver good news—I asked you to have conversations with the VSOs—American Legion, VFW, Vietnam Veterans, 

and folks who are very interested in talking to you—and again, I 

would encourage you in this setting to do so, if you become confirmed or whether you become confirmed. 

Dr. SHULKIN. Yeah. You know, I think I have told you, but if not, 

I am absolutely clear, on the record, that the VSOs are—have been 

an absolute valued and treasured resource to me as a voice for veterans. I consider my relationships with them absolutely critical to 

the success of what I currently do, and certainly critical to the success of a Secretary. I meet with them on a regular basis. I e-mail 

with them. I take phone calls. My staff does too, so that commitment is absolutely there. If we need to do it more than we are 

doing it, then we will do it more than we are doing it. 

Senator MORAN. I notice that President Trump, his words on 

Choice were—President Trump says, ‘‘Ensure our veterans get the 

care they need, wherever and whenever they need it. No more long 

drives. No more waiting. No backlogs. No more excessive red tape. 

Just care and support they earned with their service to our country.’’ And in regard to accountability, something I have yet to raise 

this morning, ‘‘Fire the corrupt, incompetent VA executives who let 

our veterans down. Use the power of the presidency to remove and 

discipline the Federal employees and managers who have violated 

the public trust, and failed to carry out the duties on behalf of our 

veterans.’’ 

I assume you are, as a nominee, you are supportive of both President Trump’s statements. I would ask you, just on a—how would 

you grade yourself? If you come to this Committee 6 months from 

now, what would be the scorecard by which we could determine or 

I could determine whether you have met the goals of your service 

as the Secretary of the department? 

Dr. SHULKIN. Well, we can talk about what the right time to 

come back and do that is, but, listen, there is only one goal that 

is important to me. Ask the veterans what they think of the services that they are getting, and what their trust level is of us, in 

204 

terms of being able to deliver that. That is the most important outcome. We can define metrics on how to do that, but this is an organization—I think this is really what you have been saying all 

along—that has to be veteran-centric. That is the only reason we 

exist. That is the only reason why you have a Secretary, to make 

sure that they are advocating on behalf of them. 

So, let us ask them and let us see if we are doing a better job. 

Senator MORAN. Well, that is fine. 

Mr. Chairman, I will conclude with this. Dr. Shulkin, you have 

the advantage of having served in the VA for 18, 20 months. 

Dr. SHULKIN. Mm-hmm. 

Senator MORAN. It is also a disadvantage because I put you on 

a higher platform as somebody who cannot use the excuses, ‘‘I am 

going to go out and ask veterans what they need.’’ You know the 

problems, and there ought not be a significant learning curve. 

Yours is not about conducting a town hall meeting and learning 

from veterans what the problems are. In my view, you have the 

ability, the background, to actually solve the problems. 

So, from my perspective, the answer to this question will not be 

‘‘we are still conducting a survey,’’ and I do not think that is what 

you are saying. My point, in a sense, is to compliment you for your 

experience, but also to say that I think more is expected of you as 

a result of that experience. 

Dr. SHULKIN. Yeah. Senator, you are not going to hear me asking 

for a learning curve. If you are moving toward confirmation, I hope 

you do it swiftly, because I am eager not to waste another day. I 

want to get on with this. I think the veterans deserve it. I think 

our employees deserve us building a system that meets their needs, 

so that they can serve veterans better, and there is not going to 

be a day wasted. 

Senator MORAN. Thank you, Doctor. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Moran. We will go to 

Senator Boozman. 

Senator BOOZMAN. Thank you, Mr. Chairman. I will be brief. We 

appreciate, again, you being here, and I had a very, very good visit 

with you in the office. 

I was going to ask you a question about the opioids that we 

talked about in the office, but instead of that, something that is related to that is we also talked about me being very supportive of 

the VA’s adaptive sports programs, which I think should be expanded. Right now we have the big programs, but to expand them 

to the smaller communities, the smaller regions, in the sense that 

if we do those kind of things, then we will lessen the opioid problems and some of these other things that we are experiencing as 

a result of veterans just being in really difficult situations, where 

they need to get their minds off of things and into something positive. 

Can you tell us, are there plans to expand the program, perhaps 

on a smaller scale, to include these areas? And what constraints do 

you see in expanding the programs on the local and community 

level? 

Dr. SHULKIN. Yeah. 

Senator BOOZMAN. How can we help? 

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Dr. SHULKIN. I did not appreciate the importance of adaptive 

sports until I came to the VA, because, frankly, I have never been 

part of a health system that even thought about this as part of 

health care and well-being. But when I got into the mountains of 

Aspen with 400 veterans, and got them part of getting them out 

of their wheelchairs onto the mountains, it transformed my view of 

how we can help people. 

So, the stories that you talk about, about getting people off of 

medications, people who are suicidal, to regain a joy in their life 

and to start living again, were inspirational. 

I did it again this summer in San Diego with surfing with veterans. I had never surfed before. A pretty incredible experience. 

So, I am a big, big believer, because I have seen this. We need 

to do more of it. We need to get into the smaller communities. I 

am not looking for additional monies from the Federal Government. 

What I am looking to do is to get sponsors, corporate sponsors, 

which we have so many of. There are probably some in the room 

today and our VSOs, like DAV, who supports our efforts, and many 

of the other VSOs. I am looking for us to have other people see how 

vital this is in transforming people’s lives. They are going to want 

to be part of it, once they experience it. 

Senator BOOZMAN. Very good. Thank you, Mr. Chairman. 

Chairman ISAKSON. Senator Tester. 

Senator TESTER. Thank you, Mr. Chairman. We have had some 

issues with third-party administrators in the State. You are aware 

of it. What can we do to hold them more accountable for their contractual obligations to the VA and to the taxpayer and to the 

veterans? 

Dr. SHULKIN. Yep. I think it is called competition, Senator. When 

we brought the Choice Program up, we only had two bidders for 

the Choice Program, and we accepted both of them. And now that 

we are going out for an RFP, this is going to be a much, much better competition. We already have interest from many more vendors. 

Frankly, this is going to be an open process, and those who can deliver on doing the better job are going to win the contracts. 

Senator TESTER. Well, to my knowledge there was only one that 

bid on Montana. And I will tell you that they have taken some 

things, they have embedded some people, they supposedly increased their call center, but they still do not know Montana. 

Is there any thought of having the VA be the administrator for 

that Choice Program? 

Dr. SHULKIN. The redesign in the Choice Program that we are 

going to come back to you with allows the VA to do the things that 

it does well, which is dealing with veterans, doing customer service, 

making sure the veterans’ needs are met. We outsourced that in 

the Choice Program and we learned that was a mistake. We are 

not going to do that again. 

But, on the other hand, VA is not good at many of these managed care functions, claims processing, and some of the network 

adequacy that you have to maintain. So, what we want to do is 

make the decision based upon what makes sense for the veterans, 

what needs to be in VA, and what needs to be done by private industry. We believe we can find that balance. 

206 

Senator TESTER. Yeah. I will just tell you, from my perspective, 

the VA might not be good, and may have room for improvement, 

and they do, but the third-party administrators are worse, truthfully, at least in our case. 

So, I would like to cut to the chase. There is a lady from Billings 

that said—she wrote me a note and said, ‘‘What can David Shulkin 

do to ensure that all service men and women coming home from 

overseas duty get the medical attention they need, including mental health care?’’ 

Dr. SHULKIN. Well, you know, we have to do a couple of things. 

The most important is access, and that has been our focus. That 

is why if you go to Billings you are going to find same-day services 

in mental health. But, we need more mental health professionals, 

which we are seeking to hire more mental health professionals. 

And we need to use our technology, like tele-mental health, that we 

are using for 336,000 veterans today. We need to continue to expand that. We have just established national hubs—ten national 

hubs of tele-mental health, so we can reach areas like Billings, that 

may not have the number of health care professionals it needs. 

So, we have a lot more to do but we think we are headed in the 

right direction, and we are committed, and we are not going to rest 

until we meet everyone who is returning to have their needs met. 

Senator TESTER. OK. You come from the health care side. 

Dr. SHULKIN. Mm-hmm. 

Senator TESTER. OK? There has been some concern by some folks 

who are paying attention that the VBA side may suffer with you 

as Secretary of the VA. I am just being flat honest. You have commented about the freeze, and you did—and I congratulate you on 

that—get them to unfreeze, for the most part, the health care folks. 

But you still have a backlog on veterans’ benefits. 

What is your intention to do there? Is this not a manpower 

issue? 

Dr. SHULKIN. Yeah. First of all, it was not just health care that 

we got exempted. The National Cemetery too—— 

Senator TESTER. OK. 

Dr. SHULKIN [continuing]. Because it is very important to be able 

to get people—— 

Senator TESTER. Gotcha. 

Dr. SHULKIN [continuing]. The proper burial. 

Senator TESTER. Thank you for that. 

Dr. SHULKIN. What I firmly believe is, what I have learned over 

the 18 months, we are one VA, and you do not get health care if 

you cannot get benefits. And benefits is not going to suffer if I am 

confirmed as Secretary, because it is important to veterans and we 

have to focus on it. 

The issue of a 90-day freeze, I am working with our current 

Under Secretary, Tom Murphy—— 

Senator TESTER. Yes. 

Dr. SHULKIN [continuing]. That if this really starts to impact our 

ability to get veterans benefits, that is something I am willing to 

address with the administration. 

I am not going to forget about it. I am going to advocate for what 

veterans need. 

207 

Senator TESTER. Over the course of the campaign, President 

Trump has said that the VA is a disaster, the most corrupt agency 

in the United States. Do you agree with that? 

Dr. SHULKIN. The President and I spoke about where the VA 

needs to go, and that is where we focused all of our attention. I did 

not talk to him about his past comments, but he and I agree, absolutely, firmly aligned, that we need to do a lot better for our veterans. We agreed upon that moving forward, that the Secretary’s 

role is going to be to get those changes made. 

Senator TESTER. How do you feel about the workforce in the VA? 

Dr. SHULKIN. I feel we have such a tremendous workforce. I am 

so proud of our employees. Just bear with me 1 second, because, 

you know, I just cannot stop thinking about this. When I was in 

St. Louis, I actually made a visit with Senator McCaskill—we visited the VA. They asked me to meet an employee, one of our employees, though she did not want to really talk to me because she 

was very humble. 

But what they told me about her is, the week before there was 

a veteran who had come 3 hours to his appointment in St. Louis, 

and they kept him waiting, so he missed his bus home. So, she is 

walking out to go home, with her coat, she sees this veteran in the 

waiting room, and she says, ‘‘Can I help you?’’ and he says, ‘‘Well, 

I missed my bus. I have nowhere to go. I do not know St. Louis. 

I am worried about staying here overnight.’’ She said, ‘‘I will drive 

you home.’’ He said, ‘‘It is 3 hours.’’ She said, ‘‘Let’s go,’’ and she 

drove him home. 

These are our employees. These are the people that people do not 

hear about. They are there, not for the money. They are there despite the bad press. They are there because they are passionate 

about helping veterans. Thirty-five percent of our employees are 

veterans themselves. These are the best people in health care, and 

I am proud to serve with them. 

Senator TESTER. Do you believe that beating the hell out of the 

entire VA workforce is productive? 

Dr. SHULKIN. Beating them up? 

Senator TESTER. Yeah. 

Dr. SHULKIN. Oh, I think it is destructive. I think it has hurt our 

ability to recruit. It has demoralized our workforce. It demoralizes 

those of us who are trying to improve it, and it has got to stop. I 

appreciate the Chairman and you both helping us with that. 

Senator TESTER. VA job applications are down by about onethird. Is that correct? 

Dr. SHULKIN. Even more, at the height of the crisis, they were 

down 78 percent. We are getting back. 

Senator TESTER. Do you think that is part of the reason they are 

down by a third, because it has come in vogue to beat the hell out 

of the VA? 

Dr. SHULKIN. A big part of the reason. 

Senator TESTER. All right. A couple more questions, if I might. 

We would love to have you come out to Montana, for a number 

of reasons. We have got some great employees out there too. And 

make no mistake about it: the ones that are bad, we need to get 

rid of and get them out of the system. There is no doubt about that. 

But I will you there are some tremendous people out there. 

208 

I am wondering if you could find it to come to our great State, 

which has 10 percent of the population of veterans, second-highest 

only to Sullivan’s State, of veterans. So, we can take a look at what 

is out there and take a look at the distances and visit with some 

of the veterans and the staff. 

Dr. SHULKIN. Well, after I go to Alaska and West Virginia, apparently—— 

Senator TESTER. We are kind of on the way to both of those 

places. 

Dr. SHULKIN. There you go. [Laughter.] 

I will meet you there. 

Senator TESTER. It is good. 

Senator MORAN. Kansas is on the way, too. 

Senator TESTER. All right. 

I will present some questions for the record, but in closing, Mr. 

Chairman, I will tell you that I was not as prepared for this meeting as I should have been; and I will tell you why. These lights are 

bright and the beam comes down and hits off of Paul Rieckhoff’s 

head—— 

[Laughter.] 

Senator TESTER [continuing]. And increases the intensity, where 

I can hardly see David Shulkin. I am telling you, it is tough. 

Chairman ISAKSON. I thought that was a halo. [Laughter.] 

Thank you very much, Mr. Tester. I appreciate everything, Jon. 

As Ranking Member, I am looking forward to a great year, and I 

think we have already shared the common goals that I am going 

to talk about in just a second, but before I do, Jerry Moran has another question. 

Senator MORAN. I did say one. I will ask three real quickly. Is 

that the same as one? 

Chairman ISAKSON. No. It is three times as many. [Laughter.] 

Senator MORAN. First of all, I was pleased to hear something you 

said, Dr. Shulkin. I think it was in response to the Senator from 

Montana’s questions. We introduced legislation in the past, Senate 

Bill 1463, and it is corresponding with exactly what you said. Our 

goal was to get rid of the 40 miles—the issue we face is that people 

cannot use Choice because the VA has come up with reasons why 

they cannot, and we want them to be able to use Choice. So, it is 

whether the service is available—— 

Dr. SHULKIN. Yeah. 

Senator MORAN [continuing]. Not whether there is a facility. 

Dr. SHULKIN. I understand. 

Senator MORAN. You said that, and that is the nature of how I 

think we improve choice, is to make certain that, again— 

colonoscopy is an example I use, and a shingles shot is easy. A guy 

wants a shingles shot at home, the VA says, ‘‘No, you cannot do 

that. You live within 40 miles of a CBOC,’’ and the veteran says, 

‘‘Oh, no, no. That is fine. I have called them. They do not do shingles shots.’’ The VA’s answer is, ‘‘It does not matter. There is a facility within 40 miles.’’ 

Dr. SHULKIN. Right. 

Senator MORAN. Those are things we can get rid of, and you indicated that in your response to Mr. Tester, and I appreciate that. 

209 

Second, the authorities—you have responded to a letter of mine. 

Since the Chairman is critiquing the time, I would say I would still 

welcome an answer to this question. What authorities do you not 

have—what specific authority do you need to discharge the kind of 

people that Jon Tester just said we need to get rid of? And the example that we used with you, and the letter you responded to me, 

is the physician assistant who committed sexual acts against PTSD 

patients at Fort Leavenworth, the hospital, and he was allowed to 

retire. That has those victims of those crimes wondering, how did 

the VA let this happen in the first place, but second, why would 

not this person be fired instead of retired? And we still do not know 

the answer of what has transpired there, and I do not know that 

you will tell me that today, but I am still anxious in knowing. 

Dr. SHULKIN. Yeah. Yeah. I look forward to working with you on 

that, because I do not want to be overseeing an agency that allows 

that to continue to happen. 

Senator MORAN. And the final thing I would say—Mr. Chairman, 

I am anxious to help you in any way I can as we try to make certain that the VA does its job well, to support these Secretary and 

the employees at the VA. I look forward to working with you as the 

Chairman of MILCON/VA Appropriations Subcommittee to see that 

good things happen. And you can convince me that money is the 

issue, but first of all convince me that we are using the money that 

we get today in the very best way and we will be an ally. 

Dr. SHULKIN. I agree. Thank you, Senator. 

Senator MORAN. Thank you. 

Chairman ISAKSON. Thank you, Senator Moran. We are going to 

close—I am going to close out. I have not asked any of my questions yet and I have three or four to ask. But I want to make— 

for the record and for all the staff, for all the Members of the Committee, we are going to hold open the Committee records until tomorrow at 6 p.m. for any questions that any member feels they 

need to ask. They will have until six o’clock tomorrow night to submit those to us. Dr. Shulkin will be able to watch the Falcons beat 

the Patriots on Sunday, and then get his answers in by Monday at 

6 p.m. Is that fair enough? 

Dr. SHULKIN. That is good. 

Chairman ISAKSON. I am doing everything I can. I think you can 

see the Committee has been dedicated to this hearing. We have not 

had any of the monkey business, or whatever you want to call it, 

that we have heard going on at some of the other committees. We 

want to work this thing through, have your confirmation vote 

taken so you can get back to helping veterans and getting that 

done. So, be sure you get your answers back as quick as you can. 

Dr. SHULKIN. We will. 

Chairman ISAKSON. We will finish our FBI review sometime before Monday is over, so we will have everything done. Hopefully we 

will be able to have a vote on confirmation, up or down, at the end 

of next week. 

Is that too soon? Did I say something wrong? We can do it by 

then, could we not? 

STAFF. Yeah. 

Chairman ISAKSON. For once I was right. That is great. I usually 

get that wrong. 

210 

Let me just say this. Dr. Shulkin, you have heard from Jon Tester, you have heard from Mr. Moran, you have heard from a number 

of the other members about Choice, and you have heard from me, 

and we have talked an awful lot about it. Choice needs to work, 

and it needs to be a real choice. It is the veteran’s choice, not the 

VA’s choice, or not the private sector’s choice. We need to see to it 

that there are not limitations on who can go to a doctor in the private sector, that if they go to a doctor in the private sector we have 

accountability in the system to ensure the doctor does what they 

should. 

Second, we need to make sure that the rate that we pay does not 

have a differential in it. Right now, if I am not mistaken, there are 

doctors getting different levels of pay that are doing care in the 

community. Is that right? 

Dr. SHULKIN. Yes. Depending upon the geography and whether 

it is a rural area or not, yes. 

Chairman ISAKSON. But it should be the Medicare rate, I think— 

is that right? 

Dr. SHULKIN. Yes, in most parts of the country. 

Chairman ISAKSON. If it is rural, is there a special dispensation 

for rural? 

Dr. SHULKIN. Exactly. 

Chairman ISAKSON. As long as it is because of the mileage, the 

distance, or whatever, that is fine. But we do not need competition 

in metro areas—— 

Dr. SHULKIN. Right. 

Chairman ISAKSON [continuing]. Where services are available, by 

reimbursing different levels of rates to doctors. It should be the 

same and it should be the Medicare rate. 

Dr. SHULKIN. Yes. 

Chairman ISAKSON. Am I right that in 2016, there were 2 million 

more veterans’ appointments served at the VA than there were the 

previous year? 

Dr. SHULKIN. 2.1 million. Yes, sir. 

Chairman ISAKSON. I think some—Choice contributed to that. 

Dr. SHULKIN. Oh, absolutely. 

Chairman ISAKSON. It contributed to that by having more available places for veterans to get an appointment in a timely fashion. 

Dr. SHULKIN. Yes. 

Chairman ISAKSON. I do not consider that—that was an increased cost of operation for the VA that only because the VA was 

being utilized, when before, they were not costing as much because 

they could not give the service—— 

Dr. SHULKIN. Right. 

Chairman ISAKSON [continuing]. Because we did not have enough 

personnel. 

So, for all this—wherever the people are that do the models back 

at CBO, that we have to base our legislation on, and we get our 

letters on, they need to understand that when they saw the 

amounts—the cost that went up, it was because veterans finally 

were getting the benefits they were supposed to get from their 

service. It was not an increase in the cost of the benefits. Is that 

right? 

Dr. SHULKIN. I agree with that. 

211 

Chairman ISAKSON. And the more—the better the Choice Program works, in terms of easy access and not so much paperwork, 

the less it is going to cost the Federal Government to run the Veterans Administration and the less pressure it is going to be on the 

VA to have office buildings, hospitals, and facilities, because we 

will have a utilization of private sector which has those things, 

which will help lower the pressure on the VA. 

Dr. SHULKIN. Yeah. 

Chairman ISAKSON. The Denver hospital is the perfect example. 

The first challenge I tackled when I became Chairman was to find 

out we had a 1 billion—that is 1 billion with a B—dollar cost overrun in the construction of the Denver hospital. We went out to the 

hospital, Senator Blumenthal and I. Were you with us on that trip? 

Senator TESTER. I was not. 

Chairman ISAKSON. We got there and when we opened Pandora’s 

Box, which we did, we had a hospital that was 43 percent funded, 

57 percent unfunded, and nobody knew what to do. 

Now, with the help of the entire Senate, Senator Blumenthal and 

I and the Committee, we got the money to finish that hospital, and 

part of it is now completed, as I understand. Part of it is now completed. 

The overrun is not $1 billion but it is pretty close, and when you 

get to something like that, you cannot just not finish it. You have 

got to finish it. But if you should not be starting it, you should not 

have started it either, and I think with Choice working the way it 

should, with good management of the VA, we will lessen the pressure on the VA to build hospitals and buildings, and raise the 

amount of money that is available for VA to provide services to veterans. And I think that is the perfect system you can have, because 

that is where I want the money going. 

Dr. SHULKIN. Yeah. 

Chairman ISAKSON. I want to see to it the veterans getting the 

benefits that they have earned by serving their country. 

Last, and most importantly, I am sick and tired of turning on 

Fox television and CNN and whoever it is—I do not want to discriminate—all of them, I mean, whatever you call them. Every 

morning I get up at six o’clock to do my exercises, and I turn on 

my television set, and there is rarely a week goes by that at least 

one morning, and sometimes more, somebody has got a story about 

maggots being found in the wound of a veteran in a hospital, or 

drugs being dispensed in the wrong way to a veteran, almost like 

it is candy, or somebody doing something that just does not make 

any sense at all—Phoenix being the poster child for that all happening, by the way, I might add. 

I want to be a part of a news-free VA that only is making news 

because of the good things it is doing, not the few isolated bad 

things that happen. But those things should not happen, and the 

things I quoted were things that actually have happened in recent 

months. And I want to work with you and work with Jon Tester 

and work with the Committee to tell the good stories of the Veterans Administration on health care on the floor of the Senate, and 

in the travels that we will make in the next 2 years. 

But I want to make sure you commit to me that, when you have 

situations like this pop up, you will quickly tackle them, you will 

212 

quickly respond to them, and you will do everything you can within 

your power to see to it the people responsible for it are reprimanded to the extent you have the ability to do that. Will you 

promise me that? 

Dr. SHULKIN. You have my commitment, Senator. 

Chairman ISAKSON. Now, with me saying that, the last thing I 

want to say is this. When Richard and I worked so hard on the— 

and Jon, and everybody did last year—we got to the accountability 

portion, where we wanted to be able to fire people, and because of 

the Merit Systems Protection Board and a lot of other limitations, 

that could not be done. 

There are a lot of people who think that the Merit Systems Protection Board and some of the employee protections that exist in 

the government are there to keep them from getting fired and give 

them protection to do their job, but a lot of them it gives them 

cover not to do as much of a job as they want to—not a lot, but 

a few. We want to—I want to see if we can work through this year 

to find a way with labor, with our different interests from the two 

different parties, and everybody else will say, ‘‘Is not there some 

way that Dr. David Shulkin could let his agency set goals, be tested, but his agency be monitored? And if there is someone—if there 

is someone—that does not respond to the goals that are set for 

them, does not respond to the care we want them delivering, that 

there is a way to then have a disciplinary action that brings about 

accountability.’’ 

I would like to see you—help you do that. It may not be reinstatement of the Merit Systems Protection Board. It may not be 

anything that I have talked about. But, there is some way we have 

got to give you the tools that you need to run an agency of 314,000 

employees, and 6.5 million beneficiaries in the Veterans Administration. 

Dr. SHULKIN. Yes. I agree, sir. 

Chairman ISAKSON. We will all work with you to try to do that. 

We do not want to fire anybody. We do not want to privatize the 

VA. We do not want to fire anybody. We do not want any of the 

stories that are going on to go around. But, we do want to start 

looking to solve the problems at the VA and see to it what it is to 

the public, what it is to us, and that is the best health care delivery 

system it could be for our veterans. 

With that said, do you have anything else to say, Jon? Jon, do 

you have anything else? 

Senator TESTER. No. The only thing I would like to say, Johnny, 

is thank you. David, we look forward to working together to make 

this confirmation happen as quickly as you can get your stuff in. 

I also wanted to thank you for being here today, David, and putting 

yourself up for this position. 

Dr. SHULKIN. Thank you. Thank you very much. 

Chairman ISAKSON. Questions for the record need to be in the office of the Committee by tomorrow night at 6 p.m. Answers from 

Dr. Shulkin, they need to be 24 hours after the Falcons win the 

game against the Patriots, which is Monday. [Laughter.] 

We appreciate your time. We appreciate your testimony—— 

Dr. SHULKIN. Thank you. 

213 

Chairman ISAKSON [continuing]. And we appreciate your service 

to the country. 

Dr. SHULKIN. Thank you. 

Chairman ISAKSON. This hearing is adjourned. 

[Whereupon, at 5:16 p.m., the Committee was adjourned.] 

(215) 

A P P E N D I X 

LETTER FROM HON. ROBERT P. CASEY, JR., U.S. SENATOR FROM PENNSYLVANIA


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216 

PREPARED STATEMENT OF REP. TIM WALZ, RANKING MEMBER, U.S. HOUSE

COMMITTEE ON VETERANS’ AFFAIRS


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VA Choice Program 

Congress authorized the Choice Program under the Veterans Access, Choice and Accountability 

Act of2014, P.L. 113-146 in response to a nationwide systemic VA patient access crisis. We 

need the VA to move towards a more integrated, permanent community care program that can 

respond to demands and needs for each city, region and state across the country. We need to 

decrease wait times and continue to deliver quality services to veterans and their families. The 

Choice Program has provided success in some areas, but in others, including my own district, we 

have experienced significant challenges that are unacceptable. As we work together to 

consolidate non-VA care, it is my hope that Congress and Dr. Shulkin work together to ensure 

the Department has the authority, budget, staff and provider and care networks in place to better 

coordinate care as the veteran population continues to age and more servicemembers transition 

home. 

President's Memorandum on the Federal Hiring Freeze 

The President's Memorandum on the federal hiring freeze issued on January 23, 2017 will harm 

veterans by leaving them without access to the critical care and services they deserve. Our 

nation's veterans have already sacrificed enough. They should never be asked to bear the brunt 

of this freeze. Whether it's a veteran applying for a job at another federal agency or scheduling a 

procedure at a VA hospital, this freeze will be felt across the country. Any partial lift or cherrypicked exempted positions is unacceptable. One in three people hired by the federal government 

is a veteran and this is nothing less than a burden and strain on the everyday lives of our men and 

women who served. Senator Tester and I teamed up to lead a letter to President Trump from our 

colleagues calling for the full lift of the freeze. As we move forward, Dr. Shulkin's assistance is 

identifying how this is impacting veterans and vacant positions still unfilled at the Department 

will be enormously helpful in advocating for veterans. 

Mental Health 

I look forward to continuing our bipartisan work to ensure that veterans receive the mental health 

care and services they deserve. Many of our nation's heroes return home only to face a 

completely new, internal war. We owe it to those who put their life on the line for our freedom to 

fight with them as they heal their invisible wounds. Chairman Roe and I founded the Invisible 

Wounds Caucus in the House prior to our leadership posts with our respective committees and so 

this an issue we feel strongly about across the House Veterans' Affairs Committee. 

Dr. Shulkin and the new Administration have a moral obligation to improve the availability of 

mental health providers, mental health care and wrap-around services in every region and 

network as VA's data continues to show drastic and horrifying shortage. This is nothing short of 

a crisis and it is a bipartisan issue we must address today. 

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2117apWAL3.eps

Economic Security 

Our goal as a nation is to provide those who serve with the opportunity to achieve the American 

Dream; to utilize their skills, support their families, and have passion for their work. Make no 

mistake about it, employing a veteran is not only morally right, it makes sense economically as 

well. Veterans provide employers with a strong, skilled, and dedicated workforce. Put simply, 

veterans know how to get the job done. The veterans working in my office exemplify this every 

day and I'm proud to spearhead this bipartisan mission with my colleagues. I encourage Dr. 

Shulkin to continue the work of the previous Administration on bolstering the service-to-career 

pipeline and continue its partnership with the Department of Labor VETS. Whether it's 

protecting the Post 9/ll GI bill or improving the tuition assistance programs for transitioning 

servicemembers, I hope Dr. Shulkin and this Administration will work with House Democrats on 

these moral obligations to each veteran. 

Affordable Care Act 

As we explore short and long-term solutions for VA and non-VA care, we must take into 

consideration any potential impacts of repealing The Affordable Care Act. With over 22 million 

veterans in our country, only 9 million are enrolled in the VA. The millions of veterans who do 

not use VA or only use VA as a part of their health care needs is a critical component of our 

nation's care system. Since 2013, the ACA has reduced the number of uninsured elderly veterans 

by an estimated 42 percent according to the National Health Interview Survey. While the ACA 

has brought tremendous opportunity throughout our nation, we must recognize that increased 

access to care in some parts of the country does not translate into all. As both committees 

continue our work on the long-term implications of the Choice Program and coordinating care in 

the community, I urge Dr. Shulkin and the Department to take seriously the pending health care 

challenges ahead for our veterans and their families in the months to come beyond the VA. 

I appreciate the opportunity to share our thoughts and perspective today. I have optimism and 

confidence we can move forward together in a direction that truly improves the lives of veterans 

for generations to come. 

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LETTER FROM LAURA THEVENOT, CHIEF EXECUTIVE OFFICER, AMERICAN SOCIETY FOR

RADIATION ONCOLOGY


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American Society for Radiation Oncology 

January 24, 2017 

Page 2 

We urge swift Senate confirmation of Dr. Shulkin, and we look forward to working with 

him in this important role. 

Sincerely, 

Laura Thevenot 

Chief Executive Officer 

CC: The Honorable Phil Roe 

Chair 

House Veterans' Affairs Committee 

The Honorable Tim Walz 

Ranking Member 

House Veterans' Affairs Committee 

ASTRO is the largest radiation oncology society in the world, with 10,000 members practicing in both 

hospitals and community based centers who specialize in treating patients with radiation therapies. 

As the leading organization in radiation oncology, biology, and physics, the Society is dedicated to 

the advancement of the practice of radiation oncology by promoting excellence in patient care, 

providing opportunities for educational and professional development, promoting research and 

disseminating research results, and representing radiation oncology in a rapidly evolving health care 

environment. 
221 

LETTER FROM WILLIAM J. RAUSCH, EXECUTIVE DIRECTOR, GOT YOUR 6 


2117apRAU.eps

January 31, 2017 

The Honorable Johnny Isakson 

U.S. Senate 

412 Russell Senate Building 

Washington, D.C. 20510-6050 

(202) 224-9126 

The Honorable Jon Tester 

U.S. Senate 

582A Hart Senate Office Building 

Washington, DC 20510 

(202) 224-2074 

Dear Chairman Isakson and Ranking Member Tester, 

In the military, "got your six" means "I've got your back." As a coalition, Got Your 6 works to 

integrate that commitment of support into popular culture, engage veterans and civilians 

together to foster understanding and empower veterans to lead in their communities. Got Your 6 

knows that veterans leave the military seeking new challenges and we fight to ensure there are 

opportunities for them to continue their service while receiving the care and support they need. 

We believe that when the Department of Veterans Affairs is successful, veterans are successful. 

That's why during Dr. David Shulkin's time as VA Under Secretary Health, Got Your 6 worked 

closely with him to reform VA while putting veterans first. Over that time, Dr. Shulkin helped 

propel VA along a transformational path that sets the current administration up for success. 

While Dr. Shulkin does not have our shared experience of military service, he has demonstrated 

his unwavering commitment of serving our veterans and our nation through his work at the VA. 

Dr. Shulkin understands the needs of veterans and our desire to transform VA into a model 

agency. We look forward to working with Dr. Shulkin, his staff, and the entire Trump 

Administration to ensure that the reforms that have taken place over the last two years move 

forward and that veterans are continued to be put first. We proudly support his nomination and 

hope for a swift confirmation to become the ninth United States Secretary of Veterans Affairs. 

Sincerely, 

-N;# 

William J. Rausch 

Executive Director 

Got Your 6 
222 

LETTER FROM RANDY REEVES, PRESIDENT, THE NATIONAL ASSOCIATION OF STATE

DIRECTORS OF VETERANS AFFAIRS, INC. (NASDVA) 

Æ 


2117apREE.eps