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FROM TUMULT TO TRANSFORMATION: THE COMMISSION ON CARE AND THE FUTURE OF THE 

VA HEALTHCARE SYSTEM 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

WEDNESDAY, SEPTEMBER 7, 2016 

Serial No. 114–78 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

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(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

Wednesday, September 7, 2016 

Page 

From Tumult To Transformation: The Commission On Care And The Future 

Of The VA Healthcare System ............................................................................ 1 

OPENING STATEMENTS 

Honorable Jeff Miller, Chairman ........................................................................... 1 

Honorable Mark Takano, Acting Ranking Member .............................................. 3 

WITNESSES 

Nancy Schlichting, Chairperson, Commission on Care ........................................ 4 

Prepared Statement ......................................................................................... 37 

Delos M. (Toby) Cosgrove, M.D., Vice Chairperson, Commission on Care ......... 8 

Prepared Statement ......................................................................................... 41 

STATEMENTS FOR THE RECORD 

The American Federation of Government Employees, AFL 09CIO ..................... 43 

AMVETS ................................................................................................................... 45 

Concerned Veterans For America ........................................................................... 52 

Disabled American Veterans (DAV) ....................................................................... 55 

The American Legion .............................................................................................. 62 

The Enlisted Association of The National Guard of The United States ............. 65 

Iraq And Afghanistan Veterans of America .......................................................... 70 

Military Officers Association of America ............................................................... 77 

NOVA ........................................................................................................................ 81

Paralyzed Veterans of America (PVA) ................................................................... 82 

Veterans of Foreign Wars of The United States ................................................... 88 

Vietnam Veterans of America (VVA) ..................................................................... 96 

Healthcare Professionals Federal Union ............................................................... 100 

MATERIALS FOR THE RECORD 

Letter From Chairman Miller To Mark Takano ................................................... 101 

Letter From Robert A. McDonald To President Barack Obama .......................... 102 

Text of a Letter From The President ..................................................................... 117 

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FROM TUMULT TO TRANSFORMATION: THE 

COMMISSION ON CARE AND THE FUTURE 

OF THE VA HEALTHCARE SYSTEM 

Wednesday, September 7, 2016 

COMMITTEE ON VETERANS’ AFFAIRS, 

U. S. HOUSE OF REPRESENTATIVES, 

Washington, D.C. 

The Committee met, pursuant to notice, at 10:49 a.m., in Room 

334, Cannon House Office Building, Hon. Jeff Miller [Chairman of 

the Committee] presiding. 

Present: Representatives Miller, Lamborn, Bilirakis, Roe, 

Benishek, Coffman, Wenstrup, Walorski, Abraham, Zeldin, 

Costello, Radewagen, Bost, Takano, Brownley, Ruiz, Kuster, 

O’Rourke, Rice, and Walz. 

OPENING STATEMENT OF JEFF MILLER, CHAIRMAN 

The CHAIRMAN. I am going to go ahead and ask our two witnesses to come to the table. Thank you so much for allowing us to 

take care of a piece of business that was important to both sides. 

I will now call the Committee to order. 

I thank everybody for joining us for today’s oversight hearing, 

‘‘From Tumult to Transformation: The Commission on Care and 

the Future of the VA Healthcare System.’’ You will remember that 

the Commission on Care was established two years ago by the Veterans Access, Choice and Accountability Act and it was tasked with 

examining access to care and how best to organize the Department 

of Veterans Affairs health care system and deliver care to our Nation’s veterans over the next two decades. The commission’s final 

report was delivered at the end of June, and with us today to discuss it and the 18 recommendations it includes are Commission on 

Care Chairperson Ms. Nancy Schlichting and Vice Chairperson Mr. 

Toby Cosgrove, Dr. Toby Cosgrove. 

I want to thank them for being here today, and I truly want to 

express my gratitude to them and all the commission members for 

their time and effort that they put into the important work of the 

commission. I want to say thanks to the many veterans service organizations and other stakeholders that provided statements for 

the record for today’s hearing. The advice, counsel, and support offered by our VSO partners is vital to the work of our Committee 

as we work everyday on behalf of America’s veterans. I am personally grateful for the input that they have provided me as Chairman 

and will, I am sure, continue to provide this Committee as ConLeonard.horne on VACREP0180 with DISTILLER

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gress moves forward to strengthen the VA health care system for 

future generations of America’s heroes. 

Like me, the VSOs and by and large we are supportive of many 

of the recommendations that the commission has made. The commission rightly recognizes that the current VA health care system 

has many strengths, many strengths, as well as weaknesses. Moving forward it will be important to ensure that any transformative 

effort that VA undergoes preserves those strengths, which include 

in many cases the provision of care equal in quality to that, that 

is available outside the department walls. 

However, VA’s weaknesses, which include persistent access failures; non-compliance with Federal prompt pay laws; a lack of accountability; a bloated and self-preserving bureaucracy; and billions 

of taxpayer dollars lost to financial mismanagement of construction 

projects to IT programs, bonuses for poor performing employees, 

and more, are legion and growing. This is evidenced not only by the 

commission’s almost 300-page final report but also by the thousands of pages that made up last year’s independent assessment, 

the years of work performed by this Committee, the GAO, the VA 

Inspector General, and others, and most importantly by the daily 

experiences of the millions of veterans who rely on VA for care, are 

all too often left disappointed. 

I wholly agree with the commission’s call for creating an integrated VA community care system, modernizing VA’s outdated IT 

systems, better managing VA’s vast capital assets, reorganizing the 

massive and unfocused Veterans Health Administration central office, reviewing eligibility for care in light of the modern health care 

landscape, and much, much more. However, I disagree, as does the 

administration and many of the VSOs, with the commission’s call 

for the establishment of a board of directors to provide governance, 

set long term strategy, and direct and oversee reform. The commission is right to recognize that VA’s position as our Nation’s second 

largest Federal bureaucracy carries inherent challenges that are 

deserving of our detailed consideration. However, given the crises 

that seem to erupt anew on almost a daily basis where VA is concerned and any efforts to shield the VA health care system from 

executive and legislative branch oversight is a non-starter. 

Outsourcing the crucial role of a cabinet secretary to an independent board that is neither elected nor accountable to the American people would be irresponsible in my opinion and inappropriate, not to mention unconstitutional. 

The debt that our Nation owes to her veterans is a debt that we 

all share and the commission’s work represents the culmination of 

a unique moment in history for VA and the veterans that VA exists 

to serve. There have been and likely will be other commissions devoted to examining VA and how well the department is meeting its 

most important mission, and that is providing accessible, high 

quality care to our Nation’s veterans. But it is incumbent on all of 

us not to let the work of this commission fall by the wayside like 

so many other studies have. And I assured you both, this is not one 

that will sit on a shelf and gather dust. Ignoring this opportunity 

would be a dereliction of our duty. 

The scandals that have characterized VA for the last several 

years have opened the door to finally changing the systemic culture 

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and deeply entrenched problems that face VA and their health care 

system. Translating that momentum into lasting and meaningful 

reform will require a commitment to having uncomfortable conversations about how as a Nation we can begin to pay the debt we 

owe the men and women of our armed forces and to taking the 

risks that are necessary to challenge the status quo that has left 

them wanting and waiting. 

Whoever sits in this chair after me will be responsible for and 

I am sure will be more than capable of moving the ball forward, 

and I am hopeful that today’s hearing will help set the tone for 

that effort. With that, I will yield to the Ranking Member Mr. 

Takano for an opening statement. 

OPENING STATEMENT OF MARK TAKANO, ACTING RANKING 

MEMBER 

Mr. TAKANO. Thank you, Mr. Chairman, for calling today’s hearing. 

Since we first learned of the wait time controversy in Phoenix, 

this Committee has been on a path toward reforming the Department of Veterans Affairs. 

The passage of the Veterans Access, Choice and Accountability 

Act in the 113th Congress required the Independent Assessment of 

the Health Care Delivery Systems and Management Processes of 

the Department of Veterans Affairs. This gave us a good view of 

the VA health care delivery systems and management processes. 

A year later, the enactment of the Surface Transportation and 

Veterans Health Care Choice Improvement Act of 2015 required 

the VA to come up with a plan to consolidate all care in the community programs. 

Now, the Commission on Care has released its recommendations 

for transforming veterans’ health care over the next 20 years. 

I am pleased to receive these recommendations, but am disappointed the VA was not invited to respond and share its input 

this morning. Per the legislation, the VA had 60 days to comment 

on these recommendations and just provided its response to us late 

last week. I am also disappointed the witness we requested, Commissioner Michael Blecker, was not allowed to join our other witnesses to testify here today. I thought the issues and concerns he 

raised in his dissent letter were insightful and needed to be part 

of the discussion as this Committee weighs the best path forward 

for the VA. I ask unanimous consent that Mr. Blecker’s dissent be 

entered into the record. 

The CHAIRMAN. Without objection, so ordered. 

Mr. TAKANO. With all the reports and studies we have seen over 

the last two years, it is clear to me that the status quo, the VA 

as we know it, is unacceptable. 

That said, I don’t believe that completely remaking the VA is the 

right answer either. There is an important balance between transforming the VA while maintaining the services and support that 

millions of veterans rely on. 

I am concerned that some of the Commission on Care’s recommendations might in fact weaken the VA health care system. 

Much like I have seen happen with charter schools, proposals to 

funnel funding to private contractors and for profit care will take 

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desperately needed resources away from our veterans, and should 

be immediately rejected. 

Shifting resources to pay for the privatization of care will have 

impacts throughout the spectrum of care for our veterans. In addition to reducing quality and access to care, it could deprive the VA 

of cutting edge medical research and IT innovation, top notch clinician training, and stifle the VA’s critical role in responding to national emergencies and natural disasters. 

We cannot view expanded choice or the private sector as the panacea for solving the challenges the VA faces. Long wait times and 

workforce shortages impact private care, too. Care in the community should be locally targeted to augment, not supplant the VA. 

Instead of stripping additional resources from veterans health 

care our first priority should be making sure the VA has the staff 

and resources it needs. Downsizing and dismantling the VA in 

favor of sending veterans with unique health conditions and urgent 

mental health needs to navigate the private sector is bad policy. 

Lastly, another big concern I have is the cost associated not just 

with the recommendations made in this report, but with whatever 

solutions we agree upon that makes the VA more efficient and capable of providing more timely health care to our veterans. It is incumbent upon us to keep the promise we made to our veterans by 

ensuring they can access their first choice for care, and to defend 

the rights and work place protections of the 114,000 veterans who 

work at the VA, and their coworkers, who serve veterans everyday. 

Again, I appreciate the work that the Commission on Care has 

done over the past year, and I look forward to hearing your testimony today. And thank you, Mr. Chairman. I yield back the balance of my time. 

The CHAIRMAN. Thank you very much. Members, as I mentioned 

earlier joining us on our first and only panel this morning is Ms. 

Nancy Schlichting, the Chairperson of the Commission on Care, 

and the Chief Executive Officer of the Henry Ford Health System; 

and Dr. Delos Cosgrove, better known to many of you as Toby, the 

Vice Chairperson of the Commission on Care and the Chief Executive Officer of the Cleveland Clinic. I appreciate both of you being 

here with us this morning. And again, for all of the hard work and 

many hours that you put into the work of the commission. I understand that you are both going to be presenting oral testimony this 

morning, just as you both had provided written testimony. With 

that, Ms. Schlichting, we will begin with you. You are recognized 

for five minutes. And I will tell you that if you do go over and the 

red light starts blinking, we will not gavel you down because we 

are anxious to hear your remarks. You are recognized. 

Push your mike button one more time because for some reason 

it is not picking you up. 

STATEMENT OF NANCY SCHLICHTING 

Ms. SCHLICHTING. Okay. There we go. 

Chairman Miller, Ranking Member Takano, and Members of the 

Committee. Thank you very much for the invitation to discuss the 

report of the Commission on Care, for your support of the commission over these months, and also the extension of time to complete 

our work. It has truly been a privilege and an honor to chair the 

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commission charged with creating the roadmap to improve veterans health care over the next 20 years, and I am very pleased 

to be here today with my colleague, Dr. Delos (Toby) Cosgrove, the 

CEO and President of the Cleveland Clinic, who will also present 

after my testimony. 

For 35 years I have served in senior leadership roles in large 

hospitals and health systems, and for the last 18 years I have been 

in Detroit at Henry Ford Health System, for 13 years as its President and CEO. Henry Ford is an integrated health system with $5 

billion in annual revenue and 27,000 employees that owns both a 

large delivery system as well as an insurance company. My experience in leading Henry Ford Health System through a major financial turnaround and navigating our organization through years of 

massive job loss in Michigan, population decline, and the bankruptcies of our city and major employers while still growing substantially, making major capital investments in our community, 

and winning the 2011 Malcolm Baldrige National Quality Award 

have prepared me very well for the demands and complexity of the 

commission’s work. 

I am proud to be here today with one of our veterans at Henry 

Ford, Spencer Hoover, who is Vice President of Planning and Business Development. He served as an airborne infantryman in the 

82nd Airborne out of Fort Bragg, North Carolina, with two combat 

tours, one in Afghanistan and one in Iraq. He was honored with 

six medals and is now 70 percent disabled as a product of his injuries from combat and training. And Spencer, if you would recognize 

yourself? 

[Applause.] 

Ms. SCHLICHTING. Also with me today are the commission’s Executive Director Susan Webman and two staff, actually three staff, 

John Goodrich, Ralph Ibsen, and Susan Edgerton. John and Ralph 

are also veterans. 

Our commission was composed of 15 talented and diverse leaders, two-thirds of whom are veterans. Five have served in significant health system leadership roles, three have served in VA, four 

have been leaders in veterans service organizations, we had four 

physicians, two nurses, and even two lawyers. We developed several principles to guide our work, including creating consensus and 

being data driven, also creating actionable and sustainable recommendations, and most importantly focusing on veterans receiving health care that provides optimal quality, access, and choice. 

The independent assessment report that you commissioned was 

invaluable as a foundation for our work. It is a comprehensive, systems focused, detailed report that revealed significant and troubling weaknesses in VHA’s performance and capabilities. Our work 

took place over ten months with 12 public meetings over 26 days 

and we sought to have the broadest debate possible and we had intense debate and dialogue over the issues. But our unified focus 

throughout the process was, what is best for our veterans? 

I believe we have produced a very good report, strategic, comprehensive, actionable, and transformative. Twelve of the commissioners signed the report, signaling bipartisan support, and the 

three who did not had divergent views. Two felt we had not gone 

far enough, and one felt we went too far. 

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The VHA requires transformation, which is the focus of our recommendations. There are many glaring problems, including staffing, facilities, informational technology, operational processes, supply chain, and health disparities that threaten the long term viability of the system. Perhaps even more importantly, the lack of leadership continuity, strategic focus, and a culture of fear and risk 

aversion threaten the ability to successfully make the transformation happen over the next 20 years. Transformation is not 

simple or easy. It requires stable leadership, expert governance, 

major strategic investments, and a capacity to reengineer and drive 

high performance. Some of our commissioners believed in moving 

VA to a payer only model. They believe that government cannot 

run a complex health system and that veterans should have the 

same choice that Medicare beneficiaries have. Yet we believe at the 

end of the day that VA and VHA under current leadership, Secretary McDonald and Under Secretary Shulkin, are making 

progress and are aligned with most of our recommendations. And 

we believe that VHA should be invested in for several reasons. 

One is the model of integrated care, much like Kaiser or 

Geisinger or even Henry Ford. The clinical quality that is comparable, or in some cases better than the private sector. The history of clinical innovation and veterans focused research, medical 

education, and emergency capacity. The specialty programs, especially mental health, polytrauma, rehabilitation rarely replicated in 

the private sector. The role as a safety net provider for millions of 

complex and low income veterans that may not or could not be 

filled by the private sector in many markets. In fact, as we have 

seen the implementation of the Affordable Care Act, it has been 

difficult in many instances to meet the access need simply because 

of the shortages of primary care physicians and mental health providers in many markets across the country. 

Our recommendations fall into four major categories. First, creating a VHA care system which fully integrates VHA, the private 

sector, and other Federal providers. VHA would continue to provide 

care coordination and would fully vet the provider network to ensure that veterans receive care from individuals who understood 

military competency, understood the need for access, transparency 

of their performance information, and many other critical criteria. 

We also included the fact that veterans should have a choice of primary care providers within those networks to ensure the ease of 

access and meeting their needs. 

The second category is leadership system and governance, again 

focusing on continuity and leadership development to ensure sustainable leadership over time to implement these recommendations. And we also recommended a board of directors to provide 

oversight and the expertise in health care that is critically needed. 

We also in the third category focused on operational infrastructure, information technology, facilities management, performance 

management, human resources and workforce, supply chain, and 

diversity and health care equity. And finally, we have a category 

around eligibility, focusing on the needs of other than honorable 

discharged veterans who have health care needs and in retrospect 

deserve them, and also eligibility design which has not been looked 

at in many years and probably would be worthy of taking a look. 

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The objective of every commissioner throughout this process has 

been that our report would not sit on a shelf and that in fact it 

would be implemented. And we ask for your help today to make 

our report come to life. We ask that you provide VA needed authority to establish integrated care networks through which enrolled 

veterans could receive care from credentialed providers without regard to geographic distance or wait time criteria. We are asking to 

address the fundamental weaknesses in VHA governance and to 

provide VA more flexibility in meeting its capital asset and other 

needs, including establishing a capital asset realignment process 

modeled on the DoD BRAC process; waiving or suspending the authorization and scorekeeping requirements governing major VA 

medical facility leases; lifting the statutory threshold of what constitutes a VA major medical facility project; reinstating broad authority for VHA to enter into enhanced use leases, and easing for 

a time limited period otherwise applicable constraints on divestiture of unused VA buildings; and establishing a line item for VHA 

IT funding, and authorizing advanced appropriations for that account; and also creating a single personnel system for all VHA employees to meet the unique staffing needs of our health care system. 

I would like to amplify one very key point which other commissioners view as foundational. The commission saw VHA’s governance structure as ill-equipped to carry out successfully the kind of 

long-term transformation required to reinvigorate VA health care. 

Continuity of leadership and strategic vision cannot be assured 

under a governance framework marked by frequent turnover of 

senior leadership and near constant focus on immediate operational 

needs. The commission believed that two fundamental governance 

changes were needed, establishment of a board of directors with 

authority to direct the transformation process and set long-term 

strategy, and change in the process for the appointment for and 

tenure of the official currently designated as the Under Secretary 

for Health. 

We are mindful that some of our recommendations have significant cost implications and we worked with health economists in 

modeling different options. Implicit in our discussions, though, has 

been the question, should the Nation invest further in VA health 

care system? Our report answers that question in the affirmative, 

even as it underscores the need for sweeping change in that system. We do not suggest at all that Congress has not already made 

very substantial investments in the system. Rather, we call for 

strategic investments in a much more streamlined system that 

aligns VA care with the community. 

In my judgment, our report points the way to meeting the central 

challenge Congress identified in 2014, improved access to care 

while offering a vision that would expand choice, improve care 

quality, and contribute to improved patient well-being. It is a vision that puts veterans first. My experience tells me that veteran 

centered focus will ultimately improve the service veterans receive, 

while strengthening the system and providing increased transparency and accountability. In my view this is a vision that merits 

your support. 

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I would be very pleased to be a continued resource to this Committee as you continue on your work. And I would also be very 

happy to answer any questions, as I know Toby will after his presentation. Thank you. 

[THE PREPARED STATEMENT OF NANCY SCHLICHTING APPEARS IN

THE APPENDIX]

The CHAIRMAN. Thank you very much. Dr. Cosgrove, you are recognized. 

STATEMENT OF DELOS M. (TOBY) COSGROVE M.D. 

Dr. COSGROVE. Chairman Miller, Ranking Member Takano, and 

Members of the Committee, thank you for inviting me to speak 

about the Commission on Care’s final report today. As a former Air 

Force surgeon, I care deeply about the welfare of the Nation’s veterans, and I am honored to serve as Vice Chairman of the Commission on Care, and as a Member of my VA Advisory Committee. 

Over the course of my work with the VA I have become well acquainted with the department and understand its contributions as 

well as its challenges in meeting our veterans’ needs. As CEO of 

the Cleveland Clinic, an $8 billion health care system serving communities across the country and internationally, I am keenly aware 

of the magnitude of the challenges facing VA health care system 

leaders. 

Mr. Chairman, the veterans health care system must make 

transformative changes to meet the health care needs of veterans 

today and tomorrow. If these changes are not made, the VHA’s 

many systematic problems threaten the long-term viability of VA 

care. The final report contains 18 different recommendations. 

Today I am going to address four specific areas that include the establishment of an integrated community based health system, quality metrics, information technology, specifically the electronic 

health records, and supply chain. 

Given the commission’s charge to examine veterans’ access to 

care, it was concluded early on that greater reliance on and closer 

integration with the private sector held the greatest promise for 

improving not only access, but affording veterans greater choice. As 

you know, the commission considered and debated options that 

would provide for different degrees of choice. The recommended option in the commission’s final report reflects a consensus position, 

so many supported an option that would provide veterans with still 

greater choice of private sector providers. The commission agreed 

that the VHA must establish high performing, integrated community-based health care networks to provide timely and quality care 

to our veterans. The report envisions a continued role for the VHA 

health system, but as was said if the challenges and opportunities 

described in the final report are left unaddressed, we are concerned 

that our veterans will not receive the kind of high quality care that 

they deserve. 

Among our proposals the commission recommends that the VHA 

adopt a continuous improvement methodology, such as Lean Six 

Sigma, to engage staff and improve the culture. This will help but, 

it will also take significant investments in time, effort, and resources to modernize and streamline such essential functions as 

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human capital management, capital asset management and leasing, business processes and information technology. The commission recommended that the VHA should implement core metrics 

that are identical to those used in the private sector. Veterans deserve to know that the health care they are receiving either from 

the VHA or from the community provider is of high quality. If 

these metrics are put in place, it will be easier to evaluate the system’s performance, and Congress will have a benchmark from the 

private sector to compare both its progress and improvement over 

time. Congress and the American people deserve to know that the 

VHA is getting value for their investment. 

Years ago, the VHA was a leader in the field of electronic health 

records. Unfortunately this is no longer the case. Therefore the 

commission believes that VHA should transition to the same type 

of commercial off-the-shelf electronic health records as other providers. By using a proven product, many of the scheduling and 

building problems would be resolved. Further, these systems could 

help the VA identify areas of opportunity and utilization to promote better access to care for our veterans and promote interoperability, which is critical as our veterans move to different care 

sites. 

Finally the commercial electronic health record would also allow 

VHA to link financial and clinical information, a critical 

functionality for running a modern health care delivery system. 

The best and most prevalent commercial electronic health record 

programs allow staff and patients to schedule patient care easily 

and provide legitimate performance measures for wait times, unit 

costs, clinical care outcomes, and productivity that conform to those 

of the rest of the health care industry. Many of our country’s best 

hospital systems have converted home grown information systems 

to commercially based systems. VHA must do the same to remain 

current and engage the rest of the health care delivery system. It 

must also have its own leadership, specifically a Chief Information 

Officer for the VHA information system that allows VHA to adjust 

its information needs as the health care industry evolves. 

As a VHA contractor, Cleveland Clinic has experienced firsthand 

the burdensome antiquated system that is currently in place to receive payments. We are required to provide documentation in hard 

copy form sent via the postal services as they could not accept either fax, email, or other electronic submissions. If a request results 

in more than 100 pages, we must burn the records to a disc. Because we do not have any mechanism to track whether the documentation has been received, we have heard on many occasions 

that they never received the paper records and we have no recourse 

other than to send them again. The independent assessment that 

Congress commissioned found that the VHA should keep claims adjudication and payment separate from its care delivery. 

The health care system that the commission envisions for the 

VHA will continue to expect exceptional performance from its network of providers and providers should expect timely and accurate 

payment in return. 

Supply chain is another area ripe for VHA streamlining. The 

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bates the variation and process the VA pays for products. The VA 

should consolidate and reorganize procurement and logistics for 

medical and surgical supplies under one leader. The VHA has 

enough market share to leverage prices that could result in savings 

of hundreds of millions of dollars. 

At the Cleveland clinic, we are constantly evaluating and reviewing our supply chain products and processes. Today, our supply 

chain is working with teams of clinicians led by a physicians’ champion to justify purchases of more expensive supplies by engaging 

clinical staff in the value-based sourcing effort that illustrates that 

cost and quality do not have to be mutually exclusive. 

Clinicians are made aware of the costs and outcomes are associated with different brands. Once the clinical staff has to justify the 

higher costs and understands whether it will add value to the care 

outcomes based on empirical evidence they make purchasing decisions based on value. Such efforts are then integrated into patientcentric utilization management and inventory management efforts 

to ensure the appropriate use of our resources. 

A clinician-engaged, value-based supply chain management practice model has allowed us to save $247 million over the last several 

years. 

We are continuing to reform our process by entering into purchasing consortium with other nonprofit health care providers and 

ensuring that we are continually searching for improvements in 

cost management. 

Of course, leadership is the key to transformational change. The 

Commission speaks to the need to create a pipeline of internal 

leaders and to make it easier for private sector and military clinical 

and administrative leaders to serve in the VHA. Market-based pay 

is critical to bringing in leaders capable of taking the VHA to the 

next level. 

The Commission also proposes that Congress provide VHA a governance board to provide a long-term strategic vision and successfully drive the transformation process. Both the chairperson and I 

would be happy to talk more about this aspect of the report. 

Mr. Chairman, transforming a system as large and as complex 

as the VHA will require streamlining multiple services, redesigning 

care delivery and more: this report offers a roadmap to success. Realizing the vision the report proposes will require new investments, 

both financial and in expertise, enactment of legislation an strong 

leadership. 

Thank you for your attention, and I am happy to address questions. 

[THE PREPARED STATEMENT OF DR. COSGROVE APPEARS IN THE

APPENDIX]

The CHAIRMAN. Thank you very much, Doctor. We appreciate you 

both being here. 

For either of you that would want to answer this question, do 

you agree with the President and the Secretaries who have both 

stated that many of the Commission’s recommendations are already being implemented via the MyVA initiative? 

Ms. SCHLICHTING. I think that, you know, it is difficult for us to 

really evaluate that because we are not within that structure at 

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11 

this point, but I think in terms of strategies and direction, I think 

there are many areas that are aligned, but it is hard to understand 

within that, do they have all of the plans that will allow that to 

be executed, and I think those are the questions that I would have. 

The CHAIRMAN. Dr. Cosgrove? 

Dr. COSGROVE. Yes. I don’t think we can know exactly. For example, electronic medical record, we don’t know, have they proceeded 

to purchase an off-the-shelf electronic medical record or not, which 

I think is absolutely imperative. 

The CHAIRMAN. And neither do we. We are still trying to find 

that question out also. 

This is something that probably other Members won’t touch, but 

I will, since I am retiring at the end of this term, but what do you 

think the biggest benefit of a BRAC-like process within the VA 

would be for VHA, and also what do you think the big impediment 

would be? 

Ms. SCHLICHTING. Just a couple of comments on the facility challenge I think that VA has. When we looked at the breadth and 

depth of all the VA facilities across the country, the average age 

of a physical plant is about 50 years. To give a comparison, at 

Henry Ford that is nine years, and I think across the country it 

is around ten. 

So the issues that VA will face over time in terms of their facilities, and also the fact that they are very inpatient-oriented today 

as opposed to more outpatient-focused are really significant. So we 

think that the BRAC can provide some objective view and input on 

how exactly the VHA facility networks are performing today, where 

the problems are and where change needs to occur. It also could 

provide, much as it did during the military closures, you know, the 

opportunity for some objectivity and some protection from the political challenges. 

Closing hospitals is a very hard thing to do. I have closed three 

in my career and I don’t wish it on anyone; it is a very challenging 

thing to do and particularly for Members of Congress who are concerned about job loss in communities that might happen. 

The opportunity though in health care is different than the military closures: there is no substitute. So the opportunity for jobs to 

be preserved in communities through more partnership with the 

private sector exists, and also the evaluation of other capacity within that community could serve veterans better with lower costs 

long term. So I think it is with that in mind that we really believe 

this would help the process. 

Dr. COSGROVE. I would just add to that. I also have closed two 

hospitals and realize how difficult that is and how politically entangled this is as a decision-making process. Also, I think there are 

over 220 facilities right now that are not in use and have not been 

either sold or abandoned or begun to be taken down because it has 

been unable to get that accomplished through the current system. 

The CHAIRMAN. And one final thing. There was a statement 

made in VA’s letter to the President regarding the final report that 

indicated that VA is not in favor of eliminating the current Choice 

Program restrictions by mileage criteria and the time restriction of 

30 days because they desire not to sacrifice VA’s four statutory 

missions. I know the report called for a total elimination of the 

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12 

mileage and the time requirement, and I would like to ask if you 

could address why you went further. 

Ms. SCHLICHTING. Well, as you know, Choice was a very difficult 

discussion among the commissioners because we had wide-ranging 

views around Choice. I think we felt that we had to find a balance 

because we understood the fact that there was the danger of weakening the current VHA system if in fact Choice was too broad, but 

what we did do is believe that those limitations in many cases were 

causing really undue problems for veterans and oftentimes, you 

know, the timing involved of even being able to assess some of 

those limitations caused access issues. So we felt that we were erring on the side of choice of primary care provider and also 

strengthening the VA’s control of those networks, because if VA 

could set up those networks in a way that really created the right 

capacity, the right access without endangering the ability of VHA 

to continue their important mission, that was what we were trying 

to find. We were trying to find that sweet spot between choice and 

also, you know, the issues of maintaining a system that is critically 

important. 

The CHAIRMAN. I will go ahead and yield to Mr. Takano for his 

questions. 

Mr. TAKANO. Thank you, Mr. Chairman. 

You know, many of the national veterans service organizations 

are very troubled by Recommendation No. 1. They are concerned 

that instituting Choice as a core policy could lead to a large percentage of veterans to pursue more conveniently located community 

care, this could end up jeopardizing the viability of unique VA services. Your own economist projected a steep migration to community 

care. 

I have one question for you both. What analysis did you conduct 

to test how this concern may play out? And second, why did you 

not recommend pilot testing such a radical change as this? 

Ms. SCHLICHTING. Well, we did actually talk a lot about how do 

you roll this out and felt that probably a phased approach to really 

test some of the assumptions was important, and there were many 

commissioners that spoke to that issue. 

You know, the execution/implementation is very complex and it 

will take time, and I think it will require, much as any major 

change does, some testing and refining and continuing to tweak 

this. But I think on the choice issue it is important to balance this 

question of choice and making sure access is really available within 

every market across the country with the issue of how we are trying to also control frankly, you know, those networks to better 

serve veterans. So it is really finding that balance that I think is 

very important. 

Mr. TAKANO. The Commission’s guiding principles called for recommendations to be data-driven. What specific data did the Commission rely on in recommending that the VA health care system 

should be organized around the principle that veterans should be 

able to choose to receive care from a community provider even 

when the VA can provide the veteran timely care in reasonable 

proximity to the veteran’s home? 

Ms. SCHLICHTING. But if you begin to think of the VHA care system in the way that we did, it is not a question of VA versus proLeonard.horne on VACREP0180 with DISTILLER

13 

vider in the community. It is one system that should be operating 

in a much more integrated way and every provider that is within 

that VA care system then would be able to provide access for veterans. So it is a different mind set than today, and I also think 

should be balanced against all the investments in improving operations that we are recommending within the VHA. 

Mr. TAKANO. As you know, the VA health care system is necessarily very transparent when it comes to wait times and health 

outcomes. How does the Ford Health Care System and the Cleveland Clinic measure wait times? Do those health care systems or 

for that matter any private health care system post wait times publicly and, if not, why not? 

Ms. SCHLICHTING. We actually do now. We have an electronic 

system where people can call in to clinics and find out wait times 

for that day for same-day access. And the other thing we have really changed is the whole notion of access. We now believe that 

same-day access not only for primary care, but specialty care is a 

standard that we are setting for our health system. 

Dr. COSGROVE. And ten years ago we instigated the same-day access. We now see 1.1 million same-day access for our patients and 

the waiting time in the emergency room from door to doctor is ten 

minutes. 

Mr. TAKANO. So would you expect, therefore, private providers 

participating in this system in an integrated network to be held to 

the same wait time rules and requirements as the VA? 

Ms. SCHLICHTING. Yes. 

Dr. COSGROVE. Yes. 

Mr. TAKANO. So I am also concerned about your recommendations to expand Veterans Choice to all veterans regardless of the 

days waiting or distance, I am concerned that it is financially 

unsupportable and might in fact weaken the VA’s health care system and perhaps significantly increase the share of veteran’s care 

provided outside the VA. Did the Commission look at the costs of 

these recommendations and how this might affect the vital research and education missions that the VA conducts for the good 

of the Nation? 

Ms. SCHLICHTING. We did look at cost, and we have included estimates in our report around what we think that would mean; it is 

hard to know, though. I will tell you, there are certain assumptions 

as you go into these cost estimates that are based on, you know, 

certain assumptions that may or may not actually come true. 

And part of the question is how rapidly can some of the improvements in operations to improve access within VA be put in place, 

because it is quite conceivable that more patients would gravitate 

to VA for many reasons, as opposed to always assuming that they 

are going to go in the private sector. It is not as clear as some people would like it to seem. 

Dr. COSGROVE. And I would point out on that last point that 

there are a number of veterans who currently do not get the care 

from the VA, if the VA improved its access and improved its ability 

to take care of them that they would migrate to. There are 22 million veterans across the United States, only six million get some 

care from the VA. And so the assumptions are very difficult to 

project. 

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14 

Mr. TAKANO. Okay, thank you. 

Mr. Chairman, my time is up. 

The CHAIRMAN. Thank you very much. 

Mr. Lamborn, you are recognized for five minutes. 

Mr. LAMBORN. And thank you, Mr. Chairman, for having this important hearing. I want to thank the Chair and Vice Chair of the 

Commission for appearing before us today, and for the time and effort they have put into this report. 

We have two main challenges today, as I see it. First, how do we 

at least ensure that we take what is good in the report and make 

a reality. One hundred and thirty seven previous reports on VA 

health care have already been presented and are sitting on the 

shelf gathering dust. 

Second, and this is maybe an even harder challenge, to evaluate 

whether the proposed recommendations go far enough. We like to 

use words like transformation and reform, but how willing are we 

really to challenge the status quo and consider bold reform. 

We all remember the managerial failures of 2014 that came to 

light; the inconsistent care, the manipulated data and other manifestations of dysfunction. And we also remember the words of the 

independent assessment in 2015, which found that the VHA’s systematic problems demanded, quote, ‘‘far reaching and complex 

changes that when taken together amount to no less than a system-wide reworking of VHA,’’ unquote. 

So when will we have a system-wide reworking of the VHA? I 

have a hundred thousand veterans in my congressional district, 

and I will say that the calls they are giving complaining about VA 

service haven’t diminished and are about the same as it was a couple of years ago before we tried to make and the VA tried to make 

some changes. They don’t believe that things have substantially 

changed for the better. 

With that, Mr. Chairman, I ask unanimous consent that the 

Commission report dissent from Commissioner Hickey and Commissioner Selnick be entered into the record. 

The CHAIRMAN. Without objection. 

Mr. LAMBORN. That is one perspective I think we should look at 

on an opportunity for transformation. 

Dr. Cosgrove, I would like to ask you a question about the quality of VA health care. According to the report, quote, ‘‘Care delivered by VA is in many ways comparable or better in quality to that 

generally available in the private sector,’’ unquote. However, the 

independent assessment found, quote, ‘‘on most majors veteran-reported experiences of care in VA hospitals were worse than patientreported experiences in non-VA hospitals,’’ unquote. 

Is VA care better than the private sector, the same or worse? I 

know that is a very broad question, but it is a very critical question. 

Dr. COSGROVE. It is very difficult to answer that. There is only 

a handful of comparative studies that have been published comparing the two care; some of them suggest that it is better, some 

of them suggest that it is not equal or not as good as. And I think 

part of the problem is that they have not been reporting the same 

as reported in the private sector, and one of the suggestions that 

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15 

we made and so that you begin to compare the quality is that you 

have exactly the same metrics as reported in the private sector. 

For example, the Society of Thoracic Surgeons reports the mortality rates and morbidity rates of cardiac surgical cases and thoracic surgical cases across the country, the VHA is not a member 

of that and does not report its—that is not to say that it is better 

or it is worse, they just don’t report. 

Mr. LAMBORN. Okay. I mentioned earlier that Commissioners 

Hickey and Selnick signed a dissenting letter. What accommodations were made to their views, if any? 

Ms. SCHLICHTING. Well, both of them participated in all of our 

discussions and had the same opportunity as everyone to put their 

ideas forward, which they did. And at the end of the day, we built 

a consensus around the report recommendations, which 12 of the 

commissioners approved, and their dissent opinions were included 

on the Web site as well. 

But, you know, with all due respect, neither Stewart Hickey nor 

Darin Selnick have ever run a complex health system and to say 

that what we are proposing is not transformative, I think is a complete un—it is just not true. The integration process of creating a 

VHA care system is a significant transformative process that will 

take many, many years to complete. Recognizing the complexities 

of both facilities and staffing issues and leadership, and all of the 

components that we included in our report, as well as IT interoperability to allow that to take place is very transformative. Neither 

of those individuals have ever implemented a major change in a 

health system as Dr. Cosgrove and I have, and I think we recognize the transformative aspects of what we are proposing. 

Mr. LAMBORN. Thank you, Mr. Chairman. 

The CHAIRMAN. Ms. Brownley, you are recognized. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

And I want to thank both of you for your time and commitment 

on putting this roadmap together. I know it is an inordinate 

amount of time that you have put in and, quite frankly, all the 

commissioners, so I just want to thank you for it. And there is 

much to it that I like very much, and I think it is critically important that we have a clear roadmap by which we can base a discussion. I think this is really the most important discussion this Committee needs to undertake, is that we need to figure out what the 

transformation is and what it is going to look like for now and into 

the future. 

And I clearly believe that community partnership with the VA is 

part of the solution. Particularly for primary care and some specialty care, I think that partnership is critically important. I think 

there are some services that the VA provides that the community 

can’t provide. And so that partnership I think it is really important. And I think as we talk about this, you know, to me, I see it 

sort of in a sliding scale and where is exactly, you know, the sweet 

spot in terms of what that partnership really means going forward. 

So I really, really do appreciate the report very much and, Mr. 

Chairman, I hope that we will spend a great deal of time having 

future discussions on this until we can all come to, I think, a consensus in terms of moving forward. 

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16 

I wanted to ask, you know, a very specific question relative to 

the report, because it certainly affects my district. In my county 

that I am very close to the L.A. medical facility, West L.A. Medical 

facility, which is a huge facility, and thank you, Mr. Chairman, for 

your leadership on moving forward with the West L.A. facility. But 

my veterans also are, by mileage are close enough to the facility, 

but by traffic and getting there, you know, it can take a day to 

have a visit. 

And so we are working hard to try to expand our VA facility 

within the district, it has been authorized and so forth, but the way 

the VA does their leasing arrangement, and you are probably 

aware of this, is the way the CBO accounts for it makes it very difficult for us or anyone to approve the resources when you are 

counting a 20-year lease or a 30-year lease all up front. 

So I am just wondering, I actually have a bill that is called Build 

a Better VA Act, but what my bill would do is to sort of harmonize 

the way the VA does this, the way General Services does this for 

other Federal facilities, so that we can break down this barrier the 

way CBO is scoring it. Do you have any comments relative to that 

or did you discuss that at all? 

Ms. SCHLICHTING. Well, probably not specifically, but I will say 

that around the facility questions, there was a tremendous desire 

on the part of our commission to simplify and make things more 

agile for people leading these health care facilities today. 

As you know, health care is changing dramatically. There is 

probably as much change taking place today in the delivery of care 

as we have seen in 50 years, rapid changes in terms of technology, 

and where care can be delivered safely and effectively, and the 

ability to really create those access points from an outpatient facility standpoint. You know, at Henry Ford, we continue to build 

more outpatient care all the time. I mean, it is a constant effort 

to keep up with those access needs. And for the reasons you mentioned, that is one of the reasons we took out the time limit and 

the distance, because every market is different and sometimes you 

are actually having huge barriers that are unintentional just because of the way that market might function. 

Ms. BROWNLEY. I think that is also really important as we look 

at this that we have to really look at each sort of area and community and region, because everybody is going to have very different 

needs. 

And what about in terms of this vision and roadmap, where does 

telemedicine fall into all of this? 

Dr. COSGROVE. I think telemedicine is a very integral part of it, 

and the VA has taken a very nice lead in many of the aspects, particularly looking after chronic disease. We think that this is going 

to be something that will be ubiquitous across the country, and will 

greatly eliminate the need for traveling great distances. 

As you stop and think about the health care system in the 

United States, it was developed at a time when there was not a lot 

you could do for people in the hospital, and very poor transportation; now there is a lot that you can do for people and great 

transportation. And added on top of that is virtual visits, which are 

going to reduce the travel and the access, and improve the access 

enormously, particularly in areas of chronic disease. 

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17 

So we are moving ahead very very fast on that as the VA has 

taken a nice lead there. 

Ms. BROWNLEY. Thank you. 

Ms. SCHLICHTING. The only thing I would add on that point is 

that there is also a lot of digital health development going on today 

where patients themselves can self-monitor and report information, 

communicate differently, and that is, I think a great frontier as 

well. 

Ms. BROWNLEY. Thank you very much and I yield back. 

Dr. COSGROVE. Could I just add just one thing? You know, going 

back to the electronic medical record, once you have a commercially 

available electronic medical record it allows you to make your appointments yourself on your electronic medical record, and that 

electronic medical record should be available to all patients. And so 

you have to begin to engage the patients and one of the ways to 

do that is through the electronic medical record. 

The CHAIRMAN. And I do want to salute the VA with the new 

person in charge of IT with LaVerne Council, I think she gets what 

is necessary and I hope that that progression will continue. 

Mr. Bilirakis, you are recognized. 

Mr. BILIRAKIS. Thank you, Mr. Chairman, I appreciate it. And I 

thank the panel for their testimony. Thank you for all these great 

suggestions. 

What do you think is a realistic timeframe for the large-scale 

transformations that the Commission’s report calls for, assuming 

that the VA is already implementing some of the recommendations 

they claim they are making? When do you think veterans should 

expect to see meaningful change in the care they are receiving in 

terms of quality and access? 

Ms. SCHLICHTING. I think realistically, we are looking at a fiveto-ten-year transformation process, but I also think that any time 

you go through that, you are looking for those early wins, those 

things that veterans can see quickly that improve their patient 

care experience. So there are some things, particularly in the area 

of technology, and certainly just customer service aspects that can 

be improved very quickly to help veterans feel more confident in 

that change process. 

Mr. BILIRAKIS. Very good. 

Dr. Cosgrove? 

Dr. COSGROVE. Yeah, could I just add that I had an experience 

with changing the culture of the Cleveland Clinic and it took me 

five years, and that organization was only 80,000 individuals, and 

something that is as large as the VA, I think is going to take even 

longer. 

Mr. BILIRAKIS. Thank you. Again, building on that, what benchmarks should we be looking for as the VA implements these recommendations, and do you believe the VA has the capability and 

foresight to track the relevant data? 

Ms. SCHLICHTING. Well, I think much like Dr. Cosgrove does at 

the Cleveland Clinic and we do at Henry Ford, we have a balanced 

scorecard, if you will, that provides data on a very regular, frequent basis that focuses on our patient-engagement scores, our employee engagement, the clinical quality outcomes. All of the metrics 

that Dr. Cosgrove referenced that are comparable to the private 

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18 

sector should be available, I think in a transparent way for people 

to assess the quality, as well as the service provided in each VA 

facility. 

So I think that level of transparency and having a scorecard that 

focuses on regular accountable results is very critical in this process. 

Dr. COSGROVE. For example, we report almost a hundred quality 

metrics to the Federal Government on an annual basis and in fact 

we have quarterly scorecard meetings with all of our department 

heads going over all of these, the metrics, and I think you have to 

be a completely data-driven metric organization in order to achieve 

these transformations. 

Mr. BILIRAKIS. Thank you. Understanding that not just one solution will solve all of the agencies shortfalls, if you had to identify 

to single best—the biggest problem, the biggest problem, what 

would that be affecting the VA health system, and what is the solution to that problem? The single biggest problem; I know there are 

several. 

Ms. SCHLICHTING. You know, I think all of us felt that this truly 

is a systems-oriented approach, that many of the recommendations 

are interdependent, but if I were to put one on the table, I would 

talk about leadership sustainability, because it is virtually impossible—I mean, Toby has been at the Cleveland Clinic how many 

years? 

Dr. COSGROVE. Thirteen. 

Ms. SCHLICHTING. Yeah, yeah, and both of us have served in 

CEO roles at 13 years in our organizations. When you have turnover in the under secretary position every couple of years, it is very 

difficult to sustain change, and I think that really is holding back 

the kind of transformative work that potentially could happen and 

obviously needs to happen. 

Mr. BILIRAKIS. Would you agree, Doctor? 

Dr. COSGROVE. Well, I would say that it is one thing that you can 

do rapidly that will change the organization, and that is the electronic medical record. I mean, that can be done in a short period 

of time. The rest of the transformation is going to be much longer. 

Mr. BILIRAKIS. Thank you very much. 

I yield back, Mr. Chairman. 

The CHAIRMAN. Ms. Kuster, you are recognized. 

Ms. KUSTER. Thank you, Mr. Chairman. 

And thank you for being with us today. This is a critically important report and certainly at the heart of what our role is, so we appreciate the time that you both have put in and your wisdom. 

I want to dive right in. I spend a great deal of time with my veterans and visiting our clinics and hospital during the August district period, and you talk about data-driven and I agree with you, 

I just want to point out one example of an unintended consequence 

that we face, many of us around our districts, and that is with regard to the heroin epidemic that is threatening the country. What 

we discovered and this is broader than the VA, but that the use 

of quality metrics with regard to bringing down the pain surveys, 

bringing down the numbers, inadvertently incentivized physicians 

to push opiate medication, which then led to high rates of addiction. We have a wonderful project at the White River Junction VA, 

Leonard.horne on VACREP0180 with DISTILLER

19 

Dr. Julie Franklin, getting out in front of this with our veterans 

and I met with a number of them, using alternative remedies for 

pain maintenance, pain medication, including acupuncture, yoga, 

all these different criteria. 

And I just wanted to see if you would comment both on the risk 

of being so data-driven that you have unintended consequences, but 

also your view on alternative remedies within the VA system. 

Dr. COSGROVE. Yeah. Well, I don’t think there is any question 

that this measurement of pain as part of the HCAP scores did lead 

to increased use of opiates. 

Ms. KUSTER. And the good news is we did change it, by the way. 

Dr. COSGROVE. Yes, I know that you did, and we were instrumental and pushing hard to get that done. 

Ms. KUSTER. Thank you. 

Dr. COSGROVE. But I think that it is—again, the opiate problem 

is multidimensional and it is going to require a lot of creative 

thought. I think certainly other alternatives are going to be part 

of it, also I think education and expectations of patients is going 

to be an important aspect of beginning to change that. But this is 

an epidemic, in Ohio it is a huge epidemic. 

Ms. KUSTER. Yes, you have been very hard hit. 

Mr. Coffman and I have a bill that we are hoping to get attached 

as an amendment that would provide a pilot project for VAs to do 

this type of alternative remedies for pain management. We have 

had a reduction at this one hospital, 50 percent on opiate prescriptions, and I got to tell you, the one-on-one conversations I had and 

the quality of life for people whose lives have been turned around. 

So I just wanted to bring that one up. 

Dr. COSGROVE. Congratulations. I think that is a great piece of 

work. 

Ms. KUSTER. Good, thank you. 

And the other one is, you talked about the safety net provider 

and I think that is an important consideration that we can’t lose 

sight of. Many times as I visit our veterans facilities it is the lowerincome veterans who don’t have access to private care, they don’t 

have access to private insurance; this is their provider of choice. 

And you mentioned about a shortage of primary care and mental 

health professionals. I know my colleague Mr. O’Rourke in El Paso 

will discuss that, but we also have a bill about physician assistance 

coming out of our military, and I just welcome your thoughts on 

that approach where we can sort of grow our own and use the skill 

set of veterans coming out of our military, great experience, and 

how we could put that to work to reduce the shortage of providers. 

Dr. COSGROVE. Well, I would say that the military provides a tremendous workforce for health care. We have hired over a thousand 

veterans in the last five years, because we recognize that they are 

highly trained, experienced, and they have a great culture that 

they bring to us. 

Ms. KUSTER. Great work ethic. 

Dr. COSGROVE. Great work ethic. And we are delighted to have 

them and we actively recruit both nurses and physician’s assistants 

coming out of the military and go to the bases to do that. 

Ms. KUSTER. Great. 

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Ms. SCHLICHTING. And I would just add, I think the concept of 

growing your own is very important within the VA system, because 

the dedication of the veteran workforce is incredible, and an opportunity I think to really leverage that makes a lot of sense. And we 

are looking at similar issues around growing our own in areas we 

simply can’t find the talent that we need. 

Ms. KUSTER. Great. Well, thank you for your good work. 

And thank you, Mr. Chair, for indulging a shameless promotion 

of my two bills left to be attached as amendments to going forward. 

Thank you. 

The CHAIRMAN. I understand you did a field hearing in Aurora, 

Colorado about— 

[Laughter.] 

Ms. KUSTER. And it was excellent, it was great work. I want to 

thank my Chair. 

The CHAIRMAN. Thank you. 

Dr. Roe, you are recognized. 

Mr. ROE. Thank you, Mr. Chair. 

And I want to start out by thanking the Committee that put this 

together, it is a remarkable piece of work. Thank you for taking the 

time away from your shops, all the Committee Members. This is 

probably the most important piece of work I have seen in my almost eight years here in Congress, which could really make a difference if we could implement this. 

And during the convention, instead of spending most of my time 

politicking, I spent an afternoon at the Cleveland Clinic and certainly, and I want to talk about BRAC in a minute, but the way 

you evaluate your needs is you build the needs to the modern 

health care system, and the entire health care system is undergoing radical changes in the U.S. right now, a shifting from the 

concrete silos to outpatient, more and more surgery. I mean, a hundred-bed hospital today can do what a 500-bed hospital did 30 

years ago. I think the VA is still stuck at the 500-bed. 

A couple things. Let me just summarize what I have heard so 

far. One, I believe that to move this system forward we need an 

integrated care model that involves the private sector and the VA 

sector in primary care; and, two, Dr. Cosgrove you pointed out that 

to have an electronic health system that is 20th century. I think 

that we had this debate sitting right here, I remember this, three 

years ago where DoD and VA tried to make these two antiquated 

systems interact and they could not. I mean, I have been all over 

the place trying to see how these experiments failed. 

A modern system solves a lot of the scheduling problems, payment problems, data problems that you talk about right now. They 

have done a remarkable job of working around these problems, but 

there is new technology out there and the DoD made that decision. 

The VA sat right there and tried to convince the DoD to put in a 

30-year-old or 20-year-old system and they didn’t do it, they went 

ahead and took it off the shelf. So I think that would be something 

they need to do. That solves your supply chain, all those things we 

talked—it doesn’t totally solve it, but helps solve it. 

And lastly, I think is the BRAC. And it may be my last term too, 

but you can vote for the BRAC and the gas tax, and you probably 

won’t be here can. But I think we have to sit down and evaluate 

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what those assets are and where you can get the best care. If the 

best heart surgeon is the Cleveland Clinic, it is about providing the 

best care for veterans. I think that is what this is all about; not 

sustaining a bureaucracy, but providing the best care and where 

that care can be given most cost-effectively. 

So I admire what you have done. And to say our Committee has 

not provided the resources for the VA, when I came here in 2009 

we spent about 95, $97 billion on all VA care, cemeteries, disability 

and health care. Today it is 165 billion without choice. I would say 

that Congress has done a job, it is just that—and we have gone 

from 250,000 employees to 330. And in the private sector you have 

had to figure out how to do it more efficiently with less people, because your revenue, I promise you, has not been going up like it 

did, you had to better manage. So I commend you for that. 

And my last question I want, do you think if we can come to the 

consensus those four things I have pointed out, and it won’t be 

easy, and we pass it, do you think the VA can carry it out? And 

I know that you said, I hate to put you on the spot, but you pointed 

out that leadership is the key for transformational change; is that 

leadership there? 

Ms. SCHLICHTING. You know, I think leaders get better over time 

also. You know, the current leadership has been in place a very 

short amount of time actually and have, I think, made some 

progress in key areas and have set the right tone for improving access. But I also think they need some time and it is hard to judge 

whether that can happen unless there are sustainable leaders in 

place, which is why we recommended the idea of five-year terms for 

the under secretary, and having that individual actually selected 

by the board of directors, so that that process can move forward 

and that individual feels the support of a group of people that are 

really trying to move transformation forward. 

I recognize that that may be unconstitutional. There may be 

ways around that that can help with oversight, but— 

Mr. ROE. That hasn’t stopped us from doing a lot, the Constitution hasn’t— 

[Laughter.] 

Mr. ROE [continued]. —before, but the question is do you think 

we can? Because I think this is a remarkable document, and I 

think it has a chance to put veterans and doctors back in charge 

of their care and not a system. And I just wonder if you think we 

can do it, because if you could, I think you would truly transform 

the health care system that veterans receive. 

Dr. COSGROVE. I think it is going to take time and this is not 

going to be quick, this is going to be incremental, and it is going 

to take continuing change of a very big system. 

Mr. ROE. I think the key one is making a decision on the EHR. 

I think that that one is one that begins to solve a lot of these other 

problems you are trying to do with different software systems now 

that don’t work well together. 

Dr. COSGROVE. I think, you know, I would just say one other 

point to move to that. You know, we have and many people around 

the country have learned that you can’t maintain an electronic 

medical record in an individual facility, it is moving too fast, and 

that is why the commercial aspect of this has kept up with the 

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22 

changes and made them uniform across the country. So I think it 

is absolutely imperative. 

Mr. ROE. Okay. Thank you, Mr. Chairman. I yield back. 

The CHAIRMAN. Mr. O’Rourke, you are recognized. 

Mr. O’ROURKE. Thank you, Mr. Chairman. 

I would also like to thank the Chair and Vice Chair for their 

work and the sacrifice of their time, and frankly their commitment 

to their day jobs in order to be able to fulfill this commitment to 

the veterans in this country and to the American people. And I 

really appreciate the way in which you conducted the review and 

made the recommendations. And so I just want to add my thanks 

to all my colleagues’. 

I would like you to discuss what I think is the most pressing crisis facing our veterans in the VA and the single greatest unmet 

need right now in the system, and that is the tragic number of veterans who are taking their lives every day in this country. The new 

estimate from the VHA after looking at data from all 50 states is 

that it is 20 veterans a day who are taking their lives. I think that 

is the single greatest opportunity to stop these preventable deaths, 

if we take this seriously, confront it and organize to provide far better care than the care that is being delivered to veterans right now. 

As I hope you remember from our discussion, in El Paso, because 

of the high number of veteran suicides, the inability for too many 

veterans to be able to see a mental health care provider, never 

mind the wait time, originally estimated at 14 days, we now know 

it is over two months on average, but a third of veterans in El Paso 

couldn’t get in at all. That has prompted us to propose a solution 

in El Paso that we are trying to pilot right now to focus VA care 

specifically, that care that is delivered in-house on those conditions 

that are unique to service or combat, and PTSD, traumatic brain 

injury, traumatic amputations, military sexual trauma, there is a 

long list of these, that I believe we want someone who knows how 

to treat veterans, perhaps only treats veterans and active duty 

servicemembers, knows the things to look for, the questions to ask, 

the treatments to prescribe. Is there a way to resolve that idea 

with this idea of a network where you do leveraged capacity in the 

community? And for those conditions perhaps that are not connected to combat or service we prioritize community care, but for 

those conditions that are unique to that experience of being a veteran we make the VA the center of excellence for the treatment of 

those conditions. 

I would love to get your take on that idea. 

Ms. SCHLICHTING. Actually, we agree with that. The recommendation that we put forward really focuses on those unique 

capabilities of VHA absolutely being supported, invested in, continue to grow and develop, because it has been shown, my understanding is that it has been shown that those veterans that actually seek care within the system end up with a much lower suicide 

rate, because they are being managed, their care is being managed 

and they are in touch with health professionals who provide that 

kind of support on a daily basis, which is really critical for those 

types of needs. 

But unfortunately it is how do you embrace and get people into 

the system who otherwise may not be willing to go there, and I 

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23 

think that is one of the challenges. And you are right about the fact 

that in the private sector doesn’t mean that people are well 

equipped to handle the complex mental health needs of veterans. 

In fact, in many cases we have the same problems, if not more 

acute problems of having enough mental health providers in our 

community today. 

Dr. COSGROVE. And I would just say that I think there are a couple things that begin to recognize what Nancy’s last comment was, 

is the shortage of mental health providers. Increasingly, I think 

you are going to see virtual visits begin to augment the shortage 

and help the shortage of mental health providers, and similarly 

group visits and group therapies for those individuals, and we have 

found both of those to be very useful. 

Mr. O’ROURKE. You know, I think as long as we can prioritize 

that excellence in care around those conditions, especially those 

that could potentially lead to veteran suicide, and are able to reduce the number of veterans who take their own lives, improve outcomes, improve access, I think the system that you are proposing 

makes all the sense in the world. 

We learned this summer that the VHA has 43,000 positions that 

are authorized, have the funds appropriated for, but are un-hired 

today, and we are fools to believe that we will ever hire all 43,000 

of those. So let’s prioritize within the VA on those areas where we 

can do the most good, make the greatest positive difference for 

those veterans, and for me that is clearly mental health and reducing the number of veteran suicides. 

And then we face another issue, which you raise, which is how 

do we produce enough doctors in the country generally to ensure 

that we have capacity for veterans in the community. But I think 

if we can leverage the two, what we should do really well in the 

VA with what exists in the community today and follow our Ranking Member’s lead in creating more graduate medical education positions, then I think we are going to be on the path to fixing this. 

So my time is up, but again thank you for your work on this, I 

am really grateful for the effort. 

The CHAIRMAN. Dr. Benishek, you are recognized for five minutes. 

Mr. BENISHEK. Thank you, Mr. Chairman. 

Well, I thank you so much for the great work you did. I don’t 

know exactly where to begin with all the things that have come up 

today. 

And the two things that strike me from your testimony and your 

answers to many of the questions is, Ms. Schlichting, your comment about the leadership and how critical that is to transforming 

the VA. Having not so much a political appointee at the head, but 

having a board of directors like a regular hospital, like a regular 

system that, you know, people are on the board, I was on a board, 

and then a continuity of care over a period of time so that these 

things can be developed, I think that is critical. 

I think it kind of behooves us to make that happen and I see that 

as a challenge to this Committee to take the bold steps necessary 

to basically implement your plan. I don’t want to say I agree with 

everything, but if we don’t do this we are going to be faced with 

30 more years of the same thing we have been doing now, and I 

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24 

think that is the critical takeaway from this very important commission’s work. 

And the thing that you said, Dr. Cosgrove, the other thing I take 

away from this is the critical need for an IT system that makes 

sense. I mean, to me that is your testimony from the two of you 

is leadership and immediate action on an IT system which, you 

know, really can be changed. 

I just want to bring up a question that always bugs me and that 

is, when you estimate the cost of implementing these things, how 

did you estimate the costs of the VA care? Because when we try 

to figure out what it actually costs the VA to see a patient, you 

know, in the private sector we know what it costs to see a patient, 

all right? But the VA doesn’t do that. How did you estimate that? 

Because we haven’t been able to get a figure on that. 

Ms. SCHLICHTING. Well, let me just say that one of the things I 

think that probably struck all of us that are in the health care industry was how little focus on cost VA has. And that was sort of 

shocking because we live in a world where we have to constantly 

focus on costs per unit of service, costs for, you know, a full episode 

of care over time, creating, you know, population health management techniques so that we in fact can understand cost and whether we are contributing to value and improvements in quality, and 

that doesn’t exist today within a budget-oriented VA system, and 

I think that is one of the challenges as we looked at this cost question of how we move forward. 

So I think one thing that probably should have been in the report 

that wasn’t was this notion of getting more cost-oriented in terms 

of some of the metric around performance. 

Mr. BENISHEK. Well, that is my frustration here, is what does it 

cost the VA to see a patient, there is like no clue. 

Ms. SCHLICHTING. Yeah. And in fact, if you look at the model, I 

mean, and look at what is changing in health care today, you 

know, we are getting away from the volume-oriented kind of measures. We are trying to focus on outcomes of care, you know, clinical 

results, as well as are we making a difference in terms of just the 

efficiency of care that we provide. 

So it really, I think this is part of the transformation. And Dr. 

Cosgrove pushed very hard on this during our deliberations of how 

do we get metrics that are more comparable so that in fact we can 

determine the effectiveness of the VA system over time. But I 

would add that I think, you know, if you view this in phases, there 

are ways to test some of these assumptions and begin to look at 

those cost elements that could be projected out over time so that 

you can really see. 

The other thing is this issue around facilities. If all the facilities 

had to be replaced versus creating this integrated model, there is 

a lot of potential cost savings and cost mitigation over time that 

I think would help. 

Mr. BENISHEK. Well, the only thing further I want to bring up 

and it is related to the status quo of the VA, now one of my big 

complaints is that working there, I had very little input as to how 

things worked in my clinic or in, you know, making sure that 

things ran efficiently. It seemed like others who weren’t really involved in the patient care were making the decisions as to, you 

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know, how many staff to have, how to make the staff flow, you 

know, I mean patient flow and all of that. So I think that would 

come with the leadership changes. 

But is there any other comment that you would like to make on 

that, Dr. Cosgrove? 

Dr. COSGROVE. Yeah, I just think that you need to bring physicians more into every aspect of delivering care and running the organization. I gave the example of purchasing, previously physicians 

were not involved in that; we found tremendous efficiencies by 

bringing them in. And without involving physicians in the leadership of the organization, I think you are missing an intellect and 

a set of knowledge that is necessary to have a high quality organization. 

Mr. BENISHEK. Thank you very much for your work, and it is up 

to us to get this show on the road. 

The CHAIRMAN. Thank you, Doctor. 

Miss Rice, you are recognized. 

Miss RICE. Thank you, Mr. Chairman. 

Would either one of you want to be the Secretary of the VA by 

any chance? 

[Laughter.] 

Miss RICE. Just out of curiosity. 

Dr. COSGROVE. I had that opportunity, thank you. 

Miss RICE. So I just want to echo some of the comments that Mr. 

O’Rourke made. We recently had a veteran take his own life in the 

parking lot of the Northport VA, which is so disturbing, and so I 

couldn’t agree more with Mr. O’Rourke about this being such a top 

priority for the VA to handle. 

I also totally agree with Dr. Benishek that the two issues in 

terms of accountability and the electronic health system, records 

system, are critically important. I mean, every single hearing that 

we have, the number-one issue that we talk about is accountability, 

whether it is for how whistleblowers are treated by higher-ups, 

wait times, the enormous cost overruns for construction projects, 

you know, the list goes on and on and on. 

And it seems to me, Ms. Schlichting, if you could just address the 

whole issue of how you would create a more effective hierarchy. 

The board of directors, how would they be chosen? Why do you say 

that the Under Secretary of Health position should be one that has 

a fixed time limit versus the Secretary, somewhat similar to the 

head of the CIA and the FBI, right, that have set times? 

I mean, if you could just talk more about that, because to me, 

I mean, I don’t know if that will get to changing the underlying 

culture of the thousands of employees who are under the Secretary 

and the Under Secretary, but if you could just talk a little bit more 

about that. 

Ms. SCHLICHTING. Sure. Well, first of all, culture starts at the 

top. There is absolutely no doubt in any organization that the tone 

that is set and the way it is deliberately carried out every single 

day in decisions, in reaction to things, in how, you know, leaders 

respond appropriately to the needs of an organization, I think is 

very, very important. 

And as we look at the VA and you have again someone who is 

really running the health system, obviously the Secretary is reLeonard.horne on VACREP0180 with DISTILLER

26 

sponsible for all of the veterans functions, but the health system, 

at least the way we understood it, is run by the Under Secretary 

of Health from a, you know, operational standpoint, and yet that 

position has turned over repeatedly. And so the ability to set that 

tone and follow through on a whole host of strategic initiatives and 

making decisions on a daily basis gets cut off and then the next 

person comes in. And it is very hard for an organization other than 

to hunker down and sort of wait for the next leader, it is very hard 

for an organization to embrace those kinds of changes. 

The reason the board is in our view very important is, first of 

all, the board stands behind that individual and helps them be better. They are there for a broad base of input, expertise, again that 

level of accountability, which happens on a more regular, routine 

and organized basis. So that board sitting there saying, you know, 

we thought this was your strategic plan, it is not to usurp Congress, but it is to get that performance up. Congress ultimately is 

responsible, has the power of the purse, and all of the other aspects 

of your authority, but the idea is to bring some health care expertise in and other leadership to engage that CEO on a regular basis 

to make the kind of changes that are necessary. 

Miss RICE. Thank you. 

Dr. Cosgrove, the electronic health records, just what has been 

the problem within the VA in terms of addressing that issue? 

Dr. COSGROVE. The VA started out by developing one of the first 

and best electronic medical records, and over time, I think they suffered from the same problem that Massachusetts General Hospital 

did, Johns Hopkins, Mayo Clinic, Henry Ford, that they could not 

keep up with the changes that were needed across the organization. And so there are now 130 versions of that electronic medical 

record across the system, and that has fallen behind in its capabilities, and also has not added the sort of capabilities that you now 

see commercially available. And it is time to do the same thing 

that many other organizations have done, and abandon the homemade project simply because there is not enough IT expertise within the organization to keep updating it. 

Miss RICE. Right, right. 

Well, I want to just echo what everyone, every Member of this 

Committee has said, which is to thank both of you for really your 

Herculean efforts, and my hope is that all of us here are going to 

be able to see the wisdom of your report and begin to implement 

it in a way that is not partisan at all, because the bottom line is 

giving the kind of health care to the men and women who served 

this country that they deserve. So thank you very much. 

And thank you, Mr. Chairman. 

The CHAIRMAN. Thank you very much. 

Mr. Coffman, you are recognized. 

Mr. COFFMAN. Thank you, Mr. Chairman. 

And thank you both for your tremendous work on this, it is just 

incredibly important. I am looking at Recommendation 10 when 

you talk about changing the culture of the VA and it is such a corrosive culture. I mean, if we look at the appointment wait times 

scandal where appointment wait times were manipulated to bring 

them down by denying veterans care and maintaining these secret 

waiting lists so people could get cash bonuses, I mean, number one, 

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nobody was ever prosecuted for that, and it was systemic, and 

number two, nobody was even asked to give back their bonus. 

And so when you have a system where it literally takes an act 

of God to fire somebody, and where it seems like the only people 

who are disciplined and fired are the whistleblowers who bring 

these problems forward, I mean, it would seem that the route of 

the problems at the VA lie in the culture of the VA. I just wonder 

if you could respond to that and some of the internal discussions 

maybe you had that aren’t necessarily in this report in terms of the 

range of views on your commission. 

Ms. SCHLICHTING. Well, there is no question the independent assessment report commented significantly on the problems of the 

culture of the VA. I think we felt very strongly that in order to 

change culture you have to make sure, again, sustainable leadership has to be in place and leadership that people have confidence 

in, that are going to make those tough calls and make those decisions that are appropriate. 

Mr. COFFMAN. But if leaders can’t—that it becomes so difficult 

to get rid of subordinates. 

Ms. SCHLICHTING. Well, I am not sure I believe that, you know— 

Mr. COFFMAN. But that over time that people just don’t even try. 

Ms. SCHLICHTING. Well that is the problem. 

Mr. COFFMAN. Yeah. 

Ms. SCHLICHTING. People, frankly, and I have seen it in our own 

organization that people say, well, we can’t fire people. I said, oh, 

yes, you can; you have to work at it. 

Mr. COFFMAN. Right. 

Ms. SCHLICHTING. You have to make sure that you are going 

through the appropriate discipline process, that people are given 

due process, which is important. 

Mr. COFFMAN. Sure. 

Ms. SCHLICHTING. But that you have to do it. And that is about 

leadership development at all levels; that is not just at the top, 

that is front line supervisors, that is managers and people that 

really are going to make those decisions on a daily basis about the 

quality of their workforce and their decisions and getting it done. 

Mr. COFFMAN. But also it seems like the leadership of the VA, 

that leaders when they are responsible don’t take responsibility 

when wrongdoing occurs and are never held accountable. So we are 

talking about not just the rank and file, but we are talking about 

the top of the authority— 

Ms. SCHLICHTING. But my sense was that a Secretary was fired 

over that and when that did happen, that is when Secretary 

McDonald came in. So I think clearly there was a decision made 

that reflected the seriousness of the problem in Phoenix, but I also 

think people need time to change that culture. 

Dr. COSGROVE. And I think you also have to invest in leadership 

training and bringing people along, and I think it goes into a couple of categories. I think it goes into the category of experience 

with feedback, which is difficult and painful sometimes to get and 

to give, and the second thing is they have to have a certain amount 

of intellectual training that goes with that, and it may fall into the 

80–20 or the 90–10 ratio. But nonetheless, you have to have an acLeonard.horne on VACREP0180 with DISTILLER

28 

tive leadership, education and training program, which is nonexistent right now. 

Mr. COFFMAN. Thank you. And I don’t know how we ever really 

have a full discussion about transforming the Veterans Health 

Care Administration when we don’t know what their costs are for 

any given specific procedure, and as a Committee, we have requested that. And it is stunning that they either know it and don’t 

want to give it to us or they don’t know it themselves. What do you 

think the case is? Do you think they just don’t know it or do you 

think they don’t want to give it to us? 

Ms. SCHLICHTING. My sense is that that needs to change. And 

frankly I think it has been based on, you know, a focus on a yearby-year budget process as opposed to in our world, we rely on revenues to set the level of expense. So we have a very strong focus on 

cost, this is a very different model. And I think frankly it would 

be helpful to think about how to get that cost focus more directly 

built into the process of the budget and how, you know, they justify 

expenses. 

Dr. COSGROVE. I also think there is a matter of collecting the 

data and, if you don’t have the data, you know, you can’t understand it. And that data includes the severity of the illness, all of 

that goes into determining how much cost per veteran to take care 

of them. 

Mr. COFFMAN. Thank you, Mr. Chairman. I yield back. 

The CHAIRMAN. Thank you. 

Mr. Walz, you are recognized. 

Mr. WALZ. Thank you, Mr. Chairman. 

And I too want to echo my thanks to both of you. You did exactly 

what we were hoping would happen in that conference Committee 

when we created the Commission of Care and the request for it 

that you would come up with specific recommendations to improve 

veterans’ care, but you would also help facilitate a national dialogue that was sorely missing in a transformational type of way. 

I represent the Mayo Clinic in Rochester, Minnesota too, and 

they are like many of you, and they will say there is different models. Cleveland Clinic, Henry Ford, Kaiser, there are others that do 

it, but there are certain fundamentals that are true throughout all 

these organizations and how they deliver that, integrated clinical 

practice, education, research, and then that focus on leadership. 

The one thing that I think is so refreshing about what you came 

up with, and I will hit on a couple of those points you brought up, 

I remember ten years ago asking why we did a quadrennial defense 

review, with an understanding that the world of 1986 looks entirely 

different than the world of 2016 from a resource-allocation perspective to how we would defend this Nation and all of that, but never 

done on the VA. So we plodded on year to year, year-to-year budgets. We actually did something I thought was somewhat innovative 

and it took a stretch from this Congress to do advanced appropriations to give a little more continuity to that, to make some decisions like your organizations make decisions, but it challenges us 

in ways that we haven’t been. 

And I also want to thank you, and I think, Dr. Schlichting, you 

are doing a very good job of stressing this, trying to remove this 

simplistic argument of public versus private sector, or the idea that 

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VA health care can be discussed in a vacuum outside of health care 

in general. This gives us an opportunity to holistically change the 

entire system. And we know that there are going to be assumptions 

that maybe don’t pan out the way they went, you know, lo and behold, we find in the ACA that a lot of people who didn’t have 

health care insurance before, like to go to the doctor now, and some 

of them were sicker than we assumed in some cases. Those things 

have an impact and instead of just fretting or pointing fingers, let’s 

come back and find a workable solution, and that is going to challenge all of us. 

I wanted to hit on the first one. This one just has me tied in 

knots, the board of directors issue, because I absolutely hear where 

you are coming from, if I go to Mayo Clinic they will say this is 

a great suggestion, I can guarantee you, just like you are saying, 

because the one thing is they are saying, Tim, you may have some 

expertise in geography or China, artillery, and each of these Members brings their own thing, but have you ever run a large health 

care operation? And as a Member of Congress it is our job to try 

and gather and learn as much information, and we are ultimately 

responsible for the oversight. So there is a real hesitancy to give 

away what feels like giving away that authority, but the need to 

put that in there. 

Now, this has been challenged on the constitutional issue, it has 

been challenged for all kinds of reasons. How important, if I could 

ask you, do you believe that mechanism is for transformation? If 

we are going to fight this fight, it is going to be big and it is going 

to be transformational with the big T. So how do you see it, if I 

asked you, if we do this and, you answered a little earlier, do some 

of these recommendations separately, but you really need to look 

at holistically, how important prioritized is this board of directors? 

Ms. SCHLICHTING. I will tell you that probably of all of the recommendations, this had unanimity among our commissioners, and 

I think it was felt to be, if not the most important, one of a very 

small number of the most important recommendations that we 

came up with. 

Mr. WALZ. Dr. Cosgrove? 

Dr. COSGROVE. I completely agree. You know, the fact that you 

have over 500 people trying to run the VA seems a little much. 

Mr. WALZ. This may be an Achilles heel of democracy, but we are 

ultimately responsible to the taxpayers, we ultimately have to do 

that. Giving away that authority even to a Secretary is very, very 

hard to do, and then giving it to another layer in there. But I am 

with you on this that I am certainly willing to have this discussion. 

And behind you there is a whole room full of folks who have spent 

decades supporting veterans; they are not in opposition to this, 

they are there to ask these hard questions about this recommendation, how is it going to impact. 

But my question to you too—and I could not agree more, this 

sustainable leadership. I have seen it at the macro level, I have 

seen it at the micro level, in the VA and outside of this, that it is 

absolutely critical. We are going to have to restore some trust that 

people want to go to work there, that it is not this assault on the 

integrity of everyone who is there and to see a unified commitment 

to getting this. How many of these things do you think should be 

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implemented, even if they could be, through internal rulemaking 

on the executive side? I always make the argument on this, that 

I think we are better off if we do it. We keep responsibility, we 

have ownership, and we have the American people behind us. It 

takes a while, but do you see that we should just enact some of 

these and get moving, or should we have this national debate and 

fix it through this way? 

Ms. SCHLICHTING. Well, I am not the expert on the rulemaking 

at all, but I think that our staff really identified in the report those 

areas where Congress really does need to take action, and those 

areas we felt could be done within the executive branch. 

But, you know, the truth is, as I think everyone in this room acknowledges, this is a bipartisan issue. These are our veterans, it 

is critically important that we find a way to deliver better health 

care, and we felt strongly that in the area of leadership and governance that new structures were needed in order to provide that 

oversight, whether it is the IT project—I will tell you, at Henry 

Ford we had a special Committee of our board to oversee the implementation of the Epic system, and without that, I am not sure we 

would have done as well. 

Mr. WALZ. Well, I thank you for that. And I think I echo Dr. Roe, 

and probably Dr. Wenstrup who will probably come up on this, this 

physician leadership piece, I really have buy-in on that. And again, 

I am somewhat biased that Mayo Clinic plucks their leadership 

from their physicians and that rotates through, and that has proven to be a successful model. 

I yield back. 

The CHAIRMAN. Thank you. 

Dr. Wenstrup, you are recognized. 

Mr. WENSTRUP. Thank you, Mr. Chairman. 

I want to thank both of you, and I would like to thank the entire 

team that worked on this. It was not just you two, as you will acknowledge, as you are shaking your head. 

Obviously, our goal was to provide care for those in need for our 

veterans, and one of the things that I have seen that assures our 

veteran patients as much as anything else is having a primary care 

doctor they call their own. That is one of the successes that I see 

at the CBOCs. What I do not like is the stigma sometimes that any 

doctor that is not within those walls is a non-VA doctor, and I 

think we need to change that stigma. They are VA doctors just as 

much as anyone else, that they are part of a system and Dr. Roe 

referred to that. 

And when it comes to choice, I think we need to embrace greater 

choice, because the decisions on referrals and choices should come 

between the primary care doctor and the patient, and we don’t 

need another layer of bureaucracy of people that don’t know the 

doctor or the patient that decide who you get to go to, where and 

when, because as you know, making a referral is based on many 

things and knowing your patient. It has to do with personalities 

sometimes, it has to do with the level of expertise, it has to do with 

comorbidities and the severity of those comorbidities, and there is 

no panel that can embrace that; only the primary care doctor and 

the patient can embrace that. And that is the type of system I 

think we need, because if I was a patient in that system I would 

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31 

be saying, Doctor, are you referring me to this person because you 

have to, or because it is the best fit for me? And that is what we 

have to open our minds to is having that capability. 

And then it comes to reality, we have got to know the cost and 

efficiencies of what is taking place. I have said since the day I got 

here almost four years ago, how much are you spending per RVU 

you are producing, do you have any idea? And to this day, I still 

haven’t gotten that answer. We did have one independent survey 

here and I think Dr. Abraham will attest to this. They said that 

for a primary care visit it was between four and $600. Well, you 

can make a pretty good living on the outside at four to $600 per 

patient visit. 

So obviously we have got to be able to have that type of data to 

make our decisions, because certainly, let’s use the example of say 

an organ-transplant team, not every VA should have or can have 

an organ-transplant team. So you have to have one within the VHA 

system that people can refer to, because that is the most efficient, 

the most effective and the best care. 

So we have heard a lot today. I am getting to a question and that 

is, where do we need to go as far as next moves? And I think we 

all kind of, would agree that the electronic record is a first move, 

and along with that, the decision on how we go about handling a 

board of directors, constitutionally or otherwise. So beyond those 

two, what would you say would be the next move where we can 

weigh in and have some impact on the next move in bettering our 

situation? 

Ms. SCHLICHTING. We may have different points of view on this, 

but I would say the personnel system itself. Because one of the critical elements is attracting talent and there is still a lot of openings 

within the VA system in all types of jobs, whether it is, you know, 

leadership or front line or physicians, and I think that looking at 

how to create a more organized system that ensures that in all positions there is an ability to attract that talent. 

And I actually think that with that, the VA would do a much better job attracting talent across the country, because there are many 

people, including some at Henry Ford, that have gone to work for 

the VA because they want to help veterans, and I think if they felt 

that that system were more efficient and effective, they would be 

there. 

Mr. WENSTRUP. Doctor? 

Dr. COSGROVE. Yes, I think you clearly need that, but I think ultimately, at the end of the day, culture is the main thing that 

makes any organization work. It is all about people, it is not about 

bricks and mortar. And changing the culture, that is going to require sustainability of the leadership and a sustained push at 

changing the culture of the organization. 

And, you know, the focus clearly has to be on the patient, the 

veteran, and how are you going to do the best thing for the veteran 

and everything will flow from that. That is your North Star, that 

is your raison d’etat, and everybody in the organization needs to 

understand that from the get-go. 

Mr. WENSTRUP. And I appreciate the comments on provider input 

in how we go about conducting the business of taking care of people. 

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Thank you. I yield back. 

The CHAIRMAN. Thank you very much. 

Mr. Takano, you are recognized for a second round. 

Mr. TAKANO. Thank you, Mr. Chairman. 

Did the Commission look at all about the difficulty of the VA 

being able to hire military doctors in the VA? Are there any complications or things that we can do to—I have heard there are some 

issues related to that. 

Dr. COSGROVE. I am not sure. You have to tell us what the issues 

are. 

Ms. SCHLICHTING. Yeah, I am not. 

Mr. TAKANO. I was just—apparently you don’t have an answer to 

the question, but I just wanted to pose it. 

The other thing, is I wanted just to make mention, and I thank 

my colleague Mr. O’Rourke for bringing up the medical residencies 

and we have increased them. My understanding is the VA has not 

been able to assign all of them, only 300 out of the 1500, and I just 

want to take a moment to make an appeal to my Republican doctor 

colleagues to address the Medicare cap and the time extensions. I 

would hate to lose those because the clock is running out. 

One issue that has come up over and over again is the way 

that—our VSO testimony is their concerns regarding private sector 

metrics. The VA has testified many times that the private sector 

does not measure things that are important to veterans’ health 

care. How did the Commission envision the VA adopting private 

sector measures if the private sector does not measure them, in 

terms of that there are some things that the private sector doesn’t 

measure? 

Ms. SCHLICHTING. Can you give an example? 

Mr. TAKANO. There are specific things that may be unique to 

what the VA does as far as what veterans do. 

Ms. SCHLICHTING. You know, we— 

Mr. TAKANO. Mental health comorbidity as an example. 

Ms. SCHLICHTING. Well, those issues exist in the private sector 

as well, and we have a very large behavioral health population at 

Henry Ford, and worked on initiatives such as perfect depression 

care where we have tried to reduce the level of suicide to zero for 

a managed population. And, you know, while the background and 

issues might be somewhat unique, the comorbidity problem exists. 

And so, you know, we have to constantly drive toward results 

even when we have those conditions, whether it is socioeconomic 

risk, or it is other health factors and combat experience that affect 

people. So I think there is a way to work toward that set of metrics 

that could be very comparable. 

Dr. COSGROVE. We are looking at the same sort of things. We are 

looking at socioeconomic determinants, mental health determinants, as well as physical determinants. 

Mr. TAKANO. But here is the thing: are they truly comparable? 

I know you do these metrics, but are— 

Ms. SCHLICHTING. Well, the one thing I will tell you, being in Detroit, is we live in a world of trying to always have reasons why 

our data looks worse and we try not to have those excuses, that we 

clearly believe there are strategies to improve care even when we 

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tions. We serve, as many organizations do, a lot of veterans that 

don’t seek care within the VA. 

And so I think we have got to really drive toward those kinds 

of metrics that push us in a direction of much higher performance. 

Mr. TAKANO. Comparing the VA to private sector care is not always a fair comparison. For instance, the VA must adhere to Federal hiring and firing practices that allow for fair treatment and 

due process. I heard you engage with one of the other Members 

and I was delighted to hear that you believe that a central problem 

is leadership, training and follow-through, making sure there is 

progressive discipline, and that a lot of these personnel procedures 

exist in the private sector care as well. 

And I might have you elaborate more on what you said before, 

because accountability is one of the things this Committee is struggling with. 

Ms. SCHLICHTING. Well, you know, it is very easy in a health care 

environment to find reasons why people don’t perform, it just is, 

and often there is a pattern of making excuses for people. And it 

is critical that we push on that level of accountability and performance in all positions: front-line staff, physicians, nurses, leaders. 

And I think that is part of the culture that Toby and I have talked 

about today is creating that sense that you have to perform at a 

high level, and that in fact you are going to follow through on making sure that if people aren’t doing that, that there are consequences. 

Dr. COSGROVE. And I would just add to that. Any time I have 

found a problem, regardless if it is on a nursing floor or in a hospital, it goes right back to leadership. You change the leadership, 

you put a better leader in, you get better performance. I can’t 

stress too much the importance of leadership. 

Mr. TAKANO. And investing in the training and— 

Ms. SCHLICHTING. Absolutely. 

Mr. TAKANO. And you believe it is possible for there to be accountability, that we can improve accountability at the VA? 

Ms. SCHLICHTING. Yes. 

Dr. COSGROVE. There has to be accountability. I mean, do you 

not have accountability when you get voted on every year—every 

other year? 

Mr. TAKANO. But in other words, you don’t do away with due 

process, that due process has to be a part of that accountability 

system, but leadership has to work with that due process. 

Ms. SCHLICHTING. Let me make a comment, though. I do think 

human resources as a division within VA is undervalued and 

under-invested in, from my vantage point, in terms of the quality 

and the experience of HR leadership, because it really takes strong 

leadership on the HR side to really put those processes systems in 

place to make sure that people are following them. And when we 

talked with some of the HR leaders, we did not get the sense that 

that was the tradition of the VA system to have that level of leadership. 

Dr. COSGROVE. And I would completely second that. It was embarrassing to hear the level of HR activities at the VA. 

Mr. TAKANO. So perhaps rather than focusing in on the due process procedures and all of that, I mean, there is some value in that, 

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34 

but focusing on the investment in HR would be a worthwhile thing 

for this Committee to look at. 

Ms. SCHLICHTING. Yes. 

Mr. TAKANO. Great. Thank you. 

The CHAIRMAN. Thank you. 

Dr. Abraham, you are recognized. 

Mr. ABRAHAM. Thank you, Mr. Chairman. 

Just a quick comment. Phenomenal work, and you bring to this 

Committee that we as the Committee expect and the taxpayers expect and that is credibility. The way I understand the math, you 

guys command $13 billion of revenue between both clinics and that 

has done successfully. So you are the experts in the room on managing health care. 

On the choice, certainly we are all fortunate on the Committee 

here to have thousands of veterans in our districts, and we realize 

how important we are to represent them and how fortunate we are. 

I am a big advocate of choice and the arguments I have heard 

against it as far as expanding the distance or taking away the obstacles is that it would weaken the VA system simply because you 

could possibly have a migration of patients. In my opinion, I think 

it would actually strengthen the VA system. If it makes them more 

competitive, things get better with competition. 

And, Doc, just going back to your comment, I have worked with 

EMRs such as all the three physicians on my right have. You said 

the Cleveland Clinic reports up to 100 quality metrics. You and I 

both know that those metrics could be reported just like that with 

an EMR because they are entered into the database. 

Dr. COSGROVE. Yes. 

Mr. ABRAHAM. So that answers the question of quality metric 

measurement right there. So, you know, it is a huge thing to get 

EMRs in place, they work, and again we need to do it commercially. The way you eat a whale is one bite at a time. And of those 

four things that you highlighted in your testimony, the EMRs and 

the supply chain. Hopefully the VA is leveraging their volume of 

catheters, name whatever, trach tubes, you just name, but if they 

are not, you guys, I think you said you save like $274 million over 

a period of time. If the VA is not doing that, then, wow, shame on 

them for not getting in the game long ago, because they order millions of quantities of supplies probably on a quarterly basis. 

Dr. COSGROVE. Yes. 

Mr. ABRAHAM. So do you have a comment on that, Doc? 

Dr. COSGROVE. Yes. I think one of the other things I emphasized 

is that particularly for physician choice issues like pacemakers or 

artificial knees or hips, to get the physicians involved and then you 

can drive down to a couple of choices and then you can drive the 

price down with the providers of those pieces of equipment, and 

that is where we have had major savings. 

Mr. ABRAHAM. It is just good business. 

Ms. SCHLICHTING. You know, interestingly, the VA does a terrific 

job on drug purchases. 

Dr. COSGROVE. Yes, they do. 

Mr. ABRAHAM. Why not on supplies? 

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Ms. SCHLICHTING. So it was surprising to us to see that they 

weren’t providing, you know, the same type of approach on the 

non-drug medical supplies. 

Mr. ABRAHAM. Well, again, thanks for your work, we appreciate 

it. 

And I yield back, Mr. Chairman. 

The CHAIRMAN. Thank you very much. 

Mrs. Radewagen, you are recognized. 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. 

I too want to welcome you both and thank you for your leadership and service. 

Ms. Schlichting, in my home district, American Samoa, over 60 

percent of the veterans have to travel off-island at a minimum of 

five hours by air for medical appointments. In the Commission’s 

final report as part of the commissioner site visit observations, the 

report cites poor access to VA care for rural veterans as one of the 

major weaknesses of the VA. For instance, in American Samoa, the 

hospital is in such need of upgrades to facilities and equipment, as 

well as being short-staffed, that the VA drastically limits the use 

of the hospital for VA health care. 

Were the U.S. insular areas included in this evaluation as part 

of the under-served and/or rural areas? And would you please highlight which of the Commission’s recommendations are aimed to address these under-served areas, especially those you think would 

apply to the U.S. insular territories? 

Ms. SCHLICHTING. You know, to be candid, we did not spend time 

on the specific issues that your place of origin really has. But on 

the other hand, we did pay a lot of attention to the issues of rural 

access and really thinking about how to provide improved access. 

This was one of the reasons we though it was so critical to really 

look at a more integrated model of care, because in many parts of 

our country and beyond we have situations where veterans simply 

cannot get the access they need locally through the VA, but in fact 

are using in some cases private health care, but perhaps not organizing it as well. And the organization is actually very critical to 

the outcomes of care, care coordination and making sure people 

have the kind of providers that they need. 

So what we recommended was this integrated model of creating 

one system, so that in every part of, you know, where veterans live 

and work that they have access to what they need in a way that 

really enhances their outcomes, but we did not look at that specifically. 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. I yield back. 

The CHAIRMAN. Thank you very much. 

Mr. Takano, any other questions? 

Mr. TAKANO. I have no questions and neither do any of the other 

Members. 

The CHAIRMAN. Okay. Thank you very much. 

I have one other quick question, it kind of piggybacks on what 

Mr. Takano was asking about training and my question is, we all 

agree that due process is very important, my question is should it 

take a year or longer to discipline an employee or to fire them? 

Ms. SCHLICHTING. Well, you know, the way I look at that is it 

depends on the situation that they are dealing with. In most cases, 

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you know, due process is much more efficient than that, but if 

someone has a serious issue that has appeals built in, sometimes 

time has a way of, you know, increasing. But I think the key is 

measuring is the process efficiently operating, and those are things 

that should be evaluated to really determine whether that timing 

makes sense or not. 

The CHAIRMAN. Dr. Cosgrove? 

Dr. COSGROVE. Yes, I agree. You know, for example, as a physician we do annual reviews of everybody at the Cleveland Clinic, including physicians, and we do not just fire someone unless it is 

something terribly egregious without having gone through the due 

process over a period of time. Sometimes that is more than a year 

of collecting a physician’s information, but depending upon the—we 

have fired some people on the spot for egregious things that have 

occurred. 

The CHAIRMAN. All right, thank you very much. 

Also I would like to again thank the ten Veterans Service Organizations that did in fact provide written testimony for today. It is 

a very important part of the record, as is the written testimony 

that VA provided as well. 

Again, I think you heard from every Member of this Committee 

a great appreciation of the time and the effort that you and all 

Commission members did provide. The document is very important 

for us, for transforming a department that is in need of serious 

transformation into the 21st century. 

And I would say that all Members would have five legislative 

days with which to revise and extend or add any extraneous material regarding this hearing. 

Without objection, so ordered. 

And with that, this hearing is adjourned. 

[Whereupon, at 12:44 p.m., the Committee was adjourned.] 

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(37) 

A P P E N D I X 

Prepared Statement of Nancy Schlichting 

Chairman Miller, Ranking Member Takano, and Members of the Committee: 

I am pleased to appear this morning to discuss the workings, deliberations, findings, and recommendations of the Commission on Care, which I was privileged to 

chair. And I am delighted to be accompanied by my colleague, Dr. Delos (Toby) Cosgrove, the Commission Vice Chairperson, and the Chief Executive Officer (CEO) of 

the Cleveland Clinic. I also want to take this opportunity to thank you for your support of the Commission, and your assistance in providing us an extension of time 

to complete our work. 

For the last 13 years, I have served as the CEO of the Henry Ford Health System 

(Henry Ford), a Detroit-based $5 billion, 27,000-employee organization, which I 

joined after many years of senior-level executive positions in health care administration. I believe my experience in leading Henry Ford through a dramatic turnaround 

of its finances and culture and in winning a Malcolm Baldridge National Quality 

Award and national awards for customer service, patient safety, and diversity initiatives played a role in the President’s selecting me to chair this important body. I 

accepted this position not only because I was honored to be selected, but because 

I hoped that this commission could make a difference. I believe our report offers 

that promise. 

As you well know, Mr. Chairman, just a little more than two years ago, Congress 

and the Administration faced a real crisis of confidence in a health system some had 

once seen as providing the best care anywhere. In 2014, alarming delays in providing needed care, and the scandal surrounding deceptive reporting on patientscheduling, led to the enactment of a far-reaching omnibus law that established the 

Commission on Care. 

Congress is to be commended for including in that law provisions that commissioned an independent assessment of VA health delivery and that charged our commission to assess access to care and critical strategic issues. I was privileged to 

work with a group of commissioners who brought a diverse, rich breadth of experiences and perspectives while sharing a strong commitment to our veterans. 

The Commission’s Veteran-Centered Approach 

The Independent Assessment, released in September 2015, was invaluable in providing the Commission a comprehensive, carefully-researched, system-focused analysis that both informed our work and provided an invaluable integrated framework 

for our examination and deliberations. 

As we explained in our interim report, early on the Commission adopted a set of 

principles to guide our work; that identified both how we would proceed and the 

core values we would honor. Our adherence to those principles proved critical, in 

my view, to the development of a final report that is value-based and centered on 

our veterans. 

While each of those principles was meaningful and important to our work, let me 

highlight just a few I think are particularly relevant to our dialogue this morning: 

• The deliberations and recommendations of the Commission will be data-driven 

and decided by consensus. 

• The Commission will focus on ensuring eligible veterans receive health care 

that offers optimal quality, access, and choice. 

• Recommendations will be actionable and sustainable, focusing on creating clarity of purpose for VA health care, building a strong leadership/governance structure, investing in infrastructure, and ensuring transparency of performance. 

I believe you will find that these core principles profoundly influenced and are 

deeply embedded in the content of our final report. 

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1 VA care has often been cited to be as good as or better than that of private sector. The 

following paper, identifying about 60 studies by disease type, supports that statement. http:// 

avapl.org/advocacy/pubs/FACT%20sheet%20literature%20review%20of%20VA%20vs%20 

Community%20Heath%20Care%2003%2023-16.pdf 

Our work over a ten-month period—including 12 deliberative and educational 

meetings over the course of 26 days—was not easy. Our public hearings were wideranging; our discussions were frank. Through testimony and dialogue, the Commission considered the broadest span of perspectives we could assemble: these included 

senior VA leaders and VA program and subject-matter experts; stakeholders, including representatives of national veterans service organizations, union and association 

leaders representing Veterans Health Administration (VHA) employees, individual 

veterans, Choice Program contractors, representatives of medical school affiliates 

and associations of behavioral health care professionals; former VHA Under Secretaries of Health and VHA network and medical center administrators; experts in 

health care and health care economics; and members of this Committee. Our Commission, with its diverse membership, had spirited discussions, debates, and sometimes difficult deliberations - perhaps not unlike the process that leads to good legislation. Importantly, too, those deliberations were conducted in public sessions, in a 

process which was stronger for its transparency. Like your own work on this Committee, we were focused on and bound together by the unifying question, ‘‘What’s 

best for the veteran?’’ I believe we have been true to that challenge, and that our 

report provides actionable, sustainable recommendations - many of which invite congressional action. 

Importantly, we discussed at length the challenge of determining what veterans 

themselves want. To what, we asked, could we look to find the ‘‘voice of the veteran?’’ Time constraints and regulatory requirements ruled out conducting a Commission survey of veterans. But we pursued multiple other avenues and sources to 

tap and ascertain veterans’ views, certainly including your advice, Mr. Chairman, 

that we engage the veterans’ service organizations, who participated fully in our 

work. 

Status of VA Health Care Delivery System and Management Processes 

In its sweeping report, the Independent Assessment identified troubling weaknesses and limitations in key VA systems needed to support its health care delivery. 

Reaching very similar findings, the Commission concluded that—if left 

unaddressed—problems with staffing, facilities, capital needs, information systems, 

procurement and health disparities threaten the long-term viability of VA care. Importantly, though, neither the Independent Assessment nor our review called into 

question the clinical quality of VA care. Quite the contrary. The evidence shows that 

care delivered by VA is in many ways comparable to or better in clinical quality 

than that generally available in the private sector. 1 This is a testament to the high 

quality of its clinical workforce. 

Yet we found a system that faces many grave problems: high among them, an ongoing leadership crisis, confusion about strategic direction, significant variation in 

performance across the VA health system, and a culture of risk aversion and distrust. Despite the various deep problems facing VHA, our report does not propose 

shuttering the system or placing its future at risk. 

With our focus on what is best for the veteran, the commissioners recognized that 

the VA health care system has invaluable strengths. It is an integrated health care 

system with a compelling mission that combines care-delivery, educating health professionals, conducting research, and carrying out a contingency national-emergency 

mission. VHA has developed and operates unique, exceptional clinical programs and 

services tailored to the needs of millions of veterans who turn to it for care. For example, its behavioral health programs, particularly their integration of behavioral 

health and primary care, are largely unrivalled, and profoundly important to many 

who have suffered the effects of battle or military sexual trauma, or for whom VHA 

is a safety net. VHA’s ‘‘wraparound’’ case-management services meet the most vulnerable veterans where they are to prevent them from falling through the cracks. 

As the largest national health care system, VHA continues to have the capacity to 

bring about reforms in the larger health care industry. By way of example, it pioneered bar-coding of pharmaceutical drugs, and championed improvements to patient-safety through systematic identification and review to identify root causes of 

medical mistakes and ‘‘near misses.’’ In working to close access gaps, VA has developed one of the largest telehealth and connected-care operations in the world. While 

VHA can learn from private sector care, we also benefit from its successes. 

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Transformation 

We are clear, however, in our view that VHA must change, and change profoundly, because veterans deserve a better organized, high-performing health care 

system. Certainly, some elements of such a high-performing system are already in 

place. VA has high-quality clinical staff, and this integrated health care system is 

marked by good care-coordination. VHA today, however, relies significantly on community providers to augment the care it provides directly, although those community partners are not part of a cohesive system. VA and VHA are already undergoing substantial change under the leadership of Secretary Robert McDonald, Deputy Secretary Sloan Gibson, and Under Secretary for Health David Shulkin, and it 

is important to recognize and encourage this change process. 

All of our commissioners agreed on the need to transform VA health care. At the 

heart of that transformation, we call for VA to establish high-performing health care 

networks that include and that integrate the care provided by credentialed community-based clinicians along with VHA and other federal providers, and that afford 

veterans primary care provider-choice, without regard to criteria like distance or 

wait times. The establishment of integrated care networks - what we refer to in the 

report as a new VHA Care System - is nothing less than a fundamental change in 

the model of VA care-delivery. It is a model that will much more closely integrate 

VHA with its community partners, with an emphasis on coordination of care that 

is so important to the population VHA serves, one with more chronic illness and 

behavioral health conditions than the general medical population. High quality care 

is a critical element, so we propose that VA control network design; set high standards for community-provider participation, to include a credentialing, quality and 

utilization performance, and military/cultural competence; and tightly manage the 

networks. Our vision for this transformed system is one that would offer major improvements: improved access to care, care-quality, and choice, with resultant improvement in patient well-being. 

Such a system, which Dr. Cosgrove and I would be happy to discuss in more detail, would provide our veterans with the high quality health care they richly deserve. But successful implementation of that recommendation is not only contingent 

on legislative action but, as importantly, on adoption of other major inter-dependent 

initiatives proposed in our report. In short, our report - as well as the Independent 

Assessment - makes very clear that providing veterans access to needed care cannot 

be achieved by ‘‘tweaking’’ existing programs or mounting a complex new delivery 

framework on a weak infrastructure platform. Rather, it requires an integrated systems approach that not only redesigns VA’s health care delivery system, but re-engineers fundamental internal systems. Transformation will require streamlining key 

functions such as IT, HR, procurement, facilities-management; investing in IT and 

facilities; building a strong leadership system; strengthening VHA governance; and 

reorganizing the relationship between VHA leadership and the field. Clearly, it will 

take time and will require relentless commitment by all stakeholders. 

Let me add that in recommending a transformation of VA health care delivery 

and the systems that underlie it, we used the term ‘‘transformation’’ advisedly to 

mean fundamental, dramatic change - change that requires new direction, new investment, and profound re-engineering. Virtually all the commissioners agreed our 

recommendations are bold, though you have, no doubt, heard isolated voices of disagreement. One view disputes our belief that our report’s recommendations would 

be truly transformative, and says instead that the report proposes only limited reforms and will do little to redirect veterans’ health care. At the same time, our work 

has also been characterized as a ‘‘horrendous, anti-veteran proposal.’’ Both critiques 

widely miss the mark, in my view. Our focus, however, was not on how our recommendations would be characterized, but with developing a report that would result in meaningful improvement in veterans’ care. I believe we have laid that foundation. 

‘‘Privatization’’ 

It is no secret that the Commission debated the merits of so-called ‘‘privatization’’ 

or of veterans being offered unfettered choice from among all Medicare-qualified providers. It is also no secret that some among the membership are deeply skeptical 

of government-run health care, and some believe current trends will ultimately lead 

VA to a payer only role. Regarding the 20-year horizon to which the Commission 

was to look, though, we can foresee continued dynamic change in health care. Already, there has been a dramatic increase in outpatient care. We can also speak 

with some confidence about the potential for explosive growth of telemedicine, increasing emphasis on preventive care, the introduction of precision medicine and the 

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2 Kenneth W. Kizer, MD, MPH, ′′Veterans and the Affordable Care Act,′′ JAMA, vol. 307, no. 

8 (Feb. 22/29, 2012) accessed at https://commissiononcare.sites.usa.gov/ files/2016/01/20151116- 

02-VeteranslandlthelAffordablelCarelActlJAMAlFeb2012lVol307-No8.pdf 

toring of patients with chronic illnesses. But we’re also in agreement that the rapid 

changes overtaking health care make it impossible to accurately forecast further 

than five years out. 

While we cannot fully foresee the medical breakthroughs of the next decades, the 

Commission did acknowledge important realities: 

• Despite profound challenges it must overcome, the VA health system is important to millions of veterans and has great value in providing clinical care, educating health professionals, conducting research, and carrying out a contingency 

national-emergency mission. • Millions of veterans will continue to need care in the future that VA provides 

through critical programs and special competencies that are either unique or of 

higher quality or greater scope than is available in the private sector. • Many veterans have complex medical and well-being needs, often greater than 

are commonly present in the general population. • As a result, in considering the option of VHA becoming solely a payer, one must 

acknowledge that health care systems and facilities across this country are generally not equipped to meet many of the unique and complex health needs 

among the roughly six million veterans whom VA treats annually, particularly 

those with the highest priority in law: the service-connected disabled and those 

with limited financial means. • The difficulties veterans have experienced in accessing timely care in the VA 

health care system are also relatively common experiences among health care 

consumers outside VA where national shortages of primary care physicians, 

psychiatrists, and certain specialists are everyday problems. • Finally, many private health care systems have not established programs to 

fully coordinate care - an important attribute of VA-provided care. 

This last point has particular relevance to the idea that veterans would be better 

served if they were simply provided a card or care-voucher that entitle them to get 

care virtually anywhere at VA expense. That strategy would surely lead to more 

fragmented care. As described by one highly acclaimed former Under Secretary for 

Health- 

‘‘Fragmentation of care is of concern because it diminishes continuity and coordination of care resulting in more emergency department use, hospitalizations, diagnostic interventions, and adverse events. The VA serves an especially large number 

of persons with chronic medical conditions or behavioral health diagnoses - populations especially vulnerable to untoward consequences resulting from fragmented 

care.’’ 2

Needed Congressional Action 

Importantly, our recommendations highlight the critical role we see for Congress. 

The Commission certainly recognizes that veterans’ access to care has long been a 

high congressional priority. Congress has strengthened the foundation of care-delivery through legislation, provided needed medical-care funding, and conducted important oversight. In creating our Commission, you asked the important question, how 

can the Nation best deliver veterans’ care in the years ahead? Let me highlight 

some of the critical steps we recommend Congress take: 

• Provide VA needed authority to establish integrated care networks through 

which enrolled veterans could elect to receive needed care from among 

credentialed providers without regard to geographic distance or wait time criteria; 

• Address fundamental weaknesses in VHA governance; 

• Provide VA more flexibility in meeting its capital asset and other needs, including - 

(1)Establishing a capital asset realignment process modeled on the DoD BRAC 

process; 

(2)Waiving or suspending the authorization and scorekeeping requirements governing major VA medical facility leases; 

(3)Lifting the statutory threshold of what constitutes a VA major medical facility 

project; 

(4)Reinstating broad authority for VHA to enter into enhanced-use leases; and 

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(5)Easing, for a time-limited period, otherwise applicable constraints on divestiture of unused VHA buildings. 

(6)Establishing a line item for VHA IT funding and authorize advanced appropriations for that account. 

• Create a single personnel system for all VHA employees to meet the unique 

staffing needs of a health care system; and • Invest in needed VHA IT funding and facilities. 

I’d be happy to discuss any of these in more detail, but let me amplify one point, 

which our commissioners viewed as foundational. The Commission saw VHA’s governance structure as ill-equipped to carry out successfully the kind of transformation required to re-invigorate this health system, which all agreed would be 

a multi-year process. Continuity of leadership and long-term strategic vision—critical both to implementing a transformation and to sustaining it - cannot be assured 

under a governance framework marked by relatively frequent turnover of senior 

leadership and near-constant focus on immediate operational issues. The Commission believed that two fundamental governance changes were needed: establishment 

of a board of directors with authority to direct the transformation process and set 

long-term strategy, and change in the process for the appointment for and tenure 

of the official currently designated as the Under Secretary for Health. Of course, I’d 

be happy to discuss these and other recommendations in more detail. 

Cost 

Let me emphasize that the Commission’s aim was to develop recommendations 

that are actionable, sustainable, and would realize the vision of improving veterans’ 

access, quality of care, choice, and well-being. We did not set out with the preconceived notion that bold transformational change was needed. Rather we stayed 

true to our guiding principles and to where our findings led us. Also, we were not 

constrained by cost considerations, though we did recognize early that the U.S. taxpayer is one of the Commission’s stakeholders and we worked with health economists to model different options. Our report includes an appendix chapter that presents estimates of the cost of alternative policy proposals. 

We recognized that our recommended option for expanding community care 

through the establishment of integrated care networks would result in higher utilization of VA-covered health care and, accordingly, in additional costs, in the view 

of our economists. But we believe adoption of other Commission recommendations 

and options discussed in our report can help mitigate the increased costs. Projecting 

costs, as you know, includes elements of uncertainty. Our economists could not estimate savings or costs that might result from reducing infrastructure, for example. 

Similarly, they could not assign costs to needed investment in IT and facilities. 

Implicit in our discussions, though, has been the question - should the Nation invest further in the VA health care system? Our report answers that question in the 

affirmative, even as it underscores the need for sweeping change in that system. We 

do not suggest that Congress has not already made very substantial investments in 

the system. Rather we call for strategic investments in a much more streamlined 

system that aligns VA care with the community. 

In my judgment, our report points the way to meeting the central challenge Congress identified in 2014: improved access to care, while offering a vision that would 

expand choice, improve care-quality, and contribute to improved patient well-being. 

It is a vision that puts veterans first, not an approach crafted to win buy-in from 

system administrators or other interests. My long experience tells me that that veteran-centered focus will ultimately improve the service veterans receive while 

strengthening the system and providing increased transparency and accountability. 

In my view, this is a vision that merits your support. 

I would be pleased to be a resource to this Committee as you continue to work 

on these issues. I would also be happy to respond to your questions. 

f 

Prepared Statement of Delos M. (Toby) Cosgrove, MD 

Chairman Miller, Ranking Member Takano, and Members of the Committee, 

thank you for inviting me to speak about the Commission on Care Final Report 

today. 

As a former Air Force surgeon, I care deeply about the welfare of the Nation’s 

veterans and I have been honored to serve as vice chairperson of the Commission 

on Care and as a member of the MyVA Advisory Committee. Over the course of my 

work with the VA, I have become well-acquainted with the Department and underLeonard.horne on VACREP0180 with DISTILLER

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stand its contributions as well as its challenges in meeting our veterans’ needs. As 

CEO of Cleveland Clinic, an $8 billion dollar health care system serving communities across the country and internationally, I’m keenly aware of the magnitude of 

the challenges facing VA health care leaders. Mr. Chairman, the veterans’ health 

care system must make transformative changes to meet the health care needs of 

veterans today and tomorrow. If these changes are not made, the VHA’s many systemic problems threaten the long-term viability of VA care. 

The final report contained eighteen (18) different recommendations. Today, I am 

going to address four specific areas that include; the establishment of integrated 

community-based health care networks, quality metrics, information technology 

(specifically electronic health records), and supply chain. 

Given the Commission’s charge to examine veterans’ access to care, it was concluded early on that greater reliance on, and closer integration with, private sector 

care held the greatest promise for improving not only access, but affording veterans 

greater choice. As you know, the Commission considered and debated options that 

would provide for different degrees of choice. The recommended option in the Commission’s Final Report reflects a consensus position, though many supported an option that would provide veterans still greater choice of private sector providers. The 

Commission agreed that the VHA must establish high-performing, integrated, community-based health care networks to provide timely and quality care to our veterans. 

The report envisions a continued role for a VHA health care system, but as we 

said - if the challenges and opportunities described in the final report are left 

unaddressed we are concerned that our veterans will not receive the kind of highquality care that they deserve. Among our proposals, the Commission recommends 

that VHA adopt a continuous improvement methodology such as Lean Six Sigma to 

engage staff and improve the culture. This will help, but it will also take significant 

investments in time, effort, and resources to modernize and streamline such essential functions as human capital management, capital asset management and leasing, business processes, and information technology. 

The Commission recommended that the VHA should implement core metrics that 

are identical to those used in the private sector. Veterans deserve to know that the 

health care they are receiving either from VHA or from a community provider is 

of high-quality. If these metrics are put into place, it will be easier to evaluate the 

system’s performance and Congress will have benchmarks from the private sector 

to compare both its progress and the improvement over time. Congress and the 

American people deserve to know that VHA is getting value for their investment. 

Years ago, the VHA was a leader in the field of electronic health records. Unfortunately, this is no longer the case. Therefore, the Commission believes that the VHA 

should transition to the same type of commercial off-the-shelf electronic health 

records as other providers. By using a proven product, many of the scheduling and 

billing problems would be resolved. Further, these systems could help the VA identify areas for opportunity and utilization to promote better access to care for our 

Veterans and promote interoperability which is critical as veterans move to different 

care sites. Finally, the commercial EHR would also allow VHA to link financial and 

clinical information-a critical functionality for running modern health care delivery 

systems. The best and most prevalent commercial EHR programs allow staff and 

patients to schedule patient care easily and to provide legitimate performance measures for wait times, unit costs, clinical care outcomes and productivity that conform 

to those of the rest of the health care industry. Many of our country’s best hospital 

systems have converted homegrown information systems to commercially-based systems. VHA must do the same to remain current and engage with the rest of the 

health care system. It must also have its own leadership-specifically a chief information officer for VHA information systems that allows VHA to adjust its information 

needs as the health care industry evolves. 

As a VHA contractor, Cleveland Clinic has experienced first-hand the burdensome, antiquated system that is currently in place to receive payment. We are required to provide documentation in hard copy form sent via the postal services as 

they will not accept either fax, email or any other electronic submission. If a request 

results in more than 100 pages we must burn the records to a disc. Because we do 

not have any mechanism to track whether the documentation has been received, we 

have heard on many occasions that they ‘‘never received the paper records’’ and we 

have no recourse other than to send them again. The Independent Assessment that 

Congress commissioned found that VHA should keep claims adjudication and payment separate from its care delivery. The health care system that the Commission 

envisions for VHA will continue to expect exceptional performance from its network 

of providers and providers should expect timely and accurate payment in return. 

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Supply chain is another area ripe for VHA streamlining. The Commission’s report 

stated that the ‘‘purchasing processes are cumbersome which has driven VA staff 

to workarounds and exacerbates the variation in process the VA pays for products.’’ 

The VA should consolidate and reorganize the procurement and logistics for medical 

and surgical supplies under one leader. The VHA has enough market share to leverage prices that could result in savings of hundreds of millions of dollars. 

At Cleveland Clinic, we are constantly evaluating and reviewing our supply chain 

products and processes. Today, our Supply Chain is working with teams of clinicians 

led by physician champions to justify purchases of more expensive supplies by engaging clinical staff in a value-based sourcing effort that illustrates that cost and 

quality do not have to be mutually exclusive principles. Clinicians are made aware 

of the costs and outcomes associated with different brands. Once the clinical staff 

has to justify the higher costs and understands whether they add value to care outcomes based on empirical evidence, they make purchasing decisions based on value. 

Such efforts are then integrated into patient-centric utilization management and inventory management efforts to ensure the appropriate use of our resources. A clinician-engaged, value-based supply chain management practice model has allowed us 

to save $274 million dollars over the last six years. We are continuing to reform our 

processes by entering into purchasing consortia with other nonprofit health care 

providers and ensuring that we are continually searching for improvements in cost 

management. 

Of course, leadership is the key to transformative change. The Commission speaks 

to the need to create a pipeline for internal leaders and to make it easier for private 

sector and military clinical and administrative leaders to serve in VHA. Marketbased pay is critical to bringing in leaders capable of taking VHA to the next level. 

The Commission also proposes that Congress provide for a VHA governance board 

to provide a long-term strategic vision and successfully drive the transformation 

process. Both the chairperson and I will be happy to talk more about this aspect 

of the report. 

Mr. Chairman, transforming a system as large and complex as VHA’s will require 

streamlining multiple systems, redesigning care-delivery, and more. This report offers a roadmap to success. Realizing the vision the report proposes will require new 

investment, (both financial and in expertise), enactment of legislation, and strong 

leadership. 

Thank you for your attention. I am happy to address any questions you may have. 

f 

Statements For The Record 

THE AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO 

Chairman Miller and Ranking Member Takano: 

The American Federation of Government Employees, AFL–CIO and its National 

VA Council (AFGE) thank the Committee for the opportunity to share our views regarding the final recommendations of the Commission on Care. AFGE represents 

nearly 700,000 federal employees including more than 230,000 employees of the Department of Veterans Affairs (VA). Within the Veterans Health Administration 

(VHA), AFGE represents employees at nearly every medical center and is by far the 

largest representative of medical and mental health professionals and support personnel. 

Overview 

Although the Commission did not formally adopt the controversial ‘‘strawman’’ 

proposal, the impact would be very similar. Both would dismantle our veterans’ only 

specialized integrated health care system and incur unsustainable costs that will inevitably lead to lower quality care and fewer health care services for fewer veterans. 

Both would also destroy veterans’ true source of ‘‘community care’’: care provided 

within the Veterans Health Administration (VHA) that is closely coordinated with 

VA vet centers and Veterans Benefits Administration (VBA) benefits and employment services. The Commission’s description of non-VA care as ‘‘community care’’ 

is a misnomer. Veterans strongly prefer to receive their care from the VA over the 

private sector according the Vet Voice Foundation poll and other recent polls. 

The Commission recommendation (#15) to eliminate all civil service protections 

under Title 5 would increase retaliation against employees who report mismanagement and take veterans’ preference rights away from thousands of veterans who 

choose VHA careers. The loss of seniority-based pay under the Commission’s proposed new Title 38 personnel system would severely weaken the VA’s ability to reLeonard.horne on VACREP0180 with DISTILLER

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tain experienced providers. The proposed elimination of Title 5 due process protections and Merit Systems Protection Board appeal rights would allow managers to 

hire and promote based on favoritism and political affiliation instead of merit. 

As the Committee contemplates the future of the VA health care system, AFGE 

also strongly urges the Committee to save our treasured health care system from 

‘‘death by a thousand cuts.’’ VA health care is already being dismantled ‘‘brick by 

brick’’ through the closures of many emergency rooms, intensive care units and 

other essential medical units. AFGE is also very concerned about the impact of 

VHA’s overreliance on contractor-run outpatient clinics on quality of care, care coordination and costs and the secretive process for issuing and renewing these contracts. The most recent stealth attack on VHA is the imminent replacement of nearly all VHA compensation and pension (C&P) disability exams with contractor exams 

without any apparent analysis of the impact on veterans’ disability ratings, access 

to integrated VHA care or costs. 

Recommendations #1 and #9: AFGE vehemently opposes Commission recommendations that would result in a massive shift of VA care to the private sector 

through unrestricted access to non-VA primary and specialty care and the transfer 

of primary control over veterans’ care from the Secretary to an unelected corporatestyle board running a new VHA Care System. AFGE concurs with Commissioner 

Michael Blecker that these drastic changes would result in ‘‘the degradation or atrophy’’ of critical veterans’ health services. VA would also lose the critical core capacity that has enabled it to be the Nation’s leading source of medical training and cutting edge research. Our nation would also lose the critical assistance that the VA 

provides through its ‘‘fourth mission’’ during national emergencies and natural disasters, from Hurricane Katrina to the Orlando mass shooting. 

VHA must remain the primary source of veterans’ care, the exclusive provider of 

primary care and the exclusive care coordinator. VHA must retain control over the 

design and oversight of local, integrated care networks. AFGE fully supports the 

proposal for local integrated care networks developed by the Independent Budget 

veterans’ service organizations and the similar proposal included in the VA’s Plan 

to Consolidate Community Care. 

Putting a private governance board at the helm would also vastly reduce the ability of Congress and veterans to hold wrongdoers accountable for mismanagement, 

corruption and patient harm. The Commission acknowledged that the board would 

not have to comply with the open government requirements of the Federal Advisory 

Committee Act and most likely would not be subject to the Freedom of Information 

Act. 

Recommendation #2: The Commission’s proposal to relieve the Secretary of the requirement under the Millennium Act to report annually to Congress on the number 

of beds closed the previous year constitutes another unjustified assault on accountability. AFGE agrees that current bed count data is inadequate but the solution is 

not less data. We have repeatedly sought Congressional oversight of ‘‘bed count 

gaming’’ where managers manipulate bed count data to hide the number of actual 

beds available to veterans. When beds are closed (primarily due to management’s 

unwillingness to hire sufficient nurses), veterans are sent to non-VA hospitals that 

are less equipped to treat their unique conditions, often imposing greater costs on 

veterans and taxpayers. 

If the bed count reporting requirement is eliminated, thousands of veterans’ beds 

will be lost forever, staff will be laid off, and smaller facilities may not survive. VA 

beds have also played a critical role in our national disaster response plan; during 

Hurricane Katrina, patients were moved to VA medical centers in Houston and 

other locations. Therefore, we urge the Committee to reject this recommendation 

and instead, conduct oversight of ways to improve bed count data collection with the 

input of veterans’ groups and representatives of front line employees. 

Recommendation #6: AFGE strongly opposes the use of a BRAC-like process to 

address VHA’s facility and capital asset needs. We are equally opposed to giving a 

governance board any role in determining VHA’s infrastructure needs. It is likely 

that any board-run process would be plagued by the same self-interest that impaired the decision making process of a Commission filled with health care executives. 

AFGE concurs with the Independent Budget veterans service organizations that 

a far more urgent need is to address current infrastructure gaps that threaten safety and interfere with care delivery. Clearly, a BRAC is not the answer. The RAND 

Corporation recently reported that through at least 2019, demand for veterans 

’health care services is likely to exceed supply. 

Recommendation #15: In its report, the Commission portrays civil service protections afforded to Title 5 employees as the enemy of innovation and quality improvement (‘‘a relic of a bygone era’’, ‘‘an island disconnected from the larger talent marLeonard.horne on VACREP0180 with DISTILLER

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ket for knowledge-based professional and administrative occupations that are mission-critical’’). The Commission then reveals its true agenda for eliminating Title 5 

rights: it wants to make it easier to fire employees it doesn’t like and hire through 

cronyism. 

What the report does not tell us is that the Department of Defense federal agencies operate health care systems effectively with Title 5 workforces that have full 

due process and collective bargaining rights that they use to speak up against mismanagement and negotiate with management over working conditions to the benefit 

of their patients. 

This recommendation would eliminate all Title 5 rights currently afforded to the 

majority of VHA employees. These include full Title 5 employees, most of whom are 

service-connected disabled veterans (e.g. police, housekeepers, food service workers) 

and Hybrid Title 38 employee (e.g. Medical Support Assistants, nursing assistants, 

pharmacists, psychologists and social workers). Both groups would lose their right 

to third party review of removals and demotions by the Merit System Protection 

Board. 

Both groups would also lose most of their collective bargaining rights that allow 

them to negotiate over working conditions such as scheduling, assignments and 

training. 

Veterans who choose to work in VA health care after saving lives on the battlefield would also be greatly harmed by this Commission recommendation. Federal 

case law has made it clear that employees appointed under Title 38 (Hybrids and 

full Title 38 employees) are not covered by the Veterans Employment Opportunities 

Act (VEOA) and therefore lack veterans preference protections against being passed 

over for a non-veteran in hiring. AFGE concurs with the Independent Budget that 

Congress should enact legislation to extend the VEOA to all VHA employees. 

The proposed new Title 38 personnel system would ignore seniority when setting 

pay, at a time when VHA is facing low morale and increased attrition among providers with valuable experience because many new hires are being paid more than 

their senior counterparts. 

Other recommendations 

AFGE generally supports recommendations #3 (appealing clinical decisions), #5 

(health care disparities), #14 (diversity and cultural competence), #16 (human capital management) and #17 (eligibility for those with other-than-honorable discharges). 

AFGE supports modernized information technology (IT) (#7) but urges Congress 

to mandate greater involvement of front-line employees using new IT systems to ensure successful implementation. 

AFGE does not take a position on recommendation #4 (VHA transformation) because further investigation of the cost-effectiveness and lack of transparency of the 

Veterans Engineering Resource Centers is needed. We also take no position on #8 

(supply chain) or #12 (VISNs) at this time. 

We object to #10 (leadership) if it involves a governance board. AFGE also opposes 

# 11 (leadership succession) because direct hire authority will increase cronyism and 

discrimination against veterans. AFGE also opposes #13 (performance standards) 

because of its overreliance on private sector standards that are not applicable to 

VHA’s mission or its unique patient population. AFGE is opposed to recommendation #18 (expert body to address eligibility) as unnecessary. 

In closing, AFGE urges the Committee to reject all proposals to dismantle the VA 

health care system and shut the doors of its medical centers, either through unrestricted access to non-VA care under a governance board-run system or legislation 

to extend the broken temporary Choice program. Lawmakers should also investigate 

the growing number of incremental attacks on VA health care including outsourcing 

of C&P exams, contractor-run outpatient clinics and elimination of VA-provided 

emergency care and ICU services. 

Instead, AFGE urges the Committee to serve the best interests of veterans and 

the Nation by investing in VA’s own high performing integrated, veteran-centric 

health care system. AFGE welcomes the opportunity to work with the Committee 

and VSOs s to ensure continuous improvement in our Nation’s treasured health care 

system for veterans. 

f 

AMVETS 

Chairman Miller, Ranking Member Takano, and distinguished Members of the 

Committee, 

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Since 1944, AMVETS (American Veterans) has been one of the largest congressionally-chartered veterans’ service organizations in the United States and includes 

members from each branch of the military, including the National Guard, Reserves, 

and Merchant Marine. We provide support for the active military and all veterans 

in procuring their earned entitlements, and appreciate the opportunity to present 

our views at this oversight hearing, ‘‘From Tumult to Transformation: The Commission on Care and the Future of the VA Healthcare System.’’ 

As widely noted, the Commission on Care was established by section 202 of Public 

Law 113–146 and worked for ten months examining veterans’ access issues with the 

Department of Veterans Affairs (VA) health care, and talked with many experts and 

veterans services organization leaders on how best to organize the Veterans Health 

Administration (VHA) to ensure successful delivery of high-quality health care to 

qualifying veterans over the next two decades. 

The Commission released its final report on June 30, 2016 and developed 18 recommendations intended for the purpose of extensive organizational transformation, 

not a disjointed fix to everyday issues. 

Redesigning the Veterans’ Health Care Delivery System 

The VHA Care System 

Recommendation #1: Across the United States, with local input and knowledge, 

VHA should establish high-performing, integrated community health care networks, 

to be known as the VHA Care System, from which veterans will access high-quality 

health care services. 

The Commission Recommends That: 

• VHA Care System governing board (see Recommendation #9) develop a national 

delivery system strategy, including criteria and standards for creating the VHA 

Care System, comprising high-performing, integrated, community-based health 

care networks, including VHA providers and facilities, Department of Defense 

(DoD) and other federally-funded providers and facilities, and VHA-credentialed 

community providers and facilities. 

• Develop integrated community-based health care networks with input of local 

VHA leadership to ensure their composition is reflective of local needs and veterans’ preferences. 

• Integrated, community-based health care networks must include existing VHA 

special emphasis resources. In areas where VHA has special expertise, VHA 

should enhance care by collaborating with community care providers to implement services that may not exist. 

• Build out networks in a well-planned, phased approach, overseen by the new 

governing board, which determines the criteria for the phases to ensure effective strategic execution. 

• VHA credential community providers. To qualify for participation in community 

networks, providers must be fully credentialed with appropriate education, 

training, and experience, provide veteran access that meets VHA standards, 

demonstrate high quality clinical and utilization outcomes, demonstrate military cultural competency, and have capability for interoperable data exchange. 

• Providers in the networks should be paid using the most contemporary payment 

approaches available to incentivize quality and appropriate utilization of health 

care services. 

• The highest priority access to the VHA Care System to be provided to serviceconnected and low-income veterans. 

• Eliminate current time/distance criteria (30 days/40 miles) for community care 

access. 

• Veterans choose a primary care provider from credentialed primary care providers in the VHA Care System. 

• All primary care providers in the VHA Care System coordinate care for veterans. 

• VHA Care System provides veterans with health care coordination and navigation support. 

• Veterans choose their specialty care providers from credentialed specialty care 

providers in the VHA Care System with a referral from their primary care provider. 

The Commission noted that the temporary Choice Program has proven to be 

flawed, and that VHA must instead establish high-performing, integrated, community-based health care networks, to be known as the VHA Care System. With the 

exception of the creation and involvement of a governing board, AMVETS supports 

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this recommendation and will continue to work with VA in its goal of consolidating 

Community Care Programs through the MyVA initiative. 

Recommendation #2: Enhance clinical operations through more effective use of providers and other health professionals, and improved data collection and management. 

The Commission Recommends That: 

• VHA increase the efficiency and effectiveness of providers and other health professionals and support staff by adopting policies to allow them to make full use 

of their skills. 

• Congress relieve VHA of bed closure reporting requirements under the Millennium Act. 

• VHA continue to hire clinical managers and move forward on initiatives to increase the supply of medical support assistants. 

AMVETS is in support of this recommendation. 

Recommendation #3: Develop a process for appealing clinical decisions that provides veterans protections at least comparable to those afforded patients under other 

federally supported programs. 

The Commission Recommends That: 

• VHA convene an interdisciplinary panel to assist in developing a revised clinical 

appeals process. 

AMVETS is in support of this recommendation and believes that there needs to 

be a national process in place for veterans to appeal clinical decisions that is equitable and easy to understand. 

Recommendation #4: Adopt a continuous improvement methodology to support 

VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center. 

The Commission Recommends That: 

• The Veterans Engineering Resource Center (VERC) assist in transformation efforts, particularly in areas of access and that affect system-wide activities and 

require substantial change, such as human resources management, contracting, 

purchasing, and information technology. 

• The many idea and innovation portals within VHA be consolidated under 

VERC. 

• A culture to inspire and support continuous improvement of workflow processes 

be developed and fully funded. 

• VHA’s reengineering centers be enabled to proactively identify problem areas 

within the system and offer assistance. 

AMVETS is in support of this recommendation. 

Health Care Equity 

Recommendation #5: Eliminate health care disparities among veterans treated in 

the VHA Care System by committing adequate personnel and monetary resources to 

address the causes of the problem and ensuring the VHA Health Equity Action Plan 

is fully implemented. 

The Commission Recommends That: 

• VHA work to eliminate health disparities by making health care equity a strategic priority. 

• VHA provide the Office of Health Equity adequate resources and the authority 

to build cultural and military competence among all VHA Care System providers and employees. 

• VHA ensure that the Health Equity Action Plan is fully implemented with adequate staffing, resources, and support. 

• VHA increase the availability, quality, and use of race, ethnicity, and language 

data to improve the health of minority and other vulnerable veterans with 

strong surveillance systems that monitor trends in health status, patient satisfaction, and quality measures. 

AMVETS is in support of this recommendation. 

Facility and Capital Assets 

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Recommendation #6: Develop and implement a robust strategy for meeting and 

managing VHA’s facility and capital-asset needs. 

The Commission Recommends That: 

• VA leaders streamline and strengthen the facility and capital asset program 

management and operations. 

• The VHA Care System governing board be responsible for oversight of facility 

and capital asset management. 

• Congress provide VHA greater budgetary flexibility to meets its facility and capital asset needs and greater statutory authority to divest itself of unneeded 

buildings. 

• Congress enact legislation to establish a VHA facility and capital asset realignment process based on the DoD Base Realignment and Closure Commission 

(BRAC) process to be implemented as soon as practicable. The Commission recommends the VHA Care System governing board subsequently make facility decisions in alignment with system needs. 

• New capital be focused on ambulatory care development to reflect health care 

trends. 

• VHA move forward immediately with repurposing or selling facilities that have 

already been identified as being in need of closing. 

With the exception of the creation and involvement of a governing board, 

AMVETS supports this recommendation. 

Information Technology 

Recommendation #7: 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. 

The Commission Recommends That: 

• VHA establish a Senior Executive Service (SES)-level position of VHA Care System chief information officer (CIO), selected by and reporting to the chief of 

VHA Care System (CVCS) with a dotted line to the VA CIO. The VHA CIO is 

responsible for developing and implementing a comprehensive health IT strategy and developing and managing the health IT budget. 

• VHA procure and implement a comprehensive, commercial off-the-shelf (COTS) 

IT solution to include clinical, operational and financial systems that can support the transformation of VHA as described in this report. 

AMVETS is in support of this recommendation. 

Supply Chain 

Recommendation #8: Transform the management of the supply chain in VHA. 

The Commission Recommends That: 

• VHA establish an executive position for supply chain management, the VHA 

chief supply chain officer (CSCO), to drive supply chain transformation in VHA. 

This individual should be compensated relative to market factors. 

• VA and VHA reorganize all procurement and logistics operations for VHA under 

the CSCO to achieve a vertically integrated business unit extending from the 

front line to central office. This business unit would be responsible for all functions in a fully integrated procure-to-pay cycle management. 

• VA and VHA establish an integrated IT system to support business functions 

and supply chain management; appropriately train contracting and administrative staff in supply chain management; and update supply chain management 

policy and procedures to be consistent with best practice standards in health 

care. 

• VHA support the Veterans Engineering Resource Center (VERC) Supply Chain 

Modernization Initiative including consistent support from leadership, continued funding and personnel, and the alignment of plans and funding within OIT 

to accomplish the modernization goals. 

AMVETS is in support of this recommendation. 

Governance, Leadership, and Workforce 

Board of Directors 

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Recommendation #9: Establish a board of directors to provide overall VHA Care 

System governance, set long-term strategy, and direct and oversee the transformation 

process. 

The Commission Recommends That: 

• Congress provide for the establishment of an 11-member board of directors accountable to the President, responsible for overall VHA Care System governance, and with decision-making authority to direct the transformation process 

and set long-term strategy. The Commission also recommends the governing 

board not be subject to the Federal Advisory Committee Act (FACA) and be 

structured based on the key elements included in Table 5. 

• The Board recommend a chief of VHA Care System (CVCS) to be approved by 

the President for an initial 5-year appointment. Additionally, the Commission 

recommends the governing board be empowered to reappoint this individual for 

a second 5-year term, to allow for continuity and to protect the CVCS from political transitions. If necessary, the CVCS can be removed by mutual agreement 

of the President and the governing board. 

AMVETS does not support establishing a board of directors to be responsible for 

overall VHA governance. 

Leadership 

Recommendation #10: Require leaders at all levels of the organization to champion 

a focused, clear, benchmarked strategy to transform VHA culture and sustain staff 

engagement. 

The Commission Recommends That: 

• VHA create an integrated and sustainable cultural transformation by aligning 

all programs and activities around a single, benchmarked concept. 

• VHA align leaders at all levels of the organization in support of the cultural 

transformation strategy and hold them accountable for this change. 

• VHA establish a transformation office to drive progress and report on it to the 

CVCS and the new VHA Care System board of directors. 

With the exception of the creation and involvement of a governing board, 

AMVETS supports this recommendation. 

Recommendation #11: Rebuild a system for leadership succession based on a 

benchmarked health care competency model that is consistently applied to recruitment, development, and advancement within the leadership pipeline. 

The Commission Recommends That: 

• VA establish, as an OMB management priority for VHA, the goal of implementing an effective leadership management system in the agency. 

• VHA executives prioritize the leadership system for funding, strategic planning, 

and investment of their own time and attention. 

• VHA adopt and implement a comprehensive system for leadership development 

and management that includes a strategic priority of diversity and inclusion. 

• Congress create more opportunities to attract outside leaders and experts to 

serve in VHA through new and expanded authority for temporary rotations and 

direct hiring of health care management training graduates, senior military 

treatment facility leaders, and private not-for-profit and for-profit health care 

leaders and technical experts. 

AMVETS is in support of this recommendation. 

Recommendation #12: Transform organizational structures and management processes to ensure adherence to national VHA standards, while also promoting decision 

making at the lowest level of the organization, eliminating waste and redundancy, 

promoting innovation, and fostering the spread of best practices. 

The Commission Recommends That: 

• VHA redesign VHA Central Office (VHACO) to create high-performing support 

functions that serve VISNs and facilities in their delivery of veteran-centric 

care. 

• VHA clarify and define the roles and responsibilities of the VISNs, facilities, 

and reorganized VHA program offices in relation to one another, and within national standards, push decision making down to the lowest executive level with 

policies, budget, and tools that support this change. 

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• VHA establish leadership communication mechanisms within VHACO and between VHACO and the field to promote transparency, dialogue, and collaboration. 

• VHA establish a transformation office, reporting to the CVCS with broad authority and a supporting budget to accomplish the transformation of VHA and 

manage the large-scale changes outlined throughout this report. 

AMVETS is in support of this recommendation. 

Recommendation #13: Streamline and focus organizational performance measurement in VHA using core metrics that are identical to those used in the private sector, 

and establish a personnel performance management system for health care leaders 

in VHA that is distinct from performance measurement, is based on the leadership 

competency model, assesses leadership ability, and measures the achievement of important organizational strategies. 

The Commission Recommends That: 

Organizational Performance Measurement 

• VHA streamline organizational performance measures, emphasize strategic 

alignment and meaningful effect, and use benchmarked measures that allow a 

direct comparison to the private sector. 

• The new Office for Organizational Excellence work with experts to reorganize 

its internal structure to align business functions with field needs and consolidate and eliminate redundant or low-priority activities. 

Personnel Performance Management System 

• VHA create a new performance management system appropriate for health care 

executives, tied to health care executive competencies, and benchmarked to the 

private sector. 

• The CVCS and all secondary raters hold primary raters accountable for creating 

meaningful distinctions in performance among leaders. 

• VHA recognize meaningful distinctions in performance with meaningful awards. 

AMVETS is in support of this recommendation. 

Diversity and Cultural Competence 

Recommendation #14: Foster cultural and military competence among all VHA 

Care System leadership, providers, and staff to embrace diversity, promote cultural 

sensitivity, and improve veteran health outcomes. 

The Commission Recommends That: 

• VHA implement a systemic approach to establishing cultural and military competence across VHA and its community providers, and provide the resources required to fully integrate the related strategy into veterans’ care delivery. 

• Cultural and military competency training be required on a regular basis for 

VHA Care System leadership, staff, and providers. 

• Cultural and military competency be criteria for allowing community providers 

to participate in the VHA Care System. 

AMVETS is in support of this recommendation. 

Workforce 

Recommendation #15: Create a simple-to-administer alternative personnel system, 

in law and regulation, which governs all VHA employees, applies best practices from 

the private sector to human capital management, and supports pay and benefits that 

are competitive with the private sector. 

The Commission Recommends That: 

• Congress create a new alternative personnel system that applies to all VHA employees and falls under Title 38 authority. The system must simplify human 

capital management in VHA; increase fairness for employees; and improve flexibility to respond to market conditions relating to compensation, benefits, and 

recruitment. 

• VHA write and implement regulations for the new alternative personnel system, in collaboration with union partners, employees, and managers, that: 

• Meets benchmark standards for human capital management in the health care 

sector and is easy for HR professionals and managers to administer; 

• Promotes veteran preferences and hiring; 

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• Embodies merit system principles through simplified, sensible processes that 

work for managers and employees; 

• Creates one human capital management process for all employees in VHA for 

time and leave, compensation, advancement, performance evaluation, and disciplinary standards/processes; 

• Provides due process and appeals standards to adverse personnel actions; 

• Allows for pay advancement based on professional expertise, training, and demonstrated performance (not time-in-grade); 

• Promotes flexibility in organizational structure to allow positions and staff to 

grow as the needs of the organization change and the success of each individual 

merits; 

• Establishes simplified job documentation that is consistent across job categories 

and describes a clear path for staff professional development and career trajectories for advancement; 

• Eliminates most distinctions (except for benefits) between part-time and fulltime employees; and 

• Grandfathers current employees with respect to pay and benefits. 

• VHA ensure all positions, to include human resources management staff, are 

adequately trained to fulfill duties. 

AMVETS is in support of this recommendation and believes it is crucial for recruiting and retention that VHA employees receive pay and benefits on par with the 

private sector, and that reliable funding in place to ensure the continuity of this 

measure. 

Recommendation #16: Require top executives to lead the transformation of HR, 

commit funds, and assign expert resources to achieve an effective human capital 

management system. 

The Commission Recommends That: 

• VHA hire a chief talent leader who holds responsibility for the operation’s entire HR enterprise, is invested with the authority and budget to accomplish the 

envisioned transformation, and reports directly to the chief of VHA Care System. 

• VA and VHA prioritize the transformation of human capital management with 

adequate attention, funding, and continuity of vision from executive leaders. 

• VA align HR functions and processes to be consistent with best practice standards of high-performing health care systems. 

• VA Human Resources and Administration and the Office of Information and 

Technology should create an HR information technology plan to support modernization of the HR processes and to provide meaningful data for tracking, 

quality improvement, and accountability. 

AMVETS is in support of this recommendation. 

Eligibility 

Recommendation #17: Provide a streamlined path to eligibility for health care for 

those with an other-than-honorable discharge who have substantial honorable service. 

The Commission Recommends That: 

• VA revise its regulations to provide tentative eligibility to receive health care 

to former servicemembers with an OTH discharge who are likely to be deemed 

eligible because of their substantial favorable service or extenuating circumstances that mitigate a finding of disqualifying conduct. 

AMVETS is in support of this recommendation and emphasizes those ‘‘who are 

likely to be deemed eligible’’ instead of a blanket opening of the system to all veterans with an other-than honorable discharge. Our organization has heard from 

many veterans who were improperly diagnosed or treated for their invisible wounds 

- some 40 years ago and others much more recently. Considerable progress has been 

made in the last decade in regards to identifying behavioral and physical symptoms 

of mild-to-moderate traumatic brain injuries and post-traumatic stress disorder. 

Veterans who honorably served prior to exhibiting these symptoms deserve a path 

to eligibility to access the specialized health care that VA offers. 

Recommendation #18: Establish an expert body to develop recommendations for VA 

care eligibility and benefit design. 

The Commission Recommends That: 

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1 The MITRE Corporation. (September, 2015). Independent Assessment of the Health Care 

Delivery Systems and Management Processes of the Department of Veterans Affairs Volume I: 

Integrated Report, 17. 

• The President or Congress task another body to examine the need for changes 

in eligibility for VA care and/or benefits design, which would include simplifying 

eligibility criteria, and may include pilots for expanded eligibility for nonveterans to use underutilized VHA providers and facilities, providing payment 

through private insurance. • The SECVA revise VA regulations to provide that service-connected-disabled 

veterans be afforded priority access to care, subject only to a higher priority dictated by clinical care needs. 

AMVETS is not in support of this recommendation. On March 13, 2015 VA announced the formation of the MyVA Advisory Committee (MVAC) which brought together experts from the private, non-profit, and government sectors to advise the 

Secretary of Veterans Affairs on improving customer service, veteran outcomes, and 

setting the course for long-term reform and excellence. MVAC currently has 12 priorities which are to: 

• Improve the Veterans Experience • Increase Access to Health Care • Improve Community Care • Deliver a Unified Veterans Experience • Modernize VA’s Contact Centers • Improve the Comp & Pension Exam • Develop a Simplified Appeals Process • Continue to Reduce Veteran Homelessness • Improve Employee Experience • Staff Critical Positions • Transform OIT • Transform Supply Chain 

AMVETS believes it would be in the best interest of VA to continue to work with 

the MVAC on additional goals, as needed, but to not dilute the current well-founded 

relationship. In fact, many of the recommendations in the Commission on Care report touch on the priorities that VA is working towards and where they have acknowledged work needs to be done. 

It is clear from many ongoing and recent reports that the VA health care veterans 

receive is on par or better than the private sector, high-quality, specialized, and patients are satisfied with the outcome. Access to care remains the most unstable part 

of the equation, yet measureable progress is being made. As stated earlier, AMVETS 

supports VA’s plan to consolidate community care to address the access issue, and 

looks forward to its further implementation. 

Mr. Chairman and members of the Committee, this concludes my testimony and 

would be happy to answer any questions the Committee may have. 

f 

CONCERNED VETERANS FOR AMERICA 

Chairman Miller, Ranking Member Takano and distinguished members of the 

Committee, thank you for allowing Concerned Veterans for America to submit for 

the record on this important issue. In 2014, as the Nation stood in shock at the revelation that VA had manipulated data contributing to the deaths of veterans, Congress acted quickly, passing the Veterans Access, Choice and Accountability Act of 

2014. That legislation included, among other things, a requirement that a commission be established in order to examine the state of VA health care and to make 

recommendations as to how it might be improved. On June 30th, 2016, the Commission on Care released its final report outlining its recommendations for the future 

of VA health care after nearly nine months of deliberation. 

The Commission had a legislative mandate requiring the implementation of all 

recommendations that the President considers feasible, advisable, and able to be implemented without legislation. Thus, it was uniquely empowered to make bold recommendations regarding the future of veteran health care. 

As was shown by the Independent Assessment-which was also mandated by the 

Veterans Access, Choice and Accountability Act of 2014 and was released in September, 2015-‘‘Solving [the] problems [at VA] will demand far-reaching and complex 

changes that, when taken together, amount to no less than a system-wide reworking 

of VHA.’’ 1 Unfortunately, the Commission’s recommendations amount to far less. 

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2 Walters, H. et al. (2009, December). Commission on the Future for America’s Veterans: Preparing for the Next Generation. Commission on the Future for America’s Veterans. 3 Schlichting, N. et al. (June, 2016), Commission on Care Final Report. 98. 4 Ibid., 60. 5 Ibid., 61. 6 Ibid., 23. 

To be sure, there are aspects of the recommendations that represent real progress 

for veteran health care delivery. 

Currently, veterans who use VA are the only constituency in the country that 

does not, as a matter of course, have choice in how they receive their health careincluding federal employees and Medicaid users. The Commission’s recommendations aim to give veterans increased options in this regard. Injecting the principle 

that veterans should have the same opportunities as the rest of the population to 

select the health care delivery that best suits their needs is a step in the right direction; this is progress. 

Furthermore, the Commission recommends that the governance of VHA be restructured to include a board of directors. This is a recommendation that has resurfaced time and again, from the 2009 report of the Commission on the Future for 

America’s Veterans 2 -whose signatories included representatives of The American 

Legion and Disabled American Veterans-to the Fixing Veterans Health Care Task 

Force Report put forth by our organization. Currently, VA governance-a combination 

of bureaucratic and congressional management-functions to undermine rationalization of VHA operations. As the Commission’s final report states ‘‘New governance 

and changes to assure continuity of leadership are critical to meeting the needs of 

VHA and veterans who depend on it. At the core of this foundational recommendation, the Commission calls for establishing a VHA board of directors’’. 3 This is also 

progress. 

In addition, the recommendations include an appeal to Congress to ‘‘enact legislation, based on DoD’s BRAC model, to establish a VHA capital asset realignment 

process to more effectively align VHA facilities and improve veteran’s access to 

care.’’ 4 This much-needed VHA facility realignment would allow under-utilized and 

outdated facilities to be jettisoned, allowing the funds required for up-keep to be redirected toward caring for veterans. As the report notes, ‘‘If VA could sell, repurpose, or otherwise divest itself of unused or underutilized buildings in a timely, costeffective manner, it would free funds for the purposes for which they are appropriated.’’ 5

Unfortunately, however, the recommendations stop short of bold transformation 

that would constitute a true ‘‘system-wide reworking,’’ opting instead for a set of recommendations that, as mentioned, have good aspects, but are unlikely to ultimately 

address the problems that VA faces. 

Over the course of the Commission’s meetings, some in the media began to preemptively question the very legitimacy of the Commission by questioning the notion 

that there had, in fact, been a scandal at VA at all, and noting that the Commission 

had been created out of the legislative response to the scandal. This was, apparently, because there was fear regarding what kinds of proposals might be put forth 

by the Commission. While these attempts at de-legitimization of the Commission 

were largely unsuccessful, the relative timidity of the Commission’s final report reflected the effects of the attacks. 

Though it is true that the recommendations incorporate the principle of choice, 

they effectively leave VA at the center of the decision-making process regarding 

where and how veterans receive care. 

The recommendations stipulate that VA should establish ‘‘Integrated communitybased health care networks’’ in response to the ‘‘misalignment of capacity and demand that threatens to become worse over time’’. 6 This, no doubt, is the result of 

the Commission attempting to ‘‘split the difference’’ between the measures required 

to create a truly high-preforming, veteran-centric system and the scruples of some 

stakeholders whose lack of imagination or ideological pre-commitments constrain 

the range of possibilities that they will entertain. While this recommendation understandably attempts to balance concerns about care coordination with increased 

choice, by insisting that VA remain in control of credentialing providers, VA remains very much at the center of the decision-making process-not the veteran. 

Furthermore, the establishing and credentialing of provider networks-which 

sounds like a relatively simple task-is actually far more complicated than it seems. 

The Commission’s recommendation essentially proposes a system that resembles 

TRICARE Prime-a system that has proven unworkable. In fact, last year the Military Compensation and Retirement Modernization Commission (MCRMC) recommended it be replaced by ‘‘TRICARE Choice,’’ an updated model which would 

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7 Maldon, A., et al. (January, 2015) Report of the Military Compensation and Retirement 

Modernization Commission, 79. 8 Kime, Patricia, ′′Tricare Choice: What’s in it for you?,′′ Military Times, March 16, 2015, 

http://www.militarytimes.com/ story/military/benefits/health-care /2015/03/16/commission-proposes-tricare- choice/24458697/. 9 In 2013, TRICARE made some fairly drastic changes to, and reductions in, the availability 

of TRICARE Prime. For an overview see, for example, http://uhs.fsu.edu/insurance/ newDocs/ 

PSA—Reduction—FS.pdf. 10 Schlichting, N., et al. (June, 2016), Commission on Care Final Report, 161. 11 Jamie Taber, Gideon Lukens, and Merideth Randles, ′′Estimating Costs for Veterans 

Health Part 2,′′ (presentation, Commission on Care, Washington, DC, March 22-23, 2016), 7. 

https://commissiononcare.sites.usa.gov/ files/2016/03/ Estimating-Costs-for-Veterans-Health-Part2-Day-2- 032316-1.pdf 12 See, e.g. The MITRE Corporation. (September, 2015). Independent Assessment of the 

Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs Volume I: Integrated Report, 2 and A-3. 13 Maldon, A., et al. (January, 2015) Report of the Military Compensation and Retirement 

Modernization Commission, 209. 14 Full text can be found here: https://mcmorris.house.gov/ wp-content/uploads/2016/06/ 

McMorris-Rodgers- Discussion-Draft-VA.pdf. 

allow ‘‘beneficiaries to choose from a selection of commercial insurance plans offered 

through a Department of Defense health benefit program.’’ 7 As Military Times reported, ‘‘Under that proposal, beneficiaries would choose a health plan from a menu 

of programs compiled by the federal Office of Personnel Management, similar to the 

health plans offered to federal employees.’’ 8 Considering that VA has had difficulty 

meeting its current responsibilities, it is not easy to see how it can be expected to 

effectively do what the Department of Defense was unable to with TRICARE 

Prime. 9

The Independent Assessment admonishes that VA is in need of a ‘‘system wide 

reworking’’ in order to meet its responsibilities. Maintaining the current system asis, while tacking on the added responsibility of establishing and operating networks 

based loosely on a failed model, would only compound VA’s challenges. 

There are three other areas where the recommendations are deficient. 

First, there is a need, before anything else, to analyze and update the overall eligibility and benefits package to determine whether and to what extent it needs to 

be altered. The Commission recommendations rely on an outdated eligibility and 

benefit package that has not been critically analyzed and updated since the enactment of the Veterans’ Health Care Eligibility Reform Act of 1996. Recommendation 

Number 18 proposes the ‘‘Establish[ment of] an expert body to develop recommendations for VA care eligibility and benefit design.’’ 10 Until the VA eligibility and the 

benefits package is updated and modernized, the other Commission recommendations will be hampered and only partially effective for operations, cost, quality and 

access improvement, as they will remain out of sync with the best practices of modern health care systems. 

Second, although there were some high-level cost estimates of alternative policy 

proposals, the recommendations do not include the effect of cost mitigation strategies and options that reduce risk for VHA policy and planning. For example, documents prepared by Milliman Inc. and presented to the Commission indicate that, 

given certain assumptions, Care in the Community could actually be cheaper than 

care received in VA. 11 Clearly, more careful consideration of the cost/savings possibilities is needed. 

Third, both the Independent Assessment and the Commission on Care have identified a need to conduct a survey representative of the views of millions of veterans 

receiving health care from VHA. 12 An effective model for this kind of a comprehensive survey of veterans health care needs and preferences would be those done by 

the MCMRC and cited in their 2015 report. 13 Until this is done, it will be difficult 

to ascertain exactly what kinds of policies might meet the needs of veterans as they 

understand them. 

A Way Forward 

While it is true that more data and analysis are needed, there are policy proposals 

available that we believe represent a better way forward. 

In June, Rep. Cathy McMorris-Rodgers released a discussion draft of a bill entitled The Caring for Our Heroes in the 21st Century Act. 14 We believe this discussion draft contains an excellent proposal that reflects the kind of comprehensive 

health care reform that VA needs. It utilizes a systems approach that contains all 

of the components needed to fix the VA health care system in a fiscally responsible 

way. Notably, all of the Commission on Care recommendations are, to a greater or 

lesser extent, compatible with this legislation. And, by including an implementation 

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commission in the proposal, the legislation would provide a mechanism for further 

improvement based on the additional cost, survey and systems data and analysis 

referenced above. 

The Caring for Our Heroes in the 21st Century Act offers a truly new way of looking at veterans’ health care. It goes beyond the VA’s current centralized model that 

traps veterans into a deficient system of unresponsive and inconsistent care, instead 

creating a system that is flexible and adaptable to the needs of the individual veteran and their family. It is, in our opinion, the best legislative proposal aimed at 

fixing VA health care that has yet been put forth. This is because it prioritizes the 

needs of veterans over the VA bureaucracy and seeks to transform a dated, sclerotic 

government agency into a high-functioning modern health care organization. It represents a change that is long overdue and one that our veterans deserve. 

Reform is never easy, but veterans deserve nothing less. 

For questions or additional information regarding this testimony, please contact 

Mr. Shaun Rieley at Concerned Veterans for America, srieley@cv4a.org or 517–447– 

3542. 

f 

Disabled American Veterans (DAV) 

Chairman Miller, Acting Ranking Member Takano, and Members of the Committee: 

Thank you for inviting DAV (Disabled American Veterans) to submit testimony 

for the record on the report and recommendations of the Commission on Care to improve the veterans health care delivery system over the next twenty years. As you 

know, DAV is a non-profit veterans service organization comprised of 1.3 million 

wartime service-disabled veterans that is dedicated to a single purpose: empowering 

veterans to lead high-quality lives with respect and dignity. Virtually all of our 

members rely on the Department of Veterans Affairs (VA) health care system for 

some or all of their health care, particularly for specialized treatment related to injuries and illnesses they incurred in service to the Nation. 

Mr. Chairman, since the waiting list scandal and access crisis were uncovered by 

Congress and the national media in the spring of 2014, a vigorous national debate 

has commenced about how best VA should provide timely, high-quality, comprehensive and veteran-focused health care to our Nation’s veterans. After dozens of Congressional hearings, multiple internal reviews, numerous media investigations, enactment of temporary programs and laws, expert stakeholder input, an independent 

assessment, and recently the final report from the Commission on Care, all parties 

need to move from debating VA’s future to creating the future VA health care system America’s veterans deserve. 

With the current veterans ‘‘choice’’ program set to expire next year, Congress and 

VA must now choose whether to extend, expand or otherwise modify the current 

choice program, or to move beyond it to develop a new system of care based upon 

an integrated network of VA and community providers capable of meeting veterans 

health care needs in the future. 

As this Committee is well aware, Congress passed the Veterans Access, Choice, 

and Accountability Act (Public Law 113–146) in August 2014 in direct response to 

the access crisis and waiting list scandal at the Phoenix, AZ VA Medical Center and 

other locations around the VA system. The primary purpose of the Choice Act was 

to address veterans’ access barriers by creating a new temporary choice program 

that allowed certain veterans to choose community care if they would otherwise be 

forced to wait more than 30 days for requested care, or travel more than 40 miles 

to a VA facility to receive requested care. The act also required an outside, independent assessment of the VA health care system, and it established the Commission on Care to study and develop recommendations for VA to improve the delivery 

of health care to veterans on a longer term basis. 

Since its inception two years ago, the choice program has been beset with problems, some caused by the design of the law and others due to the urgent implementation schedule mandated by Congress. As the number of veterans using the choice 

program has risen, so have the number of problems they have encountered related 

to care coordination, appointment scheduling and provider payments. Although DAV 

and other VSOs supported passage of the choice program as an emergency response 

to the access crisis, it was neither intended to be nor supported as a permanent centerpiece of VA’s health care delivery model. To address technical and implementation challenges with the choice program, Congress enacted two subsequent acts 

(Public Laws 113–175 and 114–41) but has not made any further legislative changes 

while awaiting the Commission on Care’s final report. 

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1 Independent Assessment of the Health Care Delivery Systems and Management Processes 

of the Department of Veterans Affairs, The MITRE Corporation, September 1, 2015, p. B-3. 

The Independent Assessment mandated by Public Law 113–146, conducted primarily by the MITRE and Rand Corporations., produced voluminous data, information and recommendations about improving health care to veterans. The first and 

most important finding of the assessment was that the root cause of VA’s access 

problems was a ‘‘.misalignment of demand with available resources both overall and 

locally.’’ leading to the conclusion that ‘‘.increases in both resources and the productivity of resources will be necessary to meet increases in demand for health care.’’ 

in the future. 1 Further, despite these deficits, the assessment confirmed what DAV, 

other VSOs and dozens of independent studies have reported over the past two decades: VA quality of care, on average, is as good as or better than, care in the private 

sector. 

Last year, as mandated by Public Law 114–41, VA developed and submitted a 

plan to Congress to consolidate non-VA community care programs, including the 

choice program. VA’s plan would create a high-performing network comprised of 

both VA and linked community providers. Although VA has already begun taking 

steps to move forward with a consolidation plan, VA is awaiting Congress to enact 

enabling legislation to facilitate the new consolidated program that would bring 

VA’s plan to fruition. 

Furthermore, the Independent Budget (IB) veterans service organizations (DAV, 

the Veterans of Foreign Wars, and Paralyzed Veterans of America) developed a joint 

Framework for Veterans Health Care Reform that proposed a similar concept of 

local veteran-focused integrated health care networks. Both the IB framework and 

the VA plan call for VA to remain the coordinator and primary provider of care, 

with community providers integrated when needed to guarantee veterans access to 

care. This integrated network approach has been publicly supported by dozens of 

other veterans and related organizations, reflecting the views and sentiments of millions of veterans they, and DAV, represent. 

The Commission on Care spent almost a year reviewing the Independent Assessment, hearing from stakeholders and other outside experts, and developing its recommendations to improve health care for veterans. While the Commission considered a wide range of ideas and options, including proposals to privatize VA, and one 

plan (the ‘‘strawman proposal’’) that called for dismantling the VA health care system over the next two decades. Ultimately, the Commission rejected the radical 

ideas, instead reaching a consensus on recommendations that hold many similarities 

to the plans put forward by VA and mainstream veterans organizations. The first 

and foremost Commission recommendation calls for establishment of ‘‘high-performing, integrated community-based health care networks’’ with VA acting as the 

coordinator and primary provider of care. Although some important differences are 

apparent among the integrated network plan proposed by the Commission, the 

IBVSOs and VA, respectively, each of the three proponents calls for strengthening 

the existing VA health care system by incorporating community providers into integrated networks. Moreover, each proposal maintains VA as the coordinator and primary provider of care, and each views the use of community providers and choice 

as a limited means to expand access in circumstances in which VA is unable to meet 

local demand for care. 

After two years of spirited and passionate debate about the future of veterans 

health care, we envision a clear path forward that builds on the strengths of the 

existing VA system, while expanding access by seamlessly integrating the best of 

community care to ensure no veteran must travel too far or wait too long for care. 

Congress and VA must now begin the steps to finalize plans and move forward with 

the evolution of veterans health care. Equally important, both Congress and the 

next Administration must make a commitment to ensure that the resources necessary to complete this transformation. 

While we agree with most of the Commission’s recommendations to strengthen 

the leadership, management and operation of the VA health care system, some remain of concern to us, and are explained below. 

Recommendation #1: 

Across the United States, with local input and knowledge, VHA should establish 

high-performing, integrated community-based health care networks, to be known as 

the VHA Care System, from which veterans will access high-quality health care services. 

Based on National Resolution No. 238, adopted by delegates to our most recent 

National Convention, that calls for specific reforms in VA health care, DAV supports 

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2 Commission on Care Final Report, June 30, 2016, p. 28. 3 Commission on Care Final Report, June 30, 2016, p. 28. 4 Ibid. 5 Ibid, p. 31. 

the overall structure and intent of this recommendation to create integrated networks. Nevertheless, our resolution does not support the recommended option to 

allow veterans to choose any primary or specialty care provider in a network made 

up of VA and private care providers because it would result in less coordinated care, 

worse health outcomes, lower overall quality and significantly higher costs that 

could ultimately endanger the overall VA system of care that millions of veterans 

rely on, particularly veterans who were injured or made ill during military service. 

As the Commission report states, ‘‘Veterans who receive health care exclusively 

through VHA generally receive well-coordinated care. [whereas] ...fragmentation 

often results in lower quality, threatens patient safety, and shifts cost among payers.’’ 2 While veterans’ individual circumstances and personal preferences must be 

taken into consideration, decisions about access must first and foremost be based 

on clinical consideration, rather than on arbitrary distances or waiting times. However, in order to ensure consistently reliable access as well as high quality for enrolled veterans, VA must retain the ability to coordinate and manage the networks. 

As the Commission’s report states, ‘‘Well-managed, narrow networks can maximize 

clinical quality.’’ and, ‘‘Achieving high quality and cost effectiveness may constrain 

consumer choice.’’ 3

Furthermore, the Commission’s recommended option to allow every individual veteran to determine which VA or non-VA providers in the network they would use 

could affect access for other veterans and could lead to increased costs. The Commission itself notes that in establishing networks, VA ‘‘.must make critical tradeoffs regarding their size and scope. For example, establishing broad networks would expand veterans’ choice, yet would also consume far more financial resources.’’ 4 In 

fact, the Commission’s economists estimate that the recommended option could increase VA spending by at least $5 billion in the first full year, and that it could 

be as high as $35 billion without strong management control of the network. The 

Commission also considered a more expanded choice option to allow veterans the 

ability to choose any VA or non-VA provider - without requiring them to be part 

of any defined network - and the economists estimated such a plan could cost up 

to $2 trillion more than current VA expenditures over the first ten years. 

While we agree that the VA health care system must evolve by integrating community providers into its networks, VA must retain the ability to coordinate care 

and manage workload within the networks. In general, the networks must have the 

ability to expand to include community providers if veterans face access challenges 

or VA is unable to provide sufficiently high quality care. The size, scope and design 

of local networks, as well as clinical workflow, must be directed by VA based on a 

demand-capacity analysis in each market in order to assure quality and adequate 

access to care. 

DAV is particularly concerned about the Commission’s projection that more than 

40% of the medical care currently provided inside VA facilities would shift to nonVA network providers if this recommended option is implemented. 5 Note that the 

‘‘40% estimate is derived from the Commission’s estimate that 60% of the 68% of 

care that is eligible for community care under the recommended option would shift.) 

Such a large transfer of patient care workload from VA facilities would produce a 

dramatic impact on VA’s ability to maintain a critical mass of patients necessary 

to safely and efficiently operate its programs and facilities. An outflow of workload 

of this magnitude would undoubtedly lead to a number of facilities cutting services 

or closing, thereby depriving veterans of the option to receive all or even any of their 

care from VA providers. The elimination of VA as an option would be particularly 

devastating for severely injured, ill and disabled veterans who rely on VA for specialized care. 

Furthermore, we are alarmed that the Commission report specifically states that 

no consideration was given to whether its recommended option would weaken or diminish VA’s medical and prosthetic research, academic, and national emergency 

preparedness missions, which continue to be vital aspects of the VA health care system overall. In particular, the VA research program serves as a harbor to ensure 

that veterans receive the most current, safest and most effective treatments available for service-related conditions, and to advance the standard of health care both 

within VA and beyond. The report also explicitly states that the Commission did not 

consider whether a sufficient number of private providers would be willing to take 

on additional patient loads from VA at Medicare reimbursement rates, how such a 

shift from VA to private providers would affect underserved communities, or how 

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6 Commission on Care Final Report, June 30, 2016, pp. 32-33. 7 Ibid, p. 4. 8 Independent Assessment of the Health Care Delivery Systems and Management Processes 

of the Department of Veterans Affairs, The MITRE Corporation, September 1, 2015, p. K-1. 

reduced patient workload within VA facilities would affect the quality of care of veterans remaining in the VA system. 6

In addition to these concerns, it is critical to emphasize that the creation of seamless integrated community networks cannot be accomplished quickly or without a 

significant infusion of new resources to develop and deploy a modern IT and management infrastructure necessary to successfully operate the networks, particularly 

to achieve seamless scheduling, care coordination and provider payment functions. 

We agree with the Commission that networks should be, ‘‘. built out in a wellplanned, phased approach.’’ 7 Furthermore, it is imperative that before and during 

the development of these networks, VA should regularly consult and collaborate 

with local and national veterans organizations and leaders, as well as other key 

stakeholders and community partners to gauge progress. 

Recommendation #6: 

Develop and implement a robust strategy for meeting and managing VHA’s facility 

and capital-asset needs. 

DAV agrees with the recommendation to streamline and strengthen VA’s facility 

and capital asset program management and operations. We also agree with the recommendation to give VA greater budgetary flexibility to meet its facility and capital 

asset needs, particularly overcoming Congressional budget scoring rules that have 

complicated VA’s ability to open new leased clinic space. We also agree that VA 

needs to have the ability to realign its health care resources to address changes in 

the veteran population, demographics, location and health care needs, as well as 

evolving health science and technology. However, we do not agree that it is necessary or advisable to create an inflexible process, similar to the BRAC process, 

which has been employed to close military bases. The development of integrated 

community networks must be based on dynamic demand and capacity analysis, 

which would include modeling of the need to expand, contract, or relocate VA facilities. Local stakeholder input would be essential to ensure that local health care coverage would not be negatively affected by any facility realignment. DAV and our IB 

partners also believe that expanded usage of public-private partnerships should be 

explored as another way to address VA’s infrastructure needs. 

However, even with these reforms, significant increases in infrastructure funding 

will be necessary to address VA’s access challenges. The Independent Assessment 

discussed earlier in this statement found that the, ‘‘..capital requirement for VHA 

to maintain facilities and meet projected growth needs over the next decade is two 

to three times higher than anticipated funding levels, and the gap between capital 

need and resources could continue to widen.’’ 8 Without change, the estimated gap will be between $26 and $36 billion over the next decade. For FY 2017, DAV and 

our IB partners recommended $2.5 billion for all VA infrastructure programs; however, the Administration requested only $1 billion. Both chambers of Congress settled for this inadequate funding level in this pending appropriation. While certainly 

a need exists to maximize savings from closing unused or underutilized facilities, 

the Commission’s report points out that these savings are estimated at only $26 million per year, an amount that would not begin to make up for the shortfall in infrastructure spending required to maintain the remaining VA system. Also, under 

budget formulation policies, any such savings from closed or downsized facilities 

most likely would be lost to VA. Unless Congress and future Administrations begin 

to provide realistic funding levels to repair, maintain and replace existing VA health 

care infrastructure, these reforms will be significantly challenged. 

Recommendation #9: 

Establish a board of directors to provide overall VHA Care System governance, set 

long-term strategy, and direct and oversee the transformation process. 

DAV does not support the recommendation to take control of the VA health care 

system away from the VA Secretary and give it to an unelected, independent Board 

of Directors that would be less accountable to the President, Congress, veterans and 

the American people. Separating veterans health care services from other veterans 

benefits and services would result in a loss of comprehensive and coordinated support for veterans, particularly those injured or ill from their service. Creating another layer of bureaucracy between veterans and the VA health care system would 

create more problems than solutions. We appreciate the Commission’s interest in 

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recommending greater stability and continuity of leadership; however; better means 

are available to accomplish these goals without undercutting VA’s uniquely integrated system of services and benefits. 

Rather than create an inherently political and bureaucratic layer between veterans and their health care system, these same purposes could be accomplished 

through the establishment of strategic planning mechanisms currently being used 

by the Departments of Defense and Homeland Security. Specifically, we propose 

that VA be required to undergo a Quadrennial Veterans Review (QVR), similar to 

the Quadrennial Defense Review (QDR) and Quadrennial Homeland Security Review (QHSR). The QVR, similar to its counterparts, would establish a national strategy to guide the creation of federal policies and programs for veterans, and would 

be timed to overlap with Presidential administrations to provide continuity and insulation from political influence. 

In addition, similar to the Departments of Defense and Homeland Security, there 

should be established a Future Year Veterans Program (FYVP) that would establish 

five-year resource needs and projections that VA would need in order to implement 

the policies and programs set out in the QVR. VA should also fully convert its budgeting and spending systems to a Planning, Programming, Budgeting and Execution 

(PPBE) system also used by the Departments of Defense and Homeland Security in 

order to assure accountability in how VA allocates it resources to meet immediate, 

short-term and long-term strategic goals. Establishing new planning and budgeting 

functions could provide VA stability and continuity in a more practical, effective and 

feasible manner than trying to establish a semi-independent governance board. 

In addition, consideration should be given to overlapping the terms of the Under 

Secretary for Health and other senior VA leaders with Presidential elections, to provide additional stability and continuity, and to insulate these officials from political 

influence. 

ADDITIONAL COMMENTS ON COMMISSION ON CARE 

RECOMMENDATIONS 

Recommendation #2: 

Enhance clinical operations through more effective use of providers and other 

health professionals, and improved data collection and management. 

DAV supports this recommendation but notes that additional funding would be 

essential in order for VA to hire the new support staff discussed by the Commission. 

Recommendation #3: 

Develop a process for appealing clinical decisions that provides veterans protections 

at least comparable to those afforded patients under other federally-funded programs. 

DAV supports the recommendation to create a fair, transparent and timely process to appeal clinical decisions, and we have testified before Congress on this concept. We would emphasize the importance of including veteran patients and veterans advocates during the development of this procedure. 

Recommendation #4: 

Adopt a continuous improvement methodology to support VHA transformation, and 

consolidate best practices and continuous improvement efforts under the Veterans 

Engineering Resource Center. 

DAV supports the recommendation for VHA to adopt a model of continuous improvement and to share and standardize best practices in accordance with our Resolution No. 244, which calls for VA to maintain a comprehensive health care system 

for enrolled veterans, endemic to which is continuous improvement and the advent 

of best practices. We also agree that the three Veterans Engineering Resource Centers should play a more prominent role in the maintenance and improvement of 

such a system. Currently, VA employs numerous clinical researchers and operates 

numerous centers of excellence, health services research and development centers, 

and other centers devoted to continuous improvement, quality enhancement, patient 

safety and other factors affecting the state of care for veterans’ health. Each has 

its own history, mission and proven accomplishments that have and continue to 

serve veterans. In addition, because systems engineering, as with other systemic 

change approaches, has limitations particularly in network-based complex adaptive 

systems, such limitations should also be considered when implementing this recommendation. 

Recommendation #5: 

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Eliminate health care disparities among veterans treated in the VHA Care System 

by committing adequate personnel and monetary resources to address the causes of 

the problem and ensuring the VHA Health Equity Action Plan is fully implemented. 

DAV supports the recommendation to more effectively address health care equity 

issues. We refer the Committee to DAV’s 2014 report, Women Veterans: The Long 

Journey Home, which details the barriers and program inequities that women veterans face. Our report offered specific recommendations to remedy these challenges. 

Recommendation #7: 

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. 

DAV supports the recommendation to modernize and give VHA functional control 

over its IT systems in accordance with our recommendations in the IB. To assure 

full coordination of the proposed integrated networks will require full implementation of new IT systems and complete interoperability across VA and network providers. We would again note that significant time and dedicated resources will be 

required to achieve this goal. 

Recommendation #8: 

Transform the management of the supply chain in VHA. 

DAV generally agrees with this recommendation. We would note in consonance 

with our recommendations in the IB that some supply and acquisition programs and 

services are critically important to veterans, such as those affecting the procurement 

of prosthetics and sensory aids. Careful consideration must be given to balancing 

national standardization concepts with local flexibility to meet the unique needs and 

preferences of veterans who need these specialized services to address their disabilities. 

Recommendation #10: 

Require leaders at all levels of the organization to champion a focused, clear, 

benchmarked strategy to transform VHA culture and sustain staff engagement. 

DAV supports this recommendation, on the basis of National Resolution No. 238, 

urging VA to adopt a broad reform agenda for the future in health care, and in that 

respect would note our specific support for VA’s MyVA initiative that is already beginning to address these concerns. 

Recommendation #11: 

Rebuild a system for leadership succession based on a benchmarked health care 

competency model that is consistently applied to recruitment, development, and advancement within the leadership pipeline. 

DAV supports the intent of this recommendation on the basis of our recommendations in the IB dealing with the need for reforms in VA’s human resources management programs, and again notes that VA’s MyVA initiative and other new leadership programs are also beginning to address these issues. 

Recommendation #12: 

Transform organizational structures and management processes to ensure adherence to national VHA standards, while also promoting decision making at the lowest 

level of the organization, eliminating waste and redundancy, promoting innovation, 

and fostering the spread of best practices. 

DAV supports eliminating waste and redundancy and standardization where possible; however, because this recommendation would impact such a large part of VHA 

organizational structure, we believe it requires further study. 

Recommendation #13: 

Streamline and focus organizational performance measurement in VHA 

using core metrics that are identical to those used in the private sector, 

and establish a personnel performance management system for health care 

leaders in VHA that is distinct from performance measurement, is based on 

the leadership competency model, assesses leadership ability, and measures the achievement of important organizational strategies. 

DAV generally supports the intent of this recommendation, although we would 

emphasize that not all performance metrics could or should be identical to those 

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used in the private sector due to the unique nature of the VA health care system 

and the significant differences between patient case mix in VA facilities versus 

those in private care. Health care outcomes and patient satisfaction could be measured consistently between VA and private providers; however, metrics related to 

cost, value or efficiency are less likely to provide meaningful comparisons because 

of differences in how VA and private systems are funded, the role of private health 

insurance, the primary-preventative model of VA health care and the interconnection of VA’s complementary services and benefits-none of which generally exist in 

private care. VA should continue to develop and optimize metrics that provide 

meaningful feedback about its unique health care model, as well as help develop 

new benchmarks that both VA and the private sector can use to strengthen performance measurement. 

Recommendation #14: 

Foster cultural and military competence among all VHA Care System leadership, 

providers, and staff to embrace diversity, promote cultural sensitivity, and improve 

veteran health outcomes. 

DAV generally agrees with this recommendation. In terms of providing military 

culture competency, VA providers are generally well-trained, though there remains 

room for improvement. As networks are developed, transferring some level of military/veteran cultural competency to non-VA providers will be critical, although they 

may never possess the same level of immersion or understanding about the impact 

of military service as VA providers who work full-time inside a veteran-focused environment. We would also agree that non-VA providers should be expected to deliver 

the same level of veteran-focused care as VA providers, such as by requiring all providers to ask patients about their military history and possible toxic exposures, as 

is required for VA providers. 

Recommendation #15: 

Create a simple-to-administer alternative personnel system, in law and regulation, 

which governs all VHA employees, applies best practices from the private sector to 

human capital management, and supports pay and benefits that are competitive with 

the private sector. 

DAV recognizes the need to strengthen VA’s ability to recruit, hire, retain and 

hold accountable all VA employees. Nevertheless, we do not take a position on 

whether the creation of an alternative personnel system would be the best way to 

accomplish these goals. 

Recommendation #16: 

Require VA and VHA executives to lead the transformation of HR, commit funds, 

and assign expert resources to achieve an effective human capital management system. 

DAV supports this recommendation on the basis of our human resources management concerns expressed in the IB. 

Recommendation #17: 

Provide a streamlined path to eligibility for health care for those with an other 

than honorable discharge who have substantial honorable service. 

DAV supports this recommendation on the basis of our National Resolution No. 

226, adopted by delegates to our most recent National Convention, which calls for 

a more liberal review of other than honorable discharges for purposes of receiving 

VA benefits and health care services in cases of former servicemembers whose posttraumatic stress disorder, traumatic brain injury and military sexual trauma or 

other trauma contributed to their administrative discharges characterized as other 

than honorable. 

Recommendation #18: 

Establish an expert body to develop recommendations for VA care eligibility and 

benefit design. 

DAV does not believe a new commission or task force is needed to make adjustments to veterans health care eligibility or benefits design. The Secretary already 

possesses tools to control access through enrollment decisions, and Congress retains 

complete discretion to modify eligibility requirements, to adjust the health care benefits package or other benefits through the legislative process. 

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1 http://www.prweb.com/releases /2016/07/prweb13535231.htm 

Mr. Chairman, this concludes DAV’s testimony. We thank the Committee for inviting DAV to submit this testimony for the record, and we are prepared to respond 

to any questions by Committee Members on the Commission’s report and our positions on VA health care reform. 

f 

THE AMERICAN LEGION 

Chairman Miller, Acting Ranking Member Takano and distinguished members of 

the Committee, on behalf of National Commander Charles E. Schmidt and The 

American Legion; the country’s largest patriotic wartime service organization for 

veterans, comprising over 2 million members and serving every man and woman 

who has worn the uniform for this country; we thank you for the opportunity to 

comment regarding The American Legion’s position on the Commission on Care and 

the future of the VA health care system. 

The American Legion has worked extensively on matters concerning veterans for 

nearly 100 years. Our work includes all business lines managed and operated by 

The Department of Veterans Affairs (VA) through sustained physical involvement, 

review of national policy, and donations of resources, funding, personnel, and experience. It is with the voice and support of the largest voting block of veterans in the country that The American Legion presents the following analysis and recommendations 

regarding the report offered by The Commission on Care dated June 30, 2016. 

The American Legion acknowledges the Commission relied heavily on the Independent Assessment as per congressional instructions, as well as some limited testimony from VA, Veteran Service Organizations (VSO), and media reports; but the 

primary foundation for discussion and findings were based on internal discussions 

among commissioners based on individual filters, experiences, and loyalties; and 

thus this report is reflective of those individual opinions. 

The American Legion will not address the entire report, rather we will highlight 

the parts we believe have merit for further study or implementation, and those 

areas where we believe implementation would be detrimental to all veterans seeking 

health care from the VA, whether directly, or through a managed community relationship. 

We are in general agreement with most of the Commission’s recommendations 

and are pleased to see they are in line with transformation currently underway at 

VA through the MyVA initiative. 

As you know, three of 15 Commission members did not sign the final report, with 

two commissioners opposing the final report because they felt it didn’t go far 

enough. Commissioner Michael Blecker also did not sign, saying the main recommendation, for the Veterans Health Administration (VHA) Care System, went too 

far. 

The American Legion’s positioning on the report places us closer to Commissioner 

Blecker’s. As he explained in his June 29 dissent: 

I cannot agree to the Commission’s first and most significant recommendation, establishment of a proposed ‘‘VHA Care System.’’ Given the design of this proposed new 

delivery model, the adoption of this proposal would threaten the survival of our nation’s veteran-centered health care system as a choice for the millions of veterans who 

rely on it. Although this is only one of many recommendations in the Report, this 

single recommendation risks undermining rather than strengthening our veteran-centered health care system, and I cannot agree to it. 1

We also believe that recommendations of more privatization that some are trying 

to mask as ‘‘Choice’’ fail to take into consideration that veterans already have a 

myriad of choices, more so than most Americans. Choosing to see a contracted primary care physician as opposed to a VA primary care physician is a choice most 

veterans using VA health care already have through their private insurance, 

Tricare, Medicare, Medicaid or several other options. These ‘‘choices’’ also come with 

additional expenses to the veteran. Converting VA health care to an insurance 

payer would increase out-of-pocket expenses for veterans who rely solely on VA for 

all of their health care needs, and who may not have alternate insurance options. 

That said, here are our initial comments on a few of the most important recommendations: 

Recommendation #1: Across the United States, with local input and knowledge, 

VHA should establish high-performing, integrated community health care networks, 

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2 Resolution No. 46: (Oct 2012): Department of Veterans Affairs (VA) Non-VA Care Programs 

to be known as the VHA Care System, from which veterans will access high-quality 

health care services. 

This recommendation includes several sub-recommendations. Here we will address two of the most salient ones separately because they each have separate and 

distinct implications and will require individualized policy and/or legislative modifications in order to accomplish. The overarching theme of this recommendation involves a robust and integrated community care network. 

A.The American Legion supports realigning VA’s community care program and 

has provided testimony that discusses its restructuring. In relevant part, we said: 

The American Legion believes in a strong, robust veterans’ health care system 

that is designed to treat the unique needs of those men and women who have served 

their country. However, even in the best of circumstances there are situations where 

the system cannot keep up with the health care needs of the growing veteran population requiring VA services, and the veteran must seek care in the community. 

Rather than treating this situation as an afterthought, an add-on to the existing 

system, The American Legion has called for the Department of Veterans Affairs 

(VA) to ‘‘develop a well-defined and consistent non-VA care coordination program, 

policy and procedure that includes a patient centered care strategy which takes veterans’ unique medical injuries and illnesses as well as their travel and distance into 

account. 2

Over the years, VA has implemented a number of non-VA care programs to manage veterans’ health care when such care is not available at a VA facility, could not 

be provided in a timely manner, or is more cost effective through contracting vehicles. Programs such as Fee-Basis, Project Access Received Closer to Home (ARCH), 

Patient-Centered Community Care (PC3), and the Veterans Choice Program (VCP) 

were enacted by Congress to ensure eligible veterans could be referred outside the 

VA for needed, and timely, health care services. 

Congress created the VCP after learning in 2014 that VA facilities were falsifying 

appointment logs to disguise delays in patient care. However, it quickly became apparent that layering yet another program on top of the numerous existing non-VA 

care programs, each with their own unique set of requirements, resulted in a complex and confusing landscape for veterans and community providers, as well as the 

VA employees that serve and support them. 

Therefore, Congress passed the Surface Transportation and Veterans Health Care 

Choice Improvement Act of 2015 (VA Budget and Choice Improvement Act) in July 

2015 after VA sought the opportunity to consolidate its multiple care in the community authorities and programs. This legislation required VA to develop a plan to consolidate existing community care programs. 

On October 30, 2015, VA delivered to Congress the department’s Plan to Consolidate Community Care Programs, its vision for the future outlining improvements 

for how VA will deliver health care to veterans. The plan seeks to consolidate and 

streamline existing community care programs into an integrated care delivery system and enhance the way VA partners with other federal health care providers, academic affiliates and community providers. It promises to simplify community care 

and gives more veterans access to the best care anywhere through a high performing network that keeps veterans at the center of care. 

Generally, The American Legion supports the plan to consolidate VA’s multiple 

and disparate purchased care programs into one New Veterans Choice Program 

(New VCP). We believe it has the potential to improve and expand veterans’ access 

to health care. 

Network Structure 

The American Legion supports allowing VA to set up tiered networks. As we understand it, this structure is meant to empower veterans to make informed choices, 

provide access to the highest possible quality care by identifying the best performing 

providers in the community, and enabling better coordination of care for better outcomes. However, it does not dictate how veterans will use the network. The American Legion wants to make clear, though, that we do not support a wholesale option 

to circumvent the VA infrastructure or health care system entirely. 

Prompt Pay 

We support a provision mandating that all claims be made electronically by January 1, 2019 and an eligible provider should submit claims to Secretary within 180 

days of furnishing care or services. 

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3 http://www.legion.org/legislative/ testimony/231623/pending-veterans-affairs-legislation 4 https://www.congress.gov/bill/ 114th-congress/house-bill/216 

Episode of Care 

Provisions ensuring that an eligible veteran receives such care and services 

through the completion of the episode of care, including all specialty and ancillary 

services deemed necessary as part of the treatment recommended in the course of 

such care and services. 

Emergency/Urgent Treatment 

The American Legion supports requiring VA to reimburse veterans for the reasonable value of emergency treatment or urgent care furnished in a non-Department 

facility in a final bill. 

Conclusion 

Ensuring veterans have access to appropriate, timely, high-quality care is critical. 

VA needs to overhaul its outside care reimbursement programs, consolidating them 

into a more efficient bureaucracy able to dynamically interact with the network of 

federal, public, and private providers that are to supplement VA direct provided 

care. 3

B.Choice of primary care provider 

The American Legion opposes allowing a complete option of primary care providers within the proposed VHA Care System based on the Commission’s faulty 

analysis. The Commission supports this recommendation based on a Congressional 

Budget Office (CBO) estimate of cost that was calculated using Medicare rates. The 

Commission, however, gave no consideration to Medicare rules for billing structure 

and how those rules would apply to the current quality of care provided to veterans 

through VHA primary care physicians. VHA physicians are not restricted as to the 

amount of time they are able dedicate to each patient, or the number of presentations per patient. Medicare, on the other hand only provides payment based on 

a 10 or 15 minute consultation, which then denies veterans the full complement and 

quality of care they are entitled to through their earned benefits. If scored by CBO 

properly, the cost of this recommendation would be at least triple if not more, and 

is thus financially unsustainable. The American Legion finds the recommendation 

and subsequent analysis by the Commission to be in error and believe that it should 

not be considered by the Administration. 

Recommendation #9: Establish a board of directors to provide overall VHA Care 

System governance, set long-term strategy, and direct and oversee the transformation 

process. 

The American Legion does not support the creation of a governing board. We do 

find value in the Commission’s discussion and recommendations that point out inconsistent leadership due to rotating political appointments and a leadership vision 

with a lack of continuity. The American Legion supports appointing a Veterans 

Health Administration (VHA) leader for a minimum of a 5 year term, with an option 

for an additional 5 year reappointment. We could also support the same consistency 

for the Deputy Secretary position. 

Congress is also part of the problem here. When Representative Beto O’Rourke 

addressed the Commission on Care on March 22nd of this year, he noted that part 

of the problem with VA has been a severe lack of continuity in oversight due to an 

unwillingness of Members to serve on the VA Committees: it’s not glamorous, there 

are real problems to be addressed, and there are no ‘‘mission accomplished’’ banners. 

Members tend to leave the Committee as soon as they are able - to the point that, 

on day one as a new congressman assigned to the Committee, he found himself 

third in seniority on the Democratic side. 

The American Legion thinks consideration should also be given to proposals that 

the Secretary of Veterans Affairs develop and submit to Congress a Future-Years 

Veterans Program and a quadrennial veteran’s review. 4

Recommendation #15: Create a simple-to-administer alternative personnel system, 

in law and regulation, which governs all VHA employees, applies best practices from 

the private sector to human capital management, and supports pay and benefits that 

are competitive with the private sector. 

This proposal to shift all 300,000 VHA employees away from Title Five and onto 

Title 38 to provide the department with more flexibility in pay, benefits and recruiting is worth serious consideration. While the change would be designed to ease hirLeonard.horne on VACREP0180 with DISTILLER

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ing and firing at the agency, the report says the new system should maintain due 

process appeal rights and merit system principles and we concur. 

Recommendation #18: Establish an expert body to develop recommendations for VA 

care eligibility and benefit design. 

Included in this recommendation is consideration of the feasibility of allowing veterans’ family members and currently ineligible veterans to purchase VHA care 

through their health plans in areas where VHA hospitals and other facilities might 

otherwise need to close. In many parts of the country, VHA currently maintains hospitals and other health care facilities that are underutilized or in danger of becoming so. A related challenge is maintaining safe volume of care when patient loads 

decline. 

As the report notes, ‘‘closing a low-volume hospital may be the answer in some 

instances. But closing VHA facilities reduces the choices available to veterans. Increasing the volume of patients treated by VHA in areas where it currently has excess capacity may ameliorate these challenges.’’ 

Appendix C of the report discusses the outline of developing pilot programs to test 

the feasibility of avoiding VA hospital closures by allowing veterans’ spouses and 

currently ineligible veterans to purchase VA care in selected areas. The American 

Legion supports further investigation of this proposal. 

The American Legion appreciates the hard work from all of the commission members and we look forward to working with this administration and the incoming 

Congress and administration to ensure veterans are provided with the high level of 

expert health care that they have earned. 

Secretary McDonald’s words on the report serve as a worthy stopping point for 

now: ‘‘However, until all veterans say they are satisfied, I won’t be satisfied. Nobody 

at VA will be satisfied, but our progress so far proves that VA’s current leadership, 

direction and momentum can produce the necessary transformation.’’ 

Conclusion 

As always, The American Legion thanks this Committee for the opportunity to explain the position of the over 2 million veteran members of this organization. For 

additional information regarding this testimony, please contact Mr. Warren J. Goldstein at The American Legion’s Legislative Division at (202) 861–2700 or 

wgoldstein@legion.org. 

f 

THE ENLISTED ASSOCIATION OF THE NATIONAL GUARD OF THE 

UNITED STATES 

The Enlisted Association of the National Guard of the United States (EANGUS) 

was created in 1970 by a group of senior Non-Commissioned Officers. It was formally organized / incorporated in 1972 in Jackson, Mississippi, with the goal of increasing the voice of enlisted persons in the National Guard on Capitol Hill for enlisted National Guard issues. Beginning with twenty-three states, EANGUS now 

represents all 54 states and territories, with a constituency base of over 414,000, 

hundreds of thousands of family members, as well as thousands of retired members. 

Headquartered and with offices in Alexandria, Virginia, EANGUS is a long-time 

member of The Military Coalition (TMC) and is actively engaged with the Guard/ 

Reserve Committee, the Health Care Committee, and the Veterans Committee. 

EANGUS often partners with other National Guard related associations such as the 

National Guard Association of the United States (NGAUS), the Adjutants General 

Association of the United States (AGAUS) and the Reserve Officers Association 

(ROA) to pursue common legislative goals and outcomes. 

EANGUS is a non-profit organization that is dedicated to promoting the status, 

welfare and professionalism of enlisted members of the National Guard by supporting legislation that provides adequate staffing, pay, benefits, entitlements, 

equipment and installations for the National Guard. 

The legislative goals of EANGUS are published annually. The goals and objectives 

are established through the resolution process, with resolutions passed by association delegates at the annual conference. From these resolutions come the issues that 

EANGUS will pursue in Congress, the Department of Defense, and in the Department of Veterans Affairs. 

President - Chief Master Sergeant John Harris, US Air Force Retired 

Executive Director - Sergeant Major Frank Yoakum, US Army Retired 

Legislative Director - Mr. Daniel Elkins 

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The Veterans Health Administration (VHA) Care System 

Recommendation 1: Across the United States, with local input and knowledge, VHA should establish high-performing, integrated community health 

care networks, to be known as the VHA Care System, from which veterans 

will access to high-quality health care services. 

The Enlisted Association of the National Guard of the United States (EANGUS) 

recommends integrated, locally based health care networks that will take advantage 

of the current public and private health care infrastructure. These local networks 

will provide the aid necessary to serve their community’s veterans and their health 

care needs. Furthermore, we recommend that the U.S. Department of Veterans Affairs (VA) remains the coordinator and guarantor of care for veterans. It is the VA’s 

role to develop the systems necessary to equip veterans to make informed decisions 

on behalf of their health care needs. 

While EANGUS supports the elimination of current wait-time and distance-based 

eligibility standards, we fully recommend that the VA remains the primary care provider for veterans when such care is readily available. When the VA is unable to 

be the primary care provider, veterans must be given the opportunity to present 

their personal preferences and needs to a VA health care professional in order to 

find a provider - whether they’re private, public, or VA - that best suits them. This 

procedure would not only empower veterans to make informed decisions, but would 

also best utilize the networks within the VHA Care System. 

We also recommend that the VA have the power to waive primary care referral 

for such specialty care like optometry and audiology that do not necessarily require 

a primary care consult. 

And, while EANGUS is in support of a phased implementation of the VHA Care 

System that requires ongoing evaluation and management, we are not in agreement 

with Recommendation Nine. We recommend that the construction and integration 

of local networks be managed by a team of VA subject matter experts, receiving consistent guidance from local VA health care professionals and other Veterans Service 

Organizations. 

Clinical Operations 

Recommendation 2: Enhance operations through more effective use of 

providers and other health care professionals, and improved data collection and management. 

EANGUS fully supports this recommendation to implement training programs for 

medical support assistants (MSA). MSAs will ensure that VA health care providers 

are able to spend more time actually treating veterans, rather than being tied down 

with administrative tasks. 

In addition, the VA must also be able to keep up with the high turnover rates 

associated with MSAs and other entry-level positions at a local level. To do this the 

VA is currently implementing an expedited hiring process for MSAs as part of the 

MyVA transformation. EANGUS fully supports this initiative, but recommends that 

the VA have statutory authority to directly hire entry-level employees to fill high 

turnover positions. 

Recommendation 3: Develop a process for appealing clinical decisions 

that provides veterans protections at least comparable to those afforded 

patients under other federally supported programs. 

We support the recommendation to reform and enhance the current appeals process afforded veterans in order to mitigate disagreements between veterans and their 

health care providers, and to ensure that veterans obtain excellent and necessary 

medical attention. 

Currently, veterans who disagree with their health care provider can appeal to 

that specific medical facility’s chief medical officer. Veterans are only then able to 

appeal to their area’s Veterans Integrated Service Network director (VISN), who 

rarely overturns a decision made by a medical center’s chief medical officer. This 

decision by the VISN director is final unless veterans further appeal to the Board 

of Veterans Appeals. Given a time sensitive medical issue requiring immediate 

treatment, this is not an option, and veterans are left either untreated or subject 

to undesirable treatment plans. 

Veterans have had vastly different experiences appealing clinical decisions within 

multiple VISNs due to the lack of a national, system wide appeals process. 

EANGUS is in favor of a systematic and dependable appeals process, and we strongly agree with the commission’s recommendation to implement an interdisciplinary 

panel to revise the VA’s clinical appeals process. This panel must safeguard veterans’ ability to provide justification or evidence to support their appeals, which 

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many VISNs do not permit, and to have the ability to appeal clinical decisions above 

the VISN level. 

Recommendation 4: Adopt a continuous improvement methodology to 

support VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center. 

EANGUS is in agreement that the improvement of employee experience is an improvement to the VA health care system as a whole. When VA employees take pride 

in their work, they actively look for ways to improve the efficiency and productivity 

of their positions. However, there are not yet adequate processes for employees to 

identify problems or provide solutions. We support this recommendation to empower 

VA employees to identify and disseminate best practices, and to reward innovative 

employees who work to improve the care provided to veterans. 

Health Equity 

Recommendation 5: Eliminate health care disparity among veterans 

treated in the VHA Care System by committing adequate personnel and 

monetary resources to address the causes of the problem and ensuring the 

VHA Health Equity Action Plan is fully implemented. 

EANGUS fully supports this recommendation. Health care disparities based upon 

social or economic status must be eliminated from the VA health care system. We 

have heard of women veterans being confused with and treated as caregivers or 

spouses, or having their veteran status being questioned because of their gender. 

All veterans must be treated with the dignity and respect they have earned and deserve, regardless of such difference as race, background, or gender. 

We, therefore, strongly support implementing a cultural and military competence 

program throughout all VHA network providers and employees. It is crucial for veterans to receive informed care from health care providers who are aware their 

needs, and familiar with the health conditions associated with military service. This 

includes all VA health care providers as well as private providers within the integrated VHA network. The provision of cultural competence training will ensure that 

all veterans will receive care that is pertinent and tailored to their unique needs, 

and improve health care outcomes overall. 

Facility and Capital Assets 

Recommendation 6: Develop and implement a robust strategy for meeting 

and managing VHA’s facility and capital asset needs. 

We mostly agree with the Commission’s recommendations regarding the management of capital infrastructure. In order to streamline the VA’s ability to enter into 

necessary leases, and to lease unused property more efficiently, we support waiving 

congressional rules requiring budgetary offset, and to expand enhanced-use lease 

authority. 

We also are in agreement with the Commission that the ability to reevaluate the 

total cost of multiple, minor construction projects is necessary. But, we recommend 

the VA have the ability to umbrella multiple, minor construction projects under one 

contract, if these projects interdepend upon each other for completion. Furthermore, 

we suggest the implementation of differing classifications of major construction 

projects to ensure that the building of new medical centers does not conflict or enter 

into competition with facility expansions or seismic corrections. 

The Commission recommends a new board to analyze and recommend changes regarding the needs of current infrastructure to include the development of the VHA’s 

integrated health care system. But we at EANGUS recognize that most of the functions of this recommended board are already being carried out by the Federal Real 

Property Council (FRPC) and the Strategic Capital Infrastructure Plan (SCIP). We 

do not believe that adding another stage of bureaucratic process will solve an already inefficient system. Instead, we urge congress to grant the VA the full authority to close facilities, or certain departments within facilities, as they see fit. 

We at EANGUS do not agree with the Commission’s recommendation to realign 

the Defense Base and Realignment Commission (BRAC). Currently, the SCIP already deals with the issue of closing inefficient and dilapidated property, but as it 

has already been stated, they have been mostly ineffective and unable to prune the 

current infrastructure in order to promote efficient growth of the VHA network. 

Again, we urge Congress to grant the VA the authority to oversee and dismantle 

current VHA infrastructure as they see fit, as this is the most cost effective and 

timely way to dispose of out-of-date and inefficient facilities in order to make room 

for the continual improvement of VHA’s infrastructure. 

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Furthermore, we urge Congress to explore means to create more partnerships between the VA and the Department of Defense (DoD), in line with the example set 

by partnerships formed between the VA and DoD in Chicago. Their model of partnership has proven to increase budgetary savings, expand available scope of care, 

and increase the access of care for servicemembers and veterans. 

Finally, we encourage Congress to explore the model set by the National Guard 

in their continued pursuit to partner with local providers. The National Guard’s 

model has improved the accessibility of care for servicemembers and veterans where 

DoD infrastructure is not yet in place, and such a model within the VA could continue to bridge the gaps in the VHA network to provide necessary health care for 

veterans until infrastructure can catch up to current needs. 

Information Technology 

Recommendation 7: 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. 

We at EANGUS support the Commission’s recommendation to appoint a chief information officer (CIO) that focuses on efficient and strategic health care information technology (IT) in order to better serve the needs of the VA health care system. 

This CIO for the Veterans’ Health Administration must work closely with VHA staff 

to efficiently implement IT systems that meet the needs of its users, and report to 

the Veterans Affairs’ Assistant Secretary for Information and Technology LaVerne 

Council to maintain interoperability with the IT programs of the Veterans Benefits 

Administration and National Cemetery Systems. 

We recommend that the VHA CIO have a multiyear budget that ensures health 

care programs are sufficiently supported and implemented. 

We do not have a position on whether the VA should purchase a commercial, offthe-shelf, electronic health care system (COTS), or themselves develop an in-house 

electronic health care system. But, we strongly urge that the new electronic health 

care system be interoperable with the Department of Defense’s Electronic Health 

Record system (EHR), regardless if it is a COTS product, or developed in-house. Investing in the interoperability of the VHA’s and DoD’s health record systems is the 

most cost effective and efficient solution. It will eliminate countless man-hour’s 

squandered hunting down records for servicemembers and veterans, and it will ensure that no servicemember or veteran will ever be denied care because of inefficient 

and outdated bureaucratic recordkeeping. 

Supply Chain 

Recommendation 8: Transform the management supply chain in VHA. 

EANGUS fully supports this recommendation that aims to reorganize and standardize the VA’s supply chain. This will effectively leverage economies of scale, increase responsiveness and efficiency of the supply-chain, and reduce operating costs. 

This recommended transformation of the management supply chain must rely on 

local feedback and their buy-in to be successful. So, while each individual medical 

facility will no longer be able to dictate where their supplies are purchased, there 

must remain the option to request specific supplies and products in order to provide 

the best quality care. We see this as similar to the already-existing non-formulary 

requests for prescriptions that are not on the VA’s formulary. Lastly, this recommended transformation must evaluate whether specified requests are preferred 

or clinically needed by veterans, such as prosthetics. 

Board of Directors 

Recommendation 9: Establish a board of directors to provide overall VHA 

Care System governance, set long-term strategy, and direct and oversee the 

transformation process. 

EANGUS does not support this recommendation to establish a separate board of 

directors. We do not see current problems to be due to lack of management, but 

rather a lack of leadership in Veterans Affairs itself. This recommended governing 

board would be constituted of political appointees who, despite being health care executives, would not use the VA health care system. We do not believe that a separate board of appointees, having no real vested interest to improve the care and 

services for veterans, will outperform or better guide the VHA Care System transformation than improved leadership within the VHA itself. 

Furthermore, we foresee that a governance board will not resolve the imbalance 

between capacity and demand that is pointed out in the Commission’s report. It will 

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other step for the approval of VHA budget requests, which currently still have to 

be approved by the Office of Management and Budget and appropriated by Congress. Rather than limiting how much care the VA is able to provide, we recommend 

a reformation of the congressional appropriations process. We, therefore, urge Congress to empower the VA so that it does not need to lean on outside accountability 

measures in order to effect the changes necessary for the system to prosper, but 

allow the VA to resolve internal issues themselves. This will ensure that the VA 

receives its required resources more efficiently so as to better serve the health care 

needs of veterans. 

Leadership 

Recommendation 10: Require leadership at all levels of the organization 

to champion a focused, clear, benchmarked strategy to transform VHA culture and sustain staff engagement. 

EANGUS is in full support of this recommendation. As previously discussed in 

Recommendation 4 and Recommendation 5, the continuous improvement of employee experience will not only sustain the transformation of the VHA health care 

system, but also work to restore and build up veterans’ trust in their health care 

system. 

Recommendation 11: Rebuild a system for leadership succession based on 

a benchmarked health care competency model that is consistently applied 

to recruitment, development, and advancement within the leadership pipeline. 

EANGUS strongly supports this recommendation. We believe in the importance 

of a systematic plan of mentorship, advancement, and succession, and we recognize 

the need for nationally structured programs that will recruit, develop, retain, and 

advance high performing leaders. Strong leadership development programs will empower VA employees to fill vacant leadership positions in the future, effectively 

building a nationwide leadership team of seasoned and invested employees to run 

VHA medical facilities. 

Recommendation 12: Transform organizational structures and management processes to ensure adherence to national VHA standards, while also 

promoting decision making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the 

spread of best practices. 

EANGUS is in support of this recommendation. We agree with the Commission 

that rapid growth within the VA central office and VISN network has weakened authority, blurred respective roles, and confused the boundaries of responsibility of 

each branch, impairing the VA’s ability to meet veterans’ health care needs. The implementation of clear boundaries and responsibilities to separate and focus the VA 

and VISN will empower all available resources within both organizations to accomplish their distinct and necessary purposes for the sake of the VHA. 

Recommendation 13: Streamline and focus organizational performance 

measurement in VHA using core metrics that are identical to those used in 

the private sector, and establish a personnel performance management system for health care leaders in VHA that is distinct from performance measurement, is based on the leadership competency model, assesses leadership 

ability, and measures the achievement of important organizational strategies. 

EANGUS generally supports this recommendation. We agree that it is important 

to implement an objective performance management system that can evaluate results throughout the VHA Care System, and to hold VA leaders accountable to implement improvements. 

However, we do not believe the metrics of performance measurement must be 

identical to those used in the private sector. These metrics ought to borrow the best 

practices currently employed in the private sector, while also giving allowances for 

the singular mission of the VHA, and the differences between private and public 

health care systems. 

Diversity and Cultural Competence 

Recommendation 14: Foster cultural and military competence among all 

VHA Care System leadership, providers, and staff to embrace diversity, 

promote cultural sensitivity, and improve veterans’ health outcomes. 

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EANGUS fully supports this recommendation. As stated in Recommendation 5, 

enhanced cultural and military competence training ensures the equity, improves 

the quality, and efficiently tailors the care that veterans’ need. It is crucial for veterans to receive informed care from health care providers who are aware their 

needs, and familiar with the health conditions associated with military service. The 

better informed and prepared VHA network providers become, the more cost effective and efficient the provision of care becomes, thereby sustaining the VHA itself, 

and better serving the servicemembers and veterans in need. 

Workforce 

Recommendation 15: Create a simple-to-administer alternative personnel 

system, in law and regulation, which governs all VHA employees, applies 

best practices from the private sector to human capital management, and 

supports pay and benefits that are competitive with the private sector. 

EANGUS does not support this recommendation of the Commission. Currently, 

there are already two separate agencies attempting to coordinate as a personnel system in order to recruit, hire, train, and manage a competent workforce for the VHA. 

As things stand, the current laws and regulations governing how government employees are hired, paid, and disciplined are not adequate for the sustenance of a 

high performing health care system. However, we do not see the solution coming 

in the form of yet another system. This will only lead to further confusion and more 

bureaucratic steps that muddle the actual execution of hiring, paying, and disciplining a competent workforce. 

EANGUS recommends, rather, a transformation of the current two-party system, 

where both USAJobs and the VA clearly demarcate their target demographic and 

untangle from each other. We believe that if Congress grants the VA with more authority to navigate its own hiring practices, it will streamline the netting and implementation of a capable workforce for the VHA, and resolve the current problems 

within the VHA personnel system. 

Recommendation 16: Require VA and VHA executives to lead the transformation of HR, commit funds, and assign expert resources to achieve an 

effective human capital management system. 

EANGUS supports this recommendation. As discussed above, we fully support the 

empowerment and higher call of leadership within the VA to implement changes 

and safeguard this process of VHA transformation. We urge Congress to continue 

to empower the VA to manage its own employees and resources more fully, thereby 

streamlining the process of stabilizing an effective human capital management system, and removing the hurdles caused by external agencies that slow down the VA 

from accomplishing its unique goals. 

Eligibility 

Recommendation 17: Proved a streamlined path to eligibility for health 

care for those with an Other-Than-Honorable discharge who have substantial honorable service. 

EANGUS supports this recommendation to provide eligibility to veterans with 

Other-Than-Honorable discharges, given that they are combat veterans, and their 

overall service is deemed to be honorable. 

Recommendation 18: Establish an expert body to develop recommendations for VA care eligibility and benefits design. 

EANGUS supports this recommendation. We have seen that past evaluations and 

changes to eligibility criteria resulted in increased access to care for previously 

uncared for populations of veterans, and eligibility was realigned to match with updated delivery models. Recognizing that the implementation of an integrated health 

care system will change the model of delivering care, and having seen the benefits 

of evaluating eligibility criteria, we support the idea of an expert body to evaluate 

potential access barriers and current eligibility criteria, and to make recommendations to the VA based upon their findings, in order to ensure that service-connected, 

homebound, and disabled veterans run into no barriers or delays that would keep 

them from service and care. 

f 

IRAQ AND AFGHANISTAN VETERANS OF AMERICA 

Chairman Miller, Ranking Member Takano and Distinguished Members of the 

Committee: 

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On behalf of Iraq and Afghanistan Veterans of America (IAVA) and our more than 

425,000 members, thank you for the opportunity to share our views on the recently 

released Commission on Care Report. The Commission on Care was created by the 

Veterans Choice, Accountability and Access Law of 2014 and was charged with providing a framework for designing the Veterans Health Administration (VHA) for the 

next 20 years. IAVA appreciates the opportunity to have the voices of this nation’s 

newest veterans heard as we discuss the long term future of veteran health care. 

Overall the Commission on Care report has put forward thoughtful analyses and 

recommendations for reforming VHA. IAVA broadly agrees with many of the recommendations, but also has reservations with a few, which are outlined in detail 

in this testimony. Further, we have an overarching concern with the lack of consideration for how these recommended changes to VHA will impact the Department of 

Veterans Affairs (VA) as a whole, particularly VHA’s ability to continue coordinating 

with the Veteran Benefits Administration (VBA) and National Cemetery Administration (NCA) as well as its ability to continue leading in health research and clinician training. 

Regardless of the specifics of each recommendation, one thing is certain: Reforming VHA into a truly 21st century health care system will require significant coordination between VA, the larger administration, Congress, VSO partners, and the veterans we all serve. This coordination must be done in a bipartisan, veteran-centric 

manner that understands transformative change requires resources. IAVA encourages Congress to listen to the needs of the VA and fund any necessary changes at 

adequate levels without cutting existing critical benefits, like the GI Bill. 

General Analyses 

1. The report fails to consider how these recommendations to VHA will 

impact the VA as a whole, particularly VHA’s ability to continue coordinating with the the VBA and NCA. One of the most unique aspects of the VA 

is its ability to offer wrap-around services to the veterans in its care. VHA is not 

only responsible for health care, but also oversees critical programs like suicide prevention and veteran homelessness. Over the years, the necessary coordination between VHA, VBA and NCA has continually improved. While not perfect, the crosscoordination of the these administrations is critical in maintaining VA’s ability to 

provide these wrap-around services and fully support the veteran. This report does 

not address this critical need for coordination and how coordination would be impacted if these recommendations to VHA were implemented, but it must. 

2. The report fails to analyze the impact of recommended VHA reforms 

on VHA’s ability to conduct research and train future clinicians. Seventy 

percent of physicians receive some level of professional training from the VA. VA 

also trains over 20,000 nurses and nearly 35,000 people in other health related 

fields annually. This, combined with the robust research program that has led to 

groundbreaking discoveries in prosthetic development, spinal cord injuries, mental 

health injuries and burn care, expands VHA’s impact in the community beyond any 

simple health care provider. These additional roles are critical aspects of the VHA 

footprint that were not accounted for in the development of the Commission on Care 

report. The impact of implementing these recommendations on these additional critical VHA roles must be taken into account. 

3. The report does not acknowledge the challenges faced by VA due to the 

misalignment of demand, resourcing and authorities. The Independent Assessment of VA conducted by the Mitre Corporation found that a misalignment between demand, resourcing and authorities is one of the critical challenges of the VA 

to execute effectively on its mission. This report does not address this challenge. As 

the writers of the Independent Budget point out, at its current state VA is underfunded and cannot meet demand. Budget approval rests with Congress; only they 

can properly align demand and resources. And such substantial reform efforts, while 

needed, will require proper and realistic resourcing. IAVA would again echo our concern of recent Congressional efforts to pay for new services and benefits at the VA 

by cutting existing benefits and make a strong recommendation that this method 

not be used to fund transformative change within VHA. 

4. The report is presented as a series of independent recommendations; 

it fails to acknowledge that the success of implementing a single recommendation likely depends on the execution of others and will also require extensive time and resources to execute effectively. The Commission on 

Care report puts forward a number of recommendations that will require time and 

resources to implement, and yet the challenges inherent to such a long-term, resource-intensive process are not addressed. Further, the report outlines a series of 

independent recommendations, but does a poor job of showing their interconnectedness. For example, an integrated network of care cannot be built without an upLeonard.horne on VACREP0180 with DISTILLER

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dated technology platform and infrastructure to support the network. Yet these, and 

the costs associated with them, are not mentioned in the recommendation to create 

an integrated network of care. This lack of integration gives a false sense of overall 

cost of implementing this plan. It also fails to emphasize that in many cases, if one 

recommendation is adopted without others, the overall plan to improve VHA will 

fail. It is critical to recognize that while these recommendations are presented as 

stand-alones, many will be intertwined and one cannot be fully achieved without 

others. 

5. The report failed to take into account reforms and programs that the 

current VA Secretary has already planned and/or implemented. The Secretary conducted an extensive internal assessment of the VA when he was initially 

appointed to the position in 2014. As a result, he has put into action the myVA initiative, which addresses many of the points raised by the Commission on Care report. The report does not specifically address this initiative or take under consideration potential redundancies of the recommendations of the Commission report. 

6. The report recommendations are broad, contradictory at times, and 

can be left somewhat open to interpretation. This presents a challenge as leadership and the makeup of Congress changes. The broad and contradictory nature 

of the report does not provide clear and concise direction and the intent of the Commission in making these recommendations might be lost to political leanings. 

Analyses of Report Recommendations 

Recommendation #1: Across the United States, with local input and knowledge, VHA should establish high-performing, integrated community-based 

health care networks, to be known as VHA Care Systems, from which veterans will access high-quality health services. 

IAVA Analysis: IAVA recognizes that the VA cannot fulfill its mission alone and 

a fully integrated network of care that includes community providers will be essential to achieving this mission. We also agree with the need for an integrated model 

that requires patients to consult with a primary care provider to receive specialty 

care services and removes the arbitrary eligibility criteria enacted by the Choice 

Program. However, we disagree with primary care services being available outside 

of the VA, even if it is limited to within the community network. While well-intentioned, IAVA is concerned that a broad interpretation of this recommendation creates a framework whereby VHA as an institution can slowly be phased out. Furthermore, IAVA is not convinced the primary care providers outside the VA could effectively treat the whole veteran and effectively help veterans navigate the VA. A veteran’s primary care provider needs to be the quarterback of their care; they’ve got 

to be central and fully integrated into the team. 

Additionally, the budget assessment for this recommendation makes a number of 

assumptions that may or may not hold true. First, the economic analysis does not 

include cost assessments for upgrading the IT platforms to support a truly integrated network, costs associated with the needs of the physical infrastructure of facilities nor additional administrative costs to support this new model. 

Although not specifically addressed, this recommendation also assumes that community providers will be available and able to absorb the demand created by integrating this network. The model estimates as much as 60 percent of VA care shifting to the community network (from 34 percent currently). This will likely create 

a large demand on a community medical system already struggling to meet the demand of existing civilian patients (a challenge already realized by VA Choice providers). Finally the implementation of such a system does not take into account the 

impact on research and training, and could have a severe negative economic impact 

if not mitigated. 

Overall, IAVA supports an integrated network of care that includes community 

providers, with integration of VA primary care providers managing the patient care 

and an overall resource estimate that considers additional costs needed for administrative support, IT systems and infrastructure required to support the network. We 

find this recommendation well intentioned, but too broad, lacking critical pieces of 

analysis, and with a fatal flaw: the external primary care provider. 

Recommendation #2: Enhance clinical operations through more effective 

use of providers and other health professionals, improved data collection 

and management. 

IAVA Analysis: There is a growing shortage of physicians and the health care 

community will need to be open to expanding responsibilities for all health professionals. IAVA agrees with the need for VHA to more effectively engage its professional staff and ensure that clinicians have the support staff, both clerical and clinLeonard.horne on VACREP0180 with DISTILLER

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ical, they need to use their time more efficiently and effectively to treat patients. 

We also agree that data integrity and collection must be a priority. 

Recommendation #3: Develop a process for appealing clinical decisions 

that provides the veterans protections at least comparable to those afforded 

under other federally-supported programs. 

IAVA Analysis: IAVA has no strong opinion on this recommendation. IAVA does 

support the intent to convene an interdisciplinary panel to further assess and offer 

recommendations regarding revising the clinical appeals process to ensure the veteran is receiving a judicious and uniform process when appealing a clinical decision. 

Recommendation #4: Adopt a continuous improvement methodology to support VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center. 

IAVA Analysis: IAVA has continually recognized that one of the challenges at 

VHA is sharing best practices across the VHA system of care. Under the leadership 

of Secretary McDonald and the Undersecretary for Health, Dr. Shulkin, VHA continues to try and identify innovative solutions at the local level and bring these to 

the greater VHA community. However, streamlining these practices has been a challenge. We concur with the intent of this recommendation, VHA must establish an 

effective way to identify these transformative programs and share them across the 

VA in a streamlined and efficient way. However, we are not confident that the Veterans Engineering Resource Center is the appropriate entity to meet this intent. 

Recommendation #5: Eliminate health care disparities among veterans 

treated in the VHA Care System by committing adequate personnel and monetary resources to address the cause of the problem and ensuring VHA 

Health Equity Action Plan is fully implemented. 

IAVA Analysis: IAVA agrees that VHA should adopt as a primary mission the 

elimination of health care disparities among the veterans it serves. As the report 

states, minority populations are growing in the U.S. as a whole, and also within the 

veteran community. For VA to fully recognize its mission to serve veterans, it must 

be focused on serving all veterans. 

IAVA has recently focused on improving services to women veterans. Women veterans are a minority group, but they are not homogeneous. Women veterans are a 

very diverse population. We agree with the report’s findings that the VA prioritize 

and fully resource serving minority populations. Additionally, we agree that while 

VA has improved its focus on understanding these populations through research, 

more must be done. There is an overall lack of data on vulnerable populations and 

a lack of data on how VA is doing to support these populations. This data gap must 

be closed. In doing so, VA will have the tools to finally address the needs of these 

populations in a data-informed way. 

Recommendation #6: Develop and implement a robust strategy for meeting 

and managing VHA’s facility and capital-asset needs. 

IAVA Analysis: As the Commission on Care report recognizes, the VHA infrastructure is in dire need of attention. The average facility is 50 years old, resources 

for updates are nowhere near adequate and the ability for VA to conduct needs assessments of its facilities and act on those assessments are hindered by Congressional oversight. IAVA agrees that the VA must have more flexibility to meet its 

facility needs. We also recognize the growing importance of ambulatory care needs, 

while balancing the availability of inpatient facilities 

Additionally, we feel it is imperative to recognize the current challenges for VA 

to enter into agreements with health care partners to share space, equipment or 

personnel. Current law makes it nearly impossible for these private-public partnerships to be entered into, and in order for VA to implement recommendation one of 

this report, an integrated network of care, this capability is essential. 

IAVA also agrees that there could be resources gained by empowering VA to make 

these critical facilities decisions. There are a number of legislative changes that can 

be made to address the critical infrastructure needs of the VA. It will be imperative 

that Congress work with the VA to make these needed changes a reality. 

Recommendation #7: 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 practices. 

IAVA Analysis: IAVA recognizes the VA IT system will be a critical component 

of an integrated system of VA care. Currently, the IT system is woefully outdated 

and does not afford the possibility of this integrated system. The current care in the 

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community programs and providers do not interface with VA in a streamlined manner, making care disjointed. Further, the report points out that a lack of standard 

clinical documentation and a standardized electronic health records (EHR) across all 

facilities makes record sharing across facilities and from facility to veteran very difficult. IAVA agrees with these findings. In order for VHA to provide a streamlined, 

high quality and timely level of care, the IT system must be brought into the 21st 

century. VHA must have a detailed strategy and roadmap to achieve this level of 

IT and it will require the support of Congress to fulfill its vision. 

IAVA has advocated not only for an update to the VHA IT system, but also the 

development of an interoperable EHR between Department of Defense (DoD) and 

VA and within VA. This is critical to providing patient service to the military/veteran population. It is is also required by law and past due. However, with an integrated network, the need for interoperability will go beyond the VA and DoD and 

include its community partners. 

We are concerned that the priorities of VHA’s IT needs are getting lost in the Office of Information and Technology and agree VHA needs an IT advocate working 

to meet the IT needs of VHA. However, we believe this would also benefit VBA and 

NCA and they too should have IT advocates. 

Finally, we agree that the budget cycle as it stands now makes it very difficult 

for VHA to plan for and execute on IT needs, and concur that VHA’s IT budget 

needs should also be on a two year cycle with VHA’s advance appropriations cycle. 

Recommendation #8: Transform the management of the supply change in 

VHA. 

IAVA Analysis: This is beyond the scope of IAVA’s expertise and therefore we 

take no position. However, we support any mechanisms that could improve efficiencies and allow for resources to be reallocated elsewhere in VHA with these improved efficiencies. 

Recommendation #9: Establish a board of directors to provide overall VHA 

Care System governance, set long-term strategy and direct and oversee the 

transformation process. 

IAVA Analysis: IAVA understands the reasoning behind this recommendation 

and agrees that continuity in leadership is critical to long term reform. However, 

it can be very difficult to impose private sector practices (Board of Directors) on a 

public sector entity (VHA) because of the nature of that public sector entity. 

In an attempt to increase accountability in VHA, establishing a board runs the 

risk of the opposite effect. Particularly with the establishment of the board through 

various political appointees, the board risks becoming another entity where inaction 

becomes the norm because of opposing viewpoints. Additionally, as described the 

board has no fiduciary control; Congress will continue to be the final oversight authority. IAVA is concerned that the addition of the board adds another layer to the 

already burdensome bureaucracy. A board of directors without fiduciary responsibility effectively becomes an advisory board, and VA already has one, and arguably 

multiple, of those established through the myVA Board and the VSO community. 

We understand the Commission’s concerns over continuity of senior leadership 

roles such as the Undersecretary of Health and are willing to consider a longer term 

of appointment for the Undersecretary of Health, but believe that this requires further analysis on the impact on VBA and NCA. More generally, with a change in 

governance structure such as this recommendation, there must be considerations as 

to how this impacts the coordination between VHA, VBA and NCA. 

There is also further consideration to be made as to the role that VSOs, Congress 

and other informal advisors already play in this capacity. 

Recommendation #10: Require leaders at all levels of the organization to 

champion a focused, clear, benchmarked strategy to reform VHA culture 

and sustain staff engagement. 

IAVA Analysis: As the report recognizes, the cultural and organizational health 

of VHA must be positively transformed before the VHA can function at its greatest 

potential. IAVA strongly agrees that in order to build a healthy culture, VHA must 

instil greater collaboration, ownership, and accountability among its employees. We 

applaud the strong dedication found among VHA employees and continue to advocate for policies and opportunities that best strengthen and support the VA’s workforce. 

We agree with the report’s recommendations that stress a systems-oriented, leadership-supported, and flexible approach to cultural transformation. However, IAVA 

is concerned that this cultural transformation must be conducted throughout all of 

the VA and not exclusively siloed within VHA. Given the strong inter-agency coLeonard.horne on VACREP0180 with DISTILLER

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operation at the VA and the need for VA leadership at its highest levels to support 

these goals, implementing the changes suggested by the report must be done across 

the whole VA. 

Additionally, the concept of the transformation office has the potential to help 

drive and focus the suggested cultural changes. However, we would need to understand the specifics of how the transformation office would function, how it would 

disseminate policies and training, and how it would be able to support local and national change to understand if such an office would be a more effective model of 

change than the current system. Since the report also directs this new transformation office to report directly to the suggested governing board, we would echo 

here our concerns detailed under the analysis of recommendation nine. 

Recommendation #11: Rebuild a system for leadership succession based on 

a benchmarked health care competency model that is consistently applied to 

recruitment, development, and advancement within the leadership pipeline. 

IAVA Analysis: IAVA overall agrees that VHA does not have a strong plan in 

place for leadership development and growth and this is critical for the continued 

success of VHA. Under Secretary McDonald, the need for leadership development 

has been recognized and is one of many areas where IAVA is excited to see progress 

already being made. 

Recommendation #12: Transform organizational structures and management processes to ensure adherence to national VHA standards, while also 

promoting decision making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the 

spread of best practices. 

IAVA Analysis: IAVA supports streamlining VHA and empowering staff to make 

decisions, but in empowering the staff VA must ensure they have the right tools and 

metrics to make informed decisions. IAVA supports reducing redundancies and simplifying organizational structure, but also want to ensure that in simplifying vital 

processes are not lost. 

We have also supported the VA Secretary’s request for more budgetary authority 

to make these critical decisions and route resources to where the need rests. We understand the need for a health care system to have that additional flexibility, but 

that must be carefully balanced with ensuring vital programs continue to be funded. 

Recommendation #13: Streamline and focus organizational performance 

measurement in VHA using core metrics that are identical to those used in 

the private sector, and establish a personnel performance management system for health care leaders in VHA that is distinct from performance measurement, is based on the leadership competency model, assesses leadership 

ability, and measures the achievement of important organizational strategies. 

IAVA Analysis: IAVA broadly agrees with the need for VHA to streamline and 

focus its organizational performance measures and establish the same in a personnel performance measure system. These metrics must be clearly defined, measurable, and speak more to the need for meaningful measures tied to safety, quality, 

patient experience, operational efficiency, finance and human resources (as indicated in the Independent Assessments). We also see value to tying these metrics to 

private sector measures given recommendation one to create and integrate the network of care, but hesitate to rely too much on the private sector measures given 

that VHA also has its own unique aspects that might warrant some measures outside of the private sector. Additionally, this is another area being addressed by the 

VA Secretary’s myVA transformation plan. 

Recommendation #14: Foster cultural and military competence among all 

VHA Care System leadership, providers and staff to embrace Diversity, promote cultural sensitivity and improve veteran health outcomes. 

IAVA Analysis: IAVA completely agrees that military cultural competence is critical for all who provide care to veterans. A recent RAND report that looked at military cultural competence among community mental health providers defined this 

not just as knowledge and comfort with the military culture, but also knowledge of 

evidence-based practices to treat mental health injuries and ability to practice these 

techniques. It’s critical to recognize that competence applies at all levels, from the 

individual greeting as the veteran walks in the door, to the provider treating the 

patient. All VA staff must be trained in this. Additionally, providers and their support staff must understand the specific health indicators for this population to better serve them. IAVA supports all of the recommendations in this section specific 

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to asking about military health history and awareness of all veteran groups, including providing quality care for women veterans and the LGBT community. This will 

be a critical requirement for any community providers that are adopted into the 

VHA network, whether it be the current care in the community programs, or some 

future iteration. 

Recommendation #15: Create a simple to administer alternative personnel 

system, in law and regulation, which governs all VHA employees, applies 

best practices from the private sector to human capital management and 

supports pay and benefits that are competitive with the private sector. 

IAVA Analysis: IAVA is an active advocate for a dedicated focus on VA staffing. 

Specifically at VHA, we agree that attracting talent to VHA will be critical at all 

levels of the staffing hierarchy, and so competitive salaries and hiring incentives 

will be critical in doing this, as well as expediting the hiring process. We also recognize the tradeoff of moving from a Title 5 to a Title 38 hiring structure, including 

potential impacts on the diversity of the hiring pool. We recommend that should this 

recommendation be considered, this concern be addressed and then monitored if the 

recommendation is implemented. Given that VA serves a unique and diverse population, we want to be sure that the staff that serves this population maintains that 

same diversity. 

We also agree that VA HR should take a more proactive approach in developing 

leaders within VHA. We encourage VA to consider how VA HR can balance the 

needs to meet regulatory requirements, but more importantly emphasize professional development and fostering leaders among the VA ranks, as well as improving 

morale and hopefully as a result, retention. 

Any discussion on improving VA personnel systems must also include a discussion 

on increasing accountability at the VA. While a vast majority of VA employees serve 

veterans in an exemplary way, there are also those who discredit the VA through 

underperforming or plain negligent acts. Being able to jettison these employees in 

an expedited manner while also protecting whistleblowers and rewarding those that 

do serve in an exemplary way are the keys to restoring VA morale. 

Recommendation #16: Require VA and VHA executives to lead the transformation of HR, commit funds and assign expert resources to achieve an 

effective human capital management system. 

IAVA Analysis: In order to achieve recommendation 15, recommendation 16 

must also be a priority. To reform the personnel hiring and HR administrative systems, leadership must be in support and must prioritize it. 

Recommendation #17: Provide a streamlined path to eligibility for health 

care for those with an other-than-honorable discharge who have substantial 

honorable service. 

IAVA Analysis: IAVA agrees with this recommendation. Those with Other-ThanHonorable (OTH) discharges can be among the most vulnerable in our veteran population. They are at a higher risk for suicide and homelessness, and often as a result 

of their discharge status may have no VA resources available to them. Community 

programs often mirror the eligibility criteria of the VA, and so even these resources 

may not be available to them. They become stuck in limbo, possibly needing help 

for an injury sustained while in service, but not able to obtain that help because 

they are not eligible due to their discharge status. For some, the injury obtained 

during service might have even contributed to the OTH discharge received. 

Awarding temporary eligibility to these individuals will allow for access to critical 

services without delay in health care due to the current process for determining eligibility. However, it’s important to stress that with this change will be a resource 

burden on the VA that will require Congress to support. With increased demand 

comes increased need for resources. 

Recommendation #18: Establish an expert body to develop recommendations for VA care eligibility and benefit design. 

IAVA Analysis: This remains a critical issue within the veteran community and 

updates to VA eligibility have not been addressed in 20 years. It is past time to do 

so. IAVA agrees with the recommendations to form a body to review these criteria 

and develop recommendations to meet the needs of all veterans. 

Again, IAVA appreciates the opportunity to outline our review of the Commission 

on Care. Change is necessary, and working together we know the VA and the health 

care it provides can be strengthened to provide the highest quality care for veterans 

in this nation’s history. IAVA looks forward to continuing to work alongside this 

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Committee, Secretary McDonald and our fellow VSO partners to evaluate and implement changes necessary to best achieve this goal. 

f 

MILITARY OFFICERS ASSOCIATION OF AMERICA 

CHAIRMAN MILLER, RANKING MEMBER TAKANO, and Members of the Committee, the Military Officers Association of America (MOAA) is pleased to present 

its views on the Department of Veterans Affairs (VA) Commission on Care Report 

under consideration by the Committee today, September 7, 2016. 

MOAA does not receive any grants or contracts from the federal government. 

EXECUTIVE SUMMARY 

On behalf of our 390,000 members, MOAA appreciates the Congress’ vision in establishing an independent commission to look at how best to organize and deliver 

health care in the VA Health Administration (VHA) in the 21st Century. 

After reports of secret waiting lists at the VA medical center in Phoenix, Arizona, 

MOAA urged President Obama to establish an independent commission in order to 

make immediate and long-range systemic changes necessary to provide the best 

quality care and support services to our Nation’s servicemembers, veterans and 

their families. 

After 10 months of intense deliberations, public meetings, testimony, and extensive inputs from experts across the country, including MOAA, the federally-directed 

Commission on Care issued its final report on June 30, 2016. 

MOAA was particularly grateful for the open and collaborative process commissioners established in order to receive information, feedback and viewpoints from 

veterans themselves, as well as from veteran and military service organizations representing this constituency. 

Overall, MOAA supports most of the Commission’s findings, and we are pleased 

to see many of the report recommendations incorporate the changes Secretary 

McDonald and veterans service organizations (VSOs) have been advocating for since 

the implementation of the Veterans Access, Choice and Accountability Act of 2014 

(Choice Act). 

While much more remains to be done, we appreciate the Commission’s sincere effort to strike a balance of sustaining and improving VA health care delivery while 

enhancing civilian care opportunities. 

Along with our VSO partners, we look forward to working with the President, 

Congress and the VA to translate the Commission’s recommendations into effective 

action. 

The following section provides MOAA’s views and concerns on selective issues and 

recommendations for your consideration. 

COMMISSION ON CARE REPORT ANALYSIS AND RECOMMENDATIONS 

MOAA believes Chairperson Nancy Schlichting’s statement on the final report released on July 5, 2016, is an excellent characterization of the current system and 

provides a compelling reason for why immediate reform is needed. 

‘‘The system problems in staffing, information technology, procurement and other 

core functions threaten the long term viability of VA health care system and that 

key VA systems do not adequately support the needs of 21st century health care,’’ 

stated Schlichting, CEO of the Henry Ford Health System. ‘‘The Commission found 

that no single factor can explain the multiple systemic problems that have frustrated VA efforts to provide veterans consistent timely access to care. Governance 

challenges, failures of leadership, and statutory and funding constraints all have 

played a role. As the Final Report states, however, ’VHA has begun to make some 

of the most urgently needed changes outlined in the Independent Assessment Report (Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs Report, published January 1, 

2015), and we support this important work.’’ 

MOAA supports the following key elements of the report recommendations: 

Redesigning the Veterans’ Health Care Delivery System 

• Establish high-performing, integrated community-based health care networks to 

be called ‘‘VHA Care System (VCS)’’ to include VA facilities and Department of 

Defense (DoD) and other federally-funded providers and facilities. 

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• VCS networks retain existing special-emphasis resources and specialty care expertise (e.g., spinal cord injury, blind rehabilitation, mental health, prosthetics, 

etc.). 

• Community providers must be credentialed by VHA to qualify to participate in 

community networks, ensuring providers have the appropriate education, training, and experience. 

• Highest priority access to health care would be provided to service-connected 

and low-income veterans. 

• Eliminate the current time and distance criteria for community care access (30 

days/40 miles). 

• VCS should provide overall health care coordination care and provide navigation support for veterans. 

• Veterans would choose a primary care/specialty care provider in VCS-specialty 

care requires referral from the primary care provider. 

• VHA should increase efficiency and effectiveness of providers and other health 

professionals by improved data collection and management, adopting policies to 

allow them to make full use of their skills. 

• Eliminate health disparities by establishing health care equity as a strategic 

priority. 

• Modernize VA’s information technology (IT) systems and infrastructure. 

While VA alone cannot meet all the health care needs of veterans, the system 

does provide for a foundational platform upon which to build. The Commission acknowledges the importance of this foundation up front in the report: 

′′VHA has many excellent clinical programs, as well as research and educational 

programs, that provide a firm foundation on which to build. As the transformation 

process takes place, VHA must ensure that the current quality of care is not compromised, and that all care is on a trajectory of improvement.′′ 

MOAA believes the new health care system delivery model needs to preserve wellknown programs and competencies in VHA’s mission areas of clinical, education, research, and national emergency response-all critically important elements and capabilities integrally linked to the broader VA mission as well as the American medical 

system. 

The report does note however, that while care delivered in VHA in many ways 

is comparable or better in clinical quality to that generally available in the private 

sector, it is inconsistent from facility to facility because of operational systems and 

processes, access, and service delivery problems. 

Specialty programs and resources are unique and distinctive capabilities which 

set VHA apart from the private sector in its ability to deliver critical and specialized 

medical services. This is particularly true in the areas of behavior health care programs, integrated behavioral health and primary care through its patient-aligned 

care teams, specialized rehabilitation services, spinal cord centers, and services for 

homeless veterans-core competencies and capabilities which should be expanded, enhanced, and shared across government and private sector health systems. 

These unique medical capabilities, combined with other government (DoD and 

other federal health systems) and private sector partners to create high-performing 

networks of care, would allow VHA to more effectively assimilate its system of care 

through integrated community-based health care networks of the VCS. Such change 

would result not only in greater system optimization, but also better serve our veterans. 

MOAA is pleased the Commission recognized VA’s primary overall role in coordinating health care and helping veterans navigate the system whether care is delivered in VA medical facilities or through community providers. Though the new system would allow veterans the option to choose a primary care provider (PCP) from 

all credentialed PCPs across the system, and all PCPs would be responsible for coordinating veterans care, MOAA believes VA must retain ultimate responsibility for 

veterans’ health care and managing health information and patient outcomes to ensure quality and continuity of care and services. 

Like many VSOs, we support the elimination of the current time and distance criteria for community care access (30 days and 40 miles). Implementation of the 

Choice Act using the current restrictive and arbitrary eligibility criteria has created 

problems that require a fresh look at what the standards should be in the new VA 

health system. 

MOAA is also supportive of refocusing health care benefits to allow service-connected, disabled and low income veterans’ higher priority. Additionally, VHA must 

eliminate existing health disparities by making health care equity a strategic priority. The report outlined a number of racial and ethnic health inequities in the sysLeonard.horne on VACREP0180 with DISTILLER

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tem. More must be done to institutionalize cultural and military competency and 

eliminate system disparities as we move forward in the transformation. 

Similarly, MOAA agrees with the Commission’s approach to allowing health care 

providers and professionals such as advanced practice registered nurses to work to 

their full licensure potential. This is already being done in many states and government health agencies, including the Defense Department, and offers a positive solution for addressing VHA’s suboptimal productivity levels. MOAA has strongly advocated for such change as a means to help expand current system capacity and capability. 

Further, the report highlighted the need for VA to invest in transforming its antiquated, disconnected IT systems and infrastructure to improve veterans’ health and 

well-being. MOAA agrees such an investment in a comprehensive electronic health 

care information platform is foundational to VA’s ability to establish, operate and 

sustain a health system equal to or better than what is found in the private sector. 

This platform must be interoperable with other systems within the network, enabling scheduling, billing, claims, and payment. It should be easy for veterans to access their own information so they can better manage their health. Years of underfunding VA IT and financial management clinical, administrative, and business systems has prevented VA from evolving and innovating to remain relevant and agile 

as private sector medicine and patient health needs change over time. 

Governance, Leadership, and Workforce 

MOAA agrees with Commission recommendations to: 

• Develop and implement a strategy for cultural transformation. 

• Reform and modernize VA’s leadership and human capital management systems to recruit, train, retain, and sustain high quality health care professionals 

and executive-level leaders. 

• Create a simple-to-administer alternative personnel system. 

• Transform the organizational structure of VHA and reengineer business processes. 

Cultural transformation across the VA enterprise is imperative and it starts at 

the top with effective leadership. VA’s last major transformation occurred in the 

mid-1990’s. Former Under Secretary of Veterans Health, Dr. Kenneth Kizer told 

commissioners, ‘‘Today’s VHA is intensely, unnecessary complex, and lacks a clear 

strategic direction, and is hampered by overly top-down management at VA’s Central Office (VACO), where the staff size more than doubled in a five year period between fiscal years 2009 to 2014 as a result of centralizing a portion of field operations functions to VACO.’’ 

Of all government agencies, VHA has one of the lowest scores in terms of the organizational health and has repeatedly appeared on the Government Accountability 

Office’s (GAO) high-risk list. GAO has documented well over 100 outstanding systemic weaknesses covering a wide-range of management and oversight problems in 

the VA health care system, including insufficient oversight of employees and leadership. 

While the VA has a reputation for having a highly dedicated staff focused on serving veterans, VHA is often perceived by employees as being very bureaucratic, driven by politics and crisis, and having a risk-adverse culture, with little connection 

to leadership. These findings from the Independent Assessment are persistent and 

prevalent across the system even though VA has undertaken a number of initiatives 

in recent years to address the culture of the environment. 

MOAA agrees with the Commission’s recommendation to create an integrated and 

sustainable culture of transformation where all programs and activities are aligned, 

and leaders at all levels of the organization are responsible and accountable for improving organizational health and staff engagement. 

Such transformation must also include reforming and modernizing VA’s leadership and human capital management systems across the enterprise. Currently VHA 

lacks a comprehensive system for leadership and employee development and urgently requires a workforce management and succession planning strategy for attracting, training, retaining, and sustaining high quality health care personnel and 

executive-level leaders. 

MOAA urges the Committee to support improvements to the Department’s leadership and human capital management systems by providing the necessary funding 

and authorities needed to implement the report recommendations. The VA needs 

the financial incentives and hiring authorities to attract outside leaders and experts 

who want to serve in VHA, to include temporary and/or direct hiring of health care 

management graduates, senior government and private sector health system leaders 

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and experts to stabilize the current workforce and to remain competitive in the 

health care market. 

Additionally, VHA must embrace a systems approach to transforming its organizational structure and reengineer business processes to align with the VHA mission, 

eliminate unclear, duplicative functions, and clarify roles and responsibilities at 

VACO on down to field offices and medical facilities. VHA needs a more simplified 

organizational structure, performance measurements, and processes for business operations-the current operating system is unnecessarily complex, confusing and cumbersome. 

The Commission proposes one model for streamlining VHA structure to reflect the 

structure used in large private-sector hospital systems. MOAA believes this should 

be a priority to eliminate duplication, consolidate program offices, and create a flatter and more sustainable structure. 

Eligibility. MOAA agrees with the Commission proposal to establish an expert 

body to develop recommendations for VA care eligibility and benefit design. 

The criteria for determining health care eligibility has not changed in 20 years 

even though VA’s health system has seen tremendous change during this time. Current criteria are outdated and confusing to veterans and VHA staff and are inconsistently administered across the system. 

The report also spotlighted ‘‘that nothing in law or regulation assures service-connected, disabled veterans of priority of care.’’ The new system must assure priority 

to these as well as other vulnerable segments of the veteran population. 

Major Areas of Concern 

MOAA has some concern about Commission proposals to: 

• Establish a Governing Board of Directors to provide overall VCS governance, 

set long-term strategy, and direct and oversee the transformation process. • Provide a streamlined path to eligibility for health care for those with OtherThan- Honorable (OTH) Discharge who have substantial honorable service. 

The Commission recommends an 11-member board which would be accountable 

to the President, having decision-making authority to establish long-term strategy 

and implement and oversee the transformation of the new health system. 

The Board of Directors would also provide recommendations to the President for 

appointment of a Chief of VHA Care System (CVCS) for a five-year term (could be 

reappointed for a second term). The CVCS would report to the Board and function 

as a chief executive officer of VHA. The idea is to provide longer-term continuity 

in VHA operations and prevent disruption in leadership that often comes with political transitions. 

As with many of our VSO partners, MOAA supports the concept of a longer-term 

appointment for the Under Secretary of Health to ensure continuity when changes 

in leadership occur in the Executive and Legislative Branches, but would not be 

supportive of establishing a Board of Directors. MOAA believes Congress’ role of 

oversight is essential in holding VA accountable in caring for veterans, and Congress must continue to be veterans’ strongest advocate. Establishing a Board of Directors would usurp Congress’ role, add an additional level of bureaucracy, and in 

our view, likely slow progress and hinder transformation. 

Finally, the Commission recommends VA revise its regulations to provide tentative health care eligibility to former servicemembers with an OTH discharge who 

are likely to be deemed eligible because of their substantial favorable service or extenuating circumstances (e.g., traumatic brain injury or post-traumatic stress that 

likely contributed to their OTH discharge). 

MOAA understands the Commission’s concern about VA’s strict interpretation of 

what is truly dishonorable service and agrees the ambiguous and subjective application of regulations resulted in disparities in adjudicating veterans’ cases. MOAA has 

supported establishment of boards to review and upgrade discharges in such cases 

where appropriate. VA estimates there are over 700,000 OTH cases, and it would 

cost upwards of $846 million to implement the Commission’s recommendation, but 

acknowledges the true size of the population and costs are unknown. 

VA also acknowledges the need to streamline the Veterans Benefits Administration’s characterization of discharge adjudication process when veterans apply for 

benefits. The current process is not standardized and is taking far too long for decision-making, preventing veterans from getting the care they need sooner rather 

than later. While VHA has established partnerships with community organizations 

to help link non-eligible veterans to care outside the system, more needs to be done 

to address these disparities. MOAA recommends Congress direct VA to provide more 

information on the current scope of the problem, potential costs and the impact on 

VHA of such changes before implementing the Commission’s recommendation. 

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CONCLUSION 

MOAA appreciates Chairman Miller’s response to the report in a July 6, 2016, 

Washington Post article by stating, ‘‘The report makes it abundantly clear that the 

problems plaguing the VA medical care are severe. Fixing them will require dramatic changes in how VA does business, to include expanding partnerships and community providers in order to give veterans more health care choices.’’ 

MOAA is confident that collectively we can achieve dramatic transformation in 

VHA which will serve our Nation, veterans and their families for decades to come. 

While it will take a significant commitment and investment by government and nongovernment communities, we believe reform is possible and achievable. Our veterans and their families deserve no less. 

MOAA thanks the Committee for considering the important findings and recommendations in the report. Our organization looks forward to working with the 

Congress, the VA and the Administration to reform and modernize the VHA system 

of care. 

f 

NOVA 

September 6, 2016 

The Honorable Jeff Miller 

Chairman 

House Committee on Veterans’ Affairs 

345 Cannon House Office Building 

Washington, D.C. 20515 

Dear Chairman Miller: 

On behalf of the over 3,000 members of the Nurses Organization of Veterans Affairs (NOVA), we would like to offer our thoughts regarding the Commission on 

Care Final report being discussed before your Committee today. 

NOVA thanks the Commissioners for their hard work and believes many of the 

recommendations offered will improve the care we provide veterans every day at VA 

facilities around the country. Recommendations to include providing additional resources to modernize IT, increase HR and other support staff, strengthen capital assets and recruit and retain a high quality professional workforce, all have our support. 

The most glaring recommendation - and one that has received strong opposition 

from veterans’ advocates and those in the community working to care for veterans 

- is a proposal that would create a VHA Independent Board which would govern the 

VA health care system. 

NOVA strongly opposes giving an outside board - made up of civilian health care 

executives who may have never set foot into a VA facility - the authority to make 

decisions about the care and services provided America’s veterans. Creating another 

layer of bureaucracy, which would take VA’s ability to manage care away from those 

who are held accountable by this very body seems ill-advised. Oversight for veterans’ health care handed over to a newly created external board would all but dismantle the most effective and innovative features of the current VA system - the 

Primary Care/Mental Health Integrated approach. It also fails to take into account 

the many wrap around services that VA offers veterans, while ironically recognizing 

that VA provides better coordinated care than any of its private sector partners. 

NOVA agrees in order to reform VA so it can best serve our nation’s veterans, 

we must expand access to services that it currently provides by hiring at VA facilities where demand exceeds available staffing, where geographic challenges exist, 

and specific services are not offered, allowing veterans the option of using purchased 

care available through its community providers. 

Community providers should be a crucial part of the integrated network of care, 

but VA must remain the first point of access and coordinator of all care. As nurses, 

managing workflow and coordinating care is key to providing the quality that serves 

as a model for VA’s ‘‘whole health’’ approach to care. 

NOVA asks that any discussion regarding the Commission’s proposed recommendations to improve gaps in service be made in a thoughtful, transparent process and involve all stake holders. Preserving an integrated health care community 

designed to put veterans first must include VA. It is VA care that veterans overwhelming prefer and deserve. 

Sincerely, 

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1 Commission on Care, Final Report, June 30, 2016, p. 32 (hereafter ′′Report′′). 

Sharon Johnson, MSN, RN, President 

Nurses Organization of Veterans Affairs 

f 

PARALYZED VETERANS OF AMERICA 

Chairman Miller, Ranking Member Takano, and members of the Committee, Paralyzed Veterans of America (PVA) would like to thank you for the opportunity to 

express our views on the Commission on Care’s Final Report. We appreciate the 

Committee’s continued commitment to thoroughly examining the best way forward 

for comprehensive reform in the delivery of veterans health care. 

Redesigning the Veterans’ Health Care Delivery System 

The VHA Care System 

Recommendation #1: Across the United States, with local input and knowledge, 

VHA should establish high-performing, integrated community-based health care networks, to be known as the VHA Care System, from which veterans will access highquality health care services. 

PVA supports the creation of fully integrated health care networks with the Department of Veterans Affairs (VA) maintaining responsibility for all care coordination. This part of the recommendation is consistent with the proposal that PVA 

along with our partners in The Independent Budget (IB)-DAV and VFW-put forward 

late last year. We also support eliminating the 30-day and 40-mile standards for access established as part of the Choice program. The IB offered a similar recommendation last year suggesting that access to care and when and where to seek 

service should be a clinically-based decision determined by the veteran and his or 

her provider, not an arbitrary access standard. Despite our support for the concept 

of creating fully integrated health care networks, we have some significant concerns 

with other aspects of the Commission’s recommendation. 

We are first, and foremost, concerned with the Commission’s recommendation for 

‘‘choice.’’ The report proposes that veterans should have unrestricted choice for any 

primary care provider within their newly-constructed network. In order to access 

specialty care (outside of VA’s specialized services), veterans would be required to 

get a referral from their designated primary care provider. 

The Commission does not, however, discuss what the boundaries should be in establishing the networks. The breadth of the networks is limited only by the Commission’s assumption that the networks will be ‘‘tightly managed’’ by VA and that 

primary care providers wishing to participate will meet certain quality standards. 

Together these two parameters do not establish a clear picture as to what extent 

VA may efficiently dilute its capacity to deliver care in favor of outsourcing to the 

private sector. 

These networks must be developed and structured in a way that preserves VA’s 

capacity to deliver high-quality care while specifically preserving its core competencies and specialized services. Without a critical mass of patients, VA cannot 

sustain the very infrastructure that supports and makes VA specialized services 

world-class. Providing veterans unfettered choice as to their provider jeopardizes 

this baseline of patients. A better proposal is found in VA’s Plan to Consolidate 

Community Care Programs, which rests on a principle of using community resources to supplement service gaps and better realign VA resources. This sets a natural boundary that would prevent the networks from expanding to a harmful and 

unmitigated degree. Ultimately, the Commission failed to articulate what constitutes a ‘‘tightly managed’’ network, and it admittedly did not contemplate 

‘‘[r]eductions in the volume of care within VA facilities, and potentially adverse effects [on] quality . . . .’’ 1 The result we are left with is lip service paid to preserving 

VA’s specialized services. 

In addition to VA specialized services, there is insufficient discussion regarding 

care coordination within these networks. The recommendation suggests that care coordination take place through all primary care providers, but VA would assume 

overall responsibility for care coordination of all enrolled veterans. There is no delineation, though, as to exactly where VA and community providers hold responsibility. 

The recommendation is conflicting and could ultimately lead to finger pointing instead of well-coordinated care for veterans being served in the community. We 

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2Department of Veterans Affairs, Plan to Consolidate Programs of Department of Veterans 

Affairs to Improve Access to Care, October 30, 2015, pp. 21-25, http://www.va.gov/ opa/publications/ va—community—care—report—11—03—2015.pdf. 3 VHA Patient Advocacy Program, VHA Handbook 1003.4 (2005). 

would again point to VA’s Plan to Consolidate Community Care Programs. 2 VA’s 

proposal would administer care-coordination based on the intensity of coordination 

needed. This method offers the functionality and flexibility needed to ensure that 

patients with complex cases receive adequate attention and resources. It also tailors 

the level of care coordination to each individual patient’s complexity and needs, regardless of whether the patient receives care in VA facilities or in the community. 

We are further concerned with the report’s consideration of funding for the new 

health care delivery system. It does not clearly reconcile how VA currently determines its appropriations needs through the Enrollee Health Care Projection Model 

(EHCPM) with how it will have to determine its appropriations needs through the 

new system with local leadership input. 

The report also considers cost-sharing, particularly for veterans with non-service 

connected disabilities. The cost-sharing opportunity would be used to expand options 

for choice, but it would likely come with increased costs for Priority Group 4 (nonservice connected catastrophically disabled) who do not currently have a cost for 

their care. This proposal is contemplated within the larger context of determining 

priority of service. The report recommends priority be given to service-connected disabled veterans and those with low incomes, but it does not properly consider the 

relationship of Priority Group 4 veterans to the system. 

Finally, as VA begins to involve community providers at a greater rate, it is essential to ensure that the process for adjudicating medical malpractice claims is the 

same whether that care was received in the community or within VA. In almost all 

cases, the current process under 38 U.S.C. §1151 treats malpractice claims the same 

regardless of where they received care. However, certain unique situations still 

present inequitable results for veterans. 

Clinical Operations 

Recommendation #2: Enhance clinical operations through more effective use of 

providers and other health professionals, and improved data collection and management. 

PVA generally supports this recommendation as it would allow providers in the 

VA health care system to practice within the full scope of their licenses. The report 

also addresses bed capacity reporting as originally established by P.L. 106–117, the 

‘‘Veterans Millennium Health Care and Benefits Act.’’ It appears to endorse a requirement for VA to report beds as closed, authorized, operating, staffed, and temporarily inactive. 

We reiterate our support for reinstating the capacity reporting requirement originally established by P.L. 104–262, the ‘‘Veterans’ Health Care Eligibility Reform Act 

of 1996.’’ VA has not maintained its capacity to provide for the unique health care 

needs of severely disabled veterans. Reductions in both inpatient beds and staff in 

VA’s acute and extended care settings have been continuously reported throughout 

the system of care, particularly since the capacity reporting requirement expired in 

2008. 

Recommendation #3: Develop a process for appealing clinical decisions that provides veterans protections at least comparable to those afforded patients under other 

federally-funded programs. 

PVA supports this recommendation as it aligns VA with widely accepted medical 

practice. As it stands, each Veteran Integrated Service Network (VISN) has its own 

process for appealing clinical decisions. Failure to standardize the appeals process 

across VA naturally produces a disparity in outcomes among similarly situated veterans seeking to bring clinical disputes. Furthermore, external review of final VA 

decisions is subject to the discretion of the VISN director. 

One aspect of current VA policy that is not addressed in the Commission’s report 

is the latent conflict of interest in the patient advocate office that each VA facility 

employs to manage and resolve complaints. While patient advocates generally serve 

as the liaison between patients and clinicians, their ability to fully advocate on behalf of the veteran is hampered by the fact that they are forced to present criticism 

to those who hold the keys to their career. The ‘‘program operates under the philosophy of Service Recovery, whereby complaints are identified, resolved, classified, 

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4 Report, p. 54. 5 Department of Veterans Affairs, Evidence Brief: Update on Prevalence of and Interventions 

to Reduce Racial and Ethnic Disparities within the VA, http://www.hsrd.research.va.gov/ publications/esp/ HealthDisparities.pdf, pp. 1, 3, 33. 6 Id., p. 28, 31. 7 Report, p. 137. 

menting complaints in order to facilitate positive changes at VA is productive, but 

the incentive to downplay patterns of conduct and other pervasive issues exists and 

limits potential progress. As a solution, PVA has suggested before that the patient 

advocates should be removed from their current personnel structure and report instead to the MyVA Veterans Experience Office in order to offer more robust, constructive criticism when patterns emerge among veteran complaints. 

Recommendation #4: Adopt a continuous improvement methodology to support 

VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center. 

PVA supports this recommendation. The principle of diffusing knowledge and best 

practices throughout VA is important and should be encouraged. As the report indicates, VA currently has resources, such as the Veterans Engineering Resource Center (VERC), that are underutilized. To truly capitalize on these available benefits, 

though, VA must thoroughly pursue personnel management reform. A large contributor to stagnant innovation and distribution of best practices is due to persistent, 

wide-spread vacancies in senior leadership positions. Acting directors or senior managers, as opposed to permanent leaders, have a limited ability to implement longterm changes because of the uncertainty of their tenure. Fixing the issues that pervade the personnel system will go hand-in-hand with success in adopting a continuous improvement methodology. 

Health Care Equity 

Recommendation #5: Eliminate health care disparities among veterans treated 

in the VHA Care System by committing adequate personnel and monetary resources 

to address the causes of the problem and ensuring the VHA Health Equity Action 

Plan is fully implemented. 

PVA supports certain aspects of this recommendation, but we believe that this 

recommendation perpetuates a false narrative about VA health care prematurely 

and without a thorough understanding of the scope of the problem. Health care systems across the United States are acknowledging and seeking to address health care 

equity, inequality and disparities. VA has conducted its own studies and found that 

disparities do exist. Dealing with these disparities when and where they exist requires affirmative steps to combat the problem. It is essential, however, to thoroughly understand the root causes and true scope of the problem before implementing an effective plan. 

VA’s unique history of providing care for historically underserved populations, 

particularly poor or near poor veterans with chronic medical conditions and behavioral health conditions, suggests that patterns within the private sector should not 

be arbitrarily appropriated to VA without thorough examination. Furthermore, because cost is often not a barrier to care within VA, a significant distinction between 

VA and private sector care must be made based on the absence of typical market 

influences affecting private sector outcomes. 

Before mandating that VA make ‘‘implementation of the VHA Health Equity Action Plan (HEAP) nationwide’’ 4 a strategic priority in the face of all the other competing issues, more research and better information is needed to help inform VA’s 

planning and allocation of resources. The 2015 Evidence Brief relied upon by the 

Commission’s report specifically states that the sources of the disparities identified 

were not examined. 5 The Evidence Brief concludes that more research, specifically 

related to the sources or causes of the disparities is needed before an accurate assessment of the issue can be made. 6 To this end, we support the proposal to plusup the staff dedicated to examining this issue within VA. It will not only encourage 

VA to determine how pervasive certain issues are and root out causes of the disparities that exist, but it will also permit VA to apply lessons learned from its own successes, such as its leadership on the issue of health care equity in the LGBT community acknowledged by the Commission in its discussion related to diversity and 

cultural competence. 7

Facility and Capital Assets 

Recommendation #6: Develop and implement a robust strategy for meeting and 

managing VHA’s facility and capital-asset needs. 

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Position: PVA strongly supports this recommendation. VA’s capital asset management has been substandard, to say the least, in recent years. We support, in accordance with the recommendations of The Independent Budget, the expansion of 

ambulatory or urgent care. We also believe that VA must make a concerted effort 

to right size its infrastructure, in light of the amount of unused and underutilized 

capacity in the system. However, we are not absolutely convinced that a BRAC-modeled concept is the most effective way for VA to realign its capital footprint. Finally, 

we fully support the recommendation the report offers to free the VA of the strict 

fiscal constraints that have hampered its ability to manage its capital leasing program. 

Information Technology 

Recommendation #7: 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. 

PVA fully supports this proposed recommendation. We have repeatedly advocated 

for reform to VA’s IT system management and enterprise through The Independent 

Budget (IB). The IB strongly opposed IT centralization in 2006 (a move forced by 

then Chairman of the House VA Committee, Steve Buyer). We believe many of the 

problems identified by the Commission originated with that centralization, and the 

report essentially affirms our belief. We believe that the Commission’s recommendations could be taken even further to fully decentralize IT into VHA once again. This 

will provide more health care IT innovation, flexibility with the IT budget and better IT outcomes. 

However, we recognize that cost for these reforms remains a significant hurdle to 

advancement. Indeed, VA’s Plan to Consolidate Community Care Programs similarly called for significant IT upgrades in order to be successful. The plan was presented to this Committee in late 2015 and was well-received on both sides of the 

aisle, but several members of Congress balked at the cost of paying for this necessary upgrade. Ultimately, we strongly believe that this is a cost that must be met 

for VA to have the opportunity to fully modernize its IT infrastructure. This is particularly true in light of the discussion regarding use of commercial off-the-shelf 

(COTS) IT products. 

PVA has no strong position on whether VA should choose a COTS solution for its 

IT systems or design its own systems. However, it would seem that leveraging 

COTS would make innovation and modernization more dynamic and possibly more 

cost efficient. 

Supply Chain 

Recommendation #8: Transform the management of supply chain in VHA. 

The Commission accurately outlines the supply and contracting problems within 

VHA and VA. The corresponding recommendations are good business concepts if VA 

and VHA have the funding, ability and leadership to implement them. The recommendation to have VA and VHA re-organize all procurement and logistics operations for VHA under the VHA Chief Supply Chain Officer (CSCO) is the correct 

organizational solution. However, in order to implement the recommendations, there 

must be multiple changes in other departments throughout VA and VHA. Absent 

these changes, implementation of these recommendations will cause disruption, confusion and uncertainty at the Central Office level and will be even worse at the field 

level. 

PVA has also identified some additional concerns with the recommendation. The 

attempt to standardize medical equipment and supplies, as offered in the report, 

would include prosthetic equipment. The danger is that there is no leadership or 

expertise in VHA to manage the standardization of prosthetics. There are certainly 

prosthetic items and supplies that can be standardized, but even those items must 

be carefully reviewed by an expert clinical team composed of clinicians, contracting, 

prosthetic and veteran representatives who use the particular items under consideration. Additionally, the report does not contemplate how far down the supply chain 

standardization of prosthetic equipment should go. 

If VA was to pursue the reforms recommended in this section, PVA has a number 

of implementation level items that could be offered to improve the process and increase the likelihood of a successful transformation. 

Governance, Leadership and Workforce 

Board of Directors 

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Recommendation #9: Establish a board of directors to provide overall VHA Care 

System governance, set long-term strategy, and direct and oversee the transformation 

process. 

While PVA understands the intent of this recommendation, we do not support it. 

We agree with the notion that too frequent turnover of VHA leadership has stymied 

innovative leadership and transformational change. However, replacing politicallyappointed leadership with a Board comprised of leaders representing multiple political ideologies will likely lead to even greater gridlock. At the very least, it is simply 

trading one political entity for another; it does not get rid of the political interference. We can easily envision a scenario where this new appointed Board becomes 

a reflection of the political leadership of Congress that has demonstrated no ability 

whatsoever to govern or compromise. While the current leadership of VA is based 

on nomination by the President and approval by the Senate, this proposal takes political influence too far. One only need to look at the workings of the Commission 

itself and a number of its politically-motivated members to realize the potential negative consequences politically-driven decisions could have on the delivery of health 

care for veterans. 

Additionally, while the recommendation places emphasis on ensuring veterans are 

included on the Board, it does not include any real consideration of veterans’ service 

organization representation. 

Leadership 

Recommendation #10: Require leaders at all levels of the organization to champion a focused, clear, benchmarked strategy to transform VHA culture and sustain 

staff engagement. 

PVA supports this recommendation. This recommendation cuts at the necessary 

leadership to effect the cultural changes required to make VHA a more responsive 

and dynamic organization. 

Recommendation #11: Rebuild a system for leadership succession based on a 

benchmarked health care competency model that is consistently applied to recruitment, development, and advancement within the leadership pipeline. 

PVA supports this recommendation. Succession planning for leadership is a problem that exists across the federal government, not just at the VA. The process by 

which senior leaders are brought into the VA system, particularly VHA, is cumbersome and complicated. VA too often loses out on some of the best candidates because of the nature of the HR process that fills open leadership positions. The direct-hire authority proposed by the report could provide improved opportunities to 

bring on critically needed senior staff in the health care system. Additionally, a renewed focus on leadership development and management could ensure that the best 

candidates are retained in the VHA system. 

Recommendation #12: Transform organizational structures and management 

processes to ensure adherence to national VHA standards, while also promoting decision making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the spread of best practices. 

PVA generally supports this recommendation. We believe the vision that the Commission provides for how to change the organizational structure of VHA could prove 

beneficial to improving management of the system and implementation of policy. We 

are disappointed that the report does not provide more discussion about the inefficiency of the current VISN structure. Additionally, we remain skeptical about the 

efficacy of the proposed simplification of the VHA budget. While this sounds reasonable out of context, it does not reflect the complicated nature of budget development 

and appropriations distribution within VHA. 

We do support the notion of more transparent and detailed accounting and disclosure of VHA’s expenditures. This recommendation is consistent with recommendations made by the IB during debate and passage of legislation to establish advance 

appropriations for VA health care. 

Recommendation #13: Streamline and focus organizational performance measurement in VHA using core metrics that are identical to those used in the private 

sector, and establish a personnel performance management system for health care 

leaders in VHA that is distinct from performance measurement, is based on the leadership competency model, assesses leadership ability, and measures the achievement 

of important organizational strategies. 

PVA generally supports the creation of a workgroup to establish a new performance management system for VHA leadership. However, we are not certain that it 

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is appropriate to establish performance metrics that are identical to those used in 

the private sector. The nature of VA health care delivery is appreciably different 

from the delivery of health care in the private sector. While there are some aspects 

that are similar, the VA health care system is not so much like the private sector 

that it should be evaluated in exactly the same manner. With this in mind, performance standards for employees and management should not be exactly the same either. 

Diversity and Cultural Competence 

Recommendation #14: Foster cultural and military competence among all VHA 

Care System leadership, providers, and staff to embrace diversity, promote cultural 

sensitivity, and improve veteran health outcomes. 

PVA generally supports this recommendation; however, we take exception to the 

implication that VHA somehow lacks the cultural and military competence to provide veterans’ health care. VA is the embodiment of veteran cultural competence, 

and it is, in fact, one of the notable reasons veterans who receive health care from 

VA prefer it over the private sector. We strongly support the recommendation that 

cultural and military competence be criteria for allowing community providers to 

participate in the VA’s integrated health networks. In the past, private providers 

have openly testified before the House Committee on Veterans’ Affairs that one of 

their primary concerns with treating veterans is not understanding veterans and 

their experiences as patients. This very circumstance is one of the primary reasons 

that the private sector is not the ultimate solution to VA’s access problems. 

Workforce 

Recommendation #15: Create a simple-to-administer alternative personnel system, in law and regulation, which governs all VHA employees, applies best practices 

from the private sector to human capital management, and supports pay and benefits 

that are competitive with the private sector. 

Recommendation #16: Require VA and VHA executives to lead the transformation of HR, commit funds, and assign expert resources to achieve an effective 

human capital management system. 

PVA supports many of the pragmatic ideas found in recommendations 15 and 16 

related to VHA workforce issues. A modernized and effective human resources operation is vital to any organization, especially one as large as VA. We believe the federal personnel system is one of the largest hindrances to effective management of 

the VHA system. Recommendations 15 and 16 deal with two aspects critical to successful reform: the authorities which govern the personnel system and the overall 

management of human resources (HR) within VHA. 

The multiple authorities governing the VHA personnel system are incompatible 

with a dynamic high-performing health care system. Hiring managers and their employees must attempt to understand the end-to-end hiring process under four separate rules systems. This unnecessarily adds complexity to the hiring system which 

is difficult for both the potential employee and the human resources staff to navigate. The unnaturally slow hiring process also produces lost talent. Quality employees do not often have the luxury to wait around for a VA employment application 

to be processed. Similarly, when an employee announces his or her forthcoming retirement or departure from VA, HR is unable to begin the recruiting or hiring process for that position until it is actually vacated. It not only causes an unnecessary 

vacancy - exacerbated by the lengthy hiring time - but it also prevents a warm 

handoff between employees and any chance for training or shadowing. 

PVA also believes that VA has suffered from its inability to be competitive with 

its private sector health care counterparts who do not face the same restrictions on 

pay and benefits for critical staff. We support the recommendations to align pay and 

benefits to make the VA more competitive for important staff with the private sector. 

The broad recommendation to consolidate all personnel authorities into one alternative personnel system will bring wide benefits, but it must also include increased 

flexibility in the actual hiring process. It must also establish clear standards for disciplining or removing poor performing employees without diminishing current due 

process protections afforded by law. 

In short, the VHA workforce arena is ripe for numerous practical changes that 

would provide realistic opportunities to reconcile personnel reform and preservation 

of the due process protections currently afforded to VHA employees. 

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Eligibility 

Recommendation #17: Provide a streamlined path to eligibility for health care 

for those with an other-than-honorable discharge who have substantial honorable 

service. 

PVA supports this recommendation. This recommendation mirrors legislation introduced earlier this year-S. 1567 and H.R. 4683, the ‘‘Fairness for Veterans Act’’- 

which PVA publicly supported. There is overwhelming evidence that the effects of 

war can cause psychological harm, drastically changing the personality and behavior 

of servicemembers. Sometimes those effects manifest and adversely affect the terms 

of the veteran’s discharge. It is a poor irony and ultimately unjust to withhold care 

for an injury incurred during service solely because that injury provoked or caused 

the actions which led to their discharge classification. While most commanders are 

dedicated and caring leaders, many do not have the intimate knowledge of a 

servicemember’s behavior prior to the trauma they experienced during military service. Other leaders may even find it ‘‘expedient’’ to rapidly discharge an individual 

to rid themselves of a problem in the unit. Too often these discharges are determined without regard to the cause of the altered behavior. Having an effective 

mechanism to review the discharge in a deliberate manner can ensure that veterans 

deserving of care for injuries incurred as a result of their service are not denied. 

Recommendation #18: Establish an expert body to develop recommendations for 

VA care eligibility and benefit design. 

PVA is very cautious of this recommendation. The Commission generally supports 

with evidence its belief that the issue of eligibility needs to be reexamined or updated in order to better align capacity and demand. But it does not support or even 

present a rationale for why this undertaking should be conducted by an entity outside VA or Congress. The recommendation to outsource this task treads into the territory of eligibility with a different, and potentially harmful, perspective - that of 

business efficiency. 

The benefits currently afforded to, for example, Priority Group 4 veterans reflects 

years of hard work and advocacy that forced our country’s representatives to make 

tough business decisions within the context of long-accepted philosophical principles. 

What this country owes its veterans and what it can afford to pay cannot always 

be reconciled. It does not absolve this nation’s responsibilities to its veterans. In 

such circumstances VA and Congress should act from the perspective that they 

must fight not just to better manage resources but to also find the necessary appropriations to cover the obligation. ‘‘Restructuring the debt’’ and trimming veterans 

from the rolls based on a cold and calculated business-driven decision is not an option. The budget must not be balanced on the backs of veterans. 

Conclusion 

Mr. Chairman, we would like to thank you once again for the opportunity to testify on this important issue. This concludes our statement for the record. We would 

be happy to answer any questions the Committee may have. 

f 

VETERANS OF FOREIGN WARS OF THE UNITED STATES 

MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE: 

On behalf of the men and women of the Veterans of Foreign Wars of the United 

States (VFW) and our Auxiliary, thank you for the opportunity to offer our thoughts 

on the Commission on Care’s final report. 

The VFW thanks the Commission on Care for their hard work and extensive deliberations on how to improve the health care and services a grateful Nation provides its veterans. In particular, we thank Chairperson Nancy Schlichting for her 

work to build consensus among the commissioners and for her willingness to work 

with the major Veterans Service Organizations (VSOs) in order to gain an understanding of what veterans like and want to see improved in their health care system. 

While the VFW does not support every recommendation made by the Commission, 

we certainly believe the Commission accomplished its mission to propose bold transformation that can improve access to high quality care for our Nation’s veterans. 

The VFW urges Congress and VA to act on the recommendations we support and 

consider alternatives to the ones we oppose. 

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Recommendation #1: Across the United States, with local input and 

knowledge, VHA should establish high-performing, integrated community 

health care networks, to be known as the VHA Care System, from which 

veterans will access high-quality health care services. 

Similar to the Independent Budget’s ‘‘Framework for Veterans Health Care Reform,’’ the Commission recommends developing high performing, integrated and 

community based health care networks that leverage the capabilities of private and 

public health care systems to meet the health care needs of veterans in each community. The VFW is glad to see the Commission also agrees that VA must remain 

the coordinator of care for veterans and must develop systems and processes to help 

veterans make informed health care decisions. Doing so is vital to ensuring veterans 

receive high quality and coordinated care, rather than fragmented care which the 

Commission agrees results in lower quality and threatens patient safety. 

That is why the VFW opposes the Commission’s proposal to give veterans a list 

of primary care providers and then find one willing to see them. The VFW does not 

believe it is necessary to trade quality care coordination for choice. Veterans in need 

of a primary care provider must be offered the opportunity to discuss their preferences and clinical needs with a VA health care professional to determine which 

provider (including private sector, VA and other public health care providers) best 

fits their preferences and clinical needs. This would ensure veterans make informed 

choices and receive care tailored them. 

The VFW is also concerned that the Commission’s recommendation on how veterans would navigate its proposed community delivered service (CDS) within the 

Veterans Health Administration (VHA) care system ignores the Commission’s key 

findings regarding care coordination. Instead of fully leveraging the nurse navigators ‘‘to help veterans coordinate their care in VA and in the community,’’ as the 

Commission describes as a possible supplement to its CDS recommendation, it calls 

for private sector primary care providers to coordinate the care veterans receive and 

leaves veterans to fend for themselves when scheduling appointments with community specialty care providers. 

While we agree that a veteran’s primary care provider must have visibility of all 

the care a veteran receives at VA and in the community, we strongly believe VA, 

not the primary care provider, must serve as veteran’s medical home. This includes 

helping veterans schedule appointments with specialty providers when they receive 

a referral from their primary care provider, which would ensure veterans receive 

care that fits their preferences and clinical needs. This also includes consolidating 

a veteran’s medical history into one electronic health care record that is accessible 

by the veteran’s VA and community health care providers. 

In an effort to alleviate demand on its primary care providers, VA is moving towards direct scheduling for certain specialty care, such as optometry and audiology. 

The VFW agrees with VA that certain types of care may not require a primary care 

consult and believes VA must have the ability to waive primary care referral requirements for such specialties. Such waivers must also apply to veterans who receive care through community care networks, which further exemplifies the need for 

VA to serve as the medical home for enrolled veterans. 

Counter to the Commission’s recommendation, the VFW does not believe that the 

majority of eligible care would shift from VA facilities to the community care networks. VFW surveys and direct feedback from veterans indicate that veterans would 

like to receive more of their care from VA health care professionals who know how 

to care for their service-connected conditions. In the VFW’s ‘‘Our Care’’ report from 

September 2015, we found that 53 percent of veterans prefer to receive their care 

from VA providers, which is higher than VA’s reported reliance rate of 34 percent. 

VFW surveys of veterans who are eligible for the Choice Program under the 40-mile 

rule, which affords them the option to receive private sector care without a referral 

from a VA provider, also indicate that the majority of veterans continue to prefer 

VA providers despite having unfettered choice. 

However, the VFW is very concerned that open networks could lead to veterans 

receiving care from providers that are available instead of the ones they prefer. The 

VFW has heard from veterans who use the Choice Program that they would prefer 

to go to VA, but their local VA facilities do not provide the services they need, or 

they would have to wait too long for an appointment. 

The VFW fears that VA and Congress would interpret such veterans’ use of private sector care as their preference for private sector care, when in reality they 

would have preferred to receive VA care, but private sector care was their only option. Doing so could lead to more resources being directed to community care networks and further depleting resources VA is given to expand access to the care veterans prefer. That is why the VFW believes continuous evaluation and adjustments 

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to community care networks, as recommended by the Commission, must be based 

on veterans’ preference, not simply utilization of networks. 

Regardless if care is delivered through community providers or VA medical facilities, VA must remain the guarantor of care to ensure such care is high quality, veteran-centric and accessible. That is why the VFW strongly supports the Commission’s recommendation that VA require community care network providers to report 

quality, service and access metrics. The VFW also believes veterans who receive 

care through community care networks must be afforded the same patient rights 

and protections they receive at VA medical facilities. 

The VFW also supports a phased implementation of integrated networks with ongoing management and evaluation, national strategy and local flexibility to ensure 

veterans’ needs are met. However, the VFW opposes the Commission’s recommendation of establishing a board of directors, as discussed in our views of recommendation number nine, and believe management and implementation of integrated networks must be overseen by a multidisciplinary team of VA subject matter experts 

with direct and consistent guidance from local VA health care professionals and 

VSOs, similar to the approach VA used to develop its plan to consolidate community 

care programs and authorities. 

Clinical Operations 

Recommendation #2: Enhance clinical operations through more effective 

use of providers and other health professionals, and improved data collection and management. 

The VFW supports the recommendation to develop training programs for medical 

support assistants (MSA) to ensure VA health care providers devote more time to 

treating veterans rather than administrative tasks. 

While training is important, VA must also address the high turnover in MSA and 

entry level positions at the local level. VA has developed an expedited hiring process 

for MSAs as part of the MyVA transformation. The VFW fully supports this initiative, but believes VA must have statutory authority similar to the VA Canteen Service, which is exempt from title 5 hiring requirements and can directly hire entry 

level employees to fill high turnover positions. 

The VFW does not take a position on the recommendation to grant full practice 

authority to advance practice registered nurses. The VFW defers to VA in determining the most efficient and effective scope of practice of its providers. However, 

we will hold VA accountable for providing timely access to high quality health care, 

regardless if such care is provided by an advance practice registered nurse or a physician. 

Recommendation #3: Develop a process for appealing clinical decisions 

that provides veterans protections at least comparable to those afforded 

patients under other federally supported programs. 

VFW members have experienced firsthand the pitfalls of VA’s clinical appeals 

process. The VFW agrees with the Commission that a well implemented clinical appeals process is necessary to improve patient satisfaction, ensure veterans obtain 

medically necessary care, and mitigate disagreements between veterans and their 

health care providers. Currently, veterans who disagree with clinical decisions by 

their health care provider can appeal to the medical center’s chief medical officer, 

who is reluctant to overturn a decision made by VA health care providers. A veteran 

is then able to appeal to the Veterans Integrated Service Network (VISN) director, 

who rarely overturns a decision made by a medical center chief medical officer. The 

VISN level decision is final, unless a veteran appeals to the Board of Veterans Appeals, which is not a viable option for veterans who require time sensitive medical 

treatments. 

Due to the lack of a system wide clinical appeals process with national oversight, 

veterans have experienced vast differences when appealing clinical decisions between multiple VISNs. That is why the VFW strongly agrees with the commission’s 

recommendation to convene an interdisciplinary panel to revise VA’s clinical appeals 

process. Such a panel must ensure veterans have the ability to provide justification 

or evidence to support their appeals, which many VISNs do not permit. Veterans 

must also have the ability to appeal clinical decisions above the VISN level. 

Recommendation #4: Adopt a continuous improvement methodology to 

support VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center. 

The VFW agrees that improving employee experience is a vital aspect of reforming the VA health care system. The majority of VA employees take pride in their 

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jobs and continuously identify ways to improve efficiency and productivity. However, 

such employees have not been given the tools or the processes to identify problems 

and make changes. That is why the VFW supports efforts to identify and disseminate best practices and recognize innovative employees who improve the care veterans receive. 

Health Equity 

Recommendation #5: Eliminate health care disparities among veterans 

treated in the VHA Care System by committing adequate personnel and 

monetary resources to address the causes of the problem and ensuring the 

VHA Health Equity Action Plan is fully implemented. 

The VFW supports this recommendation and agrees that health disparities based 

on social and economic differences have no place in the VA health care system. The 

VFW has heard directly from women veterans that VA employees have confused 

them for caregivers and spouses, or have challenged their veteran status because 

of their gender. Veterans of all races, backgrounds, and genders have sacrificed in 

defense of this Nation and must be treated with the respect and dignity they have 

earned and deserve. 

The VFW strongly supports building cultural and military competence among all 

community care network providers and employees. It is important that veterans receive care from providers who understand their health care needs and are familiar 

with the health conditions associated with their military service. This includes providers in VA medical facilities and private sector providers who participate in community care networks. By providing cultural competence training, VA would improve health care outcomes and ensure veterans receive care that is tailored to their 

unique needs. 

Facility and Capital Assets 

Recommendation #6: Develop and implement a robust strategy for meeting and managing VHA’s facility and capital asset needs. 

The VFW agrees with most of the recommendations provided regarding capital infrastructure. 

We agree that waiving congressional rules requiring budgetary offsets for a period 

of time and expanding the enhanced-use lease authority will allow VA to enter into 

needed leases, without accounting for the cost of the entire lease in the first year. 

However, suspending this offset requirement for a few years will leave VA in the 

same position it finds itself in today if Congress does not find a long term solution 

to VA’s leasing authority. VA also needs broader authority to enter into enhanceduse leases agreements. Public Law 112–154 reduced VA’s authority to allow for only 

adaptive housing. Returning it to its prior authority will allow VA to lease more of 

its unused or underutilized property, while still contributing to the mission of VA. 

The VFW also agrees that reevaluating the total cost of minor construction 

projects is needed. Currently, VA will submit multiple minor construction projects 

that appear to be related for a single facility. This is evidence that either the $10 

million cap on minor construction projects needs to be increased or VA needs the 

authority to bundle multiple minor contracts for the ease of planning and appropriating several minor projects at one time without violating the $10 million cap. 

Regardless of whether the cap amounts are adjusted, underfunding will continue to 

place much needed construction projects in competition with each other. Congress 

must fund VA construction accounts to a level where projects to expand access are 

not in competition for resources for new facilities or eliminating safety risks in facilities VA must maintain. 

The Commission recommends that a board analyze and make recommendations 

regarding VA’s infrastructure needs and the CDS networks. The VFW believes that 

most of the functions of this proposed commission are already being carried out by 

either the Strategic Capital Infrastructure Plan (SCIP) or the Federal Real Property 

Council (FRPC). The VFW believes that the current roles of SCIP and the FRPC 

would need to be expanded to include the evaluation of community care on the overall capital planning process. SCIP analysis should be expanded to include the feasibility for public-private partnerships and sharing agreements with other public and 

community provides. This would fulfil the idea of better leveraging community resources to expand VA’s capacity and capabilities. 

The VFW does not agree with the Commission on Care’s BRAC realignment commission. The SCIP process already addresses the issue of under/unutilized property, 

and it is Congress that has failed to act to remove these properties. The reason they 

have failed to act is the same reason they would fail to act under a BRAC-style recommendation—local pressure from the veterans’ community would cause them to 

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vote ‘‘no.’’ The solution is to develop better communication with the local veterans’ 

community and present the replacement plan that will occur when their VA hospital 

is closed. Veterans’ fear of losing VA care drives Congress’ inaction, and no commission or board will fix that without improved communications. 

Information Technology 

Recommendation #7: 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. 

The VFW agrees that VHA must have a chief information officer (CIO) to focus 

on the strategic health care information technology (IT) needs of the VA health care 

system. VA Assistant Secretary for Information and Technology LaVerne Council 

has discussed the need for a senior level employee to oversee VHA IT projects. The 

VFW agrees that the VHA CIO must work closely with VHA clinical and operations 

staff to ensure IT systems meet the needs of their users, but continue to report to 

the Assistant Secretary for IT to ensure interoperability with Veterans Benefits Administration (VBA) and National Cemetery Administration (NCA) systems. 

The VFW agrees that the lack of advance appropriations for VA’s IT accounts has 

hindered VA’s ability to properly fund IT projects, specifically ones associated with 

VHA which is funded under advance appropriations. That is why the VFW has continuously called for Congress to provide advance appropriations for all of VA’s budget accounts. We thank this Committee and the Senate Committee on Veterans’ Affairs for enacting legislation to authorize advance appropriations for VA’s medical 

services and mandatory accounts to ensure veterans can continue to receive care 

and benefits during a government shutdown, but it is vital that VA’s remaining accounts, including IT, community care, research, NCA, VBA, Inspector General and 

VA’s four construction accounts receive advance appropriations to ensure VA can 

fulfill its mission to veterans. 

The VFW does not have a position on whether VA should purchase a commercial 

off-the-shelf (COTS) electronic health care system. However, the VFW agrees that 

VA should turn to COTS products when such products are financially beneficial and 

lead to improved services for veterans, but VA must have the authority to develop 

homegrown products when necessary. 

Supply Chain 

Recommendation #8: Transform the management of supply chain in VHA. 

The VFW supports this recommendation to reorganize and standardize VA’s supply chain to leverage economies of scale. This recommendation is similar to one of 

Secretary Robert McDonald’s MyVA priority goals aimed at building an enterprisewide integrated medical-surgical supply chain that leverages VA’s scale to drive an 

increase in responsiveness and a reduction in operating costs, which the VFW fully 

supports. 

This transformation must rely on local level feedback and buy-in to succeed. While 

each medical facility cannot continue to dictate where their medical supplies are 

purchased, they must be given the opportunity to request specific supplies or products if needed in order to provide the best quality care. This is similar to non-formulary requests for prescriptions that are not on the VA’s formulary. The transformation must also consider whether specific products are preferred or clinically 

needed by veterans, such as prosthetics equipment that may cost more, but lead to 

a better quality of life for veterans. 

Board of Directors 

Recommendation #9: Establish a board of directors to provide overall 

VHA Care System governance, set long-term strategy, and direct and oversee the transformation process. 

The VFW opposes this recommendation. The VFW believes VA needs leadership, 

not management by Committee. Similar to the Commission on Care, the governance 

board would include political appointees, the majority of whom would be civilian 

health care executives and veterans who do not use the VA health care system. 

How, when and where veterans receive their health care cannot be determined by 

appointees who do not have a vested interest in improving the care and services veterans receive. 

Additionally, the VFW believes that a governance board would result in more bureaucracy. VHA’s budget requests would still need to be approved by the Office of 

Management and Budget and appropriated by Congress. This recommendation also 

fails to resolve the misalignment between capacity to provide care and the demand 

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on its programs that is highlighted in the Commission’s report. The VFW recommends reforming the congressional appropriations process to ensure VA receives 

the resources it needs to meet veterans’ health care needs, instead of creating more 

bureaucracy and further limiting how much care VA is able to provide. 

A number of reform ideas have been discussed to address this issue. One proposal 

is to make VA’s health care accounts mandatory spending. Doing so would exempt 

VA health care accounts from discretionary budget caps which have limited VA’s 

ability to expand access and implement needed reforms. Another proposal is to provide VA a true two-year budget by authorizing VA to transfer advance appropriations to its current year budget to cover budget shortfalls. However, such ideas have 

not been given proper consideration by Congress. The VFW believes it is time to 

consider innovative reforms to the VA health care appropriations process. 

This Committee, the Senate Committee on Veterans’ Affairs, the Secretary of Veterans Affairs and the President must continue to provide oversight and management of the VA health care system with or without a governance board. Thus, a 

governance board would mean that VHA leadership would have additional management and reporting requirements which would only serve to further stymie the 

needed transformation process. 

Leadership 

Recommendation #10: Require leadership at all levels of the organization 

to champion a focused, clear, benchmarked strategy to transform VHA culture and sustain staff engagement. 

The VFW supports this recommendation. As discussed above, employee experience 

is vital to restoring veterans’ trust and confidence in their health care system. Secretary McDonald is in the process of addressing this recommendation by transforming VA from a rules based culture to a principles based culture that empowers 

VA employees to do what is right, instead of fearing reprisal for not following every 

rule. Several veterans have reported improvements in the culture at VA medical facilities, but more work is still needed. 

Recommendation #11: Rebuild a system for leadership succession based 

on a benchmarked health care competency model that is consistently applied to recruitment, development, and advancement within the leadership 

pipeline. 

The VFW supports this recommendation. We agree with the importance of succession planning and the need for robust structured programs to recruit, retain, develop and promote responsible and high performing leaders. Specifically, the VFW 

strongly supports the recommendation to adopt and implement a comprehensive 

system for leadership development and management. VA employees must be prepared and willing to fill vacancies in leadership positions to ensure VA is not required to rely on temporary leadership to run its medical facilities. 

Recommendation #12: Transform organizational structures and management processes to ensure adherence to national VHA standards, while also 

promoting decision making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the 

spread of best practices. 

The VFW generally supports this recommendation. We agree that the VA central 

office and VISN office staff have grown too rapidly and that fragmented authorities, 

lack of role clarity and overlapping responsibilities impacts VA’s ability to deliver 

high quality and efficient health care. Specifically, the VFW agrees that VHA must 

consolidate program offices to create a flat organizational structure to streamline 

VHA’s current cumbersome and duplicative organizational structure. 

The VFW understands the Commission’s recommendation that Congress should 

reduce the number of VA appropriations accounts. While it is essential for Congress 

to use its power of the purse to influence VA programs, Congress must do so effectively and not impede VA from fulfilling its mission. For example, the Military Construction and VA Appropriations Act recently passed by the House and being considered by the Senate limits VA’s VistaA Evolution project to $168 million, but requires 

VA to meet certain requirements before the funds become available. While the VFW 

understands the need for such reporting requirements, we believe VA must have the 

flexibility to use such funds immediately. Withholding such funds only serves to further delay VA’s plans to modernize its electronic health care record. 

Recommendation #13: Streamline and focus organizational performance 

measurement in VHA using core metrics that are identical to those used in 

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tem for health care leaders in VHA that is distinct from performance measurement, is based on the leadership competency model, assesses leadership 

ability, and measures the achievement of important organizational strategies. 

The VFW supports this recommendation. It is important to develop a performance 

management system that effectively measures outcomes and holds VA leaders accountable for improvements. 

However, the VFW does not believe such performance measures need to be identical to those used in the private sector. VA performance measures must adopt best 

practices from the private sector, but they must also acknowledge VA’s unique mission and the fundamental differences between private and public health care systems. 

Diversity and Cultural Competence 

Recommendation #14: Foster cultural and military competence among all 

VHA Care System leadership, providers, and staff to embrace diversity, 

promote cultural sensitivity, and improve veterans’ health outcomes. 

The VFW strongly supports this recommendation. As discussed above, cultural 

and military competence training of providers would ensure veterans receive care 

that is tailored to their unique needs. 

It is particularly important to build cultural competency among community care 

providers who do not have experience caring for veterans or may not be aware of 

best practices when caring for veterans with service-connected wounds and illnesses. 

A study by the RAND Corporation found that only 13 percent of private sector mental health care providers are ready and able to provide culturally competent and evidence based mental health care to veterans. The VFW believes VA must leverage 

the capacity of the private sector to provide mental health care to veterans, but it 

must also ensure veterans who use community care receive high quality and veteran-centric care by providing military competency training and sharing best practices with community care providers and ensuring such practices are adopted. 

Workforce 

Recommendation #15: Create a simple-to-administer alternative personnel system, in law and regulation, which governs all VHA employees, 

applies best practices from the private sector to human capital management, and supports pay and benefits that are competitive with the private 

sector. 

The VFW supports this recommendation. VA must be able to recruit, train, retain 

and discipline a high performing workforce. The VFW agrees that civil service laws 

and regulations that govern how government employees are hired, how much they 

are paid, and how they are disciplined were not designed to support a high performing health care system. VA must have a personnel system that eliminates barriers to hiring and retaining high quality employees. 

We agree with the Commission that Congress must afford VA employees appropriate due process to appeal disciplinary actions. The VFW has also supported a 

number of accountability measures considered by this Committee, including H.R. 

5620, the VA Accountability First and Appeals Modernization Act of 2016, which 

would expand the Secretary’s ability to remove or demote employees for poor performance or misconduct. Overall, the process that is taken to remove or demote VA 

employees who commit malfeasance must ensure such employees are no longer allowed to collect a paycheck or harm veterans, but protect good employees and whistleblowers from being wrongfully terminated or retaliated against. 

The VFW also agrees with the need to improve VA’s student loans reimbursement 

programs. However, VA is already authorized to reimburse health care professionals 

up to $120,000 over five years of student debt, which is similar to the National 

Health Service Corps’ loan repayment plan program. While the VFW would support 

increasing the amount VA health care professionals may receive, it would not make 

VA more competitive when hiring or retaining high quality employees, because local 

facilities are not given enough funds to fully utilize this program. For example, the 

VFW heard from a VA nurse that her medical center is given $80,000 per year for 

the education debt reduction program. These means the facility could reimburse 

three providers the maximum allowed amount of $25,000 or divide the $80,000 

amongst its dozens of providers and render the retention incentive ineffective. To 

properly utilize this incentive, Congress and VA must properly fund this program. 

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Recommendation #16: Require VA and VHA executives to lead the transformation of HR, commit funds, and assign expert resources to achieve an 

effective human capital management system. 

The VFW supports this recommendation. We often hear from VA medical facilities 

that they struggle to hire needed staff because of the cumbersome human resources 

(HR) process. Specifically, the outdated and ineffective rules and regulations that 

govern when and how VA can recruit possible candidates puts VA at a disadvantage 

when competing with the private sector to recruit high quality health care professionals. 

Secretary McDonald has made some progress in addressing this issue by deploying rapid process improvement workgroups which identify and resolve regulatory 

barriers that adversely impact the hiring process and improve an applicant’s experience when applying for VA jobs. However, the VFW agrees with the Commission 

that VA HR systems and processes must be prioritized and improved. It is unacceptable for VA HR professionals to be required to operate 30 disparate IT systems. 

When HR is unable to do its job efficiently, VA medical facilities are not able to fill 

vacancies quickly, which leads to access problems that negatively impact veterans. 

It is also deplorable that VA’s cumbersome HR rules and processes impede its ability to remove or demote wrongdoers. 

Eligibility 

Recommendation #17: Provide a streamlined path to eligibility for health 

care for those with an Other-Than-Honorable discharge who have substantial honorable service. 

The VFW fully supports the recommendation to amend VA’s current health care 

eligibility regulation and provide VA health care and benefits to veterans with other 

than honorable (OTH) discharges, if their overall service is deemed honorable. 

Under current law, a veteran who meets other eligibility criteria and has a discharge that is other than dishonorable is eligible for VA health care. However, VA’s 

process for determining which veterans are considered to have an other than dishonorable discharge is flawed, and generally results in veterans who have anything 

less than an honorable discharge being denied benefits. 

This is a particular concern for veterans who served honorably in combat, but 

were administratively discharged upon returning home due to relatively small infractions, like missing formations or being charged with alcohol-related incidences. 

VA regulations do not consider discharges for minor offenses as dishonorable, if such 

veteran’s service was otherwise honest, faithful and meritorious. 

Unfortunately, VA’s process for determining eligibility is not consistent and often 

fails to properly account for a veteran’s entire service. In their recent report, ‘‘Underserved: How the VA Wrongfully Excludes Veterans with Bad Paper,’’ Swords to 

Plowshares, the National Veterans Legal Service Program and the Veterans Legal 

Clinic at the Legal Service Center of Harvard Law School found that instead of 

granting OTH veterans the health care and benefits they have earned, VA has 

lumped them in with bad conduct and dishonorable discharges, which are reserved 

for servicemembers convicted of wrongdoing at a court martial—thus resulting in 

90 percent of OTH veterans being denied the benefits and services they have 

earned. 

Without access to VA health care, those suffering from service-related mental 

health injuries are left on their own to deal with their mental health symptoms, 

making recovery nearly impossible. The VFW supports amending VA’s regulation to 

ensure veterans with OTH discharges who committed minor infractions but otherwise completed honorable service, receive full eligibility for health care and benefits. 

Additionally, VA must also ensure veterans who present to a VA medical facility 

with a medical condition that requires urgent or emergent medical attention, such 

as a veterans who shows signs of suicidal ideation, are not required to undergo a 

cumbersome character of discharge review before receiving lifesaving care. Veterans 

who are later determined to be ineligible for VA health care must be transitioned 

to other health care options, but veterans cannot be denied lifesaving care simply 

because VA rules require a flawed and time consuming character of discharge review process. 

Recommendation #18: Establish an expert body to develop recommendations for VA care eligibility and benefits design. 

In every past evaluation and change to the eligibility criteria for health care, access to care was increased to unserved populations of veterans, or eligibility was realigned to conform with an updated delivery model. With those two facts in mind, 

and understanding that the development of an integrated health care system will 

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deliver care under a different model, the VFW supports the idea of studying access 

barriers based on current eligibility criteria while ensuring service-connected, homebound and catastrophically disabled veterans do not incur barriers or delays in services or care. Additionally, the VFW would oppose any proposal to increase the 

health care cost shares for veterans. 

f 

VIETNAM VETERANS OF AMERICA (VVA) 

Chairman Miller, Ranking Member Takano, and distinguished members of this 

august Committee, Vietnam Veterans of America presents for the record, and for 

your consideration, our observations on the final report of the Commission on Care. 

Before we offer VVA’s comments, we do want to acknowledge the yeoman efforts, 

accomplished on a very tight timeline, by the commissioners and the very knowledgeable and gifted commission staff. In particular, we want to applaud the strong 

and steady leadership of commission chair Nancy Schlichting, who piloted a ship 

with a diverse crew with very different ideas through very rocky waters. She deserves our praise, and your thanks. 

During public meetings of the commission, a number of folks, including the Chairman of this Committee, acknowledged that without a buy-in from the veteran’s service organizations, the commission’s recommendations, their vision, would not go very 

far. Although there are several very well-thought-out and logical recommendations 

that ought to be adopted via legislation from Congress or regulation from the Department of Veterans Affairs, the ‘‘big picture’’ as conceptualized by the commission 

is in many respects problematical, and cannot garner VVA’s assent. 

Certainly, however, VVA does not quibble with the stated mission of the commission: to enhance and improve a health care delivery system that will ‘‘provide eligible veterans prompt access to quality health care.’’ 

Let us begin with some facts: 

• The Commission on Care was borne of the so-called Choice Act, enacted into 

black-letter law after legislators and the media finally recognized a situation 

that had existed for some two decades. It was a ‘‘scandal’’ that galvanized Congress to act, however belatedly. In fact, the media often put the adjective ‘‘beleaguered’’ before ‘‘VA’’ in their reportage after the scandal broke. That neither 

Congress nor the Administration nor the media had taken heed about a longstanding situation before did not even make the back-story. 

• The Veterans Health Administration is an integrated managed care network, 

the largest in the nation. Long before the legislation that created the Choice 

Act, a provision of which established the Commission on Care, the VHA availed 

veterans of care by community providers, when necessary or appropriate. More 

than one out of every ten VA health care dollars was expended outside of VA 

Medical Centers and community-based outpatient clinics, or CBOCs. 

• VA Medical Centers, for the most part, provide ‘‘one-stop shopping’’ for primary 

and specialty care, something that is not afforded at most private-sector hospitals and health care facilities. In addition, the VHA, under the gritty leadership of the current Under Secretary for Health Dr. David Shulkin, is making 

significant strides in transforming the VA health care system and embracing 

greater community care. 

• The quality of care in VHA facilities is good to excellent and is in many areas 

superior to care from private hospitals or medical centers. This the commission 

has acknowledged. The issue is, as it has been, one of access into VA health 

care facilities, where there are too few clinicians to meet the needs of the veterans the VA is charged with serving. Yet the shortage of health care professionals is hardly limited to the VA; this is a national problem, one that is particularly acute in rural and remote areas as well as in inner cities. 

Now, it should be noted at the outset that the commission’s recommendations for 

transformative change in health care delivery are not intended as an immediate palliative; rather, the charge of the commission was to envision what the VA health 

care delivery system should look like in 20 years, and to provide a blueprint on how 

to get there. 

To the commission’s credit, commissioners rejected the goal of some to privatize 

VA health care. They nixed the idea of unfettered ‘‘choice,’’ of giving eligible veterans the option of going to any private-sector health care providers of their choosing, with the VA footing the bills, which would have transformed the VA, in effect, 

into a source of income. They would scrap the time (30 days) and distance (40 miles) 

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criteria for access to community care, one of the provisions of VACAA, the Veterans 

Access, Choice, and Accountability Act. 

Several of the commission’s recommendations ought to be seriously considered 

and adopted, via either legislation or executive action. These, which can be done 

under the current construct of the VHA, include: 

• Convening ‘‘an interdisciplinary panel to assist in developing a revised clinicalappeals process’’ (Recommendation #3). 

• Consolidating idea and innovation portals, and best practices and continuous 

improvement efforts, in the currently underutilized Veterans Engineering Resource Center. The commission imagines the VERC as having considerable 

input in properly aligning ‘‘systemwide activities [that] require substantial 

change’’- human resource management, contracting, purchasing, information 

technology (Recommendation #4). 

• Making health care equity ‘‘a strategic priority,’’ increasing ‘‘the availability, 

quality, and use of race, ethnicity, and language data to improve the health of 

minority veterans and other vulnerable veteran populations with strong surveillance systems that monitor trends in health status, patient satisfaction, and 

quality measures’’ (Recommendation #5). 

• Because the VHA ‘‘not only lacks modern health care facilities in many areas, 

but generally lacks the means to readily finance and acquire space, to realign 

its facilities as needed, or even to divest itself easily of unneeded buildings . 

. . it is critical that an objective process be established to streamline and modernize VHA facilities . . .’’ The commission also offers that the ‘‘facility and capital asset realignment process’’ be modeled after the wildly unpopular but necessary DoD Base Realignment and Closure Commission (BRAC) process ‘‘as 

soon as practicable.’’ With Congress not overly enthusiastic about the BRAC 

process for eliminating outmoded or unneeded DoD facilities here in CONUS, 

to think that legislators will embrace this idea of shuttering VA facilities is piein-the-sky (Recommendation #6). 

• ’’. . . VA requires a comprehensive electronic health care information platform 

that is interoperable with other systems; enables scheduling, billing, claims, 

and payment, and provides tools that empower veterans to better manage their 

health’’ (Recommendation #7). 

• Because VHA’s supply chain management ‘‘is encumbered with confusing organizational structures, no expert leadership, antiquated IT systems that inhibit 

automation, bureaucratic purchasing requirements and procedures, and an ineffective approach to talent management,’’ the VA should establish the position 

of VHA chief supply chain officer, to be compensated ‘‘relative to market factors,’’ the first step in achieving ‘‘a vertically integrated business unit extending 

from the front line to central office’’ (Recommendation #8). 

Perhaps the key recommendation of the commission that we can embrace is the 

need to achieve strong, sustained - and sustainable - leadership on all levels of the 

VHA. Congress must therefore authorize ‘‘new and expanded authority for temporary rotations and direct hiring of health care management training graduates, 

senior military treatment facility leaders, and private not-for-profit and for-profit 

health care leaders and technical experts.’’ The VHA also should establish ‘‘two new 

programs. The first is to create opportunities for VHA physicians to gain masterslevel training in health care management to prepare them to lead a medical facility. 

Second, VHA should work to create rotations in VHA for external physicians who 

are completing graduate health care management programs.’’ 

What the commission advocates here, and what was a key discussion point during 

its public meetings, is the need to attract, and to train, the best and the brightest, 

who would serve for a set term or the long term, and who would be recompensed 

according to the market in a particular catchment area. To achieve this, Congress 

must empower the VHA to offer competitive salaries and benefits to attract the 

most qualified candidates, both from within and from out of the VHA hierarchy 

(Recommendation #11). 

The commission notes the need for ‘‘developing the cultural and military competence of [VHA] leadership, staff, and providers, as well as measure the effects of 

these efforts on improving health outcomes for vulnerable veterans.’’ The commission is on target in asserting that ‘‘cultural and military competency’’ must be 

among the criteria for ‘‘credentialing’’ external clinicians to treat veterans (Recommendation #14). 

Finally, here is a relatively radical recommendation that warrants congressional 

scrutiny and consideration: ‘‘Provide a streamlined path to eligibility for health care 

for those with an other-than-honorable discharge who have substantial honorable 

service.’’ The commission recognizes, rightfully, that some former servicemembers in 

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fact ‘‘have been dismissed from military services with an other-than-honorable 

(OTH) discharge because of actions that resulted from health conditions (such as 

traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], or substance 

use) caused by, or exacerbated by, their service,’’ thus rendering them ineligible for 

VA health care and other benefits. ‘‘This situation leaves a group of former 

servicemembers who have service-incurred health issues (namely mental health 

issues) unable to receive the specialized care VHA provides’’ - care that they vitally 

need. 

The commission proposes, ‘‘VA revise its regulations to provide tentative eligibility 

to receive health care to former servicemembers with an OTH discharge who are 

likely to be deemed eligible because of their substantial favorable service or extenuating circumstances that mitigate a finding of disqualifying conduct.’’ This may not 

be simply a matter of the VA revising regulations - Congress will need to enact legislation to enable the VA to treat these veterans - but it is an idea worthy of merit. 

THE FUNDAMENTAL PROBLEM, however, with the commission’s 

conceptualization for the future of VA health care commences in the language of its 

initial recommendation. This calls for ‘‘. . . community-based health care networks’’ 

that will ‘‘integrate health care within communities.’’ This would essentially fold 

VA-provided health care into a wider community-oriented network of providers rather than integrating local or regional providers into a VA network. It is this overall 

structure envisioned by the commission of a ‘‘new’’ VHA that is the problem. 

Perhaps more basic to the relationship between clinician and patient is the assumption that most veterans want to choose their primary and specialty health care 

providers. This precept, the second basic issue we have with the commission’s blueprint, is fundamentally flawed. The commissioners tripped up in paying fealty at the 

altar of Choice, in conceptualizing an entirely new governance structure, in sublimating VA health care facilities into an expansive community context dubbed the 

‘‘VHA Care System.’’ Yes, by all means VA clinicians should continue to refer veterans to outside providers when and where appropriate to improve access as well 

as to provide care that VA clinicians are unable to deliver. However, no, the VA 

should not cede, as the commission recommends, the role of primary care clinician 

to non-VA personnel; this would be a critical misstep, undermining the integrity and 

managed care the VA offers. 

If a veteran needs to see a specialist, s/he often has little ability to divine on his 

or her own whom to go to and must rely on the recommendation of their primary 

care provider. In the brave new world envisioned by the commission, the veteran 

can ‘‘choose’’ to see the ‘‘credentialed’’ specialist of his/her choice. Does anybody really think that this will enable a veteran to get same-day service from a busy clinician? Alternatively, provide better care than s/he can receive at a VAMC or CBOC? 

On the other hand, save the system money? 

In addition, consider the potential for this: If a patient who is covered by private 

health insurance chooses to be treated by a physician not in the network assembled 

by her health insurer, she has to pay that doctor out of pocket and fill out a claim 

form to receive some reimbursement from her insurer. Yet what if that veteran 

wants to go to a clinician whom the VA has not credentialed? Will he have to shell 

out his own money, even if he has a disability rated at, say, and 70 percent? Will 

that veteran complain to his Member of Congress, who will then demand from the 

local VHA Care System why Dr. X has not been ‘‘credentialed’’? It is not difficult 

to foresee a bureaucratic headache of major proportions. 

‘‘Foundational among the changes’’ the commission seeks is ‘‘forming a governing 

board to set long-term strategy and oversee the implementation of the transformation process, and building a strong, competency-based leadership system.’’ This 

is the third fundamental misconception of the commission. The governing board that 

the commission envisions as necessary to achieving a ‘‘bold transformation’’ ignores 

reality. Their ‘‘Board of Directors’’ would be a paper tiger that, without the power 

of the purse, can only recommend, not appoint or institute, thus making it a board 

of advisors. 

In addition, veteran service organizations and veteran leaders in effect already 

function as an informal board of advisors on the national and local levels. The VA 

would have far fewer perceptional problems if its leaders and senior managers acknowledged this and worked in concert with VSOs as a matter of course, seeking 

and embracing our ideas and input at the beginning of a process, not pro forma near 

its conclusion. 

The commission also calls for the creation of ‘‘a simple-to-administer personnel 

system, in law and regulation, which governs all VHA employees, applies best practices from the private sector to human capital management, and supports pay and 

benefits that are competitive with the private sector.’’ Such a system would render 

VA hiring as separate and unequal to how hiring is done in the rest of the federal 

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government. (There can be little argument that ‘‘VHA lacks competitive pay, must 

use inflexible hiring processes, and continues to use a talent management approach 

from the last century.’’) Hence, the recommendation that ‘‘Congress create a new alternative personnel system . . . in collaboration with union partners, employees, and 

managers . . . that applies to all VHA employees and falls under Title 38 authority 

. . . and improves flexibility to respond to market conditions relating to compensation, benefits, and recruitment.’’ 

On one hand, this makes eminent good sense: to obtain and retain top professionals in both medical treatment and hospital administration, the VA health care 

system needs to be competitive with the incentives in the private sector. Moreover, 

certainly, VHA’s ability to hire qualified staff cannot continue to be hamstrung by 

bureaucratic constraints and ineptitude. While many clinicians choose to work at 

the VA because of job security and protected pensions, others also feel a calling to 

use their skills to care for the men and women who have served the nation in uniform, many of whom have special needs derived from their wartime experiences. 

On the other hand, however, Congress quite likely will be skeptical at best about 

setting precedent by creating an alternative personnel system. Convincing you in 

Congress to in effect turn the VHA into a quasi-governmental entity while continuing to fund its operations will be the ultimate hard sell. It was the wait-time 

access issue, a long-time reality in many VA medical centers that raised the ire of 

Congress, not the quality of health care delivered by VAMC personnel. Integrating 

additional health care providers into the VA system, where appropriate and when 

needed, is part of the rejuvenation of the VHA under the current Undersecretary. 

This makes sense. 

The conceptualization of the commission to create a new entity, one in which VA 

and private sector clinicians, many with similar skill sets, in essence ‘‘compete’’ to 

treat veterans will not materially improve health care for those veterans who obtain 

their care at a VA facility. It is likely to dramatically increase the costs of providing 

care; and it is likely to lead to the underutilization of certain VA medical centers 

and community-based outpatient clinics and the subsequent shuttering of several of 

them, with the consequent turmoil in staff morale and, eventually, the loss of tens 

of thousands of jobs. Still, the VA must resolve a situation that continues to plague 

it: ‘‘Hiring timelines [for medical professionals] can span 4–8 months compared to 

private-sector hiring that takes between 0.5 and 2 months.’’ (See Recommendation 

#16.) 

There is yet one more recommendation that we find problematical. 

Prefacing this, the commission acknowledges that the capacity of the VA to provide care ‘‘is constrained by appropriated funding.’’ In its recommendation that Congress or the President charge some entity with examining the ‘‘need for changes in 

eligibility for VA care and/or benefits design, which would include simplifying eligibility criteria,’’ the commission opens the door to initiating pilot projects ‘‘for expanded eligibility for nonveterans to use underutilized VHA providers and facilities, 

providing payment through private insurance.’’ 

The 1996 eligibility reform act created eight ‘‘priority’’ groups of veterans eligible 

for VA health care. Priority 7 and Priority 8 veterans, who are not afflicted with 

service-connected conditions, must agree to a co-pay for the health care and prescription drugs they receive from the VA. They account for some 40 percent of thirdparty collections by the VA. In addition, the Vet Centers, as a matter of course, do 

treat the family members of veterans, a necessity to successfully treat many of the 

mental health maladies suffered by the veterans they love. 

To open a beleaguered health care system to non-vets seems counter-productive. 

Moreover, it also would dilute the very essence of what should be a veteran-centric 

system. Because there is a certain specialness inherent in receiving care in a place 

where your service is acknowledged, where an array of conditions - traumatic amputations, spinal cord injuries, mental health afflictions - are understood, where you 

are among your peers. On this, a monetary value cannot be placed (Recommendation #18). 

The commission acknowledges the raison d’etre for its own creation by the same 

act of Congress that initiated the so-called Choice Program: the issue of access. Yet 

it also acknowledges, ‘‘Access is not a problem for VHA alone: Delivering timely care 

is challenging for many providers and health systems, in part due to the unavailability of providers in some communities and national shortages of some categories 

of health professionals.’’ 

The commission notes the key question with which Congress must grapple: Does 

the VA health care delivery system, despite the wait-time scandal, require ‘‘fundamental, dramatic change - change that requires new direction, new investment, and 

profound reengineering’’? This is a question VVA and other VSOs, MSOs, and veterans across the country need to consider: Can the VA, given the impetus generated 

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by the issue of access, fix itself, or does it require a radical reformation, one that 

can conceivably result in its demise? 

We believe that the VA, specifically the Veterans Health Administration, can fix 

itself and in fact is fixing itself, in great measure because of the impetus generated 

by passage of the VACAA. We would hope that you in Congress will monitor what 

VA leadership is accomplishing; and that members of the media who cover veterans 

issues would focus less on dramatically highlighting the problems and more on what 

is being done to ameliorate them. When the VA messes up, by all means report it 

and let Congress call VA leadership on the carpet. However, report, and so acknowledge, some of the good things that the VA has been doing, e.g., making what is now 

a cure for hepatitis C available to all veterans enrolled in the VA health care system. Thousands of lives are being saved, and this, too, ought to be reported. 

Vietnam Veterans of America appreciates having the opportunity to submit, for 

the record, our position and our conclusions vis a vis the recommendations of the 

Commission on Care. In addition, we thank you and members of the Senate Veterans Affairs Committee for all that they have done, and are doing, for veterans and 

our families. 

f 

HEALTHCARE PROFESSIONALS FEDERAL UNION 

POLICY BRIEF RE COMMISSION ON CARE FINAL REPORT: MAJOR RECOMMENDATION

IGNORES DATA, RISKS VETERANS’ HEALTHCARE

from 

Association of VA Psychologist Leaders 

Association of VA Social Workers 

Nurses Organization of Veterans Affairs 

Veterans Affairs Physician Assistant Association 

American Federation of Government Employees 

National Federation of Federal Employees 

National Association of Government Employees 

National Nurses United 

American Psychological Association 

National Association of Social Workers 

July 22, 2016 

On June 30, 2016, the Commission on Care submitted its Final Report required 

by the Veterans Access, Choice, and Accountability Act of 2014. 

As organizations comprised of and representing health care practitioners, researchers, educators, administrators and personnel devoted to serving Veterans, we 

have serious reservations about the report’s major recommendation to replace the 

current VHA with a new entity, to be known as the VHA Care System. In the proposed VHA Care System, Veterans would be permitted to receive care from any local 

facility or provider who has been credentialed by VHA. Oversight for Veterans’ 

health care would be handed over to a newly created, external governance board. 

According to the Commissions’ charter, ‘‘final recommendations will be data driven.’’ As we demonstrate below, the recommendation to establish a new VHA Care 

System is at odds with compelling evidence of the VHA’s current effectiveness. VHA 

can best serve Veterans by expanding access to services the VHA currently provides. 

• The current VHA system provides health care that is as good as, and more often 

superior to, non-VA care. The Commission’s Final Report affirmed this higher 

quality in VHA, as does RAND’s 2015 evaluation (http://www.rand.org/pubs/research—reports/RR1165z2.html), RAND’s 2016 summary (http://www.rand.org/ 

pubs/research—reports/RR1165z4.html) and a 2016 literature review of 60 scientific publications (http://bit.ly/1UOlEmF). The VHA outperforms non-VA care 

on adherence to recommended preventative care guidelines, adherence to recommended treatment guidelines, outpatient processes and outpatient outcomes. 

Nevertheless, the Commission’s Final Report ignores the implication that vastly 

expanding reliance on local non-VA providers and facilities could worsen, not 

improve, Veterans’ health care. 

• The proposed VHA Care System disassembles one of the most effective, innovative features of current VHA care - the Primary Care/Mental Health Integration 

approach. The Final Report concedes that such integration is largely missing in 

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grated, wrap around services the VA offers through financial, educational, housing, caregiver and employment support. 

• The Final Report recognizes that VHA provides better coordinated care. ‘‘Veterans who receive health care exclusively through VHA generally receive wellcoordinated care, yet care is often highly fragmented among those combining 

VHA care with care secured through private health plans, Medicare, and 

TRICARE. This fragmentation often results in lower quality, threatens patient 

safety, and shifts cost among payers’’ (page 28). It is the VHA, not the disjointed, larger non-VA system, which is the true provider of Veteran-centric 

community care. 

• The Final Report anticipates that 60 percent of eligible care will shift from VHA 

facilities to outside networks (p.31). The net result will reduce, not expand, Veterans’ choices, since to pay for this shift, a VHA Care System will incrementally 

downsize the number of VHA providers and programs. The VHA system would 

be weakened. 

• The Final Report estimates the cost of creating and implementing a new VHA 

Care System to range from $65 billion to $85 billion in 2019, with a middle estimate of $76 billion (p. 32). That’s $11 billion more than the FY 2017 VHA medical care budget. If Congress saw fit to fund billions more yearly, there are better ways to strengthen the VHA, starting with expanded hiring at VA facilities 

where demand for services exceeds available staffing. But if Congress did not, 

the Final Report suggests that the expensive VHA Care System could offset 

costs by decreasing the number of Veterans eligible for VA health care, cutting 

services, or increasing Veterans’ out-of-pocket expenses. In any of those scenarios, Veterans are worse off. 

In sum, given the evidence of overall quality, efficiency, integration and innovation within the VHA, we believe that efforts to reform the VHA can best serve Veterans by expanding access to services the VHA currently provides. Where geographic challenges exist and/or VHA does not offer specific services, the VHA should 

purchase services from non-VA partners. 

Any proposed transformation of the VA health care system should be data driven. 

Don’t risk our Veterans’ health care on unproven ideas. We must preserve and 

strengthen the VHA integrated health care community that Veterans deserve and 

overwhelmingly prefer. 

Contact Information; 

Thomas Kirchberg, PhD 

President, Association of VA Psychologist Leaders 

(901) 596–6708 

Ron Gironda, PhD 

President-Elect, Association of VA Psychologist Leaders 

(813) 380–9378 

president1@avapl.org 

f 

Materials For The Record 

LETTER FROM CHAIRMAN MILLER TO MARK TAKANO 

September 8,2016 

The Honorable Mark Takano 

Acting Ranking Member 

House Committee on Veterans’ Affairs 

333 Cannon House Office Building 

Washington, DC 20515 

Dear Acting Ranking MemberTakano, 

Yesterday, at the business meeting regarding the issuance of a subpoena for 

records pertainingto, among other things, the Administrative Investigat ion Board 

(AIB) report for the Aurora Replacement Medical Center construction project, you 

implied that only the Minority had concerns about VA mismanagement of the 

project and only the Minority was willing to withhold funding for its continuation 

. Specifically, you suggested that the Majority pushed through authorization ‘‘in the 

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middle of the night’’ by a voice vote ‘‘over the concerns of the Minority.’’ Nothing 

could be further from the truth. 

A review of the two extenders bills increasing the authorization for the project from $900 million to just over $ 1 billion (S. 1568) and then again to $1 .675 billion 

(S. 2082) show that both passed in the full light of day with strong bipartisan support. S. 1568 passed the House at 2:28 PM while S. 2082 passed at 3:08 PM, neither 

of which are remotely close to the middle of the night. Moreover, while S. 1568 

passed the House without objection by unanimous consent, the yeas and nays for 

S. 2082 were taken resulting in a final vote of 423–0. The record includes your vote 

in favor of that authorization increase. See http://clerk.house.gov/evs/201 5/ 

roll526.xml. 

Please also consult the Congressional Record related to S. 2082. See 161 Cong. 

Record 142, 1–16719-l-!6727 (1st Sess., Sept. 30, 2015), https:VW.Congress.gov/crec/ 

201 5/09/30/CREC- 2015–09–30-pt l -PgH67 I9–4.pdf. You will see that I expressed 

serious reservations about authorizing an additional $625 million absent accountability by VA management and conditions on how the Department would cover the 

cost without jeopard izing medical care accounts. These concerns were reflected in 

the thoughtful remarks of our colleague Representative Dina Titus. You should also 

be aware that the authorization included a critical provision stripping VA of dayto -day management authority over super construction and transferring it to another federal entity, such as the Army Corps of Engineers. 

Construction of the Aurora project has run $1 billion over its original budget and 

has been the subject of ongoing outrage from members of both parties of this Committee. If there was a misunderstanding regarding your comments, please let me 

know. But, I felt it important to correct the record on such an important topic. 

If you have any questions or concerns, please contact Jon Towers, Staff Director, 

at (202) 225-3527. 

With warm personal regards, I am, 

Sincerely 

JEFF MILLER 

Chairman 

CJM/hr 

f 

LETTER FROM ROBERT A. MCDONALD TO PRESIDENT BARACK 

OBAMA 

August 2, 2016 

The Honorable Barack Obama 

President 

The White House 

Washington, DC 20500 

Dear Mr. President: 

Two years ago, you tasked me to transform the Department of Veterans Affairs 

(VA) for the 21st Century. Since then, VA has established a comprehensive, enterprise-wide transformational process named MyVA, which has already increased Veterans’ access to health care and begun improving Veterans’ experience of VA’s benefits and services. 

The direction we have taken and the progress we have made has been largely 

validated by the Commission on Care (Commission) in its Final Report, which VA 

received on July 7, 2016. After thoroughly reviewing the report, and receiving input 

from our Veterans Service Organizations (VSOs), I am pleased to say that 12 of the 

Commission’s 18 recommendations are objectives VA has already accomplished or 

has been working toward for the past two years as part of the MyVA transformation. Although we differ with the Commission on some details and are pursuing alternative approaches where warranted, we agree with the Commission that 

many changes planned by MyVA, recommended by the Commission, and strongly 

supported by VSOs, will likely require resources and remedies that only Congress 

can provide. These issues and our many transformation efforts are summarized in 

the enclosure to this letter. 

VA strongly disagrees with the Commission on its proposed ‘‘board of directors’’ 

to run the Veterans Health Administration (VHA). Such a board is neither feasible 

nor advisable for both constitutional and practical reasons. The U.S. Department of 

Justice has concluded that the Constitution prevents Congress from appointing perLeonard.horne on VACREP0180 with DISTILLER

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sons to exercise authority over Executive branch agencies and as such, would prevent the proposed board from exercising the authorities assigned to it by the Commission. The Commission’s proposal would also seem to establish VHA as an independent agency, undoing the work of the VSOs in creating VA as a Cabinet-level 

department. The powers exercised by the proposed board would undermine the authority of the Secretary and the Under Secretary for Health, as well as weaken ownership of the MyVA transformation and VHA performance. This could potentially 

disrupt and degrade VA’s implementation of critical care decisions that affect Veterans. The proposed independent VHA agency would also run counter to our ongoing efforts to improve the Veteran’s experience by integrating Veterans health care 

with the many other services provided to Veterans by the Veterans Benefits Administration and the National Cemetery Administration. 

At present, VA is served by 25 advisory Committees, including a newly reconstituted Special Medical Advisory Group, which consists of leading medical practitioners and administrators, and a newly established MyVA Advisory Committee, 

which brings together business leaders, medical professionals, government executives, and Veteran advocates. These advisory Committees advise VA on strategic direction, facilitate decision making, and introduce innovative business approaches 

from the public and private sectors. With their help, the Department has begun the 

process of transforming VHA from a loose federation of regional health care systems 

to a highly integrated national enterprise, based on a new model of care with VA 

as both the payer and provider. This model will provide Veterans with the full spectrum of health care services and additional choice, but without sacrificing VA’s 

foundational health services upon which many Veterans depend. Additionally, many 

VSOs fear that the Commission’s vision would compromise VA’s ability to provide 

specialized care for spinal cord injury, prosthetics, traumatic brain injury, post-traumatic stress disorder, and other mental health needs, which the private sector is 

not as equipped to provide. 

In October 2015, VA submitted to Congress our Plan to Consolidate Community 

Care, which lays out our vision of a consolidated community care program that is 

easy to understand, simple to administer, and meets the needs of Veterans, community providers, and VA staff. This plan incorporates feedback from key stakeholders, 

including VHA field leadership and clinicians, representing diverse groups and 

backgrounds. VA has already begun what work we can without legislation to make 

the plan a reality. Over the course of the last 12 months, our Choice Provider network has grown by 85 percent. The network now has over 350,000 providers and 

facilities across the Nation. Over 930,000 unique Veterans have used the Veterans 

Choice Program (VCP). Over 100,000 Veterans with 40-mile eligibility used VCP 

through May 2016. Authorizations for care under the Veterans Access, Choice, and 

Accountability Act (VACAA) have increased by 82 percent over 9 months (October 

2015 to June 2016), and VCP authorizations have quadrupled from approximately 

380,000 in fiscal year (FY) 2015 to almost 2 million in FY 2016. 

However, VA cannot accomplish the ongoing transformation through MyVA or recommend by the Commission without critical legislative changes and funding. VA 

has aggressively pursued these needed changes and funding. As you know, more 

than 100 legislative proposals for Veterans were included in your 2017 Budget. 

Many of these proposals are vital to maintaining our ability to purchase community 

care. We continue to work to move these critical initiatives forward and are encouraged by the fact that most have been considered in legislative hearings or included 

in omnibus bills moving towards floor consideration, like the bipartisan Veterans 

First Act, which passed the Senate Veterans Affairs’ Committee unanimously. These 

bills include some of the provisions of the Purchased Health Care Streamlining and 

Modernization Act we submitted to Congress in May 2015, such as an enhanceduse lease authority, compensation reform for medical professionals, and a measure 

of budgetary flexibility to respond to Veterans emerging needs and overcome artificial funding restrictions on providing Veterans care and benefits. These provisions 

would go a long way toward ensuring the success of MyVA, but other important legislative issues still need to be addressed, especially the consolidation of VA’s many 

purchased care authorities and modernization of VA’s archaic claims appeals process. 

Your strong support for Veterans has been critical to the progress made so far, 

but VA needs Congress’ assistance to make the transformation intended by the 

Commission and already underway in MyVA to accomplish the changes needed to 

serve Veterans as the need and deserve to be served now and for generations to 

come. 

Thank you for your continued support of our Nation’s Veterans. 

Sincerely, 

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Robert A. McDonald 

Enclosure 

August 2016 

DEPARTMENT OF VETERANS AFFAIRS

REVIEW OF THE COMMISSION ON CARE

Over the past two years, the Department of Veterans Affairs (VA) has been working energetically, through its MyVA initiative, to transform the Veterans Health Administration (VHA) from a loose federation of regional health care systems to a 

highly integrated national enterprise, based on a new model of care with VA as both 

the payer and provider. This model will provide Veterans with the full spectrum of 

health care services, plus more choice, but without sacrificing VA’s foundational 

health services that many Veterans depend on. 

In October 2015, VA delivered to Congress a plan for evolving our current system 

into a high-performance network based on timely access to foundational services and 

integration of private-sector providers. Building on more than a decade of working 

with community partners through multiple mechanisms, this plan would consolidate 

the various mechanisms, expand our network of providers, and enhance the network’s capability to deliver services essential to Veterans’ health. 

Many of the Commission on Care’s (Commission) recommendations are aimed in 

the same direction and are already being implemented as part of VHA’s MyVA 

transformation. VA finds 15 of 18 Commission recommendations feasible and advisable (#1–3, 5–8, 10–16, and 18) and 3 not feasible or advisable (#4, 9, and 17). VA 

is already implementing changes with the same intent as 12 recommendations (#1– 

3, 5, 7–8, 10–11, and 13–16); recommends alternative approaches to 2 recommendations to bring them in line with other MyVA reforms (#6 and 12); and will work 

with the President, Congress, Veterans Service Organizations, and other stakeholders on recommendation #18. 

Many of the Commission’s recommendations also require action by Congress. VA 

has aggressively pursued legislative changes and funding that would enable VA to 

achieve its MyVA vision. More than 100 proposals for legislative changes were included in the President’s 2017 Budget. VA also submitted to Congress in May 2015 

the Purchased Health Care Streamlining and Modernization Act, parts of which 

have been incorporated into the Veterans First Act in the Senate. Many of VA’s proposals, which are vital to maintaining our ability to purchase non-VA care, are 

pending Congressional action. 

Recommendation #1: VHA Care System 

‘‘Across the United States, with local input and knowledge, VHA should establish high-performing, integrated community-based health care networks, 

to be known as the VHA Care System, from which Veterans will access highquality health care services.’’ 

VA finds this recommendation feasible and advisable and is already implementing 

changes as part of VA’s MyVA transformation, with some modifications in approach 

to achieve the vision described above. 

In October 2015, VA submitted to Congress its Plan to Consolidate Community 

Care, which lays out our vision of a consolidated community care program that is 

easy to understand, simple to administer, and meets the needs of Veterans, community providers, and VA staff. This plan incorporates feedback from key stakeholders, 

including VHA field leadership as well as clinicians, representing diverse groups 

and backgrounds. 

Immediate steps to improve the stakeholder experience were identified and included in the plan, including reducing unnecessary steps in the processes to enroll 

and connect Veterans with community care; improving communications between 

VHA, provider, and Veterans; improving care coordination in the long term for Veterans through improved exchange of certain medical records; and aligning the Veteran’s community care journey along five major touch points: eligibility, community 

care network, referral and authorization, care coordination, and provider claims payment. 

Eligibility: The Plan recommends the creation of eligibility criteria to streamline 

the many different requirements for community care into standard criteria without 

opening community care to all enrolled Veterans. This is VA’s principal point of difference with the Commission on its proposed VHA Care System. VA believes the 

Commission’s recommendation to extend community-care eligibility to all Veterans 

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teria (30 days and 40 miles) is not advisable without Congressional funding due to 

the expected cost increase and desire to not sacrifice VA’s four statutory missions: 

delivering hospital care and medical services to Veterans, educating and training 

health professionals, conducting medical and prosthetic research, and providing contingency support to other Federal agencies during emergencies. Many VSOs fear 

that the Commission’s vision would jeopardize VA’s ability to provide specialized 

care for spinal cord injury, prosthetics, traumatic brain injury, posttraumatic stress 

disorder (PTSD), and other mental health needs, which the private sector is not as 

equipped to provide. For this reason, VA opposes elimination of the current time 

and distance criteria. 

Community Care Network: VA has since begun developing the requirements for 

the new community-care network contract, with standards and criteria developed 

from input by industry, facility staff, and program office staff representing a broad 

spectrum of needs. These standards and criteria will be included in the draft Request for Proposal (RFP) for the community care network that will open for bid later 

in calendar year 2016. Legislation is needed to improve Veterans experience by consolidating existing programs and standardizing eligibility criteria. 

Referral and Authorization: To ensure that Veterans have access to the full spectrum of health care services, VA will focus on areas in which it can excel (VA-delivered foundational health services) and develop locally defined community partnerships for specialty care as needed. Standards and criteria for specialty care referrals 

are currently being developed for inclusion in the draft RFP. While the primary care 

provider will coordinate referrals for specialty care within the integrated VHA Care 

System, VA should be seen as the prime provider for special emphasis services. For 

example, VA is the leader in integrating primary care and mental health care and 

should be seen as the primary care provider for these services. When VA cannot provide a primary care provider, Veterans will be able to select from credentialed providers in the high-performing network. 

Care Coordination: The Plan stresses care coordination with a focus on customer 

service, emphasizing the need for care coordination for Veterans who receive community care as well as in VA. This coordination would include both the primary care 

provider staff as well as other VA staff. In cases where VA cannot provide the care 

coordination for Veterans, the services may be provided through the community care 

network. In other cases, VA coordinators make more sense. This is true in the Alaska VA Healthcare System, where VA staff will fill an intermediary role currently 

performed by VCP contractor TriWest to make scheduling an inherently VA activity, 

in response to local concern that calling out-of-state VCP contractors resulted in 

delays in care coordination, mostly attributed to time-zone differences and a lack of 

understanding of Alaska’s unique geography. 

Provider Claims Payment: VHA is also already working to streamline reimbursement methodologies among its various community care programs and to develop a 

standardized, transparent process for reimbursing providers in an integrated delivery network. VHA and the Centers for Medical and Medicaid Services (CMS) are 

identifying CMS innovations in value-based payment methods on a limited basis. 

Legislation is needed to revise reimbursement rates under the Veterans Access, 

Choice, and Accountability Act to allow for flexibility from Medicare fee-for-service 

reimbursement methodologies to value-based methodologies of the future. 

Legislation is needed to effectively consolidate existing community care programs, which would reduce confusion among Veterans, community providers, and 

VA staff. The Commission states that in order to achieve the recommendations, VA 

must have ‘‘flexible and smart procurement policies and contracting authorities.’’ VA 

strongly agrees and has aggressively pursued legislative changes that would ensure 

that the appropriate level of flexibility is available to best serve Veterans. In May 

2015, VA submitted the Purchased Health Care Streamlining and Modernization 

Act to Congress. This legislation supports key points of VA’s Plan to Consolidate 

Community Care and would allow VA to enter into agreements with individual community providers outside of Federal Acquisition Regulations, without forcing providers to meet excessive compliance burdens. 

VA is also concerned that the Commission’s cost estimates do not accurately reflect the likely cost of its proposed system. From a baseline estimate of $71 billion, 

the Commission estimates that the cost of its recommended option for Veterans’ 

health care for fiscal year (FY) 2019 ranges from $65 billion to $85 billion, with a 

middle estimate of $76 billion. However, the Commission estimates the cost could 

increase to $106 billion in FY 2019 if VA is unsuccessful in tightly managing the 

network and focusing on costs. We appreciate the analysis underpinning the Commission’s estimates, but caution that the cost of implementing the Commission’s recommendation is likely to be significantly higher, for the following reasons: 

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• The estimates do not include the substantial investment in information technology (IT) resources that would be required to fully integrate VA care with 

community care or the administrative/contractual costs of operating the community-delivered services component of the integrated network. 

• The estimates assume that VA can realign and consolidate personnel in five 

years to best provide health care to Veterans, which is an aggressive timeline. 

• The estimates do not address the cost of realigning or divesting capital assets 

as additional care is delivered in the community. While VA agrees in principle 

with the Commission’s recommendation to develop and implement a robust 

strategy for meeting and managing VHA’s facility and capital-asset needs (see 

Recommendation #6), we note that the realignment, consolidation, and divestiture of capital assets will require substantial resources and time. 

• The estimates are highly dependent on Veteran enrollment in, reliance on, and 

utilization of VA health care, all of which are difficult to predict, as most Veterans enrolled in the VA health care system have other sources of health care 

coverage. Extending community care to more Veterans could cause Veterans 

who now rely on Medicare, Medicaid, or private insurance to use VA care for 

more of their health care needs because of lower copays or greater convenience, 

increasing VA’s costs. 

• Finally, we must caution that the estimates do not reflect the entire VA Medical 

Care budget as they do not include the cost of programs that are not modeled 

by the VA Enrollee Health Care Projection Model. These programs include readjustment counseling, non-medical homeless programs, Caregivers, Health Professions Educational Assistance Program, Income Verification Match, 

CHAMPVA, Spina Bifida, Children of Women Vietnam Veterans, etc. In total, 

they are estimated to cost $8.2 billion in FY 2017. 

Recommendation #2: Enhancing Clinical Operations 

‘‘Enhance clinical operations through more effective use of providers and other 

health professionals, and improved data collection and management.’’ 

VA finds this recommendation feasible and advisable and is already implementing 

changes as part of VA’s MyVA transformation, with some modifications in approach. 

VHA is already engaged in processes to make full use of the skills held by VHA 

providers and other health professionals. VHA is a leader in the use of clinical pharmacists to increase capacity by renewing prescriptions or ordering medication refills 

independently, after the initial prescription by a licensed physician or nurse practitioner. In addition, many VA clinical pharmacists have a scope of practice that provides prescribing authority and enables them to run pharmacist-managed clinics focused on medication therapy management for chronic diseases. For example, about 

one third of all prescriptions for the treatment of the Hepatitis C virus are written 

by clinical pharmacists 

VHA has also developed a draft regulation that would standardize full practice 

authority for advanced practice nurses, to assure a consistent continuum of health 

care services by the practitioners across VHA and decrease the variability in advanced nurse practice that currently exists as a result of disparate State practice 

regulations. The proposed draft regulation was published in the Federal Register; 

we are now reviewing comments received. Implementation of full practice authority 

will increase Veteran access by alleviating the effects of national health care provider shortages on VA staffing levels and enabling VA to provide additional health 

care services in medically under-served areas. Implementing this policy, as recommended by the Commission, will allow VA to parallel the policies of other Federal 

agencies, including the Department of Defense (DoD) and the Indian Health Service, 

as well as many institutions in the private sector. 

VHA’s Diffusion of Excellence initiative is an operational infrastructure that allows for sharing of promising practices across the enterprise. This model 

incentivizes and institutionalizes the identification and diffusion of practices nationwide so that every facility has the opportunity to implement the solutions that are 

most relevant to them. In the first round of submissions, 13 Gold Status Best Practices were selected from more than 250 ideas through a series of reviews and a final 

‘‘Shark Tank’’ competition. The next step assigned each Gold Status Best Practice 

and their originating Gold Status Fellows to Action Teams managed by the Diffusion Council for implementation VHA-wide. 

VA seconds the Commission’s call for Congress to relieve VHA of bed-closure reporting requirements under the Millennium Act. The Act’s arbitrary requirements 

have not kept up with changes in the Veteran population or the health care environment. Legislation is needed to remove the Act’s bed change reporting codified at 38 

U.S.C. 8110(d) and the staffing level and service requirements specific to such bed 

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changes under section 38 U.S.C. 1710B(b), while retaining staffing and service requirements for all other Extended Care Services. VA would replace the mandated 

congressional reporting of bed closures with a stronger, clearer, and more stringent 

internal process to review and if appropriate, approve bed closure proposals. 

VA is already moving forward to hire and train more clinical managers and medical support assistants (MSAs). In response to Section 303 of the Veterans Access, 

Choice, and Accountability Act of 2014 (PL 113–146), each VA Medical Center now 

has a Group Practice Manager (clinical manager). Additional hiring and training of 

these group practice managers will continue through February 2017. VHA is also 

developing new training and hiring procedures for MSAs throughout the organization as part of MyVA. VA has developed and launched an MSA hiring project called 

‘‘Hire Right, Hire Fast’’ and is currently piloting a new hiring procedure that allows 

for industry-standard bulk hiring of MSAs to hire MSAs within 30 days of a vacancy. Two-week, standardized onboarding training for all new MSAs is also being 

developed and piloted. Both new processes will begin being deployed nationally this 

fall. 

Recommendation #3: Appealing Clinical Decisions 

‘‘Develop a process for appealing clinical decisions that provides veterans 

protections at least comparable to those afforded patients under other federally-supported programs.’’ 

VA finds this recommendation feasible and advisable and is already implementing 

changes as part of VA’s MyVA transformation, with some modifications in approach, 

taking into account important differences between the mission and authority of the 

VA health care system and other Federally-supported programs. 

VHA is already in the early stages of developing a regulation in response to the 

Commission’s recommendation. This regulation will establish a cohesive baseline 

national policy for clinical appeals. A clinical appeals regulation will be published 

for notice and comment in accordance with the Administrative Procedure Act. Recently enacted legislation in section 924 of the Comprehensive Addiction and Recovery Act of 2016 establishes an Office of Patient Advocacy in the Office of the Under 

Secretary for Health. In addition, in 2015 VHA established the Office of Client Relations to assist Veterans clinical care access concerns. 

An interdisciplinary panel will be tasked with evaluating feedback from these offices and other Veteran support resources to improve the overall clinical appeals 

process, consistent with external benchmarks and factors described by the Commission, Federal regulations and statutes, and sound clinical practice. The resulting 

recommendations may differ in certain aspects from those envisioned by the Commission, but will undoubtedly be a uniform, fair, world-class clinical appeals process 

that protects Veterans and is fully compliant with law and regulation. VA’s revised 

process will complement the Veterans Experience Office’s efforts to better serve Veterans, make improvements based on customer feedback, and engage the community. 

Recommendation #4: Consolidation of Improvement Efforts 

‘‘Adopt a continuous improvement methodology to support VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center.’’ 

VA finds this recommendation neither feasible nor advisable, but is already implementing an alternative approach that institutionalizes continuous improvement as 

part of VA’s MyVA transformation. 

Health care improvement takes place within a complex socio-technical system 

with multiple aspects of technology and technical expertise. Placing improvement 

under an engineering system, such as the Veterans Engineering Resource Center 

(VERC), may harness the technical aspects of improvement, but it will not provide 

the balance of critical cultural and people aspects. VA believes doing so would unbalance safety and efficiency and not be successfully transformational. 

Ongoing VA transformation efforts have been achieved by specifically aligning 

VERC assets with enterprise priorities so that appropriate engineering perspectives 

and skills are interwoven with current organizational priorities. To institutionalize 

VHA’s commitment to continuous improvement, VHA will realign the VERC and the 

operational improvement arm of Strategic Analytics for Improvement and Learning 

(SAIL) under the Principal Deputy Under Secretary for Health. This will elevate the 

health-system subject matter experts who drive transformation in VHA’s organizational structure, while continuing to use the VERC to ensure that supporting engineering resources are available across all VA transformational efforts. 

Additionally, VA’s enterprise approach to improving performance-through Lean 

Six Sigma (Lean) tools and training, Leaders Developing Leaders training, MyVA 

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Performance Improvement Teams, MyVA Communities, the MyVA Ideas House, and 

many other initiatives across the VA system-has taught us the value of a central 

repository for local programs and ideas, both successful and unsuccessful. To that 

end, VA and VHA have embraced the Integrated Operations Platform (IOP) hub, a 

knowledge-management technology platform developed by the VERC in partnership 

with subject matter experts. The IOP consolidates information on continuous improvement activities across VA in key programs, and as a result, best practices and 

innovation activities are currently visible in one common platform. 

VA has invested significantly in developing Lean capacity at local levels so that 

problem solving is done at the lowest level and with a team of safety, quality, and 

improvement professionals. This prepares the local facilities to improve their current environment while scanning constantly for emergent new problems. 

Recommendation #5: Eliminating Healthcare Disparities 

‘‘Eliminate health care disparities among veterans treated in the VHA 

Care System by committing adequate personnel and monetary resources to 

address the causes of the problem and ensuring the VHA Health Equity Action Plan is fully implemented.’’ 

VA finds this recommendation feasible and advisable and is already working to 

address each of the Commission’s concerns as part of VA’s MyVA transformation. 

VA’s Office of Health Equity (OHE) was established in 2012 with the mission of 

championing health equity among vulnerable Veterans. The office developed the 

Health Equity Action Plan (HEAP) in 2014 in conjunction with the Health Equity 

Coalition and with concurrence from the Under Secretary for Health. The HEAP is 

VHA’s strategic roadmap to reducing Veteran health disparities. It aligns with the 

goals of MyVA and the VHA Strategic Plan. VHA will make health equity a priority 

by directing implementation of the HEAP nationwide. 

The appropriate placement of OHE within the VHA organizational structure, 

along with adequate resources, will be considered as a priority component of the 

broader VHA restructuring addressed in Recommendation 12. This will take into account funding and staffing levels commensurate with the scope and size of Federal 

offices of health equity established in the Department of Health and Human Services, based on direction in the Affordable Care Act. VA will also identify health equity leaders and clinical champions in each VA District, Veteran Integrated Service 

Network (VISN), and Medical facility who can catalyze and monitor actions to implement the HEAP and further advance the elimination of health disparities. 

VA has undertaken systematic actions to identify and address health care disparities and inequality. Examples include the development of Hepatitis C Virus Disparities dashboard projected, scheduled for launch by the end of FY 2016; data support 

and research collaborations with the Quality Enhancement Research Initiative designed to identify health care disparities; establishment of a Population Health office that has developed clinical case registries focusing on the needs of special populations; and establishment of the Women’s Health and Lesbian, Gay, Bisexual, 

Transgender (LGBT) program offices. VA Medical Facilities constitute 20 percent of 

Human Rights Campaign’s Health Care Equality Index participants in 2016, and 

they were the only facilities to achieve leader status in some States. 

Recommendation #6: Facilities and Capital Assets 

‘‘Develop and implement a robust strategy for meeting and managing 

VHA’s facility and capital asset needs.’’ 

VA finds this recommendation feasible and advisable but recommends alternative 

approaches as part of VA’s MyVA transformation. 

VA believes that the Commission’s recommendation is critical to enabling the successful transformation of the large-scale health care system to a higher-performing 

integrated network to serve Veterans. Without a strong suite of capital planning 

programs, tools, and resources, VA will not be able to fully realize the benefits and 

Veteran outcomes expected from implementing an integrated health care network. 

VA also strongly agrees with the Commission that greater budgetary flexibility and 

greater statutory authority are essential to meeting VA’s facility needs, realigning 

VA’s capital assets, and streamlining processes to divest itself of unneeded buildings. 

VA recommends alternative approaches to two issues: 

• Once VA determines its mix of health care services and how they are provided 

at the market level based on the integrated health care approach, realignment 

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alignment commission (IFRC) to focus solely on VA’s infrastructure needs once 

the mission services are determined. The IFRC would develop a systematic capital-asset-focused realignment plan for infrastructure needs to be presented to 

the Secretary of Veterans Affairs and the President for decision, with Congress 

approving or disapproving the plan on an up-or-down vote. 

• With regard to focusing new capital on ambulatory care development, VA proposes a balanced approach to maintain needed infrastructure and other key 

services (e.g., rehabilitation, community living centers, and treatment for spinal 

cord injury, traumatic brain injury, polytrauma, and PTSD), while at the same 

time appropriately investing in ambulatory care in needed markets. The balanced approach would be based on a market-by-market determination of the appropriate mix of services to ensure Veterans have access to needed care. 

VA agrees with the recommendation to move forward immediately with 

repurposing or disposing facilities that have already been identified as being in need 

of closing. Continued focus in this area is needed and VA is already working towards this goal, subject to the availability of staff and resources. 

VA also acknowledges that there will be anticipated challenges in implementing 

such large-scale realignments and restructuring of VA’s footprint. Legislation will 

likely be required facilitating changes to VA’s capital infrastructure to implement 

a transformation of this nature, including: 

• Establishing an IFRC to develop a systematic capital-asset-focused realignment 

plan. 

• Streamlining processes to meet the intent of laws and regulations, such as the 

National Historic Preservation Act and the National Environmental Policy Act 

that would make repurposing and divesture more timely and effective. 

• Potentially restructuring appropriations to allow for more flexible transfer and 

reprogramming authority, including potential threshold adjustments. 

• Exploring methods (both legislative and administrative) to take advantage of 

private-sector financing. 

• Revising the major medical lease authorization process to align the requirements in concert with practices at other Federal agencies. 

• Granting VA authority to retain and utilize proceeds generated from real property divestitures. 

• Expanding enhanced-use leasing authority. 

Further analysis will be required to determine the specific level of resource investments required to implement the Commission’s recommendations. It is clear that 

significant additional resources will be required. In addition, divestiture of unneeded 

VA assets is unlikely to generate significant savings because of the upfront resources required to execute the divestiture and minimal market value of the majority of VA’s assets. Without the proper resources, tools, and authorities, attempts to 

divest of assets or streamline capital project execution will not be effective. 

Recommendation #7: Modernizing IT Systems 

‘‘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.’’ 

VA finds this recommendation feasible and advisable and is already implementing 

changes as part of VA’s MyVA transformation, with some modifications in approach, 

understanding that investments in IT will force difficult decisions concerning the allocation of limited financial resources among all VA programs and services, as well 

as across the Federal government. 

As part of the MyVA Breakthrough Initiative to transform VA IT, VA will soon 

appoint a Senior Executive System (SES)-equivalent position for a Chief Health 

Informatics Officer (CHIO), reporting to the Assistant Deputy Undersecretary for 

Health for Informatics and Information, to collaborate with the VA Chief Information Officer (CIO) and the IT Account Manager toward developing a comprehensive 

health IT strategy and supporting budget proposal. The CHIO and ADUSH will be 

responsible for prioritizing all health technology programs and initiatives, with strategic technological guidance from the VA CIO and IT Account Manager for health. 

To comply with the Federal Information Technology Acquisition Reform Act 

(FITARA), the CHIO does not take the place of the VA CIO, but instead works in 

concert with IT management to ensure that health initiatives are appropriately 

prioritized within the portfolio, while the CIO works with VA senior leadership so 

that all technology initiatives are prioritized holistically, thus ensuring complete 

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ready collaborating on the vision and strategy for a single integrated Digital Health 

Platform (DHP). 

VA has also established five district senior-executive Customer Relationship Manager positions to work with the local VHA, Veterans Benefits Administration, National Cemetery Administration, and staff office leaders, aggregate feedback for 

analysis by VHA and OI&T senior leadership, and enhance a continuous feedback 

loop. The VA CIO recently established the Veteran-focused Integration Process program within the Enterprise Program Management Office (EPMO) to facilitate continuous improvement and constant collaboration. 

The Commission recommended that the VA CIO develop and implement a strategy to allow the current nonstandard data to effectively roll into a new system, and 

engage clinical end-users and internal experts in the procurement and transition 

process. VHA is currently working with OI&T to ensure that the Veterans Information Systems and Technology Architecture (VISTA) data is mapped to national 

standards. The new CHIO will be responsible for engaging clinical end-users in the 

transition to the new DHP. The Under Secretary for Health and the CIO will establish a joint program office responsible for the implementation of the DHP. This process will be focused on delivering and coordinating high-quality care for Veterans. 

The EPMO is responsible for portfolio management and has adopted a policy of 

‘‘best-fit, buy-first’’ in its Strategic Sourcing function. This ensures that existing 

best-in-class technology solutions are purchased whenever possible, rather than 

being developed and maintained by VA. These functions, in combination with the 

role and focus of the IT Account Manager, will provide the required focus for VHA 

to implement a comprehensive commercial off-the-shelf IT solution to include clinical, operational, and financial systems. 

Recommendation #8: Modernizing Supply Chain 

‘‘Transform the management of the supply chain in VHA.’’ 

VA finds this recommendation feasible and advisable and is already implementing 

changes as part of VA’s MyVA transformation, with some modifications in approach. 

VA believes the components of this recommendation that suggest establishment 

of a Chief Supply Chain Officer (CSCO) and realignment of all procurement and logistics operations under the CSCO executive position are feasible and advisable, but 

it recommends an alternative approach to fulfill the Commission’s intent. The structural solution recommended by the Commission would not adequately address underlying management challenges associated with organizational complexity and the 

need to improve integration processes impacting the supply chain. Realignment of 

VHA’s supply-chain structure, including roles and responsibilities of the various VA 

Central Office staff offices, health networks, and medical facilities, should derive 

from and be integrated with the transformation of the overall VHA health care organization structure. The intent of the Commission will be met by addressing alignment issues as the supply-chain breakthrough initiative evolves and is synchronized 

with VHA’s overarching strategies to transform VHA’s organizational structure. 

As an alternative, the intent of the Commission is already being addressed in an 

effective manner under the current MyVA Breakthrough Initiative to transform 

VHA’s supply chain. This initiative is a more comprehensive approach to fulfilling 

the Commission’s intent and is already driving much needed improvements in data 

visibility and quality, synchronization of technology deployments, standardization, 

contract compliance, and training. Already in FY 2016, VHA supply-chain transformation efforts have yielded approximately $45 million in cost avoidance. VHA has 

also developed a two-year supply-chain transformation stabilization guidance that 

will put VHA in a far better position to make effective decisions and investments 

beyond FY 2018 for vertically aligning VHA’s management structure and for more 

efficient sourcing and distribution of all clinical supplies and medical devices. This 

will increase the availability of supplies for the care of Veterans and result in cost 

avoidance for American taxpayers. 

With regard to the component of the recommendation asking VA and VHA to establish an integrated IT system to support business functions and supply-chain 

management, although feasible it is more advisable that technology investments beyond those currently in the pipeline should be avoided until such time that a mature supply-chain baseline is established, upon which prudent future IT investment 

decisions can be based. This is especially important given VA’s Financial Modernization System initiative and emerging plans for a new DHP, both of which will impact 

legacy and contemporary supply-chain systems and interfaces, as well as influence 

system-improvement alternatives and investment decisions over the next two to five 

years. Supply-chain system improvements must be integrated and synchronized 

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ciencies in service delivery and support analysis of integrated data to meet VHA’s 

current and future needs. 

Finally, as suggested, VHA will continue to use VERC capabilities to support the 

transformation of supply-chain management in accordance with the MyVA Breakthrough Priority Initiative #12: VHA Supply Chain Transformation. As a point of 

clarification, the Commission report is technically incorrect in that the VERC is not 

leading the MyVA supply-chain modernization initiative; rather, the VERC is a 

highly valued enabling organization engaged by the VHA Procurement and Logistics 

Office to support the MyVA initiative. 

Recommendation #9: Governance Board 

‘‘Establish a board of directors to provide overall Veterans Health Administration (VHA) Care System governance, set long-term strategy, and direct 

and oversee the transformation process.’’ 

VA finds the Commission’s recommendation neither feasible nor advisable due to 

its unconstitutionality. However, VA believes the intent of the Commission can be 

achieved regarding the term appointment of the Under Secretary for Health. 

The U.S. Department of Justice has concluded that the proposed board of directors, as appointed and with the powers proposed by the Commission, would be unconstitutional for several reasons. Permitting Congress to appoint the board members would violate the Constitution’s Appointments Clause (U.S. Const. art. II § 2, 

cl. 2), as well as the separation of powers, insofar as congressionally appointed 

board members would be exercising significant operational authorities within the 

Executive Branch. In addition, giving this board authority to reappoint the Under 

Secretary for Health would violate the Appointments Clause and the separation of 

powers. Finally, requiring the board to concur with the President in removing the 

Under Secretary for Health would give the board a veto authority over the President, impairing the President’s ability to ‘‘take Care that the Laws be faithfully executed,’’ (U.S. Const. art. II, § 3), and violating the separation of powers. 

The proposed board would also seem to separate VHA from VA without necessarily insulating VHA from political pressure or improving VHA oversight or operations. The powers exercised by the proposed board would undermine the authority 

of the Secretary and the Under Secretary for Health and weaken ownership of the 

MyVA transformation and VHA performance, potentially disrupting and degrading 

VA’s implementation of critical care decisions affecting Veterans. The independence 

granted VHA would run counter to our ongoing efforts to improve the Veteran’s experience by integrating Veterans health care with the many other services VA provides through the Veterans Benefits Administration and the National Cemetery Administration. Furthermore, VA is already advised by the Special Medical Advisory 

Group, which consists of leading medical practitioners and administrators, and by 

the MyVA Advisory Committee, which brings together business leaders, medical 

professionals, government executives, and Veteran advocates with diverse expertise 

in customer service, strategy development and implementation, business operations, 

capital asset planning, health care management, and Veterans’ issues. These Committees already provide VA with outside expert advice on strategic direction, facilitating decision making and introducing innovative business approaches from the 

public and private sectors. 

The Commission correctly notes that frequent turnover of the Under Secretary for 

Health has had a negative impact on VHA and greater stability in this important 

leadership position is needed. VA supports a term appointment of the Under Secretary for Health spanning Presidential transitions to ensure continuity of leadership and continued transformation of VHA. Previously, 38 U.S.C. § 305 provided for 

a four-year term for the Under Secretary for Health with reappointment possible, 

but this provision was removed in 2006. A term appointment could be reinstated, 

beginning with the current Under Secretary for Health. This is critically important 

at this juncture given the need to see the ongoing transformation of VHA through 

to completion. Under Secretary for Health candidates are currently recommended by 

a commission established solely for that purpose. More analysis is needed to determine length of tenure and timing of reappointment. 

Recommendation #10: Leadership Focus 

‘‘Require leaders at all levels of the organization to champion a focused, clear, 

benchmarked strategy to transform VHA culture and sustain staff engagement.’’ 

VA finds this recommendation feasible and advisable and is already implementing 

changes as part of VA’s MyVA transformation, with some modifications in approach. 

Recent or ongoing actions serving the Commission’s intent include: 

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• VA has established the MyVA Task Force to guide VA through the transformation and established a Department-wide MyVA transformation office, 

which has formulated an integrated plan for transformation and is organizing 

the work on 12 breakthrough priorities. 

• Metrics and key performance indicators are in place for each breakthrough priority. Each breakthrough priority has a designated, accountable official who is 

a member of the senior leadership team and a near-full-time responsible official 

in charge of driving progress. 

• One of the 12 breakthrough priorities in the MyVA Transformation is employee 

engagement, for which we have a comprehensive action plan. 

• VA has also established a MyVA Advisory Committee (MVAC) consisting of 

business leaders, medical professionals, government executives, and Veteran advocates. VA leadership meets quarterly with the MVAC, leveraging them as a 

corporate board from which to seek counsel on the overall transformation. 

• MyVA has engaged leaders and employees throughout the organization via 

Leaders Developing Leaders (LDL) (over 54,000 participants to date), VA101 

(over 79,000 participants to date), various skills trainings, LDL projects, breakthrough pilots, broad communications to include the MyVA Story of the Week 

that goes out every Friday to all employees, and local initiatives. 

• VA established MyVA district offices to facilitate transformation efforts 

throughout VA and also now conducts quarterly surveys of the VA workforce 

and incorporates this feedback into VA’s transformation actions. 

• Secretary, Deputy Secretary, and Under Secretary for Health have provided role 

models for transparency, Veteran focus, and principles-based leadership. 

• VHA programs and program offices and the Office Human Resources & Administration (HR&A) representatives have held regular meetings in the past year 

to discuss a single, benchmarked concept for organizational health and coordinate messaging. 

• VHA’s National Leadership Council has endorsed personalized, proactive, patient-driven health care as one of VHA’s strategic goals and strongly supported 

the formation of organizational health councils. 

• Many VHA facilities and networks have some version of an organizational 

health council already existing. 

• All program offices and facilities receive employee survey data annually down 

to the workgroup level to facilitate action planning and improve employee engagement. Brief pulse surveys have recently been implemented to measure employee engagement at the facility level quarterly. 

• VHA’s National Center for Organizational Development has use of Prosci 

change management materials and is pursuing a system-wide license. 

Recommendation #11: Leadership Succession 

‘‘Rebuild a system for leadership succession based on a benchmarked 

health care competency model that is consistently applied to recruitment, 

development, and advancement within the leadership pipeline.’’ 

VA finds this recommendation feasible and advisable and is already implementing 

changes as part of VA’s MyVA transformation, with some modifications in approach. 

VA is consolidating leadership training behind a model we created as part of our 

MyVA transformation called ILEAD. Previously, VA had multiple leadership models 

across VA, which led to no common language or culture of leadership, and the models were not customized for VA. The enterprise-wide ILEAD modal will incorporate 

the principles of ‘‘servant leadership’’ and VA’s ICARE core values, aligned with the 

Federal Executive Core Qualifications. VHA and the VA Corporate Senior Executive 

Management Office are in the first stages of developing a competency model for 

VHA’s senior leadership positions that will incorporate VA’s ILEAD model with the 

technical competencies essential to successfully leading VHA’s complex clinical operations. The VHA senior leader competency models will ultimately cascade down 

through the organization and be incorporated in its hiring, development, performance assessment, and advancement programs. 

VHA has outlined a leadership talent management strategy, benchmarked against 

the best practices in private industry, and begun initial development of processes 

and tools to give VHA greater insight and control over its health care leadership 

succession pipeline. Initial efforts are focused on creating a cadre of leaders to fill 

future medical center director positions. At the individual level, VHA senior executives serve as mentors to staff members, coaches for VHA leadership development 

programs, and models through their own leadership behavior. 

Current VHA initiatives serving the Commission’s intent include: 

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• VHA made leadership development a priority of its MyVA effort, specifically to 

develop and retain passionate leaders to lead transformational efforts across the 

Administration. • Filling key leadership position through a strong succession pipeline is identified 

as a priority for VHA in the 2016 VHA Workforce and Succession Strategic 

Plan. • VHA has fully embraced the LDL philosophy-nearly 30,000 VHA employees 

have participated in the leader-led cascaded training since it began in September 2015. • VHA’s National Leadership Council has adopted the VA leadership model, 

which now includes the concept of ‘‘servant leader.’’ • VHA leaders are integrally involved in the development and conduct of its formal leadership development programs. Leaders serve as coaches and mentors 

to program participants, in addition to personally facilitating sessions on a wide 

variety of leadership topics. • VHA established the Healthcare Leadership Talent Institute (HLTI) to provide 

coordinated focus to VHA’s talent management efforts. HLTI links VHA’s workforce-planning and talent-development programs through the design and deployment of a set of talent management products and processes, which are in the 

pilot-testing phase. • VHA is collaborating with the VA Corporate Senior Executive Management Office in implementing the December 2015 Executive Order on Strengthening the 

SES. These efforts include building a foundational leadership competency model 

for VA, instituting an executive rotation program to provide career-broadening 

experiences outside of each executive’s current position, enhancing the SES performance management system, and outlining an SES-level talent-management 

process for VA-wide implementation. 

Recommendation #12: Organizational Structures and Management Proc- esses 

‘‘Transform organizational structures and management processes to ensure adherence to national VHA standards, while also promoting decision 

making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the spread of best practices.’’ 

VA finds this recommendation feasible and advisable but recommends an alternative approach to reorganizing the VHA Central Office (VHACO), consistent with 

VA’s MyVA transformation. 

VHACO has undergone a stepwise ascent to improving the organizational structure to be more responsive to field requirements through the development of large 

programs responsible for organizational excellence and developing the future state 

health care plan. Immediate reorganization would divert attention from key organizational priorities such as improving access to health care. Known challenges associated with reorganization (which occurs with the regularity of each presidential election cycle), are impaired employee engagement, loss of institutional knowledge, and 

diversion of attention from critical challenges such as insuring Veterans have sameday access to primary care and mental health care services. Legislation would be 

required to streamline appropriations, and review by oversight bodies would be impacted by the changes described. Finally, the reorganization for VHACO should derive from and be integrated with the transformation of the overall VHA health care 

organization structure. VHA will initiate a VHACO and VISN organization analysis 

at the beginning of calendar year 2017. 

Recommendation #13: Performance Measurement 

‘‘Streamline and focus organizational performance measurement in VHA 

using core metrics that are identical to those used in the private sector, and 

establish a personnel performance management system for health care leaders in VHA that is distinct from performance measurement, is based on the 

leadership competency model, assesses leadership ability, and measures the 

achievement of important organizational strategies.’’ 

VA finds this recommendation feasible and advisable and is already implementing 

changes as part of VA’s MyVA transformation, with some modifications in approach. 

VHA is consolidating its health care operations metrics to provide a consistent, 

system-wide view of key performance indicators. In October 2015, VHA launched a 

Performance Accountability Work Group (PAWG) as a governance mechanism for 

performance measurement at all levels of the organization. The PAWG’s first task 

was to conduct a systematic review of all existing performance measures (numLeonard.horne on VACREP0180 with DISTILLER

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bering over 500), which resulted in a core set of approximately 20 key indicators, 

aligned to industry-wide approaches. SAIL scoring system is a critical component of 

these indicators, as well as predictive trigger systems that are the main inputs into 

a health operations center, which will facilitate centralized quality management. 

The leadership of the Office of Organizational Excellence (hereafter, 10E) has undertaken a strategic review across all current business processes to identify realignment opportunities-for instance, focusing ISO 9000 on its original target, which was 

the reprocessing of reusable medical equipment, and reinvesting the resources that 

will be freed up to enhance the ability of VERC to support the adoption of LEAN 

management approaches in support of the Under Secretary for Health’s five priorities for strategic action. 

We have also engaged a senior industry consultant to assist us with the process 

of executive recruitment and development; created a system-level VHA Performance 

Scorecard aligned along transformational priorities; simplified the template used for 

senior health care executive performance management plans; and started work to 

align business functions within the Office of Organizational Excellence to promote 

a unified approach to performance reporting, performance improvement, and the 

identification and spread of strong clinical and business practices. 

Finally, the Diffusion of Excellence initiative (see Recommendation #2) sources 

best practices from frontline employees in the field, and brings the combined resources of 10E to support their implementation where appropriate in under-performing VA sites. 

Recommendation #14: Cultural and Military Competence 

‘‘Foster cultural and military competence among all Veterans Health Administration (VHA) Care System leadership, providers, and staff to embrace 

diversity, promote cultural sensitivity, and improve veteran health care outcomes.’’ 

VA finds this recommendation feasible and advisable and is already working to 

address the Commission’s concern as part of VA’s MyVA transformation. 

VA has implemented training related to cultural and military competence, in 

some cases by partnering with external stakeholders (i.e., Equal Employment Opportunity Commission, the Joint Commission, Commission on Accredited Rehabilitation Facilities, DoD) and numerous national diversity-focused affinity and advocacy 

organizations. Examples of this coordinated training include Military Culture Training for Community Providers, Cultural Competency, Generational Diversity, Introduction to Military Ethos, Military Organization and Roles, Professional Stressors 

& Resources and Treatment Resources & Tools. From April 1, 2015, to July 22, 

2016, the last four courses were accessed 2,533, 1,527, 1,172, and 1,070 times respectively. VA will continually assess its cultural and military competence training 

portfolio for content, target audience, and training modalities to identify additional 

training needs. 

VA Office of Diversity and Inclusion has mandatory training in the area of cultural competence as part of its Equal Employment Opportunity (EEO), Diversity 

and Inclusion, and Conflict Management training for all VA managers and supervisors and mandatory annual EEO, Workplace Harassment, and No FEAR training 

for all VA employees. VA also maintains programs focusing on targeted populations, 

including a LGBT Awareness Program (issues referenced in the Report), Office of 

Women’s Health Services; Office of Health Equity; and a Center for Minority Veterans. 

VHA also has a large portfolio of clinical training programs, including several in 

the area of cultural and military competence in health care delivery. The Office of 

Health Equity developed virtual patient cultural competency training under the Employee Education Service contract for the Virtual Medical Center project. Presently, 

military competence training is available to any provider, and they are encouraged 

to take the training. Providers currently under contract are not required to complete 

the course, but future contracts will require completion. 

Recommendation #15: Alternative Personnel System 

‘‘Create a simple-to-administer alternative personnel system, in law and 

regulation, which governs all VHA employees, applies best practices from 

the private sector to human capital management, and supports pay and benefits that are competitive with the private sector.’’ 

VA finds this recommendation feasible and advisable and is already working as 

part of VA’s MyVA transformation, with some modifications in approach 

VA supports the Commission’s legislative proposal recommendation to establish a 

new alternative personnel system that applies to all VHA employees and falls under 

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Title 38 authority, provided outside stakeholders support the legislative and policy 

changes required to create this new system. 

VA currently is preparing for consideration a legislative proposal for the FY 2018 

budget process to modify 38 United States Code to give the Secretary the authority 

to establish a human-resources management system unique to VA. 

In the absence of a simple-to-administer alternative personnel system, VA has 

also proposed modifications to existing statutes to provide some relief to the currently complex personnel system and also help with recruitment and retention. 

These proposals include establishing an appointment and compensation system 

under Title 38 for VHA occupations of Medical Center Director, VISN Director, and 

other positions determined by the Secretary that have significant impact on the 

overall management of VA’s health care system. VA is considering proposals to do 

the following: 

• Eliminate Compensation Panels for physicians and dentists, which have been 

found to be administratively burdensome. 

• Eliminate performance pay for physicians and dentists, which has been found 

to be extremely difficult to administer. 

• Establish premium pay for physicians and dentists to allow flexibility in scheduling and eliminate the daily rate paid to these occupations based on 24/7 availability. 

• Modify special rate limitation to increase the maximum allowable special rate 

supplement providing enhanced flexibility to pay competitively within local 

labor markets. 

• Exempt VHA health care providers appointed to positions under 38 U.S.C. 7401 

from the dual compensation restrictions for reemployed retired annuitants. 

The VHA Strategic Human Resource (HR) Advisory Committee and Workforce 

Management and Consulting’s Human Resource Development group are proposing 

a comprehensive VHA HR Readiness Program designed to improve the overall operational capabilities of the VHA HR community. The program will identify and integrate all existing and available internal and external training resources into a clear, 

consistent, and logical roadmap to readiness. 

Under the MyVA program, the Staff Critical Positions Initiative was launched to 

improve hiring of key leadership and other critical positions throughout VHA. VHA 

is moving ahead with the ‘‘Hire Right, Hire Fast’’ initiative for MSAs. The initiative 

is being piloted at a number of facilities and will provide products and guidance in 

2016, including additional screening for customer service tools, an interview scoring 

rubric, job posting templates, HR milestone scripts, and much more. These products 

are designed to increase the supply of MSAs, as well as emphasize the customer 

service principles and skills needed for success. 

VHA has embarked on a Rapid Process Improvement Workshop effort within the 

HR community to examine the hiring process and identify improvement opportunities, to include operational processes and policies. Plans are also under development 

to establish a centralized architecture to designate lines of authority in setting 

training requirements, career paths, etc. 

Recommendation #16: Effective Human Capital Management 

‘‘Require VA and VHA executives to lead the transformation of HR, commit 

funds, and assign expert resources to achieve an effective human capital 

management system.’’ 

VA finds the Commission’s recommendation both feasible and advisable and is already pursuing the following initiatives as part of VA’s MyVA transformation. 

Hire Chief Talent Leader and Grant Authorities: VHA currently has a national 

search underway for its senior most HR executive position. Presently that role does 

not possess the authority recommended by the commission. It is anticipated that the 

HR&A transformation program, and the efforts associated with Recommendation 12 

in conjunction with the Under Secretary for Health, would work together toward the 

optimal organization structure for HR across VA and within the administrations including appropriate authorities. This process will help clarify the ideal roles and responsibilities of the VHA Chief Talent Leader. 

Transform Human Capital Management: As part of MyVA, VA HR&A has 

launched the Critical Staffing Initiative to improve the hiring of key leadership and 

other critical positions throughout the VA. This effort has been working on nearterm improvements to hiring medical center directors and other key medical center 

leaders. So far, this project has identified and is beginning to implement significant 

improvements to the hiring process and to proliferate hiring best practices across 

the organization. VA HR&A is currently planning a process to engage stakeholders 

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across VA to identify next steps for implementing the recommendations outlined in 

recent study commissioned by VA. A concept paper entitled ‘‘VISN HR Shared Service Excellence’’ is also being evaluated. This concept paper incorporates a number 

of recommendations contained within the white paper noted above, but with specific 

emphasis on HR roles within the VISNs and VA Medical Centers. The Commission’s 

recommendations will be taken into consideration in the process. 

Implement Best Practices: The VISN HR Shared Service Excellence paper is heavily weighted toward the sharing of best practices that have been developed in a few 

highly performing field HR organizations. Best practice sharing is also a significant 

component of the MyVA Critical Staffing initiative. Also, the HR&A transformation 

effort is intended to rely heavily on health care and other industry best practice 

models. 

Develop HR Information Technology Plan: The Commission’s recommendation addresses an issue which VA’s early HR transformation efforts are just beginning to 

address. While there are currently efforts planned and underway to implement HR 

Smart for personnel and payroll records, and USA Staffing to enable the recruiting 

process (acknowledged by the Commission), VA would benefit from casting these 

and other anticipated efforts in a more strategic IT plan. Such a plan would better 

enable implementation and integration prioritization and capital planning. 

Recommendation #17: Eligibility for Other-than-Honorable Service 

‘‘Provide a streamlined path to eligibility for health care for those with an otherthan-honorable discharge who have substantial honorable service.’’ 

VA finds this recommendation neither feasible nor advisable. 

The Commission’s own estimates indicate this change would cost $864 million in 

FY 2019, increasing to $1.2 billion in FY 2033. This recommendation therefore appears to contemplate health care for anyone with another-than-honorable discharge. 

While VA agrees with the principle of serving this population of Veterans, the cost 

of doing so makes the recommendation not feasible at this time. 

Many Servicemembers with other-than-honorable discharges qualify for health 

care for service-connected conditions and other benefits under existing authorities. 

VA will continue to serve this population. VA is also drafting proposed regulations 

which will update and clarify 38 C.F.R. §§ 3.12 and 17.34 to improve processes and 

procedures relating to character of discharge determinations and expand tentative 

health care eligibility for certain former Servicemembers. 

These changes will address many of the concerns raised by the Commission. For 

example, the rules will provide improved guidance about the consideration of mitigating factors such as extended overseas deployments, mental health conditions, 

and other extenuating circumstances. Also, VBA has, within the past year, updated 

its manual to streamline its other-than-honorable adjudicative procedures to expedite health care eligibility determinations and improve the Veteran experience by 

shortening the wait time. 

Recommendation #18: Expert Advisory Body for Defining Eligibility and 

Benefits 

‘‘Establish an expert body to develop recommendations for VA care eligibility and benefits design.’’ 

VA finds this recommendation feasible and advisable. 

Substantial changes in the delivery of health care have occurred since Congress 

last comprehensively examined eligibility for VHA care through passage of Public 

Law 104–262, Veterans’ Health Care Eligibility Reform Act of 1996, and taking a 

close look at eligibility criteria in light of current (and projected future) resources 

and demand makes sense in the context of VA’s ongoing efforts to reshape the future of VA health care. VA will work with the President, Congress, Veterans Service 

Organizations, and other stakeholders to determine the path forward in the tasking 

of an expert body to examine and, as appropriate, develop recommendations for 

changes in eligibility for VA health care benefits. 

Recommendation 18 also includes a separate and distinct recommendation for VA 

to ‘‘revise VA regulations to provide that service-connected-disabled Veterans be afforded priority access to care, subject only to a higher priority dictated by clinical 

care needs.’’ While VA supports the objective, VA already has regulations (38 C.F.R. 

17.49) and policy in place giving priority in scheduling to service-connected Veterans 

and believes these meet and fulfill the Commission’s intent. 

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TEXT OF A LETTER FROM THE PRESIDENT 

THE WHITE HOUSE 

OFFICE OF THE PRESS SECRETARY

For Immediate Release September 1, 2016 

TEXT OF A LETTER FROM THE PRESIDENT 

TO THE SPEAKER OF THE HOUSE OF REPRESENTATIVES 

AND THE PRESIDENT OF THE SENATE 

SEPTEMBER 1, 2016 

Dear Mr. Speaker: (Dear Mr. President:) 

My Administration is committed to the ongoing transformation of the Department 

of Veterans Affairs (VA) and I strongly support many of the recommendations and 

the underlying objectives offered by the Commission on Care (Commission) in its 

final report transmitted on July 6, 2016. These recommendations underscore the 

fundamental challenges that face the VA health care system, and the reforms needed to provide America’s veterans with the high quality health care they need and 

deserve—both now and in the future. We have made great strides in delivering improved care to our veterans over the past 8 years, and we will continue to work tirelessly to uphold the solemn responsibility to ensure all our veterans are getting the 

care and benefits they have earned. 

I concur with 15 of the 18 Commission recommendations, many of which are already being implemented as part of the ongoing MyVA transformation that the Secretary of Veterans Affairs (Secretary) has put in place. These include areas such as 

enhancing clinical operations, establishing a more consistent policy for appealing 

clinical decisions, eliminating disparities in how health care is delivered to veterans 

from different backgrounds, modernizing IT systems, and establishing new processes 

for leadership development and performance management. These reforms are steps 

in the right direction and will help put VA on a trajectory to ensure veterans continue to receive timely and high quality care, while strengthening the VA health 

care system that millions of veterans depend on every day. I appreciate and applaud 

the Commission for their work. 

Of particular note, I strongly support the Commission’s principle that creating a 

high-performing, integrated health care system that encompasses both VA and private care is critical to serving the needs of veterans. In fact, my Administration outlined its approach to achieve this same goal in VA’s Plan to Consolidate Community 

Care, submitted to the Congress in October 2015. While this approach must be implemented in a fiscally sustainable way, it builds on more than a decade of work 

with veterans, health care providers, and community partners, to streamline and 

enhance VA’s capability to deliver services essential to veterans’ health. VA’s plan 

also recognizes the importance of strengthening VA’s partnerships with other Federal health care providers, including the Department of Defense and Indian Health 

Service, as well as tribal health programs, academic teaching affiliates, and Federally Qualified Health Centers. 

At the same time, it is critical that we preserve and continue to improve the VA 

health care system and ensure that VA has the ability to serve veterans. Research 

shows that in many areas, such as mental health, VA delivers care that is often 

better than that delivered in the private sector. VA also provides unique, highly specialized care for many medical conditions, such as spinal cord and traumatic brain 

injuries, which are simply not available to the same extent outside of VA. In addition, VA provides a comprehensive approach to wellness that includes the treatment 

of physical injuries and mental health. This multidisciplinary approach allows providers to address the full spectrum of veteran needs beyond medical care, including 

other VA benefits and services. 

For these reasons, I concur with the Commission’s vision for creating integrated 

care networks that more tightly coordinate VA and non-VA care, but urge the Congress to act on this recommendation by enacting VA’s Plan to Consolidate Community Care. The alternative approach outlined in VA’s plan would achieve the goals 

of the Commission to create a veteran-centric approach to care that appropriately 

balances issues of access, quality, and cost-effectiveness. It would more clearly enLeonard.horne on VACREP0180 with DISTILLER

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sure the long-term viability and sustainability of the VA health care system, preserve VA’s role as the primary coordinator of care for veterans, and safeguard its 

ability to carry out its other research, education, and emergency preparedness missions that are critical to our Nation’s well-being. And it would ensure that veterans 

have access to the care they need—whether at the VA or out in the community— 

without forcing untenable resource tradeoffs that would limit the ability of VA to 

carry out other parts of its mission on behalf of veterans. 

We must also ensure that VA has the ability to operate this integrated health 

care system in a rational, efficient, and dynamic way that best serves the interests 

of both veterans and taxpayers. For that reason, I have concerns with the Commission’s proposed governance structure for the VA health care system. The proposal 

would undermine the authority of the Secretary and the Under Secretary for 

Health, weaken the integration of the VA health care system with the other services 

and programs provided by the VA, and make it harder—not easier—for VA to implement transformative change. Moreover, the Department of Justice has advised that 

the proposed recommendation would violate the Appointments Clause of the Constitution. I do, however, support portions of the recommendation that would establish a term appointment for the Under Secretary for Health, to ensure that position 

is removed from the turmoil and turnover of the political cycle. 

For those recommendations I agree with and whose objectives are not yet 

achieved, I am directing the VA to develop plans to complete their implementation. 

Additionally, in recognition of the role of the MyVA initiative in transforming the 

VA as military service evolves, I have directed the Secretary of Veterans Affairs to 

incorporate the principles of the MyVA initiative into VA strategic planning, leadership training, and performance monitoring. In those areas where legislation is required, my Administration will work closely with the Secretary to transmit to the 

Congress the relevant legislative proposals, which I recommend be enacted without 

delay. 

Improving veterans’ health care remains a critical issue of national importance, 

and my Administration will work with veterans and military families, the Congress, 

Veterans Service Organizations, and other stakeholders to ensure all our veterans 

are getting the care and benefits they need when they need them. 

Sincerely, 

BARACK OBAMA 

Æ 

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