U.S. GOVERNMENT PUBLISHING OFFICE

29–742 PDF WASHINGTON : 2019

S. HRG. 115–537 

THE STATE OF THE VA: A PROGRESS 

REPORT ON IMPLEMENTING 2017 

VA REFORM LEGISLATION 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

JANUARY 17, 2018 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

JON TESTER, Montana, Ranking Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

RICHARD BLUMENTHAL, Connecticut 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

ROBERT J. HENKE, Staff Director 

TONY MCCLAIN, Democratic Staff Director 

Majority Professional Staff 

Adam Reece 

Gretchan Blum 

Leslie Campbell 

Maureen O’Neill 

David Shearman 

Jillian Workman 

Minority Professional Staff 

Dahlia Melendrez 

Cassandra Byerly 

Jon Coen 

Steve Colley 

Simon Coon 

Michelle Dominguez 

(III) 

C O N T E N T S 

JANUARY 17, 2018 

SENATORS 

Page 

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

Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana ...................... 16 

Prepared statement .......................................................................................... 17 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 13 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 57 

Manchin, Hon. Joe, III, U.S. Senator from West Virginia ................................... 60 

Tillis, Hon. Thom, U.S. Senator from North Carolina .......................................... 64 

Blumenthal, Hon. Richard, U.S. Senator from Connecticut ................................ 66 

Letter for the record ......................................................................................... 67 

Heller, Hon. Dean, U.S. Senator from Nevada ..................................................... 78 

Hirono, Hon. Mazie K., U.S. Senator from Hawaii ............................................... 80 

Cassidy, Hon. Bill, U.S. Senator from Louisiana .................................................. 83 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 88 

Sullivan, Hon. Dan, U.S. Senator from Alaska ..................................................... 90 

WITNESSES 

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

accompanied by Peter Shelby, Assistant Secretary for Human Resources 

Administration; Cheryl Mason, Chairman of the Board of Veteran Appeals; 

Dr. Amy Fahrenkopf, Acting Deputy Under Secretary for Health for Community Care; Dave McLenachen, Director of Appeals Management; Peter 

O’Rourke, Executive Director of the Office of Accountability and Whistleblower Protection; and Robert Worley, Director of Education Services .......... 2 

Prepared statement .......................................................................................... 4 

Response to requests arising during the hearing by: 

Hon. Jerry Moran ......................................................................................... 13,14 

Hon. Jon Tester ............................................................................................. 57,78 

Hon. John Boozman ...................................................................................... 58,59 

Hon. Richard Blumenthal ............................................................................ 71 

Hon. Bill Cassidy....................................................................................... 84,85,86 

Response to posthearing questions submitted by: 

Hon. Johnny Isakson .................................................................................... 97 

Hon. Jon Tester ............................................................................................. 101 

Hon. Jerry Moran ......................................................................................... 109 

Hon. Dean Heller .......................................................................................... 110 

Hon. Bill Cassidy .......................................................................................... 111 

Hon. Thom Tillis ........................................................................................... 112 

Hon. Dan Sullivan ........................................................................................ 115 

Hon. Patty Murray ........................................................................................ 116 

Hon. Sherrod Brown ..................................................................................... 122 

Hon. Mazie K. Hirono ................................................................................... 125 

Hon. Joe Manchin III ................................................................................... 125 

APPENDIX 

National Organization of Veterans’ Advocates, Inc. (NOVA); prepared 

statement .............................................................................................................. 129 

Fuentes, Carlos, Director, National Legislative Service, Veterans of Foreign 

Wars of the United States (VFW); prepared statement .................................... 131 

(1) 

THE STATE OF THE VA: A PROGRESS REPORT 

ON IMPLEMENTING 2017 VA REFORM 

LEGISLATION 

WEDNESDAY, JANUARY 17, 2018 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 2 p.m., in room 418, 

Russell Senate Office Building, Hon. Johnny Isakson, Chairman of 

the Committee, presiding. 

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

Rounds, Tillis, Sullivan, Tester, Murray, Brown, Blumenthal, 

Hirono, and Manchin. 

OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 

U.S. SENATOR FROM GEORGIA 

Chairman ISAKSON. I call this meeting of the Senate Veterans’ 

Affairs Committee to order. I appreciate Secretary Shulkin being 

here today and all his hard work. 

The Ranking Member is on his way. I am going to start with my 

brief opening statement, and by the time that is over hopefully he 

will be here for his brief opening statement, upon which we will 

immediately go to Secretary Shulkin and then to the Members of 

the Committee for questions and answers. 

Let me say, at the outset, that this meeting is not about what 

has happened in the past. It is about what is happening right now, 

to correct some of the things that have happened in the past. This 

is an accountability hearing. I have told the Secretary that we 

want to really take the legislation that we passed last year on accountability, appeals, all the things that we passed, and give the 

VA the tools to address the significant problems confronting the 

veterans of America, the VSOs of America, and this Committee. We 

want to begin moving away from the problems of the past and toward the solutions of the future, in particular on: appeals; accountability; the GI Bill; all those things that are important to the veterans and their families; plus the leadership of the VA, as well. 

I also want to thank Secretary Shulkin. I have always been complimentary of him. A lot of people say, ‘‘You are too nice to him.’’ 

I am not too nice to him, as he has been good to the veterans and 

I am going to be good to him. He has been a forthright leader that 

the administration is lucky to have, I believe the veterans are 

lucky to have, and I feel like this Committee is lucky to have. Now, 

we are at the time where there are no excuses. There are no exVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
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cuses for why we do not correct the problems we have had with hiring. There are no excuses for why we do not correct the problems 

we have had with information technology. There is no excuse for 

not correcting the problems we have with veterans appeals, and 

other areas. 

So, this is all about accountability. It is all about standing forward. It is all about looking at the past and what we did and looking for the results that are to come in the future, so that we do 

a good job for the veterans of the United States of America. 

Mr. Secretary, I am going to swear you in for the purposes of this 

hearing. If you will stand and raise your right hand. 

Do you solemnly swear or affirm that the testimony you are 

about to give before the Senate Committee on Veterans’ Affairs will 

be the truth, the whole truth, and nothing but the truth, so help 

you God? 

Secretary SHULKIN. I do. 

Chairman ISAKSON. You may be seated. 

Mr. Secretary, I am going to recognize you for your 5 minutes, 

when the Ranking Member shows. 

Secretary SHULKIN. OK. 

Chairman ISAKSON. Welcome. 

Secretary SHULKIN. Thank you. 

STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, 

U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED 

BY PETER SHELBY, ASSISTANT SECRETARY FOR HUMAN RESOURCES ADMINISTRATION; CHERYL MASON, CHAIRMAN OF 

THE BOARD OF VETERAN APPEALS; DR. AMY FAHRENKOPF, 

ACTING DEPUTY UNDER SECRETARY FOR HEALTH FOR 

COMMUNITY CARE; DAVE MCLENACHEN, DIRECTOR OF APPEALS MANAGEMENT; PETER O’ROURKE, EXECUTIVE DIRECTOR OF THE OFFICE OF ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION; AND FINALLY, ROBERT WORLEY, 

DIRECTOR OF EDUCATION SERVICES 

Secretary SHULKIN. Chairman Isakson, Senator Moran, Senator 

Boozman, thanks for inviting me here to talk about VA’s program. 

More important, on behalf of the veterans the VA serves and our 

employees who serve them, thank you for your staff’s tireless, bipartisan work. It is has been great. 

We certainly appreciate and respect your leadership, Mr. Chairman, and partnership in establishing those issues that we are trying to tackle at the VA head-on. Some of them, as you have said, 

we know have lingered for years. I have always said I think we 

have the best committees in Congress and that is in large part due 

to the leadership. 

Chairman ISAKSON. We agree with that, by the way. 

Secretary SHULKIN. Yeah. Well, I would not say it if it was not 

true. I took an oath. So—— 

[Laughter.] 

Joining me today, seated behind me—I just wanted to introduce 

you in case I need a lifeline and get some help today—Peter Shelby, who is our Assistant Secretary for Human Resources Administration; Cheryl Mason, who is our Chairman of the Board of Veteran Appeals; Dr. Amy Fahrenkopf, who is our Acting Deputy 

3 

Under Secretary for Health for Community Care; Dave 

McLenachen, who is our Director of Appeals Management; Peter 

O’Rourke, who is the Executive Director of the Office of Accountability and Whistleblower Protection; and finally, Mr. Robert 

Worley, who is our Director of Education Services. 

A year ago, at my confirmation hearing before this Committee, 

I testified that I would seek major reform and transformation of 

VA. Today, to guide VA reform and transformation we are focused 

on five priorities. The first, which is to provide greater choice for 

veterans; second, to modernize our systems; third, to focus our resources on what is most important to veterans; fourth, to improve 

the timeliness of how we deliver our services; and fifth, prevent 

veteran suicide, which is our top clinical priority. The President’s 

Executive order last week, which supported transitioning military 

members with mental health services during that first critical year 

as veterans is an important step. 

Thanks in large part to your leadership, which helped us pass 

the legislation in 2017, the legislation I hope we will be discussing 

today, we are making progress on all five of those priorities. Appeals reform would be a good example. It is about modernizing antiquated systems and focusing resources while giving veterans 

more timely services and greater choice. 

Accountability and whistleblower protection is essential to our 

unwavering commitment to honoring veterans. It too is about sensible response of modern systems that process and support our people to make VA better. The Forever GI Bill gives veterans greater 

choice. More profoundly, it is about greater opportunity, especially 

for veterans returning to communities to pursue careers and fulfill 

dreams. 

Beyond these reforms, we have announced same-day services for 

primary care and mental health at every VA facility across the 

country. We have extended mental health to veterans with otherthan-honorable administrative discharges. So far, we have disposed 

of 111 out of 430 vacant or underutilized buildings. We published 

data publicly on wait time, quality data, customer satisfaction data, 

and last week we published our opioid prescription rates across the 

country. There are no other health systems in the country that 

publish this type of data. 

And, because of that—I hope it is because of that—we are earning our veterans’ trust back. At the end of this last year, 70 percent 

of veterans who responded to our survey said that they felt like 

valued customers at VA. That is up from 46 percent in 2014. 

Mr. Chairman, Members of the Committee, we are deeply grateful for your role in supporting all those changes and others like 

them. They are immensely important. But, when I look back over 

this year, we are still largely managing through incrementalism, 

patching and repairing old systems and processes and reacting to 

crises. VA still is far short of the kind of bold transformational 

change that we need to serve veterans in the decades ahead. From 

health care to benefits, we have to fundamentally and holistically 

change our service delivery paradigm. 

My objective, when it comes to health care for our veterans, is 

to have a fully-integrated, interoperable, operationally-efficient 

health care system that is easy for veterans, employees, and comVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
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munity partners to navigate. A full spectrum of care for veterans 

that capitalizes on our foundational services, delivering on our 

promise to provide world-class services. We need a consistent, 

seamless experience for veterans at every VA facility across the 

country. We need a national network of modern facilities that 

meets the changing needs of veterans locally. We need simple, convenient choice for eligible veterans among a network of high-quality community providers in a single consolidated program. 

Mr. Chairman, I applaud your efforts to get this done. Your draft 

legislation that passed out of this Committee is highly responsive 

to the needs of veterans, and we are all grateful for the work that 

you and the Committee have done so far to make this a reality. 

Benefits are a gateway to VA services and we need benefit determinations to be simpler. Veterans should know what to expect and 

have more predictability. They should not have to endure the burden of filing claim after claim after claim. Benefits should better 

enable lifetime of independence and success for veterans, economic 

opportunity, physical and mental well-being, and financial security 

for the severely disabled. In short, we need to begin an earnest dialog with stakeholders about veterans’ benefits. 

Mr. Chairman, in the days and months ahead, I invite and welcome your support and leadership in helping us define and then 

pursue the kind of worthy, transformational change the VA needs 

so we can all achieve what we hope to achieve. I look forward to 

your questions today. 

[The prepared statement of Secretary Shulkin follows:] 

PREPARED STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, 

U.S. DEPARTMENT OF VETERANS AFFAIRS

Good afternoon, Chairman Isakson, Ranking Member Tester, and Distinguished 

Members of the Senate Committee on Veterans’ Affairs. Thank you for the opportunity to testify today about the successes the VA team is achieving for the Nation’s 

Veterans, their families, and advocates with the valuable legislative tools you provided to us in 2017. 

ACCOUNTABILITY

The Department of Veterans Affairs took expedient action to implement the Secretary’s new authority to hold employees accountable provided for in the Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017. 

Within weeks of the enactment of the law, the Secretary developed and effected 

guidance to ensure both VA managers and employees are held to the highest standards of performance, integrity, and conduct. 

The Department developed four Human Resources Management Letters as guidance to managers and Human Resources personnel on how to implement several of 

the disciplinary provisions. Training was provided to managers, H.R. personnel, and 

the Office of General Counsel on the provisions of the Act, and how it would be 

implemented. 

Additionally, the Department developed several resources to assist H.R. personnel 

in understanding and applying disciplinary provisions of the Act, such as flow 

charts outlining the requirements of the accountability authorities available to the 

Department, comparison guides between requirements under the Act and VA bargaining unit obligations, and frequently asked question guides. The Department 

continues to modify guidance and update Human Resources Letters as needed and 

as adverse action cases are heard before the Merit Systems Protection Board. 

The VA’s Office of Accountability and Whistleblower Protection (OAWP) was established and the head of the OAWP was appointed on May 12, 2017 under the authority of the President’s Executive Order. OAWP is currently being led by an SES 

executive director who reports to the Secretary. 

The executive director provides clarification and advice related to accountability, 

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ship throughout VA. OAWP sends a senior team to raise awareness of accountability 

and whistleblower issues to executive leadership councils and other leadership meetings at VA facilities across the country. 

On June 12, 2017, OAWP began receiving whistleblower disclosures from employees into the Central Whistleblower Office authorized under The Patient Protection 

Act of 2016 (PL 114–223). After enactment of the Department of Veteran Affairs Accountability and Whistleblower Protection Act of 2017 (PL 115–41), the OAWP enhanced its whistleblower capabilities, developing a new Whistleblower Disclosure 

Form (VA Form 10177) to streamline the process and integrate disclosure intake 

into the Office’s new Triage Division. OAWP developed a triage, tracking, and referral process to ensure all disclosures are managed and resolved centrally. When appropriate, OAWP engages with the Office of Special Counsel (OSC) and the Office 

of Inspector General to refer disclosures and accept referrals for action. As of January 8, 2018 OAWP has received and validated 1,029 disclosures since June 2017. 

OAWP is protecting whistleblowers by utilizing its authority to place a temporary 

hold on personnel actions in cases where whistleblower retaliation is alleged or a 

disclosure is unresolved. Working with the OSC, OAWP ensures that the ability to 

seek corrective action is preserved. As of January 8, 2018 OAWP has held 72 

actions. 

On December 14, 2017, OAWP began discussions with the Department’s Executive 

Secretary to begin providing oversight of OSC’s referred disclosures. OAWP is working on value-added processes and procedures to ensure all OSC disclosures are investigated and resolved appropriately. OAWP is also working closely with OSC to 

ensure whistleblower retaliation cases are investigated and employees are protected. 

OAWP is evaluating methods, procedures, and information technology solutions 

for the systematic recording, tracking, reviewing, and confirming implementation of 

recommendations from audits and investigations carried out by the Office of Inspector General, Medical Inspector, Special Counsel, and the Comptroller General of the 

United States. Also being evaluated are the technological requirements for analyzing data produced by OAWP and the Office of Inspector General’s telephone hotlines and whistleblower disclosures in order to identify trends and reports to the 

Secretary. 

Since establishment, OAWP has been receiving, reviewing, and investigating allegations of misconduct brought against senior executives; employees in a confidential, 

policy-determining or policy-advocating position; and supervisors; when the allegation involves whistleblower retaliation. As of January 8, 2018 OAWP has completed 

77 investigations involving 149 persons of interest. OAWP’s current inventory is 139 

investigations involving 228 persons of interest. 

APPEALS REFORM

The Veterans Appeals Improvement and Modernization Act of 2017, enacted on 

August 23, 2017, is the most significant statutory change in decades affecting VA 

claims in the appeals process. It provided much needed reform for Veterans, and 

VA is committed to the law’s full implementation. 

VA developed an implementation plan, which was collaboratively prepared by the 

Board of Veterans’ Appeals (Board) and the Veterans Benefits Administration (VBA) 

with input from other components of VA involved in the implementation of the Veterans Appeals Improvement and Modernization Act. VA initiated this plan immediately after the law’s enactment, and fully expects to implement the new claims 

and appeals process by February 2019. VA is utilizing the 18-month period to promulgate regulations, establish procedures, hire and train personnel, implement information technology system changes, conduct outreach in order to train stakeholders on implementation of the new law, and gather data for trends analyses and 

metrics reporting. Due to the magnitude and scope of the statutory changes, VA is 

using a governance structure to oversee and document appeals modernization implementation and using dedicated project management experts to institute key project 

management tools and deliverables. To track implementation progress, the plan includes timelines, interim goals and milestones, risk mitigation strategies, reporting 

requirements, and deadlines that were established to ensure timely execution. 

VA has also undertaken enterprise-wide efforts to modernize the appeals process 

through improvements in technology. As part of this effort, information technology 

funds were used to develop and optimize paperless functionality in VA appeals processing. With Fiscal Year (FY) 2017 IT funding, VA began a multi-phase process of 

enhancing appeals functionality in the paperless environment. Initial key appealsspecific functionality in the paperless environment will focus on seamless integration of systems, and key accountability and work efficiency features. Digital Service 

at the VA (DSVA) launched Reader at the Board in November 2017, is working with 

6 

the Board to launch enhanced appeals on Vets.gov appeals by March 2018, and will 

begin testing Caseflow at the Board in the second quarter of 2018 with subsequent 

BVA-related enhancements and additional user groups. 

The Board is currently on pace to produce over 81,000 decisions during FY 2018 

which would represent a historic level of production. In FY 2018, the Board will also 

gain efficiencies by issuing a new decision template in February 2018, exploring new 

case review techniques throughout the spring and summer of 2018 and allowing delivery of decisions in close proximity to a Veteran’s hearing beginning in February 2018. The Board will begin to train all staff on the new appeals process in 

April 2018, and outreach training with Veterans Service Organizations in the summer of 2018. 

The Veterans Appeals Improvement and Modernization Act will also permit VA 

to test assumptions in the implementation of a new claims appeals system. Accordingly, VA has decided to carry out a pilot program during the implementation period, the Rapid Appeals Modernization Program (RAMP). The program, which was 

launched on November 1, 2017, allows eligible participants with pending disability 

compensation appeals in VBA the voluntary option to have their decisions reviewed 

in the higher-level or supplemental claim review lanes outlined in the new law. 

RAMP provides Veterans early access to the benefits of the new system, while also 

allowing VA to better position itself for full implementation in February 2019. Since 

disability compensation-related appeals account for the vast majority of all pending 

appeals, the program allows most Veterans with pending compensation benefit appeals to participate. 

VA will use the data collected during RAMP to create a capacity model based 

upon actual data. During this program, VA will gather data and conduct trends 

analyses on aspects of Veterans’ behavior, to include their decision to opt—in to the 

new system, employee productivity, processing timeliness, and inventory measures. 

VA will use that data to assist in developing future resource requirements as part 

of the annual budget process. VA intends to update the model when actual data can 

be used to replace projected data, when assumptions are shown to be no longer 

accurate, or based on any change in resources resulting from annual budget appropriations. 

With RAMP, VA has already made great strides toward implementing the new 

process; for instance, DSVA was able to support VA to design the Caseflow Intake 

application as a solution for managing Veterans’ elections to participate in the 

RAMP process using agile development technology. In addition, after garnering 

input from Veterans Service Organizations, VA deployed and is in the process of refining a more detailed decision notice for compensation appeals, as well as the 

RAMP election notice. Furthermore, with the implementation of RAMP, VA is documenting enhancements to VBMS that allow higher-level adjudicators to capture 

duty to assist error data. 

FOREVER GI BILL

VA has taken significant steps in the five months since the Colmery Act was enacted to implement thirteen provisions that were effective immediately, so that Veterans and beneficiaries could take advantage of their expanded benefits. In early 

November, VA notified nearly 8,000 beneficiaries that they may be potentially eligible for restoration of entitlement under a Special Application provision. To date (as 

of January 5, 2018), VA has received and processed close to 600 applications and 

restored over 3,500 months of entitlement to students, granting them the opportunity to continue to pursue their academic and education goals. VA is sending an 

explanatory letter and choice of election form to almost 3,200 individuals who lost 

their eligibility to the Reserve Educational Assistance Program (REAP), but now, 

because of the Colmery Act, can elect to have their qualifying active duty service 

periods credited toward establishing eligibility under the Post-9/11 GI Bill Program. 

The most notable and recognized change to the GI Bill benefit by the Colmery Act 

is the removal of the 15-year time limitation for Veterans who transitioned out of 

the military after January 1, 2013, and eligible dependents, to use their Post-9/11 

GI Bill benefits. As of December 20, 2017, all newly issued GI Bill Certificates of 

Eligibility and manually processed award letters are updated to notify eligible beneficiaries that they no longer have an expiration date to use their GI Bill benefit. 

By the end of January 2018, VA will have sent an email notification to over half 

a million Post-9/11 GI Bill beneficiaries informing them that they can now use their 

remaining entitlement when the time is right for them and their families. 

An extensive outreach and promotional campaign is well underway to ensure that 

all Veterans and beneficiaries are aware of the Colmery Act’s enhancements to the 

GI Bill. VA’s Facebook posts on the Colmery Act including those related to the perVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6621 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
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manent authorization of the work-study allowance have reached almost half a million individuals, a Twitter Town Hall received 173,000 views and 1,800 engagements, and VA has sent multiple mass emails to over 1 million recipients to amplify 

its communications platform for the Colmery Act. During the December 12, 2017, 

Forever GI Bill hearing by the House Committee on Veterans’ Affairs, Subcommittee on Economic Opportunity, VA live-tweeted pertinent information to be 

transparent and share news in real time. In late November 2017, VBA’s Deputy 

Under Secretary for Economic Opportunity conducted interviews with 23 radio and 

TV stations reaching an audience of over 3.5 million. Additionally, VA has briefed 

stakeholders ranging from School Certifying Officials to Veterans Service Organizations to encourage their involvement and support in getting the word out about the 

Forever GI Bill. 

VA is working closely with State Approving Agencies (SAAs) on changes that impact them because of the Colmery Act and has notified SAAs that they may now 

authorize independent study programs at certain educational institutions, like career and technical education schools. SAAs and VA are collaborating to redesign 

compliance reviews for oversight purposes, and VA has allocated increased SAA 

funding for FY 2018. 

VA will deliver by March 1, 2018 to Congress an implementation plan outlining 

IT system improvements to maximize the automation of educational claims processing, and VA’s Digital Services team has partnered with Education Service to collect priority enrollment information from schools for display on the GI Bill Comparison Tool. 

A few provisions of the Colmery Act already aligned with policies and procedures 

in effect. Examples include codification of the VetSuccess on Campus program, allowing Veterans participating in the Vocational Rehabilitation and Employment program to extend eligibility if called to active duty in certain cases, and providing 

School Certifying Officials additional flexibility when a course start date does not 

align with that of an academic term. 

A great deal of work remains to be done with 18 provisions slated to go in effect 

on August 1, 2018, including sections 107 and 501. These sections change the way 

VA pays monthly housing stipends by aligning payment to the location where students physically attend the majority of their classes and removing the exemption 

to the Department of Defense’s one percent reduction to housing allowance. While 

VA’s Office of Information and Technology has committed to implementing an IT solution for these two critical sections, it is resource challenged in balancing efforts 

related to the remaining 20 Colmery Act provisions with IT needs and the overall 

goal to decommission the antiquated Benefits Delivery Network, which is the system that currently handles much of Education claims processing and payments. 

With this consideration in mind, VA is optimistic that all 22 provisions with an IT 

requirement will have an IT solution in place by the end of FY 2019. To mitigate 

any impact to Veterans and beneficiaries using their education benefits, by 

May 2018, VBA will have hired 200 temporary field employees, and reallocated senior staff and experienced claims processors to specialized teams to account for increased workload and new programs related to the Colmery Act. VA will continue 

to regularly assess workload demands and resource needs, and adjust its staffing 

levels in order to properly deliver education benefits to Veterans and beneficiaries. 

In the coming months, VA will continue planning and working toward finding IT 

solutions and revising and developing sensible policies and procedures for implementation. VA will stay committed to its ambitious outreach campaign to include 

targeted messaging and engagement to thousands of Purple Heart recipients, who 

starting August 1, 2018 will be entitled to Post-9/11 GI Bill benefits at the 100-percent benefit level for up to 36 months, regardless of their time in service. Additionally, VA will communicate to Reservists and National Guard members their expanded access to GI Bill benefits as these individuals will now be able to use time 

spent on authorized medical care and certain orders as creditable toward GI Bill entitlement. VA remains steadfast in its effort to raise awareness of the Colmery Act’s 

broad impact to Veterans and beneficiaries so they are given the opportunity to take 

advantage of their expanded and enhanced benefits. 

WORKFORCE IMPROVEMENTS

VA is making progress in implementing the provisions of Title II (Personnel Matters) of the VA Choice and Quality Employment Act of 2017 to improve hiring authorities of the Department. Two of the most critical focal points of this title are: 

1) Section 210—Plan to hire directors of medical centers; and 2) Section 213—Expansion of direct-hiring authority. We have developed and implemented a plan for 

hiring highly qualified directors for each of our medical centers. As a result, we conVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6621 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
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tinue to make progress in staffing these positions. During calendar year 2017, we 

reduced the time to hire Medical Center Directors (MCDs) by about 23%. Currently, 

125 of 140 MCD positions are filled. Of the remaining 15 positions under recruitment, 10 have a potential hire identified and are either going through the OPM approval process or have an established entrance on duty date. 

Consistent with Section 213 of the Act, we are collaborating with the Office of 

Personnel Management (OPM) to expand direct-hire authority (DHA). We have submitted a formal request to OPM to receive DHA for 15 occupations because of our 

urgent critical hiring need to meet mission requirements. This need is in direct support of the Administration’s charge to improve the quality of and access to care for 

our Nation’s Veterans and their dependents. We must use options such as DHA to 

assist in meeting the unique recruitment challenges that we face over the next few 

years. 

COMMUNITY CARE AND FUNDING FOR CHOICE

Demand for community care remains high, with over 32.7 million outpatient medical care appointments completed in FY 2017. In FY 2017, VA community care appointments for outpatient medical care were approximately 36% of all such appointments provided through VA, a 4 percentage point increase from FY 2016. 

Over 1.1 million Veterans utilized the Veterans Choice Program in FY 2017, an 

increase of about 35,000 Veterans from FY 2016. Outpatient appointments for VA 

medical care in the Choice Program comprised approximately 50% of all such VA 

community care completed appointments in FY 2017. 

In August 2017, with Choice Program poised to run out of funding and no successor program yet in place, Congress appropriated $2.1 billion in emergency funding to continue the Choice Program. In December 2017, Congress included an additional $2.1 billion for the Choice Program in the continuing resolution package while 

discussions continue regarding the future of VA community care. 

Although more still can be done, VA continues to make progress toward business 

process improvements to streamline the delivery of community care for Veterans. 

We have implemented tools to share health information, when permitted by law, 

with community providers via encrypted email, through a web-based application, as 

well as through industry standard health information exchanges. We have introduced tools for our staff to ensure standardized authorizations for community care, 

including specification of the services to be provided. We continue to work toward 

awarding new community care network contracts to purchase community care. 

Earlier this month, VA announced a series of immediate actions to improve the 

timeliness of payments to community providers. The actions will address the issue 

of delayed payments head-on and produce sustainable fixes that solve ongoing payment issues that affect Veterans, community providers and other VA partners. 

On January 9, 2018, VA published a rulemaking that allows it to process claims 

for reimbursement of the reasonable costs of emergency treatment for non-serviceconnected conditions when only a portion of those costs were paid by a Veteran’s 

other health insurance. These regulations will authorize VA to reimburse emergency 

treatment costs in more instances. 

In October and November 2017, VA submitted the Veteran Coordinated Access & 

Rewarding Experiences (CARE) Bill to Congress. Veteran CARE is Veteran-centric 

and focuses on Veteran clinical needs. VA appreciates that Congress has developed 

legislation which includes many of the provisions included in CARE. We need Congress to pass legislation to give Veterans a system that works and that meets or 

exceeds the best the private sector has to offer. This is about building a VA that 

Veterans choose for their care—we want Veterans to Choose VA. The Administration’s bill included $4 billion in spending authority, fully offset, to ensure a smooth 

transition to the new, consolidated community care program when implemented in 

FY 2019. We continue to urge the inclusion of offsets against any new mandatory 

spending to promote fiscally responsible stewardship of the taxpayer dollar. 

Consistent with the Administration’s proposal, VA believes that the future of community care should include the following tenets: 

• Improve Veterans’ choice of community providers in meeting their healthcare 

needs. 

• Simplify Veteran eligibility with a focus on Veterans’ clinical needs. 

• Pave the way for consolidation of all community care programs. 

• Add convenient care benefits. 

• Set timely payment standards. 

• Include provider agreements with flexible payment rates that streamline how 

we pay for care, including care in State Veterans Homes. 

• Permit medical records sharing in the network when needed for Veteran care. 

9 

• And address clinical staffing shortages through expansion of graduate medical 

education and by improving VA hiring and retention of staff. 

DISABILITY COMPENSATION CLAIMS BACKLOG

VA is committed to providing Veterans with the care and services they have 

earned and deserve. For the eighth consecutive year, VBA has completed over a million disability claims and anticipates completing a record number of claims in FY 

2018. 

The VBA’s disability claims backlog continues to fluctuate at a relatively steady 

state between approximately 70,000 and 85,000 claims. VBA ended the calendar 

year with just over 80,000 backlog claims pending and is committed to reducing the 

backlog further. In the past, VBA focused claims processing resources on significant 

investments in staffing and overtime, as our claims volume far exceeded the relative 

timelines of claims actionability. However, as VBA has reduced the pending claims 

inventory, we remain focused on continuous deployment of incremental process improvements and technology initiatives to identify actionable inventory which will 

help further reduce our backlog and increase the timeliness of claims processing. 

VBA’s primary intent within backlog reduction is three-fold: ensuring the current 

system works efficiently by evaluating throughput metrics, ensuring efficient staff 

utilization by confirming appropriate actions are completed, and identifying additional actionable workload through process reviews. Our throughput metrics make 

sure our workloads, especially backlog claims, are processed timely and efficiently. 

Additionally, VBA has initiated focused quality reviews to detect human errors, 

found potential system-wide and employee-level improvements in initial claim 

actions, and identified procedural improvements. We also continue to proactively 

deploy effective workload management practices and explore other process 

enhancements. 

VBA is similarly looking to reduce backlog via the expansion of VBA’s contracted 

medical exam authority. Beginning in FY 2017, Congress granted VA the discretion 

to expand the Contract Medical Disability Examination (MDE) program from 15 regional offices to as many as the Secretary considers appropriate. The main purpose 

of this expanded contract Compensation and Pension (C&P) exam authority is to 

provide timely exams for Veterans residing in both the US and abroad. Contract 

exam expansion enables VBA to supplement Veterans Health Administration’s 

(VHA’s) internal C&P exam capacity to deliver faster claims decisions to Veterans 

and reduce the number of claims pending over 125 days. 

DECISION READY CLAIMS

As part of VA’s continued efforts to improve Veterans’ experience with the disability claims process, VA has developed the Decision Ready Claims (DRC) initiative—an extension of Fully Developed Claims. DRCs are claims for disability compensation submitted with the help of accredited VSOs, who certify that all supporting evidence (e.g. medical exam, military service records, etc.) is included with 

the claim at the time of submission to VA. Veterans who choose to submit their 

claim under DRC can expect to receive a decision within 30 days from the time VA 

receives the formal claim. DRC enables VBA to focus resources on reducing claims 

pending over 125 days as well as improving timeliness. 

In addition to claims for increased disability compensation (commonly known as 

claims for increase), as of December 2017, DRC was expanded to certain claims for 

direct service connection, presumptive service connection, secondary service connection, and Dependency and Indemnity Compensation. Transitioning servicemembers 

can use the DRC process to file pre-discharge claims less than 90 days from leaving 

the military. 

INFRASTRUCTURE–28 LEASES

VA is pleased to report that the 28 leases authorized in the 2017 Choice Act are 

moving forward expeditiously. VA is utilizing a streamlined set of contract documents that more closely align with General Services Administration (GSA’s) model 

in procuring these leases. VA is also adjusting its physical security, sustainability, 

and construction standards to more closely align with other Federal agencies, as 

well as private-sector healthcare, to increase speed to market, and cost-savings. Finally, VA is leveraging an enhanced partnership with GSA to procure 7 of the 28 

leases. 

The following seven (7) leases are being procured through the VA-GSA partnership: Pittsburgh, PA; Hampton Roads, VA; Tampa-Lakeland FL; Tampa, FL; Corpus 

Christi, TX, Denver, CO, and Rapid City, SD. GSA is reviewing the requirements 

packages and is in the process of assigning staff for execution of these projects. 

10 

The remaining 21 leases are being procured by VA through its Office of Construction & Facilities Management, Office of Real Property, using a delegation of GSA’s 

leasing authority. All of these projects have started in earnest. All advertisements 

for the Choice Act leases under procurement by VA are slated for release by the 

end of Spring 2018, with issuance of the VA Request for Lease Proposals in the 

Summer/Fall 2018, and award slated for Spring/Summer 2019. 

ELECTRONIC HEALTH RECORD

On December 13, 2017, a strategic pause was announced in the Electronic Health 

Record (EHR) acquisition process; the purpose of the pause is to conduct an additional and external assessment of national interoperability language contained in 

the Request for Proposal that would ultimately support an EHR contract award. 

MITRE Corporation was selected to coordinate and lead an independent assessment of the aforementioned contract language. The independent review was held on 

January 5, 2018, and consisted of a diverse, distinguished and highly respected 

group of Clinicians, Chief Information Officers and Executives, well-versed in national interoperability challenges/issues, from across the healthcare industry. 

MITRE is in the process of capturing the recommendations and comments provided during the January 5, 2018 interoperability forum and will submit a final report to the VA Secretary and other stakeholders for review by the end of January 2018. 

Thank you for the opportunity to appear before you today to provide you with 

VA’s progress on implementing the legislation in these important areas. This concludes my testimony, and I welcome any questions that you or other Members of 

the Committee may have. 

Chairman ISAKSON. Thank you, Secretary Shulkin. I appreciate 

those remarks very much, and I hope the Ranking Member is coming. Is he still coming? [Pause.] 

He is. OK. 

I will start—you can start the clock on me. Let me make somewhat of what may appear to sound like an announcement at the 

beginning of the hearing. The Secretary and I have been in a lot 

of conversations over the past month or so, and I want to thank 

him for his stated support for what the Committee passed out of 

Committee. As we all know, we had a 14-to-1 vote, and as we all 

know we had some differences of opinion on the Veteran’s Choice 

bill and the Care bill that we passed out of Committee. I did everything I could to try to bring about unanimous common ground, but 

I did not get that totally done. 

So, I made a phone call to the White House and talked with the 

President, and, I believe, if I am not mistaken, the Secretary was 

on that phone call, as well as a number of other people of interest. 

The President—and this is my repeating what I remember him 

saying to me—he said, ‘‘You are all good guys. You have got good 

solutions on both sides. You all see if you cannot work it out.’’ We 

tried to get together a couple of meetings to work it out, but that 

did not materialize for one reason or another. 

My goal, as Chairman of the Committee, is to find a positive resolution no matter what problem I confront, and not because it 

comes from my wisdom, but my persistence to see to it we keep our 

eye on the goal. Of course, the goal is choice for our veterans, better quality health care, and a more accountable VA. 

It is my understanding the President and the Administration is 

going to send our Committee, in the next couple of days, some suggestions that they are looking at, that might help us bring about 

a resolution. I intend to work with Senator Moran, the other Members of the Committee, and the full Committee, to see if we cannot 

11 

do that, so we can take to the floor a unanimously-supported bill, 

or a bill that at least everybody had their chance to support and 

can have their chance to amend on the floor. 

One way or another, it is time our veterans had a veterans’ policy that serve their choices, gave them the choices they need, funded them so they were not subject to the last-minute ‘‘we are out 

of money’’ routines, which this bill does, by the way. We consolidate 

the stovepipes from seven to one. Correct, Mr. Secretary? 

Secretary SHULKIN. Mm-hmm. 

Chairman ISAKSON. To get those things done that we have to do. 

So, I want to announce up front that that is forthcoming. When 

it gets here I will get it to the Committee, we will begin work on 

it, and try and get ourselves in the regular order to find a bill that 

we can unanimously get to the floor, one way or another, and if we 

cannot, I then will have known I made every effort to do so. I will 

do everything I can to take it in regular order and have it debated 

and fully amended on the floor, if that is necessary. 

Whatever the case, our veterans deserve the best of us; the best 

of us is to pass a bill that we can agree on, and the best of us is 

to find the common ground to set up that meeting. So, I intend to 

do that and I appreciated the input the administration has given 

us, and I look forward to continuing to work with them. 

I am going to extend—and I have got a little time left. You know, 

there are three or four things I want to talk about, Mr. Secretary. 

One thing that concerns me deeply is the four positions that remain unfilled at the Department. One is your former position. We 

plucked you out of VA leadership to become the leader of VA. That 

was a good idea. The bad idea is it still does not have anybody in 

your place, where you were in terms of Under Secretary of Health. 

The Assistant Secretary of Accountability and Whistleblower Protection is not in place. That person needs to be in place. The Under 

Secretary for Benefits, which is a critical position at the VA, needs 

to be in place. The Assistant Secretary for Information Technology, 

which is absolutely critical, particular with the Cerner technology 

coming in, has got to be filled somewhere sooner rather than later. 

I have asked these questions privately and have looked—and I 

know you are trying. But this is one of those things where we— 

A for effort is not good enough. We have got to find a way to get 

the best people in the United States of America in these disciplines, working for the Veterans Administration and working for 

our veterans. 

Can you tell us what progress you have made and what you are 

doing on those four posts, in particular? 

Secretary SHULKIN. Yes. Let me give you a quick update on that. 

For the CIO candidate, we have made a selection and that person 

is now going through a vetting process at the White House. Our indications are that that is moving along smoothly. 

For the Under Secretary of Benefits we had a commission—as 

you know, by law we need to form a commission. They selected 

three candidates. We made our top choice. That person withdrew 

and we have now gone on to our second choice—fortunately, all 

three candidates are excellent candidates—and that person has 

also gone through vetting at the White House, and they understand 

the critical nature of this. 

12 

On the Under Secretary of Health, we have—this is now going 

to be our third commission. We have had two commissions prior 

that did not select a candidate. The third commission will be 

chaired by Deputy Secretary Bowman on January 25 and 26. We 

have 11 candidates who have applied for that. We hope to have a 

successful selection out of that third commission process by January 26, of which we would then forward three names on to the 

President for consideration, that would go through vetting. 

On the Assistant Secretary for Accountability and Whistleblower 

Protection, Mr. O’Rourke is the executive in charge of the Accountability and Whistleblower Protection Office. He is here today. 

Chairman ISAKSON. That prompts me to tell you what happened 

this morning in the HELP Committee. We had testimony on disasters and preparedness, and out of the blue one of the chief people 

in charge of that for our country made a point to compliment the 

Veterans Administration and what the veterans hospitals and medical personnel did to help in the rescue of senior citizens in Houston during the terrible flood that we had, which magnified, for me, 

the importance of remembering that the VA health care system is 

a huge delivery system that serves, by the nature of its definition, 

our veterans, a more senior population. I wanted to compliment 

you and the doctors on what they did to earn that praise, because 

that is a real good thing to have. 

Secretary SHULKIN. Thank you. 

Chairman ISAKSON. From a standpoint of accountability, I want 

to see some accountability with regard to the appeals process. I 

read your report and I read your remarks. I know you are working 

on a demonstration project on appeals. Is that correct? 

Secretary SHULKIN. Yes. 

Chairman ISAKSON. What timetable do you have, are you working toward, to move away from a demonstration project to a project 

that is fact-of-the-matter; exactly how we are going to handle these 

appeals in the future, to stop the backlog from growing and begin 

to dissipate the backlog? 

Secretary SHULKIN. Well, today the backlog stands at 470,000 appeals, so we have a lot of work to do. Because of your legislation, 

we are now implementing a new process, of course. That will be 

fully implemented in early 2019, but we have actually started to 

make major improvements already. 

This year, we are on track to do 81,000 appeals. That would be 

30,000 more than last year. At this period right now, of this fiscal 

year, we are at 21,000 appeals. That is 10,000 more than this time 

last year. So, we are getting better and faster, and we have 

brought on new staff. 

Second, we have begun—and this was actually because of the 

feedback that we got the last time that we were together—we have 

begun to offer veterans now the choice, in their legacy appeals, to 

opt into the new process, so they do not have to wait. We have had 

3 percent of veterans opt in. These are people with long appeals 

who opted into—this is the pilot project—the new project. And, 

here is the good news. They are getting their decisions within 30 

days, and 75 percent of those decisions are going in favor of the 

veteran. 

13 

So, it is actually a pretty good deal. Instead of waiting 5 or 6 

years, if they opt in for a 30-day decision, 75 percent approval rate, 

which is beginning to address those legacy appeals. I am hoping, 

through our veteran service organizations and through your offices, 

we will encourage more veterans to consider—because this is an 

elective option—to choose to opt into the new process. They will get 

faster decisions and we hope accurate, good decisions for them. 

Chairman ISAKSON. My time is up, but as it ends I want to say 

this. I know our VSOs are represented here today. We did not ask 

them to testify because this was Dr. Shulkin’s day. The VSOs are 

going to have their chance to address the entire House and Senate 

Committees in a few weeks—— 

Secretary SHULKIN. Mm-hmm. 

Chairman ISAKSON [continuing]. In the Dirksen Building, in our 

annual report, and we look forward to their input. 

Yet, I hope the VSOs and the agencies will do everything they 

can to disseminate the fact that our veterans who have had pending appeals are given the option to opt out and go into the new, 

modernized program. Three percent of them have done so, and 

those that have done so have gotten a response in 30 days. That 

is a light-years improvement in terms of appeals, and I commend 

you on what you started. Let us help him finish it by getting our 

veterans a timely appeal answer. 

Senator Moran. 

STATEMENT OF HON. JERRY MORAN, 

U.S. SENATOR FROM KANSAS 

Senator MORAN. Mr. Chairman, thank you very much. Let me 

start with just a—well, let me first say that I am going to depart 

our hearing as soon as my questions have been answered, and I 

would pay honor in this setting to Senator Bob Dole, who we will 

all be in the Capitol to honor today. In Kansas, and perhaps the 

country, there is no more esteemed public servant, but in my view, 

while his public service was tremendous, his military service, and 

then his commitment to those with disabilities and the veteran 

community is exemplary. No one meets that standard, so I pay a 

tribute to Senator Dole. 

Let me just raise a few points and I am going to make a comment and ask a question, Mr. Secretary. First, I want to note that 

your cancellation of the contract for Region 4, for Community Care, 

troubles me. I understand that Senator Heller is also going to raise 

this topic with you today. You have a request from the Subcommittee on Appropriations to explain what happened in that regard, and I look forward to that answer. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. JERRY MORAN AND

HON. DEAN HELLER TO HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPART- MENT OF VETERANS AFFAIRS

Please provide information regarding the reasoning for the cancellation of the Region 4 CCN contract 

Response. VA received proposals in response to the Community Care Network 

(CCN) solicitation on June 30, 2017 and performed evaluations in accordance with 

the criteria established in the solicitation. VA took the following four factors into 

consideration for award decisions for CCN Region 4: (1) Technical, (2) Past Performance, (3) Socioeconomic Concerns, and (4) Price. The evaluations resulted in the 

14 

need to conduct negotiations. After negotiations were held, VA received the final 

proposal revisions on December 14, 2017 and immediately began conducting evaluations of these revisions. Award decisions must result in a contract that represents 

the ‘‘best value’’ to VA. After evaluations were completed, it was determined that 

final proposal revisions for Region 4 did not provide the ‘‘best value’’ to VA, all factors considered, or for our taxpayers. VA amended the solicitation to remove Region 

4 since a contract award was not possible. 

Senator MORAN. Second, I will be submitting several questions 

for the record. I am interested in knowing the VA’s efforts in regard to full implementation of the Toxic Exposure Research Act, 

something that Senator Blumenthal and I sponsored and became 

law in December 2016. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. JERRY MORAN TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Please provide an update on VA’s full implementation of the toxic exposure research act (PL 114–315) 

Response. VA, through the Post Deployment Health Services office, has contracted 

with the National Academy of Science to meet the requirements specified in section 

632 of the law. This consensus report is expected to be completed by NAM by early 

2019. As to the research oriented Federal Advisory Committee and accompanying 

research, as outlined in section 633 and 634 respectively, VA has yet to form the 

charter and begin work as these next steps would be contingent upon the findings 

of the report. 

Senator MORAN. Finally, you have had conversations with me 

about electronic health records, originally about a reprogramming. 

Now I see that there are other reasons that you are not proceeding, 

and I am concerned about what is taking place here. I have sent 

you a letter which I would ask you to respond to. 

Then let me talk about the topic that the Chairman mentioned, 

in regard to the bill that passed the Committee. I want to direct 

this not to the Chairman but to you, Secretary Shulkin. I have 

been working closely, in my view, with the Chairman and the 

Ranking Member, other Members of this Committee, and those in 

the VA that you designated for me to work with, and with the 

White House, to make certain that the future of Community Care 

for veterans works and works well for veterans and the providers 

who serve those veterans. 

It is of utmost importance to me to reform Choice and to pass 

the right policies that will work for veterans in accessing health 

care that they deserve. It is also critical that Members of Congress 

continue to push for a change in the VA culture and to promote implementation of policies directed by Congress instead of the VA 

often narrowing the scope and thwarting the intent of Congress. 

This is, in fact, the conversation that you and I had, almost exclusively, during your confirmation hearing in February 2017. 

Pushing for a culture that transforms the VA, in my view, we 

have to hold you and other VA leaders accountable, and in my view 

too often commitments and pledges that are made to this Committee and to individual Members regarding legislative efforts on 

behalf of our veterans, the follow-up, the experiences are typical of 

what I have found with implementation of congressional past legislation. The VA changes course and it thwarts the intent of Congress. You and I had this conversation during your confirmation 

hearing. 

15 

On numerous occasions, you and I have met in my office, we 

have had numerous telephone conversations, and in those meetings, and in those telephone conversations, you expressed support 

for access standards in the eligibility of Choice reform. In every instance, in my view, you led me to believe that you and I were on 

the same page. What I have—what I remember you saying is this: 

the need for specificity in legislation is there, and then I quote you, 

‘‘If it is left to the reg process, nothing in the VA will change.’’ You 

told me that. 

I learned, though, that you have said something quite different 

to the Chairman and to the Ranking Member. I am of the opinion 

that our inability to reach an agreement is, in significant part, related to your ability to speak out of both sides of your mouth—doubletalk. My understanding is that others have had this experience 

and there is a shared frustration about the circumstance. 

So, Mr. Secretary, you have been sworn to give testimony today. 

I am looking for a straightforward answer. A yes or no would be 

good. Do you believe that the eligibility criteria to determine if a 

veteran can receive care in their community ought to be explicitly 

linked to the access standards? Yes or no? 

Secretary SHULKIN. Of course, I believe that eligibility criteria 

should be explicitly linked to access standards, and I believe that 

those access standards need to be developed by the VA. 

Senator MORAN. Mr. Chairman, let me ask the Secretary, do you 

support the access standards that are in our bill? You have told me 

that. True? 

Secretary SHULKIN. I support the access standards that are in 

the bill that the Senate committee passed 14 to 1. 

Senator MORAN. Those access standards are very similar. The 

issue is whether they are then tied to eligibility. Why would you 

not tie the access standards to eligibility? Why have access standards if they do not matter who is eligible for Community Care? 

Secretary SHULKIN. Well, Senator Moran, first of all, I applaud 

your efforts to get this right. I think it is grossly unfair to make 

the characterizations that you have made of me, and I am disappointed that you would do that. But, I think that you have—I 

do not disagree with where you want to get to. I do believe that 

it is our job to give veterans more choice about how and where they 

get their health care. 

I think the issue is that I am trying to do this in a way that will 

work for veterans and work for VA. I have seen, as you said before, 

Congress passed legislation that makes it more complicated and 

that makes it not work for veterans, and what I am trying to do 

is give you my best advice about how this works. The best way that 

I know how to do it is the way that the Committee, 14 to 1, passed 

their vote, and I do believe that because of your efforts we can 

make those eligibility criteria, those access standards, clearer to 

veterans so they understand it—that should be our goal—and then 

make sure that they do have choices based upon their clinical 

needs of their condition. That is what you do in a health care system. That is what I am driving to get at. 

I do not believe that we are at a faraway position here. We are 

now talking about the best way to implement what we all want for 

16 

veterans, which is the best care and giving them the most choice 

that they can get in that care. 

Senator MORAN. Well, Mr. Secretary, I am sorry that you take— 

you are disappointed in my approach to this hearing today. I chose 

my words intentionally. 

Secretary SHULKIN. Mm-hmm. 

Senator MORAN. I believe it to be the case. I think you tell me 

one thing and you tell others something else, and that is incompatible with our ability to reach an agreement and to work together. 

I intend to be a Member of Congress who holds you accountable for 

what you tell me. 

I hope the next step is—the Chairman indicated that the White 

House was sending language. I certainly would welcome a conversation, a discussion among the Members of this Committee, the 

Ranking Member and the Chairman, the White House, and you. 

This is, as you say, not that difficult, but it is an important issue. 

It is not one that is just a matter of a few words. It matters in the 

result that we get for accountability at the VA. 

Mr. Chairman, thank for the opportunity to question the witness. 

Chairman ISAKSON. Thank you for your attendance. I now want 

to do two things. First of all, I want to echo your praise for Senator 

Dole. A great American, a great American hero. A guy whose campaign I ran in the Southeastern United States in 1988, I might 

add. I have always been proud of it. I kind of got the political itch 

because of it. He is a great humanitarian and a great human being. 

I appreciate the Secretary and Senator Moran’s candor in their 

feelings about what we are trying to do. What I am trying to do, 

as Chairman, is get us to a point where our dirty laundry is clean, 

it is folded, it is in the cabinets, and what we are doing works for 

the veteran. You do that when everybody gets their chance to have 

their say, when every fact is on the table, and we are all willing 

to work together. That is what this is all about, that is what we 

are going to do, and what I hope comes from the White House will 

be a catalyst in the next few days, which is why I wanted to tell 

everybody about that. I found out about it today. You found out 

about it today. So, when we get it in a couple of days you will get 

notice from me as to when we have the hearing. 

Thank you, Senator Moran, for your input. 

Senator MORAN. Mr. Chairman, I welcome that. 

Chairman ISAKSON. Please tell the Dole family we all get there 

if I shut my mouth. So—— 

Senator MORAN. Thank you. 

Chairman ISAKSON. Thank you. 

Senator Tester, you have got a choice. You can answer questions 

or you can go to opening statement, or, as big as you are, you can 

do whatever you want. [Laughter.] 

HON. JON TESTER, RANKING MEMBER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. No. That is all right. I will just ask some questions. The opening statement will be for later, and I apologize to 

the Members. I usually kick it over to you, but I have another committee I have got to get to very quickly. 

[The prepared statement of Senator Jon Tester follows:] 

17 

PREPARED STATEMENT OF HON. JON TESTER, RANKING MEMBER, 

U.S. SENATOR FROM MONTANA

Secretary Shulkin, thank you for being here. Mr. Chairman, thank you for your 

dedication to our Nation’s veterans. Largely due to your leadership, this Committee 

had a historic year in terms of the number and scope of bills we’ve had signed into 

law. A great deal of credit also goes to each member of Committee, as well as the 

tremendous advocacy of the VSOs in attendance and across the country. 

Mr. Secretary, last year, you came before this Committee and made a dramatic 

and urgent appeal for us to modernize the appeals process. We acted. 

You came to us and said you needed more tools to hold bad actors at the VA accountable, and to protect whistleblowers. We acted. 

You came to us multiple times when the Choice Program was running out of 

money. We acted. And then we acted again. And then we acted again. 

For months, you also came to us and pitched ideas about how to scrap the Choice 

Program. And how to replace it with a community care program that puts veterans 

and their doctors in charge of where to receive care. We turned those ideas into a 

bill that passed this Committee 14–1 and with the support of 26 VSOs. And I don’t 

want to let this moment pass without saying in the clearest terms how disappointed 

I am that you did not publicly announce your support for a bill on which we collaborated for months. 

If VA is not going to publicly advocate for its legislative priorities, you should not 

expect this Committee or this Senator to do so. 

Nevertheless, I am still committed to working with you and this administration 

to address the continued challenges of veterans and their families. Those challenges 

are daunting. They require action, not words. And they require us all working 

together. 

In recent months, the VA and the Administration have rolled out a number of initiatives, most of which I have agreed with, but many of which have included little 

or no substance. We can help you make them successful, but there’s little we can 

do if we’re given no notice and no information. 

And I’m afraid VA will continue to spin its wheels until you address the dramatic 

staffing vacancies that impact everything from the delivery of health care to the 

safeguarding of veterans’ personal information. This is a fight I have waged for 

years. Nearly every time we have spoken, or I have spoken with your predecessors 

of both parties, I have asked for specific things that can be done to help recruitment 

and retention efforts. 

And nearly every time, I have delivered—whether it was more flexibility, additional resources or additional authorities. 

Yet here we are—somewhere between treading water and drowning. And veterans 

in places like Montana can’t access the timely care they need and have earned. 

These vacancies must be a higher priority for you and the Department. Otherwise, 

VA won’t be able to fulfill its mission, and will setting itself up for failure as it 

moves forward on implementation of the many reforms that have come out of this 

Committee. We have a lot of ground to cover, and I look forward to getting started. 

Thank you. 

Senator TESTER. First of all, welcome, Mr. Secretary. When it 

came to the Caring for Our Veterans bill, we had consulted with 

the VSOs, and, in fact, got support of 26 of the VSOs. We actually 

consulted with you and the VA to make sure this stuff would work, 

including Members on this Committee and members off this 

Committee. 

In your written testimony you said the VA believes that the future of Community Care should include eight tenets. Those tenets 

are: improve veterans’ choice of community providers in meeting 

their health care needs; to simplify veterans’ eligibility with a focus 

on veterans’ clinical needs; to pave the way for consolidation of all 

Community Care programs; add convenient care benefits; set timely payment standards; include provider agreements with flexible 

payment rates and streamline how we pay for care, including care 

in State veterans’ homes; permit medical record-sharing in the network when needed for veterans’ care; and addresses clinical staffVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6601 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
18 

ing shortages through extension of graduate medical education and 

by improving VA hiring and retention of staff. 

I would just tell you that the Caring for Our Veterans Act checks 

every one of those boxes, and it checks every one of those boxes because when we drafted it we had those tenets in mind. So, I would 

really look forward, and I think look forward to a strong press release in support of this bill, and I will tell you why—because there 

is a certain amount of frustration, as you can tell—— 

Secretary SHULKIN. Of course. 

Senator TESTER [continuing]. From Senator Moran, the Chairman, myself, and others on this Committee, that you have been silent. OK? 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. So, thank you. 

Section 211 of the Accountability Act requires the VA to track 

the usage of new authorities granted, and we have given you a lot 

of new authorities—— 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER [continuing]. Over the past year, thanks to the 

good work of the Chairman. When will we see this report? 

Secretary SHULKIN. The report was due in December 2017, so I 

apologize that it is not there. The staff has had extreme difficulty 

tracking what you have required in that report, prior to the implementation of the Accountability Act. 

Senator TESTER. So what—— 

Secretary SHULKIN. I have instructed them to give whatever data 

they have to you and tell you what data they cannot collect. 

Senator TESTER. So, when can we expect it? 

Secretary SHULKIN. I am going to say, is it reasonable to ask for 

2 weeks? 

Senator TESTER. Two weeks it is. We will hold you to it. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. JON TESTER TO HON. 

DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Please provide, within two weeks, a report regarding the tracking of new authorities granted as required in section 211 of the accountability act. 

Response. The Section 211 Report did not ask for any data post implementation 

of the Act. It was all tied to the 3-year period prior to the Act (which we included 

in the June 30 Report to Congress on the 1st anniversary of OAWP, attached). It 

was broken down by categories of 713 (senior leaders) and 714 (workforce). 

19 

ATTACHED REPORT


117OAWP1.eps

Department of Veterans Affairs 

Report 

To 

The Committee on Veterans Affairs of the Senate 

And 

The Committee on Veterans Affairs of the House of 

Representatives 

On the Activities of the 

Office of Accountability and Whistleblower Protection 

For the Period: 

June 30, 2017 - June 30, 2018 

This report is required under 38 U.S.C. §323(f) 
20 


117OAWP2.eps

VUUvUVi , ••• , •••• ,, ••••• ••••••••••• , •••• , •••••••••••••••••••••••••3 

................................................................ 4 

............................................... 6 

II. ...................................................................... 18 

Activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 

V. to statute .......................... 22 

211 

The Department gathered the best available data to provide baseline information to 

assist evaluating the impact of the VA Accountability and Whistleblower Protection 

Act. This additional data is presented as an appendix to this report. 
21 


117OAWP3.eps

Introduction 

The Office of Accountability and Whistleblower Protection (OAWP) represents the 

culmination of many years of effort to improve accountability within the Department of 

Veterans Affairs and to establish a new capability to centrally receive and address 

whistleblower disclosures. Congress built on and strengthened the capabilities 

developed internally by the Department creating OAWP through Public Law 115-41 in 

2017. 

OAWP absorbed and expanded on the work formerly performed by the Office of 

Accountability Review and the Central Whistleblower Office to establish an intake, 

investigation, and accountability vehicle to support the VA Secretary's efforts to better 

fulfill the Department's mandate to" ... care for [those] who have borne the battle ... ". 

OAWP is led by Executive Director Kirk Nicholas who provides oversight for the 

Secretary's accountability agenda. OAWP is headquartered in Washington DC and has 

satellite resources and programs across the United States. 

OAWP serves to improve the performance and accountability of VA senior executives 

and employees through thorough, timely, and unbiased investigation of all allegations 

and concerns. Where these actions are found factually true, OAWP will provide 

recommended actions related to the Senior Executive or other senior leader's removal, 

demotion or suspension based on poor performance and/or misconduct. Additionally, 

OAWP provides protection of valued VA whistleblowers against retaliation for their 

disclosures under the whistleblower protection provisions of38 U.S.C. section 714. 

OAWP is dedicated and empowered to provide transparency and build public trust and 

confidence throughout the entire VA system. The Office is committed to preserving the 

cultural integrity of the Department and conducting balanced, fair and efficient 

investigation of VA whistleblower disclosures, timely remedial resolutions and 

responsive recommendations. 

This report is required under 38 U.S.C. §323(f) as a description of OAWP's activities 

over the preceding year and recommendations for improvements in VA accountability 

and whistleblower protection. 

3 
22 


117OAWP4.eps

Background 

The Office of Accountability and Whistleblower Protection (OAWP) is a newly created 

Office within the Department of Veterans Affairs (VA) dedicated to improving the ability 

of the Department to meet needs of Veterans through investigation of whistle blower 

disclosures and allegations of senior executive misconduct or poor performance. On 

April 27, 2017 the President of the United States signed Executive Order 13793 creating 

OAWP to advise and assist the Secretary of Department-wide issues of accountability. 

OAWP's roles and responsibilities were expanded significantly by Public Law 115-41 , 

enacted June 23, 2017. 

OAWPACCOUNTABILITY PROCESS 

General workflow of disclosures submitted to OAWP 

Investigation and resolution of Senior Leader misconduct has been the topic of multiple 

memoranda from VA Leadership over the years, centralizing the reporting, investigation, 

and resolution of these matters in various forms. In its last incarnation, the Office of 

Accountability Review (OAR) was created within the Office of General Counsel to 

elevate and address these issues. This office, formed in response to access to care 

issues, revealed gaps that could only be effectively addressed through action above the 

individual Administrations and Staff Offices. 

4 
23 


117OAWP5.eps

OAWP was initially established through Executive Order 13793, Improving 

Accountability and Whistleblower Protection at the Department of Veterans Affairs, 

signed on April 27, 2017. Mr. Peter O'Rourke was appointed as the first Executive 

Director on May 12, 2017. Under the Executive Order the fledgling office was directed 

to: 

(a) Advise and assist the Secretary in using, as appropriate, available 

authorities to or terminate any VA manager or employee who has 

violated the public's trust and failed to carry out or her duties on behalf of 

veterans, and to recruit, reward, and retain high-performing employees; 

(b) Identify statutory barriers to the Secretary's authority to discipline or terminate 

any employee who has jeopardized the health, safety, or well-being of a veteran, 

and to recruit, reward, and retain high-performing employees; and report such 

barriers to the Secretary for consideration to the need for legislative changes; 

(c) Work closely with relevant VA components to ensure swift and effective 

resolution of veterans' complaints of wrongdoing at the VA; and 

(d) Work closely with relevant VA components to ensure adequate investigation 

and correction of wrongdoing throughout the VA, and to protect employees who 

lawfully disclose wrongdoing from retaliation. 

On June 22, 2017, Congress presented the President with crucial legislation to 

permanently effect change in VA regarding accountability and whistleblower protection. 

The President signed this bill as Public Law 115-41, the VA Accountability and 

Whistleblower Protection Act, on June 23, 2017. This statute codified and expanded 

OAWP, assigned it specific responsibilities, and implemented new authorities to hold 

senior leaders and employees accountable. OAWP absorbed the then-current staff and 

workload of the OAR into its new stand-alone structure. OAWP immediately began 

operations under its new mandate. 

5 
24 


117OAWP6.eps

I. Organization & Structure 

Based on the Executive Director's assessment of the requirements to meet its 

obligations the new organization was initially established with five divisions 

(Investigations; Advisory & Analysis; Central Whistleblower Office; Knowledge 

Management & Operations; and Administrative Support) of96 full-time equivalent 

employee (FTEE) positions, with approximately 48 actually on-board. 

As the Office's workload crystalized around the new authorities and responsibilities of 

P.L. 115-41 the organizational structure was revised. The structure maintained five 

divisions, redistributing resources and assignments, as well as adding the Office of 

Executive Director. The structure is: Office of the Executive Director; Triage Division; 

Investigations Division; Advisory & Analysis Division; Knowledge Management 

Operations; and Human Resources and Office Support. This structure consists of 102 

FTEE. As of June 1, 2018, OAWP had 73 employees onboard with several additional 

hires pending. 

Since its inception, OAWP has been operating its full range of case work. Starting at 

approximately 1/3 its authorized staff, the year has been characterized by the 

challenges in staffing a number of diverse positions to complete the full range of cases 

and activities under the Public Law. 

Office of Accountability and Whistleblower Protection 

Executlve Office of th• Director 

I {FTE 7, Onboord 6) I Humaft R~~ •IWI Offke Support KMwfed1e MIM~t Openitk>IU em 1s. OnbcN<d n (FT£ 9. Onbollrd 8) 

I I 

Trl•c• Dtvtdon lmN~st tions Dlvlston Ad'vbory and An~~fvd• CMvh.lon 

tFTE 26, Onbofod 19) ~FTE 30, Onbo•rd 221 (nt JS, Onboard 11) 

Staff levels as of June 1, 2018 

6 
25 


117OAWP7.eps

Executive Office of the Director -

Leading and supporting OAWP's accountability work, the Executive Office of the 

Director ensures transparent and timely intake, investigation, and resolution of 

accountability concerns. This office is the principal interaction point on accountability 

issues between OAWP and all Senior VA leadership. It provides strategic direction, 

policy development, training, and ensures integration of OAWP's operations with the 

Secretary's vision for accountability and whistle blower protection. 

The Executive Office of the Director is headed by the Executive Director, Office of 

Accountability and Whistleblower Protection (OAWP) and includes the Deputy 

Executive Director, Senior Advisors, the Executive Director's Executive Assistant; and 

the Hurnan Resources and Operations Support team. 

The Executive Office of the Director is responsible for the leadership, administration and 

support for OAWP's operational divisions: Triage; Investigations; Advisory & Analysis; 

and Knowledge Management. 

tert to Right: Todd Hunter, Oeputy ExecutJve Director OAWP; 

Kirk Nicholas, Executive Oitector OAWP; and Peter O'Rourke, Acting VA Secretary 

7 
26 


117OAWP8.eps

Triage Division is the first point of contact for whistleblower disclosures and allegations 

of senior executive misconduct. The Triage staff assesses the information submitted 

and, as needed, conducts initial development of the submission with the disclosing 

party. Triage maintains oversight of all matters submitted to OAWP, ensuring issues 

are brought to resolution. 

Triage Division consists of a Division Director, two Regional Directors, and 16 Human 

Resources Specialists (Employee Relations) as Case Managers. 

Comprised of competent, capable and compassionate team members that help quickly 

manage resolution of VA employee whistleblower disclosures. The division determines 

matters fall within OAWP's scope and the appropriate course of action to take on each 

matter. The team provides guidance, oversight, analysis and training on the 

whistleblower program and ensures VA administrations implement recommendations 

from audits and investigations carried out by various entities including Office Special 

Counsel (OSC) and Office of Inspector General (OIG). 

The Triage Division is the entry point for matters within the Office's purview. 

These submissions include disclosures of information as well as completed reports or 

other findings (e.g. Merit Systems Protection Board decisions or Office of Special 

Counsel findings) involving senior leader misconduct. Triage maintains multiple 

avenues to receive disclosures including via a toll-free telephone number, email, and 

fax. A website submission form is under development. Whistleblower disclosures and 

completed reports are further referred for resolution. 

The Triage Division refers received whistleblower disclosures for further investigation if 

there is reason to believe the disclosure is evidence of one of the categories of 

wrongdoing. See 38 USC §323(c)(1 "Reason to believe" has been applied as 

"reasonable belief. 

Depending on the specifics of the whistleblower disclosure, referrals may be then made 

to: the Office of Medical Inspector (for clinical or healthcare allegations), Office of 

Inspector General (for potentially criminal allegations), OAWP's Investigations Division 

(for allegations involving senior leaders), or the individual VA Administrations (i.e. VHA, 

VBA, or NCA) or Staff Offices (for allegations of wrongdoing not involving senior leaders 

or otherwise not referred to another office). Except those disclosures referred to OIG, 

whistleblower disclosures referred outside OAWP remain under the oversight of OAWP 

Triage, and require a completed investigatory report be submitted to OAWP for review 

and acceptance prior to concluding the matter. 

8 
27 


117OAWP9.eps

Completed determinations, such as MSPB decisions or OSC reports, that include 

misconduct by a Senior Leader or whistle blower retaliation by a supervisor are referred 

from the Triage Division directly to the Advisory and Analysis Division for resolution. 

OAWP also developed and published an Optional Form for Employee Disclosure to 

inform and assist employees submitting complete disclosures. 

From June 2017, through June , 2018, Triage Division has received nearly 2,000 

submissions. The specific types and quantities are displayed on the following charts. 

A "whistleblower disclosure" defined in the VA Accountability and Whistleblower 

Protection Act as: 

" ... [A]ny disclosure of information by an employee of the Department or individual 

applying to become an employee of the Department which the employee or 

individual reasonably believes evidences-

- A violation of law, rule, or regulation; or 

Gross mismanagement, a gross waste of funds, an abuse of authority, 

or a substantial and specific danger to public health or safety. 

"Reasonably believes" is an objective test based on the information known, or 

readily discoverable by the submitter, that the information submitted shows 

alleged wrongdoing. 

Submissions that involve an allegation of senior executive misconduct or whistleblower 

retaliation are referred to OAWP's Investigation Division. Submissions alleging criminal 

wrongdoing are referred to the VA Office of the Inspector General. Submissions that are 

"whistleblower disclosures, but do not involve senior executive misconduct or 

whistleblower retaliation are referred to the appropriate Administration or Staff' Office for 

investigation. Referred "whistleblower disclosures" remain subject to OAWP oversight 

and the resulting investigation is subject to review and acceptance by OAWP. 

Submissions that do not meet the statutory definition of a "whistleblower disclosure" and 

do not involve allegations of senior executive wrongdoing are referred to the appropriate 

VA Administration or Staff Office for awareness. These "non-whistleblower disclosures" 

do not require an investigation or report to OAWP. 

9 
28 


117OAWP10.eps

16" 

%of Disclosures by Type Since JUN 17 

51" 

• Violltton ot ~nv ~. 

rulie Of rtsu&aclon a we ft',:.liatiOn 

• Abuw of .JUlhofity 

a SU:bit_..ntbl Mld sped1c 

d¥1gtt to public health 

~toa.ntbt and~flc 

d~tttoutety 

The above chart displays the breakdown of disclosures by general category of the disclosure as received 

by OAWP since June 2017 through May 2018. 

• 

% of Disclosures by Administration 

SinceJUN 17 

........ T 

• VHA 

• VBA 

• OIT 

a OALC 

a 8VA 

• OSP 

The above chart displays the percentage of disclosures received broken down by Administration or Staff 

Office from June 2017 through May 2018. 

10 
29 


117OAWP11.eps

l!O 

100 

50 

Count of Disclosures by Type by Month 

190 

16) 164 

149 Ul 

119 

JO 

lU ... 

171 • VW.tlOftoflltfYLiw, nAtOt 

·-

G~s~mf'tll 

• WH.un~ inC! 'IPf(Jtc d...,..,to.,_,blc:tltllh 

~llililndf!PKifi( 

~toi;l/fl'f 

• Not. W! dl$1tklw,. 

The above chart graphically displays the types of disclosures received by month from June 2017 through 

May 2018. 

1 20 

Not a WB disdosur~ 110 107 80 61 66 42 89 102 lOS 101 147 1018 

Gr.ndTo~ 30 lU l24 163 149 lSJ 119 164 198 212 171 204 1999 

The above chart displays the type of disclosures received by month from June 2017 through May 2018. 

11 
30 


117OAWP12.eps

Investigations Division 

Investigations Division is the most visible division in OAWP, interacting with witnesses 

and persons-of-interest to resolve cases. Investigators conduct inquiries to gather 

evidence and testimony to resolve allegations of senior executive misconduct or 

whistleblower retaliation. Depending on the specifics of a case, inquiries may be 

conducted on-site or virtually. 

Investigations Division is currently comprised of a Division Director, two Regional 

Directors, and as of June 1, 2018, 19 Human Resources Specialists (Employee 

Relations) as Administrative Investigators. 

The Division began operations on June 23, 2017 with 15 Investigators, since October 

2017 this number has increased to 21 Investigators as of June 1, 2018. The two 

Regional Directors and 6 additional Investigators will enter on duty after June 1, 2018. 

Investigations Division is the primary entity within the VA for investigating senior leader 

misconduct, including allegations of whistleblower retaliation. The division assesses 

allegations and determines the appropriate scope and method of investigation. 

Investigators plans and conducts the actual investigations, gathering relevant evidence 

to substantiate or not substantiate the allegations. Investigators are typically assigned 

in two-person teams with a Lead and secondary investigator assigned to each case. 

Investigations Statistics 

On June 23, 2017, Investigations Division had a legacy workload from the Office of 

Accountability Review of 116 investigations involving 216 Persons of Interest (POls). 

From June 23,2017, through June 1, 2018, Investigations Division: 

Completed 128 investigations involving 236 POls; 

Received 261 cases involving 482 Senior Leaders; 

Had 125 pending or ongoing investigations, involving 264 POls. 

Current Investigations lifecycle Timeline as of June 1, 2018: 

Inventory: 36 Days 

(Pending assignment) 

Functional investigation: 50 days Report Approval: 14 days 

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31 


117OAWP13.eps

Advisory and Analysis Division 

Advisory and Analysis Division is the principal accountability arm of OAWP. The staff 

analyzes investigative results and advises VA leadership regarding appropriate steps to 

resolve matters. These could include performance management, disciplinary actions, or 

recommending no action. 

Advisory and Analysis Division is comprised of a Division Director and 10 Human 

Resources Specialists (Employee Relations). 

Advisory and Analysis Division makes recommendations regarding disciplinary and 

accountability actions to the Secretary and other senior officials. The division works 

closely with senior management to prepare disciplinary actions in instances of senior 

leader misconduct or poor performance. Advisory & Analysis also provides training to 

VA leadership on the Accountability Law and provides guidance to management 

officials on the implementation of the Accountability Act and whistleblower protections. 

Adll&t$& ActiCIIIS FOf Senor leader cases the Secretary ISOOCil'led 

ltlat adlon IS ll!Ccmnended by 0/11/M' F« 

GS.15and below ca5e50/IIIM' ..,, COflad the 

Pl<>po<sang aioal Wl1h a oeccrrmendaboo 

Proposal Issued 

~IISISsuedlO~..,Ih 

<Mdencefile ~ I@5I)OndS 

wtll1n 7 days ol Pf<IPOS8l 

CaseR.._ 

PIARMews the case- to 

detennne appropoate acbon 

Draft Proposal OeciS!CIIIand Rectess 

Oeos.onrssued Wllhln 15 business days of 

proposal Senor leaders can gnevethe dedSlon 

to lhe Seaetary Bolh Ser>or Leaders anc1 

GS.15 rove addlttonataweal ngh:s 

h consuttatton With alee of Genefal 

Counsel. 0/11/M' wtl draft the 

P<oposed OdiOO 

13 
32 


117OAWP14.eps

From June 23, 2017 through June 1, 2018, Advisory and Analysis Division: 

Received 39 cases directly from Triage as developed matters (e.g. MSPB 

decisions or OSC findings) involving 65 POls; 

Completed 182 cases, including 130 cases resulting from OAWP investigations; 

Recommended disciplinary or adverse actions 54 cases involving 58 unique 

POls; 

Had 49 potential disciplinary or adverse actions. 

14 
33 


117OAWP15.eps

Advisory and Analysis Division has recommended disciplinary or adverse action against 

individuals occupying senior executive positions under 38 U.S.C. §713 as shoVv11 on the 

accompanying two pages. 

"Administration" indicates the major c'rganizatior1al 

"OAWP Recommendation" 

"Action Proposed" is determined by the Proposing Official. 

"Initial Decision" reflects the determination of the Deciding Official. 

"Grievance Decision" reflects the VA Secretary's decision regarding any grievance filed by the subject employee regarding the Initial Decision. 

Administration OAWP Action Proposed Decision Grievance 

Recommendation Decision 

VHA Removal Removal Removal No grievance 

filed 

VHA 30-day No action No action No grievance 

suspension available 

VHA Removal Demotion Demotion Grievance 

Denied 

(Demotion 

Upheld) 

VBA 15-day 1-day Reprimand No grievance 

suspension suspension filed 

Removal Demotion (to Demotion (toGS- Mitigated to a 

GS-14) 14) Demotion to 

GS-15 

VHA Reprimand Reprimand Reprimand Mitigated to 

admonishment 

VHA 5 -10-day No action No grievance 

suspension. available 

OAWP later 

recommended no 

action. 

VHA 15- 30-day Reprimand Reprimand No grievance 

suspension filed 

VHA 5 10-day Admonishment Admonishment No grievance 

suspension available 

VHA 60-day 3-day Reprimand grievance 

suspension suspension filed 

removal 

VBA 60-day 60-day Retired in of No grievance 

suspension - suspension decision available 

removal 

VHA 15-day 15-day 15-day suspension No grievance 

*OSC Report suspension suspension filed 

(minimum 12-

day required) 

15 
34 


117OAWP16.eps

Continuing the Advisory and Analysis Division recommendations of disciplinary or 

adverse action against individuals occupying senior executive positions under 38 U.S.C. 

§713 as shown. 

"Administration" indicates the m;,i11r m·,-eniinti,nn;,l 

"OAWP Recommendation" 

"Action Proposed" is determined by the Proposing Official. 

"Initial Decision" reflects the determination of the Deciding Official. 

"Grievance Decision" reflects the VA Secretary's decision regarding any grievance filed by the subject employee regarding the Initial Decision. 

Administration OAWP Action Proposed Decision Grievance 

Recommendation Decision 

VHA Reprimand Written None (Counseling 

Counseling not proposed/ 

decided) 

VHA Reprimand Reprimand Written counseling No grievance 

available 

VHA 30-day None None No grievance 

suspension employee available 

retired 3/31 

before proposal 

issued 

VHA Reprimand Written None (Counseling No grievance 

counseling not proposed/ available 

decided) 

VHA 15-day Written None (Counseling No grievance 

suspension counseling is not proposed/ available 

removal decided) 

OGC Demotion- Demotion Written No grievance 

Removal Counseling available 

VHA Removal Removal Settlement grievance 

Agreement available 

(retired) 

VHA Removal Removal None Resigned No grievance 

same day as available 

proposal 

VHA Reprimand - 5- Reprimand Admonishment grievance 

day suspension available 

VHA Removal 12-day Retired in lieu of No grievance 

*OSC Report suspension suspension available 

(minimum 12-

day 

suspension 

required) 

VHA Removal None- Resigned None Resigned No grievance 

prior to proposal prior to proposal available 

16 
35 


117OAWP17.eps

OAWP Operational Support 

Knowledge Management Operations 

Knowledge Management Operations provides and maintains the data backbone to 

OAWP. It manages and improves the automated systems used by OAWP to assign, 

track, and report on matters. It provides strategic analytical assessments and business 

process improvements. 

Knowledge Management Operations is comprised of a Division Director and 7 staff 

members. 

Knowledge Management Operations serves as the primary lead for providing process, 

systems, analytical and performance consultative services to OAWP. Team members 

develop and maintain solutions for workload data tracking and management. The 

division serves as the primary entity responding to requests for data contained in the 

Office of Accountability and Whistleblower Protection systems. 

Human Resources and Office Support 

Human Resources and Office Support is comprised of 7 staff members in several 

functional areas. The Human Resources and Office Support (HRO) Division provides 

support to the Executive Director, the Deputy Executive Director, and the four primary 

divisions of the Office of Accountability and Whistle blower Protection (OAWP). Program 

Management Analysts focus on budget and finance; prepare correspondence 

responding to queries from Members of Congress, veterans and the public; field FOIA 

requests; coordinate and travel arrangements for OAWP's investigators and principals; 

human resources activities for recruiting, hiring and supporting full time employees. 

II. Budget 

OAWP had a budget of 17.3 million dollars for personnel and operations costs for June 

23, 2017through June 1, 2018. The funding was provided on a reimbursable basis 

from the VA Administrations and Staff Offices. 

17 
36 


117OAWP18.eps

Ill. Other Activities 

OAWP briefed VHA leadership at the Veterans Integrated Service Network (VISN) 

Directors Conference in November 2017. Following that meeting, OAWP conducted six 

briefings to individual VISN Executive Leadership Conferences involving the relevant 

VISN Director, the Medical Center Directors, Chiefs of Staff, Associate Directors for 

Patient Care Services, Assistant Directors and Associate Directors for each of the 

facilities in the relevant VISN. OAWP briefed the VBA Senior Leader Conference in April 

2018. 

OAWP made similar presentations to the American Federation of Government 

Employees (AFGE) leadership conferences in New Orleans LA in January 2018 and 

Orlando FL in February 2018 as well as a presentation to all five national unions' 

leadership in Aril 2018. The briefings provided an overview of OAWP and an 

introduction to the operation of Accountability and Whistleblower Act. 

Manchester VA Medical Center Edith Nourse Rogers Memorial Roseburg VA Health Care System, 

Manchester, NH Veterans Hospital Roseburg, OR 

Bedford MA 

Will iam Jennings Bryan Dorn VA Central Western Massachusetts C.W. Bill Young 

VA Medical Center Healthcare System VA Medical Center 

Columbia, SC Leeds, MA Bay Pines, Fl 

OAWP has also responded to emergent VA needs by depbying intake and investigation 

teams to Manchester MA, Bedford MA, Roseburg OR, Columbia SC, Leeds 

(Northampton) MA,, and Bay Pines FL, as situations emerged in those locations. 

These teams provided real time disclosure intake and development of critical concerns 

at those facilities. 

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37 


117OAWP19.eps

IV. Moving Forward 

1. Improving investigatory capability 

OAWP hired a Senior Advisor for Investigations to improve the training and 

credentialing of our Administrative Investigators. OAWP reviewed its investigatory 

needs and re-wrote the position description for investigators to improve focus on 

investigatory skills, hiring personnel in the 1810, General Investigation, Occupational 

Series. 

2. Enhancing Advisory and Analysis Division's operations 

OAWP is seeking, through the following recommendations for statutory changes, 

authority to hire Attorneys to practice law within the scope of OAWP operations. 

3. Improving case management and data analytics 

OAWP reviewed several software platforms to provide case management and 

information management functionality and expects to implement a solution before the 

end of Fiscal Year 2018. 

4. Improving whistleblower protection 

a. Whistleblower Program Specialists 

The majority of processes built into OAWP are focused on resolving individual 

disclosures and holding Senior Leaders accountable for misconduct or poor 

performance. However, as OAWP matured the need for employees specializing in 

working with those disclosing information to our office, particularly those potentially 

experiencing retaliation, became apparent. Initially as a trial, OAWP hired one 

Whistleblower Program Specialist (WPS) and has added an additional employee in 

this role. The WPS works with disclosing employees to address and resolve 

difficulties experienced by the disclosing employee arising from their disclosing 

activity. Additionally, the WPSs are responsible for conducting whistleblower 

disclosure awareness training, advising OAWP leadership on whistleblower issues, 

and conducting day-to-day program management of the Office's whistleblower 

program. 

b. Whistleblower Integration/Mentor program 

An aspect of making disclosures of alleged wrongdoing is that the employee making 

the disclosure may feel themselves marginalized or excluded from the organizational! 

group. Additionally, for some employees, whistle blowing turns into an ad-hoc job 

description. Balancing the need to encourage employees to disclose alleged 

19 
38 


117OAWP20.eps

Executive Director OAWP meeting with facility leader> hip 

and the first participants in the Mentor/Integration Program 

wrongdoing with the need to 

have employees performing 

the work for which they were 

hired. For application in 

appropriate cases, OAWP has 

created an Integration/Mentor 

program to engage the 

disclosing employee along 

with their senior leadership. 

Adapted to the specifics of the 

individual case, an OAWP 

WPS works with the employee 

and the designated senior 

leader to facilitate 

communication, address 

concerns from either party, 

and ideally reach a result that has the employee gainfully performing VA work and 

management engaged in addressing issues identified through whistleblowing or other 

activities. Since June 23, 2017, through June 1, 2018, the program has been used twice 

on a trial or prototype basis and is expected to broaden in application as OAWP's 

capacity improves. 

c. Employee Assistance Program for whistleblowers through OAWP 

Many VA facilities use in-house Employee Assistance Programs (EAP) to offer personal 

counseling to individual employees. Employees who disclose wrongdoing, particularly 

those who feel they are facing retaliation for doing so, experience different stressors 

than a typical employee. Additionally, where EAP services are offered using in-house 

counselors there is often significant concern regarding confidentiality of matters 

discussed in the counseling setting. Consequently, OAWP intends to seek an external 

EAP program under the general authority granted to the heads of agencies under title 5, 

section 7901. The programs is expected to be provided by a contract provider to 

address multiple biopsychosocial areas. Access to this specific EAP program would be 

through the OAWP whistleblower program. Based on discussion w~h whistleblowers as 

to the types of stressors they encountered fol lowing their disclosures. 

5. Whistleblower training under 38 USC § 733 

Title 38 U.S.C. § 733 requires the Secretary of the VA to provide training to the 

Department's employees and supervisors regarding whistleblower disclosures. While 

there is current training provided under the earlier requirements of the No Fear Act and 

20 
39 


117OAWP21.eps

the OSC Certification Program under 5 U.S.C. 2302(c), is not as comprehensive as 

the requirements under section 733. OAWP intends to finalize the training materials 

and deployment plan by September 30, 2018. 

21 
40 


117OAWP22.eps

~v:nl~~r~~tin,n· To create, maintain and advance the quasi-independent nature of OAWP, 

a separate legal unit essential. The Act itself separated OAWP from OGC for a 

reason as the OGC responsible for defending agency and being the sole source 

of legal advice and guidance. However, in matters which the Office of General 

Counsel has provided legal advice and accountability actions result potentially from that 

advice, there is at least the appearance of a conflict. Additionally, reliance on OGC for 

legal review and guidance has introduced delays into the proposal process as well 

competing or conflicting guidance to management officials. 

~v:r'll!:in~t~n,n· These changes are intended to ensure similar burdens of proof 

disciplinary actions from reprimands through removals. The current arrangement 

places a higher burden of proof for lesser actions (reprimands and suspensions of 14 

22 
41 


117OAWP23.eps

days or less). Additionally, the language affecting the whistleblower protections is to 

clarify that when the action held due to open cases with OSC or OAWP cases, the 

statutory timeframe to decide the proposal is suspended until the hold is resolved. 

Finally, while uncommon, the need for a "safety valve" to ensure employees \Aiho 

present a threat to self or others are not retained despite having open cases with OSC 

or OAWP. As pictured the "safety valve" would require a determination at no lower level 

that an Under or Assistant Secretary to ensure a disinterested review of potential threat. 

Ex:pla.natioln: This change is to align the timeframes and process of section 731 with 

those already present for discipline sections 713 and 714. Section 731 provides a 

unique, combined advance notice & reply period. This unique statutory requirement 

alongside the statutory timeframes required under sections 713 or 714 presents an 

obstacle to proposing actions involving whistleblower retaliation and other misconduct. 

t:x;p1anat101n: This change involves setting the burden of proof at substantial evidence 

and lack of mitigation on appeals of actions involving professional conduct or 

competence or not involving professional conduct or competence taken against title 38 

providers thereby ensuring greater consistency across the workforce. 

t:x:pla:natloln: The current language in 38 U.S.C. section 323(c)(1 )(H) describes a 

specific sub-set of individuals to be investigated by OAWP. While the listed individuals 

represent some senior leaders in the a broader dEfinition is needed to ensure all 

supervisors and managers responsible for leading major VA activities are consistently 

held to the same standard of accountability. For example, a typical VA medical center 

is led by a group of five employees (Medical Center Director; Chief of Staff; Nurse 

23 
42 


117OAWP24.eps

Executive; Assistant Director, and Associate Director). As currently written only three 

(Medical Center Director, Chief of Staff and Nurse Executive) of the five are within the 

scope of OAWP's statutory charter. Additionally, the senior leadership of other major 

VA facilities fall outside the current statutory coverage such as Cemetery Directors and 

General Schedule office directors of VBA Regional Offices. Finally, the current 

language of 38 U.S.C. section requires recommendations to the Secretary 

for such disciplinary action as the Assistant Secretary considers appropriate based on 

the results of the OAWP investigations. Request consideration of designating 

Assistant Secretary, AWP as the proposing official for all disciplinary actions 

24 
43 


117OAWP25.eps

Appendix- Revised Report submission from Section 211 Requirements 

ln accordance with the VA Accountability and Whistleblower Protection Act, P .L. 115-

41, Section 211, the Secretary of Veterans Affairs shall measure and collect information 

on the outcomes of disciplinary actions carried out by the Department of Veterans 

Affairs during the three-year period ending on the date of the enactment of this Act and 

the effectiveness of such actions. 

This report requires historical information not systematically gathered during the look 

back period (three-year period prior to enactment of the Act). in late 2014 the Office of 

Accountability Review (OAR), response to the access-to-care developed an 

ad-hoc tracking system outside the Department's human resources information system. 

This ad-hoc system captures limited de-identified data points as entered by each 

individual facility human resources offices across the Department. 

The Office of Accountability and Whistieblower Protection (OAWP) discontinue use 

of the current ad-hoc system once an effective disciplinary tracking system has been 

procured. 

Following discussion with Committee staff the Department assembled an estimate of 

the time needed to capture the retrospective date. Detailed later in the report, the broad 

estimate is approximately 7,000 staff hours. 

The specific content requirements of Section 211 (b )(2) are: 

(A) The information collected under subsection (a)(2). 

Subsection (a)(2) sought the following data: 

(A) The average time from the initiation of an adverse action against an 

employee at the Department to the final resolution of that action. 

Pre-June 23, 2017, average processing times from proposal to effective date 

was 57 days. 

(B) The number of distinct steps and levels of review within the Department 

involved in the disciplinary process and the average length oftime required to 

complete these steps. 

(C) The rate of use of alternate disciplinary procedures compared to traditional 

disciplinary procedures and the frequency with which employees who are 

subject to alternative disciplinary procedures commit additional offenses. 

25 
44 


117OAWP26.eps

(D) The number of appeals from adverse actions filed against"' ..... '"''"'\/"'"'"' 

Department, the number of appeals upheld, and the reasons 

appeals were upheld; 

(E) The use of paid administrative leave during the disciplinary process and the 

length of such leave. 

Regarding (a)(2)(A), for the period January 1, 2015 June 22, 2017, the average time 

from issuance of a proposal of an adverse action until decision of that action was 55 

days. 

Regarding (a)(2)(B), the specific steps and levels for review involved in the disciplinary 

process within the Department varies with the specific authority being exercised (e.g. 

title 5, title 38). Broadly the steps are: information gathering or investigation; 

assessment of results; development of proposed action; issuance of, and reply to, the 

proposed action; decision regarding the proposed action; appeal or grievance regarding 

the decision. There is no data available regarding the length of time for each step. 

Regarding (a)(2)(C)-(E), during the three-year period prior to enactment of the Act, the 

Department did not have systems or other capabilities to capture and analyze the 

requested information regarding: usage of alternative disciplinary procedures; appeals 

of disciplinary actions; or the use of paid administrative leave in the disciplinary process. 

In order to capture the data requested that was not acquired at the time the actions 

were taken the following estimates were developed: 

Approximately 5,700 hours to review and capture the data for over 5,600 adverse 

actions taken during lookback period [(a)(2)(A) and (B)]. 

Approximately 500 staff hours to review and capture data related to alternative 

discipline and use authorized absence during the lookback period [(a)(2)(C) and (E)]. 

Approximately 800 hours to review and capture the required data for the nearly 

3,000 appeals over the lookback period [(a)(2)(D)]. 

The estimated times are purely touch times to review the files and capture the 

necessary data. 

However, to establish a baseline to assess the impact and effectiveness of the Act the 

following data was gathered from the ad-hoc VA Wide Adverse Action Tracker: 

The figures in the four left columns represent the numbers for the labeled groups of employees SL 

& SES Actions); The figures the two far-right columns represent the numbers for the entire workforce 

for that action and period. 

26 
45 


117OAWP27.eps

Senior Executive Actions: 

Count of Actions by Type, Sl & SES Actions 

Pre (09/01/2014-06/22/2017) and Post (06/23/2017-05/31/2018) OAWP 

Sl & SE S Act ions 

~of Total Anions TOlall at 

Arnon Ta ~n /1 Pr~ & Post OA\VP Actions Tat~n %of Total St-ttl~nts Taken Senlem~u 

09/2014.06/2015 5 0_1% 6,432 1,207 

Admonisllmont 0.0% 1.638 323 

Reprimand 0.1% 1.S9S 301 

Shan S<Jspemion 0.0% 1,254 210 

~S<Jspemion 0.0% 376 66 

Demotion 0 .0% 39 10 

Probatk>naryTormination 0.0% 797 151 

3 0.4% 733 146 

2016 1S 0.2% 8131 1389 

0.1% 1,961 307 

Reprimand 0.3% 2.008 319 

Short S<Jspemion 0.0% 1.590 296 

~S<Jspemion 0.4% 462 79 

Demotion 3.3% 61 11 

Probationary T mnination 0.0% 1,042 196 

Rtmovol 3 0.3% 1,007 181 

06/201 2017 9 0.1% 8,233 395 

Mnonishmtnt 4 0.2% 2.011 84 

Reprimand 3 0.2% 1.968 80 

Short SUspension 0.0% 1,631 87 

~ Suspension 0.0% 448 24 

Demotion 0.0% 68 

Probationary Termination 0.1% 1.044 57 

Removal 0.1% 1.063 56 

2018 7 0_1% 

0.0% 

Re:primand 0.0% 40 

Shan S<Jspension 0.0% 39 

~ SUspension 0.3% 8 

Otmotion 1.1% 9 

Probationary Termination 0.0% 1,175 21 

Removal 0.2% 1.632 31 

Grand Total 36 0.1% 31,89~ 3,169 

27 
46 


117OAWP28.eps

Count of Actions by Type, SES Title 38 Equiv. Actions 

Pre {09/01/2014·06/22/2017) and Post {06/23/201Hl5/31/2018) OAWP 

SES Title 38 Equiv. Actions 

# at T Ofal Acnons T Ofal ~ of 

A<tlon Taken II Pr~ & Post OAWP ActKms Taken ,., of Total Senlements Taken Senloments 

09/2014.o6/201S 0.1% 6,432 1,207 

Admonishment .~. 1,638 323 

Reprimand 0.1% 1..595 301 

Sllon S~nsion O.lm 1.254 210 

Lone SUspension 0.3% 376 66 

Demotion O.<m 39 10 

Probauonary T erminatJOn 0.3% 797 151 

Removal 0.3% 733 146 

062 0.1% 1 8131 1389 

0.3% 1,961 307 

O.<m 2,008 319 

0.1% 1,590 296 

O.<m 462 79 

Demotion o.o,-. 61 11 

Probationary Termination 0.2% 1,042 196 

Removal o.o,-. 1,007 181 

06/2016-06/2017 0.1% 2 8,233 395 

Admonishment 0.1% 2,011 84 

Reprimand o.o,-. 1,968 80 

Short Suspension 0,1,.. 1,631 87 

Lone Suspension O.<m 448 24 

Demotion O.<m 68 7 

Probationary Termination 0.0% 1,044 57 

Removal 0.5% 1,063 56 

11 

o.<m 

Reprimand 0.2% 40 

Sllon Suspension 0.1% 1,779 39 

Lone Suspension O.<m 316 8 

Demotion 1.1% 93 9 

Probationary Termination 0.1% 1,175 21 

Removal 0.2% 1,632 31 

28 
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117OAWP29.eps

General Workforce: 

Count of Actions by Type, Title 38 Other 

Pre {09/01/2014-06/22/2017) and Post {06/23/2017-0S/31/2018) OAWP 

Title 38 Otht>r Actions 

# ot Total Aroons TO!ill #of 

Arnon Taken II Pre & Pon OAWP Acnons Taken "• of Total Settle-m~nts Taken Settlements 

Admonishment 261 15.9% 45 323 

Reprimand 244 15.3% 35 301 

Short Suspension 130 10.4% 21 210 

loni Suspension 32 8.5% 3 66 

Demotion 5 12.8% 1 10 

Probationary Termination 61 7.7% 6 797 151 

Removal 100 13.6% 20 733 146 

06/2015-06/2016 1,044 12.8% 136 8,131 1389 

Admonishment 300 15.3% 26 1,961 307 

Reprimand 366 18.2% 45 2,008 319 

Short Suspension 135 8.5% 26 1,590 296 

long Suspension 43 9.3% 462 79 

Demotion 9 14.8% 61 11 

Probauonary T enninauon 54 5.2% 7 1,042 196 

Removal 137 13.6% 27 1,007 181 

06/2016-CG/2017 990 12.0% 39 8.233 395 

Admonishment 303 15.1% 9 2,011 84 

Reprimand 2n 14.1% 8 1,968 80 

Short Suspension 162 9.9% 9 1,631 87 

long Suspension 41 9.2% 3 448 24 

Demotion 8 11.8% 68 7 

Probationary T ermlnation 56 5.4% 1,044 57 

Removal 143 13.5% 9 1,063 56 

Admonishment 15.6% 

Reprimand 358 17.1% 40 

Short Suspension 181 10.2% 39 

loOi Suspension 40 12.7% 316 8 

Demotion 4 4.3% 93 9 

Probationary Termination 58 4.9% 1,175 21 

Removal 178 10.9% 3 1,632 31 

29 
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117OAWP30.eps

Count of Actions by Type, GS 1-6 

Pre (09/01/2014-06/22/2017) and Post {06/23/2017-05/31/2018) OAWP 

GS 1-6 Actions 

# of T atal 1\ctioM T atal • of 

ActiOn Tdl<en 1/ Pre & Post OAWP Acoons T•ken % o!Totdl ~ttlements Taken s.,n~m>enu 

2.456 38.2% 450 6432 1207 

630 38.5% 106 1,638 323 

542 34.0% 95 1,595 301 

490 39.1% 85 1,254 210 

Lon& Susponsion 151 40.2% 32 376 66 

Oemotion 3 7.7% 39 10 

Probationary Termination 332 41.7% 70 797 151 

Removal 308 42.0% 62 733 146 

06/2015-06/2016 2,953 36.3% 462 8,131 1.389 

Atlmonishment 725 37.0% 96 1,961 307 

Rep<imand 655 32.6% 88 2,008 319 

Short Suspension 584 36.7% 93 1,590 296 

long Suspension 175 37.9% 27 462 79 

Demotion 4 6.6% 61 11 

ProbationaJY Tenninallon 436 41.8% 89 1,042 196 

Removal 374 37.1% 69 1,007 181 

06/2016-06/2017 3.142 38.2% 140 8.233 395 

Atlmonistvnem 771 38.3% 28 2,011 84 

Reprimand 727 36.9% 28 1,968 80 

Short Suspension 601 36.8% 29 1,631 87 

Long Suspension 175 39.1% 448 24 

Oemouon 11 16.2% 68 7 

Probationary Termination 447 42.8% 26 1,044 57 

Removal 410 38.6% 21 1,063 56 

3.307 36.4% 75 9,097 178 

Atlmonishment 740 36.9% 15 2,003 30 

Reprimand 702 33.4% 19 2,099 40 

Short Suspension 644 36.2% 16 1,779 39 

Lolli SIJSP"nsion 120 38.0% 5 316 8 

Oemotion 10 10.8% 93 9 

Probationary T ermlnatlon 503 42.8% 1.175 21 

Removal 588 36.0% 12 1.632 31 

30 
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117OAWP31.eps

Count of Actions by Type, GS 7-10 

Pre {09/01/2014-06/22/2017) and Post {06/23/2017-05/31/2018) OAWP 

GS 7-10 Actions 

# of Total Actoons Total # of 

Arnon Taken If Pr~ & Post OAWP ActJons Taktn 'Y. of Total ~td~mtnts Taktn S"nlemtnt< 

09/2014-oG 2015 857 13.3Y. 219 6,432 1.207 

Admonishment 231 14.1% 71 1.638 323 

Reprimand 248 15.5% 61 1,595 301 

Shon S~nslon 178 14.2% 35 1,254 210 

long Susp-lon 37 9.8% 6 376 66 

Demotion 16 41.0Yo 4 39 10 

Probationary T erminatoon 68 8.5% 19 797 151 

Removal 79 10.8% 23 733 146 

06/201s-<l6/2016 1,077 13.2% 233 8,131 1,389 

Admonishment 281 14.3% 62 1,961 307 

Reprimand 272 13.5% 43 2,008 319 

Short Suspension 221 13.9% 54 1,590 296 

Lo,. Su5P"nsion 66 14.3% 14 462 79 

Demotion 15 24.6% 3 61 11 

112 10.7% 28 1,042 196 

110 10.9% 29 1,007 181 

17 1035 12.6% 48 8 33 395 

253 12.6% l2 2,011 84 

267 13.6% 11 1,968 80 

256 15.7% l2 1,631 87 

Long Suspension 55 12.3% 3 448 24 

Demotion 15 22.1% 1 68 7 

Probationary Termination 73 7.or. 5 

Removal 116 10.9% 4 

.. 18 1,248 13.7% 22 

292 14.61'. 5 2,003 30 

306 14.6% 7 2.099 40 

262 14.7% 3 1,779 39 

Long Suspension 48 15.2% 316 8 

Demotion 24 25.8% 93 9 

93 21 

223 

4,217 

31 
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117OAWP32.eps

Count of Actions by Type, GS 11-1.5 

Pre (09/01/ 2014-06/22/2017) and Post (06/23/2017-05/31/ 2018) OAWP 

GS 11-15 Actions 

n of T"'al ~t>ons T"'al #of 

Action Taken /1 Pre & PoM OAWP Actions Taken "• ol Totdl Settlements Taken Settlem~ts 

09/2014-06 2015 737 11.5% 168 6,432 1,207 

Admonishment 200 122% 48 1,638 323 

Reprimand 229 14.4% 59 1,595 301 

Short Sus~nsion 157 12.5% 34 1,254 210 

Lon& SIJSilension 51 13.6% 9 376 66 

Demotion 11 28.2% 4 39 10 

Probationary Termination 36 4.5% 6 797 151 

Removal 53 7.2% 8 733 146 

06/201~ 016 948 11.7% 261 8,131 1,389 

Admonishment 231 11.8% 70 1,961 307 

Reprimand 282 14.0Yt 82 2,008 319 

Short~nsion 202 12.7% 57 1,590 296 

LongS~on 68 14.7% 14 462 79 

Demotion 24 39.3% 8 61 11 

Probationary Termination 40 3.8% 8 1,042 196 

Removal 101 10.0% 22 1,007 181 

06/2016-06/2017 951 11.6% 60 8,233 395 

Admonishment 246 12.2% 19 2,011 84 

Reprimand 267 13.6% 17 1,968 80 

Short Suspension 196 12.0Yt 10 1,631 87 

ton& Suspension 62 13.8% 448 24 

Demotion 27 39.7% 2 68 7 

Probationary T erminat:ion 39 3.7% 2 1,044 57 

Removal 114 10.7% 1,063 56 

1,099 12.1% 24 9,097 178 

272 13.6% 4 2,003 30 

273 13.0% 6 2,099 40 

209 11.7% 4 1,779 39 

Lone Suspension 43 13.6% 1 316 8 

Demotion 41 44.1% 5 93 9 

Probationary Termlnation 31 21 

Removal 

32 
51 


117OAWP33.eps

Count of Actions by Type, WS 1-15 

Pre (09/01/2014-06/22/2017) and Post (06/23/2017-0S/31/2018) OAWP 

WS 1-15 Actions 

n of Total A<toons Total• or 

AC!lon Taken 1/ Pr~ & Post OAWP Actions T ak~n %or Total Settl~ments Taktn Settlorn•nts 

09/2014-%/2015 107 1.7% 19 6,432 1,207 

Admonlshmem 22 L3% 5 1,&38 323 

Reprimand 3& 2.3% 5 1,595 301 

Shon Suspension 25 2.~ 4 1,254 210 

Lone StJSp..nsion 6 1.&% 1 376 66 

Demo don 4 10.3% 1 39 10 

Prollationary T ermlnation 4 0.5% 797 151 

Removal 10 1.4% 2 733 140 

06/2015-ot;/2016 U 4 1.4% 13 8,131 1,389 

Admonishment 31 1.6% 4 1,961 307 

Reprimand 26 1.3% 2 2,008 319 

Short Suspension 32 2.~ 4 1,590 29& 

lo~ StJSp~nsion s 1.1% 462 79 

Oemolion 4 &.6% 61 11 

Probationary T ormination 0.5% 1 1,042 196 

Removal 11 1.1% 2 1,007 181 

06/201 17 130 Lo% 4 8,233 395 

Admonlshmem 36 LS% 2,0ll 84 

R~primand 35 1.8% 1,968 80 

Shon Suspension 33 2.~ 1,&31 87 

LORi Susp..nsion 8 LS% 448 24 

Demotion 0 8.8% 2 68 7 

Prollationary T ermlnation 7 0.7% 1,044 57 

Removal 5 0.5% 1,063 56 

:g 

18 174 L9% 9,097 178 

Admonishmem 40 2.~ 2,003 30 

Reprimand 45 2.1% 2,099 40 

Shon Suspension 49 2.8% 1,779 39 

LORi Suspension 4 L 3% 316 8 

Demotion 11 1L8% 1 93 9 

Prolladonary Termination 7 0.6% 21 

R~moval 18 1.1% 2 31 

33 
52 


117OAWP34.eps

Count of Actions by Type, Wl1-15 

Pre {09/01/2014-06/22/2017) and Post (06/23/2017-05/31/ 2018) OAWP 

WL 1-15 Acti ons 

# ol Total Aroons T Dtill # of 

Action Taken If Prep. Post OAWP Actions Taten %of Total Sen1ements Taken Settlements 

09/2014-06 15 23 0.4% 4 6,432 1.207 

Admonishment 8 0.5% 2 1,638 323 

Reprimand 5 0.3% 1 1,595 301 

Short Suspension 5 0.4% 1,254 210 

long Suspension 3 0.8% 376 66 

Demotion 0.0% 39 10 

ProballOllary T erminatoon 1 0.1% 797 151 

Removal 0.1% 733 140 

06/201~2016 31 0.4% 9 8.131 1,389 

Admonishment 9 0.5% 3 1,961 307 

Reprimand 9 0.4% 2 2,008 319 

Short Suspension 5 0.3% 1,590 296 

lofli: Suspension 2 0.4% 462 79 

Demotion 1.6% 61 11 

Probationary T ermlnation 4 0.4% 2 1,042 196 

Removal 1 0.1% 1 1,007 181 

06/2016-06/2017 29 0.4% 1 8,233 395 

Admonishment 6 0.3% 2,011 84 

Reprimand 13 0.7% 1,968 80 

Short Suspension 4 0.2% 1,631 87 

long SUspension 0.0% 448 24 

Demo!lon 0.0% 68 7 

Probationary Termination 0.2% 1,044 57 

Removal 4 0.4% 1,063 56 

""" 52 

Admonishment 11 0.5% 

Reprimand 18 0.9% 40 

Short SUspension 14 0.8% 39 

long SUspension 0.0% 8 

Demotion 0.0% 9 

Probationary Termination 1 0.1% 1,175 21 

Removal 8 0.5% 1,632 31 

14 

34 
53 


117OAWP35.eps

Count of Actions by Type, WG 1-15 

Pre (09/ 01/ 2014-06/22/ 2017) and Post (06/ 23/2017-05/ 31/ 2018) OAWP 

WG 1-15 Actions 

~ of Total Arnons T oral n or 

Action Taken II Pr~ & Post OAWP Actions Tak~n %of Total ~ttlements Taken Settlements 

09/2014.()6/2015 293 20.1% 211 6,432 1,207 

Admonishment 264 16.1% 46 1,638 323 

Reprimand 253 15.9% 44 1,595 301 

Short Suspension 254 20.3% 31 1,254 210 

long Suspension 94 25.0% 14 376 66 

Demotion 0.0% 39 10 

ProbatiOnary T erminatoon 266 33.4% 47 797 151 

Removal 162 22.1% 29 733 146 

06/2015.()6/2016 l,n9 2L9% 257 8,131 1.389 

Admonishment 359 18.3% 44 1,961 307 

Reprimand 351 17.5% 53 2,008 319 

Short Suspen<ion 382 24.0% 59 1,590 296 

lo~ SUspemion 100 2L6% 18 462 79 

Demotion 2 3.3% 61 11 

336 32.2% 52 1,042 196 

249 24.7% 31 1,007 181 

1,811 22.0% 97 8,233 395 

375 18.6% 15 2,011 84 

346 17.6% 13 1,968 80 

356 21.8% 25 1,631 87 

long Suspension 107 23.9% 6 448 24 

Demotion 0.0% 68 7 

Probationary T erminalion 380 36.4% 23 1,044 57 

Removal 247 23.2% 15 1,063 56 

1,962 21.6% 39 9,097 178 

312 15.6% 5 2,003 30 

Reprimand 370 17.6% 3 2,099 40 

Short Suspeo<ion 401 22.9% 13 1,n9 39 

lo~ Suspension 60 19.0% 316 8 

Demotion 1 1.1% 93 9 

Probationary T ermlnatron 448 38.1% 11 1,175 21 

Removal 364 22.3% 6 1,632 31 

35 
54 


117OAWP36.eps

(B) The findings of the Secretary with respect to the measurement and collection carried 

out under subsection (a). 

The Department's human resources information system gathers data based on the governmentwide and VA-specific data needs. Current government-wide requirements do not support 

requests for data outside the specific data elements captured in the regular course of business. 

In late 2014 the Office of Accountability Review (OAR), in response to the access-to-care crisis, 

developed an ad-hoc tracking system outside the Department's human resources information 

system. This ad-hoc system captures de-identified data points as entered by each 

individual facility human resources offices across the Department. 

The OAWP will discontinue use of the current ad-hoc system once an effective disciplinary 

tracking system has been procured. 

(C) An analysis of the disciplinary procedures and actions of the Department. 

The ad-hoc tracking system does not capture responsive data to this request. Therefore, the 

OAWP is not able to analyze the procedures and actions. This ad-hoc system captures limited 

de-identified data points as entered by each individual facility human resources offices across 

the Department. 

The OAWP discontinue use of the current ad-hoc system once an effective disciplinary 

tracking system has been procured. 

(D) Suggestions for improving the disciplinary procedures and actions of the 

Department. 

The requirements under the VA Accountability and Whistleblower Protection Act have provided 

an opportunity to improve disciplinary procedures and actions of the Department. 

Employees hired under title 38 United States Code, section 7401 (1) should be subject to the 

same burden of proof and provided the same whistleblower protections as those covered by 

section 714. Currently these employees are not covered by section 714 which is inconsistent 

with the employee population. 

(E) Such other matters as the Secretary considers appropriate. 

For period, June 23, 2017 April 30, 2018, the Office of Accountability and Whistleblower 

Protection has been involved the following number of action involving senior leaders 

throughout the Department: 

2 Admonishments 4 Reprimands 

3 Demotions 5 Suspensions 

7 Removals 2 Resignations in lieu of Removal 

5 Retirements in Lieu of Removal 
55 

Senator TESTER. Your predecessors have testified that leadership 

includes working with underperforming employees to make them 

better at their jobs, rather than just firing them. Is that your philosophy too? 

Secretary SHULKIN. Yes, it is, that every good manager works 

with their employees to make them better, to give them feedback. 

When an employee deviates from a professional, moral standard, 

sometimes you cannot coach them. Sometimes you have to help 

them find—— 

[Overlapping speakers.] 

Senator TESTER. Do you believe that your leadership is doing 

that within the VA? 

Secretary SHULKIN. Yes. Well, I think that we have room for improvement, because when you look at our employee engagement 

scores, they are not improving the way that I believe that they 

should. So, we are relooking at our efforts to do that better. 

Senator TESTER. OK. On the Choice Bill that was passed last August, Congress expanded your direct hiring authority for positions 

for which there was a shortage of highly qualified candidates. Am 

I correct that the VA has still not used this authority to hire? 

Secretary SHULKIN. Yeah. When you look at—my understanding, 

Senator, is that the direct hire authority as given to us—— 

Senator TESTER. Yep. 

Secretary SHULKIN [continuing]. For medical center directors and 

network directors—— 

Senator TESTER. Yes. 

Secretary SHULKIN [continuing]. And I think, unintentionally, it 

capped the salary that we are able to offer at a salary that is lower 

than what we currently offer. So, we have not been able to 

utilize—— 

Senator TESTER. OK. 

Secretary SHULKIN [continuing]. The direct hire authority in the 

way that I believe it was intended to be used. 

Senator TESTER. So, how can that—how can that be fixed? 

Secretary SHULKIN. It is a very small—— 

Senator TESTER. You can do it by rule? 

Secretary SHULKIN [continuing]. Technical fix. 

Senator TESTER. Can you do it by rule? 

Secretary SHULKIN. No. You are going to have to do it legislatively, but it is a very small technical change that we have given 

some technical—— 

Senator TESTER. OK. And—— 

Secretary SHULKIN [continuing]. Advice. 

Senator TESTER. And it gave you authority on those positions—— 

Secretary SHULKIN. Yeah. 

Senator TESTER [continuing]. But it also gave you authority for 

employees that you would deem critical. 

Secretary SHULKIN. Yes, and we have gone to OPM with 15 different critical occupations that they have agreed to move forward 

with us on direct hire authority that I believe we will start to implement in the next several weeks. 

Senator TESTER. OK. We have had the conversation before. At a 

town hall meeting in Great Falls, MT, Monday, I will tell you the 

56 

first question that came up was workforce vacancies. This is just 

Montana—— 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER [continuing]. I’m sorry about being self-centered 

on this. I just want to tell you that we are in a crisis. We may be 

in a crisis in Alaska, and we may be in a crisis in North Carolina, 

and every other State, too. I do not know that, but I can tell you 

in Montana, we are in a crisis. 

Let me give you an example. Billings, MT, is supposed to have 

seven docs in that clinic; we have got four, and two of those are 

looking for another position. 

Secretary SHULKIN. Yep. 

Senator TESTER. When you overwork employees, they tend to hit 

the road. 

Secretary SHULKIN. Yep. 

Senator TESTER. So, my question is, what is the problem? I have 

talked to you many times. I know you are committed to this, yet 

it does not seem—it seems like it is getting worse. In fact, it does 

not seem like it, in my State it is getting worse. 

Secretary SHULKIN. Yeah. Well, in Montana, as you know, you 

have an 11.2 percent turnover rate of your employees, but for physicians it is 23 percent. That is a problem. You have a 24 percent 

vacancy rate for practical nurses. 

Senator TESTER. I have got all that. 

Secretary SHULKIN. So—— 

Senator TESTER. So, what can we do to fix it? 

Secretary SHULKIN. Here is what we—— 

Senator TESTER. What are you doing to fix it? 

Secretary SHULKIN. Here is what we are doing. First of all, we 

have to hire more staff and we have to make sure that we keep 

them. We have announced, for Montana, an increase of up to 

$120,000 for primary care physicians in educational debt reduction—— 

Senator TESTER. Yes. 

Secretary SHULKIN [continuing]. For nurses—I am sorry—for psychologists and nurse practitioners, a $10,000 hiring bonus, and 

for social workers a $5,000 hiring bonus. That is a beginning to 

start to address people to look at the VA as a place to come to 

work. Then we have to, as you said, if we cannot fully staff the 

clinic, it puts more pressure on our current staff that are there, 

and so it is a vicious cycle. So, we are working to recruit. 

Senator TESTER. Thank you for that, but time is of the essence. 

I do not speak for Senator Rounds; he will speak for himself on 

this. 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. But, as you well know, there was a House bill 

that was going to have a Base Realignment and Closure (BRAC) 

done. They could literally shut down damn near every facility in 

Montana if they did a BRAC, because we have got no staffing. 

Secretary SHULKIN. Right. 

Senator TESTER. This is really, really, really important. 

Secretary SHULKIN. It is. 

Senator TESTER. OK. 

Secretary SHULKIN. It is. It is. Absolutely. 

57 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. JON TESTER TO HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Please provide a list of five specific things that VA is doing above and beyond 

what is currently being done to address clinical vacancies in Montana. 

Response. Montana has taken the following actions address clinical vacancies in 

Montana: 

1. Participation in Hiring Fairs: 

a. 12/15/17: Focused hiring fair for Medical Support Assistants in Missoula. Included on the spot interviews and tentative offers on the spot. Currently have made 

23 offers. 

b. 3/21/18: Participating in Billings Job Jamboree in partnership with Sheridan 

VAMC. 

c. 4/15/18: Kalispell Health Expo 2018. 

2. Institutionalized use/increased emphasis for hiring incentives: 

a. Emphasis on the following: 

• Use of Recruitment and Relocation incentives • Permanent Change of Station allowances • Student Loan Repayment Program • Increased Education Debt Reduction Program funds for 2018 

3. Process improvement/Reduced Hiring Bureaucracy: 

a. Speeds up hiring process when vacancy identified. 

4. Authorized 3 new Human Resources positions and 1 lead specifically dedicated 

to recruitment in foundational services. 

Senator TESTER. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Tester. Let me just say, 

for the record, the Ranking Member’s cooperation throughout the 

process of working on the Choice legislation has been stupendous. 

I appreciate his help very much, and we are going to get to the finish line in large measure because of his support and the support 

of the members of his caucus as well as ours, for this good legislation, and I appreciate it very much. 

Mr. BOOZMAN. Senator Boozman. 

HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN. Thank you, Mr. Chairman, and thank you, 

Secretary, for being here. We do appreciate your hard work. 

I would like to talk to you a second about a bill, the VET TEC 

Act, which we were able to include in the Forever GI Bill. It is a 

technical education pilot. I know that we do not have a Deputy 

Under Secretary for Economic Opportunity. He has retired. I would 

like to know who is going to be responsible for implementing it and 

how we are doing. 

Secretary SHULKIN. Yeah. 

Senator BOOZMAN. Talk a little bit more about—— 

Secretary SHULKIN. Yeah. Well—— 

Senator BOOZMAN [continuing]. Who is going to fill that spot, and 

again, you might also elaborate even more about how we can help 

you with these really key, you know, things that are deficient in 

the sense of not being able to fill your staff. 

Secretary SHULKIN. Right. Well, first of all, I think you helped 

a great deal with the Forever GI Bill. I think this is a great success 

story of what this Committee was able to do in 2017. As you know, 

of the GI Bill, the Forever GI Bill, we have enacted already 13 of 

34 of the provisions. But, the one that you are talking about, the 

TEC Act, which is more the STEM, the scientific, technical trainVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00061 Fmt 6633 Sfmt 6601 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
58 

ing, that is going to require—that is one of the ones that we have 

not yet implemented because it is going to require some IT solutions. What we are doing is, we have a Request for Information out 

now to look to how we can get private industry to help us implement that. Otherwise, we are going to need to build that in-house, 

which is going to be more expensive. 

So, we are looking for the best way to get that implemented and 

committed to getting it implemented. But, on many of these, the 

34, 22 of the provisions require IT assistance. 

Senator BOOZMAN. How will you determine the courses that are 

eligible, such as coding, things like that? 

Secretary SHULKIN. Under the TEC Act? Well, you asked who is 

responsible for it. Our Acting Under Secretary for Benefits, Mr. 

Tom Murphy—— 

Senator BOOZMAN. OK. 

Secretary SHULKIN [continuing]. Has accountability under that 

area. Rob Worley, who is here with us today, is the Director of 

Educational Benefits. 

Senator BOOZMAN. OK. So, we will follow up with them. 

Secretary SHULKIN. Yes. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. JOHN BOOZMAN TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

What challenges does VA face implementing the VET TEC program, how does VA 

plan to overcome those challenges, and what will be the timeline? 

Response. Veterans Affairs (VA) requires a legal determination regarding the 

need to award VET TEC via Federal acquisitions or if VA is able to leverage its 

authority to approve via the normal process. Both options provide timely awards to 

training programs for participation in the 5-year pilot. VA is currently gathering 

necessary information to assist VA’s Office of General Counsel (OGC) with finalizing 

their legal opinion. 

VA estimates that as many as 50 percent of prospective applicants may not meet 

necessary skills screening by training institutions. Reputable IT training providers 

will conduct applicable screening criteria to all applicants. We recognize that if a 

Veteran does not meet initial screening they may benefit from various upskilling opportunities in an effort to better position them for future application windows. VA 

is working with a large coalition of partners to establish a series of no-cost publicprivate partnerships that will create a ‘‘hope pathway’’ for Veterans seeking to 

upskill. This pathway will leverage existing services by the Department of Labor 

(DOL), in addition to free community college programs and mentorship tools. 

The VET TEC pilot program has not previously been attempted at this scale; 

therefore the criteria for selection of prospective VET TEC providers will require extensive market research prior to the implementation of the pilot program. VA will 

evaluate programs using industry best practices to ensure effective design, implementation and evaluation of the pilot. 

The requirement of 50 percent of vendor payment taking place upon a Veteran’s 

job placement is one of the more difficult aspects of implementation and may deter 

providers from participating. VA plans to establish ‘‘employer coalitions’’ in partnership with DOL, VA’s Vocational Rehabilitation and Employment, and the VET TEC 

training institutions to ensure Veteran job placement satisfies criteria for payment. 

Timely hiring of staff is critical to proper implementation. VA is in the process 

of making appropriate staffing determinations and authorization of necessary staff 

hiring. We should complete hiring of this staff by May 2018. 

VA anticipates receiving a legal opinion from OGC within the next 60 days and 

expects to initiate or start the official pilot program by February 2019. 

Senator BOOZMAN. Thank you. According to the VA OIG report 

on the consolidated patient account centers, in 2015, the VA billed 

third-party payers approximately $7.2 billion for medical treatment. I think we collected about $2.5 billion. The Department conVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00062 Fmt 6633 Sfmt 6601 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
59 

siders third-party collections as revenue in its annual budget 

projections. 

How does the VA project its expected collections for each year, 

and how does that match up with what we are actually collecting? 

Secretary SHULKIN. We do give our projected collections as part 

of our budget request, because, as you have said, it is an offset to 

essentially our—what is given to us in our budget. Our finance 

team does the projections based upon actuals of last year and then 

sets a target for improvement. This is something that we have targeted, to improve collections. One of the provisions that I think is 

being considered under the current legislation is a requirement to 

disclose third-party insurance, because that is part of the challenge 

that we have. If we do not know a veteran has other insurance it 

is very hard for us to go and to collect it. So, that is something that 

we are working on. 

Senator BOOZMAN. Right. I believe we have a pilot program going 

on in five areas—— 

Secretary SHULKIN. Yes. 

Senator BOOZMAN [continuing]. In relation to this. Do you have 

any—— 

Secretary SHULKIN. On the third-party collection efforts. 

Senator BOOZMAN. Exactly. 

Secretary SHULKIN. Yeah, yeah. 

Senator BOOZMAN. I know that is not done. Do you have any preliminary things that you can talk to us about? 

Secretary SHULKIN. I do not have an update and I do not know 

if anybody behind me has an update on that. I do not think there 

is an expert on that, but we can get you that update. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. JOHN BOOZMAN TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Please provide preliminary data/information regarding the third-party collection 

effort pilot program that is set up in five areas. 

Response. As an effort to further improvements and accountability, Section 201 

of the Choice Act mandated a comprehensive examination of Veteran Affairs (VA) 

ability to deliver accessible high-quality health care to Veterans. These assessments 

evaluated the areas of staffing, training, facilities, business processes, and leadership. 

The focus of Revenue Transformation is to implement new or enhance existing industry best practices and eliminate any inefficiency in VA’s business processes specific to the revenue cycle. As a result of Revenue Transformation, VA has recognized 

an increase in collected revenue and the protection of other revenue that would be 

impacted by the changing healthcare landscape. 

KEY ACCOMPLISHMENTS

Registration: The goal of the Registration portfolio is the comprehensive and timely identification of Veteran insurance information. Currently, the portfolio has increased education to Veterans and VA staff on insurance capture which resulted in 

decrease in front-end denials by over 75% at five test sites. It has also improved 

Veteran education on the importance of providing insurance at test sites, leading 

to the achievement of an insurance capture rate that is 8% higher than the national 

average. The portfolio developed a standardized dashboard to assist VA managers 

in monitoring the success of VA’s insurance capture efforts. 

Clinical Documentation: The Clinical Documentation portfolio team is improving 

accuracy and timeliness of clinical documentation through streamlined processes 

and innovative solutions. The portfolio has developed a dashboard to monitor thirdparty billings and collections at the provider level to improve visibility and awareVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6621 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
60 

ness. Additionally, the portfolio developed two standardized interactive templates 

(primary care and inpatient) focused on improving clinical documentation accuracy. 

Coding: The Coding portfolio is focused on reducing outpatient revenue coding 

backlogs. Consolidation of resources and work assignment has resulted in the coding 

of an additional 94,944 encounters, resulting in a net reduction of 33,376 coding encounters pending at our test sites. The Coding Portfolio team has assisted in reducing coding pending volumes at test sites by 35% since January 2017. 

Charge Capture: The Charge Capture portfolio is implementing process improvements to enhance operational efficiency and improve revenue collections. By developing enhanced billing methods for Community Care the total number of claims 

submitted to Other Health Insurance (OHI) has increased by 30,070, resulting in 

a $1,466,889 increase in total collections from May 2017 to December 2017. The 

portfolio has also launched an initiative to capture and submit the National Drug 

Codes for injectable procedures performed in an office setting to OHI at test sites 

and has reduced denials for these procedures by 10%. 

Billing & Collections: The Billing & Collections portfolio is identifying inefficiencies in the existing revenue cycle to implement methods to improve overall collectability. The portfolio has developed and deployed net collections performance to 

align with industry best practice and replace collections to billing. The national net 

collections rate for the last 3 months is as follows: October—95.9%; November— 

96.2%; December—96.8%. A new function/process to increase the efficiency of payer 

analysis reviews in facilities was implemented. A contract to perform recovery audit 

services of collected and closed claims was initiated and an award is anticipated in 

the third quarter of Fiscal Year 2018. 

Denials Management: The Denials Management portfolio is refining the existing 

denials process through innovative technology, procedures, and training materials 

for VA staff. Overall Enterprise Denials Rate, based on First Run Yield, has gone 

down from ∼12% in January 2017 to ∼8% by December 2017. 

Revenue Integration Portfolio: The Revenue Integration Portfolio is consolidating 

functionality to streamline processes across the VA revenue cycle. The team has 

completed a nationwide review of the clinic set up for potential high dollar clinics. 

The review resulted in an additional 351 Cardiology clinics and 518 Radiology clinics now being designated high dollar, which drives 3rd party billing activities. This 

has resulted in increased collections of $1,446,687 from July 2017 to December 2017. 

Senator BOOZMAN. OK. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Boozman, and before I 

go to Senator Manchin, let me just take the liberty, if I may, of 

asking Gretchan Blum to stand up behind me. Gretchan? 

Gretchan has been with the Committee since I came to the Committee as Chairman 3 years ago. She is going to greener pastures 

in Oregon, which is a beautiful coastline. Lots of veterans, lots of 

good people. She has been a tremendous help to our veterans and 

this Committee. We want to acknowledge and thank you for your 

service. 

[Applause.] 

Chairman ISAKSON. Senator Manchin. 

HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA 

Senator MANCHIN. Thank you, Mr. Chairman. I appreciate it. 

Thank you, Dr. Shulkin, for being here. 

I need to bring something of a local interest to your attention. 

On December 20, a high-risk veteran contacted my office after his 

bypass surgery was canceled while he was laying on the operating 

table in the Clarksburg VA, which is the Louis A. Johnson VA 

medical center. It is a great hospital. The reason for cancellation 

being that spots were found on the tools processed by the autoclave. That is the reason. 

Now let me tell you how time elapsed. 

We have been told that they have estimated it will be at least 

10 weeks before a temporary—just before a temporary—sterilizaVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00064 Fmt 6633 Sfmt 6601 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
61 

tion unit will be operational, but it will also take a whopping 16 

to 18 months to replace the one that is deficient. It has been reported—I understand up to what the Region 5, the VISN 5 level. 

That is your region. I do not know if it has ever gotten to you all. 

There has got to be something, doctor, when something this egregious happens. We cannot do any—we are done, and this is a big 

hospital, of course, so we need your help. 

Secretary SHULKIN. Right. 

Senator MANCHIN. Thank you for your help on that. 

Next of all, I sent a letter last week, after reading the New York 

Times story that reported that the Oregon VA medical center has 

tried to improve their quality metrics. Well, we start looking into 

this, how it affects us in our State, and, for example, I have found 

that the emergency department medium time for administering 

pain medication, statistic on the HospitalCompare.gov website, it is 

listed as not available, and is also footnoted as no cases met the 

criteria for this measure. That seems unacceptable to me in emergency—for an emergency department. 

How are you equipping local VA medical center staff to track and 

record these types of vital data, and who in West Virginia VAs are 

responsible for collecting the data. We could not find out—— 

Secretary SHULKIN. Yes. 

Senator MANCHIN [continuing]. From my office. 

Secretary SHULKIN. On HospitalCompare.gov, which is run out of 

the Department of Health and Human Services—— 

Senator MANCHIN. Are you all working with it? Try, OK. 

Secretary SHULKIN. VA used to have all its data up there—— 

Senator MANCHIN. Uh-huh. 

Secretary SHULKIN [continuing]. And due to contract issues with 

the Department of Health and Human Services, not VA, they lost 

the ability to take VA data. They are now actively working to get 

it back up by the end of this year. They will have all that data back 

up. We still collect and product all that data and we publish the 

data ourselves on accesstocare.va.gov. So, we do have that data, we 

do make our comparisons to local hospitals. We would be glad to 

share that with you. We wish it were up on the HospitalCompare 

site because we think it is a great site, and by the end of the year 

HHS will have that back up for us. 

Senator MANCHIN. Opioid addiction. You know about opioid addiction in my State, in West Virginia, but also throughout the entire veterans’ community. It is something of great concern. The 

President basically declared a medical—— 

Secretary SHULKIN. A public health emergency. 

Senator MANCHIN [continuing]. Public health. I have told him I 

am very appreciative of that. I wish it would have gone farther, but 

I am very appreciative of what we are getting—— 

Secretary SHULKIN. Mm-hmm. 

Senator MANCHIN [continuing]. But we have not gotten anything 

yet. I do not know how it is affecting you all, with your fight on 

opioid addiction, or how that will help you if we can get this money 

to start flowing. We are asking the money to flow not based on population but based on need, where the greatest occurrences are. 

Secretary SHULKIN. Mm-hmm. 

62 

Senator MANCHIN. Have you seen any changes there? Have you 

gotten any help whatsoever? Also, you all need to be—you need to 

be recognized in an affirmative way for basically not allowing your 

VA patients to dictate the dispensing as part of the overall care 

they are getting and what quality of care, which could penalize 

your hospitals. I thank you all to change that. 

Secretary SHULKIN. Mm-hmm. 

Senator MANCHIN. You have helped that move all the way 

through the whole—— 

Secretary SHULKIN. Mm-hmm. 

Senator MANCHIN [continuing]. Department of Human Services. 

Secretary SHULKIN. Mm-hmm. Right. Well, first of all, I participated in the President’s commission. 

Senator MANCHIN. Right. 

Secretary SHULKIN. I think it is important. We brought the Members of the Committee to the Cleveland VA that has a 3 percent 

prescribing rate, the lowest in the country, to see the best practices, and that did make it into the report. 

Senator MANCHIN. Right. 

Secretary SHULKIN. Last week, we started to publish, at VA, 

every medical center’s prescribing rate for opioids. No other system 

in the country, no other hospital in the country does this. It is 

available now, so everybody can see. 

Senator MANCHIN. It is on your website? 

Secretary SHULKIN. It is on our website, the opioid posting. 

Senator MANCHIN. OK. 

Secretary SHULKIN. Finally, let me just say, we have made a 41 

percent reduction since our efforts began in 2010, with our Opioid 

Safety Initiative. 

Senator MANCHIN. Mm-hmm. 

Secretary SHULKIN. We have more work to do. What this website 

says, it shows us where we have a lot more work to do. But remember, the key is not just simply withdrawing opioids. 

Senator MANCHIN. Sure. 

Secretary SHULKIN. These are patients who are in pain. The 

question is—— 

Senator MANCHIN. We recognize that. 

Secretary SHULKIN [continuing]. Before we start opioids, before 

you reach for it first, are there alternatives that you can do to help 

relieve pain and not put your patient at risk of addiction? So, that 

is what we are really focused on. A lot of the veterans think this 

is about we have targets to withdraw opioids. We do not. We want 

doctors to continue to eliminate pain, but we want them to make 

smart choices, give veterans informed choice. 

Senator MANCHIN. Right. We are doing the same thing, and we 

do not want any patient to think they are being penalized whatsoever—— 

Secretary SHULKIN. Right. 

Senator MANCHIN [continuing]. Being without their other alternative methods too, not the alternative drugs that are being developed right now—— 

Secretary SHULKIN. Absolutely. 

Senator MANCHIN [continuing]. That are not addictive. 

63 

With that being said, the one that still haunts me and bothers 

me more is homelessness—— 

Secretary SHULKIN. Yep. 

Senator MANCHIN [continuing]. Which we have had an increase 

in homelessness—— 

Secretary SHULKIN. Yeah. 

Senator MANCHIN [continuing]. From 2016 and 2017. 

Secretary SHULKIN. Yes. 

Senator MANCHIN. I cannot even fathom how any veteran should 

ever not have a roof over their head—— 

Secretary SHULKIN. Right. 

Senator MANCHIN [continuing]. And a place to sleep, for what 

they have done for us. 

Secretary SHULKIN. Right. 

Senator MANCHIN. What is happening there? Is it—— 

Secretary SHULKIN. Right. 

Senator MANCHIN. So, as you know, from 2010 until now, we 

have had a 46 percent reduction in homeless veterans. We still 

have 40,000 homeless veterans—way, way too many. Females have 

gone up—— 

Secretary SHULKIN. Yes. 

Senator MANCHIN [continuing]. Female veterans homelessness is 

up 7 percent. 

Secretary SHULKIN. Last year their rate went up 2 percent—— 

Senator MANCHIN. Yeah. 

Secretary SHULKIN [continuing]. Which is going the wrong 

direction. 

Senator MANCHIN. Overall. 

Secretary SHULKIN. If you take a look, there are five major cities 

in the country, but Los Angeles and Seattle are the two that went 

up the most. So, what we are doing is we need a reboot of our program. This is not less money in the program; we actually want 

more in this program. We need to do this better. We are focused 

and prioritizing doing this better. We are going to target Seattle 

and Los Angeles, in particular, but not give up on progress everywhere else. We are going to be coming out with a new, improved 

approach, but it is not less resources. It is going to be more 

resourced and more focused. 

Senator MANCHIN. Let me just—I am so sorry. I just wanted to 

follow up real quick. 

Secretary SHULKIN. Yeah. 

Senator MANCHIN. For us to know how many homeless veterans 

we have, we have to have them in our records somewhere. 

Secretary SHULKIN. Yes. 

Senator MANCHIN. There has to be contact. 

Secretary SHULKIN. Right. 

Senator MANCHIN. With that—it is not like saying, well, they 

just dropped off and they have fallen off the records. 

Secretary SHULKIN. We actually now know, by name, who most 

of the homeless veterans are. We do, once a year, what is called 

a Point In—— 

Senator MANCHIN. We have caseworkers with that—— 

Secretary SHULKIN. Absolutely. We have caseworkers for our 

homeless veterans. We do what is called a Point In Time Count—— 

64 

Senator MANCHIN. Uh-huh. 

Secretary SHULKIN [continuing]. A PIT count. We are going to do 

it here in Washington, January 28. I will be out there at midnight—— 

Senator MANCHIN. OK. 

Secretary SHULKIN [continuing]. With other people, making sure 

we accurately do that assessment. I did it in Los Angeles 2 years 

ago. Then, after we do our Point In Time counts, we will be able 

to know what—— 

Senator MANCHIN. Uh-huh. 

Secretary SHULKIN [continuing]. The progress for, if there are 

more veterans—— 

Senator MANCHIN. Right. 

Secretary SHULKIN [continuing]. Who are homeless. But, we are 

committed to continuing to stay at this until we end veteran homelessness. 

Senator MANCHIN. Thank you. 

Chairman ISAKSON. Thank you, Senator Manchin. 

Senator Tillis. 

HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA 

Senator TILLIS. Thank you, Mr. Chair. Thank you to Secretary 

Shulkin. 

One thing you mentioned in your opening comments I just wanted to get a little bit more information on is—I knew, and I was 

glad that the Department is showing some latitude in providing 

services to veterans with other-than-honorable discharge. Can you 

tell me a little bit about the scope of that and maybe the numbers 

of people that have been served at this point? 

Secretary SHULKIN. Yep. Yep. As you know, with trying to decrease veteran suicide and doing the right thing for our veterans, 

when you take a look at where our highest risk for veteran suicide 

is, it is in several categories. Homelessness and homeless veterans 

who do not have access to care, clearly, which is why we are targeting an end to that. Our other-than-honorable discharge veterans 

are very high risk as well, because they do not have access to services. So, what we have provided them with is an emergency mental 

health benefit, that provides—all they have to do is show up. We 

are going to give them 90 days’ worth of emergency mental health 

care, make sure we stabilize the crisis, and get them into longerterm treatment, if that is what is required. 

So far, we have treated, and have come to us for help, 3,200 veterans with other-than-honorable discharge. We were actually hoping the numbers are higher. 

Senator TILLIS. Over what period of time? 

Secretary SHULKIN. Since we started this. I think it was one of 

the early things I did as Secretary, so I would say 10 months ago, 

maybe. 

Senator TILLIS. OK. 

Secretary SHULKIN. We are actually hoping the numbers would 

get higher, so we continue to get that message out, that if you are 

a veteran with that type of other-than-honorable discharge and you 

need help, please come; we are going to help you. 

65 

Senator TILLIS. Now what happens if you get somebody to maybe 

a stable—— 

Secretary SHULKIN. Yep. 

Senator TILLIS [continuing]. Position, and you improve their condition. This is emergency mental health benefit. What next? Let us 

say they get sick, and it does not relate to the mental health illness. 

Secretary SHULKIN. Right. Oh, when it does not relate to the 

mental health illness. 

Senator TILLIS. Yeah. 

Secretary SHULKIN. Well, we have not extended a general health 

benefit. That is something that we would be glad to work with you 

or other Members of Congress on. That would be something that 

we would have to work on legislatively. I do not feel I have the authority to be able to do that. 

Senator TILLIS. I did not think you did. 

Secretary SHULKIN. Yeah. 

Senator TILLIS. We had a hearing in the Personnel Subcommittee 

for Senate Armed Services and it was focused on concussions—— 

Senator MANCHIN. Mm-hmm. 

Senator TILLIS [continuing]. And more data that we are getting, 

that at least could make you argue that perhaps discharges, in 

some cases, for bad behavior, actually related to—— 

Secretary SHULKIN. Mm-hmm. 

Senator TILLIS [continuing]. Other circumstances. So, I think this 

is a good step—— 

Secretary SHULKIN. Mm-hmm. 

Senator TILLIS [continuing]. Because the first thing is to try to 

stem any real tide of suicides—— 

Secretary SHULKIN. Yeah. 

Senator TILLIS [continuing]. Through the emergency mental 

health service. But, I think we need to talk more about—— 

Secretary SHULKIN. Mm-hmm. 

Senator TILLIS [continuing]. How we would manage this, and 

consider the full life cycle. What we talked about, there are the 

probabilities this sort of job that a man or woman did in the military were exposed to events that now the science suggests could 

have actually had an impact on their mental faculties or perhaps 

behaviors that led to their discharge. 

Secretary SHULKIN. Mm-hmm. 

Senator TILLIS. That would be something I would like to talk 

with you more about. 

And maybe you could just give me a quick update on—I know 

the medical health record project is going to go through phases and 

take a while to get done, but it looks like you are using a template 

similar to the DOD, and you have got resources in there. So, in 

that case, just tell me what we could do to help you, because I 

think that is a very important project that we want to see to conclusion. And you need to make sure you tell us when we set a new 

priority that potentially taps your ability to deliver on some of the 

commitments you are making. 

But what about other—you mentioned in your opening comments—— 

Secretary SHULKIN. Mm-hmm. 

66 

Senator TILLIS [continuing]. About, do you still feel like you are 

making incremental—— 

Secretary SHULKIN. Mm-hmm. 

Senator TILLIS [continuing]. Not breakthrough things. What are 

we likely to see from you, to get from some of the incremental that 

needs to be done? But, you know, what are the breakthrough 

things that you are looking at that may actually require our help 

to get it moving? 

Secretary SHULKIN. Well, I think what I am doing is trying to 

put out there that we need those breakthrough ideas, and I want 

to see an opportunity to get those ideas from you, as well as our 

veteran advocacy groups, like veteran service organizations and 

others who have those ideas. I think they can come in many different ways. They could come technologically, they could come 

through management practices, or they could come through policy 

and legislation. 

We have seen some of them, legislatively, that I think this Committee has been in the lead during this past year, like appeals 

modernization. That is going to make a difference. I think—and I 

have said this—that we need to reorganize the way that we do 

business at VA, from having a large central bureaucracy to being 

able to give people in the field more authority and accountability, 

which goes along that way. And, we need to change some of our 

management practices that, frankly, have grown stale. 

What is happening in the private sector on health care and technology is the type of transformation that I think needs to happen 

within government as well, and we are going to need to do that collaboratively. 

Senator TILLIS. Thank you. Thank you, Mr. Chair. 

Chairman ISAKSON. Thank you, Senator Tillis. 

Senator Blumenthal. 

HON. RICHARD BLUMENTHAL, 

U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thank you, Mr. Chairman. Thank you, 

Dr. Shulkin, and thank you to the men and women of the VA for 

all of their extraordinary, dedicated work. 

I am going to be sending you, today, a letter that cites the need 

for stronger protections to the post-9/11 veterans under the Post9/11 GI Bill benefits. I raised this issue with you during your confirmation hearings in January of last year. 

It has been almost a year—in fact, on February 13 it will be a 

year since your confirmation—and, quite honestly, I am deeply dissatisfied with the lack of action under existing authority, 38 U.S. 

Code, Section 3696, to crack down on the predatory practices of forprofit schools, like Corinthian and ITT, that have exploited our veterans. This letter sets forth, in detail, what those actions have been 

and why I think that the lack of action by the VA has been troubling. I know that you are sympathetic to this cause, but I would 

like to see good words followed by action, and I will appreciate a 

response to my letter. I ask that it be made part of the record, Mr. 

Chairman. 

Chairman ISAKSON. I am sorry. 

67 

Senator BLUMENTHAL. I am asking that my letter to Secretary 

Shulkin, of today, be made a part of the record. 

Chairman ISAKSON. Without objection. 

[The letter follows:] 


117BlumLtrGIBill1.eps
68 


117BlumLtrGIBill2.eps

During your confirmation hearing in January 2017 you also committed to using all 

resources and authorities available to you, as well as working with other federal agencies, to 

crack down on colleges that lie to veterans and cheat them and the taxpayers out of veterans' 

hard-earned GI Bill support. However, I remain concerned that the VA is not using its 

existing authority under 38 3696 to prohibit schools from benefiting from 

veterans' education benefits. to 2016 by the Veterans Services Clinic at 

Yale Law School, the VA has stood by for years as veterans fell prey to deceitful 

practices institutions such Corinthian Colleges and ITT Tech. Under 38 USC 

3696, the VA clear authority to suspend or otherwise restrict a school's receipt of benefits if 

educational institution in question in misleading recruiting and adve1iising or 

provides a commission, bonus, or incentive payment related to securing enrollments or 

student admissions activities. These limitations exist to protect veterans and their U'-'liJ'-''''-'-'-''H" 

from being targeted by deceptive recruiting tactics and must be fully exercised when appropriate. 

In June 2015, I wrote then Secretary McDonald to that the VA create a "risk 

index" that includes schools under investigation for fraud by DOJ, FTC, and state Attorney 

Generals in the GI Bill Tool. While the VA has added flags to delineate the 

institutions that are under Cash Monitoring, or additional oversight by the 

Department of Education for or federal compliance issues, these caution flags are 

sparse I am concerned that they do not cover the scope of the problem. Furthermore, the VA 

has yet to establish a risk index to define which schools are under the aforementioned types of 

investigation. Under section ofthe Securities Exchange Act of 1934, companies must 

notify investors if they are legal scrutiny or if there is a significant financial change that 

could their investment. Unfortunately, students are not afforded the same warning. The 

coJntnme~d omission of accurate, and information on the quality of a college 

university encourages veterans to their funded benefits at predatory 

institutions. This risk index would highlight the unscrupulous actors in the for-profit industry 

and empower student veterans to be conscious consumers when determining their respective 

postsecondary education pathway. 

While I commend VA's work to finalize the Principles of Excellence Executive Order 

and develop the GI Bill Comparison Tool, much more must be done. this tool 

allows students to compare potential educational options, examine limited of caution 

flags, and includes veteran-specific outcome information as required in the Improving 

Transparency of Education Opportunities for Veterans Act of2012. However, improvements are 

needed as its utility continues to be diminished by overly broad definitions of completion of nondegree schools' failure to report the information, 

caution flags, and the lack of user _....,,,uL•a""'"· 

With more than $4.8 billion in Post-9/11 GI Bill dollars to colleges each year, 

VA must do more to hold deceitful colleges accountable for providing education 

and preventing high-pressure recruitment tactics. The United States Government has a 

responsibility to ensure that our veterans receive the high-quality educational opportunities they 

have earned. 

2 
69 

Senator BLUMENTHAL. I want to focus right now on a deeply 

troubling, in fact, appalling incident in West Haven. I am sure you 

are aware of it by now. The West Haven VA has been sued by a 

veteran who is alleging apparently a truly egregious act of malpractice. The veteran claims that a scalpel was left in his abdomen 

during a 2013 surgery and it was discovered only after years of 

pain and dizziness. It was removed in April 2017, after an MRI by 

the VA. 

On June 6, 2017, the veteran said that he initiated an administrative claim under the Federal Tort Claims Act, regarding this 

case of medical negligence. Over 6 months later, the VA has still 

not responded, incredibly, to the claim, beyond a simple acknowledgement of its receipt. So, the veteran has now filed suit in Federal court. 

My first question to you is, is the Department investigating these 

specific allegations? 

Secretary SHULKIN. Yes. Yes. First, on this case, I think the way 

that you characterized it is accurate. It is an event that should 


117BlumLtrGIBill3.eps
70 

never happen, and I am deeply sorry that any veteran should have 

to undergo this. 

Of course, this was inadvertent on the surgeon’s part. When the 

surgeon discovered this, he, who is extraordinarily well trained, on 

the Yale faculty, practices not only at the VA but at Yale New 

Haven Hospital, went to the veteran with the Chairman of Surgery 

at the VA, and acknowledged their mistake and apologized and 

takes responsibility for it. 

While this is an extremely rare event, it happens in the country 

1,500 times a year. In the VA it does happen. It happened 12 times 

in the VA. That is a rate, in the VA, much less than what happens 

outside the VA. That is no excuse. This should never happen. We 

are looking and a root cause analysis has been done. It has actually 

been presented at the Yale New Haven Mortality and Morbidity 

Conference so that this could be evaluated by peers who are surgical peers across the Yale New Haven system. 

So we do acknowledge responsibility for this. This veteran has 

suffered enough. Fortunately, his first surgery, which was done, 

was a successful surgery, but he should not have to go through any 

more hassle in being acknowledged for what happened, and we will 

take responsibility for that. 

Senator BLUMENTHAL. Part of taking responsibility is to acknowledge and act on his claim—— 

Secretary SHULKIN. Absolutely. 

Senator BLUMENTHAL [continuing]. And to, in fact, respond positively to the request that he made for relief, under the Federal Tort 

Claims Act—— 

Secretary SHULKIN. I agree with that. 

Senator BLUMENTHAL [continuing]. Administrative procedure. It 

does not require any court proceeding. 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL. The VA has an administrative and moral 

responsibility to respond, and I am disappointed that it has not 

done so. Will you commit to doing so? 

Secretary SHULKIN. Everything you are saying, I share your sentiments, and absolutely, we will commit to that. 

Senator BLUMENTHAL. I know, because of your own background, 

professionally, as head of the University of Pennsylvania medical 

system and other positions that you note, you are—— 

Secretary SHULKIN. Sure. 

Senator BLUMENTHAL [continuing]. Very, very attentive to the 

standards of professional responsibility. I would also like a commitment that the VA protocol and practices will be reviewed so that, 

in fact, this incident can be a teaching moment. 

Secretary SHULKIN. You have that commitment. Patient safety is 

my passion. I personally spoke to the Chairman of Surgery at the 

West Haven VA. I know that she, and this surgeon, have taken 

this extremely seriously and are using this for the way that you 

and I both believe we should learn. The VA does have a practice 

across the VA system for x-rays to be done in some high-risk cases. 

We are re-evaluating whether we should be doing more on top of 

that, because these events should never happen. We are going to 

be committed to making it a safer environment. 

[The information requested during the hearing follows:] 

71 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. RICHARD

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

VETERANS AFFAIRS

Please act on the administrative claim from the Connecticut Veteran who had a 

scalpel left in his abdomen after a surgery at VA. 

Response. The Department has acted on the claim and it is currently pending litigation. 

Senator BLUMENTHAL. I appreciate your being so forthcoming—— 

Secretary SHULKIN. Mm-hmm. 

Senator BLUMENTHAL [continuing]. And I am going to follow 

up—— 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL [continuing]. And stay on it—— 

Secretary SHULKIN. Thank you. 

Senator BLUMENTHAL [continuing]. Banking on you—— 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL [continuing]. Because I know you are committed to it. 

Secretary SHULKIN. Mm-hmm. 

Senator BLUMENTHAL. I have seen the x-ray—— 

Secretary SHULKIN. Yes, so have I. 

Senator BLUMENTHAL [continuing]. Showing the scalpel, and, 

frankly, I was appalled and stunned—— 

Secretary SHULKIN. Sure. 

Senator BLUMENTHAL [continuing]. And surprised and grateful 

that this veteran is still alive. 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL. Thank you for your responses to my 

question. 

Secretary SHULKIN. OK. Thank you, sir. 

[Information on operating room directives at VA follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. RICHARD BLUMENTHAL TO HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Please review the patient safety protocols as a result of a scalpel left inside a Connecticut Veteran following a surgery at VA. 

Response. Directive 1103, Prevention of Retained Surgical Items, provides policy 

to prevent incidents of surgical items being retained in a patient following surgery. 

It is VHA policy that the surgical team must apply a standard approach to the prevention of retained surgical items when the operative procedure being performed is 

one in which there is any possibility for retention of a surgical item. This standard 

approach/patient safety protocols have been reviewed. This policy provides clear direction and guidance for Operating Room staff regarding the required responsibilities and actions. A copy of the directive is attached for your reference. 

72 

ATTACHMENT


117SurgDirective1.eps

Department of Veterans Affairs 

Veterans Health Administration 

Washington, DC 20420 

VHA Directive 1103 

Transmittal Sheet 

March 5, 2016 

PREVENTION OF RETAINED SURGICAl ITEMS 

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Directive 

policy to prevent incidents of surgical items being retained in a patient 

tnlln\Aiinf'l surgery. 

2. SUMMARY OF MAJOR CHANGES: Content to include drains and 

••r-~~,_.,;rcc as retained The also describes the Critical 

Tracking to document retained surgical 

item events intranet tool. The National Surgery Office 

( 1 ONC2) works the National Center for Patient Safety to reconcile 

retained surgical items events to ensure complete capture and lessons 

learned. 

3. RElATED ISSUES: None. 

4. RESPONSIBlE OFFICE: 

Assistant Deputy Under 

Clinical Operations is 

directed the National 

the content this Directive. 

of Surgery at 202-461-7130. 

5. RESCISSIONS: VHA Directive 2010-017, Prevention of Retained Surgical Items, is 

rescinded. 

6. RECERTIFICATION: This VHA Directive is due for recertification on or before the 

last working day of March 2021. 

David J. Shulkin, M.D. 

Under Secretary for Health 

DISTRIBUTION: Emailed to the VHA Publication Distribution List on 3/7/2016. 

T-1 
73 


117SurgDirective2.eps

March 5, 2016 VHA DIRECTIVE 1103 

PREVENTION OF RETAINED SURGICAL ITEMS 

1. PURPOSE 

This Veterans Health Administration Directive provides policy to prevent 

incidents of items being in a patient following surgery. AUTHORITY: 

38 usc 7301 

2. BACKGROUND 

a. Surgical items are defined as instruments, sharps, soft goods, drains, guidewires, 

or any materials used by the surgical team to perform an procedure. Sharps 

are surgical needles, aspirating needles, blunt needles, blades, or any items 

with a sharp or that pose a risk for skin puncture by members of the 

team. cotton gauze of various sizes, laparotomy 

absorbent materials not to remain in the patient's 

is completed. 

A surgical item is considered to be retained if it is an item or thereof not 

intended to remain and is found in any part of the patient's body the patient has 

been taken from the operating or room. Drains are retained if placed 

intentionally in the operating room for subsequent removal (example Penrose 

drain, chest tube, ureteral stent) but upon attempted removal outside the OR, all or a 

portion of the drain is unintentionally retained requiring an invasive procedure with 

informed consent for removal. 

c. The National Surgery Office and the National Center for Patient Safety 

(NCPS) collect data for retained surgical For Fiscal Year 2014, the VHA 

incidence estimated rate of retained surgical items was determined to be in 17,200 

surgical procedures. This rate compares favorably to the national incidence rate for 

retained surgical items reported to range from in every 8,000 to 18,000 procedures. 

d. The occurrence of a retained surgical item is considered a sentinel event, 

requires Root Cause Analysis (RCA), and must be reported to the NCPS. The NCPS 

~nru·ar ... ~t.:.c RCA data and reports to the National Director of NOTE: 

1050.01, VHA Improvement, 

guidance regarding sentinel event reporting and YOr'IIIIY'On1I.On:r<:> 

e. Beginning in August 2010, the NSO established the Critical Incident Tracking 

Notification process to collect retained surgical item events using a secure web-based 

intranet tool. On a quarterly basis, the NSO and NCPS reconcile retained surgical 

item events to ensure complete capture, evaluation and determination of lessons 

learned. 
74 


117SurgDirective3.eps

VHA DIRECTIVE 103 March 5, 2016 

3. POLICY 

It is VHA policy that the team must apply standard ~nr"lrr.,:~rh to the 

prevention of retained when the operative procedure performed is 

one in which there any possibility for retention of a surgical item. 

4. RESPONSIBILITIES 

the 

Director is responsible for ensuring 

level. 

The Chief of Surgery responsible for 

"'""r"' 1'"'"" procedure in which there is any po:ss1lb1irtv 

laparoscopic procedures) adheres 

(1 Soft Goods. All soft 

their original configuration 

dressings. 

that are placed in the surgical field must be left 

must not be cut or altered in any way, or used for 

Items. Surgical items intended for placement in the 

or are peripheral to the field and have the potential 

the surgical wound must be radiopaque by a radiograph} 

Non-Radiopaque Surgical Items. Non-radiopaque items that are 

the room, for example, sponges used during insertion, must 

be disposed in a separate waste receptacle designated for that purpose and never in 

the same space with counted surgical items. 

(4) Methodical Wound Exploration. methodical wound exploration must be 

performed before closing the surgical wound in every case to ensure that all surgical 

items are accounted for and extracted. 

(a) The space to be closed must be carefully examined. Special focus must be 

given to closure of a cavity within a cavity (e.g., heart, major vessel, stomach, bladder, 

uterus, and vagina). 

(b) methodical wound exploration must be performed before removing stationary 

or table mounted retractors. 

(c) The surgeon must visually and manually explore the operative field, making 

every effort to remove any and surgical items left within a body cavity. 

(d) A methodical visual inspection of the body cavity required when performing a 

minimally invasive laparoscopic, thoracoscopic, or arthroscopic procedure. 

(e) A methodical wound sweep required for cataract procedures utilizing the 

microscope. 

2 
75 


117SurgDirective4.eps

March 5, 2016 VHA DIRECTIVE 1103 

time during wound closure, the is informed of an inaccurate 

items the must the wound and 

repeat wound while 

missing surgical item. 

(5) Count of Surgical items. 

every case. 

surgical items must be counted in 

(a) A count of surgical items must occur: 

.1. Before the procedure has begun or the incision made to establish a baseline 

count; 

£When new soft goods and/or sharps are added to the field 

~When a drain or other miscellaneous item is cut, all pieces must be accounted 

for and counted. 

:1. Before the closure of a cavity within a cavity; 

~Before wound closure begins; 

~At skin closure or end of procedure; and 

LAt the time of permanent relief of either the scrub person or the RN circulator. 

OR staff must be allowed sufficient time for a count of surgical items to be 

surgical counts are performed using a standard two-person practice; the 

items are counted audibly and viewed concurrently by the scrub person and RN 

circulator. 

£Any time there is a question by any member of the surgical team regarding the 

count, an additional count must be performed. 

~ Perioperative personnel must never assume that the count on prepackaged 

sterilized items is accurate. The contents of each package must be counted 

individually by the scrub person and RN circulator using the standard two-person 

practice. if the has an incorrect number of items and the procedure has not 

begun, the entire must be removed from the OR. If the procedure has begun, 

the pack must be bagged, properly labeled, and isolated from the other counted 

items. 

:1. Counts must be performed in the same sequence each time. The count needs 

to begin at the surgical site and the immediate surrounding area, proceed to the 

instrument stand and back table, and finally to the counted items (soft goods, 

or instruments) that have been discarded from the field. NOTE: The use 

3 
76 


117SurgDirective5.eps

VHA DIRECTIVE 1103 March 5, 2016 

tags to detect technology-enabled soft goods 

and systems, are adjunct technologies 

supplement the manual counting process but not replace the requirement to perform a 

count of surgical items in every case. 

§_,_All relief personnel must be documented in the Veterans Health Information 

-'"'"'''"''''"'and Architecture (VistA) Surgery Package and will appear the 

Intra-Operative 

(c) The surgeon must be informed by OR staff at the time a discrepancy in a count 

of surgical items is discovered. It imperative that a reasonable and appropriate 

search of the field and surrounding area be undertaken to recover the item 

in question resolve the discrepancy. 

are used as therapeutic packing and the patient leaves the 

nn£:>r<:>lronn room packing in place, the number and types of items placed must be 

the VistA Surgery Package under nursing comments in the Nurse 

Intra-Operative Report. If and when the patient returns to the operating room for a 

subsequent procedure the remove of the therapeutic the number 

and type of radiopaque soft must be similarly documented excluded from 

subsequent counts of items. 

(6) Use of intraoperative Radiograph. 

(a) An lntr'<:Jr'II'"IOI"~tl\.10 I"'OirllrV'II"':Onh of the 

wound is nor-tnrrrocorl 

field is not required if a methodical 

all surgical items is correct at the 

completion of the procedure. 

(b) A r<:>rlinnr<:>nh 

be performed by a physician at the completion of the surgical 

procedure, prior to the patient's transfer from the OR, in the following circumstances: 

.1. When the surgical count is "incorrect" (i.e., the preoperative surgical item 

count plus surgical items added during the procedure is greater or less than the 

postoperative surgical item count) and the surgical item in question is not recovered 

following a methodical wound exploration. 

fl.:_ A radiologist must interpret the and notify the surgical team by 

verbal or written communication when the surgical item is not found. The 

radiologist's report must be made available to the surgical team in a timely fashion 

recommended to be less than 30 minutes from the time the r<:>ri;,...,,,.-::~,nh 

requested. Consideration should be given to obtaining 

example, an oblique view of the operative site when initial r<:>r111nr1r-::~r•hc 

reveal the item and the item still has not been found. 

to close the surgical wound prior to 

item if delaying 

4 

a report 

closure 
77 


117SurgDirective6.eps

March 5, 2016 VHA DIRECTIVE 1103 

th There is no requirement for a radiologist to interpret the if the 

surgical team subsequently finds the missing object, thereby the surgical 

count as correct. 

~When the surgical wound does not involve a body cavity and the entirety of 

the wound is visible to the team, the attending surgeon determine that 

not required when a count of items is 

the surgical team must be in agreement. The attending 

surgeon must document the circumstances and reason for not obtaining an 

intraoperative radiograph the patient's electronic health record. 

be substituted for an instrument count when the surgeon, 

scrub person, and circulator unanimously agree that the number of surgical 

instruments utilized during the operative procedure prohibits an expeditious and Unely 

count. This situation is encountered with major joint replacements. NOTE: 

A methodical wound and count of all sharps and soft must still be 

performed even a radiograph is substituted for the 

such circumstances. 

~When the clinical circumstances dictate the patient requires emergency care 

and the counting of surgical items may not be in the best interest of the patient. This 

divergence or omission from standard protocol (i.e., methodical wound exploration 

and complete surgical item count) must be documented in the OR record in the 

following manner: 

£!..:.The surgeon must include a statement in the operative report describing the 

emergent nature of the procedure, the clinical condition of the patient, and the 

reasons for divergence from or omission of standard protocol. 

th The circulating nurse must enter a statement in the "Nursing Care Comments" 

section of the Surgery Package, which appear in the Nurse Intra-Operative 

Report describing the emergent nature of the surgical procedure, the clinical condition 

of the patient, and the aspects in which standard protocol was omitted or modified. 

~In such cases, a radiograph must be obtained in the Post-Anesthesia 

Recovery Unit or Intensive Care Unit and interpreted by a radiologist to rule out a 

retained surgical item unless contraindicated by the patient's clinical condition. 

1:_ When the operative procedure being performed is one determined by any 

member of the surgical team to be at high risk for retained surgical items, even though 

a methodical wound exploration has been performed and the surgical item count is 

correct. NOTE: The following operative procedures should be considered at high risk 

for retained surgical items: involving a cavity; unexpected 

the conduct or scope operative procedure; r.n£~r"" ""'C> 

more than one surgical team; operative 

those that require a nursing 

5 
78 

Senator BLUMENTHAL. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Blumenthal. 

Senator Heller. 

HON. DEAN HELLER, U.S. SENATOR FROM NEVADA 

Senator HELLER. Mr. Chairman, thank you. Thank you for holding this hearing and I want to thank the Secretary for being here 

also. I think this Committee has done a great job and I want to 

thank both you and the Ranking Member. I think we have passed 

out of Committee, I think, in this session, 10 pieces of legislation, 

some of which have been mine and all of them have contained my 

priorities. 

I just want to tell both of you I really do appreciate being part 

of this Committee, and for the leadership that we have this Committee has passed, legislation, for example, that have already been 

mentioned, like the GI Bill for life, access to STEM programs in 

education, which was also mentioned, also the appeals process for 

faster disability claims efforts. I want to thank you, Mr. Secretary, 

for your hard work and effort on that, but clearly the work is not 

over. This Committee has probably already shared that with you 

a few times. 

Secretary SHULKIN. Mm-hmm. 

Senator HELLER. You are getting to your first-year anniversary. 

I actually believe it is February 14. I do not know what you will 

be doing on February 14, but that will be your 1-year anniversary. 

How do you like the job? Tell me. We have had several discussions 

and I know you have been with the VA for a while, but not in the 

capacity as the Secretary. How was your first year? How do you 

feel about the work that is progressing? 


117SurgDirective7.eps
79 

Secretary SHULKIN. You know, Senator, look. First of all, it is an 

honor and a privilege to be able to serve our veterans. That is why 

I am here. I am a tough grader. I am a tough grader on myself and 

my staff, and I am impatient. I know all of you are too. There is 

a lot of work to be done and we have to make more progress, and 

we are going to stick with it to be able to do that. 

But, I do believe a lot of the credit goes to you and to the House, 

who is also doing good work on their side, to be able to make the 

progress that we are making, but I think we can all do better. 

Senator HELLER. I appreciate your visits to my State, which has 

been very, very helpful to the 300,000 veterans that we have in the 

State of Nevada. Now I happened to be traveling around a little bit 

last weekend—— 

Secretary SHULKIN. Mm-hmm. 

Senator HELLER [continuing]. In some of the rural portions, 

where they have expressed some concerns. Probably the one that 

caught my attention the most—and, frankly, for that matter, my 

staff—was the cancellation of the—— 

Secretary SHULKIN. Yes. 

Senator HELLER [continuing]. Community Care Network—— 

Secretary SHULKIN. Yeah. 

Senator HELLER [continuing]. For Region 4. For those who do not 

know, Region 4 is quite a big region. The Ranking Member is in 

that region, as is Nevada, but so is Alaska, Hawaii, and California. 

We can go down the list but it is quite the region. 

Can you explain to me—— 

Secretary SHULKIN. Yeah. 

Senator HELLER [continuing]. What the situation is and why my 

staff and congressional offices did not hear about this? We found 

out on Friday. 

Secretary SHULKIN. Yeah. 

Senator HELLER. I do not know if it was out earlier than that, 

but we found out on Friday. 

Secretary SHULKIN. Yeah. Yeah. I also found out last week too. 

The Federal contracting process is a complex process, one that is 

difficult sometimes to understand. It is designed to keep the people 

that run the business, like myself, out of negotiating these contracts. That is why I found out the same week that you did. 

In this case, we divided the country up into four regions. This 

was hopefully our first award in Region 4. So, I am disappointed 

that we were not able to award it, as well. 

I will tell you the reason why we were not able to award it is 

because our contracting officers did not believe that it was in the 

interest of taxpayers to proceed with that contract. That means 

they did not believe that they should be paying the price that was 

being bid out there. They did not feel it was reasonable. 

This is going to be rebid, and we hope—and we have spoken to 

those that have bid—that they will bid again, because we believe 

that the quality of the contractors were there. It just was not—we 

were not able to reach something that made sense for the taxpayers. 

Senator HELLER. So, it is my understanding that the competitive 

process has been closed down. Is that correct? 

Secretary SHULKIN. Yes, we have put it—yes. 

80 

Senator HELLER. So, what does it mean short term, for someone 

who lives in Elko or Ely or Eureka, for these veterans who have 

to travel long distances, of course, to get health care if they are not 

provided in their communities? 

Secretary SHULKIN. Well, we are talking about, right now, your 

veterans are being served by a third-party administrator that runs 

many of the aspects of the Choice program, and that will continue. 

We think that that contractor right now is doing a good job, improving its service to your veterans. We have been in direct contact 

about issues and they have been very responsive about fixing them. 

So, business as usual. It will continue to be to serve the veterans. 

I know the contractor currently is committed to that. We hope to 

have a competitive rebid process that will result in a good outcome 

for veterans, contractors, but, importantly, the taxpayers. 

Senator HELLER. Mr. Secretary, my time has run out but I again 

want to thank you, again, for coming to the State—— 

Secretary SHULKIN. Mm-hmm. 

Senator HELLER [continuing]. Spending time with our veterans, 

your accessibility, your understanding of the issues and problems 

we have, and willingness to work to improve the issues that we 

have in front of us. I think this Community Care contract is one 

of them—— 

Secretary SHULKIN. Mm-hmm. 

Senator HELLER [continuing]. And I look forward to working with 

you, trying to solve this particular problem. 

Secretary SHULKIN. Thank you. 

Senator HELLER. Thank you. 

Secretary SHULKIN. Thank you very much. 

Senator HELLER. Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Heller. 

Senator Hirono. 

HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII 

Senator HIRONO. Thank you, Mr. Chairman. The fact that the 

VA has a large number of vacancies throughout the country, and 

not just in Montana but also in Hawaii, and you were given tools— 

VA was given tools to make the hiring process work a lot more efficiently, and yet we seem to be continuously behind the 8-ball. 

So, have you put your finger on why it is so hard? I realize there 

are, you know, a lack of certain kinds of medical professionals, et 

cetera, if that is the overall problem. Are there additional tools that 

we can give the VA to enable you to hire the necessary people? 

Secretary SHULKIN. Well, yes, I do think that there is more we 

can do, but let me—Senator, let me tell you. Last year, we actually 

made progress. We have a net increase of 8,303 employees. We 

hired close to 40,000 but it is a net increase of 8,303. 

Senator HIRONO. Mm-hmm. 

Secretary SHULKIN. But, we know where we have critical vacancies, and that is where we want to move toward a direct hire authority that Senator Tester had talked about. 

Senator HIRONO. Mm-hmm. 

Secretary SHULKIN. OPM has been very helpful to us and indicated their support in doing that. There is this technical fix that 

we talked about, that will help us implement your intent last year, 

81 

when you gave us direct hire authority for medical center directors 

and network directors. 

Senator HIRONO. Do you need additional tools? 

Secretary SHULKIN. We do. We do. We want to continue to—right 

now we have three hiring authorities that we have to hire employees under—it is complicated—Title 5, Title 38, and a hybrid system. And the more that we can move, for our health care employees, toward a Title 38, it makes the process faster and more competitive with the private sector. 

Senator HIRONO. So, is that going to take legislation? 

Secretary SHULKIN. It is something that I think we have the authority to do ourselves, and that is what we are moving toward. 

But we have come to you in the past for help. You have always 

helped us with that, and we will continue to ask you if we need 

additional help. 

Senator HIRONO. Well, please let us know. 

Secretary SHULKIN. Yes. 

Senator HIRONO. Because I know, for a fact, that in Hawaii we 

have something like 166 medical staff vacancies that need to be addressed. 

Last week, the White House released an Executive order supporting our veterans during their transition to civilian life, and ensuring access to mental health care and suicide prevention, which 

you had talked about, as a priority. So, one of the provisions calls 

for access for veterans to receive mental health care, and I want 

to know whether you have enough mental health care professionals. What do you plan to do to devote additional resources to 

recruit and retain mental health professionals, because I assume 

that is one of your shortage categories. 

Secretary SHULKIN. Right. Right. Well, first of all, thank you for 

acknowledging the Executive order, because if you look at any 

group that is at high risk for suicide it is that 12-month period 

from transition. 

Senator HIRONO. Yes. 

Secretary SHULKIN. So, this is targeted to providing every single 

transitioning servicemember with a mental health benefit. I think 

that is critically important. 

In order to do that, VA does need more mental health professionals. You know, Senator Tester certainly made this point as 

well. We have identified a need for 1,000 mental health professionals. Unfortunately, the country at large—— 

Senator HIRONO. Yes. 

Secretary SHULKIN [continuing]. Has a shortage of mental health 

professionals, so this is going to be difficult. But, we are committed 

to increasing the number of trainees in mental health residency 

programs. We work very hard with nurses, social workers, as well 

as psychologists and psychiatrists, to train as many as we can. We 

want to do more. We will continue to use efforts like our recruitment bonuses and to acknowledge that VA is actually a terrific 

place to work if you are a mental health professional. Hawaii would 

be a great place to be. 

Senator HIRONO. Yes. So—— 

Secretary SHULKIN. So, we are going to do whatever we can. 

82 

Senator HIRONO. Thank you. I want to discuss the IG report that 

showed overpayments and payment errors in the Choice program. 

Since I am running out of time, clearly, we need to be assured that 

you are taking the appropriate steps to make sure that you have 

processes in place so that these kinds of overpayments and erroneous payments are not occurring. 

Secretary SHULKIN. Yes. 

Senator HIRONO. So, I need your assurance that you are doing 

that. 

Turning to homelessness, your predecessor made a commitment 

that he would end veteran homelessness, and as mentioned by Senator Manchin, we seem to be going in the wrong direction here, 

particularly with regard to women veterans who are homeless. 

Why is it that we are heading in the wrong direction and what are 

you doing about it? By the way, where is ending homelessness in 

your order of priorities for the VA? 

Secretary SHULKIN. Well, the commitment to ending veteran 

homelessness I think you correctly said was made in 2010, and we 

absolutely are committed to that. We will not back down from that 

goal, and we will continue to drive to do everything we can to end 

veteran homelessness. So, there is the same firm commitment. 

What I have said is because of this last year, where we actually 

went up 2 percent, we have to rethink our effort. Any good business looks at what they are doing and says ‘‘if there is a better way 

to do it, we should.’’ So, we are going to come out with a new approach that doubles down on the things that are working and 

maybe uses resources from things that are not working as well. 

Here is what we know is working, and I will tell you what is not 

working. When veterans get jobs, it keeps them in sustainable 

housing. 

Senator HIRONO. Mm-hmm. 

Secretary SHULKIN. It helps in so many ways. So, we are going 

to re-double down on working with employers around the country 

to find our homeless veterans and train them and get them jobs. 

Number 2, the HUD-VASH voucher program works really well. 

Senator HIRONO. Mm-hmm. 

Secretary SHULKIN. We want to continue that partnership with 

HUD, and we look toward areas—Hawaii is one, but Los Angeles 

and Seattle too—where the—with the current value of the HUDVASH voucher, we cannot find people who want to rent us apartments. 

Senator HIRONO. Yeah. 

Secretary SHULKIN. So, we have to continue to increase the value 

of that, which we are working on. 

We have a shortage of affordable housing units, so we need to 

partner with construction people and landlords, and actually create 

more inventory of low-inventory housing, so that is going to work. 

We also need more community partnerships. We just—because VA 

cannot do this alone. HUD cannot do this alone. This is a countrywide commitment. 

So, we are going to double down on the things that work and we 

are going to come out with a fresh, new approach here. We would 

like to work with you on this, because I am not satisfied with the 

progress we are making. 

83 

Senator HIRONO. Yeah, and let us know how that is going, especially Hawaii which has, per capita, the highest number of veteran 

homeless in the entire country. 

Secretary SHULKIN. The housing market there, you know, it is so 

expensive. So, thank you. 

Chairman ISAKSON. Senator Cassidy. 

HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA 

Senator CASSIDY. Hello, Secretary Shulkin, how are you? 

Secretary SHULKIN. Hey. 

Senator CASSIDY. A lot of what I am going to be asking you today 

references a Newsweek article written in October of last year, authored by Mr. Levine. Are you familiar with it? 

Secretary SHULKIN. Yes. 

Senator CASSIDY [continuing]. The article is about how the VA 

fueled the national opioid crisis and is killing thousands of veterans. 

Secretary SHULKIN. Yeah. 

Senator CASSIDY. As you might guess from the title, it is critical 

of VA. 

Secretary SHULKIN. Yes. 

Senator CASSIDY. So, I heard today, or read, that you have now 

published facility-specific statistics regarding those prescriptions. 

Secretary SHULKIN. Yes. 

Senator CASSIDY. I have been interested in this data, in terms of 

applying to the VA, and knowing facility specificity. However, we 

have had challenges receiving the data requested and expect to receive it shortly. The article addresses Huntington, WV, where the 

local VA prescribes take-home opiates to roughly 18 percent of its 

patients, a rate that is 230 percent higher than the national average, for all adult male patients. 

I have not looked at the statistics you referenced earlier, but does 

this VA still prescribe a rate that exceeds the national average by 

230 percent? 

Secretary SHULKIN. What we published now, and, Senator 

Cassidy, I hope you will appreciate this, no other system has ever 

published this data. We are hoping that they will join us, because 

we believe, like you, that this is how you get better, by sharing 

your data and understanding it. 

What you will see, for every single one of our VA facilities, not 

only what the rate is now but what it was in 2012, and whether 

they have made improvements. Every single site, except for one, 

has made improvements in their prescribing rates in opioids. The 

one that did not may be somewhat unique. It is in the Philippines. 

It is Manila. But every domestic site in the VA has made improvements. Some made a lot more than others, and that is where we 

hope that they are going to learn from each other. 

I do not recall Huntington, WV’s, improvement rate but I know 

it has improved. 

[The information requested during the hearing follows:] 

84 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. BILL CASSIDY TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Are 18 VA state programs not reporting prescribing data with PDMPs, is this still 

the case? 

Response. 48 states and the District of Columbia are activated for PDMP data 

transmission, receiving data from the VA. 

Missouri just recently established a statewide PDMP by executive order. Nebraska’s program has transitioned to Appriss Health’s PMP AWARxE and work is underway to initiate transmissions; the state is working to implement FIPS 140–2 

cryptography required for Federal data sharing. 

Senator CASSIDY. Got it. Another issue which I asked about last 

time is if the VA is sharing its prescribing data with the PDMPs? 

Secretary SHULKIN. Yes. 

Senator CASSIDY [continuing]. The article by Mr. Levine states 

that by the end of last year, 2016, 18 State VA healthcare programs were still not reporting to the State PDMPs. Is that still the 

case, now that we are a year out from this? 

Secretary SHULKIN. I do not believe that that is the case anymore. I am going to want to confirm with you that we are in 100 

percent compliance, because that is our commitment. If we are not 

in 100 percent compliance, I am going to want to know about that, 

because we have committed to that and we should be. 

Senator CASSIDY. Thank you. The article also suggests that 

VistA, your electronic medical record program, is incapable of flagging drug interactions between benzodiazepines like Valium, and 

opioids, and details—gives anecdotes of people who are given 

polypharmacy with Ritalin along with everything in every class, as 

well as one patient who got 130 morphine tabs. Yes, it is very disturbing. Why would a veteran patient get so much? 

Is VistA capable of flagging this? Are the pharmacy programs incapable of seeing these drug interactions and flagging them? 

Secretary SHULKIN. We do measure and follow the statistics on 

patients who are on both benzodiazepines and opioids, because of 

the danger. I am not able to tell you right now. We do have drug 

interactions that come up on VistA. I see them when I use VistA. 

I am not able to tell you why we would not be able to do that. 

Senator CASSIDY. The pharmacist is quoted in this article. 

Secretary SHULKIN. Yeah. Yeah. 

Senator CASSIDY [continuing]. The pharmacist said that it, VistA, 

does not flag it. 

Secretary SHULKIN. Yeah. 

Senator CASSIDY. And he, apparently, testified to that under 

oath. 

Secretary SHULKIN. Yes. Again, I just do not know the answer to 

that. I would like to—and I would be glad to confirm with you, very 

shortly, whether that is the case or not or whether that has been 

fixed. I do not know a technological reason why we would not be 

able to do it, but—— 

Senator CASSIDY. OK. 

Secretary SHULKIN [continuing]. I may not understand it. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. BILL CASSIDY TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Is VISTA incapable of flagging drug interactions? 

85 

Response. VISTA is capable of generating drug interaction checks. 

Senator CASSIDY. Let me ask, you have mentioned how many 

fewer patients are now prescribed opioids. 

Secretary SHULKIN. Yes. 

Senator CASSIDY [continuing]. If the opioid dosing is going down, 

does the VA have any spot checks as to how many veterans have 

gone from receiving prescription opioids to perhaps seeking out illicit sources of opioids? Have we just had an apparent victory or 

is it documented to be a real victory? 

Secretary SHULKIN. Yeah. I do not know what they are doing illicitly. I mean, we just do not have a way of tracking that. 

Senator CASSIDY. Do we have, for example, drug screens of patients that theoretically have been taken off of opioids, but a drug 

screen might show that they are still taking? 

Secretary SHULKIN. Right. Those that return and had been started on opioids sign a patient informed consent that says that we will 

do the urine screening. We do the urine screenings and we report 

on that, in terms of general statistics. But, if a veteran does not 

return to us, we do not have any way of tracking that. 

Senator CASSIDY. Do we have any sense of the number or the 

percent of opioid overdoses in people whom, theoretically, are no 

longer taking opioids? 

Secretary SHULKIN. That is a good question. I have never seen 

the statistic reported that way. We do track Narcan use, and we 

distribute a lot of Narcan. That hopefully would be a measure of 

people who have overdosed that we have been able to resuscitate. 

But, I have never seen the data broken down in the way that you 

have asked. 

Senator CASSIDY. I think that would be helpful. 

Secretary SHULKIN. Yeah. 

Senator CASSIDY. It would be helpful to the Committee, because 

it would provide critical information—— 

Secretary SHULKIN. Yeah. 

Senator CASSIDY [continuing]. On whether or not we really are 

making progress to end the opioid crisis. 

Secretary SHULKIN. Yeah. 

Senator CASSIDY. We need to know whether it is more apparent 

than real. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUESTS ARISING DURING THE HEARING BY HON. BILL CASSIDY TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

1. Does VA screen those patients who were taken off of prescribed opioids for illicit drug use? • Secretary Shulkin responded that there was screening and that VA could provide a report on the results. 

Response. Patients on opioid therapy for chronic pain receive annual urine drug 

testing (OSI metric, 89 percent as of Q1fy18). Patients on opioid agonist treatment 

for opioid use disorder receive quarterly urine drug testing (sud 17 SAIL metric, 

currently 94.3%). 

All other urine drug testing is at provider discretion based on clinical presentation. 

2. Does VA have statistics on opioid deaths from those Veterans who were not 

prescribed opioids? 

Response. The latest cause of death data available is FY 2014. The following table 

includes the statistics related to Veteran overdose deaths that year, and whether 

those patients received an outpatient VA prescription for an opioid analgesic in the 

86 

year of their death. Note that overdoses were not restricted to overdoses involving 

opioids, but instead include all accidental and intentional overdoses on any drug or 

substance. The cohort of VHA users includes all persons using VHA services since 

2000; users may not have used VHA health care in FY 2014. 

Cause of death among VHA users that died in FY 2014 All VHA users 

VHA Users receiving 

an outpatient VA 

opioid analgesic prescription in FY 2014 

VHA Users who did not 

receive an outpatient VA 

opioid analgesic prescription in FY 2014 

Any overdose mentioned in cause of death information ..... 2,193 801 1,392 

Senator CASSIDY. Finally, is the VA using medication-assisted 

therapy for those who are addicted? 

Secretary SHULKIN. Yes. Suboxone and other medication-assisted 

treatment. We are seeing a rise in that, and certainly we are keeping up with the contemporary literature on that. 

Senator CASSIDY. Correct. A rise could be from a very small baseline—— 

Secretary SHULKIN. Yeah. 

Senator CASSIDY [continuing]. Which could still be very small. 

Can you perhaps submit, for the record, the percent of patients 

whom you think have opioid addictions—— 

Secretary SHULKIN. Yeah. 

Senator CASSIDY [continuing]. To include disuse orders, and how 

many have been transitioned, et cetera? 

Secretary SHULKIN. Yeah. I would be glad to get you those statistics. My impression is—although I have not looked at this in detail 

recently—that your representation is probably correct, starting 

from a small baseline, beginning to use it more, probably still underutilized, and an opportunity for us to do better. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. BILL CASSIDY TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Percentage of patients who were transitioned from opioids 

• Secretary Shulkin noted that this is done but that it was probably ‘‘underutilized’’ 

• Can VA provide what it currently is doing and/or what it will do track this for 

the future? 

Response. As of 4thQFy17, VA serves 6.29 million Unique Patients. (Source: 

VSSC VHA Pocket Card https://securereports2.vssc.med.va.gov/ReportServer/Pages/ 

ReportViewer.aspx?%2fMgmtReports%2fPocketCard%2fPocketCard&rs:Command= 

Render) 

A subset of the Unique Patient population is the number of Veterans receiving 

opioid prescriptions dispensed through the VA pharmacies. As of Q4Fy17, 418,895 

patients are receiving opioids; this is 260,481 fewer patients or a 38 percent reduction than when the data was benchmarked in Q4Fy17. The latest data for patients 

receiving opioids is Q1FY 2018 in which 398,899 Veterans received opioids, a 41% 

reduction. Both quarter’s data are included to allow a comparison to the VSSC data. 

These reductions represent the number of patients that have been transitioned from 

opioids. 

VA currently reports on the Opioid dispensing data on the website https://www. 

data.va.gov/story/department-veterans-affairs-opioid-prescribing-data. This data will 

continue to be tracked and updated on the website semi-annually. The website additionally includes regional comparison data to CMS reports on opioid prescribing 

rates by state. 

ADDITIONAL INFORMATION

After reviewing the hearing recording it appeared Senator Cassidy (at time 1:17) 

was interested in Medication Assisted Treatment. Quote from hearing ‘‘he asks ‘‘is 

87 

the VA using medication assisted treatment for addiction.’’ In response to this question VHA is providing the following additional information: 

Medication Assisted Treatment for Opioid Use Disorders 

VHA has responded to growing demand for opioid use disorder treatment by increasing access to Medication-Assisted Treatment (MAT). MAT includes counseling 

or psychotherapy, close patient monitoring, and medication using buprenorphine/ 

naloxone, methadone (administered through an Opioid Treatment Program), or extended-release injectable naltrexone. Buprenorphine/naloxone and extended-release 

injectable naltrexone are on the VHA National formulary. These are available at 

VHA facilities and through non-VA purchased care options in the community. Methadone is administered and dispensed through 32 VHA Opioid Treatment Programs 

across the Nation and through non-VA purchased care options at many facilities. 

VHA has been expanding access to MAT for patients with opioid use disorders. 

In the year ending in FY17Q4, VA treated 24,069 patients with MAT, up from 

19,333 patients in the year ending in FY14Q4, a 24% increase in patients treated 

in just 3 years. This expansion is the result of a comprehensive and integrated approach. The Buprenorphine in VA Initiative provides clinician education through 

monthly webinars, newsletters, a SharePoint with educational resources, individual 

consultations, and a national community of practice supported by an e-mail group. 

The Psychotropic Drug Safety Initiative (PDSI) combines use of informatics tools, 

action planning, and a national quality improvement collaborative to improve the 

evidence-based use of psychotropic medications. One of the PDSI program’s many 

impacts has been significantly increased rates of using medication assisted treatment among Veterans with Opioid Use Disorder. In addition, VA Pharmacy’s Academic Detailing service is developing an Opioid Use Disorder campaign using 

informatics tools and individual provider support to increase Veteran access to 

MAT. 

VHA offers several medication assisted treatments for opioid use disorder. Opioid 

Agonist Treatment includes prescription of methadone or buprenorphine delivered 

either in a licensed clinic or office-based setting. Opioid Antagonist Treatment includes prescription of injectable depot naltrexone. Only opioid agonist treatment was 

tracked until FY 2014. 

Year 

Number of patients 

that received Opioid 

Agonist Treatment 

Number of patients 

that received Opioid 

Agonist or Antagonist 

Treatment 

FY 2006 8,091 NC 

FY 2007 8,581 NC 

FY 2008 9,694 NC 

FY 2009 10,564 NC 

FY 2010 11,887 NC 

FY 2011 13,493 NC 

FY 2012 14,412 NC 

FY 2013 16,306 NC 

FY 2014 17,575 19,333 

FY 2015 19,971 21,915 

FY 2016 22,103 22,606 

FY 2017 23,406 24,069 

88 

Senator CASSIDY. I yield back. I apologize for going over my time. 

Chairman ISAKSON. Senator Murray. 

HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you very much, Mr. Chairman. Mr. Secretary, thank you for being here today. 

Last year, the Department tried to quietly take money away 

from some really essential programs—HUD-VASH, childcare, treatment for women veterans—and move the money to general purpose 

accounts where it could be spent on literally anything. Meanwhile, 

over the last year, you have come to us repeatedly, sometimes with 

just days or weeks left, saying VA will run out of funding for the 

Choice program earlier than expected. 

The Department has to start being transparent with Congress— 

it has to—about its budget needs and not keep raiding critical programs to cover these shortfalls; to give us, finally, a realistic picture of Community Care spending. Those are really basic expectations—how much you are spending and to ask for what you really 

need. 

I wanted to ask you today, will there be any changes in how VA 

manages its business operations, or is it time to consider a new approach to these functions? 

Secretary SHULKIN. Well, first of all, I think those are fair criticisms, and I have to take responsibility for some of the observations that you have. I will tell you that there is no desire to do anything underhanded or hide things. This is a system where we are 

trying to do so much so fast that we are obviously making some 

mistakes, and we have to do better at that. 

So, let me just address things. First of all, the projections on the 

Choice program, financial projections, are very, very complex to do, 

largely because—not only, but largely because of this issue that we 

hope to get fixed, with your Committee’s bill, that we have to obligate the money at the time that we order the service, not when it 

was rendered. So, it is a little bit of a guessing game that makes 

financial projections hard. 

But, we are doing better. We projected that the money which was 

left in the Choice program before you renewed it, right before the 

break, was going to run out the first or second week in January. 

It ran out the first or second week in January. You gave us $2.1 

billion. Today we have $2 billion left, which means we have spent 

$100 million already of what you gave us. 

So, I think we are getting better. We have a brand-new CFO who 

was just confirmed, thanks to you, in the last 2 weeks. But, it is 

a hard job to do it, and we are never going to be totally accurate 

unless we get some of these rules changed. 

On this issue of us doing something like taking money away from 

HUD-VASH vouchers or women’s services, it was absolutely never, 

never our intent to spend less money for women’s services or HUDVASH or mental health, or anything else. Here was our intent, 

which I stopped because of the reason that you said—it was not accurately being rolled out or communicated. So, it is not happening 

now. But, let me just tell you what my intent was, because if you 

disagree with it, I would like to talk to you. 

89 

Right now, everything is controlled out of Washington, out of a 

central office. We tell people across the field, this is how much you 

get and this is where you need to spend it. My idea of management 

is, you let the people closer to where you are serving the veteran 

be more involved in how they should spend their money, and they 

have to be accountable for the results—treating more women veterans, getting more homeless veterans off the street. You allow 

them to understand what is better in Seattle versus what is better 

in Honolulu. 

I was trying to advocate a management philosophy that has 

worked for me that I believe in. It was not rolled out well, so I 

stopped it. But, we are going to think about how to make this system work better—that was in my opening statement. We need to 

do more. We need to do better, and I am going to continue to try 

to do it. I am going to commit—we are going to do a better job of 

being transparent and collaborative with you, because—— 

Senator MURRAY. OK. Well, that is what we will be watching. 

Secretary SHULKIN. I got it. That is fair. 

Senator MURRAY. So, you know, we have had a rough year, but 

that is what we will be watching for. 

Secretary SHULKIN. That is fair. 

Senator MURRAY. Let me move to another topic. An Inspector 

General report from December found in six of seven medical centers it reviewed primary care provider panels were significantly 

below required levels, and that VHA did not provide oversight of 

that requirement. That resulted in decreased access for our veterans, and hundreds of millions of dollars of waste in appointments 

that were not filled. 

That report also found, once again, that VA’s reported wait times 

are misleading, and in this case, by the IG’s calculation, more than 

half of the newly-enrolling veterans waited longer than 30 days for 

their first appointment. 

Another IG report found that the Eastern Colorado Health Care 

System is still keeping secret waiting lists for group mental health 

care therapy. And finally, according to VA data from November, 

there are more than 35,500 vacancies in VHA. 

Those are senior-level shortcomings across the system that end 

up with reducing access to our veterans for care and wasting taxpayer dollars. So, I just want to know, who is accountable here? 

Secretary SHULKIN. Well, I am accountable, but—and there is no 

but about the accountability—the statistics that you are reporting—and this is not being defensive; I just want you to understand 

what they are. The 35,000 vacancies. We have 370,000 employees. 

That makes a 9 percent vacancy rate, which is not overly high. So, 

you are always going to have 40,000 vacancies during the course 

of the year. The 35,000 are part of that turnover rate, and as I already mentioned, we had a net gain of 8,303 employees last year. 

So, we are not only keeping up—— 

Senator MURRAY. OK. But we have got secret waiting lists for 

group mental health care, wait times. This is all from the IG. I am 

not making this up. 

Secretary SHULKIN. No. No, I have got it. We have a big system. 

Secret wait times, we have clearly said to all of our leadership are 

90 

not to occur, not acceptable. If we find them, there are disciplinary 

actions. 

In Colorado, I think that this was one clinic, and it was—I believe, and I may stand corrected—I believe that the facility actually 

identified that and dealt with that issue. So, that was there. It was 

dealt with. It was a deviation that is not acceptable. This is not 

representative of what is happening across the country. 

Wait times we continue to struggle with. We have made 

progress, there is no doubt, The data says we have made progress, 

but we are not anywhere near where we need to be. 

Senator MURRAY. No, we are not. 

Secretary SHULKIN. I agree. and we are working on it. We are 

making progress every day. What we have indicated—our progress 

in is in matching clinical urgency and need to access. 

Senator MURRAY. OK, well—— 

Secretary SHULKIN. But—yeah. 

Senator MURRAY [continuing]. This goes back to my original 

question. We need you to tell us how much you are spending—— 

Secretary SHULKIN. Yes. 

Senator MURRAY [continuing]. And what you are asking us for 

these veterans. 

Secretary SHULKIN. Yes. 

Senator MURRAY. We need to know that. 

Secretary SHULKIN. Yep. 

Senator MURRAY. OK. 

Secretary SHULKIN. Thank you. 

Chairman ISAKSON. Senator Sullivan is recognized for the patience-of-Job award. 

HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA 

Senator SULLIVAN. Thank you, Mr. Chairman. Mr. Secretary, 

good to see you. I am going to start with just some thanks and 

kudos to you and your team. We finally passed out of the Committee here the Serving Our Rural Veterans Act, which was Senator Tester and I’s bill, but you were kind of the brainstorm on 

that when you and I were in Alaska. So, your team and I—we all 

worked together well on that. Hopefully we get that across the Senate floor. So, I want to thank you for really helping inspire the idea 

and having the team. 

I also want to thank you, Dr. Ballard. Alaska is doing a great 

job. 

Secretary SHULKIN. Good. 

Senator SULLIVAN. We have added over 100 employees—— 

Secretary SHULKIN. Mm-hmm. 

Senator SULLIVAN [continuing]. Including two docs, at the CBOC 

in the Mat-Su Valley—— 

Secretary SHULKIN. Wow. 

Senator SULLIVAN [continuing]. Which has been—we have not 

had a doctor there in 5 years. 

Secretary SHULKIN. I am impressed. That is great. 

Senator SULLIVAN. It was kind of the crisis situation that Senator Tester was talking about. We filled it. I know you had a focus 

on that, so I appreciate that. 

91 

I was in the Kenai Peninsula yesterday with some constituents, 

actually having coffee; been doing a lot of that. One of them asked 

me, ‘‘Hey, what are we doing, Senator, on suicide?’’ From, you 

know, an older gentleman, just really concerned. I talked about the 

Clay Hunt Suicide Prevention Act. I talked about some of the other 

issues. So, could you literally talk to this constituent right now and 

say, ‘‘Hey, here is what else we are focusing on?’’ Because I know 

you are focused a lot, but sometimes it does not always get out, and 

I thought, you know, having the Secretary here to answer—— 

Secretary SHULKIN. Yeah. 

Senator SULLIVAN [continuing]. A constituent of mine would be 

beneficial. 

Secretary SHULKIN. Yeah. Real briefly, last week the President 

signed an Executive Order where 100 percent of transitioning servicemembers are going to have a mental health benefit for 12 

months. 

Senator SULLIVAN. Right. 

Secretary SHULKIN. We have expanded mental health services, 

emergency services, for those that are other-than-honorable. We 

are making sure our Veterans Crisis Line is being answered—now 

less than 1 percent of dropped calls and the calls answered within 

11 seconds. We are adding 1,000 mental health professionals. We 

have offered same-day services for mental health in any one of our 

facilities where people present. 

We are using predictive analytics, and a program called Reach 

Vet to identify those at highest risk by going out and actually contacting them, then bringing them in. We are using community 

partnerships like Give an Hour and the Cohen Veterans Network 

as a way to supplement the types of services available to our veterans. Our Vet Centers are open for walk-in services. We can see 

family members as well as veterans, to be able to help them. We 

are also looking at a number of other things that can help reduce 

this crisis, quite frankly. 

Senator SULLIVAN. Well, thank you for that. I know the Committee is very interested. We have a lot of bipartisan support on 

that. 

Let me ask another, you know, Senator Hirono talked about 

homelessness, and I know we are all focused on it. Probably one 

of the best ways to deal with homelessness is grow the economy, 

and I think the administration deserves credit and a lot of kudos 

on that, right? We are probably going to have a fourth quarter of 

last year that is probably going to be another really strong 3 percent, maybe even 4 percent GDP growth, right? 

Secretary SHULKIN. Yep. 

Senator SULLIVAN. I mean, we have not grown like that in over 

a decade. 

Secretary SHULKIN. Yep. 

Senator SULLIVAN. I mean, there is a lot the VA can do, but if 

you do not have a strong economy, you are going to have more 

homelessness. So, I commend the administration for its focus on 

that. 

Let me turn to an Alaska-specific issue. You know the uniqueness of our State. You have been up there, and I look forward to 

getting you up there again, as the Secretary. But, the VA central 

92 

office has made a policy call which would change the reimbursement rates for military partnerships to be in line with Medicare 

rates, and this would have a very negative impact on our VA partnerships with some of our DOD partners, the 673rd Medical Group 

there at Joint Base Elmendof-Richardson. 

Can you commit to me to make sure that you are taking feedback 

from all local VAs—you know how unique many of them are 

throughout the State—and ensure that they understand the kind 

of ramifications of this policy change? As you know, in this country 

of ours, one size never fits all. What works in Alaska does not work 

in Connecticut or other places, and vice versa. So, can you just 

make sure—can I get your commitment on this issue before there 

is some kind of big change? You will look at it for the ramifications 

in Alaska and other places, plus get feedback from leaders, like Dr. 

Ballard and others, before you guys make kind of a one-size-fitsall call, which my folks back home are saying would be very negative, at least in terms of Alaska? 

Secretary SHULKIN. Absolutely. I think you have always been effective at describing the situation in Alaska and other parts of the 

country that need different types of programs in it, and we certainly are open to that feedback. We will reach out to you to make 

sure that we are connecting with the people you think we should 

connect with. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. DAN SULLIVAN TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Prior to making any changes please commit to receive feedback from local VA facilities regarding the ramifications of the VACO policy that would change the reimbursement rates of military partnerships to be in line with Medicare rates. 

Response. The Department will solicit feedback prior to making changes. 

Senator SULLIVAN. Great. I appreciate that. 

This is just really more of a comment. I know, earlier in the 

hearing, you talked about, and the Chairman asked about making 

sure that we get the other Senate-appointed—or Presidential-appointed, Senate-confirmed positions. 

Secretary SHULKIN. Yeah. 

Senator SULLIVAN. You know, we need to get those from you. I 

would ask my colleagues on this side of the aisle, on the other side 

of the aisle, though, none of the games, right? We have had historic 

records of just holding up nominees for no other reason than to just 

hold them up on the other side. 

So, you guys get them out and I ask my colleagues here, no 

footsies with these nominees. Let us get them confirmed, let us get 

them going. We do not need 40 hours of debate on some of these. 

They are not going to be controversial. Delays and delays and 

delays on, you know, Senate, or Presidential-appointed nominees, 

particularly as it relates to the VA—— 

Secretary SHULKIN. Right. 

Senator SULLIVAN [continuing]. Would be a shame. So, we want 

to work with you on that, and I certainly hope everybody on this 

Committee wants to do that. 

Secretary SHULKIN. Senator, yes. I do not think you were here 

when I said I think we have the best Committee in the Senate. We 

93 

have not seen any of those games. You guys have done everything 

that we have asked. We owe you the nominees, and then I am 

sure—— 

Senator SULLIVAN. I agree with that. 

Secretary SHULKIN [continuing]. That you will do your job. 

Senator SULLIVAN. Good point on the Committee. 

Secretary SHULKIN. Yeah. Yeah. 

Senator SULLIVAN. Those games do not occur on this Committee. 

Secretary SHULKIN. Yeah. 

Senator SULLIVAN. The games occur on the floor of the Senate, 

where this administration’s nominees—— 

Secretary SHULKIN. Yeah. 

Senator SULLIVAN [continuing]. Have been—— 

[Overlapping speakers.] 

Secretary SHULKIN. Fortunately, not with VA. 

Senator SULLIVAN [continuing]. Delayed in ways—— 

Secretary SHULKIN. Right. 

Senator SULLIVAN [continuing]. That have been unfortunately 

historic—— 

Secretary SHULKIN. Yeah. 

Senator SULLIVAN [continuing]. And should not happen at all, 

but it definitely should not happen with nominees to go fill senior 

VA positions. 

Secretary SHULKIN. That is right. Thank you. 

Senator SULLIVAN. All right. Thank you. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you very much for your service, and 

thank you. By the way, I will point out our Secretary was the only 

Cabinet member who was unanimously approved in his nomination 

and confirmation, which is a testimony to him and the job the VA 

is doing. 

I think Senator Blumenthal and Senator Tester have another 

question or two. I would ask that they be as brief as possible and 

succinct, to get to the point. 

Who wants to be first? 

Senator TESTER. Go ahead, Senator Blumenthal. Go ahead. 

Chairman ISAKSON. Senator Blumenthal. 

Senator BLUMENTHAL. Thank you very much, Mr. Chairman, and 

thank you for spending the extra time with us and being so forthcoming in your responses. 

I want to come back to some of the questions that have been 

asked about the vacancies—— 

Secretary SHULKIN. Mm-hmm. 

Senator BLUMENTHAL [continuing]. And the 9 percent turnover 

that you described. 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL. Has the composition of that turnover, or 

the vacancies, changed at all? In other words, are there more positions? Are they more psychiatrists? I know we have talked about 

the difficulty of recruiting people, in particular, specialty providers 

to the VA. 

Secretary SHULKIN. They do and they change by location. In 

Montana, our biggest vacancy is physician assistants, a 36 percent 

vacancy rate. We have about 15 occupations that we see as critiVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00097 Fmt 6633 Sfmt 6601 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
94 

cally hard to hire right now. They are the ones that we have gone 

to OPM, Office of Personnel Management, for direct hire authority, 

that they are working with us on. We have difficulty—we have 

2,428 vacancies for physicians right now. Last year we had a net 

gain of 266. So, while we are making an improvement, it is only 

about 10 percent of the improvement we need. We have 5,507 

nurse vacancies right now. Last year we had a gain of 1,494. Nursing assistants, we have 1,268 open, and they vary by region. 

So, that is how we recruit by region. We had a recruitment problem in Little Rock last year, where we were desperately short of 

nurses. We had a hiring fair where we hired 87 nurses in a single 

day. So, we are approaching this by a regional effort, but the most 

important part is for us to know where our shortages are, and we 

do have that data. 

Senator BLUMENTHAL. I also want to ask about the education 

issue that I mentioned. 

Secretary SHULKIN. Mm-hmm. Yeah. 

Senator BLUMENTHAL. Could you give me some idea of what action has been taken—— 

Secretary SHULKIN. Yeah. 

Senator BLUMENTHAL [continuing]. What is the plan, and so 

forth? 

Secretary SHULKIN. Yeah. So, the biggest thing that we have 

done—and I really think you got it right. I do want to do something 

on this. I think that there is an issue, and I know you believe that 

too. We have put caution flags up on our comparison tool for veterans. Meaning when a veteran goes to our education site and 

looks at what their options are, there are actually caution flags for 

deceptive marketing and some of the other practices. We do about 

5,000 compliance visits a year to these schools, and where we find 

concerns, the way that I know you have them, we actually share 

that information with our veterans. 

Now a lot of veterans still go on and choose to enroll in those 

schools, and as long as they have a State accreditation our current 

policy is that we will continue to pay for that. We have been battling, sometimes publicly, with schools that have struggled with 

their State accreditations, and we are trying to hold firm to protecting veterans and doing the right thing. 

Do I think we can do more? I do, and would look forward to 

working with you on that. 

Senator BLUMENTHAL. I would welcome that work. 

Secretary SHULKIN. Mm-hmm. 

Senator BLUMENTHAL. To be absolutely frank, I have been unhappy—— 

Secretary SHULKIN. Mm-hmm. 

Senator BLUMENTHAL [continuing]. With some of the laggard and 

lacking action on the part of the Department of Education—— 

Secretary SHULKIN. Mm-hmm. 

Senator BLUMENTHAL [continuing]. Which has much bigger impact on these practices and predatory actions of for-profit schools 

around the country. So, I very much welcome your dedication to 

this cause. 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL. Thank you. 

95 

Secretary SHULKIN. Thank you. 

Senator BLUMENTHAL. Thanks, Mr. Chairman. 

Chairman ISAKSON. Thank you. Senator Tester. 

Senator TESTER. Thank you, Mr. Chairman, and thank you for 

being here, Secretary Shulkin. I would just add on to Senator Sullivan’s comments that you continue to put forth good people, some 

of which are behind you, that we have confirmed. We will continue 

to get them out of this Committee as quickly as possible. I will put 

pressure on my side of the aisle to get them through the Senate 

as soon as possible. We have not done that here, but you have put 

forth good candidates, which I think is the key. 

Look, I have an editorial comment very quickly. Timing for the 

allocation of dollars for services for the new Community Care program is in the Caring for Our Veterans Act. The fix to the medical 

director hiring provision that we talked about—— 

Secretary SHULKIN. Yeah. 

Senator TESTER [continuing]. When they did the first round is in 

the—— 

Secretary SHULKIN. Yes, it is. 

Senator TESTER [continuing]. Caring for Our Veterans Act. The 

Serving Rural Veterans Act that you worked hard on with Senator 

Sullivan is in the Caring for Our Veterans Act. We talked about 

the shortage of docs nationwide, the 1,500 residency slots are in 

the Caring for Our Veterans Act. Yet, a number of another reasons 

why we hope to get your support of this bill publicly, because I 

think this bill would have been passed already—— 

Secretary SHULKIN. Yes. 

Senator TESTER [continuing]. If we could have gotten you on 

board. 

Secretary SHULKIN. Yes. 

Senator TESTER. Look, I do not want to be hardcore about this, 

but I am going to be hardcore about this. I would really like to get 

a list of about five specific things that the VA central office is going 

to do above and beyond what you are currently doing to address 

the clinical vacancies in our State. My staff says they wanted it 

done by the end of the week but it is already Wednesday. Could 

you get that to me in a week? 

Secretary SHULKIN. Yes. 

Senator TESTER. Perfect. 

Secretary SHULKIN. Yes. 

Senator TESTER. You know, I sent out for online questions for 

you—— 

Secretary SHULKIN. Yeah. 

Senator TESTER [continuing]. And I think it is important. 

Secretary SHULKIN. Your Facebook page. 

Senator TESTER. Yes. We got a bunch of excellent questions, but 

I just picked this one. What have you done to remove the barriers 

for women’s health care and how are you responding to veterans 

with MST? 

Secretary SHULKIN. Well, I believe that we have done a lot to remove barriers for women’s health care, but we have a lot more to 

do. One of the things that we are doing is we are continuing to 

train more providers in specialty-specific practices to care for 

women veterans, so that we can expand our access. So, I believe 

96 

we are holding a conference in the very near future in Orlando to 

train another 332 VA providers in women-specific care, in which 

they will be certified to be able to go out to expand practices 

throughout the country. I think that is critical. We continue to look 

at sites that are not providing women’s health care clinics, and 

making sure that they are developing them as well. 

Women are our fastest-growing demographic. 

Senator TESTER. Yep. 

Secretary SHULKIN. We know our culture has not traditionally 

been as sensitive to them as needed. That is why we have FACA, 

a Federal advisory committee, telling us how we can do a better 

job for women veterans. We are listening to their advice. We have 

a director at the Center for Women Veterans and we are trying to 

do as much as we can. If you think that there is more we can do, 

or you—anybody is making suggestions, please let us know. 

Senator TESTER. We will do that, and thank you for that. 

One last thing. We talked about opioids. It is a huge problem, 

and we all know it is a huge problem. Within the VA, outside the 

VA, it is a problem. I know that Attorney General Sessions has 

said no more marijuana. It is going to be nowhere. Montana is one 

of those States that said it would legalize it for medical purposes. 

Look, I am not enamored with the crap—I will just tell you 

that—but the VA is a big dog, OK? 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. If marijuana helps people that have chronic 

pain, we ought to be doing research on it, and you guys do the research. 

Secretary SHULKIN. Yep. 

Senator TESTER. I know you came out with a statement that said 

no more research. 

Secretary SHULKIN. No. Actually, let me clarify that. 

Senator TESTER. Perfect. I want to hear the clarification. 

Secretary SHULKIN. OK. OK. What I said is that, first of all, VA 

has done research on marijuana—— 

Senator TESTER. Yeah. 

Secretary SHULKIN [continuing]. But it has not been dispensing 

marijuana and testing its impact. 

Senator TESTER. Yes. 

Secretary SHULKIN. It has been observational, or, let us say, for 

data analysis. 

Senator TESTER. Right. 

Secretary SHULKIN. VA can do research on marijuana, but I said 

that we are restricted, because it is a Class 1 substance, so we 

have to go through multiple agencies, and it is very challenging to 

work our way through that process. We do have the ability to do 

it. I have said I am in favor of exploring anything that will help 

our veterans and be able to relieve some of their suffering. 

So, it is challenging to get through that process. Our researchers 

are working through that process right now. If Congress made it 

easier to go through the process it would probably happen faster. 

Senator TESTER. Well, I would just tell you this. Look, I do not 

have chronic pain. I know people that do. I do not care if it is marijuana or sagebrush or thistle or cactus. I do not give a damn so 

long as it helps them. 

97 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. Especially when we are fighting the opioid crisis—— 

Secretary SHULKIN. Yes. 

Senator TESTER [continuing]. We are today, we ought to be doing 

research to make sure it is real. That is all. 

Secretary SHULKIN. I agree. 

Senator TESTER. Thank you, Mr. Chairman, for your flexibility. 

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

contribution and the contribution of all Committee Members. 

I want to wish Gretchan Blum the very best in her wishes, and 

thank you very much for what you have done for the Committee 

and our veterans. 

I thank all of you who came here today, particularly our VSO 

representatives who will be heard from at great length in February, when we have the VSO meetings, which we appreciate. 

The record will be kept open for 7 days for any Member who 

would like to include their written statement or ask questions for 

the record, or any other comments we might want to have. 

We have a long to-do list, a lot of things to do. This is a hearing 

to reflect on what we talked about and we wanted to do, the bills 

we passed to cause it to happen, and now the accountability phase, 

where, not just at this meeting, but every year we want to analyze 

where we have been and where we are going. Hopefully, we are always improving the services to our veterans, lessening, wherever 

possible, the cost to our taxpayers, but most importantly, making 

sure we pay back those who have given so much to our country, 

the veterans of the United States of America. 

With that said, is there any other business to come before the 

Committee? My staff—have I forgotten anything? 

We are good. This meeting is adjourned. Thank you. 

[Whereupon, at 3:46 p.m., the Committee was adjourned.] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 1. I have consistently said that efforts to overhaul VA’s appeals process 

must include efforts to address the over 470,000 existing appeals. In VA’s 

Comprehensive Plan for Processing Legacy Appeals and Implementing the Modernized Appeals System that was submitted to Congress in November 2017, it states 

that VA plans to allocate resources to establish ‘‘timely processing in the new system and will allocate all remaining appeals resources to address the inventory of 

legacy appeals.’’ 

a. What does ‘‘timely processing’’ mean and what are VA’s specific goals? 

Response. VA has committed to an average processing time goal of 125 days to 

complete higher-level reviews and supplemental claims under the new appeals process, and 365 days to complete appeals to the Board of Veterans’ Appeals (Board) 

in which there is no additional evidence and no request for a hearing. The Board 

is working collaboratively with the Veterans Benefits Administration (VBA), VA 

Program Management Professionals, and US Digital Service (USDS) on establishing 

timeliness goals for the remaining two dockets in the new process. VA will continue 

to gather data and conduct trend analyses on aspects of Veterans’ behavior, to include their decision to elect to participate in the new process, the distribution of 

elections among the new process lanes, claims processing timeliness, and individual 

employee productivity. The Rapid Appeals Modernization Program (RAMP) test program will provide better data and trend analysis for capacity modeling the resources 

needed for these other dockets prior to the implementation date. The Board will use 

the actual data obtained regarding appellant behavior in the new system to assist 

in developing future resource requirements as part of the annual budget process. 

98 

The 2017 Government Accountability Office report recommended that VA conduct 

additional sensitivity analyses of its forecast modeling to more accurately estimate 

future appeals inventories, timeliness, and cost factors. VA has developed a more 

robust, scalable model that allows for the recommended analysis. The model may 

serve several specific purposes, to include: 

• Estimating the legacy inventory remaining as implementation of appeals modernization approaches; • Determining the impact of the claim disagreement rate on the new system 

inventory; • Determining the distribution of resources given Veterans’ choices among new 

system lanes; • Determining the efficiency of the new process and the allocation of resources 

based on estimated employee productivity rates across the various new system decision review and appeal lanes; and • Adjusting, as needed, resources required to eliminate the legacy inventory as 

quickly as possible, while also meeting established timeliness goals in the new 

system. 

VA will continue to verify and validate the model to ensure the accuracy of its 

outputs and its utility in VA’s appeals modernization forecasting. 

Besides forecast modeling, the Board will also continue to refine and improve its 

process model to capture additional changes aimed at improving the timeliness of 

appeals under the new system. 

b. Does VA have timeliness goals for the inventory of legacy appeals? 

Response. VA tracks appeals processing goals under certain cycle measures. These 

measures track both inventory and timeliness at stages in the appeals process. As 

noted in VA’s May 2017 Annual Performance Plan and Report, among the appeals 

measures that VA tracks are the following: Notice of Disagreement (NODs) pending 

inventory, NODs average days pending, Substantive Appeals to the Board (Form 9) 

pending inventory, Substantive Appeals to the Board (Form 9) average days to complete, and Substantive Appeals to the Board (Form 9) average days pending. For 

a listing of all appeals measures, to include Board measures, that VA tracks, please 

see the full report, available at https://www.va.gov/budget/docs/VAapprFY2018.pdf. 

While VA tracks appeals processing goals under certain cycle measures, VA is unable to set a realistic and comprehensive timeliness goal that measures legacy appeals processing from the date the appeal is filed to when it is finally resolved. This 

is because appeals in the current legacy process has no defined endpoint and can 

cycle through various steps, several times, before moving to the next phase in the 

process. The current multi-step process is too inefficient; splits jurisdiction for processing appeals between the agency of original jurisdiction and the Board; and features an open record and ongoing duty to assist. As a result, the continuous evidence gathering and readjudication prolong the ability to reach a final decision. 

The rate at which the legacy appeals inventory can be resolved is dependent on 

a number of factors and variables, including funding made available to appeals 

processing through the annual budget appropriations process in future years and 

the rate of election of claimants with legacy appeals pending who opt-in to the new 

process. 

The Board is working with program management staff and Digital Service partners to develop milestones for the reduction of the legacy inventory, considering 

such dependencies as the opt-in rate from RAMP and statutory mechanisms, current 

resource levels, trends in adjudication of legacy appeals at the agencies of original 

jurisdiction, and increases in productivity resulting from the strategies discussed 

above. 

c. Does VA plan to prioritize new appeals over legacy appeals? 

Response. No. VA’s goal is to eliminate the inventory of legacy appeals as quickly 

as possible while also maintaining timely processing in the new system. The optin features, whereby Veterans with a pending legacy appeal can elect to participate 

in the new process, will assist VA in accomplishing that goal. 

The Board is working with Digital Services partners to ensure that Caseflow 

functionality includes the ability to continuously adjust the case distribution ratio 

between all Board dockets based on actual data. Adjusting the case distribution 

ratio will allow the Board to meet its 365-day average processing time goal for cases 

on the direct docket, while ensuring fair treatment of legacy appeals and appeals 

on the new system’s hearing and evidence dockets by distributing cases from the 

other dockets proportionate to the scale of each docket’s inventory. 

Question 2. VA began a Rapid Appeals Modernization Program (RAMP) to pilot 

parts of the new Appeals system and to work on the existing appeals backlog. 

a. Under RAMP, what specific parts of the new appeals process is VA testing? 

99 

Response. RAMP will assist the Department in testing a number of elements of 

the Veterans Appeals Improvement and Modernization Act of 2017 (Modernization 

Act). The initiative, which was launched on November 1, 2017, allows eligible participants with disability compensation appeals pending with VBA the voluntary option to have their decisions reviewed in the higher-level review or supplemental 

claim lanes outlined in the Modernization Act. RAMP gives Veterans early access 

to the benefits of the new system, while also allowing VA to better position itself 

for full implementation in February 2019. 

During RAMP, and with feedback from Veterans, Veterans Service Organizations 

(VSOs), and congressional stakeholders, VA is testing the new process from intake 

to issuance of a decision. This includes testing the election opt-in notice, the new 

decision notice that meets the requirements outlined in the statute, as well as internal standard operating procedures. In addition, VA is testing information technology 

solutions for managing Veterans’ opt-in elections and capturing duty to assist error 

data identified during higher-level reviews. During this program, VA will gather 

data and conduct trend analyses on aspects of Veterans’ behavior, to include their 

decision to elect to participate in the new process, the distribution of elections 

among the new process lanes, and individual employee productivity. In addition, the 

data will inform VA as to appropriate work credit, workload and resource capacity 

estimates, as well as processing timeliness and quality metrics for the new process. 

b. What lessons have been learned so far? 

Response. Although it is still too early in the process to glean any meaningful lessons learned, to date, VA has seen lower than expected opt-in rates from Veterans. 

That is in part because VA initially extended the invitation to participate in RAMP 

to Veterans who have the oldest appeals pending and may have reservations in participating in the new process. As a result, VA is currently reassessing its outreach 

and marketing campaign regarding RAMP. Also, starting in February 2018, VA will 

open up the elections to newer appeals, and will work with VSOs in reviewing processes that will allow Veterans to opt-in at a faster rate. 

c. When will this pilot program conclude? 

Response. VA plans to invite most Veterans with pending legacy appeals to participate in RAMP by February 2019 when it fully implements the Modernization 

Act. 

d. Why has VA decided to not pilot RAMP at the Board of Veterans Appeals and 

test all aspects of the system? 

Response. Currently, Veterans who receive a RAMP decision have the option of 

appealing to the Board by filing a NOD. In October 2018, the Board will begin adjudicating the first of these appeals in a phased implementation to test processes and 

technology. Implementing RAMP will allow the Board to identify and address potential issues and risks relating to implementation of the new framework. 

e. To date how many individuals with legacy appeals have opted in to RAMP? 

Response. As of May 14, 2018, 15,645 individuals, with a total of 19,208 legacy 

appeals pending, have opted to participate in RAMP. 

f. Are there any concerns that RAMP may not be an adequate solution to drive 

down the pending legacy appeal inventory? 

Response. VA believes it is too early to conclude that RAMP is not an adequate 

solution. Since the inception of RAMP, in November 2017, 15,645 individuals, with 

19,208 appeals have decided to opt in to RAMP. In addition, the earlier requirement 

that Veterans need to be ‘‘invited’’ into RAMP was removed on April 2, 2018, and 

now any eligible Veteran with a pending disability compensation appeal can choose 

to opt in to RAMP, and benefit from the faster review process. RAMP allows Veterans and appellants with pending disability compensation appeals not yet activated 

at the Board the choice for early resolution of their appeals at VBA. RAMP provides 

Veterans and appellants the choice to opt into the benefits of the new appeals 

framework and will reduce the number of appeals under the current, legacy system. 

Thus, VA is working closely with VSOs, and external stakeholders to encourage participation in RAMP. VA’s legacy reduction plan includes RAMP and initiatives to 

improve appeals production. 

g. Are there other solutions VA is looking at? 

Response. VA is working with its VSO partners in assessing ways to increase individual RAMP opt-in rates. In addition, VA is continuously evaluating ways to increase efficiencies. For instance, VBA is considering plans to consolidate processing 

of all remands at the Appeals Resource Center. The Board is completing its hiring 

plan in fiscal year (FY) 2018, seeking opportunities to enhance training and employee engagement for all staff, and working with a VA Program Management team 

and IT/Digital Service staff to re-engineer processes and implement technological 

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upgrades promoting increased decision production. The Board is already seeing positive results from our multi-faceted approach to reducing the pending legacy inventory. To date in FY 2018, the Board has signed 24,468 decisions, which is an increase of 13,073 signed decisions over the same time period in FY 2017. VA will 

consider recommendations of the Committee. 

Question 3. Under the new Appeals Act, Congress deliberately gave VA the flexibility to take the needed amount of time to get the new system right, but also gave 

the Secretary the responsibility for signing off that the new system is ready before 

it fully replaces the existing system. 

a. Although it is still early in the implementation process, does VA anticipate 

launching the new system in February 2019 or taking more time? 

Response. VA anticipates launching the new appeals system in February 2019. 

b. What specific indicators will you look for when deciding to move ahead or take 

more time? 

Response. VA will look at the following indicators when assessing its readiness 

for full implementation: 

• Status of the rulemaking: If public comments prompt extensive revisions to 

draft regulations, VA may need more time to make the revisions, gain stakeholder 

buy-in, and complete the approval process. • Lessons learned from processing of higher-level reviews and supplemental 

claims in RAMP: Should VA’s experience in RAMP indicate significant problems 

with the new processes and/or systems, VA could potentially require more time to 

resolve these issues. However, VA does not anticipate encountering any significant 

issues. 

• Status of IT systems development: If VA encounters unanticipated delays in updating IT systems to support the new appeals framework, VA may require more 

time to implement. However, at this time, VA anticipates that the updates will be 

completed on time. The Board has established timelines for development of necessary IT systems, training and hiring of personnel, and publication of regulations, 

among other dependencies. The Board is working with a VA Program Manager to 

ensure that all dependencies are on track for full implementation. In particular, the 

Board’s progress in the areas of IT systems, training, and publication of regulations 

will serve as strong indicators as to VA’s readiness to implement the new system. 

Question 4. The Accountability and Whistleblower Protection Act gave VA authority to remove unsuitable employees and authority for direct hire of some critical 

positions. 

a. What metric does VA use to determine how well it is doing at removing unsuitable employees? What are those numbers currently? 

Response. These are the two metrics that appear in the VA 2020–2024 Strategic 

Plan that will be used to measure VA compliance with the Accountability and Whistleblower Protection Act. We have not performed analysis based on these metrics. 

Performance-based action will be taken against all proven poor performers within 

90 days of substantiation of poor performance. Appropriate disciplinary or adverse 

action will be initiated against all employees within 90 days of substantiation of 

misconduct. 

b. How many employees has VA fired in 2017? How many of those were allowed 

to retire or resign? How many were terminated during an initial probationary 

period? 

Response. There were 1,582 removals between June 23 and December 31, 2017. Of 

these, 960 were removals of regular employees and 622 were terminations of probationary employees. 

c. How many employees has VA hired under its new direct hire authority for Veterans Integrated Service Networks (VISNs) and medical center directors? 

Response. In September 2017, VA hired one Medical Center Director (Shreveport, 

Louisiana) using direct hire authority. No VISN Directors were hired using the direct hire authority. 

Question 5. What direct outreach has VA done to inform school certifying officials 

about changes enacted in the Forever GI Bill? What future plans does VA have for 

direct outreach to this group? 

Response. On November 29, 2017, VA’s Education Service conducted a School Certifying Official (SCO) webinar on the Forever GI Bill and provided information on 

our progress toward implementation. The webinar also included a question and answer session in which Education Service responded to questions from SCOs. VA sent 

targeted emails to SCOs on the removal of the delimiting date for eligible beneficiaries and the expansion of approvable Independent Study programs. In early 

February 2018, Education Service held a focus group with stakeholders including 

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SCOs on its implementation plan for Section 107, and will continue to engage with 

SCOs through regularly scheduled webinars, targeted emails, state, regional, national conferences and serve as resource to SCOs as they educate students at their 

facility on the Forever GI Bill. 

Question 6. How does VA plan to fill the role of Deputy Under Secretary for Economic Opportunity in the Veterans Benefits Administration and what is your 

timeline for noticing the position and reviewing candidates? 

Response. In response to Executive Order 13781 and the Office of Management 

and Budget (OMB) Directive M–17–22, VA has a comprehensive modernization effort underway. While VA is continuing its efforts to modernize its infrastructure and 

focus resources more efficiently, we must evaluate the position and responsibilities 

of the Deputy Under Secretary for Economic Opportunity (DUSEO) in accordance 

with our modernization goals. 

VBA has a newly appointed Under Secretary for Benefits, Dr. Paul R. Lawrence. 

One of his top priorities is providing Veterans with the benefits they have earned 

in a manner that honors their service. Under his leadership, VBA is taking a comprehensive look at the layers of oversight and organizational alignment to determine 

the most effective and efficient manner to oversee the delivery of timely and accurate benefits. To ensure continuity of operations and appropriate support, the business lines that fall under the Office of Economic Opportunity are reporting directly 

to the Principal Deputy Under Secretary for Benefits. 

Question 7. Do you expect any changes to the role of the Deputy Under Secretary 

for Economic Opportunity or any significant changes to the Office of Economic 

Opportunity? 

Response. VBA is currently evaluating the role of the Deputy Under Secretaries. 

As neither the Deputy Under Secretary for Economic Opportunity or the Deputy 

Under Secretary for Disability Assistance are encumbered at this time, all business 

lines that previously reported those Deputy Under Secretaries are reporting directly 

to the Principal Deputy Under Secretary for Benefits. This allows the business line 

leaders direct access to top leadership. We will continue to assess if this type of 

oversight is sustainable long-term and make adjustments to positions and/or roles 

and responsibilities as necessary. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 8. I made it quite clear that I thought the Federal hiring freeze was a 

bad decision for the President to make, but even after that concluded, you’ve made 

the decision to continue a hiring freeze of sorts at VA. Do you still believe that is 

the right decision, and do you intend to continue it? 

Response. Consistent with OMB Memorandum M–17–22, effective April 26, 2017, 

VA removed hiring restrictions for field positions located in the Veterans Health 

Administration’s medical facilities (for medical and non-medical positions), and for 

VBA regional and field offices. The National Cemetery Administration had no 

restrictions, and that remained unchanged. Hiring restrictions were also removed 

for the following Executive level positions: Medical Center Directors; Network Directors; Cemetery Directors; and VBA Regional Office Directors. This allowed the 

Administrations to fill the positions they determined as necessary to meet mission 

requirements. 

Although the hiring freeze was lifted, the Secretary did direct that managers be 

deliberative in the hiring actions taken to ensure VA is postured for success as we 

implement overall Modernization efforts and reform plans, in accordance with OMB 

Memorandum M–17–22, that improve and ensure the more efficient and effective 

delivery of services to Veterans, while identifying opportunities to reduce duplication or overlap. To this end, VA maintains a process that requires a thorough review 

before hiring all other positions outside of those listed in the preceding paragraph. 

Hiring for all other positions in the Administrations requires the appropriate Under 

Secretary level approval. Recruitment for positions at VA’s Central Office and all 

other Executive level hiring requires approval by the VA Chief of Staff. 

Question 9. Last month, a VA official testified at HVAC that the hiring freeze 

made it difficult for VA to keep up with purchasing needed medical equipment. We 

also heard this month that the administration’s hiring freeze played a significant 

role in USDA pulling out of the agreement to support VA’s financial management 

business transformation. In addition to these instances, do you believe that veterans 

or programs serving veterans were harmed by the hiring freeze? 

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Response. As referenced in the response to Question 8, VA leaders are authorized 

to fill the positions they determine are necessary to meet mission requirements. 

While hiring managers are expected to obtain approval at the appropriate level in 

their chain of command prior to filling certain positions (non-medical/clinical positions), this should not have an adverse impact on the delivery of services to 

Veterans. 

Question 10. The latest data from VA shows that in your continuing hiring freeze, 

there are: 100 non-exempt vacancies in Human Resources, and more than 2,700 

non-exempt vacancies in VHA. 

a. How many of those VHA vacancies are within VHA’s workforce management 

or human resources office? 

Response. As referenced in the response to Question 8, VA leaders are authorized 

to fill the positions they determine are necessary to meet mission requirements. 

This includes H.R. positions across VHA. While hiring managers are expected to obtain approval at the appropriate level in their chain of command prior to filling certain positions, VHA’s Workforce Management and Consulting (WMC) Office has 

been successful in getting approval to fill critical H.R. vacancies. 

b. Do you believe addressing vacancies of positions that focus on recruitment and 

retention would help address ongoing hiring challenges? 

Response. Generally, the filling of H.R. vacancies can impact the organization’s 

ability to recruit and retain employees. It is imperative that H.R. departments have 

the necessary staffing for its organization in order to help mitigate overall hiring 

challenges. WMC has submitted its vacancies for hiring exemption waivers and they 

have been approved. As referenced in Question 8, the Under Secretary is authorized 

to approve hiring for vacant positions that are necessary to meet mission requirements. That includes vacant H.R. positions that are required to support critical hiring needs. 

Additionally, on January 24, 2018, the Office of Personnel Management approved 

VA’s request for Direct Hire Authority (DHA) for 15 occupations. H.R. Specialists 

(GS–201 series) and H.R. Assistants (GS–203 series) are included on the list occupations approved for DHA. This will assist the VA in filling these mission critical 

positions. 

Question 11. Nearly two years ago, the National Academy of Medicine released 

its final Agent Orange update, recommending three new presumptions of service 

connection for Bladder Cancer, Hyperthyroidism, and Parkinson-like conditions. I 

wrote to you in September with some colleagues and asked for a decision from VA. 

In November you released a statement stating your intent to ‘‘explore new presumptive conditions.’’ Given the length of time since the National Academy of Medicine 

released their recommendations, when can we expect these veterans to be able to 

receive the health care and compensation they earned? 

Response. Once the President’s nominee has been confirmed and sworn in as Secretary, VA will examine the current policy, complete a full review on this issue and 

provide new guidance on this issue as needed. 

Question 12. Is there a treatment protocol in place at VA for veterans with symptoms of Gulf War Illness? What is VA doing to advance their care and treatment? 

Response. VA has put considerable efforts into the diagnosis, research and treatment of Gulf War Illness (GWI) also referred to as Chronic Multi-symptom Illness. 

One of the most comprehensive documents on treatment was a joint effort by VA 

and DOD entitled: The Management of Chronic Multisymptom Illness (CMI) 2014. 

This Clinical Guideline provides comprehensive evidence based recommendations incorporating current information and practices for practitioners throughout the DOD 

and VA Health Care systems. The guideline is intended to improve patient outcomes 

and management of patients with CMI. The guideline is available at: https:// 

www.healthquality.va.gov/guidelines/MR/cmi/. 

Post-Deployment Health Services/War Related Illness and Injury Study Center 

(WRIISC) led the development of an extensive e-learning module for clinicians on 

GWI available at: https://www.train.org/main/course/1074205/. This e-learning module provides health care providers with the knowledge needed to recognize, evaluate, 

manage and treat GWI in Veterans and be able to apply the VA/DOD Clinical Practice Guideline for Chronic Multi Symptom Illness. VA also oversees the Gulf War 

Registry whereby thousands of Veterans get evaluated each year for health 

conditions. 

Recent research led by either the WRIISC and/or the Office of Research and Development, focused on the treatments of GWI, has included the topics of yoga, acupuncture, tai chi, dietary supplements such as coenzyme Q10, cognitive behavioral 

therapy, light therapy, exercise, inflammatory markers for diagnosis, and nasal continuous pressure to alleviate sleep disorders in Gulf War Veterans. 

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VA also has a Research Advisory Committee (RAC) on Gulf War Veterans’ 

Illnesses that advises VA on studies that include potential treatments. For more information, please visit https://www.va.gov/rac-gwvi/. Gulf War RAC membership includes: Academics, Researchers, Veterans, VA staff, VSOs and Scientists. For a list 

of members, please visit https://www.va.gov/RAC-GWVI/Members_and_ 

Consultants.asp. There is currently no accepted single clinical case definition for 

GWI/CMI. VA contracted with the National Academy of Medicine (NAM) to evaluate 

existing case definitions. In 2014, the NAM released a report noting it was unable 

to find a single definition. VA has developed a plan to create a single, validated case 

definition and will be initiating research this year in execution of this plan. 

Question 13. This summer, you stood with me in Montana and announced that 

you would issue new regulations to help rural communities build nursing homes for 

veterans. When will those be released? 

Response. VA is currently reviewing the proposed regulations. Upon completion 

of the review, the regulations will be published as a proposed rule, followed by a 

60-day public comment period, and a final rule that responds to public comments 

and makes the changes effective. VA anticipates the proposed rule process may take 

6 to 9 months. 

Question 14. VA has nearly 1,000 open recommendations: 772 from the OIG and 

215 from GAO. Further, VA health care has been on the GAO High Risk List for 

the past 3 years, and according to GAO, is not likely to be removed any time soon. 

a. What is your approach to addressing these open recommendations? 

Response. VA is working to implement all open Government Accountability Office 

(GAO) recommendations. Additionally, VA is working with GAO to leverage GAO 

best practices to improve the Department by the most effective and efficient means. 

VA continuously works to address deficiencies identified by GAO with an aim to 

resolve recommended actions within 3 years of report publication. 

Currently, 83 percent of VHA’s open GAO recommendations were made within 

that 3 year timeframe; 47 percent of them were made within the past 12 months. 

VHA has requested GAO consider closure on 28 percent of our open recommendations. In FY 2017 GAO closed 56 recommendations to VHA and made 46 new recommendations. 

Each Administration and Staff office within the Department is responsible for providing the status on open Office of the Inspector General (OIG) recommendations. 

The OIG process is to obtain updates every 90 days until recommendations are 

closed. Each office works with the OIG to close recommendations as quickly as 

possible. 

b. Can you assure me that VA is using a strategic approach to respond to these 

recommendations? 

Response. Yes, the Department is using a strategic approach to respond to recommendations. In FY 2017, for the first time, GAO provided all Federal Agencies with 

a list of priority recommendations. GAO identified 22 high-priority recommendations 

for VA, and the Department is working to implement them. The Office of Enterprise 

Integration considers open recommendations as they move to strategically transform 

the Department. 

Question 15. In response to a question after your confirmation hearing, you agreed 

to provide quarterly briefings to staff on the status of the Department’s open recommendations from OIG, GAO, OSC and others. When can we look forward to beginning those briefings? 

Response. VA is in the process of analyzing various trends in GAO/OIG/OSC reports and the Department looks forward to providing quarterly briefings in the 

future. 

Question 16. Do you have any data to demonstrate whether the Department’s removal actions under the new accountability law are increasing across all grades, or 

whether you’re seeing lower-level employees disproportionately affected? 

Response. The Office of Accountability and Whistleblower Protection (OAWP) does 

not have visibility on all personnel actions. OAWP’s scope for actions are the Senior 

Executive Service (SES), SES equivalents, and program managers at many levels 

that run major programs that have an impact across VA. Actions taken with lower 

grade employees are predominantly facility level actions. 

Question 17. Mr. Secretary, in September the IG released a memorandum detailing concerns with payment errors in the Choice Program. The timeframe for the review of claims was November 1, 2014, through September 30, 2016. Without yet getting into the December IG report, my very narrow question for you is—what did you 

do in response to that September memorandum? 

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Response. Through use of internal audit and assessment tools, VA had identified 

overpayments to Third Party Administrators (TPAs) through Veterans Choice Program prior to the issuance of the September 2017 OIG memo and corrective actions 

were initiated before its publication. Duplicate payments were identified to be a particular area of vulnerability and, as a result, VA’s Office of Community Care implemented an automated internal control to identify and prevent potential duplicate 

Choice payments prior to payment in the bulk payment environment. Since implementation in July 2017, over $35 million in potential duplicate overpayments have 

been prevented. 

As noted in the September 2017 memo, VA completed an extensive analysis of 

prior Choice payments made in the bulk environment in the summer of 2017 and 

identified more than $80 million dollars in potential overpayments. This information 

was shared with the Choice TPAs and VA OIG. VA continues to work closely with 

the VA OIG, VA OGC, and other government stakeholders to ensure that overpayments through the Choice program are identified and recovered. 

Question 18. In December, a more exhaustive report was released by the IG expanding on its earlier memorandum. My question for you is: where are we today? 

If the IG’s office were to knock on your door today—would it find the same 

problems? 

Response. The December 2017 OIG audit report focused on claims processing 

using the Fee Basis Claims System (FBCS), a highly manual claims processing system that is no longer utilized to process Choice claims. The process that followed, 

known as bulk payments, involved payments to TPAs in bulk form and was implemented to address delays in payments to TPAs and maintain critical provider networks in the Choice program. It was understood that this process would require 

post-payment reviews and, as noted in response to Question 17, VA has since implemented a process for preventing potential duplicate payments prior to payment and 

has conducted, and will continue to conduct, post-payment analyses to identify overpayments. 

Starting in February 2017, VA’s Financial Services Center (FSC) began processing 

Choice claims and utilize an automated payment system to conduct pre and postpayment analyses and to pay TPAs timely, reducing the burden of manual work 

that previously was required using the FBCS system. As of December 2017, more 

than 99 percent of clean claims received by the FSC were paid within 30 days of 

receipt. 

As noted in response to Question 17, VA continues to closely collaborate with the 

VA OIG, VA OGC, and other government stakeholders to ensure that overpayments 

made through the Choice program are identified and recovered. 

Looking forward, VA has incorporated many lessons learned from the Choice Program into its Community Care Network request for proposal (RFP) and future contracts will include stringent requirements for timeliness and accuracy of claims payments by TPAs. In parallel, VA will continue to strengthen its internal abilities to 

improve accuracy of payments and detect and prevent fraud, waste, and abuse 

(FWA). VA’s Office of Community Care is currently working collaboratively with 

other government agencies including CMS and the Department of Treasury on joint 

initiatives to reduce FWA. In addition, a Federal Advisory Committee consisting of 

national experts in FWA detection and prevention is advising VA and VA’s Office 

of Community Care is working closely with this Committee to identify further opportunities to reduce FWA in VA’s Community Care Programs. 

Question 19. I am pleased to see that after much prodding from Congress the Department has finally decided to more aggressively address delayed payments to community providers. What took so long for VA to become more aggressive on this 

issue? What are the changes community providers can expect? 

Response. VA has been proceeding with individual solutions to address individual 

provider needs as our teams become aware. We believe that this more comprehensive approach is needed to ensure that VA is committed to resolving the provider 

payment issues. VA is taking the following multi-pronged approach to resolve these 

issues: 

First, VA is optimizing staffing levels and labor mix to increase claims output and 

enhancing Contact Center capabilities. Customer service functions performed by the 

claims processors will be transitioned to the Contact Center over the next year. This 

will allow additional claims to be processed as the staff transition. The Contact Center will also utilize email to increase the number of inquiries they can field from 

providers 

Focus on provider education on Vendor Inquiry System, which allows providers 

direct access to claims status via a website. 

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Second, VA is increasing workload of claims processing vendors and dedicating 

teams to resolving outstanding claims with major providers. VA is shifting more 

claims to vendors over the next several months. The target is to increase to 840,000 

per month by March 2018. This represents about 40 percent of incoming claims volume. VA has also created rapid response teams to develop tailored resolutions working with the top 20 providers. Outreach has begun with a target of resolving outstanding issues by April 3, 2018. After this effort is completed, the teams will move 

onto other providers. 

The third prong is to continue to make implement IT solutions to improve productivity. Existing claims processing systems has two enhancements to reduce manual 

processing that will be implemented by September 2018. We are also implementing 

a process to convert paper claims to electronic, reducing manual entry of claims. In 

addition, a new claims processing system will be in use at the end of 2019. 

Question 20. We’ve received a lot of enthusiastic feedback from veterans about the 

Edith Norse Rogers STEM scholarship, which provides additional GI Bill benefits 

to students in programs of study that are STEM or a field which the Secretary has 

identified as a national need. Despite this enthusiasm we have not yet received any 

feedback on how this benefit will be implemented, or how the Department will use 

this new authority to identify fields of study which are a national need. When can 

we expect to see VA’s implementation plan for the Edith Norse Rogers STEM 

Scholarship? 

Response. VA is analyzing statutory requirements to develop planning documents 

for the STEM scholarship, which does not go into effect until August 1, 2019. The 

requirements for this provision do not conform to VA’s current technology and business rules for the Post-9/11 GI Bill; therefore, VA has identified the VA Regional 

Processing Office in Buffalo, NY, as the sole site dedicated to processing and tracking the STEM Scholarship. VA expects a more fully developed plan with regulatory, 

communication and program requirements to be drafted by December 2018. 

Question 21. The Forever GI Bill appropriates $30 million to the secretary for 

changes and improvements to the information technology systems used to administer veterans education benefits. Please provide us with a description of the IT requirements that VA has to improve their IT systems and a detailed spending plan 

for that $30 million? 

Response. Section 115 of the Colmery Act authorizes $30 million specifically for 

the automation of the remaining supplemental claims and original claims processing. To date, no funding has been appropriated. Notwithstanding the absence of 

resources, the Office of Information Technology (OIT) in coordination with Education Service has committed to address those provisions of the Act that are most 

critical. Those include Sections 107, 501 and 112. This work is being absorbed into 

ongoing education systems modernization effort focused on the retirement of the 

Benefits Delivery Network (BDN) that was already underway. 

Additionally, VBA’s Education Service and OIT are partnering to explore managed services opportunities to deliver all education benefits. We are targeting FY 

2019 (after the BDN decommissioning is largely complete) for a potential managed 

services implementation. 

If this approach is successful, we should be able to integrate the remaining Forever GI Bill provisions needing an IT solution into Education IT systems in FY 2019 

through managed services. If a managed services solution is deemed not feasible we 

will employ a traditional development approach, subject to the availability of 

funding. 

In summary, this approach, achieved through VBA/OIT partnership ensures that 

all Forever GI Bill provisions are implemented on time for Veterans, while enabling 

VA/OIT to best position the supporting IT environment for the future. 

Question 22. State Approving Agencies provide the on the ground workforce that 

ensures VA education benefits are being used on quality programs of study. The 

Forever GI Bill appropriated an additional $3 million to be provided to the State 

Approving Agencies for fiscal year 2019 and another $2 million for each fiscal year 

after that. Can you provide details for the Committee on how you plan to work with 

the SAAs to divide that money amongst each state? Will you ensure that states 

which currently only receive enough funding to hire one full time employee will be 

prioritized to ensure that no state is left with funding for ‘‘1.5’’ full time employees? 

Response. The Forever GI Bill authorized an additional $2 million for FY 2018 

for State Approving Agencies (SAA) funding, which increased the funding from $19 

million to $21 million. An additional $2 million will be authorized in FY 2019, increasing the total funding from $21 million to $23 million and allowing for a cost 

of living allowance increase. 

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Currently, VA is using an engineered model that distributes the SAA funding 

based on workload, training, size and type of schools, and approval and compliance 

requirements. VA will continue to work with the Contract Committee of the National Association of State Approving Agencies (NASAA) regarding the SAA allocation model and formulas. VA anticipates a thorough review of the allocation model 

prior to FY 2019, with potential contractor analysis, to ensure appropriate and equitable funding distribution. 

The current allocation model determines the individual SAA funding based on the workload required and distributes the overall funding (currently $21 million) based 

on the number of full-time employees (FTE) needed to perform the work. The model 

may determine that a state requires two FTE, and allocates $200,000 toward the 

staffing costs. However, due to fluctuations in state salaries and benefits packages 

that amount may be sufficient in one state to hire three FTEs; in another state, two 

FTEs; and in another state, one FTE. VA does not dictate to an SAA how they must 

utilize the funding provided; the SSA determines how many FTEs they can hire 

with the funding provided. 

Question 23. VA provided committee staff information on the number of students 

who applied to have their benefits restored in the wake of the ITT closure. VA stated that they received 441 applications, and have restored benefits for 302 students. 

441 students responding when over 12,000 veterans attended ITT in the 2016–2017 

school year alone is not a good response rate. What outreach is VA using to reach 

impacted students? What are examples of outreach they’ve done to reach them? And 

finally, why have 140 veterans applied but not had their benefits restored? 

Response. During the week of November 9, 2017, VA provided notification to 8,000 

students identified as potentially eligible to have benefits restored under the Special 

Application provision of Section 109. Of those, approximately 80 percent received an 

email with a letter, instructions, and a form to apply for restoration. The remaining 

20 percent received the same documentation via postal mail. As of January 26, 2018, 

VA has received over 700 applications and restored over 4500 months of entitlement 

to almost 450 individuals. 

To reach the population of students impacted by this closure, VA announced 

through its social media outlets instructions for restoring entitlement, established 

a new webpage with additional information (https://benefits.va.gov/gibill/fgib/ 

restoration.asp), and issued three email missives to over 1.2 million individuals VA 

is committed to restoring benefits to all eligible Veterans and will continue to promote and encourage Veterans to apply for restoration through all available outlets 

including Facebook and Twitter. VA plans a 90-day follow-up communications effort. 

VA was not able to restore benefits for all Veterans who applied as they did not 

meet the criteria for restoration. In most instances, it was because the beneficiary 

was not enrolled in the closed school within 120 days of its closure, or the beneficiary transferred credits to a comparable program at a new school thereby making 

them ineligible for restored benefits. 

Question 24. In a question taken for the record from your confirmation hearing 

you committed to reporting back to this Committee within three months with your 

recommendation for practical and realistic steps VA can take to ensure student veterans are protected from predatory and deceptive practices and given the information they need to make an informed choice about their college. What is the status 

of your report to the Committee? 

Response. VA was asked to report on the steps used to actively prevent and detect 

the utilization of predatory and deceptive practices by institutions approved for GI 

Bill benefits. VA now completes a three-step process to identify and remove predatory and deceptive practices and ensure student Veterans are given the information 

they need to make an informed choice about their college: 

1. Program Approval: VA has been collaborating with SAAs to ensure that advertising and recruiting materials are thoroughly vetted for accuracy during the approval process. The SAA and VA complete initial training and follow up training 

with the school officials and provide continuous updates to ensure new laws and 

policies are implemented timely for school enrollment certifications. Furthermore, 

the VA and SAAs monitor and provide guidance as school’s update or change their 

academic programs. 

2. Online Resources: VA has updated information, functionality, and options to 

the GI Bill Comparison Tool (i.e., new types of ‘‘caution flags,’’ to alert prospective 

students about judgments, settlements, and lawsuits regarding such prohibited 

practices) to ensure Veterans make informed choices about their benefits. In addition, VA continues to use the GI Bill Feedback System to receive student feedback 

about schools and to identify trends and risk indicators of ‘‘bad actor’’ schools to trigger targeted, Risk-Based Reviews. Finally, VA offers an online tutorial called ChoosVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00110 Fmt 6633 Sfmt 6621 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
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ing the Right School that educates users on the steps to take to make sure they 

find a school that is the right fit. The tutorial provides resources to gauge and 

evaluate interests, pay scales, accreditation, and Veteran support. 

3. Compliance Surveys: VA and SAAs conduct, on average, more than 5,000 compliance reviews per year, which includes examination of a school’s advertising and 

recruiting materials. VBA’s Education Service and NASAA recently established a 

Risk-Based Review Workgroup comprised of VA and SAA staff to analyze and implement policy change and to provide guidance regarding SAA coordination and completion of Risk-Based Reviews, all aimed at preventing fraudulent and misleading 

practices. 

VA does not expect to complete a report at this time. 

Question 25. HUD recently reported an increase in homeless veterans last year 

and this month HUD will conduct a Point-in-Time count of homeless veterans across 

the country. Likewise, the number of homeless female veterans increased last year 

by 7 percent. A survey conducted by the National Coalition for Homeless Veterans 

found that women veterans are likely to access services from mainstream resources, 

instead of VA-funded assistance resources. How are you going to specifically reach 

out to women veterans at risk of, or currently experiencing, homelessness? 

Response. Local services and resource gaps may vary from site to site. However, 

with the recent development and dissemination of VA policy outlining specific expectations of VA medical centers (VAMCs) regarding their participation in local coordinated entry systems, VA homeless programs are required to coordinate with local 

community providers. Such coordination is to conduct enhanced outreach efforts, as 

well as facilitate VA services for female Veterans, regardless of where they first 

seek services in that community. The outreach activities, which will be coordinated 

with community partners, will be conducted at programs, community centers, and 

specifically VAMCs as well as other sites not typically identified as ‘homeless service 

provider facilities. With the VAMC full participation in coordinated entry in each 

community, our efforts will broaden engagement of homeless women Veterans, or 

those at-risk for homelessness with VA homeless services. 

Question 26. Dr. Shulkin, the Nation and veterans are waiting eagerly for VA to 

sign the EHR contract and begin the 8-year process to fully deploy the new EHR. 

So, it’s been 7 months since your announcement, and a month since the procurement pause because of VA’s confusion about the contract’s interoperability language. 

Can you confirm whether your self-imposed December delay will lead to any price 

increase? 

Response. VA signed a contract with Cerner on May 17, 2018, to modernize VA’s 

legacy electronic health record (EHR) systems. The Department is balancing the implementation timeline of the new EHR with potential risks to cost, schedule, and 

performance minimizing potential impacts to Veterans care. VA is also working 

closely with DOD to ensure alignment with best practices from their commercial 

EHR implementation. 

Question 27. Do you have the technical experts on-board to manage the implementation of the contract? 

Response. The terms and conditions of the 10-year Cerner contract with VA calls 

for the delivery of all services and capabilities necessary to successfully replace the 

disparate VistA EHR systems across the entire VA enterprise over a 9-year and 6- 

month deployment/implementation period. To ensure the field is represented and involved in the management of the implementation, VHA is supporting the Electronic 

Health Record Modernization (EHRM) by providing experts to develop new workflow 

processes and using staff from the Office of Chief Medical Officer. It is critical that 

we have engagement from frontline staff (e.g. medical clinicians) in this process to 

ensure successful implementation. 

As an important cost control measure during the transition from the VistA-based 

EHR solution to the Cerner product, VA will utilize personnel transitioning from the 

legacy systems to train with, augment, and then ultimately replace many of the 

Cerner contracted employees. We believe this methodology enhances our integration 

posture and stability of our workforce, which in turn enriches our overall change 

management efforts. This transition will be a well-coordinated, documented, controlled, and approved transition process with a clear understanding that the quality 

of care to our Veterans must not be compromised. It is anticipated these personnel 

would be transitioned in the out-years (years 6 through 10). 

VA is providing industry competitive compensation to attract highly trained technical experts in the EHRM Program Management Office (PMO), charged with providing oversight of Cerner contract. PMO employs highly trained Government and 

Contractor personnel to provide this expert oversight in a myriad of professional disciplines including: clinical, technical, engineering, information assurance, security, 

108 

testing, acquisition, contracting, data migration, communication, independent validation and verification, training, change management, governance and many more. 

Together, these technical disciplines will manage the contract’s adherence to cost, 

schedule, and performance objectives, and the corresponding management of associated project risks. 

Additionally, functional and technology leads, and necessary support staffs, were 

assigned by DOD at the inception of contract negotiations to foster inclusion of the 

requisite lessons learned throughout the VA contract negotiation process and will 

continue post-contract award throughout EHR deployment/implementation. 

Question 28. I think I speak for all of us in saying that we look forward to you 

providing us more information on what the recent Executive Order on mental health 

will mean for veterans in the long run. There are news reports saying that VA will 

enroll all veterans for a year. We also understand from press reports this effort will 

require hundreds of millions of dollars. 

a. Please provide information about how you are planning to handle the strain 

on staff and your budget? 

Response. VA estimates as much as $100 million from VA’s existing budget will 

be used to support implementation of the Executive Order (EO), by realigning funds 

to support suicide prevention as one VA’s core priorities. 

b. What initiatives will you NOT be able to complete due to reallocation of dollars 

to this new effort? 

Response. VHA is not setting aside any current initiatives in attaining the full 

implementation of the EO. 

Question 29. We are concerned about the risks faced by veterans who received bad 

paper, many of whom received those discharges as a result of conduct resulting from 

injuries they sustained in service. With regard to the EO, what is the justification 

for excluding them from this year of care? 

Response. Currently, in some situations, VHA is bared by statute from providing 

care, beyond emergency services/stabilization. With respect to character of discharge, a transitioning Servicemember generally is not eligible for VA benefits, to 

include mental health care, if he or she is subject to a bar to benefits. Individuals 

bared from receiving benefits include those who, unless considered insane, were discharged or released as a conscientious objector or deserter, by reason of general 

court-martial, or as a result of AWOL for a certain period unless exempted. See 38 

U.S.C. 5303(a), 38 C.F.R. 3.12(c). If bared, VA may refer the individual to community resources (not at VA’s expense). For an individual ineligible for readjustment 

counseling under 38 U.S.C. 1712A, VA provides referral services to assist the individual in obtaining mental health care and services outside VA, and if pertinent, 

advises the individual of his/her right to apply for a review of the individual’s discharge or release. See 38 U.S.C.1712A(c). 

Question 30. The VA Choice and Quality Employment Act required VA to establish a database that lists vacancies for critical, difficult-to-fill, and mental health positions at VA. 

a. What is the current status on implementing that system? 

Response. VA has H.R. SMART, the VA’s personnel data system, to track vacancies for critical, difficult-to-fill, and mental health positions at VA. We have also engaged in a VA-wide effort to validate the data in the system. In February 2018, VA 

completed the Position Vacancy Reconciliation Project, an extensive cleansing of vacant position data in H.R. SMART. As a result, VA now has the ability to identify 

vacancies for mission critical, including mental health, positions. 

b. Does the system ensure that folks who were qualified for, but were not offered, 

a position are considered for other positions at VA? 

Response. The system leverages USAJobs and USAStaffing in order to generate 

a list of qualified candidates for positions. If a candidate is qualified, but was not 

offered a position, the system does not automatically allow the applicant to be considered for other positions at VA. We are working with the Office of Personnel Management (OPM) on system enhancements to USAStaffing to further improve/streamline this process. 

Question 31. Please provide a list of the 15 occupations that the Department has 

submitted to OPM for consideration for use of the direct hire authority. 

VA Response: 

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15 Occupations included in VA’s Request for Direct Hire Authority 

Position Title Occupational Series and Grade(s) Geographic 

Location 

Accountant* GS-0510-9/11/12/13/14/15 Nationwide 

Biomedical Equipment Support Specialist GS-1601-9/11/12 Nationwide 

Boiler Plant Operator WG-5402-9/10/11/12 Nationwide 

General Engineer GS-0801-5/7/9/11/12/13 Nationwide 

Health Science Specialist (Veterans Crisis Line) GS-0101-5/7/9/11/12 Nationwide 

Health Technician GS-0640-4/5/6/7 Nationwide 

Histopathology Technician GS-0646-5/6/7/8/9 Nationwide 

Human Resources Assistant GS-0203-5/6/7 Nationwide 

Human Resources Specialist GS-0201-7/9/11 Nationwide 

Information Technology Specialist** GS-2210-7/9/11/12/13/14/15 Nationwide 

Personnel Security Specialist GS-0080-7/9/11/12/13 Nationwide 

Police Officer GS-0083-5/7/9/11/12/13 Nationwide 

Realty Specialist GS-1170-9/11/12/13/14 Nationwide 

Utility Systems Operator WG-5406-8/9/10/11 Nationwide 

Utility Systems Repair WG-4742-9/10/11 Nationwide 

* Accountant Specialty Areas—General, Accounting Officer, Cost, Staff, and System. 

** Information Technology Specialty Areas—Network Services, Enterprise Architecture, Data Management, Systems Administration, Operating Systems, Application Software, Systems Analysis, Customer Support, Internet, Policy and Planning, 

and Project Management. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JERRY MORAN TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Dr. Shulkin, the Committee and I need clarity on one of your answers provided 

in the hearing January 17, 2018. When asked whether eligibility criteria to determine if a veteran can receive care in their community ought to be explicitly linked 

to the access standards, you stated, ‘‘of course I believe that eligibility criteria 

should be explicitly linked to access standards.’’ However, you present a different 

and conflicting position with the follow-on statement, ‘‘I support the access standards that are in the bill that the Senate committee passed 14–1.’’ 

As you know, the bill that the Senate committee passed (S. 2193) would establish 

access ‘‘guidelines’’ versus ‘‘standards,’’ which is different than your support for access standards. In addition, the bill passed by the Committee would ‘‘establish localized benchmarking guidelines that can inform provider and veteran clinical 

decisionmaking.’’ 

Question 32. Do you believe ‘‘benchmarking guidelines that can inform provider 

and veteran clinical decisionmaking’’ constitutes a requirement for providers to use 

such guidelines to determine if a veteran can receive care in their community? 

Response. Benchmarking guidelines do not constitute a requirement that providers must use. Future VA policy will require providers to refer to the guidelines, 

but as part of one of many pieces of information that will be used to make clinical 

decisions (unless otherwise stated). 

Question 33. How will you oversee the community care program with guidelines 

that ‘‘can inform’’ decisions but does not guarantee the guidelines will be used? 

Response. VA will provide criteria for eligibility, and guidelines to inform decisionmaking by both VA medical facilities and providers. VA will closely monitor utilization patterns of community care as well as wait times and access standards at VA 

medical facilities to provide proper oversight. 

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Question 34. How will you prevent inconsistent experiences for veterans without 

strong, data driven standards that are required to be used by providers when determining if a veteran receives care in the community? 

Response. We believe there is even more we can do for our Veterans, through internal VA policies and guidelines, such as: 

• Provide increased transparency to Veterans regarding eligibility, access, and 

quality guidelines, through both the Federal Register and public websites. 

• Provide clarity to Veterans around how they can start the process of pursuing 

community care as well as explain the appeals process. 

• Provide additional eligibility triggers for certain types of care (urgent care, routine x-rays) as long as they are clinically necessary. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. DEAN HELLER TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 35. A few months ago, a Nevadan came into my office from a military 

aviators group known as the River Rats. Over the years, many of these fighter pilots 

have been diagnosed with varying forms of cancer. 

They have begun studying the high rate of cancer in fighter pilots, potentially due 

to toxic exposure. 

We know that toxic exposure severely impacts our veterans and can harm their 

children and grandchildren. The U.S. has a responsibility to investigate these issues 

and determine whether there is a link between their service and these diseases. 

This issue needs to be looked at by the VA and the appropriate health agency. 

How will you make that happen? What is the process for veterans to address concerns about exposure and its connection to cancer? 

Response. Veterans who have concerns about potential toxic exposures during 

service and the possible connection to development of cancer are advised to speak 

with their primary care provider. They may also contact and the Environmental 

Health Clinician and Coordinator at their local VAMC. The Environmental Health 

Coordinators can help make the connection to care; the state by state index with 

contact information for Coordinators is found at https://www.publichealth.va.gov/ 

exposures/coordinators.asp. 

However, for many Veterans, particularly those of the Vietnam and the Persian 

Gulf Wars, it appears that reliable occupational and environmental health surveillance data just do not exist. To the extent that such data are available, DOD shares 

them with VA as needed. DOD has much better surveillance data available for more 

recent conflicts and events. 

A major emphasis of the DOD/VA Deployment Health Work Group (DHWG) is on 

Servicemembers with military environmental exposures. DHWG also coordinates 

initiatives related to Veterans of all eras. Joint efforts continue to increase sharing 

of health surveillance information and review of relevant literature on hazardous 

environmental exposures. DHWG analyzes complex clinical medicine, toxicology, 

and policy aspects to develop synchronized DOD and VA actions. DHWG provides 

ongoing oversight of the development of the Individual Longitudinal Exposure 

Record (ILER) project. The goal of ILER is to create a complete record of every Servicemember’s occupational and environmental exposures over the course of their career. ILER will mine several existing DOD data systems that contain in-garrison 

and deployment exposure-related information. It will link career, location, and year 

with exposure data and will be available to DOD and VA health care providers to 

help inform diagnosis and treatment, and to VBA claims adjudicators to help establish service connection. 

In addition, VA conducts ongoing surveillance of VA health care utilization 

through systematic reviews and investigation of diseases treated. This surveillance 

drives in-depth investigation of areas of special concern. These studies enable VA 

to identify potential adverse health effects associated with deployment, including 

cancer, and follow them over time. 

With regard to the health of descendants, VA has contracted with the National 

Academy of Medicine (NAM) to assess areas requiring further scientific study on the 

descendants of Veterans with toxic exposures. Formally the Committee is charged 

with producing the report titled ‘‘Gulf War and Health, volume 11.’’ The NAM committee will further assess the scope and methodology required to conduct research 

on such descendants to identify current or possible health effects in the Veterans’ 

descendants. The resulting plan and recommendations should help to identify for 

VA the way forward to best address the issue of intergenerational concerns. The 

NAM report is expected to be completed by early 2019. 

111 

Additionally, VA has an additional contract with NAM, whose committee is studying a broad range of conditions that Agent Orange might have affected the health 

of Veterans. NAM’s report is due to VA by January 2019. The Committee’s charge 

includes looking at descendant health and in particular, the Committee was asked 

to pay special attention to the potential risk of parental transmission of disease conditions to descendants. 

Question 36. Under the new Rapid Appeals Modernization Program (RAMP), what 

are the criteria used by VA to determine which veterans will receive an ‘‘invitation’’ 

to participate in this quicker appeals process? 

Response. Eligible Veterans have a pending compensation appeal in one of the following stages of the legacy appeals process: 

• Notice of Disagreement; 

• Substantive appeal to the Board (Form 9); 

• Certified to the Board (not activated); and 

• Remand from the Board. 

While VA had initially provided the invitations to appellants with the oldest appeals pending in these stages, as VA has received some initial data from RAMP 

elections, it has begun to test various assumptions on Veteran behavior. As of February 2018, VA continued to mail invitations to the oldest appellants in each of the 

stages identified above, but also sent approximately 12,000 invitations to Veterans 

with newly established appeals. This allows VA to test the assumption whether the 

age and stage of a pending appeal impacts the election rate. 

a. How many Nevada veterans have been invited to participate? 

Response. As of May 15, 2018, VA has mailed 1,239 invitations to Veterans with 

an appeal pending under the jurisdiction of the Reno Regional Office. Of that number, 109 Veterans have opted into the program. Additionally, the earlier requirement that Veterans need to be ‘‘invited’’ into RAMP was removed on April 2, 2018, 

and now any Veteran with an eligible pending disability compensation appeal can 

choose to opt in to RAMP, and benefit from the faster review process. As of May 15, 

2018, VA has identified 2,479 Nevada Veterans that are eligible to opt into RAMP. 

b. Will you start expanding this program to ensure veterans from Nevada have 

the option to participate? 

Response. The earlier requirement that Veterans need to be ‘‘invited’’ into RAMP 

was removed on April 2, 2018, and now any Veteran with an eligible pending disability compensation appeal can choose to opt in to RAMP, and benefit from the 

faster review process. 

c. Under the new program, how long has it taken to decide an appeal on average? 

Response. As of May 15, 2018, VA processed higher-level reviews in an average 

of 69.1 days and supplemental claims in an average of 53.9 days. VA’s response pertains to all RAMP completed claims as of May 15, 2018, and is not specific to Nevada residents. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BILL CASSIDY TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 37. On January 18th the National Governor’s Association noted its recommendations on how the Nation can address the opioid crisis. The National Governor’s Association recommended the need to ensure that electronic health records 

and state prescriptions drug monitoring programs are interoperable. Is VA committed to ensuring that this will be a component in VA’s future solutions to interoperability? 

Response. VA is committed to finding better ways to manage pain in Veterans, 

while limiting the risk of long-term opioid therapies. VA pharmacy currently participates in State Prescription Monitoring Data bases by transmitting (sharing/sending) 

data on controlled substance prescriptions dispensed from VA pharmacies as indicated by several legislative requirements, most recently Public Law No: 115–86. 

This data originates from our current EHR, or more specifically, the VistA Outpatient Pharmacy application package. The requirement to share data, similar to 

any network of pharmacies, remains in place regardless of the pharmacy system 

being used to process and dispense these prescriptions. The technical requirements 

for VA’s future EHRM Platform will be interoperable with State Prescription Monitoring Programs. 

112 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. THOM TILLIS TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

FOREVER GI BILL IMPLEMENTATION

Question 38. Mr. Secretary, most of us here understand the critical role that State 

Approving Agencies (SAA) play in protecting and enhancing Veterans’ education 

benefits. I understand that the GAO is presently conducting a study into the role 

of SAAs and how the VA partners with them to protect veterans. Can you share 

with us your ideas and plans pertaining to SAAs, particularly in regard to their 

funding level and their role in the oversight of institutions through conducting risk 

based surveys, as mandated and updated by the Colmery Act? 

Response. Strong oversight by SAAs helps protect Veterans in several ways. First, 

oversight ensures that the approved programs continue to meet all the statutory criteria in 38 U.S.C. Chapter 36, as well as any individual state requirements the 

SAAs used in their assessment to initially approve a course for Veteran’s training. 

Second, SAAs are familiar with the responsibilities of SCOs. SCOs are responsible 

for certifying students’ enrollments to VA, to ensure proper payment to individuals 

in receipt of VA benefits. Through oversight, SAAs can identify out-of-line situations 

that require additional training that VA or SAAs can provide; ensuring VA students 

are certified properly for payment, are in courses necessary for completion of their 

program, and that appropriate credit has been granted for their prior training. In 

this oversight review, the SAA may identify violations that could result in disapproval of programs. 

Finally, using information VA obtains from students through VA’s GI Bill complaint system, SAAs can conduct an immediate risk-based unscheduled visit to the 

school to resolve issues, or to determine if there are violations that require disapproval of the program or suspension of enrollment. The following are areas of 

focus in the complaint system: 

Recruiting/Marketing Practices Quality of Education 

Accreditation Grade Policy 

Financial Issues (e.g. Tuition/Fee charges Release of transcripts 

Student Loans Transfer of Credits 

Post-Graduation Job Opportunities Refund Issues 

Change in Degree Plan/Requirements Other (as identified by student) 

Prior to the Colmery Act, as part of VA’s strong partnership with SAAs in our 

mutual oversight and compliance responsibilities, SAAs conducted approximately 30 

percent of the targeted risk-based compliance reviews at schools where special risk 

indicators were discovered. These mutual efforts help ensure schools are held accountable and VA students are in proper programs for their educational objective, 

and are receiving proper payments. 

Regarding funding please see the response to Question 22 above. 

PROCUREMENT

Question 39. How is clinical input from VHA incorporated in the contracting and 

procurement processes for healthcare acquisitions? Do you see areas in VA procurement where that input is particularly useful yet not fully incorporated? 

Response. The VHA Procurement and Logistics Office (P&LO) involves clinician 

subject matter experts throughout the acquisition process, from inception through 

award and performance monitoring. Clinicians are Integrated Project Team (IPT) cochairs together with assigned Project Managers as requirements are developed. Clinicians remain fully engaged through technical product reviews to determine whether or not the vendor’s proposal truly meets their requirements. 

VHA has initiated a process for Clinician Driven Strategic Sourcing (CDSS) that 

further codifies the clinical role in sourcing commodities, equipment and services. 

CDSS, once fully realized, will involve physicians and other clinicians in the strategic sourcing process to improve quality, outcomes and cost. These improvements 

will support identification of high quality preferred items, and reduce variation in 

products and clinical protocols. The CDSS program also facilitates better pricing, 

and streamlines the procurement and delivery of clinical equipment, and medical/ 

surgical supplies and services throughout VHA. VHA’s Clinical Program Offices will 

113 

validate the requirements for their clinical specialties, and take the lead in managing the catalog of items and services available to their colleagues. 

Question 40. Is VA currently exploring ways to increase transparency, define the 

term ‘‘best value,’’ and eliminate contracting and administrative delays for healthcare acquisitions, notably high tech medical equipment? 

Response. VA continues to develop methods to increase transparency to industry. 

For each consolidation, VA develops milestones with planned execution dates, dependent on the number of requirements included in each consolidation, and provides 

these milestones to industry via public posting to the Federal Business Opportunities website. Although these dates are estimates and are subject to change, VA 

strives to meet all milestones. When necessary, VA provides updated milestones to 

reflect any changes, to keep industry informed on where VA is in the procurement 

process. VA has developed standard evaluation factors for High Tech Medical Equipment (HTME) requirements including 1) Availability of Features (Technical and 

Functional), 2) Availability of Service, 3) Past Performance, and 4) Price, with all 

non-price factors when combined being significantly more important than price. By 

assigning significantly more weight to the non-price factors, VA ensures we can 

achieve the best technical solution via tradeoff in order to meet the needs of the 

customer. The contracting office is consistently striving to improve contracting processes, train personnel, and engage in open dialog with industry in order to minimize 

administrative delays, provide clarity on VA requirements, and maximize efficiency 

in the HTME procurement process. 

Question 41. How does the Department interpret the Kingdomware decision when 

considering whether or not to exercise option years in contracts that predate the Supreme Court decision? How is this information disseminated to local contracting officers to ensure consistency throughout VA? 

Response. VA has department-level policy, procedures, guidance, and instruction 

regarding the Veterans First Contracting Program. Policy as it relates to Exercising 

Contract Options is as follows: • A single award contract is considered non-competitive. Therefore, the Rule of 

Two does not apply. 

• Prior to exercising an option on existing multiple award Indefinite Delivery Indefinite Quantity contracts, the Contracting Officer (CO) will determine if there are 

two or more verified Veteran-Owned Small Businesses (VOSB) awardees on the contract. If there are 2 or more, the options for the verified Service-Disabled VeteranOwned Small Business (SDVOSB)/VOSB contracts will be exercised, if appropriate. 

If the number of SDVOSBs/VOSBs is not sufficient to meet the needs of the agency, 

the CO will apply the Rule of Two to identify other SDVOSBs/VOSBs. If no additional SDVOSBs/VOSBs exist, the options for the other contracts may be exercised 

if it is in the best interest of the agency to do so. 

All contracting personnel were required to attend the 38 U.S.C. 8127 implementation training. In addition, guidance on options was provided during the Acquisition 

Workforce Innovation Symposium in November 2016 and March 2017. Finally, a refresher webinar was held in December 2016 specifically for supervisors which also 

addressed options during this training session. 

ELECTRONIC HEALTH RECORD (EHR)

In the context of the ‘‘strategic pause’’ in awarding the EHR contract to study 

interoperability. 

Question 42. Do you view interoperability among and between VA facilities to be 

the chief objective? What about interoperability with DOD? What about interoperability with the Community Care Network? 

Response. VA will employ a multi-pronged strategy to achieve interoperability 

within VA, between VA and DOD, and amongst our contracted community care providers, and will leverage a technical solution that supports nationwide interoperability and enables data to be shared amongst healthcare facilities and providers. 

More specifically our approach consists of four stages that run in parallel: 

1. VA to VA Interoperability; 

2. VA to DOD Interoperability; 

3. Community Care Partner Interoperability; and 

4. National Interoperability. 

The EHRM Program Executive Office (PEO) is focused on and accomplishing 1– 

3, and a portion of 4. Therefore, (1) VA to VA Interoperability and (2) VA to DOD 

Interoperability are completely solved through EHRM and served as the basis for 

Seamless Care to the Veteran. (3) VA to Community Care Partners is provided by 

EHRM and works off the first two objectives so VA can provide Seamless Care for 

114 

the Veteran. VA currently plans on completing the remaining portions of (4) with 

its upcoming Digital Veteran’s Platform (DVP), where we expect participation of 

other commercial EHR providers (i.e., Epic, Allscripts, etc.) to contribute to the development of a national health information exchange platform and related Application Programming Interface (API) gateways in support of interoperability across the 

entire healthcare information exchange continuum. The adoption of open standards 

for information exchange such as SMART on FHIR (Fast Healthcare Interoperability Resource) framework by all EHR providers will be a key to national success. 

Aggressive interoperability-based terms and conditions will be included in any contract with Cerner to lead the advancement of this national interoperability objective 

as well as to align fully with the DVP and its respective API gateway requirements. 

Although the focus of VA’s EHRM program is to establish intra-VA interoperability, VA/DOD interoperability, and VA-Community Care interoperability, each of 

these phases of interoperability allows VA to incrementally build toward and support nationwide EHR interoperability. Nationwide EHR interoperability amongst all 

healthcare providers will empower Servicemembers and Veterans to utilize their 

electronic health records to the fullest extent and equip providers to deliver safer 

and more efficient seamless care. 

Question 43. When looking at the full EHR ‘‘software stack,’’ are you considering 

Commercial Off the Shelf interoperability solutions that are separate from or in addition to the larger EHR contract? 

Response. For the EHRM Program, the only Commercial solutions which are 

planned for use are the D&F authorized Cerner Platform and its Interoperability 

software, and VA’s Enterprise InterSystems HealthShare software. Separately, VA’s 

API gateways plan to utilize commercial systems per the Secretary’s direction for 

VA to get out of the software development business. 

The selection of Cerner Millennium does not eliminate VA’s need to continue to 

assess the commercial market to identify additional software tools and products that 

may further enhance our overall interoperability and seamless care objectives. VA 

will be using the reciprocity process to fully leverage successful testing practices and 

results already solidified as part of the DOD deployment effort. However, under 

EHRM, there will be a comprehensive Test & Evaluation department reporting to 

the EHRM Program Executive that will be fully leveraging the breath of existing 

VA and Cerner test facilities to continue to not only test the 30 percent more capabilities being delivered under the VA contract, but also to stimulate introduction of 

more efficient/effective functional and technological industry advancements into the 

VA healthcare environment. 

OFFICE OF ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION

Question 44. Can you please provide an update on the vacancy of the Assistant 

Secretary for Accountability and Whistleblower Protection? Can you please highlight 

any challenges you are facing in sending Congress a nominee? 

Response. Once the President’s nominee has been confirmed and sworn in as Secretary, VA will complete an assessment and provide a recommendation for a nominee as Assistant Secretary for Accountability and Whistleblower Protection. 

VA INNOVATION

Question 45. With respect to VA’s ability to innovate and modernize, do you feel 

that the department currently has sufficient authority to proactively test out new 

approaches to care and payment that could increase efficiency and optimize care? 

Response. The Center for Compassionate Innovation was created to explore 

emerging therapies that are safe and ethical to enhance Veteran physical and mental well-being when other treatments have not been successful. The Center specifically evaluates innovations for special populations of Veterans who have not 

achieved optimal outcomes with traditional, evidence-based medicine including developing partnerships and collaborations with community-based organizations to optimize access to safe, innovative treatment. 

The Department has sufficient authority to proactively test out new approaches 

to care and payment that could increase efficiency and optimize care. As an example, for the first time in VA history, Veterans may receive hyperbaric oxygen therapy (HBOT) to treat Post Traumatic Stress Disorder (PTSD) symptoms. HBOT 

treatment for PTSD is considered off label use by the Food and Drug Administration 

and, therefore, is not a standard of care treatment option. 

The Center is not only using sharing and provider agreements for payment, it is 

also leveraging telehealth for care where feasible for certain treatments. 

115 

Question 46. How would authorities contained in Section 402 of VA’s CARE Proposal (Authority for VA Center for Innovation for Care and Payment) affect VA’s 

ability to pursue these new and innovative approaches? 

Response. Section 402 would allow VA, with Congressional approval, to waive certain authorities found in Sections 1701–1730A of title 38 that could otherwise limit 

VA’s ability to identify and test new and innovative approaches to care and payment. We also note that section 401 would allow for a pilot project to improve how 

VA and DOD furnish care to Veterans and Servicemembers. If this section were enacted, the VA and DOD Secretaries could determine the feasibility and advisability 

of sharing health care resources without entering into reimbursement agreements 

for such services. 

Question 47. What sorts of approaches would you pursue using this new 

authority? 

Response. Innovations would be focused on testing payment and service delivery 

models to determine whether such models improve the access to and quality, timeliness, and patient satisfaction of such care and services, as well as the cost savings 

associated with such models. VA would be able to consider changes to collections, 

copayments, payment rates, and contracting authorities. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. DAN SULLIVAN TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 48. Regarding the recent decision on the Community Care Network Acquisition for Region 4, 

a. What were the contributing factors that led to the decision to not grant an 

award under the current solicitation? 

Response. VA received proposals in response to the Community Care Network 

(CCN) solicitation on June 30, 2017, and performed evaluations in accordance with 

the criteria established in the solicitation. VA took the following four factors into 

consideration for award decisions for CCN Region 4: (1) Technical, (2) Past Performance, (3) Socioeconomic Concerns, and (4) Price. The evaluations resulted in the 

need to conduct negotiations. After negotiations were held, VA received the final revised proposals on December 14, 2017, and immediately began conducting evaluations of revised proposals. After evaluations were completed, it was determined that 

final proposal revisions for Region 4 did not provide the ‘‘best value’’ to VA, all factors considered, or for our taxpayers. VA amended the solicitation to remove Region 

4 since a contract award was not made. 

b. What will the VA’s new acquisition strategy for Region 4 be? 

Response. VA’s Office of Community Care (OCC) is currently reviewing the requirements that were included in the CCN Performance Work Statement for Region 

4. VA intends to issue a new solicitation, which will include revised requirements 

for Region 4. Once the contracting office has received the complete revised requirements, a detailed timeline concerning the re-procurement will be developed. 

c. What is the timeline for reopening competition? 

Response. Competition will be reopened in the next 2 to 3 months. 

d. Will you be proactive in notifying Members whose states are a part of this region on process and decisions regarding the acquisition moving forward? 

Response. Yes, VA will notify Members of Congress whose states are a part of this 

region on the process and decisions regarding the acquisition. 

Question 49. Regarding the VA/DOD National Resource Sharing Agreement (dated 

12/16), the AK VA/DOD joint venture recently requested an exemption from the exchange rate citing adverse budgetary and staffing impacts due to variabilities 

among localities for CMS and CMAC—especially in Alaska that would negatively affect their partnership and Veteran healthcare. Will you commit to communicate 

with Alaska’s VA leadership to fully understand the VA/DOD landscape in Alaska 

and possible impacts before implementing this change in my state? 

Response. VA and DOD have been committed to working with local VA and DOD 

facilities on this recent (December 2016) joint policy decision to standardize the VA/ 

DOD sharing reimbursement rate. We are currently testing the methodology with 

the help of local VA/DOD partners to gather input prior to a phased National roll 

out. We recently learned of Alaska’s concerns and requested the local VA/DOD sharing partners provide a briefing to the VA/DOD Health Executive Committees, 

Shared Resources Work Group (SRWG) for further consideration. SRWG is collaborating with various VHA and Air Force Surgeon General staff office experts to review Alaska’s concerns and provide guidance as applicable. 

116 

Question 50. What has the VA done regarding negotiations of new reimbursement 

rates for VA-IHS tribal sharing agreements in Alaska since current rates were last 

extended? 

Response. VA held a tribal consultation in September 2016 and a round table discussion in August 2017. During those meetings, VA and Tribal leaders discussed the 

future of Tribal Health Agreements in Alaska and the lower 48 states. This included 

potentially changing reimbursement rates to Performance Based Rates rather than 

the current rates, which are primarily based upon all-inclusive rates published by 

Indian Health Service annually. The tribes expressed major concerns about implementing new rates which are more complex to assess. Therefore, VA agreed to extend all current agreements through June 30, 2019, while continued discussions 

with Tribes will take place to enhance care coordination and potentially negotiate 

rates that are based on the quality of care provided. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

MENTAL HEALTH

Question 51. Many critical details, and much of the major policy provisions, were 

left out of President Trump’s recently signed executive order dealing with mental 

health for veterans. Please provide a comprehensive description of the changes that 

will be made pursuant to the executive order, especially— 

a. What veterans will be eligible, and for what type of care? 

Response. There are several legal authorities under which VA can provide mental 

health care, to include outpatient, inpatient, and residential services, to transitioning Servicemembers and Veterans. These authorities include: 

• Emergency circumstances. If a transitioning Servicemember or Veteran presents 

to a VA medical facility with an emergency mental health need, VA may provide 

the treatment while the emergent health care need persists. Unless otherwise eligible, the emergency care would be provided to the individual on a humanitarian 

basis (38 U.S.C. 1784), or possibly under tentative eligibility (38 CFR 17.34(a)) if 

a former Servicemember presents at a VA facility seeking care for a mental health 

condition he or she asserts is related to military service. For emergency care provided on a humanitarian basis, and for emergency care provided to a former Servicemember under tentative eligibility who is later determined to be ineligible for VA 

health care, VA will bill for the care at a cost-based rate. 

• Medical benefits package. Veterans enrolled in VA’s system of patient enrollment, established under 38 U.S.C. 1705, may receive mental health care under the 

medical benefits package (38 CFR 17.38). VA encourages all former Servicemembers 

who may be eligible to apply for enrollment. Additionally, Veterans who have a service-connected disability or disabilities rated 50 percent or more can receive mental 

health care under the medical benefits package (38 CFR 17.38) without respect to 

enrollment. See 38 U.S.C. 1705(c)(2), 38 CFR 17.37(a). 

• Other treatment authorities and bars to benefits. Transitioning Servicemembers 

and Veterans not eligible for enrollment or who elect not to enroll may still be eligible for mental health care through VA. Generally, to be eligible for enrollment in 

VA health care, a person must have been discharged or released from active military, naval, or air service under conditions other than dishonorable and, unless an 

exception applies, satisfy minimum active duty service requirement. Some Veterans 

may also be ineligible for enrollment because their income is over the applicable 

threshold. 

• With respect to character of discharge, a transitioning Servicemember generally 

is not eligible for VA benefits, to include mental health care, if he or she is subject 

to a bar to benefits. Individuals barred from receiving benefits include those who, 

unless considered insane, were discharged or released as a conscientious objector or 

deserter, by reason of general court-martial, or as a result of AWOL for a certain 

period unless exempted. See 38 U.S.C. 5303(a), 38 C.F.R. 3.12(c). If barred, VA may 

refer the individual to community resources (not at VA expense). For example, for 

an individual ineligible for readjustment counseling under 38 U.S.C. 1712A, VA (1) 

provides referral services to assist the individual in obtaining mental health care 

and services outside VA, and (2) if pertinent, advises the individual of his/her right 

to apply for a review of the individual’s discharge or release. See 38 U.S.C.1712A(c). 

• Authorities under which VA may provide mental health care to recently 

transitioned Servicemembers and Veterans who are not otherwise eligible include: 

38 U.S.C. 1705(c)(2) (for service-connected and presumptive service-connected disabilities); 38 U.S.C. 1702 and 38 CFR 17.109 (presumptive eligibility for psychosis 

117 

and other mental illness); 38 U.S.C. § 1720D (related to military sexual trauma); 

and 38 U.S.C. § 1712A and 38 CFR § 17.2000 (readjustment counseling). These authorities are discussed below, along with a discussion of eligibility for former Servicemembers with other than honorable administrative discharges. 

• Service-connected and presumptive service-connected disabilities. Under 38 

U.S.C. 1705(c)(2), VA is required to provide hospital care and medical services without respect to enrollment for (1) Veterans seeking care for a service-connected disability, and (2) for the 12-month period following their discharge or release from 

service, Veterans whose discharge or release from active military, naval, or air service was for a disability that was incurred or aggravated in the line of duty for that 

disability. This means that VA must provide mental health care to any Veterans 

seeking mental health care for a service-connected disability. Additionally, as may 

be more applicable to the EO, Veterans whose discharge or release from active military, naval, or air service was for a disability that was incurred or aggravated in 

the line of duty may receive VA mental health care for that disability, without respect to enrollment, for the 12-month period following their discharge or release 

from service. 

• Presumptive eligibility for Veterans with psychosis and other mental illness. In 

general, VA can provide treatment for an active psychosis or other active mental 

illness without copayments for recently-discharged or released Veterans who developed such psychosis or mental illness within 2 years after discharge or release from 

the active military, naval, or air service. See 38 U.S.C. 1702, 38 CFR 17.109. Such 

treatment is available without respect to enrollment or eligibility for enrollment (38 

CFR 17.37(k)), without respect to whether the Veteran served in combat, and without regard to the Veteran’s length of active duty service. These Veterans do not 

have to file a claim for service-connection or have received a formal grant of serviceconnection from VBA to receive treatment under this authority. 

• Military sexual trauma. VA provides counseling and appropriate care and services under 38 U.S.C. 1720D to Veterans who VA determines require such counseling 

and care and services to overcome psychological trauma, which in the judgment of 

a VA mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training. 

VA refers to these experiences as military sexual trauma (MST). Care for MST-related mental and physical health conditions is provided without copayments. Veterans are not required to enroll in VA’s system of patient enrollment, file a disability claim, be service-connected, or provide evidence of the sexual trauma to receive MST-related care. 

• Readjustment counseling. VA provides readjustment counseling to eligible Veterans and certain members of the Armed Forces under 38 U.S.C. § 1712A and 38 

CFR § 17.2000 through its Vet Centers. The specific categories of individuals eligible 

for readjustment counseling are set forth in law, and include Veterans and members 

of the Armed Forces who served on active duty in a theater of combat operations 

or an area at a time during which hostilities occurred in that area. Vet Centers 

maintain confidential records independent from any other VA or DOD medical 

records; Vet Centers will not disclose such records without a voluntary, signed authorization, or a specific exception permitting their release. Readjustment counseling is available without respect to enrollment and without copayment requirements. For more information or to find a Vet Center near you, go to https:// 

www.vetcenter.va.gov or call 1–877-WAR-VETS (1.877.927.8387). 

• Other than honorable administrative discharges. Former Servicemembers with 

other than honorable (OTH) administrative discharges who present to VA seeking 

mental health care may be eligible for mental health services under the OTH initiative, which is based on VA’s authority in section 2 of Public Law 95–126 (38 U.S.C. 

5303 NOTE) and 38 CFR 3.360 (service-connected health care); 38 U.S.C. 1702 and 

38 CFR 17.109 (psychosis and mental illness presumptions); and 38 CFR 17.34 (tentative eligibility). Notwithstanding any other provision of law, VA provides former 

Servicemembers with other than honorable administrative discharges the type of 

health care and related benefits authorized to be provided under chapter 17 of title 

38, U.S.C., for any disability incurred or aggravated during active military, naval, 

or air service in line of duty, with the exception of (1) any disability incurred or aggravated during a period of service terminated by a bad conduct discharge, or (2) 

when a bar to benefits (discussed above) applies. See 38 U.S.C. 5303 NOTE, 38 CFR 

3.360. Additional information is available on the OTH Fact Sheet (external link). 

b. Does VA have the excess capacity in mental health care to provide this 

treatment? 

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Response. VHA continues to evaluate capacity and the regional impact the EO 

may have. VHA is continuing the Mental Health Hiring Initiative requested by Secretary Shulkin to add 1,000 net providers to the current workforce. 

c. What happens at the end of the year for veterans who still need treatment? 

Response. This will depend upon the legal authority for providing treatment. For 

example, if the Veteran is eligible under the Presumed Eligibility for Psychosis or 

Other Mental Illness, this care does not have maximum limit, and care will continue 

beyond 12 months. In other situations, where care is to be terminated, all mental 

health providers have the ethical responsibility to ensure a transfer of care is completed to a community provider. This transfer of care is completed as part of the 

patient-provider agreement, ensuring there is no Veteran left without clinically appropriate follow-up. 

d. Will VA request additional funds to cover the hundreds of millions of dollars 

a year the Administration estimates this will cost? 

Response. It was not VA’s intention to request additional funding when the OTH 

Initiative was implemented. As VA expands healthcare eligibility, we will continue 

to work with Congressional partners in addressing fiscal impact as appropriate. 

HUD-VASH

Question 52. Data from the Department of Housing and Urban Development 

showed that there was an increase in veteran homelessness this year, and a significant increase in my home state of Washington. You stated before the Committee 

that VA will be implementing a new plan to address this issue in Seattle. Please 

provide a full description of what additional resources will be made available, any 

proposed programmatic changes, and a timeline for implementation. 

Response. The state of Washington saw an increase of over 600 homeless Veterans 

in the 2017 Point in Time Count; an increase of 41 percent over 2016. This statewide increase was caused almost entirely by increases in the Seattle/King County 

Continuum of Care, which saw an increase of 673 homeless Veterans; an increase 

of over 100 percent compared to 2016. The rest of the state actually saw a small 

net decrease. 

VA’s Homeless Program Office (HPO) is actively engaged with the Puget Sound 

VAMC and with city, county and state officials to develop a comprehensive plan to 

address the increasing numbers of homeless Veterans in Seattle and King County. 

Planning sessions have included the following: a) VAMC-specific calls focused on internal operational challenges such as rapidly filling vacant homeless program positions, and maximizing available beds and vouchers; b) calls between HPO, the 

VAMC, and city and county officials focused on refining the ‘‘By Name List’’ and 

getting consensus across agencies on the current number of homeless and at-risk 

Veterans as well as understanding inflow rates in order to best address current and 

projected demand for resources; and c) calls between HPO, the Network Homeless 

Coordinator, and officials from the State Department of Veterans Affairs and the 

Governor’s Office focused on strategies for development of additional beds and units 

to increase the stock of available housing. 

VA will continue to work with the VAMC and city, county and state officials to 

finalize a plan to decrease the number of homeless and at-risk Veterans in Seattle/ 

King County, and we will be happy to share the details of that plan once finalized. 

The Grant and Per Diem (GPD) program made the Seattle/King County Continuum of Care area a priority for funding in the current GPD Notice of Funding 

Availability. 

Question 53. I have received reports that at least one VA medical center in my 

state is proceeding with the redesignation of Specific Purpose funds to General Purpose funds, despite your statement that no changes would be made. 

a. Is there an effort underway to redesignate any Specific Purpose funds? 

Response. On February 6, 2018, a memo was issued to all Network Directors, Network Homeless Coordinators, and Medical Center Directors stating that there will 

be no conversion of Department of Housing and Urban Development—VA Supportive Housing (HUD-VASH) Program Specific Purpose funding to General Purpose 

funding during FY 2018. The memo goes on to clarify that HPO is currently disbursing HUD-VASH program Specific Purpose funding to VISNs and VAMCs based 

on the FY 2018 budget requests submitted by each VISN while adhering to the 

funding provided under the Advanced Appropriation. Once Congress passes the FY 

2018 budget the remaining annual funding will be disbursed. All HUD-VASH program requirements remain in place, including staffing, reporting, and program 

metrics. 

119 

b. What directives or instructions have been issued to VISNs regarding changes 

in funding designation, including instructions not to move forward with redesignation? Please provide a copy of any information or instructions distributed within VA 

on this topic. 

Response. As requested, enclosed please find the January 8, 2018, memo regarding the delay transitioning Special Purpose non-core funds to General Purpose. Also 

enclosed is the February 6, 2018, memo referenced in the previous paragraph, noting that there will be no conversion of HUD-VASH program Specific Purpose funding to General Purpose funding during FY 2018. 

VET CENTERS

Question 54. Vet Centers are one of the most important parts of VA’s mental 

health service system. They provide care in a unique setting, and often see veterans 

who would not seek care from a traditional clinic. So preserving their unique culture 

and autonomy is very important. 

a. Does the Readjustment Counseling Service have all the resources and authorities they need to meet demand from veterans and successfully implement new 

initiatives? 

Response. Readjustment Counseling Service (RCS) is in the final stages of implementing single points of service for our Human Resource and Fiscal functions. This 

consolidation has allowed RCS to improve all budgeting projection processes. Subsequently, RCS has asked for increases in the FY 2018 and future FY budget submissions to meet current demand and projected demand through increasing access to 

services. 

In addition, RCS is in the 7th year (with extensions) of a pilot program to provide 

recently returning Women Veterans readjustment counseling through retreats. This 

has been accomplished utilizing the existing RCS Specific Purpose budget, with no 

request for additional funding. Those who have participated in these retreats have 

seen reduction in their symptoms associated with PTSD and increases in their coping abilities. 

There are currently three Bills pending in Congress that address readjustment 

counseling in a retreat setting: 

• H.R. 91 Building Supportive Networks for Women Veterans Act (Sec. 2): This 

bill makes permanent the requirement for the Department of Veterans Affairs to 

carry out, through the Readjustment Counseling Service of the Veterans Health Administration, a program to provide reintegration and readjustment services in group 

retreat settings to women veterans who are recently separated from service after 

a prolonged deployment. 

• S. 681 Deborah Sampson Act (Section 103): Provision of Reintegration and Readjustment Services to Veterans and Family Members in Group Retreat Settings. 

(Similar to H.R. 2452) 

• H.R. 2452 Deborah Sampson Act (Section 103): Provision of Reintegration and 

Readjustment Services to Veterans and Family Members in Group Retreat Settings. 

(Similar to S. 681) 

RCS supports all three Bills, however firmly believes that all cohorts of combat 

Veterans and their families would benefit greatly from this modality. 

DATA SHARING

Question 55. The IG has testified before this Committee previously regarding barriers to VA having access to the DOD suicide database that would help VA better 

design and target suicide prevention efforts. It is unacceptable to me that this data 

is not routinely provided to VA. I understand the Departments are working on an 

agreement to fix that problem. 

Response. VA has received data from DOD partners and DOD regularly shares 

summarized data analyses on an as needed basis with VA. The DOD and VA data 

sharing Memorandum of Agreement (MoA) will allow more timely sharing of Department of Defense Suicide Event Report data and enable broader VA utilization. 

The MoA is fully developed, and is going through VA and DOD privacy clearance 

prior to DHA and VA signature. 

Question 56. When will that agreement be completed and VA will start receiving 

the DOD suicide data? 

Response. The MoA is currently going through VA and DOD privacy clearance 

prior to DHA and VA signature. Once signed, the MoA will be complete and VA will 

start receiving DOD suicide data. 

120 

FOREVER GI BILL

Question 57. Many student veterans who could benefit from provisions in the Forever GI Bill are still unaware of the changes that were made. How does VA plan 

to ensure veterans who are now eligible for expanded educational opportunities are 

properly informed of these recent changes and making decisions in their best 

interest? 

Response. VA has taken a multi-pronged approach to highlight and promote the 

Colmery Act to Veterans and beneficiaries. This includes an extensive social media 

campaign with regular posts on Facebook, a Twitter Town Hall, a satellite media 

tour that reached an audience of over 3 million, new websites, and posting Frequently Asked Questions for provisions with the most immediate impact on Veterans and beneficiaries. 

VA sent targeted emails and mail to individuals identified as eligible for Sections 

109 and 106 of the Forever GI Bill, and sent an email to over 500,000 individuals 

who may no longer have a time limit to use their Post-9/11 GI Bill benefits. VA has 

briefed VSOs, attended the Student Veterans of America National Conference, and 

sent notifications to internal and external stakeholders on Forever GI Bill changes 

and impacts. As VA moves forward with implementing other provisions and making 

changes because of Forever GI Bill, it will continue to send out targeted notifications, and regularly and aggressively promote Forever GI Bill through all available 

mediums. 

Question 58. School Certifying Officials also tell my staff that they have not received any information from VA on recent changes from the Forever GI Bill. School 

certifying officials are the first persons student veterans turn to for information regarding their benefits. Without proper outreach from VA, school certifying officials 

are relying on other unverified sources for information on recent or pending 

changes. I am worried this could lead to misinformation and confusing messaging 

to student veterans. Mandatory training for school certifying officials is crucial, 

when will VA start implementing curriculum on the Forever GI Bill? 

Response. On November 29, 2017, the VA’s Education Service conducted a SCO 

webinar on the Forever GI Bill and provided information on our progress toward 

implementation. The webinar also included a question and answer session in which 

Education Service responded to questions from SCOs. VA sent targeted emails to 

SCOs on the removal of the delimiting date for eligible beneficiaries and the expansion of approvable Independent Study programs. In early February 2018, the Education Service held a focus group with stakeholders including SCOs on its implementation plan for Section 107, and will continue to engage with SCOs through regularly scheduled webinars, targeted emails, state, regional, national conferences and 

serve as resource to SCOs as they educate students at their facility on the Forever 

GI Bill. 

VA is also meeting regularly with members and leaders from the NASAA and 

other internal and external stakeholders to discuss training development and implementation planning for Section 305. 

Question 59. Regarding the Forever GI Bill, a December memo from VA notes that 

VA has processed 600 applications out of potentially 8000 beneficiaries (7.5 percent 

of those eligible) for the restoration of entitlement from former students of ITT Tech 

and Corinthian Colleges. How did VA conclude that there were only 8000 potential 

beneficiaries, and what type of notices is VA considering to ensure the benefits restoration reaches 100 percent of those eligible? 

Response. Through data analysis, VA identified approximately 8,000 beneficiaries 

who attended a facility that met the school closure criteria between January 1, 2015, 

and August 16, 2017. During the week of November 9, 2017, VA provided notification to 8,000 students identified as potentially eligible to have benefits restored 

under the Special Application provision of Section 109. Of those, approximately 80 

percent received an email with a letter, instructions, and a form to apply for restoration. The remaining 20 percent received the same documentation via postal mail. 

As of January 26, 2018, VA has received over 700 applications and restored over 

4,500 months of entitlement to almost 450 individuals. 

VA plans a 90-day follow-up via postal mail to those individuals that were sent 

an email, but not applied for restoration. Additionally, we will call a sample of those 

who have not applied to understand their choice and to verify receipt of the initial 

notification. VA will use this information to improve its communication efforts and 

continue to regularly post updates and notices across its social media platforms, 

website, and leverage its partners to ensure impacted students are aware that VA 

can restore lost entitlement. 

121 

Question 60. Has VA placed any outbound calls to potential beneficiaries of the 

entitlement restoration who have not yet applied or been approved to notify them 

of their eligibility? 

Response. Please see our response to question 59 above. 

Question 61. Regarding the Forever GI Bill, the December update from VA notes 

that VA is ‘‘collaborating with SAAs to redesign compliance reviews’’ per the requirement to include risk-based surveys in State Approving Agency oversight activities. What guidance is VA providing on the potential risk factors that SAAs might 

use in their reviews? 

Response. VA partnered with SAAs to conduct targeted risk-based compliance reviews over the last 3 years, and has continued to examine and evaluate our compliance regimen. VA recently completed a year-long study of our compliance and liaison processes, organizational structure, and stakeholder engagement. Additionally, 

VA and NASAA constituted a working group to consider the findings from this 

study and section 310 of the Colmery Act. Among many other aspects, we will be 

collaborating on the issue of risk factors and resultant oversight and compliance 

actions. 

Question 62. What is VA’s timeline for completing the collaboration with SAAs 

and seeing risk-based reviews implemented as required by the Forever GI Bill? 

Response. As the VA-NASAA joint working group was just implemented, no specific timeline has been established. VBA expects to begin implementing potential 

changes from this workgroup in FY 2019. 

Question 63. Regarding the Forever GI Bill, the updated provided by VA notes 

that VA is ‘‘establishing IPT to develop requirements and processes’’ for the High 

Technology Pilot Program. The Senate Committee report accompanying S. 1598 emphasized that ‘‘the Committee seeks to ensure that veterans are protected against 

programs that will not allow them to obtain sustainable employment in the technology sector’’ particularly given the closure of other technology programs, including 

coding ‘‘boot camp’’ locations, and listed specific indicators of risk for VA to consider 

when entering into contracts with providers of these programs, including financial 

stability and alignment to industry-recognized certifications and credentials. How is 

VA planning to incorporate these defined outcome and quality expectations into its 

initial design of the High Technology Pilot Program? 

Response. The statutory requirements for the High Technology Pilot Program outline approval criteria and a payment schedule for contractors based on targeted 

milestones. VA will look to further expand on the approval criteria in consultation 

with SAAs, and will further clarify payment schedule milestones in the agreements 

it enters into with providers. These agreements will also include termination clauses 

and oversight measures for VA to perform compliance reviews. 

Question 64. Regarding the Forever GI Bill, the December update notes that VA 

is ‘‘reviewing statutory requirements to develop appropriate safeguards and processes’’ for the Edith Nourse Rogers STEM Scholarship. When does VA expect to conclude its review of the requirements, and what actions does it anticipate taking at 

the conclusion of this review? 

Response. VA is analyzing statutory requirements to develop planning documents 

for the STEM scholarship, which does not go into effect until August 1, 2019. The 

requirements for this provision do not conform to VA’s current technology and business rules for the Post-9/11 GI Bill; therefore, VA has identified the VA Regional 

Processing Office in Buffalo, NY, as the sole site dedicated to processing and tracking the STEM Scholarship. VA expects a more fully developed plan with regulatory, 

communication and program requirements to be drafted by December 2018. 

Question 65. The Senate Committee report on the Forever GI Bill specified that 

safeguards for the Edith Nourse Rogers STEM Scholarship should include a mechanism to ensure that schools or programs are not expanding the number of credit 

hours needed to complete a STEM program so they can receive additional tuition 

and fee payments from the Edith Nourse Rogers STEM Scholarship. Is VA capable 

of monitoring for changes in credit hour requirements and will VA ensure that it 

will examine whether additional semester or quarter hours are being required in 

non-STEM fields or for non-GI bill beneficiaries? 

Response. VA has had preliminary discussions with SAAs regarding requirements 

of the STEM provision and will engage other appropriate stakeholders as we further 

develop the implementation plan. 

Question 66. Has VA communicated with accrediting agencies or SAAs requiring 

their ability to assist in gathering information regarding program length for those 

programs which may become eligible for the Edith Nourse Rogers STEM Scholarship? 

122 

Response. Please see our response to question 65 above. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. SHERROD BROWN TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 67. How many student veterans has VA identified as eligible for restoration of benefits established in the Forever GI Bill? Please provide my office with updated numbers, disaggregated by institution, of veterans and their families from 

Ohio or attended for-profit schools in Ohio who are eligible for GI Bill benefits restoration in light of the Forever GI bill. 

Response. For the Special Application provision we have identified three Ohio 

schools whose students would be eligible for restoration: 

Name of School Number of students 

Brown Mackie College-North Canton .............. 12 

Miami-Jacobs Career College-Sharonville ....... 1 

Sanford Brown College .................................... 3 

Please note, this number does not include beneficiaries who may have 

resided in Ohio, and attended a school that closed out of state or online. 

a. What have you done to ensure that students impacted by the closure of ITT 

and Corinthian Colleges have the benefits that they have earned restored? 

Response. VA notified approximately 8,000 individuals, regarding their potential 

eligibility for entitlement restoration, of which, nearly 6,000 were ITT Tech or Corinthian students. VA created a dedicated webpage, https://benefits.va.gov/gibill/fgib/ 

restoration.asp, which addresses restoration of entitlement and includes the form 

that beneficiaries can use to apply for benefit restoration. VA is using social media 

including Facebook and Twitter to let beneficiaries know that VA can now restore 

entitlement and encourage those potentially eligible to apply. 

b. What communication via phone, mail, email, and social media has VA sent to 

these veterans? What additional communication do you have planned? 

Response. Through data analysis, VA identified approximately 8,000 beneficiaries 

who attended a facility that met the school closure criteria between January 1, 2015, 

and August 16, 2017. During the week of November 9, 2017, VA provided notification to 8,000 students identified as potentially eligible to have benefits restored 

under the Special Application provision of Section 109. Of those, approximately 80 

percent received an email with a letter, instructions, and a form to apply for restoration. The remaining 20 percent received the same documentation via postal mail. 

As of January 26, 2018, VA has received over 700 applications and restored over 

4,500 months of entitlement to almost 450 individuals. 

c. What tools and resources are being expended to ensure all students who are 

eligible to have their benefits restored are fully informed and able to reclaim these 

benefits and continue their education? 

Response. VA is continuously looking to push its communications through new 

platforms and leveraging its partners to help get its message out. To that end, VA 

plans to host a Facebook Live event in partnership with a National Military Family 

Association and using Medium to publish blogs on the Forever GI Bill. 

d. Would student veterans happen if a for-profit college or university shuttered 

their doors abruptly tomorrow have the ability to get their GI Bill benefits restored? 

Response. The Forever GI Bill sections in Section 109 also allow restoration of entitlement for VA students if a school closes. This means that VA will not make a 

charge against students’ entitlement for the portion of the period that the students 

did not receive credit toward their programs (or lost training time toward the completion of their program). For example, if a student was enrolled in a semester fulltime, and the school closed 60 days after the semester started, the student would 

have used 2 months of their entitlement. VA will restore those two months back to 

the student and the student will have those 2 months available to use at another 

time. 

Additionally, for school closings on or after August 16, 2017 (date of bill enactment), VA may continue the housing allowance for Post-9/11 GI Bill students beyond the date of closure up to the end of the term, quarter or semester, not to exceed 120 days. The law requires that VA begin making these payments of housing 

allowance on August 1, 2018. No charge to a student’s entitlement will be made for 

the extended period of eligibility for housing allowance. 

123 

Question 68. In addition to restoring GI Bill benefit eligibility to student veterans 

harmed by the precipitous closure of ITT Tech and Corinthian Colleges, this bill 

gives VA additional tools to provide oversight of programs to ensure that student 

veterans are using their benefits at reputable programs and institutions. State Approving Agencies approve, review, and monitor training and education programs 

that have access to VA education benefits. The Forever GI Bill authorized additional 

funding for State Approving Agencies (SAAs) and expanded SAA’s oversight duties 

by charging SAAs to conduct risk-based program reviews. 

a. How has VA worked with SAAs on including risk-based reviews as part of their 

oversight efforts? 

Response. Over the last 3 years and well prior to the Colmery Act, as part of VA’s 

strong partnership with SAAs in our mutual oversight and compliance responsibilities, SAAs conducted approximately 30 percent of the targeted risk-based compliance reviews at schools where special risk indicators were discovered. The Executive 

Director of VBA’s Education Service and the President of the National Association 

of State Approving Agency have constituted a Risk-based Review Workgroup comprised of VA and SAA staff to analyze and implement potential policy and procedural changes with respect to Risk-Based Reviews. 

b. How has VA worked to strengthen SAAs’ ability to evaluate and monitor programs receiving GI Bill funds? 

Response. VA reduced the number of compliance surveys required for the majority 

of SAAs for FY 2017 and FY 2018 in order to ensure SAAs have the time and resources to focus on school and facility approvals, as well as referrals made to SAAs 

regarding school concerns and student complaints. 

Question 69. As you know Ashford University, the large for-profit school, was 

found to be out of compliance in November 2017. The school had 60 days to get in 

compliance. Earlier this month, Ashford announced it would seek approval from the 

California SAA to receive VA educational benefits and VA announced Ashford would 

continue to receive GI Bill dollars as the school pursues approval from the California SAA. Please outline statutory requirements and VA procedure for communicating with student veterans if their program is found to be out of compliance. 

Detail the communication VA had with student veterans since Ashford was found 

to be out of compliance last fall. Should the California SAA not approve Ashford’s 

programs, what steps would VA take to protect student veterans and taxpayer investment in higher education and how would VA communicate that information 

with student veterans? 

Response. Section 3690(b)(3)(B)(iii) of title 38, United States Code, requires VA to 

notify beneficiaries enrolled in an affected program at least 30 days prior to suspending or disapproving benefits for failure to meet approval, recordkeeping or reporting requirements. Student notification requirements are also codified in VA regulations in section 21.4210(e)(2) of title 38, Code of Federal Regulations. In fulfillment of these statutory and regulatory notification requirements, VA identified current or recent GI Bill beneficiaries enrolled in Ashford University’s online programs 

and notified them by email, or by letter if no email address was found, of the situation and of the fact that benefit payments for enrollment in Ashford’s online programs could be discontinued in 30 days if corrective action was not taken by 

Ashford. 

Since Ashford University’s online programs were approved by the Arizona SAA, 

VA has provided information and status updates on three separate occasions. 

• November 10, 2017: Students were informed of VA’s correspondence to Ashford 

University and the Arizona State Approving Agency that GI Bill benefits could potentially end in 60 days if corrective actions are not taken. 

• December 13, 2017: Students were informed that GI Bill benefits could potentially end in 30 days if Ashford does not submit an application for approval to the 

California SAA by January 8, 2018, and support the approval process in good faith. 

• January 23, 2018: VA sent an email informing beneficiaries that Ashford submitted a timely application to the California SAA, and that benefits would not be 

interrupted as long as Ashford continues to make a good faith effort to support the 

approval process in California. 

Unless Ashford University is determined to be fully compliant with program approval requirements, Federal law mandates that VA must ultimately discontinue 

benefits for enrollment in the school’s online programs. Since June 2016, VA has notified GI Bill beneficiaries of the potential for disruption of benefits due to program 

approval issues at Ashford University on nine separate occasions in order to ensure 

that they are informed consumers and understand the potential risks of continued 

enrollment. In the event that VA is forced to discontinue benefits, we will work with 

schools, State Approving Agencies, and Veterans Service Organizations to identify 

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educational alternatives and additional resources that can assist our beneficiaries 

in continuing their educational pursuits, and we will provide that information to affected students. 

Question 70. What kind of oversight efforts has VA anticipated needing to ensure 

that new offerings from Forever GI, including the STEM Scholarship and the High 

Tech pilot program, are actually serving veterans? Please provide a status update 

on those oversight efforts. 

Response. VA is currently analyzing the statutory requirements for both these 

provisions and developing planning documents for implementation. Both programs 

will require oversight and compliance efforts to ensure proper program administration and protection for both the taxpayer and beneficiary. To accomplish this task, 

VA is establishing specialized teams located at the VA Regional Processing Office 

in Buffalo, NY. 

Question 71. What is the timeline for the interagency to make a determination 

regarding Agent Orange presumptive conditions including bladder cancer, hypothyroidism, and Parkinson’s-like symptoms? 

Response. Once the President’s nominee has been confirmed and sworn in as Secretary, VA will examine the current policy, complete a full review on this issue and 

provide new guidance on this issue as needed. 

Question 72. What is the status of the National Academy of Medicine study regarding Agent Orange exposure on descendants? I know they held a meeting in November 2017, when do you anticipate a report to VA? 

Response. VA has a current contract with the National Academy of Medicine 

(NAM) to investigate the broad range of conditions possibility associated with exposure to Agent Orange. Included in this review is a review of the potential that Agent 

Orange may have affected the health of Veterans’ descendants. The NAM’s report 

is due to VA by January 2019. The Committee’s charge includes looking at descendant health and in particular, the Committee was asked to pay special attention to 

the potential risk of parental transmission of disease conditions to descendants. 

Question 73. I support the recent executive action to provide mental health care 

for transitioning servicemembers. However, I am concerned that VA does not have 

the resources it will need to meet the additional demand. 

a. What steps are you taking to ensure that medical facilities staff mental health 

professional shortages? 

b. What additional resources-funding or personnel- are needed to meet this growing need, and how will propose bridging the gap? 

Response (73 a & b). VA has a Mental Health Hiring Initiative goal of hiring 

1,000 providers by December 31, 2018, to enhance VHA’s ability to provide mental 

health services. There is a nationwide shortage of psychiatrists and psychologists. 

Psychiatrists have been identified as the top hard to recruit and retain VHA physician specialty in FY 2016 and FY 2017. Psychologists have been identified as the 

fourth hardest to recruit and retain VHA occupation in FY 2016 and FY 2017. 

Despite national shortages in mental health providers, VHA outpatient mental 

health demand is anticipated to grow by 12 percent by 2021. The recent Executive 

Order requires all new Veterans to receive mental health care for at least 1 year 

following their separation from service. Veterans choose to get more of their mental 

health care from VA than the private sector, so there is an expectation the demand 

will exceed the previous 12 percent estimate. 

VA is expanding the use of tele-mental health to reach areas of the country with 

a shortage of providers and working with community partners to provide care in the 

community. VA has increased the number of graduate medical education physician 

residency positions in mental health by 167.55 since 2014, with the newest cohort 

expected to begin training this July. However, VA needs additional resources such 

as funding for recruitment and retention incentives, Education Debt Reduction Program, and the Student Loan Repayment Program in order to aggressively compete 

with the private sector for this limited pool of mental health providers. 

Question 74. As of the hearing there were 1,321 vacancies in Ohio, with the following breakdown: Veteran Health Administration 1,204 exempt 55 nonexempt, 

Veteran Benefit Administration 48 exempt 9 nonexempt, Human Resources and Administration 2 nonexempt, Office of Information and Technology 3 exempt. 

a. Of those exempted positions, what is the average time to fill a vacancy? 

Response. The following Time to Hire (T2H) data is based on the data utilized 

for hiring metrics during the 1st quarter of FY 2018. The data provided represents 

hiring actions made via a job announcement and does not include hires made via 

the noncompetitive hiring process. 

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T2H Overview: 

The T2H metric is measured from the date the hiring need is validated to the actual start date. OPM’s recommended T2H is 80 days. 

• VA-wide average T2H: 73 days. 

• VHA average T2H: 79 days. 

• VBA average T2H: 44 days. 

• NCA average T2H: 64 days. 

b. What is the breakdown of the VHA exempted vacancies by VAMC and 

specialty? 

Response. The Secretary removed the hiring freeze on VHA medical centers within days after expiration of the Federal hiring freeze. Medical centers are able to hire 

for all positions and occupations. 

Question 75. Does the Department support the SVAC-passed comprehensive 

health care bill? 

Response. VA finds much of value in S. 2193, as approved by the Senate Veterans’ 

Affairs Committee on November 29, 2017, but an Administration position has not 

been established on the legislation. We look forward to continuing work with the 

Committee on this important effort. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MAZIE K. HIRONO TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

GI BILL ELIGIBILITY FOR FORMER CORINTHIAN COLLEGES STUDENTS

With the passage of the Harry W. Colmery Act, also known as the ‘‘Forever GI 

Bill,’’ VA has been given authority and resources to restore education benefits to 

student veterans who lost them following the closure of for-profit institutions like 

Heald College which operated in many states including Hawaii and approximately 

enrolled 192 veterans at the time of its closure. 

Question 76. Secretary Shulkin, could you provide the Committee with an update 

on the number of affected student veterans VA has restored benefits for those who 

attended Corinthian Colleges in Hawaii and the total number across the country 

who attended for-profit institutions that closed down? 

Response. As of January 26, 2018, VA has received over 700 applications and restored over 4,500 months of entitlement to almost 450 individuals. Heald College, 

which operated in many states including Hawaii, had enrolled 192 Veterans at the 

time of its closure. Since the new passage of the law, 67 beneficiaries that attended 

a school in Hawaii could apply for restoration. Of those, only 7 students have applied. Six students were found ineligible and 1 student benefits was restored for 11 

months and 12 days. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOE MANCHIN III TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 77. In a January 5th interview with Federal News Radio, Secretary 

Shulkin proposed that a review and closure process of underutilized and vacant facilities, like the Department of Defense has with BRAC, would free up resources and 

do maintenance on its newer facilities. 

a. How does VA define ‘underutilized’ in this context? 

Response. VA kicked off an initiative in June 2017 to reduce the burden of vacant 

buildings within its inventory. At the time, VA had 430 vacant buildings that cost 

approximately $7 million a year to maintain. To date, VA has reused or disposed 

of 131 (30 percent) of the 430 assets identified as vacant and is on track to meet 

its goal of initiating disposal or reuse actions for all 430 buildings by June 2019. 

On an annual basis, VA reports the number of underutilized buildings in its inventory. An underutilized building is defined as an individual building that is occupied 

and in use, but the function(s) housed there do not require the full amount of space 

in the building to operate. Essentially, the building is too big and not right-sized 

for the functions housed in it. While an underutilized building is not as efficient as 

it could be, the functions currently housed in it are still needed. VA is not reviewing 

or closing any underutilized facilities at this time. nor is VA initiating a Base Realignment and Closure (BRAC)-like process for these buildings. 

b. What criteria would be used in the evaluation process for determining which 

facilities would be susceptible to a BRAC? 

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Response. The Department is neither planning, initiating, nor undergoing a 

BRAC-like process. VA has developed the methodology for completing market area 

health system optimization assessments in each of the 96 health care markets 

around the country, with the goal of assessing the current and future Veteran demand for health care, assessing the available Federal and non-Federal assets available to meet that demand in each market, and planning to match that capacity to 

the demand in modernized high performing networks using a data-driven approach. 

The primary drivers for decisionmaking in each market would be better access, better quality of care, and higher levels of Veterans satisfaction in each market, at a 

sustainable cost. 

These networks will be well-connected, comprehensive coalitions, led by experienced VA managers who will coordinate VA health care services, complemented 

where appropriate by DOD providers, VHA’s academic affiliates, and other high 

quality private sector providers with competence in caring for veterans with serviceconnected conditions. Once the market assessments are complete and VA has market level, VISN level and regional or national level plans, the needs for capital investments for modernization, access, quality and Veteran satisfaction will be known. 

Similarly, the need for divestments of underutilized facilities may become apparent, 

where plans for the high performing local network would render an underutilized 

facility vacant. Until this process is completed in some VISNs, the facilities susceptible to renovation, modernization, repurposing or divestment will not be fully 

known. 

The VA MISSION Act of 2018, Section 203 requires the development of Criteria 

on the ‘‘modernization or realignment of VHA Facilities.’’ VHA will work with the 

Office of Asset Enterprise Management, which has existing criteria that has been 

used, most recently, in development of the list of vacant and underutilized buildings 

that was referenced by former Secretary Shulkin in January. Additionally, VHA Operations will also be included in the discussion to insure broad understanding and 

field impact to follow the requirements of this section of the MISSION Act. 

Question 78. In terms of the 110 quality metrics posted on VA webpages— 

a. How are you equipping local VA Medical Center staff to track and record these 

metrics? 

Response. These metrics are available to all VA staff through the Strategic Analytics for Information and Learning (SAIL) reporting system via the agency’s 

intranet. SAIL includes drill-down tools that allow more detailed trending of individual metrics and access to diagnostic tools that can help facilities improve their 

performance. Employees with authorization to view Social Security Number-level 

data for their facility will also be able to identify the specific Veterans records that 

contributed to the quality measure. 

b. Who in the West Virginia VAMCs are responsible for collecting this data? 

Response. Data are collected via a centralized process for all VAMCs and are not 

dependent on local data collection efforts. This ensures the reliability of the data 

and reduces the likelihood of manipulation or ‘‘gaming.’’ The exact process of collecting data vary by the specific measure domain. For instance, patient experience 

data is collected via a survey mailed by an outside contractor to Veterans who have 

recently used VA inpatient services. That contractor conducts the survey, collates, 

analyzes, and reports results according to standard protocols established by the 

Centers for Medicare and Medicaid Services (CMS). Health outcomes data are calculated using CMS algorithms from electronic data derived from our EHR. Measures for timely and effective care are collected via standardized processes for medical record abstraction through VA’s External Peer Review Program. 

c. In your hearing, you cited that an HHS contract issues resulted in VA data not 

being able to update information on Hospital Compare website. Can you please 

elaborate on the contract issues and what VA and HHS are doing to mediate this 

in the near term? 

Response. VA and CMS have been working together to include quality measure 

data on the Hospital Compare website. Revisions to an Interagency Agreement 

(IAA) with CMS were completed, and the new VA-CMS IAA was signed in 

April 2017. Subsequent to that, CMS has been updating its processes to incorporate 

VA data in the calculation of measures for the different domains of performance 

such as Outcomes, Safety, Timeliness and Effectiveness, and Patient Experience. 

Many quality measures for VA hospitals have been updated and are posted on Hospital Compare, such as hospital survey data and readmissions and mortality measure data. CMS is also working with the VA on additional measures that can be 

added to the website. 

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Question 79. In light of President Trump’s declaration of a public health emergency, what additional resources or authorities does VA need to more effectively 

combat the opioid crisis? 

Response. Action steps if new budget dollars were identified within VHA’s budget: 

• Enhanced Pain Management Teams with multi-modality approaches and increased consultative opportunities through SCAN-ECHO and Telehealth. 

• Expand education opportunities and collaborations between VA, other Federal 

Agencies and private providers. 

• Provide Academic Detailers and other VA developed training to private providers, especially those providing care to Veterans in the community. 

• Increased capacity for high functioning primary care teams with timely access 

to pain specialty care for the most complex pain patients (stepped care). 

• Fully integrated bidirectional State Prescription Drug Monitoring Programs 

(PDMP) and data storage allowing automated checks and data retrieval reducing 

the provider burden. 

• National media campaign for STOP PAIN to enhance the awareness, availability, and utilization of VA developed best practices in the private section to 

include: 

– Stepped Care Model; 

– Treatment alternatives/complimentary care; 

– Ongoing monitoring of usage; 

– Practice Guidelines; 

– Prescription monitoring; 

– Academic Detailing ; 

– Informed consent for patients; and 

– Naloxone distribution. 

Question 80. In your written testimony, you cite that the December 2017 strategic 

pause of the Electronic Health Record Acquisition occurred so that additional and 

external assessments of national interoperability language contained in the request 

for proposal (RFP) would ultimately support an EHR contract award. 

a. Please describe specifically what assessments were done before the Cerner 

award was announced. 

Response. The MITRE Corporation was selected to coordinate and lead an independent assessment utilizing external clinical, technical, and executive-level interoperability experts to evaluate the contract language related to interoperability. 

After reviewing the assessment, the Department of Veterans Affairs (VA) adjudicated/reconciled each of MITRE’s comments into the updated request for proposal 

(RFP). 

VA took an additional step utilizing a myriad of key leaders from the private sector (e.g., Johns Hopkins, Mayo Clinic, Intermountain, Cleveland Clinic, among others), who recently implemented a new electronic health record solution, to ensure 

there were no gaps in the RFP and lessons learned were captured from the private 

sector. The comments submitted were primarily high-level lessons learned from 

their own past experiences. VA effectively re-validated the RFP language based on 

these inputs. 

b. How much will this additional MITRE Corporation assessment cost? 

Response. The MITRE Corporation Interoperability Assessment (Task 1) was 

awarded for $396,581. 

c. In the meantime, what are you doing to undergird the current EHR system to 

ensure patient care presently? 

Response. VA is committed to maintaining high-quality connections through 

health information exchanges. These connections, in turn, push further cooperation 

among the three dominant exchanges (CareQuality, CommonWell, eHealthExchange) and with regional health information exchanges. 

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A P P E N D I X 

PREPARED STATEMENT BY NATIONAL ORGANIZATION OF VETERANS’ ADVOCATES, INC. 

CHAIRMAN ISAKSON, RANKING MEMBER TESTER, AND MEMBERS OF THE COM- MITTEE, The National Organization of Veterans’ Advocates (NOVA) would like to 

thank you for the opportunity to provide a statement in response to Secretary 

Shulkin’s testimony regarding VA reform legislation passed in 2017. Our statement 

will focus on implementation of the Veterans Appeals Improvement and Modernization Act of 2017. 

NOVA is a not-for-profit 501(c)(6) educational membership organization incorporated in the District of Columbia in 1993. NOVA represents nearly 600 attorneys 

and agents assisting tens of thousands of our Nation’s military veterans, their widows, and their families seeking to obtain their earned benefits from VA. NOVA 

works to develop and encourage high standards of service and representation for all 

persons seeking VA benefits. NOVA members represent veterans before all levels 

of VA’s disability claims process, and handle appeals before the U.S. Court of Appeals for Veterans Claims (CAVC) and U.S. Court of Appeals for the Federal Circuit 

(Federal Circuit). In 2000, the CAVC recognized NOVA’s work on behalf of veterans 

with the Hart T. Mankin Distinguished Service Award. NOVA operates a full-time 

office in Washington, DC. 

Attorneys and agents handle a considerable volume and growing number of appeals at the Board of Veterans’ Appeals (BVA). In FY 2015, for example, attorneys 

and agents handled 14.9% of appeals before BVA. This number was fourth only behind Disabled American Veterans (28.1%), State Service Officers (16.5%), and American Legion (15%). U.S. Department of Veterans Affairs, Board of Veterans’ Appeals 

Annual Report Fiscal Year 2015 at 27. In FY 2016, this number grew to 15.9%, 

third only to Disabled American Veterans (28.1%) and American Legion (19.6%). 

U.S. Department of Veterans Affairs, Board of Veterans’ Appeals Annual Report Fiscal Year 2016 at 26. Similar statistics are available for FY 2017, with attorneys and 

agents representing appellants in 17% of cases, again third behind Disabled American Veterans (31%) and American Legion (18%). 

NOVA members have been responsible for significant precedential decisions at the 

CAVC and Federal Circuit. In addition, as an organization, NOVA has advanced important cases and filed amicus briefs in others. See, e.g., Henderson v. Shinseki, 562 

U.S. 428 (2011)(amicus); NOVA v. Secretary of Veterans Affairs, 710 F.3d 1328 (Fed. 

Cir. 2013)(addressing VA’s failure to honor its commitment to stop applying an invalid rule); Gray v. Secretary of Veterans Affairs, No. 16–1782 (Jan. 3, 2018)(amicus 

in support of petition for rehearing before the Federal Circuit); Robinson v. McDonald, No. 15–0715 (July 14, 2016)(CAVC amicus). 

We detail below concerns that should be addressed to ensure implementation of 

the appeals reform legislation preserves the long-standing intent of Congress: that 

the VA benefits adjudication and appeals process be veteran friendly and nonadversarial. 

OVERVIEW

NOVA appreciated the opportunity to participate in the discussion of appeals reform that led to the passage of the Veterans Appeals Improvement and Modernization Act of 2017. We also applaud VA’s ongoing inclusion of stakeholders in the discussion of its implementation plans, which has included opportunities to review 

draft regulations and documents related to its Rapid Appeals Modernization Program. NOVA remains committed to providing constructive feedback in response to 

these opportunities, and urges VA to consider and implement the recommendations 

of the stakeholder community. 

As we have previously noted, successful implementation will be key if appeals reform is truly to be the positive change veterans deserve and VA promises. SuccessVerDate Mar 15 2010 15:26 Mar 08, 2019 Jkt 000000 PO 00000 Frm 00133 Fmt 6601 Sfmt 6621 Z:\115TH COMPLETED HEARINGS, MTGS\29742.TXT PAULIN
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ful execution of VA’s proposed process hinges on its ability to consistently meet its 

goals of adjudicating and issuing decisions in the 125-day window identified for supplemental claims and deciding appeals within the one-year period before BVA. As 

demonstrated with the prior backlog of original claims and scheduling of medical 

appointments, VA often struggles to meet its own internal goals to the detriment 

of veterans. 

RAPID APPEALS MODERNIZATION PROGRAM (RAMP)

Relying on section 4 of Public Law 115–55, VA implemented the Rapid Appeals 

Modernization Program (RAMP) in November 2017. According to the Standard Operating Procedures (SOP) designed for RAMP, the Veterans Benefits Administration 

(VBA) ‘‘will administer this pilot during the 18-month period after enactment allowed for full implementation of the new process and continue processing elections 

by Veterans as long as necessary thereafter to continue to accelerate resolution of 

legacy appeals.’’ SOP at 1. Based on VA’s proposed rollout of this program, as of 

January 1, 2018, VA sent approximately 15,500 letters to veterans with appeals eligible for acceptance into RAMP. Secretary Shulkin testified that, to date, three percent of invited veterans have elected to opt into RAMP, and 75 percent of those decided have received a grant. 

As an initial matter, stakeholders need information and statistics on a regular 

basis to understand the current status of RAMP. How many appeals have been 

withdrawn from the legacy system and moved into RAMP, and what option was selected? What constitutes a grant? Have the 25 percent who received denials chosen 

to take any additional action? We realize it is still early in the process and some 

statistics might not yet be available. However, such data is important to stakeholders to understand the current state of the program and provide the best advice 

to veterans and their families. Data is also a critical component of any true pilot 

program to measure its success, and VA must commit to regular updates so stakeholders can gauge progress and suggest improvements. Furthermore, VA should ensure its field staff is receiving regular communications and training on RAMP operations, as well as updates on its progress. 

From NOVA’s perspective, there are a few reasons why there is a low opt-in rate 

to RAMP. First, VA chose not to extend the program through to BVA. Therefore, 

a veteran who withdraws his or her pending appeals (with no opportunity to return 

to the legacy system), is denied after either a higher-level review or supplemental 

claim, and wishes to appeal to BVA must now wait until the system is fully implemented—at the earliest in February 2019—to obtain BVA review. While VA has 

stated those veterans will be first in line for BVA review upon full implementation 

of the system, many representatives are reluctant to counsel an appellant to move 

into a program that does not extend to BVA and does not provide a full understanding of how the procedure will ultimately operate at BVA. Furthermore, VA’s 

recently submitted implementation plan indicates that the ‘‘average processing time 

goal for appeals under § 7107 does not apply to appeals submitted to the Board in 

response to a decision under VBA’s RAMP.’’ U.S. Department of Veterans Affairs, 

Comprehensive Plan for Processing Legacy Appeals and Implementing the Modernized Appeals System 8 (November 2017). 

Second, VA is targeting the oldest appeals. While we understand this strategy is 

designed to be fair to those who have been waiting the longest, many veterans currently receiving invitations are close enough to a BVA decision that they do not 

wish to move into something new, particularly in light of Secretary Shulkin’s welcome statement that BVA intends to decide 81,000 appeals in FY 2018. 

In addition, veterans with cases in remand status may be more likely to stay in 

the legacy system because BVA will retain jurisdiction over the appeal. The veteran 

will be entitled to expedited consideration upon return to BVA if he or she is not 

satisfied with the action taken on remand, as well as enforcement of the prior order. 

Finally, although NOVA appreciates VA efforts to ensure attorneys and agents receive copies of RAMP correspondence sent to veterans (required under its M21–1 

Adjudication Procedures Manual for all correspondence), VA’s mailing systems remain seriously flawed both for RAMP and overall adjudication procedures. NOVA 

receives nearly daily complaints from members that copies of correspondence are not 

being received. While VA has stated it plans to launch a centralized outgoing mailing system to rectify these issues, far too much correspondence has gone unmailed 

and unreceived. When VA fails to properly notify, important deadlines are missed 

and additional claims and appeals must be pursued to address VA’s failures, resulting in yet more delay in the process. 

It is clear that VA is not fulfilling its responsibilities in this regard. In July 2017, 

the Government Accountability Office (GAO) completed a report addressing VA’s 

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outgoing mail deficiencies. U.S. Government Accountability Office, Report to the 

Chairman, Committee on Veterans Affairs, House of Representatives, Veterans Affairs: Actions Needed to More Effectively Manage Outgoing Mail, GAO–17–581 

(July 2017). In addition to finding VA has an outdated mail management policy directive and handbook, it noted that ‘‘VA cannot ensure consistent mailing practices 

in its administrations and facilities because it has not provided mail managers with 

appropriate authority and responsibilities to oversee mail operations across the 

agency.’’ GAO Report at 7; see also GAO Report at 15. VA must improve its mailing 

practices, so veterans and their representatives receive proper notice of claims and 

appeals processing. 

IMPLEMENTATION OF THE VETERANS APPEALS IMPROVEMENT AND

MODERNIZATION ACT OF 2017

As part of the reporting requirements imposed under Public Law 115–55, in November 2017, VA submitted its first report, Comprehensive Plan for Processing Legacy Appeals and Implementing the Modernized Appeals System (hereinafter Comprehensive Plan). VA does not provide sufficient details for how it will handle legacy 

appeals in relation to modernized appeals once the new system is implemented. 

Based on several statements made in the report, it appears VA intends to devote 

resources first to modernized appeals and allocate ‘‘leftovers’’ to legacy appeals. See, 

e.g., Comprehensive Plan at 4 (‘‘VA will allocate available resources to meet the 

timely processing goals in the new system, as outlined in section 3(a)(3), and remaining resources are then employed to process legacy appeals.’’); Comprehensive 

Plan at 9 (‘‘VA intends to allocate resources in an efficient manner that will establish timely processing in the new process and will allocate all remaining appeals resources to address the inventory of legacy appeals.’’); Comprehensive Plan at 10 

(‘‘VBA intends to allocate field resources in an efficient manner that will establish 

timely processing in the new process and will allocate all remaining resources to address the inventory of legacy appeals.’’). VA needs to provide more details about how 

it will continue to process legacy appeals in a fair and timely manner while fulfilling 

its obligations under the new legislation, to include how it will address the substantial backlog of BVA hearing requests. 

Furthermore, in its implementation plan, VA stated it needs enhancements to the 

Veterans Benefits Management System (VBMS) to meet the statute’s specifications. 

Comprehensive Plan at 15. Secretary Shulkin also testified to VA’s ‘‘enterprise-wide 

efforts to modernize the appeals process through improvements in technology.’’ 

Statement of the Honorable David J. Shulkin, M.D., Secretary of Veterans Affairs, 

for Presentation Before the Senate Committee on Veterans’ Affairs, The State of VA: 

Progress Report on Implementing 2017 VA Reform Legislation 3 (January 17, 2018). 

Congress must ensure VBA and BVA continue to receive sufficient resources to implement necessary technological upgrades to its systems, particularly VBMS and 

Caseflow. VBMS was not designed with appeals processing in mind, and it lacks 

many features that would make work for VBA employees, BVA employees, and representatives easier and more efficient. VA should ensure VBMS enhancements continue, Caseflow is fully operational, and all representatives have access to as many 

features as appropriate to help them represent veterans as effectively as possible. 

CONCLUSION

NOVA is committed to continue working with this Committee, VA, and fellow 

stakeholders to ensure the appeals process for veterans is fair, timely, and preserves 

veterans’ due process rights. We again thank the Committee for allowing us to provide our views on implementation of appeals reform. 

PREPARED STATEMENT OF CARLOS FUENTES, DIRECTOR, NATIONAL LEGISLATIVE

SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES

CHAIRMAN ISAKSON, RANKING MEMBER TESTER, AND MEMBERS OF THE COMMITTEE, On behalf of the men and women of the Veterans of Foreign Wars of the 

United States (VFW) and its Auxiliary, it is a great pleasure to submit a statement 

for the record in response to Secretary of Veterans Affairs David J. Shulkin’s state 

of the Department of Veterans Affairs (VA) testimony. 

First and foremost, the VFW would like to thank the Committee and VA for all 

the accomplishments in 2017. Thanks to the bipartisan leadership of this Committee, Congress passed ten important veterans bills to improve benefits and service 

for those who have worn our Nation’s uniform and their families. While the VFW 

lauds the Committee’s efforts, Congress still has a long list of unfinished business. 

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The VFW looks forward to highlighting those topics when the VFW presents its legislative priorities before the Committee on March 7, 2018. 

COMMUNITY CARE

One item which should not be on the unfinished business list is S. 2193, the Caring for our Veterans Act of 2017, which was approved by committee nearly unanimously. This important bill would make much needed improvements to the way VA 

provides community and internal care to America’s veterans. Furthermore, this important bill would also correct a serious inequity between veterans who served before September 11, 2001 (9/11) and their pre-9/11 brothers and sisters by expanding 

caregiver benefits to veterans of all eras. 

The VFW implores the Committee to move this important bill as soon as possible. 

A recent continuing resolution provided VA with additional Choice Program funding, 

which is estimated to last up to five months, but veterans cannot afford for Congress to wait until the 11th hour to act. Veterans who rely on the Choice Program 

for their care are directly impacted by Congress’ inability to act swiftly on community care legislation. As we have seen in the past when funds were close to being 

depleted, when the Choice Program faces an immediate uncertainty veterans who 

are unable to receive VA care are forced to wait or travel long distances for the care 

they have earned and deserve simply because Congress has failed to act on comprehensive and permanent community care legislation. 

The VFW urges Congress to quickly pass the Caring for our Veterans Act of 2017, 

so we can finally put an end to the constant fear of budget shortfalls that leave veterans without timely access to the high quality and veteran-centric care they have 

earned. 

FOREVER GI BILL

The historic, bipartisan, and bicameral Forever GI Bill is the most significant improvement to veterans’ educational benefits in nearly a decade. Thanks to the hard 

work of the Committee and its staff, the Forever GI Bill tiger team, and a broad 

coalition of veterans, military, and educational organizations, more veterans and 

their survivors have an opportunity to pursue their educational goals. 

Thanks to the Forever GI Bill, all Purple Heart recipients will have full access 

to their GI Bill benefits; veterans attending schools that close abruptly through no 

fault of the veterans will be able to complete their degrees; thousands of involuntarily activated Reservists and Guardsmen will finally receive their well-deserved 

GI Bill benefits; surviving family members will be able to accomplish their educational goals with having to incur crippling educational debt; and veterans will no 

longer have a 15-year limitation on their earned educational benefits, which means 

veterans truly have a lifetime to use their GI Bill. 

The VFW is pleased to hear VA has implemented 13 provisions of the Forever GI 

Bill and that it is committed to ensuring all veterans impacted by changes are fully 

informed of their new benefits. However, the VFW has received mixed feedback on 

VA’s outreach efforts. VA has published informative websites and releases on the 

changes to VA education benefits. Yet, the veterans who are impacted tell us they 

have not been informed by VA about recent changes. Specifically, the VFW reached 

out to veterans who were impacted by recent school closures, and reported knowing 

they knew about the Forever GI Bill but had not been contacted by VA to have their 

educational benefits restored. 

Similarly, school certifying officials tell the VFW that they have not received any 

information from VA on recent changes to the GI Bill. School certifying officials are 

the first people student veterans turn to for information regarding their benefits. 

Without proper outreach from VA, school certifying officials are having to turn to 

other sources for information on impending changes. Doing so could lead to misinformation and confusing messaging to student veterans. VA must improve its outreach efforts and work with veterans organizations to make certain a uniform message is delivered to impacted veterans. 

APPEALS MODERNIZATION

When the negotiation process began for what would become Public Law 115–55, 

the Veterans Appeals Improvement and Modernization Act of 2017, it was made 

clear that the input and support of veterans service organization (VSO) was paramount to the enactment of the legislation. 

The VFW’s goal with appeals modernization was to build a process that placed 

the veteran first, was easy to navigate, and protected a veteran’s rights every step 

of the way. The VFW, along with several other organizations, has long advocated 

for appeals reform, and were honored to be a part of the process with the assurance 

133 

that the level of engagement that existed during the bills development would be sustained when implemented. 

However, once the legislation was passed, we began having concerns almost about 

VA’s implementation plans. As a result, in September, the VFW and DAV (Disabled 

American Veterans) sent a letter to Deputy Secretary of Veterans Affairs Thomas 

Bowman expressing our concerns with the speed of the roll out; the language used 

in the initial opt-in notification letter and phone script; and the overall lack of engagement that we, and other VSOs have been afforded up to that point. 

While VA has addressed of the issues identified on the joint letter, the VFW still 

has lingering concerns with regard to how VA is implementing these changes and 

communicating with VSOs regarding the progress that has or has not been made, 

and the data that supports that narrative. 

As an organization that represents a large portion of appellants with cases pending before the Board of Veterans Appeals (BVA), our clients depend on us to provide 

the most accurate advice in order to increase their chances of a successful appeal. 

We have been representing veterans for decades and have a good understanding of 

how the system works. Having researched the possible impact of the program on 

our clients, we have found that there are circumstances where opting-in may actually be detrimental to the veteran. 

Many of our clients have been waiting for years to have their cases heard at BVA. 

They have invested time and energy into appealing their claims, and many of them 

are appealing denials for extremely complex issues. For our organization to recommend that they opt-in to a program that is potentially faster, and may lead to 

their case being decided more quickly, but may also lead to them losing their place 

in line at BVA if they are denied would be reckless. 

As of this submission, we have not yet been shown concrete evidence from VA, 

or any of our clients that would suggest that Rapid Appeals Modernization Program 

(RAMP) will actually improve a veteran’s chance of a favorable outcome. During the 

hearing, Secretary Shulkin reported that 75 percent of RAMP decisions ‘‘are going 

in favor of the veteran.’’ While 75 percent may seem to indicate RAMP is a good 

option for veterans, VA’s testimony does not clarify how many appeals were adjudicated and what VA defines as favorable. To VA, issuing a zero percent serviceconnection may qualify as favorable. A veteran would disagree if the decision is for 

a debilitating condition that merits a higher rating. As a result, we have declined 

to recommend to veterans we serve that have received eligibility notices to participate in the program, and will continue to do so until we are provided with more 

thorough data from VA. 

The VFW urges Congress and VA to properly resource Veterans Benefits Administration (VBA) and the Board of Veterans Appeals to ensure they are able to timely 

adjudicate legacy appeals from veterans who do not opt into the new appeals process, and the potential influx of supplemental claims and higher level review 

requests at VA Regional Offices. VA must be empowered to manage its workload, 

and stakeholders must be properly informed if the new framework is expected to 

succeed. 

ACCOUNTABILITY AND WHISTLEBLOWER PROTECTIONS

The VFW strongly believes that proper accountability is vital to ensuring VA fulfills its mission to care for those who have borne the battle. VFW members across 

the country have firsthand experience with VA’s inability to quickly discipline 

wrongdoers. That is why the VFW praised the enactment of S. 1094, the VA Accountability and Whistleblower Protection Act of 2017. 

The VFW is pleased VA has taken steps toward improving accountability and 

transparency by implementing S. 1094 and publically releasing accountability reports. However, VA still has a long way to go. The VFW continues to hear reports 

of employees who are allowed to disrespect veterans or provide poor customer service. VFW members also report that whistleblower protections are not working because both patients and employees continue to fear they will be retaliated against 

if they report malfeasances. One VA employee tells the VFW that he fears the enhanced accountability measures have worsened nepotism at VA medical facilities. 

The VFW urges Congress to closely monitor implementation of S. 1094 to ensure 

wrongdoers are swiftly held accountable, whistleblowers are protected, and nepotism 

is eliminated. 

However, Congress cannot simply focus on firing bad employees. It must also ensure VA is able to quickly hire high quality employees. If VA is not able to replace 

wrongdoers with high quality employees, it will lack the staff needed to accomplish 

its mission. The VFW urges the Committee to work with VA to address barriers in 

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recruiting and retention of high quality professionals, who are willing to work at 

VA medical facilities. 

Specifically, the VFW continues to hear that VA’s licensing and credentialing 

process is excessively long and should be modified to make certain VA is able hire 

high quality doctors on a timely basis. The VFW also heard from providers who 

work at VA that they face delays transferring to underserved areas because they 

are required to undergo credentialing procedures again even though VA policy 

authorizes transfers between VA medical facilities without having to undergo credentialing. Veterans want more doctors at their VA medical facilities, but requiring 

doctors who want to serve veterans to jump through hoops prevents this from 

happening. 

Congress must also ensure VA has the authority to timely hire front line staff. 

Due to the lack of support staff, many VA providers are required to spend time on 

administrative tasks instead of treating patients or spending more time with their 

patients. VA is in the process of streamlining its hiring process for medical scheduling assistants (MSAs) and has set the goal of hiring MSAs within 30 days, which 

is half the time it takes, on average, to hire support staff today. The VFW commends VA for its efforts, but it is time Congress expands direct hire authorities to 

all Veterans Health Administration staff, not just doctors and nurses. We fear that 

VA’s workforce productivity could decline due to staffing shortages and low employee morale if Congress does not reform VA’s hiring authorities. 

HOMELESS VETERANS PROGRAMS

The nearly 50 percent reduction in veteran homelessness is laudable and the holistic partnerships and approaches taken by VA, the Department of Housing and 

Urban Development (HUD) and the Department of Labor (DOL) are absolutely critical to that success. Success, however, could be diminished if funding fails to keep 

pace with demand. Congress cannot allow VA to stymie its homeless veterans by 

reducing much needed funding. 

Specifically, the VFW has great concerns with VA’s decision to realign specificpurpose funds allocated for homeless programs as a means to provide VA health 

care facility directors with more individual control over their location’s general funding needs. In theory, this could be a successful idea. But this theory will undoubtingly be a failure without the transparency and desire to work with VSOs and 

Congress, and that cost should most certainly not come at the expense of homeless 

veterans. 

After receiving negative feedback from VSOs, and a letter from the Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related 

Agencies, VA chose to put a temporary halt on this initiative. We ask that this Committee join us in closely monitoring VA’s attempts to handicap its successful homeless veterans programs. 

Taking away the guaranteed specific-purpose funding for homeless veteran programs, such as the massive cut initially suggested by VA to HUD- Veterans Affairs 

Supportive Housing (VASH), would result in a guaranteed failure of the program. 

The specific funding for HUD-VASH is crucial to the ability of case managers within 

VA to properly perform their jobs and assist homeless veterans in all the ways they 

are intended to help. These case managers are like life coaches for homeless veterans getting their feet back on the ground. This program’s case management is the 

embodiment of the holistic approach and the answer to successfully overcoming 

homelessness. 

Since VA has reconsidered and postponed the timeline to readjust this funding, 

the VFW has eagerly awaited the opportunity to have a transparent and open conversation with VA about the intent and how to responsibly move forward. Yet, just 

because the decision was put on hold for now does not mean there were no repercussions. The VFW’s Department of California’s Homeless Service Providers have found 

that VA’s attempts to reallocate HUD-VASH funding has negatively impacted the 

program. 

The two primary concerns they have found thus far include employment rates of 

HUD-VASH case managers as well as individual state-funded programs for homeless veterans. In communities across California, such as Kerr County, VA has not 

been able to hire enough HUD-VASH case managers even with current funding. 

This results in case managers taking on an average of 50 homeless veterans instead 

of VA’s suggestion of 25 homeless veterans per case manager. While managing twice 

as many veterans as suggested, and with the travel requirements of case management, locations such as these are not able to utilize all the vouchers they receive. 

With a massive cut in funding, there is a major fear that employment rates for case 

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managers will only get worse. It has also been rumored that voucher distribution 

will be halted in some communities, out of fear that they will run out. 

Also, various states that rely on HUD-VASH funding have implemented their own 

programs to assist in combating veteran homelessness. For example, California’s 

Proposition 41, Veterans Housing and Homeless Prevention Bond, is heavily dependent on VA’s Supportive Housing as a subsidy for the bonds used to provide for 

homeless veterans and their families. This serves as an example of how cutting 

HUD-VASH funding could have even more worrisome and unintended consequences 

that cut deeper than originally thought. 

PRE-DISCHARGE CLAIMS

As the Nation’s oldest major VSO, the VFW serves 24 military installations to 

help veterans navigate and understand their earned VA benefits. To the VFW, filing 

claims prior to separation from the military is one of the most important processes 

that a servicemember can complete during the transition process. Not only does this 

ensure timely delivery of benefits after discharge, but it also increases the likelihood 

of granting benefits, setting veterans up for future success. 

As transition programs evolve, Congress, the Department of Defense (DOD), and 

VA all seek to make changes to better suit the transition experience. Many times 

these changes result in improved service for the transitioning servicemember, such 

as the Transition Assistance Program mandate included in the VOW to Hire Heroes 

Act; DOD’s deployment of the military lifecycle model for transition; VA’s establishment of the pre-discharge claims program; or the joint DOD/VA commitment to develop a single medical record for servicemembers and veterans. 

Unfortunately, sometimes changes have unintended consequences that may result 

in a degraded transition experience for the servicemember. This is where the VFW 

takes its responsibility as a veterans’ advocate to inform the agencies of jurisdiction 

and the Committee of our concerns. Recently, VA made two significant changes to 

its pre-discharge claims programs that make the VFW concerned about the future 

of this critical interaction and the professional services we provide to our transitioning military members. First, VA shifted its timelines for the Benefits Delivery at 

Discharge (BDD) program, only allowing servicemembers to submit BDD claims 

from 180–90 days prior to discharge. Second, VA eliminated the Quick Start (QS) 

claims program entirely, meaning veterans with 89 days or fewer left on active duty 

no longer have an option tailored to their unique circumstances to easily access 

their earned benefits. 

The VFW understands why VA wanted to shift the timeline for BDD to 90 days. 

We understand that this allows VA to complete exams and propose rating decisions 

to deliver benefits as close to a servicemember’s date of discharge as possible. In 

a vacuum, this is a positive step. However, coupled with the elimination of QS and 

the military’s cumbersome transition timelines, the VFW believes this change would 

disqualify most servicemembers the VFW serves from easily accessing their benefits 

on their way out of the military. 

According to VA, the VFW’s claimants on military installations who filed QS 

claims fluctuated between 33 and 50 percent over the past year. In visiting with 

our pre-discharge claims sites, we hear that most clients visit our offices with far 

fewer than 90 days left on active duty, meaning most of our past BDD clients would 

no longer be qualified for the program. Yes, VA still accepts these claims, but they 

are no longer processed expediently while the veteran still serves on active duty, 

and they are no longer tracked with a unique end product (EP) code specific to QS 

claims, formerly EP code 337. 

In the past, this EP code allowed the VFW to track pre-discharge claims work to 

perform rating reviews and ensure the best possible outcome for our transitioning 

servicemembers. Now, with the elimination of the QS EP code, claims we submit 

on behalf of transitioning servicemembers are assigned as any other claim in VA’s 

National Work Queue. VA will argue that this is not a big deal and that VFW-accredited representatives anywhere can conduct these rating reviews. While this is 

technically true, we lose optics on these claims and can no longer properly track and 

report how well VA is serving the transitioning servicemember population. If we 

cannot identify problems this early in the process, we are not setting up the servicemember for post-military success. 

As of this hearing, the VFW has six personnel stationed at the VA regional offices 

(VARO) responsible for pre-discharge claims adjudication whose sole responsibility 

is to review rating decisions and correct any possible errors. Our most recent data 

indicates that our rating review specialists catch VA adjudication errors in up to 20 

percent of pre-discharge claims and are able to resolve such errors prior to promulgation of the award. 

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Several years ago, recognizing the unique needs of transitioning servicemembers, 

VA committed not to broker work from the consolidated pre-discharge claims worksites at the VAROs in Winston-Salem, Salt Lake City, and San Diego. VA reneged 

on this promise last year with its across-the-board implementation of the National 

Work Queue, as we have testified in the past, and we do not expect VA will go back 

to its old workflows since this has seemed to increase productivity and efficiency for 

VA. However, through unique EP codes and Station of Origination filtering in the 

Veterans Benefits Management System, our pre-discharge quality control team was 

able to track and review work regardless of the VARO of jurisdiction for adjudication. This was a satisfactory middle ground to meet both the needs of VA to broker 

its work and the VFW’s need to maintain optics on transitioning servicemembers’ 

claims for quality control purposes. However, with the elimination of the QS EP 

code, we lose optics on this work and can no longer fulfill our commitment to transitioning servicemembers to perform the proper quality controls on their claims. 

Moreover, VA exacerbated an already tenuous situation by notifying transitioning 

servicemembers with fewer than 90 days on active duty that they were ‘‘disqualified’’ from filing BDD claims. Since the change went into effect October 1, 2017, we 

have heard from all of our pre-discharge claims sites and several of our VARO worksites that veterans have called or visited the offices, concerned that something went 

wrong with their claim. We even have one report from our office at Walter Reed 

National Military Medical Center that a retiree received a BDD disqualification letter 92 days prior to separation. 

This is a situation where language is critical. When the VFW was first presented 

with this letter, we vehemently disagreed with VA’s decision to send it as worded. 

This concern was ignored until the recent House Veterans’ Affairs Disability Assistance and Memorial Affairs Subcommittee hearing, after which VA has agreed to review these notification letters with VSOs. 

The VFW calls on VA to put veterans, not appearances, first. It must accept 

claims prior to separation, instead of punishing transitioning servicemembers whose 

chain of command does not permit them the opportunity to begin their transition 

process 90 days before they separate from military service. At the very least, VA 

must reestablish an EP code for transitioning servicemembers who file a claim within 90 days of separation to ensure the VFW and other veterans organizations are 

able to assist veterans in successfully transitioning from military service back to civilian life, regardless of where they choose to call home. 

VA must also rework the disqualification letters to simply notify the veterans that 

their claims have been received, but cannot be worked until they separate from 

service and submit their DD–214 paperwork. These simple steps will once again ensure that the VFW and similarly-structured organizations can continue to provide 

the advocacy our clients expect, and transitioning servicemembers will once again 

have peace of mind that VA is responsibly handling their pending benefits claims. 

Unfortunately, the VFW worries there is a larger objective with the recent 

changes to VA’s pre-discharge claims programs. While VA asserts that moving the 

window to 90 days results in better claims service, the elimination of the QS EP 

code and the rapid deployment of programs like the Decision-Ready Claims process 

indicate to the VFW that VA’s primary objective is to obfuscate the total pending 

workload. 

Based on the VFW’s estimates, we would lose optics on up to 50 percent of our 

pre-discharge workload simply by VA shuffling the BDD timelines and eliminating 

the QS EP code. The problem is not only that we lose optics on the claims, but VA 

will not formally establish the BDD-excluded claims until veterans formally submit 

their DD–214s after they separate from service. This means that any time from 89 

days to the time of the veteran’s submission does not count as pending work as it 

formerly counted when the claim was established under a QS EP code. 

To the VFW, the time when servicemembers transition off of active duty is one 

of the most significant changes they will experience in their lives. This Congress 

and the VSO community have dedicated substantial resources to make sure that we 

get this right. The VFW values the role that we are allowed to play in the process 

through both VA and DOD, and we are always looking for ways to improve. Our 

goal is that we can move forward together to ensure that our transitioning servicemembers have access to the programs, information, and services they need for a successful transition out of military life. 

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