U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2250 Mail: Stop SSOP, Washington, DC 20402–0001

37-239 PDF 2007

S. HRG. 110–132

HEARING ON THE NOMINATION OF

MICHAEL J. KUSSMAN, M.D., TO BE UNDER

SECRETARY FOR HEALTH, DEPARTMENT OF

VETERANS AFFAIRS

HEARING

BEFORE THE

COMMITTEE ON VETERANS AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

MAY 16, 2007

Printed for the use of the Committee on Veterans’ Affairs

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II)

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BARACK OBAMA, Illinois 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

LARRY E. CRAIG, Idaho, Ranking Member 

ARLEN SPECTER, Pennsylvania 

RICHARD M. BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

LINDSEY O. GRAHAM, South Carolina 

KAY BAILEY HUTCHISON, Texas 

JOHN ENSIGN, Nevada 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III)

C O N T E N T S 

MAY 16, 2007

SENATORS 

Page 

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1

Prepared statement .......................................................................................... 2

Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho ..................... 19

Prepared statement .......................................................................................... 20

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 21

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 21

Burr, Hon. Richard, U.S. Senator from North Carolina ....................................... 74

WITNESSES 

Kirch, Darrell G., M.D., President and Chief Executive Officer, Association 

of American Medical Colleges ............................................................................. 2

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

Frese, Frederick J., III, Ph.D., Member, National Board of Directors, National 

Alliance on Mental Illness ................................................................................... 6

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

Mitchell, Douglas H., Jr., MSW, LCSW, ACSW, President, Association of 

VA Social Workers ............................................................................................... 12

Prepared statement .......................................................................................... 14

Wallace, Robert E., Executive Director, Washington Office, Veterans of Foreign Wars of the United States ........................................................................... 15

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

Kussman, Michael J., M.D., Nominee to be Under Secretary for Health, 

Department of Veterans Affairs .......................................................................... 24

Prepared statement .......................................................................................... 26

Response to pre-hearing questions submitted by Hon. Daniel K. Akaka .... 28

Response to written questions submitted by: 

Hon. Daniel K. Akaka .................................................................................. 42

Hon. John D. Rockefeller IV ........................................................................ 51

Hon. Patty Murray ........................................................................................ 55

Hon. Sherrod Brown ..................................................................................... 56

Questionnaire for Presidential nominee ......................................................... 57

United States Office of Government Ethics, letter ........................................ 66

APPENDIX 

Sanders, Hon. Bernard, U.S. Senator from Vermont, prepared statement ........ 81

Inouye, Hon. Daniel K., U.S. Senator from Hawaii, letter of support ................ 82

(1)

HEARING ON THE NOMINATION OF

MICHAEL J. KUSSMAN, M.D., TO BE UNDER

SECRETARY FOR HEALTH, DEPARTMENT OF 

VETERANS’ AFFAIRS 

WEDNESDAY, MAY 16, 2007

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 10 a.m., in Room 562, 

Dirksen Senate Office Building, Hon. Daniel K. Akaka, Chairman 

of the Committee, presiding. 

Present: Senators Akaka, Murray, Tester, Webb, Craig, and 

Burr. 

OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. The hearing of the U.S. Senate Veterans’ Affairs Committee will come to order. 

I note that we have a series of votes scheduled for 10:30. My 

hope is that we can withhold all opening statements, and move directly to the testimony of the first panel as we consider the nomination of Dr. Michael Kussman to serve as Under Secretary for 

Health of the Department of Veterans Affairs. When we return 

from votes, we can proceed with opening statements and hear from 

our nominee, Dr. Kussman. But in the meantime, we will proceed 

with the panel. 

But before we do that, I want to make a special introduction and 

that is of Dr. Kussman’s wife, Ginny. Ginny, it is good to have you 

here, also Josh, who is here, as well as Josh and Deana’s significant others, as well, here with us today for this very, very special 

hearing. 

I welcome our first panel of witnesses. We have invited each of 

you to hear your perspective on Dr. Kussman’s qualifications to be 

Under Secretary for Health for the Department of Veterans Affairs. 

First, I welcome Dr. Darrell Kirch, President of the Association 

of American Medical Colleges since July of 2006. Dr. Kirch, thank 

you so much for being here today. I look forward to hearing your 

views on Dr. Kussman from the perspective of VA’s medical school 

affiliations. 

Dr. Fred Frese is a respected clinician and is here on behalf of 

the National Alliance on Mental Illness. 

I also welcome Douglas Mitchell of the Association of VA Social 

Workers. It is important to have VA employees represented at this 

2

hearing, and I am glad that you could make it here to provide us 

with your perspective. 

Finally, I have asked Robert Wallace of the Veterans of Foreign 

Wars to speak for his organization regarding Dr. Kussman. Mr. 

Wallace, as a representative of those who rely on VA health care 

and the health care system, your opinion is particularly important. 

Again, I want to thank all of you for being here today. 

Your full statements will appear in the record of the Committee. 

[The prepared statement of Hon. Daniel K. Akaka follows:]

PREPARED STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,

U.S. SENATOR FROM HAWAII

This hearing is to consider the nomination of Michael J. Kussman, M.D., to be 

VA’s Under Secretary for Health. 

Dr. Kussman, your nomination comes before the Senate at a difficult and challenging time for VA. The terrible conditions at Walter Reed put a spotlight on VA 

health care. With each passing day, more and more servicemembers are returning 

with serious traumas and injuries, which for some will mean a lifetime of care from 

VA. As servicemembers reach out to VA, inevitably we hear tragic stories of those 

who did not get the care they needed. 

There is no doubt that mental health issues will also be a challenge for VA. A 

truth of the war is that the toll will be felt by servicemembers and their families 

for years to come. I am talking about invisible wounds—wounds which cannot be 

seen but are every bit as devastating as physical wounds. 

VA’s Under Secretary for Health is one of the most important public servants. The 

next Under Secretary will guide the VA medical system at a time when so many 

new veterans will be turning to VA. From my vantage point, VA was not prepared 

to deal with the types of injuries stemming from this war. Capacity must be rebuilt. 

And the next Under Secretary will have this challenge. 

I urge you, Dr. Kussman: if you are confirmed, to first and foremost serve as an 

advocate for veterans. I am quite cognizant of the constraints placed upon you by 

the White House and OMB. I promise you my full cooperation and assistance, but 

I tell you now, that I will not be satisfied unless you work to uphold the promises 

made to all our troops.

May I call first on Dr. Kirch. 

STATEMENT OF DARRELL G. KIRCH, M.D., PRESIDENT,

ASSOCIATION OF AMERICAN MEDICAL COLLEGES 

Dr. KIRCH. Mr. Chairman, Members of the Committee, I very 

much appreciate the opportunity to testify in support of Dr. 

Kussman today. As you said, I am Darrell Kirch and I serve as the 

President of the Association of American Medical Colleges. We represent the 125 medical schools in the United States and 107 of 

those schools are closely affiliated with the VA. We also represent 

over 400 major teaching hospitals, and that includes 68 VA medical 

centers. 

It has been more than six decades that America’s medical schools 

and the VA have had this remarkable partnership around research, 

education, and patient care. I have to say that relationship means 

a great deal to me personally. The majority of my clinical experiences as a medical student, as a resident in training, happened in 

VA medical centers. The physicians, the staff of the VA, but most 

of all, the patients of the VA were among the finest teachers I had 

in my career. Additionally, my first exposure to the excitement of 

medical research and the beginning of my career as a medical scientist came seeing studies conducted at the VA to improve

patient care. 

3

It is really clear to me from the work of the Joint VA–AAMC 

Deans Liaison Committee we have that Dr. Kussman takes a great 

deal of pride in this special relationship and partnership, and it is 

also clear to me from his distinguished career that his first priority 

is ensuring first-class health care for the Nation’s veterans. 

Before I speak specifically to why I think he is so well-suited to 

carry forward our joint mission, I do want to mention two items 

that are in my written testimony that I think are critically important to our Nation going forward. The VA plan to increase support 

for graduate medical education by adding 2,000 residency positions 

over the next 5 years is absolutely vital at this time to our Nation. 

It is increasingly clear with the growth and aging of our population 

we face a severe physician shortage and this will help us dramatically with that. 

The second point I wanted to underscore is the urgent need to 

increase funding for the VA Medical and Prosthetic Research Program. This attracts high-caliber clinicians, scientists, to deliver 

care, conduct research at the VA facilities, and it is my hope that 

Dr. Kussman, the Administration, and this Congress can work to 

provide more funding for that program. 

But turning my attention to Dr. Kussman and the VA Deans Liaison Committee, I can highlight four things that I have seen 

under his stewardship where we are making great progress. 

First, we have worked with Dr. Kussman and the VA staff to ensure that the Blue Ribbon Panel on Medical School Affiliations will 

have measurable outcomes. We want this panel to help us establish 

specific criteria so that we can look at each affiliation and evaluate 

its health as a partnership. 

Second, to prevent conflicts of interest, the VA has very appropriately determined that we have to have limits on remuneration 

from affiliated institutions for VA employees who serve at the level 

of chief of staff or above. We have been pleased, though, to work 

with Dr. Kussman and the VA to ensure that while these arrangements scrupulously avoid conflicts of interest, they also address 

concerns that prohibiting certain kinds of academic compensation 

could hinder the VA’s ability to recruit the best staff from its

affiliates. 

The third thing we have worked on under Dr. Kussman’s leadership has been a pilot of the new hours bank concept for the way 

part-time physicians can work at the VA. 

Medical work is very complex and the hours bank will allow 

medical faculty who also have appointments at the VA to work 

more efficiently to negotiate pay schedules and get the job done for 

patients. 

And then last, we have worked with Dr. Kussman to ensure that 

the changes required by the Veterans’ Health Care Eligibility Reform Act of 1996 would not adversely affect the affiliations, and we 

are very pleased that recognizing the benefit of the affiliated training programs, the VA has concluded that contract awards that 

overlap with medical education have to be weighed by additional 

factors beyond just the pure contract cost. 

I thank you for the opportunity to testify today. I congratulate 

Dr. Kussman on his nomination and I personally very much look 

forward to working with him and continuing what is a truly reVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
4

markable partnership for America. I will be happy to answer any 

questions you have at any point. 

[The prepared statement of Dr. Kirch follows:]

PREPARED STATEMENT OF DARRELL G. KIRCH, M.D., PRESIDENT AND CHIEF

EXECUTIVE OFFICER, ASSOCIATION OF AMERICAN MEDICAL COLLEGES

Good morning. Mr. Chairman, Members of the Committee, I would like to thank 

you for the opportunity to testify in support of Dr. Michael J. Kussman’s nomination 

as Under Secretary for Health at the Veterans Health Administration (VHA) of the 

U.S. Department of Veterans Affairs (VA). 

My name is Dr. Darrell G. Kirch and I am President and Chief Executive Officer 

of the Association of American Medical Colleges (AAMC). The AAMC is a nonprofit 

association representing all 125 accredited U.S. medical schools; nearly 400 major 

teaching hospitals and health systems, including 68 Department of Veterans Affairs 

medical centers; and 94 academic and scientific societies. Through these institutions 

and organizations, the AAMC represents 109,000 faculty members, 67,000 medical 

students, and 104,000 resident physicians. 

For more than 60 years, academic medicine and the VA have enjoyed a remarkable partnership in our joint missions of medical education, research, and patient 

care. This relationship is especially meaningful to me because the majority of my 

own clinical experience as a medical student and resident occurred in VA medical 

centers. The physicians and staff, and especially the patients, of the VA were among 

my finest teachers. Additionally, my first exposure to the excitement of biomedical 

research, leading to my own career in science, came through studies being conducted 

at the VA to improve patient care. 

Dr. Kussman understands that the first priority is the patient. And throughout 

his distinguished military career, he has dedicated himself to ensuring world-class 

health care for our Nation’s military servicemen and women. Dr. Kussman also understands that veteran care can be improved by the partnerships the VA has built 

with medical schools and teaching hospitals. 

In my comments today, I would like to tell you more about the relationship between the VA and academic medicine—and why I believe Dr. Kussman’s leadership 

will be pivotal in carrying forward our joint missions of education, research, and patient care, with the goal of ensuring the best care for our Nation’s veterans. 

HISTORY OF VA—ACADEMIC AFFILIATIONS

Our longstanding association with the VA began shortly after World War II when 

the VA faced the challenge of an unprecedented number of veterans who would need 

medical care and a shortage of qualified VA physicians to provide these services. At 

the same time, medical schools had been looking for ways to expand graduate medical education opportunities to accommodate all physicians who had entered the 

armed services without completing specialty training. 

Responding to these pressing needs, President Truman signed Public Law 79–293, 

providing the legal basis for the VA to affiliate with schools of medicine and establishing the VA Department of Medicine and Surgery, the predecessor of the VHA. 

Less than a month after this law went into effect, the VA published Policy Memorandum No. 2, the ‘‘Policy on Association of Veterans’ Hospitals with Medical 

Schools.’’ This memorandum officially launched our partnership with the VA, enabling medical schools to staff VA hospitals with top-notch medical school faculty 

physicians, residents, and interns. The affiliated VA facilities, in turn, would provide medical schools with new venues in which to conduct research and educate 

young physicians. 

VA GRADUATE MEDICAL EDUCATION

Today, the VA manages the largest graduate medical education training program 

in the United States, with 107 of the Nation’s 125 accredited allopathic medical 

schools now affiliated with VA medical centers. The VA system accounts for approximately 10 percent of all graduate medical education in the country, supporting more 

than 9,000 full-time medical residency training positions. More than half the Nation’s physicians receive some part of their medical training in VA hospitals, as over 

31,000 medical residents and 16,000 medical students rotate through the VA health 

system each year. 

As our Nation once again faces a critical shortage of physicians, the VA has been 

the first to respond. Under Dr. Kussman’s leadership, the VA plans to increase its 

support for graduate medical education, adding an additional 2,000 positions for 

residency training over the next 5 years. The expansion will begin in July 2007 

5

when the VA adds 341 new positions. These training positions will address the VA’s 

critical needs and provide skilled health care professionals for the entire Nation. 

The additional residency positions also will encourage innovation in education that 

will improve patient care, enable physicians in different disciplines to work together, 

and incorporate state-of-the-art models of clinical care—including VA’s renowned 

quality and patient safety programs and electronic medical record system. 

VA MEDICAL AND PROSTHETIC RESEARCH

The VA research program is another important element of the affiliations that Dr. 

Kussman is charged to oversee. The VA Medical and Prosthetic Research program 

is one of the Nation’s premier research endeavors and attracts high-caliber clinicians to deliver care and conduct research in VA medical facilities. The program is 

supported by a dedicated source of funding available only to physicians with fullor part-time VA appointments. As a result, our Nation’s medical schools use VA research as a recruiting tool to attract top-quality physicians. The VA currently supports over 3,800 researchers, of whom nearly 83 percent are practicing clinicians 

who provide direct patient care to veteran patients. As a result, the VHA has a 

unique ability to translate progress in medical science directly to improvements in 

clinical care. 

As we move forward, it is imperative that the Administration work with this Congress to reverse the recent flat-funding for VA Medical and Prosthetic Research. The 

VA needs significant growth in its annual research and development appropriation 

to develop solutions for new conditions prevalent among our most recent veterans, 

as well as continuing the groundbreaking research that has benefited veterans of 

previous wars—and certainly our Nation as a whole. 

Of course, state-of-the-art research requires state-of-the-art technology, equipment, and facilities. In coordination with increases in the research budget, the Administration must also ensure a steady stream of resources dedicated to renovating 

existing research facilities. An environment that promotes excellence in teaching 

and patient care as well as research will help VA recruit and retain the best and 

brightest clinician scientists. 

VA—AAMC DEANS LIAISON COMMITTEE

Finally, I would like to talk briefly about the VA—AAMC Deans Liaison Committee—a standing committee of medical school deans and VA officials, including 

the Chief Academic Affiliations Officer, the VA Chief Research and Development Officer, and three Veterans Integrated Service Network (VISN) directors. Dr. Kussman 

and I meet regularly with this committee to maintain an open dialogue between the 

VA and academic medical centers and provide advice on how to better manage their 

joint affiliations. The agendas usually cover a variety of issues raised by both parties and range from ensuring information technology security to the integrity of solesource contracting directives. 

At its most recent meeting last February, the VA-Deans Liaison Committee reviewed the remarkable progress being made on several VA initiatives under the 

stewardship of Dr. Kussman in his capacity as VA Acting Under Secretary for 

Health. These include: 

• Establishment of the Blue-Ribbon Panel on Veterans Affairs Medical School Affiliations—This panel will provide advice and consultation on matters related to the 

VA’s strategic planning initiative to assure equitable, harmonious, and synergistic 

academic affiliations. During the panel’s deliberations, those affiliations will be 

broadly assessed in light of changes in medical education, research priorities, and 

the health care needs of veterans. The AAMC has worked with Dr. Kussman and 

VA staff to ensure that this will be an operational commission with measurable outcomes. Similarly, we have discussed the aspiration that the panel would facilitate 

putting in place criteria for evaluating the ‘‘health’’ of individual affiliation relationships. 

• Development of VA Handbook on VHA Chief of Staff Academic Appointments—

To prevent conflicts of interest or the appearance thereof, the VA has determined 

that limits on receiving remuneration from affiliated institutions are necessary for 

VHA employees at levels higher than chief of staff. While it is important to ensure 

that remuneration agreements do not create bias in the actions of VHA staff, prohibition of certain compensation from previous academic appointments (e.g., honoraria, tuition waivers, and contributions to retirement funds) could significantly 

hinder the VA’s ability to recruit staff from their academic affiliates. The AAMC has 

worked with Dr. Kussman and VA staff to develop a mutually amicable agreement 

that considers this balance. 

6

• Piloting the VA physician time and attendance/hours bank—Monitoring physician time and attendance for the many medical faculty holding joint appointments 

with VA medical centers has been complicated and inefficient. The VHA has accepted the ‘‘hours bank’’ concept to improve the tracking of part-time physician attendance. Under the hours bank, participating physicians will be paid a level amount 

over a time period agreed to in a signed Memorandum of Service Level Expectations 

(MSLE). This agreement will allow the supervisor and participating physician to negotiate and develop a schedule for the upcoming pay period. A subsidiary record will 

track the number of hours actually worked, and a reconciliation will be performed 

at the end of the MLSE period to adjust for any discrepancies. A pilot for this program has been successfully completed under Dr. Kussman’s leadership. 

• Implementing health care resource contracting for veterans’ care—VA Directive 

1663 implements provisions of the ‘‘Veterans Health Care Eligibility Reform Act of 

1996’’ (Public Law 104–262), which expands VA’s health care resources sharing authority. Dr. Kussman and VA staff have worked with the AAMC to ensure that 

these changes would not adversely affect the VA’s academic affiliations. As a result, 

the VA determined that sole-source contract awards with affiliates must be considered the preferred option whenever education and supervision of graduate medical 

trainees is required. Similarly, the decision to compete contracts for services overlapping programs in which the facility has graduate medical education training in 

place must be weighted by additional factors beyond the contract costs. The decision 

must consider all implications to the business, including the impact to the facility’s 

training program, which is a direct contributor to the facility’s productivity and may 

provide beneficial offsets. 

Mr. Chairman and Members of the Committee, I hope my testimony today has 

provided a better understanding of the extraordinary partnership between academic 

medicine and the VA, and in particular, the strong leadership Dr. Kussman has provided in many of our joint endeavors. I am confident that as Under Secretary for 

Health, Dr. Kussman’s outstanding track record in public service as well as in putting patients first will combine to strengthen what has become the Nation’s largest 

integrated health system. 

Once again, I would like to thank the Committee for this opportunity to appear 

here today and to congratulate Dr. Kussman on his nomination. Over the last 60 

years, we have made great strides toward preserving the success of our affiliations. 

I look forward to working with Dr. Kussman in the future to strengthen these model 

partnerships between the Federal Government and nonfederal institutions. I am 

happy to answer any questions the Committee may have now or at a later date. 

Thank you.

Chairman AKAKA. Thank you very much. 

Dr. Frese? 

STATEMENT OF FREDERICK J. FRESE III, PH.D., MEMBER,

NATIONAL BOARD OF DIRECTORS, NATIONAL ALLIANCE ON 

MENTAL ILLNESS 

Mr. FRESE. Chairman Akaka, Ranking Member Craig, Senator 

Murray, Senator Tester, and the other Members of the Veterans’ 

Affairs Committee, thank you very much for inviting me. I am Fred 

Frese. I am here to give voice for the National Alliance on Mental 

Illness, NAMI, on the nomination of Michael Kussman, M.D., to be 

Under Secretary for Health of the Department of Veterans Affairs. 

My formal statement was submitted earlier and I ask that that 

be included in the record. The statement provides the Committee 

background on myself and background on NAMI, on whose national 

Board of Directors I have been serving for most of the last 12 

years. With over 200,000 members and 1,200 chapters in every 

State, NAMI is the Nation’s largest membership organization that 

advocates for the mentally ill. 

At the outset, lest there be any doubt, the Committee and Dr. 

Kussman should know that NAMI supports his nomination to be 

Under Secretary for Health, albeit with some reservations, which 

I would like to discuss. 

7

Mr. Chairman, I have a personal connection with these issues. In 

addition to being a psychologist and medical school faculty member, I am also a service-connected disabled veteran. In 1966, while 

serving in the Marine Corps, I was diagnosed with schizophrenia. 

I have been treated for this condition mostly by the Veterans’ Administration, both in hospitals, and I have been in ten times, and 

as an outpatient. I believe I am an example of someone with a serious mental illness who can still contribute positively to American 

society. I am providing this Committee with my history to validate 

that mentally ill veterans such as myself can, in fact, serve in useful capacities and need not be shunted away or locked away in institutions. This, indeed, is the heart of NAMI’s message, as well. 

We at NAMI are deeply involved in the care of veterans and the 

veterans’ mental health programs nationwide because many of our 

family members and many of us are veterans. On the ground every 

day, we see the effects of national veterans service organizations 

that have been reported in the Independent Budget for years, every 

year for 21 years now, regarding the chronic underfunding of veterans’ health care. Funding shortages have caused deterioration in 

many VA programs, including those about which we are most

concerned. 

As veteran consumers and monitors, we know the VA programs 

that treat mentally ill veterans certainly need more funding for 

staff, administrative help, program development, technology, equipment, furnishings, et cetera. Our veterans, whether new ones from 

the current wars or previous military service, depend on the good 

will of key officials, such as Dr. Kussman, to meet the needs of 

those of us with these disabilities. 

In that regard, we are particularly pleased that the VA’s National Mental Health Strategic Plan has been put together to reform its mental health program, taking from the President’s New 

Freedom Commission’s recommendations on mental health. It has 

been designed and is beginning to be implemented very well and 

we are very pleased about that. 

However, the Government Accountability Office documented recently the VA’s failure to spend millions of available dollars for important initiatives that would continue these VA reforms. We ask 

the Committee to closely monitor the VA’s investments and programs in mental health to guarantee funding that will remain 

available and will be used for the purposes which you would want 

them used. 

NAMI desires a closer relationship with Dr. Kussman and those 

who work on mental health policy. A number of obstacles have 

emerged recently that become somewhat problematic. 

NAMI is represented on the Consumer Affairs Council of the 

VA’s Committee on Care of the Seriously and Chronically Mentally 

Ill Veterans, also known as the SMI Committee, authorized under 

Section 7321, Title 38 of the U.S. Code. 

Historically, the SMI Committee was an independent voice evaluating the VA. Recently, however, the activities of this Committee 

have been cut back and those of us both with the VSOs and consumer organizations have not had the input into this Committee 

that we have had in the past. 

8

Mr. Chairman, thousands of our troops have been exposed to 

massive explosions in Iraq and Afghanistan and come away apparently unharmed. We believe that these explosions have been called 

the signature injury of this war. Both Congress and NAMI will 

need to depend on Dr. Kussman’s judgment to ensure needs of 

these veterans, as well as veterans from other wars, need to be addressed. 

Mr. Chairman, NAMI appreciates your invitation to testify and 

I will be pleased to answer any questions you may have for me on 

any of these issues. Thank you very much. 

[The prepared statement of Mr. Frese follows:]

PREPARED STATEMENT OF FREDERICK J. FRESE III, PH.D., MEMBER, NATIONAL

BOARD OF DIRECTORS, NATIONAL ALLIANCE ON MENTAL ILLNESS

Chairman Akaka, Ranking Member Craig, and Members of the Senate Committee 

on Veterans’ Affairs: 

The National Alliance on Mental Illness (NAMI) appreciates your invitation to 

provide testimony regarding the President’s nomination of Michael J. Kussman, 

M.D., to be Under Secretary for Health of the Department of Veterans Affairs (VA). 

My statement today constitutes a joint effort by our NAMI Veterans Council, ably 

chaired by Mrs. Mary Gibson of Waco, Texas, as well as our full national NAMI 

Board of Directors, on which I serve as a member and also as Chairman of its Veterans Subcommittee. 

At the outset, lest there be any doubt, I want the Committee and Dr. Kussman 

to know that NAMI supports his nomination to be Under Secretary for Health, albeit with some reservations that I will discuss in more detail in this statement. 

With 210,000 members, NAMI is the Nation’s largest organization representing 

and advocating on behalf of persons with serious brain disorders that manifest in 

chronic mental health challenges. Through our 1,200 chapters and affiliates in all 

50 states, NAMI supports education, outreach, advocacy and biomedical research on 

behalf of persons with serious brain disorders such as schizophrenia, manic depressive illness, bipolar disorder, major depression, severe anxiety disorders and other 

major mental illnesses affecting children and adults. 

In addition to serving on the NAMI Board, I have a very personal connection to 

these issues. I am a veteran. In 1966 while serving in the U.S. Marine Corps, I was 

selected for promotion to the rank of Captain. During that period I was first diagnosed as having the brain disorder schizophrenia—perhaps the most severe and disabling mental illness diagnosis. Over the years since my original diagnosis, I have 

been treated within the VA health care system, both as an inpatient at the VA hospital in Chillicothe, Ohio, and as an outpatient. I believe I am an example of someone with a serious mental illness who can still contribute positively to American society. During the past three decades I have functioned as a clinical psychologist and 

an administrator, served as Director of Psychology at Western Reserve Psychiatric 

Hospital for a 15-year period, and coordinated the Summit County Recovery Project 

to assist persons in recovery from mental illness to integrate into the vocational and 

social framework of greater Akron. 

I hold degrees from Tulane University, the American Graduate School of International Management, and masters and doctoral degrees in psychology from Ohio 

University. I am currently an Assistant Professor of Psychology in Clinical Psychiatry in the psychiatry departments at both Case Western Reserve University and 

the Northeastern Ohio Universities College of Medicine. At the latter facility, I lecture psychology interns and third year medical students, as well as third and fourth 

year psychiatry residents. Additionally during the past several years I have been 

invited to deliver annual lectures at the Uniformed Services University of the 

Health Sciences and the George Mason University Law School. I am providing the 

Committee this personal history not to boast, but to validate that mentally ill citizens like me can still serve in useful capacities and need not be shunted aside or 

locked in institutions. 

Mr. Chairman, our veteran members established the NAMI Veterans Council and 

Veterans Subcommittee to assure that closer attention is paid to mental health 

issues in the Department of Veterans Affairs (VA), not only at the national level, 

but also within each Veterans Integrated Service Network (VISN). The NAMI Veterans Council includes members from each of VA’s 21 VISNs, and in that capacity 

we advocate for an improved VA continuum of care for veterans with severe and 

9

persistent mental illnesses. The council is composed of persons with mental illnesses, relatives of persons with mental illnesses, or friends with mental illnesses 

who have an involvement and interest in issues affecting veterans who suffer from 

severe and persistent mental illness. Some of the roles that Veterans Council members play include serving in liaison to VISNs; providing outreach to national veterans service organizations; educating Congress on the special circumstances and 

challenges of severe mental illness in the veteran population; and, working closely 

with NAMI state and affiliate offices on issues affecting veterans. Also our Veterans 

Council Executive Committee holds regular monthly conference calls where featured 

speakers present new information on developments in treatment, research, service 

delivery and service initiatives for veterans and active military servicemembers or 

dependents with severe and persistent mental illness. We also use these opportunities to stay informed of national developments in Congress and the executive branch 

that affect veterans struggling to recover from mental illnesses. 

Much has been reported in the news in the past few months about conditions at 

the Walter Reed Army Medical Center. Our organization—dedicated to advancing 

health care, research and improving social understanding on matters that deal with 

dysfunction of the human mind—was deeply disturbed as were you at hearing how 

combat veterans recovering from serious disabilities, including mental and emotional problems, were being maltreated and mistreated by the system then in place 

at Walter Reed. Adjusting to and recovering from, disability, whether it is physical 

or mental, is a challenge in itself that can rival the crossing of a mighty river 

against the current. But when that challenge is made more difficult by a layering 

of mindless but ‘‘official’’ bureaucracy, delay, confusion, lost records, intimidation, 

threats, hazing and other inexcusable behaviors displayed in multiple reports of the 

media, this is doubly disturbing to us. These veterans should be treated more decently, with compassion and with care, assured that their needs are going to be met 

by a grateful government, not one that is bent on minimizing the cost of war by 

reducing or hiding the liability for their injuries and illnesses. One of the bittersweet lessons that may be learned from this war is that the ultimate cost to the 

human beings who had to actually fight it cannot be hidden from public view. We 

hope that this shameful episode in the facility’s history has been laid to rest with 

renewed intentions and actions to improve our care of American military heroes. No 

veteran should be treated this way. 

NAMI members are deeply involved in the care of veterans in VA’s mental health 

programs nationwide because many are family members of those veterans. Some of 

us are those veterans. On the ground every day we see the effects of what the national veterans service organizations have reported through the Independent Budget 

for years: chronic underfunding of veterans’ health care. Funding shortages and 

emergency supplemental appropriations, combined with the regular employment of 

Continuing Resolutions as stopgap measures to provide financial resources for VA 

health care, have caused deterioration in many VA programs, including those about 

which we are concerned. 

We are particularly concerned that VA’s ‘‘National Mental Health Strategic Plan’’ 

to reform its mental health programs, has been stalled by VA’s over-arching financial problems. The General Accountability Office (GAO) issued a startling report last 

year to your House counterpart Committee documenting VA’s failure to spend several millions of available dollars in pursuit of important initiatives that would continue moving VA in the right direction to reform its mental health programs. The 

Veterans Council Executive Committee met a few months ago with Dr. Ira Katz, 

Deputy Chief Patient Care Services Officer for Mental Health, to discuss his plans 

to improve the allocation of funds dedicated to the initiatives under the new strategic plan. We hope Congress will closely monitor VA’s implementation of the new 

strategic plan to ensure it meets that promise. 

Mr. Chairman, we ask today: Is Michael Kussman qualified to be Under Secretary 

for Health? Speaking for NAMI, I must say that, while we have observed his presence in VA health care for several years, and are generally aware of his distinguished military career, it is fair to say that we at NAMI really do not know Dr. 

Kussman as well as we desire to know him. While serving as Chief Patient Care 

Services Officer, Dr. Kussman supervised the mental health programs of the Department. In that capacity and also during his term as Deputy Under Secretary, Dr. 

Kussman contributed positively to VA’s corporate decision to engage and adopt concepts from the President’s New Freedom Commission on Mental Health. He is to 

be commended for this stance. More recently as Acting Under Secretary, Dr. 

Kussman distinguished himself by making a number of comments in the media concerning the state of mental health of our fighting force in Iraq and Afghanistan. 

This statement is illustrative:

10

‘‘Readjustment and reintegration issues are very common among servicemen returning from any combat. A large portion of people have this temporary reaction. 

These are normal reactions to abnormal situations and are not considered mental 

illnesses.’’ (Washington Post, March 1, 2006)

NAMI commends Dr. Kussman’s view that we should not stigmatize veterans who 

need care for adjustment disorders that may be temporary in nature following a period of combat exposure. We strongly believe no one with a mental illness should 

be stigmatized, whatever the cause. However, some veterans of war come home with 

serious problems, including deep-seated mental health problems. We trust Dr. 

Kussman believes these veterans’ needs must be addressed by a caring VA. 

As an organization concerned about the mental health of hundreds of thousands 

of Dr. Kussman’s patients, NAMI desires to have a closer relationship with Dr. 

Kussman and those who work with him in mental health policy in Washington. A 

number of issues have emerged to make those relationships problematic, but should 

you confirm him we hope to work with Dr. Kussman to relieve them. Let me give 

you some pertinent examples. 

NAMI is represented on the consumer affairs council associated with VA’s Committee on Care of Severely and Chronically Mentally Ill Veterans, also known as 

the ‘‘SMI Committee,’’ authorized in Section 7321, Title 38, United States Code. This 

independent committee has played an active and vital role in determining policy 

and shaping programs in VA mental health care. I am privileged to have been a 

regular participant on this consumer affairs council. The SMI Committee was a 

driving force in VA’s shift toward the ‘‘New Freedom’’ philosophy. To paraphrase the 

law, the Committee has a clear mandate to assess, and carry out a continuing assessment of, the capability of the VA to meet effectively the treatment and rehabilitation needs of mentally ill veterans whose mental illness is severe and chronic. The 

law requires the Committee to identify system-wide problems in caring for such veterans; identify specific facilities at which program enrichment is needed to improve 

treatment and rehabilitation; and identify model programs that should be implemented more widely in or through facilities of the VA. The Committee is required 

to advise the Under Secretary regarding the development of policies for the care and 

rehabilitation of severely chronically mentally ill veterans, and to make recommendations to the Under Secretary for improving programs of care of such veterans; for establishing special programs of education and training relevant to their 

care; regarding research needs and priorities relevant to the care of such veterans; 

and regarding the appropriate allocation of resources for all such activities. The Secretary is required by law to submit a variety of reports to Congress on the work 

of the SMI Committee and VA’s responses to the Committee’s recommendations. 

Historically the SMI Committee met four times each year to carry out its responsibilities, held regular conference call meetings, reported at regular intervals, and 

provided VA and Congress an important and independent voice in evaluating VA’s 

mental health programs, especially those that deal with veterans with psychoses 

and other very serious problems. Several years ago, VA Central Office (VACO) determined the SMI Committee would be afforded only two meetings annually. VA rechartered the Committee in 2006 and populated it with new membership, some of 

whom were unfamiliar with the Committee’s history or role. The Consumer Affairs 

Council’s participation since that time has been severely restricted. The SMI Committee now seems moribund. To NAMI and other participating organizations, this 

is a very large matter in terms of muffling a source that has provided VA and Congress an independent means of evaluating a very important VA program. We hope 

your Committee will determine whether VA’s justification for restricting and suspending the activities of this key committee was warranted, and to examine Dr. 

Kussman’s role and reasons for those decisions. 

Another issue of concern to NAMI bears discussion today. In the past several fiscal years, VA’s expenditures in mental health have unquestionably risen, and we 

deeply appreciate this Committee’s insistence that VA mental health spending be 

maintained. Nevertheless, in the final compromise on Public Law 110–5, the ‘‘Revised Continuing Appropriations Resolution, 2007,’’ Congress removed a recurring 

requirement that VA spend at least $2.2 billion in programs of mental health care 

this year. The following text carried out that decision: 

‘‘Sec. 20810. Notwithstanding any other provision of this division, the following 

provisions included in the Military Quality of Life, Military Construction, and Veterans Affairs Appropriations Act, 2006 (Public Law 109–114) shall not apply to 

funds appropriated by this division: the first, second, and last provisos, and the 

set-aside of $2,200,000,000, under the heading ‘Veterans Health Administration, Medical Services’; the set-aside of $15,000,000 under the heading ‘Veterans 

Health Administration, Medical and Prosthetic Research’; the set-aside of 

$532,010,000 under the heading ‘Departmental Administration, Construction, Major 

11

Projects’; and the set-aside of $155,000,000 under the heading ‘Departmental Administration, Construction, Minor Projects’.’’ (emphasis added) 

While we appreciate the need to give the VA flexibility in its spending decisions 

under the Medical Services account, NAMI comes from a perspective of observing, 

and hopefully protecting, a number of programs important to our members and to 

the veterans under VA care about whom we are most concerned. The set-asides in 

prior appropriations acts gave us assurance of dependability of funding sources for 

VA programs that provide our loved ones the care they need. Without that protection, some in VA may believe they are free to shift resources from these programs 

to the detriment of veterans with serious mental illnesses. We ask that your Committee closely examine Dr. Kussman’s commitment to spend appropriate sums on 

mental health programs to ensure this commitment is kept. 

Mr. Chairman, the current overseas wars in Iraq and Afghanistan are producing 

a very heavy burden in follow-on mental health treatment and counseling requirements. While we very much want to agree with the sentiments of Dr. Kussman, that 

the vast majority of our soldiers, sailors, marines, airmen and Coast Guardsmen are 

repatriating whole and healthy, with temporary adjustment problems, some reports 

are not encouraging. About two of every ten serving members are experiencing problems of a magnitude about which we all should be concerned. About 70,000 individuals have so far touched VA with some kind of mental or emotional challenge in 

post-service life. The military departments are rotating active, reserve and Guard 

forces through these wars in multiple deployments of individuals and units. The 

press has reported a number of cases of individuals having been deployed who may 

not be in ready condition to serve, some with worrisome mental states. Given the 

drag of this war, it is not surprising that military recruiters are beginning to fail 

to meet their quotas or are meeting them by enlisting marginal candidates whose 

mental status might be of serious concern to domestic employers. Another outcome 

of these wars is the unknown degree to which ‘‘mild’’ and ‘‘moderate’’ traumatic 

brain injury (TBI) is going to manifest into behavioral, medical and psychosocial 

problems later. Thousands of our troops have been exposed to massive explosions 

in Iraq and Afghanistan but have come away apparently ‘‘unharmed’’ according to 

our current technology to measure harm. We believe the complete story of those exposures is yet to be told. 

Dr. Charles Hoge of the Walter Reed Army Institute of Research reported the following findings last year in a study he published in the New England Journal of 

Medicine:

‘‘This study has shown that overall 15–17 percent of Soldiers from combat units 

screen positive for PTSD when surveyed 3–12 months after returning from deployment to Iraq. When we added one additional question related to functional impairment at the end of the 17 question PTSD scale, we found that 10 percent of Soldiers 

surveyed 12 months after deployment reported that PTSD symptoms have made it 

very difficult to do their work, take care of things at home, or get along with other 

people. The inclusion of screens for major depression and generalized anxiety raise 

the rates of screening positive to approximately 20 percent; 16 percent of Soldiers 

surveyed 12 months after returning from Iraq screened positive for PTSD, depression, or anxiety and reported that there was functional impairment at the ‘very difficult’ level.’’

Mr. Chairman, while many say that TBI is the ‘‘signature injury’’ of these wars, 

we believe the picture is more mixed, with a large burden of the war legacy expressing itself in mental and emotional damage from both TBI, post-traumatic stress disorder (PTSD), depression, substance abuse and other problems. We hope the Committee as well as the VA will remain vigilant and sensitive to the needs of this new 

generation as time goes by, because their needs are going to exist long after cessation of deployment of our forces into Southwest Asia. In this instance both Congress and NAMI need to depend on Dr. Kussman’s judgment to ensure these needs 

are addressed with sensitivity and care. 

The Secretary of Veterans Affairs James Nicholson has testified on VA’s intentions with respect to funding mental health services in Fiscal Year 2008. On February 8, 2007, and again on February 13, 2007, he stated ‘‘The President’s request 

includes nearly $3 billion to continue our effort to improve access to mental health 

services across the country. These funds will help ensure VA provides standardized 

and equitable access throughout the Nation to a full continuum of care for veterans 

with mental health disorders. The resources will support both inpatient and outpatient psychiatric treatment programs as well as psychiatric residential rehabilitation treatment services. We estimate that about 80 percent of the funding for mental 

health will be for the treatment of seriously mentally ill veterans, including those suffering from post-traumatic stress disorder (PTSD). An example of our firm commitVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00015 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
12

ment to provide the best treatment available to help veterans recover from these mental health conditions is our ongoing outreach to veterans of Operation Iraqi Freedom 

and Operation Enduring Freedom, as well as increased readjustment and PTSD 

services.’’ (emphasis added) 

Without guidance from your Committee, Mr. Chairman, and strong oversight by 

other committees of jurisdiction, it is challenging at best for NAMI to measure 

whether, indeed, Secretary Nicholson’s commitment, and presumably one to which 

Dr. Kussman agrees, will be fulfilled next year. As consumers and monitors, we 

know the VA programs that treat mentally ill veterans certainly need more funding—for professional and support staff, administrative help, program development, 

technology, equipment, furnishings, infrastructure, family caregiver respite and 

other supports. Our veterans in need of care for serious mental health conditions, 

whether new veterans from current wars or veterans from previous military service 

periods, depend on the good will of such promises. We ask your Committee to monitor VA’s investments and programs in mental health care to guarantee funding will 

remain available and will be used for the purpose for which it is intended. 

In summary, holding in abeyance our stated reservations and looking optimistically to the future, NAMI believes Dr. Kussman is fully qualified to serve as VA 

Under Secretary for Health. We recommend you report this nomination and that the 

Senate confirm him to serve as Under Secretary for Health. Should the Senate in 

its wisdom confirm him for this position, we hope to gain a better working relationship with Under Secretary Kussman as time goes along. NAMI wants to be a partner with VA as the New Freedom reforms are put into place, and as more veterans 

of the current wars come to VA for aid. We want to work with Dr. Kussman, Dr. 

Katz and other key VA officials in Washington and across the VA system to ensure 

VA meets its responsibilities for the care of veterans with serious and chronic mental illnesses, whether from this war or previous military engagements. 

Chairman Akaka, Ranking Member Craig and other distinguished Members of the 

Committee, NAMI appreciates your invitation to testify, and we thank you for giving consideration to our views.

Chairman AKAKA. Thank you very much, Dr. Frese. 

Mr. Mitchell? 

STATEMENT OF DOUGLAS H. MITCHELL, JR., ACSW/LCSW, 

PRESIDENT, ASSOCIATION OF VA SOCIAL WORKERS 

Mr. MITCHELL. Mr. Chairman and Members of the Committee, 

good morning. I am here today representing the Association of VA 

Social Workers, all of whom are employed obviously by the Veterans Health Administration. I myself am a veteran of the United 

States Army. I served from February 1966 to September 1973. I 

also received health care in the private sector and I currently have 

elected to receive my own health care within the Department of 

Veterans Affairs. I can tell you, it is my firm belief that the health 

care available in the Department of Veterans Affairs is second to 

none. 

During the 22 years I have been employed by the Department of 

Veterans Affairs, I have been through several reorganizations and 

several changes in functioning. Most recently, I would like to talk 

about the changes that have been enacted by Dr. Kussman. Specifically, I believe that he is committed for each of our veterans to 

make the transition from active duty to veteran status as seamless 

as possible. Dr. Kussman was responsible for placing a liaison social worker at Walter Reed Army Medical Center to help ease this 

transition. Within a few months, a second social worker was added, 

and now we have 14 social workers at military treatment facilities, 

all designed to assist with easing the transition from veteran status into VA care. 

Dr. Kussman is, of course, seriously interested in those most severely injured, the polytrauma veterans. The second phase of seamless transition included a case management program to ensure that 

13

no veteran falls through the cracks. Each VA medical center has 

a nurse or a social worker, a case manager who follows their patients wherever they go, either inpatient, outpatient, or back to the 

community. 

Although the VA has had a system of four Traumatic Brain Injury Centers for years, Dr. Kussman, through his concern for OIF/

OEF veterans, required more comprehensive care. He converted 

those TBI centers to polytrauma centers to ensure that veterans received concurrent care for all of their injuries, including TBI, amputation, spinal cord injury, visual impairment, hearing loss, combat stress, and PTSD, in one location. More recently he expanded 

this with the polytrauma system of care, which includes the four 

polytrauma TBI centers and 17 additional network polytrauma 

sites. 

When the Secretary announced that he wanted to hire 100 new 

patient advocates, Dr. Kussman had a vision for how these new 

employees could help the most severely injured OIF veterans with 

their transition. The new transition patient advocates are being assigned to active duty patients while they are still on active duty. 

They go to the military treatment facility, establish contact, establish a relationship, and act as an ombudsman for those severely injured veterans as they return both to the VA and to their

community. 

Dr. Kussman understands that our patients and families are people who are experiencing multiple life crises and he fully supports 

the team effort to help patients and families cope with all of these 

challenges they are facing, which includes medical, social, psychological, and spiritual. He recognizes that we are as we go reinventing the health care system to serve a new generation of veterans and he supports this effort. 

At Dr. Kussman’s direction, a committed team of VA staff developed a template that automatically screens for medical conditions 

endemic to the Gulf area as well as TBI. This template, again, 

automatically triggers specialty consults for further evaluation. 

This multi-disciplinary team consists of physicians, nurse practitioners, physician assistants, information management, social 

work, nursing, speech pathology, and mental health practitioners. 

It is truly an effort to treat the whole veteran. 

Equally extraordinary, if I may, is the relationship that has developed in Phoenix between the Veterans Health Administration 

and the VBA regional office. Lower-level workers, myself included, 

established relationships with their lower level workers and together we developed a working relationship that resulted in a 

memo of understanding with the U.S. Army Reserves and the 

Army National Guard that we would attend every demobilization, 

every sort of activity we could in order to make these new veterans 

aware, or these potential veterans aware of benefits that were 

available to them. 

Finally, and personally, very personally, most important to me, 

is that I believe that Dr. Kussman has empowered each of us at 

the facility level to do the right thing for the veteran. Thank you. 

[The prepared statement of Mr. Mitchell follows:]

14

PREPARED STATEMENT OF DOUGLAS H. MITCHELL, JR., MSW, LCSW, ACSW, 

PRESIDENT, ASSOCIATION OF VA SOCIAL WORKERS

Mr. Chairman and Members of the Committee, good morning. I am here today 

representing the membership of the Association of VA Social Workers employed by 

the Veterans Health Administration. 

First of all, I am a veteran of the United States Army. I proudly served my country from February 22, 1966 to September 4, 1973. 

I also receive my medical care through the Department of Veterans Affairs. I am 

equally proud to do so. Having received care both outside VA and inside, I feel 

qualified to state unequivocally that there is no comparison; the VA is second to 

none. 

I have been employed by VA for 22 years. For the past 13 years, I have been assigned to the Carl T. Hayden VA Medical Center in Phoenix, AZ as the Assistant 

Chief of Social Work and for the last 10 years as the Chair of the Social Work Department. 

During my tenure in Phoenix, I have observed the VA health care system evolve 

from a rigid, facility centered hospital system with virtually little regard for resource availability to a vibrant, patient-centered system determined to deliver the 

best quality care in the most efficient manner closer to home. I would like to highlight some specifics concerning experience in the field based upon decisions Dr. 

Kussman has made. 

I believe Dr. Kussman is committed to making the transition from active duty 

military to veteran status and community life as seamless as possible. In August 

2003, Dr. Kussman started the seamless transition program. He placed a VA social 

worker at the Walter Reed Army Medical Center to help transfer active duty patients to VA medical centers. Within a few months, a second social worker was 

added. Today, we have 14 social worker liaisons at 10 military hospitals. Dr. 

Kussman supports the liaisons and knows them by name. In Phoenix, our case managers interact often with these individuals. 

• Dr. Kussman is committed to the best quality care possible for all veterans. But 

he is particularly concerned with the severely injured OEF/OIF veterans. The second phase of seamless transition included a case management program to ensure 

that no veteran falls through the cracks. Every VA medical center has nurse or social worker case managers who follow their patients wherever they go—inpatient to 

outpatient to the community. 

• Although VA has had a system of 4 Traumatic Brain Injury (TBI) Centers since 

the early 1990s, Dr. Kussman believed that the severity of the injuries of OEF/OIF 

veterans required that we provide more comprehensive care. He converted the TBI 

centers to Polytrauma Centers to ensure that veterans could receive concurrent 

treatment for all of their injuries including TBI, amputation, spinal cord injuries, 

visual impairment, hearing loss, combat stress and PTSD in one location. Further, 

he developed the Polytrauma System of Care, which includes the 4 Polytrauma/TBI 

Centers and 17 Network sites. 

• When the Secretary announced that he wanted to hire 100 patient advocates, 

Dr. Kussman had a vision for how these new employees could help the most severely injured OEF/OIF veterans with their transitions. The new transition patient 

advocates (TPAs) are being assigned to active duty patients while they are still at 

the military hospital to meet the patient and family and serve as an ombudsman 

to help them with any problems or concerns and assist them in navigating in both 

the DOD and VA systems. 

• Under Dr. Kussman’s guidance, VA developed a computerized veterans tracking 

system to (a) notify the gaining facility of the patient’s pending discharge, (b) document the patient’s status and, c) notify staff as to both the clinical and logistical 

status. 

• Dr. Kussman is a physician who understands and promotes interdisciplinary 

care. Under his leadership, all clinical team members work together with patients 

and families on treatment plans and treatment decisions. 

• Dr. Kussman also understands the importance of families and supportive services for them. He has been a staunch supporter of the VA Fisher House Program 

and has ensured that VA medical centers, particularly the Polytrauma/TBI Centers, 

address family needs. He understand that our patients and families are people experiencing multiple life crises and he fully supports a team effort to help patients and 

families cope with all of the challenges they are facing which include medical, social, 

psychological and spiritual. 

In summation, I strongly believe that: 

Dr. Kussman is a hands-on leader in terms of supporting the staff and the patients. 

15

He recognizes that we are re-inventing a health care system to serve a new generation of veterans and his enthusiastic support for innovative ideas has resulted 

in unprecedented levels of case management and high quality care for a veteran 

population transitioning from active duty to civilian life. 

An immediate local example in Phoenix is that, for more than two years, we have 

known of the need to evaluate all veterans who have been exposed to blasts, incidents or accidents that could conceivably result in neuropsychological impairment. 

At Dr. Kussman’s direction, a committed team of VA clinical staff developed a CPRS 

template that screens for medical conditions endemic to the Gulf area as well as 

TBI. This template automatically triggers specialty consults for further evaluation. 

This multidisciplinary team consists of Physicians, Nurse Practitioners, Physician 

Assistants, Information Management, Social Work, Nursing, Speech Pathology, and 

Mental Health practitioners. It is truly an effort to treat the whole veteran. 

Perhaps even more extraordinary is the relationship that has developed between 

the VBA Regional Office and the VA Medical Center due to Dr. Kussman’s leadership. The Phoenix VARO sends personnel to evening groups at our medical center 

to explain veteran’s benefits, initiate claims for service connected disability compensation and to provide access to the complete array of services available through 

VBA. In previous years, ‘‘One VA’’ was a slogan. In Phoenix, it has become the practice. 

Finally, and most important to me, Dr. Kussman empowers each of us in VA to 

do the right thing for our patients.

Chairman AKAKA. Thank you very much, Mr. Mitchell. 

Mr. Wallace? 

STATEMENT OF ROBERT E. WALLACE, EXECUTIVE DIRECTOR,

WASHINGTON OFFICE, VETERANS OF FOREIGN WARS OF 

THE UNITED STATES 

Mr. WALLACE. Thank you, Mr. Chairman, Senator Craig, and 

Members of the Committee. I am pleased to appear before you 

today representing the 2.4 million men and women of the Veterans 

of Foreign Wars of the United States and our Auxiliaries. I am 

here to discuss the nomination of Brigadier General Michael J. 

Kussman, M.D., United States Army, Retired, to be the Under Secretary for Health for the Veterans Health Administration of the 

United States Department of Veterans Affairs. 

It is my privilege to offer the strong support of the Veterans of 

Foreign Wars of the United States for Dr. Kussman, a man we believe is clearly qualified for this vital position and whom we feel 

sincerely and honestly cares about veterans and the issues they 

confront. He will be an excellent Under Secretary for Health. 

I am also pleased to note for the record that my colleagues from 

the AMVETS, Disabled American Veterans, Paralyzed Veterans of 

America, and Vietnam Veterans of America join with the VFW in 

supporting Dr. Kussman’s nomination. 

I come before you today not just as a veteran’s advocate, but as 

a VA shareholder. I earned my stock when I wore the uniform of 

this great Nation, like millions of other veterans have. As a shareholder of a corporation, I want the best leadership for the company 

that I have invested in. Veterans demand effective and efficient 

leadership in a Department in which they have also so much invested. 

We have all witnessed over the years problems that VHA has encountered. So many times, the issues could have been prevented if 

there were true leadership, management, and accountability at all 

levels of the system. Dr. Kussman’s experience demonstrates that 

he possesses these and many other qualities that make him the 

right person for the position. 

16

His years of service in the United States Army, rising to the 

rank of Brigadier General of the Medical Corps, shows he is a leader, knows how to work with others, knows how to manage people, 

hold them accountable, and at the same time knows how to motivate people. Dr. Kussman was selected as the top candidate for this 

position by an independent search Committee, a requirement of 

Congress. You made this a requirement, I believe, to ensure that 

the highest quality and most professional candidate would be recommended for this position and that no undue influence would play 

into the process. 

The American Legion, due to their constitution, is unable to publicly support or oppose any nominees. However, based on the need 

for a permanent Under Secretary for Health of VHA and the fact 

that Dr. Kussman was recommended by the search committee, they 

also agree that his nomination should move forward. 

I did not serve on the search committee. However, I have served 

on other search committees in the past and can attest to the fact 

that they are fiercely independent. The VFW’s support of Dr. 

Kussman is not just based on the search committee’s recommendation. Our beliefs are based on our personal experience interacting 

with him on health care issues faced by our Nation’s veterans. 

Dr. Kussman cares deeply about veterans and the issues confronting their health care and well-being. He is highly responsive 

to their needs. In conversations, you can tell his sincerity. When 

we differ on policy issues or have policy-related questions, he does 

not hesitate to give us a fair hearing and is open to ideas, whether 

he ultimately agrees with us or not. That is all that we as VA 

shareholders can ask for from the head of the Veterans Health Administration. 

But that truly is his strength. He cares passionately about VA’s 

mission to help veterans and their dependents and he takes criticism of the system personally, leading him to strive for excellence 

and in doing so to motivate others. He is not a person who is full 

of excuses when mistakes are made and we have found that he 

takes a personal approach to solving problems, ensuring that the 

best care is provided to our Nation’s veterans by the VA. 

Dr. Kussman can rightly pride himself on the high quality of veterans’ health care. Since 2000, he has been a part of VHA, a period 

in which VHA has rightfully been lauded for the high quality of its 

health care. Many articles in major publications have said VHA delivers the best care anywhere. His personal philosophy is to continue to improve on these facts and the quality of care delivered 

and to never allow the care given to our Nation’s veterans to diminish, just improve. 

Certainly, the system is not perfect. Access, especially for specialty care, continues to be a challenge, although we would argue 

that this is a function of a lack of dedicated and on-time resources, 

not one of administration. Once in the system, veterans are very 

pleased and typically receive the best care. There have been some 

high-profile examples yesterday where this has not been the case, 

and I do not want to make light of them, but I am confident and 

the VFW is confident that Dr. Kussman’s leadership and his strong 

desire and dedication to improving VA health care will do much to 

fix these situations. 

17

Dr. Kussman has demonstrated a deep concern about the health 

issues facing all veterans, especially those with specialized needs 

and those serving today. He wants to have VA learn more about 

traumatic brain injuries as well as improve on the delivery of mental health care. 

One of the major challenges he will face is finding qualified clinicians who fully understand the new challenges brought on by the 

war and to help the thousands of returning servicemembers who 

need first-rate mental health care and specialized services. We are 

confident that he is up to the challenge. 

We feel that his years of experience managing health care facilities and systems give him the knowledge and experience to understand the business side of VHA and how to best use taxpayers’ 

money in an efficient way while still delivering high-quality health 

care. Those years of experience demonstrate that he is more than 

qualified to lead the thousands of hardworking and dedicated employees within VHA. 

We believe he is a man who will not be afraid to butt heads with 

the Office of Management and Budget, you the Congress, or the 

Department of Defense. Many of the issues and challenges VHA 

faces today will be helped by Dr. Kussman’s military experience. 

All of us in Washington have been talking about a true system 

where DOD and VA create a seamless transition for military personnel to veteran status. We believe that if anyone can make it 

happen, it is Dr. Kussman because he understands both systems. 

The VFW sincerely believes Dr. Michael Kussman is the right 

person to lead the Veterans Health Administration and we cast our 

unanimous votes, our shares, for his immediate confirmation. We 

urge the Committee to favorably report his nomination to the full 

Senate and we ask your colleagues to confirm him as the Under 

Secretary for Health without delay. 

I thank you for the opportunity to testify today. I would be more 

than happy to answer any questions you may have. 

[The prepared statement of Mr. Wallace follows:]

PREPARED STATEMENT OF ROBERT E. WALLACE, EXECUTIVE DIRECTOR, WASHINGTON OFFICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES

Mr. Chairman and Members of the Committee: 

I am pleased to appear before you today representing the 2.4 million men and 

women of the Veterans of Foreign Wars of the U.S. (VFW) and our Auxiliaries. I 

am here to discuss the nomination of Brigadier General Michael J. Kussman, M.D. 

(United States Army Ret.) to be the Under Secretary for Health for the Veterans 

Health Administration (VHA), United States Department of Veterans Affairs (VA). 

It is my privilege to offer the strong support of the Veterans of Foreign Wars of 

the United States for Dr. Kussman, a man we believe is clearly qualified for this 

vital position, and whom we feel sincerely and honestly cares about veterans and 

the issues that confront them. He will be an excellent Under Secretary for Health. 

I am also pleased to note for the record that my colleagues of the AMVETS, Disabled American Veterans, Paralyzed Veterans of America and the Vietnam Veterans 

of America join with the VFW in supporting Dr. Kussman’s nomination. 

I come before you today, not just as a veterans advocate, but as a VA shareholder. 

I earned my stock when I wore the uniform of this great Nation, like millions of 

other veterans have. Just as a shareholder of a corporation wants the best leadership for the company they have invested in, veterans demand strong, effective and 

efficient leadership of the Department in which we all have so much invested. 

We have all witnessed over the years problems that VHA has encountered. So 

many times the issues could have been prevented if there were true leadership, 

management and accountability at all levels of the system. Dr. Kussman’s experience demonstrates that he possesses these and many other qualities that make him 

18

the right person for the position. His years of service in the United States Army 

rising to the rank of Brigadier General of the Medical Corps shows he is a leader, 

knows how to work with others, and knows how to manage people, holding them 

accountable and motivating them. 

Dr. Kussman was selected as the top candidate for this position by an independent search committee, a requirement of Congress. You made this a requirement, I believe, to ensure the highest quality and most professional candidates 

would be recommended for this position, and that no undue influence would play 

into the process. 

I did not serve on this search committee; however, I have served on search committees in the past, and can attest to the fierce independence of the process. Dr. 

Kussman’s selection as the top candidate of the three recommended to the Secretary 

is a strong indication that his credentials and interview impressed the committee—

many of whom are not involved in the day-to-day operation of VHA. It further demonstrates that they too felt he would be a capable, independent and effective leader. 

The VFW’s support for Dr. Kussman is not just based on the search committee’s 

recommendation. That just reaffirmed our beliefs that he is the right person for the 

position. Our beliefs are based on our personal experiences interacting with him on 

health care issues faced by our Nation’s veterans. 

Dr. Kussman cares deeply about veterans and the issues confronting their health 

care and well-being. He is highly responsive to their needs. In conversations, you 

can tell his sincerity. When we differ on policy issues or have policy-related questions, he does not hesitate to give us a fair hearing, and is open to ideas whether 

he ultimately agrees with us or not. 

That is all we—VA’s shareholders—can ask for from the head of the Veterans 

Health Administration. 

That truly is his strength. He cares passionately about VA’s mission to help veterans and their dependents. And he takes criticism of the system personally, leading 

him to strive for excellence, and in doing so to motivate others. He is not full of 

excuses when mistakes are made, and we have found that he takes a personal approach to solving problems, ensuring that the best care is provided to veterans in 

VA. 

Dr. Kussman can rightfully pride himself on the high quality of veterans’ health 

care. Since 2000, he has been part of VHA, a period in which VHA has rightfully 

been lauded for the high quality of its health care. Many articles in major publications have said VHA delivers the best care anywhere.

• A 2004 RAND study found that VA hospitals outperformed private facilities in 

over 294 categories of care. 

• The 2006 American Customer Satisfaction Index found that veterans had a 10 

percent higher satisfaction rate with VA health care than the general public has 

with private hospitals. 

• VA is at the forefront of advances in medical records technology, and their electronic medical records system is the envy of the medical care field. 

• VA health care is significantly cheaper per patient than private health care and 

efficiency of service has kept the increase in per patient costs far below the overall 

costs of medical inflation.

His personal philosophy is to continue to improve on these facts and the quality 

of care delivered, and to never allow the care given to our Nation’s veterans to diminish, just improve. 

Certainly the system is not perfect. Access, especially for specialty care, continues 

to be a challenge; although we would argue that this is a function of a lack of dedicated and on-time resources, not one of administration. Once in the system, veterans are very pleased and typically receive the best of care. There have been some 

high profile examples recently where this has not been the case, and I do not want 

to make light of them, but we are confident that Dr. Kussman’s leadership, and his 

strong desire and dedication to improving VA health care will do much to fix these 

situations. Dr. Kussman has demonstrated a deep concern about the health issues 

facing all veterans, especially those with specialized needs, and those serving today. 

He wants to have VA learn more about traumatic brain injuries as well as improve 

on the delivery of mental health care. 

One of the challenges he will face is finding qualified clinicians who fully understand the new challenges brought on by the war, and to help the thousands of returning servicemembers who need first-rate mental health care and specialized services. We are confident that he is up to the challenge. 

We feel that his years of experience managing health care facilities and systems 

give him the knowledge and experience to understand the business side of VHA and 

how to best use taxpayer’s money in an efficient way while still delivering highVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00022 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
19

quality health care. Those years of experience demonstrate that he is more than 

qualified to lead the thousands of hardworking and dedicated employees within 

VHA. 

Further, we believe he is a man who will not be afraid to butt heads with the 

Office of Management and Budget for proper funding, the Congress or the Department of Defense (DOD). 

Many of the issues and challenges VHA faces today will be helped by Dr. 

Kussman’s military experience. All of us in Washington have been talking about a 

true system where DOD and VA create a seamless transition for military personnel 

to veterans’ status. We believe that if anyone can make that happen, it is Dr. 

Kussman, because he understands both systems and knows the necessity of creating 

such a system for the care and treatment of our wounded warriors, ensuring that 

they receive the benefits they have rightly earned by their honorable service to our 

Nation. 

The VFW sincerely believes Dr. Michael Kussman is the right person to lead the 

Veterans Health Administration and we cast our unanimous votes—our shares—for 

his immediate confirmation. 

Mr. Chairman, as I mentioned earlier, the VFW is joined by the AMVETS, Disabled American Veterans, the Paralyzed Veterans of America, and the Vietnam Veterans of America in strongly supporting the nomination of Dr. Michael Kussman for 

the position of Under Secretary for Health, Veterans Health Administration, Department of Veterans Affairs. 

We urge this Committee to favorably report his nomination to the full Senate, and 

we would ask your colleagues to confirm him as the Under Secretary of Health without delay. 

I thank you for the opportunity to testify today, and I would be happy to answer 

any questions you may have.

Chairman AKAKA. Thank you very much, Mr. Wallace. 

I want to thank all of you for your thoughtful and comprehensive 

testimony. I believe you have given the Committee a good understanding of where your organizations stand on Dr. Kussman’s nomination, and I want you to know that I appreciate your taking the 

time to appear here today. 

As I said at the outset, because of time, we would go directly to 

this first panel and therefore did not offer an opening statement. 

At this time, I would like to include my full statement in the record 

and ask other Members for any statement or questions they may 

have for this panel. 

Chairman AKAKA. May I call first on Senator Craig? 

STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER,

U.S. SENATOR FROM IDAHO 

Senator CRAIG. Mr. Chairman, thank you for holding this hearing and doing a confirmation hearing in a way that, I think, adds 

the dimension and the reality of the personality as much as the experience and the qualifications of the personality that comes before 

us. So I thank you for that. 

I do have a full statement I will enter into the record. But I do 

want to say in entering that statement into the record that in my 

conversations with Dr. Kussman, recognizing almost 40 years now 

of the kind of experience that he brings to this position, recognizing 

that we have been without a person in this capacity for an extended period of time, the thing that I was most impressed about, 

because the credentials are evident, as you know—there is the resume, look at it, a phenomenal list of experiences—but my conversations with Mike Kussman left me appreciating something that 

sometimes you don’t hear from nominees and that was an open and 

obvious passion for the job and a sincerity and concern about veterans that really stood out. 

20

We recognize the new challenges, and I think Mr. Mitchell put 

it well. You keep reinventing this health care system to fit the new 

veteran, and we have got to do that. It has got to be a dynamic 

system, and sometimes we are not as quick to catch up, but we do 

catch up. When you have somebody in the capacity that the President has asked Dr. Kussman to serve in, you need that kind of talent, and I think it is obvious within the man. It is obviously clearly 

to me within the passion of the person that we have got before us, 

and so I am pleased. I hope we can move him and move him expeditiously. 

And let me thank this panel for their openness and their directness about this particular gentleman. It is a phenomenally important position for veterans because it will sustain and, I hope, enhance one of the best health care delivery systems in the country 

today, if not the best, and that is what we are all about here. 

Thank you, Mr. Chairman. 

[The prepared statement of Senator Craig follows:]

PREPARED STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER,

U.S. SENATOR FROM IDAHO

Good morning, Mr. Chairman. I want to thank you very much for calling this 

hearing to review the qualifications of Dr. Michael Kussman to head the VA health 

care system. I also want to thank all of the witnesses on the first panel for coming 

here this morning to voice their views on this man. 

Mr. Chairman, I’d like to say at the outset of this hearing that based on a review 

of his record and having spent some time with him personally, I believe Dr. 

Kussman is very qualified for this job. And I strongly support his nomination. 

Mike Kussman, a physician for almost 40 years, is a veteran of the United States 

Army, who retired as a Brigadier General after serving this Nation on active duty 

for over 20 years. . . . He has published numerous papers; served on countless 

boards and Committees inside and outside of government; and managed some of the 

military’s largest medical installations. 

In short, he is a highly educated and dedicated, Army veteran, with management 

experience who understands both the military and VA health care systems inside 

and out. 

But Mr. Chairman, I’d also like to suggest to the Committee that perhaps Dr. 

Kussman is more than simply qualified for the job. After all qualifications are largely just objective facts about a person. They are a person’s education and experience. 

While I hope I’m not offending him by saying this. Candidly, I’m sure there are a 

few other people along with Dr. Kussman who are technically qualified to lead VA’s 

health care system. 

But, when you add Mike’s qualifications together with the enormous passion for 

the job he displayed during my interview with him. And then you wrap that passion 

around the integrity and character of this gentleman, I find someone with more 

than just qualifications. I find the right man for the job. 

Mr. Chairman, I know you and I share this view of Dr. Kussman. So, I hope we 

are able to work with our colleagues to move quickly on his confirmation. The VA 

health care system needs strong, confirmed leadership at the helm to care for our 

veterans. We have spent nearly 9 months seeking out the person to fill the position 

left vacant by Dr. Perlin’s departure last year. 

I believe we have found that person. He enjoys the strong support of our veterans’ 

service organizations, the professional medical community, many of his former colleagues in the military, and even his current employees. I think that speaks volumes about this nominee. I hope our colleagues will join us in supporting Dr. 

Kussman. 

Thank you, again, Mr. Chairman, for holding this hearing. I look forward to hearing from all of our witnesses.

Chairman AKAKA. Thank you very much, Senator Craig. 

I would like to call on Senator Tester and Senator Murray for 

any comments, statements, or questions they may have. Senator 

Tester? 

21

STATEMENT OF HON. JON TESTER,

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman, Ranking Member 

Craig. I want to thank the panel also for being here and taking 

time out and giving us your perspective on Dr. Kussman. I appreciate that. 

I had an opportunity to visit with Dr. Kussman last week. I appreciate your frankness and that discussion. I think the biggest 

issue that I have is not the quality of care, once again, as we talked 

about, but it is access to that care and how we are going to cut 

down on those access times to make sure that those folks who 

made the commitment to this country and the military get the kind 

of care they deserve and don’t have to wait an extended period of 

time for that care. 

It is important to reiterate, though, that the VA is going to have 

increased challenges like they have never seen before with what 

has transpired in Iraq and Afghanistan and it is very, very important that as we go through with this, and I will hold my questions 

until the end, Mr. Chairman, that as we go through with this process of confirmation, that you understand that you have got a hard 

job ahead of you once confirmed because our military is coming 

back with some injuries that in previous wars probably wouldn’t 

have survived. 

So I look forward to the questions and answers and I look forward to working with you once you are confirmed because I think 

you will be. Thank you. 

Chairman AKAKA. Senator Murray? 

STATEMENT OF HON. PATTY MURRAY,

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Mr. Chairman, thank you so much for holding 

this hearing, and I want to thank all of our panelists for their testimony. 

Certainly, we do a lot of nominations here and to me this is an 

extremely important one for a number of reasons. 

Dr. Kussman obviously has an excellent resume and I had a 

chance to meet with him and appreciate his honesty and his trying 

to confront the many challenges that the VA has. 

But we all know there are 1.5 million men and women who have 

gone to Iraq and to fight terrorists around the globe who are coming home who need care that we have not thought about before, 

from traumatic brain injury to post-traumatic stress syndrome to 

loss of limb, that are fighting to get their benefits, that are fighting 

to get the right care. 

The issue of transition is enormous. We know that there are an 

increasing number of veterans from previous wars, particularly the 

Vietnam War, that are now accessing our VA and are finding it 

very difficult to get in. We have talked about a lot of these issues 

and we need somebody at the helm at the VA today that can really 

address those, not just to deal with the crisis of today but to look 

out further ahead and determine what our VA is going to look like 

in the future. That is why this position is important. 

But even more importantly to me, Mr. Chairman, is the concerns 

that we have seen consistently come from the VA over the last sevVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
22

eral years. We need a new level of frankness from the Veterans’ 

Administration. We have seen them minimize the costs of this war, 

both in money and in lives, to the detriment of the men and women 

who we have asked to serve us. We haven’t been able to get 

straight answers or real numbers, to the detriment of our servicemen and women over the past several years. 

Our own experience has been that the VA came to us with information that was inaccurate, underestimating the amount of money 

that we needed, and we had to come up with additional billions of 

dollars late in the game to address the needs of the VA in the past 

few years. The GAO has found in report after report that the VA 

has misled the Congress, concealed their funding problems, and 

based its projections on inaccurate models. And very troubling to 

me, Mr. Chairman, is a report that we got from McClatchy News

that the VA has repeatedly exaggerated the past successes of the 

VA medical systems, exactly at a time when we need honesty from 

the VA so that we can provide the resources and the policies to 

make sure that no one falls through the cracks today. 

I have been very upset most recently about inaccurate responses 

to questions that we have asked of VA. I have witnessed the VA 

transform itself into an agency that guards information like a 

mother bear hugging her cub. We need that information and that 

honesty and frankness in order to be able to do the right things on 

this Committee. 

It is troubling to me that we have watched the VA undermine 

our confidence in its leadership over the last few years, from the 

troubling issues with the budget, to the records that were lost and 

not told to us in a timely manner for the VA employees themselves, 

to backlogs for benefits, and the list goes on. Just yesterday, the 

Associated Press reported that nearly two dozen officials who received hefty performance bonuses last year at the Veterans Affairs 

Department also sat on the boards charged with recommending the 

payments. These are the kinds of things that repeatedly and repeatedly and repeatedly undermine our confidence in what the VA 

is telling us. 

So, Mr. Chairman, this nomination and this appointment to me 

takes on a very huge significance in the scheme of things. We need 

a culture of change at the VA. We need someone who will come in 

front of us and be honest and frank and tell us the truth. We need 

someone who can provide the leadership to address the real challenges of today and tomorrow. I will be looking forward to hearing 

Dr. Kussman’s response to the many questions that we have here. 

I appreciate all of your support of the nomination, but I hope 

that this Committee bears in mind how important this nomination 

is, because again, to me, it is about the real need for a culture of 

change at the VA and a new direction in honesty and frankness so 

that we, as Members of this Committee and the U.S. Senate, can 

have the information we need to do the right thing for the men and 

women who have served us so honorably. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Dr. Kussman, your nomination comes before the Senate at a difficult and challenging time for VA. The terrible conditions in Walter Reed put a spotlight on VA health care. With each passing day, 

23

more and more servicemembers are returning with serious traumas 

and injuries, as was mentioned by Senator Murray, which will 

cause many veterans to rely on lifetime of care from VA. As 

servicemembers reach out to VA, inevitably, we hear tragic stories 

of those who did not get the care they needed. 

There is no doubt that mental health issues will also be a challenge for VA. The truth of the war is that the toll will be felt by 

servicemembers and their families for years to come. I am talking 

about invisible wounds, wounds which cannot be seen but are every 

bit as devastating as physical wounds. 

VA’s Under Secretary for Health is one of the most important 

public servants. The next Under Secretary will guide the VA medical system at a time when so many new veterans will be turning 

to VA. From my vantage point, VA was not prepared to deal with 

the types of injuries stemming from this war. Capacity must be rebuilt and the next Under Secretary will have this huge

challenge. 

So I urge you, Dr. Kussman, if you are confirmed, to first and 

foremost serve as an advocate for veterans. I am quite cognizant 

of the constraints placed upon you by the White House and by 

OMB, as well, and I promise you my full cooperation and assistance. But I tell you now that I will not be satisfied unless you work 

to uphold the promises made to all of our troops. I know you 

have—and this is why I think you are so well suited for this position—that you have been working on seamless transition. This is 

another huge problem and challenge that we have ahead of us, and 

thankfully we are not starting from zero with you. Hopefully, we 

can move to bring a truly seamless transition from active duty to 

civilian life. 

We are expecting, as I told you, a series of votes that was supposed to begin at 10:30, but it is due here any minute. I just received word that we are down to three votes, a series of three 

votes, and that will happen soon. So I would like to thank our 

panel for being here, for contributing to the record of Dr. 

Kussman’s hearing. Again, thank you for being here. 

With that, I ask the Committee now stand in recess for the series 

of votes and then we will come back and take Dr. Kussman’s statement and also have questions for you, Dr. Kussman. Thank you 

very much, and we stand in recess. 

[Recess.] 

Chairman AKAKA. The Committee will again come to order. 

I would like to introduce the nominee, Dr. Michael Kussman. I 

have known Dr. Kussman for many years, since he first served in 

Hawaii in the early 1980s. His service in Hawaii included several 

senior positions at Tripler Army Medical Center and later as Division Surgeon for the Hawaii-based 25th Infantry Division. He 

joined VA in September of 2000 after retiring from a long career 

of military service at the rank of Brigadier General. He has served 

as Acting Under Secretary for Health since August of last year, 

when Dr. Perlin resigned. 

If I have the time line correct, by the time the Kussman family 

left Hawaii, their daughter, Deana, had spent half of her life in the 

islands. Deana, I hope that by now you and the rest of the family 

have found it in your hearts to forgive your dad for moving the 

24

family from the beautiful State to continue his service elsewhere. 

Maybe you can work on him to find his way back to paradise. 

Thank you for coming before this Committee today, Dr. 

Kussman, and to the entire Kussman family, as we say in Hawaii, 

E Komo mai, or welcome to our hearing. 

Dr. Kussman? 

STATEMENT OF MICHAEL J. KUSSMAN, M.D., NOMINEE

TO BE UNDER SECRETARY FOR HEALTH, DEPARTMENT OF

VETERANS AFFAIRS 

Dr. KUSSMAN. I think it is still morning, sir. Good morning, Mr. 

Chairman. Aloha to you. 

Chairman AKAKA. Aloha. 

Dr. KUSSMAN. I appreciate your comments. Before I begin my 

statement, may I mention that my wife, Ginny, whom you acknowledged, my son Josh and his fiance Laura, my daughter Deana and 

her husband Steve, are all with me today, sitting right behind me 

next to the Deputy Secretary. Their love and support, especially 

Ginny’s—I love you, dear—have made it possible for me to serve 

my country faithfully and well through my career. Without their 

help, I could not possibly have qualified for the office for which I 

have the honor of being considered. 

Mr. Chairman, I began my career with the United States Army 

back in 1970. Like many at the time, I was drafted and served my 

2-year tour honorably before leaving the Service. I finished my 

medical training, went into private practice for a few years, and 

then volunteered to return to the Army in 1979. I came back because I realize as a physician and a healer, that being an Army 

doctor allowed me to practice my profession while being of service 

to our Nation’s greatest heroes, our servicemembers. I am proud of 

my military service and privileged to have worked my way through 

the ranks to be selected as a general officer. 

When I transitioned from the military, I wanted to continue to 

serve. The Veterans Health Administration offered me that opportunity in 2000 and I could have not been more grateful. Although 

I am not still wearing a uniform, I consider myself to be still serving. I appreciate the VHA for giving me that opportunity. 

When I joined the VHA, the agency was in the process of successfully redefining itself as the standard of care by which all other 

health care providers must be measured. Just last month, for example, a new book was published. It is entitled, The Best Care 

Anywhere: Why VA Health Care is Better Than Yours. I am truly 

fortunately to have been chosen to carry the standard for this great 

organization. 

From my perspective, VHA not only offers the best health care 

anywhere, but we have the best people anywhere, as well. With the 

proper resources and the support we receive from the Senate, the 

House, the President, and the veterans service organizations, we 

can continue to set the benchmark for quality care for the Nation 

and the world. 

Mr. Chairman, soon after I came to VA, our Nation went to war. 

We have been at war for more than 4 years now. Our losses, while 

they may not be as numerous as those in past wars, have nonetheVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00028 Fmt 6633 Sfmt 6601 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
25

less affected the lives of thousands of America’s heroes and their 

families. 

Our Department has no more important mission than to restore 

those who have been injured or made ill as a result of their service 

in this war to their highest possible level of functioning. Personally 

and professionally, I accept the responsibility for VHA’s readiness 

to provide these heroes with the level of care they have earned 

through their service and the sacrifices they have made in defense 

of our freedom. That is why I am here and that is my passion. 

Our care for OIF/OEF veterans has not been perfect by any 

means. We continue to learn what world class care means to this 

new generation of servicemembers, veterans, and their families. 

Their expectations have raised the bar for our success and we continue to improve in order to meet their expectations. When things 

have not gone well for individual veterans, I have listened intently 

and then done whatever I could to ensure that whatever mistakes 

we made will never happen again. 

It is true we made some errors, but we have accepted responsibility for those errors and we will fix them properly, whatever the 

cost may be. We have learned and we will continue to learn from 

what we have done wrong. If you confirm me as Under Secretary, 

that is how we will do business throughout my tenure. 

Make no mistake, however. I believe VHA has done an exceptional job of meeting the needs of our newest generation of veterans and we have received remarkable support from the President 

and Congress. But we still face many challenges. Among them are 

to improve our level of cooperation and collaboration with our partners at the Department of Defense; to enhance our ability to treat 

veterans with severe traumatic brain injuries and to detect mild to 

moderate TBI where brain injuries are not immediately apparent; 

to continue our search for the most effective therapies for posttraumatic stress disorder and ensure those therapies are quickly 

distributed throughout our system and elsewhere; to improve access of all enrolled veterans to our world-class care, from our newest veterans to our oldest; and to meet the goal of the President’s 

New Freedom Commission on Mental Health, to emphasize recovery, not stabilization, for every mentally ill veteran. 

As Acting Under Secretary, I have established four priorities for 

improvement in our system to help us meet today’s challenges and 

tomorrow’s. First, I have made leadership, responsible, accountable, 

demonstrated leadership, the key to the VHA’s future success. We 

have many fine leaders in our organization, but the men and 

women who are willing to accept positions of leadership in our organization must also understand the responsibilities they are asked 

to accept as leaders. I am committed to getting the right people in 

the right positions for the good of the entire organization. 

Second, I believe that of the VA’s four missions—patient care, 

education, research, and emergency management—patient care is 

by far the most important. To meet the needs of the veterans it is 

our privilege to serve, we must bring the quality of our care and 

our ability to provide that care to a higher level. We are now focusing on some basic questions. Are our waiting times and our wait 

time measures appropriate? Are our customers satisfied with our 

service? And are employees satisfied with their work? I believe, and 

26

I know Members of Congress believe, we can do better in those 

areas. 

Third, I do not believe that the quality of our business processes 

matches the quality of our health care we provide. Among other 

things, we must be able to properly handle the sensitive personal 

information our veterans entrust to us. Every VA employee, especially our managers and supervisors, has a duty and responsibility 

to protect sensitive and confidential information. I have worked 

with Secretary Nicholson and others to ensure that the VHA is in 

the first rank of those who are helping to make our Department 

the gold standard in information security. 

And finally, I want to be sure that in measuring performance, we 

are measuring the right things. Our performance measures system 

is the best in health care, but we must continue to be vigilant in 

this area, especially where lives are at stake. 

Mr. Chairman, Members of the Committee, let me close by 

thanking you, Secretary Nicholson, and the President for the privilege that I have been given to continue to serve America’s heroes 

at the Department of Veterans Affairs. I am deeply humbled by the 

search committee that chose me from among many qualified candidates and by the President’s willingness to nominate me to lead 

the finest health care system in America. If I am confirmed as 

Under Secretary, I promise to work with you and all Members of 

the Congress to build a health care system that will meet the needs 

of all veterans and their families, the men and women it is VHA’s 

privilege and honor to serve. 

[The prepared statement of Dr. Kussman follows:]

PREPARED STATEMENT OF MICHAEL J. KUSSMAN, M.D., NOMINEE

TO BE UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Chairman Akaka, Ranking Member Craig, Members of the Committee and its 

staff. Good morning. 

Before I begin my statement, may I mention that my wife Ginny; my son Josh 

and his fiance, Laura; and my daughter Deana and her husband Steve are all here 

with me today. Their love and support—especially Ginny’s—have made it possible 

for me to serve my country faithfully and well throughout my career. Without their 

help, I could not possibly have qualified for the office for which I have the honor 

of being considered. 

Mr. Chairman, I began my career with the United States Army back in 1970. Like 

many at that time, I was drafted and served my 2-year tour honorably before leaving the service. I finished my medical training, went into private practice for a few 

years, and then volunteered to return to the Army in 1979. I came back because 

I realized, as a physician and a healer, that being an Army doctor allowed me to 

practice my profession while being of service to our Nation’s greatest heroes—our 

servicemembers. 

I am proud of my military service; and privileged to have worked my way through 

the ranks to be selected as a General Officer. When I transitioned from the military, 

I wanted to continue to serve. The Veterans Health Administration offered me that 

opportunity in 2000, and I could not have been more grateful. 

When I joined VHA, the agency was in the process of successfully redefining itself 

as the standard of care by which all other health care providers must be measured. 

Just last month, for example, a new book was published. It is titled ‘‘The Best Care 

Anywhere: why VA health care is better than yours.’’ I am truly fortunate to have 

been chosen to carry the standard for this great organization. 

From my perspective, VHA not only offers the best health care anywhere, but we 

have the best people anywhere as well. With the proper resources, and the support 

we receive from the Senate, the House, the President, and the Veterans Service Organizations, we can continue to set the benchmark for quality care for the Nation 

and the world. 

27

Mr. Chairman, soon after I came to VA, our Nation went to war. We have been 

at war for more than 4 years now. Our losses—while they may not be as numerous 

as those of past wars—have nonetheless affected the lives of thousands of America’s 

heroes and their families. 

Our Department has no more important mission than to restore those who have 

been injured or made ill as a result of their service in this war to their highest possible level of functioning. Personally and professionally, I accept responsibility for 

VHA’s readiness to provide these heroes with the level of care they have earned 

through their service and the sacrifices they have made in defense of our freedom. 

That is why I am here. 

Our care for OIF/OEF veterans has not been perfect by any means. We continue 

to learn what world-class care means to this new generation of servicemembers and 

veterans—and to their families. Their expectations have raised the bar for our success, and we must continue to improve in order to meet those expectations. 

When things have not gone well for individual veterans, I have listened intently—

and then done whatever I could to insure that whatever mistakes we made will 

never happen again. It’s true we’ve made some errors, but we have accepted responsibility for those errors, and we will fix them properly, whatever the cost may be. 

We have learned—and we will continue to learn—from what we have done wrong. 

If you confirm me as Under Secretary, that is how we will do business throughout 

my tenure. 

Make no mistake, however—I believe VHA has done an exceptional job of meeting 

the needs of our newest generation of veterans, and we have received remarkable 

support from the President and from Congress. But we still face many challenges. 

Among them are:

To improve our level of collaboration with our partners at the Department of Defense; 

To enhance our ability to treat veterans with severe traumatic brain injuries, and 

to detect mild to moderate TBI where brain injuries are not immediately apparent; 

To continue our search for the most effective therapies for Post-Traumatic Stress 

Disorder, and ensure those therapies are quickly distributed throughout our system 

and elsewhere; 

To improve access for all enrolled veterans to our world-class care, from our newest veterans to our oldest; and 

To meet the goal of the President’s New Freedom Commission on Mental Health 

to emphasize recovery, not stabilization, for every mentally ill veteran.

As Acting Under Secretary, I have established four priorities for improvement to 

our system, to help us meet today’s challenges—and tomorrow’s. 

First, I have made leadership—responsible, accountable, demonstrated leadership—the key to VHA’s future success. We have many fine leaders in our organization; but the men and women who are willing to accept positions of leadership in 

our organization must also understand the responsibilities they are asked to accept 

as leaders. I am committed to getting the right people in the right positions for the 

good of our entire organization. 

Second, I believe that of VA’s four missions: patient care, education, research, and 

emergency management—patient care is by far the most important. To meet the 

needs of the veterans it is our privilege to serve, we must bring the quality of our 

care, and our ability to provide that care, to a higher level. 

We are now focusing on some basic questions: are our waiting times, and our wait 

time measures, appropriate; are customers satisfied with their service; and are employees satisfied with their work. I believe, and I know Members of Congress believe, we can do better in these areas. 

Third, I do not believe that the quality of our business processes matches the 

quality of the health care we provide. Among other things, we must be able to properly handle the sensitive personal information our veterans entrust to us. 

Every VA employee, especially our managers and supervisors, has a duty and responsibility to protect sensitive and confidential information. I have worked with 

Secretary Nicholson and others to ensure that VHA is in the first rank of those who 

are helping to make our Department the gold standard in information security. 

And finally, I want to be sure that in measuring performance, we are measuring 

the right things. Our performance measurement system is the best in health care—

but we must continue to be vigilant in this area, especially where lives are at stake. 

Mr. Chairman, Members of the Committee, let me close by thanking you, Secretary Nicholson, and the President, for the privilege I have been given to continue 

to serve America’s heroes at the Department of Veterans Affairs. I am deeply humbled that the search committee chose me from among many qualified candidates, 

28

and by the President’s willingness to nominate me to lead the finest health care system in America. 

If I am confirmed as Under Secretary, I promise to work with you and all Members of Congress to build a health care system that will meet the needs of all veterans and their families—the men and women it is VHA’s privilege, and our honor, 

to serve. 

RESPONSE TO PRE-HEARING QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA

TO MICHAEL J. KUSSMAN, M.D., NOMINEE TO BE UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Question 1: The VHA leads the private health sector in many areas, such as electronic medical records, overall patient satisfaction, and negotiations with pharmaceutical companies. In what areas do you believe VA still lags behind? In what fields 

could VHA learn from the private sector or benefit from the implementation of 

methods used in the private sector, and what are your plans to make the necessary 

improvements? 

Response: I agree that the Veterans Health Administration (VHA) leads the private health care sector in the areas of electronic medical records, overall patient satisfaction, and effective negotiations with pharmaceutical companies. However, the 

Department of Veterans Affairs (VA) has room to improve regarding best practices 

from the private sector. VA is learning to leverage private sector business practices 

to increase our productivity. 

VA has implemented a private sector-based business model pilot known as the 

Consolidated Patient Account Center (CPAC) tailored for our revenue operations. 

This private sector-based business model will enable VA to increase collections and 

improve our operational performance. CPAC is addressing all operational areas contributing to the establishment and management of patient accounts and related billing and collections processes. CPAC currently serves revenue operations for medical 

centers and clinics in one of our Veterans Integrated Service Networks (VISN) but 

this program will be expanded to serve other networks.

Question 2: I consider VHA’s university affiliations, and related programs such as 

internships, medical residencies, and joint research, as among VHA’s greatest 

strengths. Aside from existing initiatives, what original plans or ideas would you 

propose in order to maintain the long-term strength of these programs? 

Response: Our university affiliations are a cornerstone of our delivery of care and 

the quality of our delivery system. This symbiotic relationship has been going on 

for over 60 years and remains strong today. As part of this relationship, VA works 

with affiliates to address concerns. For example, we are examining how VA can use 

its clinical learning environment to maximize the training of physicians for the realities of practice in the modern health care environment. VA has one of the best, 

if not the best, patient safety program in the Nation. The question then becomes, 

how can we best use this resource in our health professional training programs? We 

have had continuous and ongoing dialogue with the Association of American Medical 

Colleges to assess these and other issues. The outgrowth of dialogue such as this 

was the establishment of a Blue Ribbon Task Force to look at where we are and 

where we need to go. 

Acting on Task Force recommendations to improve and strengthen VHA’s university affiliations, I have directed VHA’s Office of Academic Affiliations to work with 

our medical school and academic medical center partners to explore new and potentially transformative approaches to medical education. The centerpiece of this approach is the emerging realization by medical educators that educational reform 

without concurrent redesign of the care delivery environment is unlikely to be successful and that clinical redesign has profound implications on the process and content of education as well. For example, one has only to consider the importance of 

continuity of care in forming the attitudes of young physicians and provider continuity in managing patients with chronic disease to appreciate the essential unity 

of education and care delivery. Indeed, learning and care are inseparable. 

But physicians alone will be insufficient in the team-based care delivery system 

of the future, and VA must increase its attention to other health professions. At my 

direction, the Office of Academic Affiliations is expanding inter-professional training 

opportunities and, in partnership with VHA’s Office of Nursing Services, has just 

launched a major initiative in nursing education, the VA Nursing Academy. 

The central intent of the Nursing Academy is to work hand in hand with the Nation’s nursing schools in addressing the major problem underlying the present nursing shortage—insufficient numbers of teaching faculty. A 5-year pilot project is already underway to identify VA facility-nursing school partnerships willing and able 

29

to invest in nursing faculty while at the same time admitting additional numbers 

of qualified students. 

VA nurses will be given faculty appointments and VA will provide additional 

funding for nursing school faculty. Innovative ways of enhancing the learning environment and nursing curriculum will be explored and the scholarly and research development of nursing faculty will be enhanced. 

As is evident from the initiatives summarized above, new, more collaborative 

management models are appropriate for the current relationship between VA and 

its affiliates. One potential model that I would like to see explored in more depth 

is ‘‘educational consortia’’—in which VA works much more closely with its academic 

affiliates to jointly manage educational programs while still retaining sole control 

of its health care delivery operations. 

In summary, I believe VA’s academic affiliations provide significant opportunities 

for improving health care for veterans while strengthening academic institutions 

throughout the country. We should, and we will, work hard to keep these relationships vibrant by continuously exploring new approaches to collaboration and securing the resources necessary to ensure excellence in our statutory educational mission.

Question 3: What is your overall direction for the VA research program? 

Response: The VA research program is a jewel in the crown of the Nation’s research capability. Over the years it has done magnificent research, and VA researchers have received two Nobel Prizes and six Lasker Awards. Our goal is that 

the research we conduct needs to have direct transferability to veteran care. Over 

the last 3 years we have shifted the direction of our research program to increase 

emphasis on research related to Operation Enduring Freedom and Operation Iraqi 

Freedom (OEF/OIF) veterans, including traumatic brain injury (TBI) and other 

neurotrauma, combat-related mental health, prosthetics and amputation health 

care, polytrauma, and other related issues. 

VA’s research is performed in house with funding coming from direct appropriation, other government entities and the private industry. We have increased our 

percentage of research dollars directly related to OEF/OIF issues to 58 percent. We 

are also continuing to focus on chronic disease research and our research in this 

area is expanding to incorporate genomics research. In addition, we are increasing 

our focus on research related to reducing health disparities, including minority and 

rural health disparities, and are beginning interventional studies in this important 

area.

Question 4: Anecdotal evidence suggests that waiting times for medical appointments—including non-specialist appointments—often reach several months, and occasionally exceed six months. In addition, it is my understanding that VA is not 

tracking the time it takes specialty medical procedures and surgeries to be scheduled once they are recommended. Finally, the IG has reported manipulation of the 

electronic waiting list and other procedures used to track waiting times. If confirmed, what would you do to ensure that waiting times are accurate and, more importantly, that veterans are not waiting excessive times for care, including medical 

procedures and surgeries? 

Response: The most important issue is making sure veterans see a provider as 

quickly as possible. Delaying the provision of care beyond reasonable periods of time 

is not acceptable. 

At present, 95 percent of all appointments are made within 30 days of the desired 

date and 98 percent within 60 days of the desired date. We have been tracking the 

number of new veterans to the system that have had to wait more than 30 days 

from the desired date to get an appointment. This number has declined from 22,000 

in May 2006 to 1,300 in March 2007. 

To ensure the accuracy of waiting times, VA has undertaken various measures to 

improve the performance of schedulers who initiate appointments. For example, we 

have made a concerted effort to identify schedulers that are making mistakes. To 

improve performance, VA developed and implemented a comprehensive policy on the 

proper way to schedule and record appointments. 

As part of the implementation process, training is mandated for all employees 

working on scheduling appointments. VHA has conducted training for schedulers to 

help them determine and document these desired appointment dates. Our efforts 

have been successful at reducing the wait times for veterans across the country. 

With respect to waiting for medical procedures and surgeries, this is not yet being 

tracked. One of my top priorities is to develop tertiary care performance standards 

to do just this.

Question 5: VISNs were implemented a dozen years ago. Since that time the total 

number of personnel assigned to each VISN has grown from the originally enviVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
30

sioned 8–10 employees to, in some cases, hundreds. Please share your views about 

what are the advantages and disadvantages of the current structure. 

Response: VHA is among the largest health care systems in the country. The 

VISN structure supports the integration of service delivery within a network. VISNs 

can provide their population of veterans with the full range of health care services 

from primary care, available at locations throughout the network, to highly specialized treatment, which may be available at only one location. Since the VISN system 

was established, the role of VISNs has grown significantly as they take advantage 

of myriad efficiencies. They have taken on a significant work load that could no 

longer be done in Central Office. 

VHA recently held a Summit Meeting in Baltimore to assess where we have come 

in the past 10 years from enrollment reform and the establishment of the VISNs 

and where we would like to go. One of the issues is the role of the VISNs vis-avis Central Office. Most agree that health care is local, so the development of regions has its advantages, but there still needs to be consistency and standardization 

of delivery of care. Although the balance between centralization and decentralization 

will always be debated, there is no absolute. It is my opinion the pendulum probably 

has swung a little too far in the direction of decentralization and needs to come back 

toward the center in order to ensure appropriate consistency and standardization.

Question 6: Are you comfortable with the amount of oversight that VA Headquarters program managers are able to conduct? In your view, is budgetary authority a requisite for such oversight? 

Response: I am comfortable with the amount of oversight VHA program managers 

have and I do not believe any additional budgetary oversight is required. Central 

Office program managers are responsible for establishing policies and procedures 

and setting standards. They work closely with the Chief Financial Officer to ensure 

program funds are appropriately planned, allocated, and used. They are not operators. Program managers advise VA leadership on what should be done. If they believe existing policies and procedures are not being followed, they have opportunities 

to raise their concerns before the National Leadership Board and, using the chain 

of command, to bring these issues to my attention. Our managers are evaluated 

based upon objective performance measurement criteria, so they have a direct interest in maintaining oversight and accountability. I do not believe budgetary authority 

is a requisite for oversight and direction.

Question 7: What would you do as Under Secretary for Health—beyond increasing 

funding for the existing EDRP and scholarship programs—to enable VA managers 

to recruit and retain health professionals, especially in the area of nursing? 

Response: VA places a high priority on hiring and retaining nurses. We are fortunate our retention rate seems to be higher than civilian markets. Our nurses believe 

in our mission and enjoy the work environment we create as well as our mission. 

We are in the process of establishing a VA Nurse Academy we hope will lead to better visibility of the VA in Nursing Schools and increased hiring. 

I would like to highlight the programs for recruitment and retention of health 

care professionals noted in your question. The Education Debt Reduction Program 

(EDRP) receives $15 million each year. This program has authorized over 5,200 

awards since its inception in 2002 for health care employees with outstanding student educational loans. There is a current total obligation through Fiscal Year (FY) 

2012 of $89 million. The impact on retention is significant. A study in 2005 revealed 

the resignation rate for EDRP nurses, physicians, and pharmacists was less than 

half that of non-EDRP staff (for nurses, 13.7 percent versus 28 percent; physicians 

15.9 percent versus 34.8 percent; pharmacists 13.4 percent versus 27.6 percent). 

In addition to continuing and enhancing the Education Debt Reduction Program, 

VHA manages one of the largest employee scholarship programs in the Federal Government, the Employee Incentive Scholarship Program. Over 6,300 academic scholarships have been awarded to VHA employees seeking degrees in health care occupations or advancing their education in the nursing professions.

Question 8: In your view, what can be done to enhance compensation for senior 

non-medical personnel? How do you perceive the discrepancy between compensation 

in VA and in the field of private hospital management, given the similar nature of 

the work? 

Response: Proper and equitable compensation for our most experienced executive 

personnel is a challenge. The government pay system prevents us from paying nonmedical personnel comparable competitive salaries. 

Growing pay disparities both within and outside VHA make it increasingly likely 

that many executives will be lured away by more lucrative private sector opportunities or will choose retirement, leaving a void in the ranks of senior leadership positions needed to ensure VHA’s continued pre-eminent position in health care. In a 

31

study published in 2000, the Hay Group affirmed the scope of responsibilities of 

VHA health care executives was, overall, comparable to that of private sector executives. 

Recent trends in VHA senior executive positions provide evidence of a growing 

problem, since turnover in medical center director positions increased from 6.8 percent in 2005 to 21.7 percent in 2006. VHA is engaged in rigorous succession planning, using such models as the High Performance Development Plan and the Leadership Development Plan, to identify, train, and retain promising managers. VA, 

like other Federal agencies, is taking advantage of Office of Personnel Management 

(OPM) programs designed to develop the next generation of leaders.

Question 9: Are you confident that current VHA authorities and procedures allow 

for sufficiently expeditious hiring of medical personnel? Please describe any recommendations that you may have for changes to the current hiring system. 

Response: No, I am not confident that our Human Resources policies and procedures allow for expeditious hiring in all areas. In fact, I believe that there have been 

instances where we lost the opportunity to hire good people because our process took 

too long for our clinical professionals. We have appointing authority under title 38 

for physicians, dentists, and registered nurses, and similar authority under our hybrid title 38 appointment for pharmacists, physical therapists, social workers, psychologists, medical instrument technicians, and others, which allows for quicker hiring for these positions, However, other allied health areas do not fall under this 

same authority and are subject to prolonged hiring processes. Like most of the rest 

of the Federal Government, we do not have this authority for other professionals 

and technical staff, but we are working internally to identify obstacles and develop 

solutions to speed up the process.

Question 10: In my view, Physician Assistants play a vital and growing role in 

the delivery of health care. You have already indicated your dedication to expanding 

the role of the PA Advisor. What new efforts would you undertake as Under Secretary for Health to ensure full participation of the PA Advisor in health care planning and to provide adequate resources for the position? 

Response: I agree that physician assistants (PA) are valuable and essential to the 

delivery of care in the VA. VHA increasingly relies on PAs for critical contributions 

to providing quality and timely health care to our Nation’s veterans. The PA Advisor is now required to travel to Central Office on a regular basis to enhance his full 

participation in the position’s expanded responsibilities. I have made the decision 

that, with the next iteration of consultant for PAs, the position will be full time and 

will be located in Central Office. I am requesting the PA Advisor provide periodic 

briefings identifying barriers and recommended changes to expand the scope of responsibilities in order to fully use PAs in VA.

Question 11: The Veterans Benefits, Health Care, and Information Technology Act 

of 2006 enacted by Congress last year added Marriage and Family Therapists and 

Licensed Professional Mental Health Counselors to the list of health professionals 

that VA may employ. Please outline your plan for how this law will be implemented, 

specifically with regard to how these professionals will be fully integrated into VA 

mental health care. 

Response: To assist with implementation of Public Law (P.L.) 109–461, VHA is 

currently evaluating the graduate training requirements for Marriage and Family 

Therapists and Licensed Professional Mental Health Counselors. Specifically, we are 

looking at the post-graduate clinical experience and supervision required for licensure, the scopes of practice developed within the states, and the evidence-base for 

the effectiveness of care provided. It is necessary to take these steps to define the 

combinations of credentials and experience, as well as the scope of practice, required 

to ensure the professionals will enhance VHA’s ability to deliver high quality mental 

health care services to veterans in need.

Question 12: Marriage and Family Therapists and Licensed Professional Mental 

Health Counselors have similar or comparable qualifications with social workers, 

who have been eligible to work with VA for years. If confirmed, how will you utilize 

these health professionals? 

Response: The education of professionals in each discipline is defined by conceptual models specific to each discipline and an understanding of the clinical needs 

of the population served. Under my direction, the Offices of Mental Health Services 

and Management Support are reviewing the knowledge-base, supervision, and experience that define training, as well as the scope of practice in other settings to develop plans using these professions to an optimal degree. These evaluations will inform the strategies for utilization.

32

Question 13: Last month, you issued a policy that introduced anesthesiologist assistant (AAs) to the VA health system. Please explain the basis for this new policy, 

including how you expect it to enhance the quality of VA health care. 

Response: In some markets, VA has difficulty recruiting nurse anesthetists. Allowing facilities to use anesthesiologist assistants (AAs) to provide care offers us another option in providing veterans timely and quality access to needed health care. 

The use of AAs in VA has been an issue even before the December 22, 2006 Human 

Resources Management Letter (HRML) No. 05–06–12 allowing human resources offices to establish these positions. Anesthesiologist assistants practiced in VA before 

this decision as contractors, and some physician assistants performed this role as 

well. 

This is a relatively new field that could potentially expand the ability of the VA 

to provide anesthesiology services to veterans. These professionals must work under 

the supervision of an anesthesiologist and more than 10 States currently offer licenses to practice. There has been some concern from the Certified Registered Nurse 

Anesthetist (CRNA) community about this approach. It is our opinion that in the 

right setting and with appropriate oversight, the use of anesthesiology assistants 

will expand our capability and in no way diminish quality. It is my understanding 

that the VA CRNA organization is not opposed to the use of AAs in VA, but they 

have some concerns about the specifics outlined in the recently published directive. 

VA leadership agrees with the VA CRNA organization that further discussion will 

take place to ensure their concerns are addressed. If needed, we would issue a new 

directive.

Question 14: What is the standard by which you would approve or reject enhanced 

use lease applications for use of VA facilities? 

Response: The Enhanced-Use Lease (EUL) legislation (i.e., 38 U.S.C. § 8161–

8169) allows VA to enter into an enhanced-use lease if: (1) at least part of the property under the lease will provide appropriate space for an activity related to VA’s 

mission; the lease will not be inconsistent with nor adversely affect VA’s mission; 

and the lease will either enhance the use of the property; or (2) the lease would provide consideration to be used to improve the health care for veterans in the affected 

community. 

Essentially, there are three levels of strategic review—one at the initial stage 

when the EUL requests (concept papers) are submitted through VISNs to VHA’s 

Capital Assessment and Management and Planning Services (CAMPS) office; another when VHA submits the concept papers to VA’s Office of Management (OM); 

and then finally when OM submits the request to the Secretary. At any of these 

levels, if it is identified that the legislative criteria is not met, the concept paper 

is disapproved and returned to the VISNs and medical centers.

Question 15: Much has been promised about ensuring that there is a smooth transition between DOD and VA for separating servicemembers. I understand you have 

been directly involved in many of VAs initiatives to improve this process. What is 

the state of progress in this area, and what more needs to be done? 

Response: Seamless Transition has been a goal of VA and the Department of Defense (DOD) for many years, but our success has been measured and has, in some 

instances, fallen short of what our veterans deserve. In August 2003, I was asked 

by Secretary Principi to co-chair a Task Force to look at specific issues related to 

the new group of severely injured OEF/OIF servicemembers. I served in this capacity until January 2005, when VA established a permanent Office of Seamless Transition, composed of representatives from VHA and the Veterans Benefits Administration (VBA), as well as an active duty Marine Corps Officer and an Army Officer. 

Unprecedented efforts were taken by both DOD and VA to put VA personnel full 

time in 10 DOD military treatment facilities (MTF) and to place full time military 

personnel in VA facilities. Our four traumatic brain injury (TBI) centers were converted to polytrauma rehabilitation centers to deal with the complex injuries of 

some of our recently injured servicemembers. VA began employing a system of clinical case management to assist in the movement of servicemembers from DOD to 

VA. We recognized the challenges faced by previous generations, and we wanted to 

simplify the process for servicemembers and their families, especially those dealing 

with medical issues. If servicemembers are not going to a Polytrauma Center, our 

case managers coordinated with the nearest VA facility as selected by the veteran. 

Veterans are scheduled to be enrolled in VA prior to leaving the MTF and social 

workers are tasked with coordinating appointments with VA, while case managers 

will handle clinical issues and Transition Patient Advocates (TPAs) address 

logistical issues for our most seriously wounded veterans and servicemembers. 

In March 2007, Secretary Nicholson announced VA would be hiring 100 patient 

advocates to serve as ombudsmen for severely injured OEF/OIF veterans. These new 

33

TPAs will assist seriously injured veterans and their families with issues and concerns and help them navigate the VA system. In March 2007, VHA published a policy document outlining the responsibilities of the TPAs, which include traveling to 

military hospitals to meet severely injured patients and their families and following 

those patients into the VA health care system. Also in March 2007, VHA began recruiting to fill the positions. As of this date, VA medical centers have hired 46 TPAs 

and are interviewing to select the remaining 54. Each medical center with vacant 

TPA positions has detailed employees to perform the functions while recruitment is 

underway. I believe that the TPAs will help us assure that no severely injured OEF/

OIF veteran falls through the cracks. 

We are improving our coordination in joint-case management situations with more 

communication. Veteran Tracking Application, VA’s adaptation of the Joint Patient 

Tracking Application system will help track and provide clinically important information. VA has also started using ombudsmen for each severely injured veteran or 

servicemember to ensure one person will follow him or her across the continuum 

of care; we are filling these positions now. We need to do better with less severely 

injured servicemembers who do not enter the Polytrauma System of Care. Our improved case management system will help them as well. 

Seamless transition for all separating servicemembers is also very important and, 

to a large degree, is handled through the Benefits Delivery at Discharge process. 

We must continue to improve our Compensation & Pension process to ensure effective, standardized and timely examinations so veterans receive the care and benefits 

they earned. 

With those limits and needs acknowledged, VA has done a great deal for our 

servicemembers. VHA staff has coordinated over 7,000 transfers of OEF/OIF 

servicemembers and veterans from an MTF to a VA medical facility. Active duty 

Army Liaison Officers are assigned to each of the four VA polytrauma rehabilitation 

centers and assist servicemembers and their families from all branches of Service 

on a wide variety of issues. VA established an OEF/OIF Polytrauma call center to 

assist our most seriously injured veterans and their families with clinical, administrative, and benefit inquiries. VA has implemented an automated tracking system 

to track servicemembers and veterans transitioning from MTFs to VA facilities. 

During the period October 2006 through March 31, 2007, over 150 severely ill/injured patients were transferred from MTFs to VA medical centers (VAMC). VA is 

participating in DOD’s Post Deployment Health Reassessment (PDHRA) program 

for returning deployed servicemembers, and between 5 November 2005 and 30 April 

2007, over 85,000 Reserve and Guard members were screened, generating more 

than 20,000 referrals to VAMCs and over 10,500 referrals to Vet Centers. 

In addition, VA signed a memorandum of agreement (MOA) with the National 

Guard in May 2005 to form state coalitions in 54 States and territories. A similar 

MOA is being developed with the U.S. Army Reserve Command and the U.S. Marine Corps at the national level. VA and the National Guard Bureau teamed up to 

train 54 National Guard transition assistance advisors who assist VA in advising 

Guard members and their families about VA benefits and services. We are currently 

reviewing the recommendations of the President’s Task Force on Returning Global 

War on Terror Heroes. Some of these recommendations are already being developed 

and implemented, such as the call to develop a system of co-management and case 

management between DOD and VA and providing full support to DOD for PDHRA 

for Guard and Reserve members, as an extension of the outreach described above.

Question 16: In an attempt to respond to the demand for care from 

servicemembers from the operations in Iraq and Afghanistan, the Administration 

has chosen to prioritize the care of veterans who served in these operations. Do you 

believe it is appropriate for older veterans to wait behind new veterans for care? 

Would you advocate for increase funding to obviate the need for this type of 

prioritization? 

Response: We certainly do not want to create a situation that pits one group of 

veterans against another. Specific clinical needs should be the final arbiter of priority access. If there is no clinical difference, it is administrative policy to expedite 

appointments for new veterans, including OEF/OIF veterans. Our goal is to have 

all veterans seen within 30 days of their requested appointment date, or within 30 

days of their request in the case of new enrollees. If we achieve that, there is no 

need to prioritize one group of veterans over another. Almost all facilities currently 

comply with this 30-day standard 90 percent or more of the time. We believe our 

current level of funding will allow us to meet that goal. The expansion of non-institutional services targeted for Fiscal Year 2008 is the most rapid expansion that can 

realistically be achieved in a single year in services for our veterans.

34

Question 17: Criticism of VA’s prosthetics, TBI, and mental health programs has 

raised the issue of VA contracting with private and/or community entities to make 

up for either perceived or real shortcomings in these programs. What are your 

thoughts about this? Is it not possible for VA to reach the pinnacle of care in these 

areas? Would you consider the need for contracting out for care in these areas? Can 

a viable VA health care system exist if its role is relegated to solely that of a payer 

versus a provider in these clinical areas? 

Response: Let me first say that our Nation’s veterans deserve the best care possible and we continually work to improve our care and services that we provide. VA 

achieves a gold standard according to external and internal measures of quality for 

our prosthetic, TBI, and mental health care. VA performs over 5,000 amputations 

each year and provides state-of-the-art care to all. Our research, academic affiliations, and clinical programs uniquely place VA as a national leader in the treatment of TBI, a position we have held since 1992 when we developed our four Lead 

TBI centers. Mental health care is one of our most important areas of concern, and 

we have led the country in the treatment of severe mental illness and substance 

abuse. In fact, our National Center for Post Traumatic Stress Disorder (PTSD) is 

a recognized international leader in the field. 

While no program is perfect, I do not feel the criticism about our prosthetic program raised by some is accurate. I will concede that early on in the war, VA was 

not adequately prepared for this new group of veterans. We dealt primarily with 

geriatric amputees, many with diabetes, making them less than ideal candidates for 

new technologies like myoelectric upper extremity prosthetics and computer-driven 

lower extremities. But, we have redirected our attention and our prosthetists and 

physical therapists have learned from the great work being done at Walter Reed 

Army Medical Center (Walter Reed) and other DOD sites. 

As far as TBI, I believe we have world class care. Again, we must provide the 

best care possible. To reassure our patients and their families, I have instructed our 

facilities to seek a second opinion from reputable civilian experts when 

servicemembers or families are concerned about our level of care or our diagnosis. 

When we have done this, these experts have usually concurred with our work and 

the services provided. The Commission on Accreditation Rehabilitation Facilities 

certifies each Polytrauma Rehabilitation Center, home to our TBI Lead centers. We 

are in the process of requesting a civilian review of our care. 

As far as mental health services, I am very proud of what we provide. We spend 

approximately 10 percent of our budget directly on mental health services and are 

the largest provider of mental health services in the country. Obviously there are 

geographic challenges, and VA appreciates the need to overcome these obstacles, 

which is why we initiated a very aggressive hiring campaign for mental health 

workers. If there are insufficient services available in an area for us to provide 

needed care, we will to consider fee-basing the care; however, in many under-served 

areas, there are few providers, if any, who would meet our quality standards for 

care. VA, as a provider of specialty care, is able to exercise direct supervision and oversight on the care and health care policies associated with our veterans. Contracting 

out this functionality entirely will lead to fragmentation of care and an adverse effect on the continuity of care needed to ensure quality of care, patient safety, and 

efficiency. 

We take our commitment to providing care to our Nation’s heroes and will continually strive to achieve the highest quality of care and services which they deserve.

Question 18: When asked by AP about a VA report stating that 30,000 or 16 percent of the 184,000 OEF/OIF veterans who had sought VA care as of late 2006 had 

symptoms of PTSD, you called this a ‘‘gross overestimation’’ of actual mental health 

disorders. However, I note that the 16 percent figure is consistent with Colonel 

Charles Hoge’s testimony at the September 28, 2006, hearing of the House Committee on Veterans’ Affairs. According to Colonel Hoge’ s research, ‘‘16 percent of 

soldiers surveyed 12 months after returning from Iraq screened positive for PTSD, 

depression, or anxiety and reported that there was functional impairment at the 

‘very difficult’ level.’’ Do you still believe the reports of PTSD are grossly overestimated? 

Response: Let me clarify what we know about mental health disorders. As of the 

end of Fiscal Year 2006, over 205,000 OEF/OIF servicemembers have come to VA; 

72,000 had symptoms of some kind of mental health disorder. That does not mean 

that they came for a mental health problem or that they actually had a mental 

health disorder. Our screening process identifies many symptoms that would not 

have been elicited without asking. Of the 72,000, 34,000 have symptoms consistent 

with PTSD. It is not clear exactly how many of these are finally diagnosed with 

PTSD, but several small studies show that 75 percent to 90 percent of those with 

35

symptoms will have some degree of PTSD. In Colonel Hoge’s first report, he states 

16 percent of servicemembers were diagnosed with PTSD, depression, or anxiety, 

but 9 percent of all servicemembers had that diagnosis prior to their deployment, 

meaning only 7 percent of servicemembers diagnosed with PTSD as the result of 

combat experience. 

With regard to your question, it is possible that many of our returning 

servicemembers have readjustment issues that are not due to mental illness but are 

normal reactions to abnormal situations. If so, it would be unfair and inaccurate to 

label them as having mental illness. I can tell you that VA is very concerned about 

cases of PTSD and we are doing everything we can to identify and provide treatment to those in need. The actual prevalence of PTSD among recent combat troops 

can only be determined by well-designed, large-scale epidemiological studies that 

rely on clinically confirmed diagnoses of PTSD. Multiple deployments to hazardous 

theaters of military operations can increase the risk of developing PTSD and other 

mental health problems and PTSD often develops over many years. The level of 

PTSD among OEF/OIF troops will not be completely known until well after the end 

of current hostilities and deployments to Southwest Asia. 

To better understand the long-term health concerns of OEF/OIF veterans, I’m 

pleased to report I approved funding for VA’s Office of Public Health and Environmental Hazards to conduct a longitudinal health surveillance of OEF/OIF veterans 

to track the illnesses and diagnoses they have after their deployment.

Question 19: As I have shared on many occasions, I am concerned about VHA’s 

ability to manage the mental health needs of servicemembers if deployments continue indefinitely. With current levels of staffing and resources, how will VHA continue to meet the mental health needs of both long-time and new veterans three 

or four years from now? 

Response: Most of our increase in PTSD patients has not been because of veterans 

returning from Iraq or Afghanistan, but from veterans of previous wars experiencing a resurgence of their symptoms. On the basis of projected need for all veterans, VHA is increasing the estimated budget for mental health services in both 

our medical facilities and our Vet Centers. We have placed a clear emphasis on 

mental health and combat related experiences, with almost $3 billion allocated to 

mental health following an increase of $545 million from 2006 to 2008. We believe 

this should be adequate to meet our needs. VHA anticipates continued growth in 

funding for mental health programs, both through Veterans Equitable Resource Allocation and the Mental Health Initiative, beyond 2008. 

We are aggressively expanding our staffing wherever possible, but I do not think 

we are yet where we need to be. The Office of Mental Health Services is working 

with Management Support to augment our current strategies for recruiting mental 

health professionals into our system. We are actively involved in research on mental 

health and clinical neuroscience where findings can be translated into improved care 

within a few years, and other, more basic studies, that may translate into more dramatic advances over longer time frames. Similarly, VA is educating and training our 

existing staff to ensure they have the knowledge and skills needed to provide the 

most up-to-date forms of evidence-based care in a safe, effective, efficient, and compassionate manner. If we cannot meet the clinical needs of these veterans with the 

appropriate type of care, then we need to leverage the civilian community. We will 

monitor this very closely and adjust resources as needed.

Question 20: Early diagnosis and referral can limit the development and effects 

of mental health problems, particularly PTSD. As such, VA and DOD must cooperate closely on an effective screening and referral system. What specific steps will 

you take to improve this cooperative system, and to make it comprehensive, reliable 

and ultimately, successful? 

Response: I agree that early diagnosis is very important. When this occurs, we 

have the opportunity to prevent or ameliorate the long term consequences of PTSD. 

It is clear that the immediate post-deployment screen is only of marginal value. Recognizing this, VA and DOD generated the PDHRA process. This occurs at 90 and 

180 days after deployment. Research shows this is an optimal time to screen for 

PTSD. We screen all OEF/OIF servicemembers that come to us for care, regardless 

of the initial diagnosis. Many people will not come and express a need for psychiatric assistance. Our goal is to ensure all servicemembers and their families are 

aware of the available help and to make it as easy as possible for them to access 

care. 

For veterans and servicemembers with severe injuries who have required medical 

evacuation from combat areas, VA and DOD conduct a comprehensive and formal 

system of seamless transition including monitoring any signs or symptoms of mental 

health conditions. 

36

For those with planned returns from deployment, veterans and servicemembers 

requiring help can be identified through PDHRA and collaborative PDHRAs 3 to 6 

months after their return. 

There are currently 83 Returning Veterans Outreach, Education and Care 

(RVOEC) teams in VAMCs across the Nation. By the end of Fiscal Year 2007 there 

will be 90 such teams in operation. The goal of these teams is to provide early assessment and care to returning OEF/OIF veterans designed to address psychosocial 

problems before they deteriorate into actual mental disorders. If existing mental disorders such as PTSD are identified clinical services are provided by the team or by 

referral to other mental health programs including PTSD clinical teams. Outreach 

activities are carried out in coordination with Vet Centers. Education on clinical 

conditions and coping skills training are basic approaches to controlling emotional/

behavioral problems in a manner that promotes coping skills yet can avoid the potential stigma of the term ‘‘treatment.’’ RVOEC teams also serve veterans in primary care settings, as do other mental health providers using evidence based collaborative and coordinated care approaches. A survey of the 38 teams established 

in Fiscal Year 2005 indicated that over 7,700 OEF/OIF veterans were seen for problems including PTSD, depression, substance use disorders and employment problems. VA is already working closely with community health providers to educate 

them on the signs and symptoms of PTSD. At the urging of the President’s Task 

Force on Returning Global War on Terror Heroes, VA is reinforcing and expanding 

this outreach.

Question 21: In this era of extensive Reserve component call-ups, do you foresee 

a need for additional Vet Centers beyond the current modest expansion? 

Response: The Vet Centers are extremely effective in providing a venue for help 

with readjustment issues. Through 2008 we will have increased our number of locations by 23 for a total of 232 while also augmenting the staff at 61 existing Vet Centers with 150 additional positions. In addition to the 100 OEF/OIF outreach workers 

hired in 2004 and 2005, VA has added 269 positions since before 2004. 

VA’s internal budget for the Vet Center program in Fiscal Year 2008 will be $125 

million dollars, which is a 25 percent increase over the program’s Fiscal Year 2006 

$100 million budget. Although we anticipate that these additional resources will be 

of great value to VA’s efforts to intervene early and serve the OEF/OIF troops returning from combat, we are aware of the increasing number of returning combat 

veterans and will evaluate the need for additional resources on an ongoing basis.

Question 22: What is your view on maintaining the continued independence of Readjustment Counseling Service and its Vet Centers from the medical operations 

under VHA? 

Response: The Vet Centers have my full and total support in their mission of providing early intervention and quality readjustment services to our Nation’s war veterans and their families. These community-based centers provide a unique combination of outreach and effective readjustment counseling services aimed to assist veterans and family members in making a successful transition from military deployment to civilian life. Vet Center services have enabled VA to better serve the newer 

generation of veterans returning from OEF/OIF. It is my view that the optimal way 

to ensure their continued success is to maintain their current status within the 

health care structure.

Question 23: VA currently has the authority to involve families only in a limited 

course of treatment. It is now apparent that increased attention to family members, 

outside of specific courses of treatment, would directly benefit veterans at risk of 

mental health problems. What changes, legislative or otherwise, would you pursue 

to increase attention to veterans’ families and to encourage their participation in the 

veteran’s recovery process? 

Response: Family involvement is essential to the care of the veteran. In fact, we 

have adapted our policies to encourage the maximum level of family support, consistent with the clinical or rehabilitative needs of the veteran, particularly in TBI 

cases. 

In VA medical centers and clinics, families are involved in treatment when this 

is covered in a treatment plan developed to benefit the veteran. This has allowed 

the dissemination and implementation of family psycho-education, an evidencebased intervention with a focus on families of veterans with serious mental illness, 

and outcomes that include decreased rates of hospitalization for the veteran. We 

have heard of a number of cases in which families are aware of mental health symptoms, but where veterans are reluctant to come for care. In these cases, there can 

be a real need for families to know that they can come to the VA to talk with mental 

health professionals about their loved one and to learn how to manage symptoms 

37

and potentially dangerous behaviors. This type of care is already available through 

Vet Centers, but we lack the authority to allow it in medical centers and clinics. 

As you are aware, Vet Centers have been authorized to provide bereavement 

counseling for family members of deceased servicemembers. Counseling after return 

from deployment often focuses on the veteran’s readjustment to the family as well 

as to the job, school, and community.

Question 24: Women make up a growing portion of the military and veteran population and are serving in theaters of combat in increasing numbers. This growing 

group of veterans will continue to require new services from VA. What steps would 

you take to keep pace with the demands of women veterans? What is your view on 

what VHA could be doing to improve services for women veterans? 

Response: Providing gender-specific, age-appropriate health care is our most important responsibility to women veterans. Since Fiscal Year 2002, 37.2 percent of 

separated women OEF/OIF veterans have sought VA health care services. This 

means we will be dealing with women veterans of child-bearing age. To properly address this situation, we created the Women Veterans Health Strategic Healthcare 

Group (SHG). I have given my full support to this SHG in planning and implementing the highest quality care to women veterans. 

VA has designed services and programs to be responsive to the gender-specific 

needs of women veterans. VA offers comprehensive health care services for women 

including: all aspects of primary care, gender-related health care, counseling for sexual trauma, pregnancy and infertility care. In addition, VA has Women Veterans 

Program Managers at every VA medical center. VA sets the benchmark for care in 

the United States in such areas as breast and cervical cancer screening. 

More and more research is being done to assess the special needs of women in 

the military, including Military Sexual Trauma (MST), and the differences in how 

women respond to stress, especially PTSD. We have a special inpatient women’s 

PTSD center in Cincinnati named Chrysalis and we will consider opening more of 

the same as the need is identified. Similarly, the Women’s Mental Health Center 

in Palo Alto was opened in October 2002 to provide treatment and support for sexual trauma. VHA’s Office of Mental Health Services recently established a MST support team to monitor MST screening and treatment, coordinate MST-related education and training, and to promote best practices in the field. New cognitive-processing therapy and behavioral therapy have proven highly effective, and these lessons are being disseminated to other locations. 

VA is pursuing improved care on multiple levels. We are:

• Providing enhanced training for primary care providers in the complexity of 

women’s health medicine; • Adding a nationally renowned female surgeon to work in our Office of the Medical Inspector; • Establishing a ‘‘provider registry’’ so VHA providers can access ‘‘realtime’’interaction on gender-related medical issues; and 

• Improving the physical environment of care, with particular attention given to 

the need for private, welcoming space for women veterans.

With regard to what else can be done, I think it would be appropriate to have 

additional research in the areas of general women’s health, such as cardiac disease, 

breast cancer, and cervical cancer rates for veterans and in issues related to military service, such as MST. We are particularly interested in collaborating with DOD 

in efforts to understand how to best respond early after sexual trauma exposure and 

to assist veterans to achieve recovery from traumatic events.

Question 25: You have testified that currently when wounded service personnel 

enter the VA health system that there is a detailed procedure to minimize the infection and spread of the acinetobacter infection. What type of testing is currently 

being used to screen patients? 

Response: When patients are admitted to VA facilities, the standard of care is to 

assess all wounds or open sores. This assessment would include a review of all 

available previous culture and susceptibility data from any other facility. Additional 

culture and susceptibility testing would be dictated by the clinical presentation and 

assessment. Acinetobacter baumanii is an organism that grows on usual media in 

VA microbiology laboratories and where routine susceptibility testing is available to 

allow appropriate antibiotic decisionmaking. 

VA has provided a great deal of information to our veterans and staff on this bacterium and we have coordinated with DOD to be sure our providers are aware of 

the potential of this bacterium. Acinetobacter baumanii was reported to be the most 

common gram-negative bacillus recovered from traumatic injuries to extremities 

during the Vietnam War. It also occurs in other non-veterans who suffer traumatic 

injuries suggesting environmental contamination of wounds as a potential source. 

38

A staff physician in Infectious Diseases at the National Naval Medical Center Bethesda (Bethesda Naval) first informed VA about multi-drug resistant gram-negative rods on the USNS Comfort and at Walter Reed. This occurred in a memorandum to the National Director for Infectious Diseases on April 22, 2004. Because 

some of these patients potentially could have been transferred to a VA Medical Center, VA prepared and released a Colleague’s Letter the next day alerting VA staff 

to this possibility. This letter also noted the general susceptibility pattern, made 

general therapeutic recommendations, and covered overall infection protocol from 

Bethesda Naval. Additional information was sent to the field on November 19, 2004 

that provided more information on isolates, susceptibility testing, and military protocols for isolation precautions.

Question 26: Witnesses from the Committee’s recent hearing on seamless transition health issues testified that there needs to be improved screening and testing 

of wounded service personnel for conditions such as TBI (traumatic brain injury) 

and infection (such as acinetobacter) as they are transferred to the VA system. Do 

you intend to have VA work with DOD to gain information about an existing testing 

mechanism for such infections currently being used at Fort Sam Houston? 

Response: We have been working closely with DOD and have developed a screening mechanism for TBI that was implemented VA wide as of 1 April 2007. VA is 

now screening all returning servicemembers for mild to moderate TBI. VA, in coordination with DOD developed a tool for effective early screening of TBI. This tool 

stands ready for use, as directed by the President’s Task Force on Returning Global 

War on Terror Heroes. While screening for mild to moderate TBI is a challenge, we 

have set up a registry to ensure follow-up for people who come up positive on the 

screen. 

VA is also working with DOD through the VA–DOD Deployment Health 

Workgroup to obtain more information about acinetobacter among recent combat 

veterans. At Fort Sam Houston, wounded patients are screened for this and other 

infectious diseases. Information about this screening and any follow-up health care 

is provided to VA in the patient record when these patients transition to VA for 

health care.

Question 27: Do you anticipate a continued need for annual increases, significantly above the rate of inflation, to VHA’s budget for the foreseeable future? In 

rough numbers, what is VHA’s budget projection through the next five fiscal years, 

and how does it relate to projected patient load? 

Response: The Administration determines the details of its appropriations request 

one year at a time. That said, our budget increases have historically been over inflation. An increase in the size of the budget equal to the rate of inflation would be 

practical only if no new veterans came into the system, veterans’ health remained 

unchanged, and there were no increased changes in the delivery of care from year 

to year. We have a very rigorous and accurate actuarial model we are continuously 

improving each year that projects our need through a budget year. In addition, VA 

and OMB together monitor performance and resources monthly to ensure no issues 

arise. We do not have a budget projection for the next 5 years.

Question 28: As stated in the proposed Fiscal Year 2008 budget, the Administration intends to continue its ban on so-called ‘‘middle-income’’ or Priority 8 veterans. 

What are your views on explicitly excluding certain veterans from the VA health 

care system? 

Response: The Enrollment Act of 1996 required VA to establish priority levels of 

veteran care to ensure that those with the greatest needs receive timely and high 

quality care. The law requires the Secretary on a yearly basis to determine what 

priorities he believes VA can support. In January, 2003, then-Secretary Principi 

made a decision precluding new priority 8s from enrolling. This was predicated on 

an unprecedented influx of enrollees and growing wait times. Over 80 percent of 

this group had other forms of health insurance and care available, so this group was 

not put in a situation where they had no access to any kind of care. Secretary Nicholson has continued that policy. VA estimates that if Priority 8 veterans were again 

allowed to enroll, 1.6 million veterans would do so in the first year at a cost of $1.7 

billion. Our 5-year estimate places the cost at $4.8 billion, and our 10-year projection estimates a cost of $33 billion. 

Any change in this determination would require several years of preparation. We 

would require new, larger facilities and additional staff to handle the added workload. Simply opening the door for Priority 8 veterans now, without taking these 

steps, would prove disastrous for the quality and timeliness of care VA provides. 

I will note, however, that VA has the authority to enroll combat-theater veterans 

returning from OEF/OIF in VA’s health care system, regardless of income level, 

making them eligible to receive any needed medical care or services.

39

Question 29: In your view, what are the merits of a predictable and viable funding 

mechanism for VA, such as mandatory or guaranteed funding? 

Response: While I am not familiar with the details of how mandatory or guaranteed funding would work, we believe it could have serious, unintended effects. VA 

has greatly benefited from a receptive Congress and Administration and has actually done better in our budget than would have been the case with mandatory funding. A strict financial formula would not be able to capture the complexity and dynamism required by a health care system for a population as diverse as our veterans. 

Potentially, rapid advances in medical science, prescription drugs, and treatment 

modalities would be stymied. 

A mandatory funding system also does not appear to allow Congress to exercise 

the oversight it now does in the budgetary process. This could result in inadequate 

funding by the Congress and the President for America’s veterans.

Question 30: What are the practical effects of running a health care system under 

the constraints of a Continuing Resolution? Are those constraints any different than 

those included in a budget request which essentially flat-lines medical care funding? 

Response: The process of a Continuing Resolution places a great strain on VA. We 

cannot move forward on new initiatives and leadership is unable to make new plans 

or significant changes in our delivery process. It is in effect a flat line budget which 

if continued could significantly impact our ability to provide needed care for our veterans.

Question 31: The theft or loss of computer equipment containing sensitive personal information on private citizens or agency employees is becoming a routine feature of our government. However, I am concerned that hastily issued security directives could lead to unforeseen difficulties and negatively impact agency operations. 

What will you do to ensure that VHA mitigates the loss of any more laptops or 

memory devices, while not harming essential functions? 

Response: Protecting Personally Identifiable Information (PII) is critically important to this agency. We owe that to our veterans. VHA is reducing the risk of future 

breaches through better physical security and better business practices. We are 

working closely with Office of Information & Technology (OI&T) to deploy data protection solutions, including encrypted laptops and encrypted removable storage 

media. We are also working with OI&T’s Information Protection Office to develop 

business requirements, validation processes, and classification requirements. 

As we have developed initiatives to protect data, we have always operated under 

the admonishment to do no harm. We are constantly dialoging with VA Ol&T about 

issues concerning patient care and the delivery of care. When we have had concerns, 

I personally have brought those up to VA leadership; they have, and are, being addressed.

Question 32: VA and DOD have allegedly been working for over a decade to develop an interoperable and bidirectional electronic health record that would facilitate the smooth transfer of medical information between DOD and VA. Please give 

your assessment of the state of development of the electronic health record, and 

what steps are needed to reach the goal. 

Response: There have been real and significant advances in the transfer of medical information from DOD to the VA. VA and DOD have achieved a significant level 

of success and are currently using standards-based interoperable electronic health 

records to share clinical data bidirectionally. 

DOD provides as much electronic data as possible using their current system. At 

present, DOD does not have a mature in-patient electronic health record that could 

be transmitted to VA. VA and DOD have agreed to work expeditiously toward the 

development of a compatible inpatient electronic health record that would leverage 

the strengths of the Armed Forces Health Longitudinal Technology Application 

(AHLTA) as well as our CPRS/VISTA. 

On January 24, 2007, the Secretaries of VA and DOD agreed to study the feasibility of a new common inpatient electronic health record system. During the initial 

phase of this work, expected to last between 6 and 12 months, VA and DOD are 

working to identify the requirements that will define the common VA/DOD inpatient 

electronic health record. The Departments are working to conduct the joint study 

and report findings as expeditiously as possible. At the conclusion of the study, we 

will begin developing a common solution. 

For now, VA receives available electronic data through secure and successful oneway and bidirectional data exchange systems. These interfaces, known as the Federal Health Information Exchange or ‘‘FHIE’’ and the Bidirectional Health Information Exchange or ‘‘BHIE’’, ensure that DOD provides VA as much of the health 

record as possible electronically. FHIE supports the care of separated and retired 

Service members and supports the transfer of pre- and post-deployment health asVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
40

sessment and reassessment data on separated Service members and demobilized 

National Guard and Reserve patients. Through FHIE, DOD has transferred electronic health data on almost 3.8 million unique separated servicemembers. VA has 

provided care or benefits to more than 2.2 million of these veterans. 

BHIE supports the care of and active duty patients and dependants using both 

systems pursuant to sharing agreements or other arrangements. BHIE is now available at all VA sites of care and is currently installed at 25 DOD host locations. 

These 25 locations consist of 15 DOD medical centers, 18 DOD hospitals and over 

190 DOD outpatient clinics. By June 2007, VA will be able to access data from all 

DOD sites. 

VA and DOD are implementing several pilot projects to expand our cooperation 

and the transfer of records that will potentially be expanded enterprise wide. In El 

Paso, Texas, VA and DOD are using BHIE to share radiology images, while in the 

Puget Sound area (and at several other locations, including Hawaii, San Antonio, 

and San Diego), VA and DOD can share inpatient discharge summaries and other 

narrative documents. 

VA and DOD also developed transferable, computable allergy and pharmacy data 

between next-generation systems and data repositories. This interface, known as 

CHDR, permits VA and DOD systems to conduct automatic drug-drug and drug-allergy interaction checks using data from both Departments to improve patient safety of those active dual consumers of VA and DOD, just as CPRS already does within 

the VA system. 

VA is now able to access DOD medical digital images and electronically scanned 

inpatient health records. We successfully piloted this program, at least in one direction (from DOD to VA), between Walter Reed and three of the four VA Polytrauma 

Rehabilitation Centers, located in Tampa, Richmond, and Palo Alto. VA clinicians 

can immediately access critical components of the veteran or servicemember’s inpatient record from DOD military treatment facilities. Bethesda Naval is also sending 

digital images to Tampa and Minneapolis. Expansion of this capability to Brooke 

Army Medical Center is planned for this summer.

Question 33: Prior to the Secretary’s directive to centralize all Information Technology (IT) operations under VA’s Chief Information Officer, VHA was responsible 

for its own IT functions. What has been the impact of this reorganization on VHA? 

What problems, if any, have resulted from the reorganization? 

Response: The VA Chief Officer (CIO) assumed authority over the Information 

Technology (IT) staff and their responsibilities on April 1, 2007, approximately 6 

weeks ago. VA is still in the early phases of constructing an IT governance framework, a critically important task. When the governance structure is established, 

VHA’s will shift toward being a ‘‘customer’’ requiring products and services from its 

new IT provider, the VA CIO. Anytime you make as dramatic a shift as we have, 

there will be challenges. Thousands of personnel have been moved from the administration to VA OI&T. I believe that this has gone amazingly well given the magnitude of the project. I believe we have worked together in a cooperative spirit to 

continue providing IT services for clinical activities and to ensure quality care for 

our veterans. The VA CIO, the Secretary, and I share the view that VHA will set 

the business requirements to ensure our internationally recognized electronic health 

record system continues to provide the highest quality of health care to veterans. 

Some of the challenges we have encountered involve ensuring everyone understands the new procedures and maintaining communication at all levels.

Question: 34: Do you believe that the Inspector General can continue the oversight 

of VA operations, if budget cuts are once again required of the OIG? 

Response: While I cannot speak directly to the adequacy of the Office of Inspector 

General’s (OIG) budget, I can say that I will provide any and all assistance or consultation the OIG requires to make the most effective use of its resources in providing oversight of VHA programs. Such consultation will assist OIG in prioritizing 

areas for review and in addressing critical concerns of the Department while maximizing available resources.

Question 35: Given the surge and complexity of claims that VA is receiving as a 

result of ongoing operations abroad, does VHA have the capacity to provide timely 

and accurate medical examinations on behalf of VBA? What would you do, as Under 

Secretary for Health, to ensure that these exams are expedited? 

Response: VHA has been working closely with VBA to ensure that OEF/OIF veterans get the evaluations that they require and deserve in a timely fashion. VHA 

compensation and pension (C&P) initial exams have a timeliness of 34 days, which 

is within the standard established in the VHA/VBA memorandum of understanding. 

We will put in the necessary resources to meet whatever goal is established. 

41

VA’s Compensation and Pension Examination Program Office (CPEP) recently 

compared workload for the first 6 months of Fiscal Year 2007 with the first 6 

months of Fiscal Year 2006. While there was an 11 percent increase in completed 

requests and an almost 20 percent increase in completed exams, we also saw a 5 

point jump (to 86 percent) for ‘‘A’’ quality C&P exams, those that meet more than 

90 percent of our quality indicators. Essentially, our quality and our timeliness have 

improved in spite of the increased workload. 

VA anticipates an increase in C&P claims from approximately 800,000 in Fiscal 

Year 2007 to approximately 815,000 in Fiscal Year 2008. As the Under Secretary 

for Health, I will ensure that VHA continues to identify and commit the resources 

needed to manage the anticipated C&P examination workload increase.

Question 36: Do VHA and VBA facility directors work together to reduce the percentage of incomplete examinations in order to improve the timeliness and accuracy 

of medical examinations? Please cite examples. 

Response: Yes, VHA and VBA facility directors and staff at all levels are expected 

to work together to improve C&P exam processes. 

Veterans Service Center officials at each regional office (RO) are required, at a 

minimum, to meet with their VHA medical center counterparts at least once per 

year to address C&P exam related issues. However, in a recent survey of communication practices between VBA ROs and VHA examining sites, CPEP found the 

majority of respondents met more frequently than once a year to address C&P 

issues, and approximately 30 percent conducted monthly meetings. In addition to 

VHA facility directors, these meetings are attended by RO service center managers, 

VAMC chiefs of staff, associate directors, and other staffers. These meetings often 

cover exam requests and report on quality, timeliness, cancellations, workload projections, staffing, and other issues. 

But even more can be done to enhance effective communication. VBA and VHA 

jointly conducted a national conference on improving communication between ROs 

and VAMCs concerning C&P exams in April 2007. VBA and VHA were both well 

represented (about 150 attendees each). VBA/VHA teams jointly developed concrete 

action plans for improving communications at this meeting. Appropriate experts are 

currently reviewing these action plans in an ongoing progress for improved service 

and support. 

Florida (VISN 8) and Southern California (VISN 22) provide two examples of our 

best practices for VBA/VHA coordination. In Florida, the VISN 8 Network Director 

and Health Systems Specialist have worked with the St. Petersburg RO Director 

and Service Center Manager to establish working collaborations resulting in VISN 

8 being one of the Nation’s leading performers in C&P exam quality. In VISN 22, 

VISN Network Director and Network Strategic Management Officer have worked 

with the VBA Western Area Director and San Diego RO Assistant Director to identify problems, establish working groups to apply systems improvement principles, 

and develop service agreements to serve as a tool for change. VISN 6 is another example where leadership has established ongoing processes for collaborative ownership of C&P exam processing issues. The Director of the Salisbury VA Medical Center has taken the lead for the VISN 6 Network Director and worked with RO Directors in Huntington, WV, Roanoke, VA, and Winston-Salem, NC. VISN 6 is a high 

performer in both quality and timeliness of exams.

Question 37: Do medical facilities reschedule examinations, when a first examination has been missed, without a Regional Office having to resubmit an examination 

request? Please provide any direction that has been given to the field regarding this 

matter. 

Response: The Chief Business Office (CBO) VHA Procedure Guide 1601E, C&P 

Examinations, states that a veteran’s C&P exam will be rescheduled by the medical 

facility on a one-time basis if the veteran requested the exam be postponed for a 

valid reason. If the veteran failed to report for the exam and provides no justifiable 

reason for missing the exam, the exam request is returned to the regional office. 

Web links to the CBO procedure guide are embedded in the electronic posting of 

VHA Handbook 1601E.01, Compensation and Pension Examinations, which is available on the VHA Intranet. The Handbook was distributed to VHA by email on 4/

5/2006. In addition, CBO provided training via conference calls and ‘‘live meetings’’ 

to VHA facilities on these procedure guidelines and the Web based educational materials. 

42

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL AKAKA TO

MICHAEL J. KUSSMAN, M.D., NOMINEE TO BE UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Question 1: Recent news stories have noted that American Samoan 

servicemembers have extremely high per capita casualty rates in our current conflicts in Iraq and Afghanistan—more than 13 times higher than the national average. While American Samoans are overrepresented in uniform, those who return 

home after their service have difficulty receiving health care. Currently, there are 

no VA hospitals in American Samoa. In fact, there is only one hospital in all of 

American Samoa, which does not provide certain types of care. Frequently, American Samoan veterans must fly to Hawaii to receive care, which can be a difficult 

process. 

I was pleased to learn that a new VA clinic is scheduled to be dedicated in American Samoa this July. Please provide me an update on the clinic, including progress 

on staff recruitment and linking to computer systems in Hawaii. Also, please describe VA’s plans over the next 5 years to better meet the needs of American Samoan veterans. 

Response: The Department of Veterans Affairs (VA) Pacific Islands Health Care 

System (VAPIHCS) will open its community-based outpatient clinic (CBOC) in 

American Samoa on June 25, 2007, and dedicate the CBOC on Saturday July 21, 

2007. The CBOC will be staffed with six employees—internal medicine physician, 

psychiatrist, social worker, nurse, medical assistant and clerk. All employees have 

been selected and accepted VA offers (three currently reside in American Samoa). 

However, the primary care provider will join the staff several weeks after the clinic 

opens. The CBOC will provide care to approximately 1,000 eligible veterans and 

support up to another 600 Army Reserve and TRICARE beneficiaries. 

The CBOC will use the VA computerized patient record system (CPRS). Initially, 

to link to electronic systems in Hawaii, CPRS will run on a ‘‘site to site virtual provider network’’ connection to an internal VA gateway. VAPIHCS and VA Office of 

Information and Technology (OI&T) are currently negotiating with several vendors 

for a permanent solution that will offer additional speed and bandwidth. VAPIHCS 

and OI&T are optimistic they will be able to successfully establish a ‘‘T1 line’’ via 

satellite. This additional speed and bandwidth will be necessary to support planned 

telehealth activities. Currently, there is no high-speed information technology cable 

to American Samoa and this is not expected to be rectified soon. 

Over the next 5 years, VA plans to establish an active telehealth program. Telehealth capabilities in cardiology, endocrinology, ophthalmology, orthopedics and 

rheumatology are currently being evaluated. The establishment and maturation of 

the American Samoa CBOC will be the linchpin to meeting the health care needs 

of veterans on American Samoa. Veterans will continue to use LBJ Tropical Medical 

Center for specialty care i.e., non-primary care and non-mental health services. 

Also, veterans will obtain needed care from VA providers traveling to American 

Samoa (e.g., currently a VA orthopedist travels to American Samoa quarterly) and 

referrals to VA facilities in Hawaii or U.S. mainland.

Question 2: On February 23, 2003, the VHA and the Indian Health Service signed 

a Memorandum of Understanding to encourage cooperation and resource sharing between the two parties, for the benefit of American Indian and Alaska Native veterans. The MOU included agreement on five mutual goals and on nine different 

items regarding health care for American Indian and Alaska Native veterans. 

Please provide a status report on VHA and IHS’s progress regarding each of the 

goals and agreed-to items. Also, please provide all reports published by the interagency work group proposed in the MOU. 

Response: The Department of Veterans Affairs (VA) and the Department of 

Health and Human Services (HHS), Indian Health Service (IHS) have partnered on 

a number of national projects to implement the goals and agreed-to items in the 

February 23, 2003, Memorandum of Understanding (MOU). In addition, local VHA 

facilities and Tribes have established programs and agreements to implement the 

goals and objectives at the local level. 

To accomplish the goals of improving beneficiary’s access to quality health care 

and services and to improve health promotion and disease prevention services to AI/

AN, VA and IHS identified five objectives: facilitating collaboration on effective 

health care delivery, promoting activities to improve health and quality of life for 

AI/AN veterans, identifying needs and gaps to ensure optimal health care for the 

AI/AN population, creating an interagency workgroup to oversee national initiatives, 

and developing a common methodology to track VA and IHS activities. VA and IHS 

created a Shared Health Care Workgroup, which drafted an Inter-Departmental Coordinated Care Policy to optimize the quality, appropriateness, and efficacy of health 

43

care services and to improve patient satisfaction. Fifteen VISNs are engaged in various access-related outreach activities, four VISNs have incorporated disease-specific 

or prevention services, and seven Networks are planning and negotiating new access 

initiatives. The Office of Rural Health will play an important role in coordinating 

with IHS to meet the needs of AI/AN veterans in rural areas. VA and IHS conduct 

monthly meetings to oversee proposed national initiatives and both agencies have 

an agreed upon framework for documenting and tracking these discussions. 

VA and IHS identified two other goals: IHS facilitating improved communication 

between VA and AI/AN veterans and tribal governments, and encouraging partnerships and sharing agreements. Four objectives support these goals: collaborating in 

the exchange of program communications and other information; cosponsoring and 

providing reciprocal support for Continuing Medical Education, training, and certification of IHS and VA health care staff; developing and implementing strategies for 

information sharing and data exchange; and developing national agreements on 

sharing related to electronic medical records systems, telemedicine, prescriptions, 

bar code medication, national credentialing programs, and other technologies. VA is 

providing training programs to IHS staff and the Tribal community through its Employee Education Service and supporting internships and residencies in three VHA 

intensive care units (Phoenix, Minneapolis, and Houston). VA and IHS are currently 

test piloting the use of VetPro, VHA’s electronic credentialing system, in the Phoenix area, and the Tribal Veterans Representative (TVR) Resource Guide and the 

TVR Facilitator Guide were completed and distributed in November 2006. VA and 

IHS are collaborating on several IT projects, including medical record and datasharing, pharmacy benefits, potential integration into IHS Integrated Behavioral 

Health package, and other forms of connectivity. Telemedicine has proven to be extremely effective in treating PTSD in AN communities. 

The final goal is to ensure appropriate resources are available to support programs for AI/AN veterans. An Interagency Working Group of senior leaders from 

VA and IHS conducts a monthly conference call to discuss programs and associated 

resource needs. VHA has also initiated a performance measurement to track 

progress. A progress report is issued quarterly detailing the group’s work and to ensure programs are implemented as planned. Two published documents are available—the first, a cumulative report from Fiscal Year 2005, and the second, a White 

Paper prepared and submitted to the White House in October 2006. These documents and the MOU are attached. 

[FY 2005 issue update, VHA and IHS collaboration report, and VA and HHS 

Memorandum of Understanding follow:]

ISSUE UPDATE FOR FISCAL YEAR 2005

VHA AND IHS SUPPORT FOR AMERICAN INDIAN ALASKA NATIVE VETERANS

ISSUE

Over the last two years, Indian Health Service (IHS) and Veterans Health Administration (VHA) have implemented a memorandum of understanding (MOU) to promote greater cooperation and sharing between the two health services to enhance 

the health of American Indian and Alaska Native veterans. This brief summarizes 

the progress made under the MOU to date and highlights a few of the more than 

150 activities and programs undertaken in FY2005. 

BACKGROUND

American Indians and Alaska Natives (AI/AN) have a distinguished history of exemplary military service to the United States. They have served in high numbers 

and were often assigned to forward combat areas. As a result, they have a wide 

range of combat related health care needs. AI/AN veterans may be eligible for 

health care from VHA or from IHS or both. Despite this dual eligibility, Indian veterans report the highest rate of unmet health care needs among veterans and exhibit high rates of disease risk factors. 

PROGRAM SUMMARY

The MOU between the Departments of Health and Human Services and Veterans 

Affairs, specifies five objectives to enhance the health of AI/AN veterans: (1) improving communication, (2) encouraging partnership and sharing, (3) expanding access 

to health services for Indian veterans, (4) ensuring organizational support, and (5) 

improving health promotion and disease prevention services. 

44

National Activities 

The Office of the Deputy Under Secretary for Health for Health Policy Coordination (DUSH/HPC), 1OH, is the principal office responsible for coordinating implementation of the MOU within VHA. The office works with the leadership and staff 

of VHA and IHS to identify priority actions and ensure they are carried out. The 

office fosters progress on national initiatives and supports local implementation activities through the annual VHA strategic planning process and quarterly VISN 

monitoring system. 

Communication: The Headquarters Advisory group meets monthly, the Steering 

Committee meets three times each year and the Area and Network Directors have 

twice been convened to discuss priorities and coordinate activities. A FAQ sheet 

about the collaborations has been developed, an annual report was produced in August 2004, and an implementation guide highlighting best practices was completed 

in January 2005. A Web site is under development. VHA has initiated connections 

to tribal and national AI/AN organizations such as the National Indian Health 

Board and National American Indian Veterans, Inc. Briefings and presentations 

about the partnerships have been made at more than a dozen events around the 

country. 

Sharing and Collaboration: VHA Employee Education Service (EES) and the 

Nashville Area of IHS signed an operational agreement in April 2005 to implement 

a sharing demonstration of VHA educational resources with IHS and tribes in the 

region. A password protected Web site has been established to provide IHS staff 

with electronic educational materials and to provide and track continuing education 

credits. Twenty programs were made available to IHS staff in 2005. 

VHA and IHS have a long partnership of sharing in software development, and 

new activities are underway to enhance this partnership. The VHA/IHS Information 

Technology Collaboration has developed a five-point work plan and has established 

a shared Web site to facilitate joint project management. An Interconnection Security Agreement that paves the way for direct network-to-network electronic communication has been signed. A project agreement for IHS use of VISTA imaging has 

been drafted and is under review. IHS and VHA staff are regularly attending the 

planning, development and training meetings of the other agency. 

Expanding Access: Access is focused at the local level. However, the national telehealth collaboration supports the use of telehealth to provide remote access to 

health services for AI/AN veterans. In April 2005, eighteen IHS staff attended the 

annual VHA telehealth coordination meeting for the first time. During the meeting, 

VHA agreed that IHS and tribal representatives will join each VHA VISN-level telehealth coordination workgroup and two test sites for joint network development 

were identified: the Billings Area IHS and the Utah telehealth network (which includes tribes). 

Organizational Support: VHA has developed an implementation guide that shares 

best practices with the field. Both VHA and IHS require progress reports from the 

field on collaboration and the expansion of services to AI/AN veterans. VHA sharing 

is an element of the IHS Area Directors performance contract with the Director of 

IHS. Starting in 2005, VHA requires that each facility provide access to American 

Indian spiritual practices equivalent to that provided for other religious affiliations. 

EES is developing a national Tribal Veteran Representative training curriculum. 

Health Promotion/Disease Prevention: IHS/VHA workgroups in Diabetes Prevention and Behavioral Health were established. On the recommendation of the Diabetes Prevention workgroup, three diabetes prevention partnerships were funded in 

Albuquerque, Los Angeles and San Diego. The programs incorporate primary prevention measures, including diet modification and physical activity, into activities 

targeted to AI/AN veterans. 

The Behavioral Health workgroup developed a framework for AI/AN communities 

to assist the 3,668 returning Operations Iraqi Freedom and Enduring Freedom 

(OIF/OEF) AI/AN servicemembers and veterans reintegrate with their families and 

communities and readjust to civilian life. The objective is to promote a community 

health model that gives tools to Tribal communities and families to help returning 

veterans address emerging adjustment reactions, traumatic stress, and Post Traumatic Stress Disorder (PTSD), emphasizing recovery as the goal. Outreach and informational materials have been developed and, to date, have been shared directly 

with four Tribes for local customization and adaptation. The program also includes 

education for local VHA, IHS and Tribal clinical staff on special health care concerns that arise following combat exposure; and training for VHA staff on cultural 

and spiritual needs of AI/AN veteran patients. 

Three projects have been funded to pilot-test evidence-based mental health treatment resource kits for use with veteran and AI/AN veteran populations. 

45

IHS Area and VHA Network Activities (Examples, Attachment 1) 

Communication: In FY2005, VISNs reported more than 120 contacts with IHS, 

Tribal leaders or AI/AN veteran groups. Nearly two-thirds of these discussions occurred directly with Tribes. 

Sharing and Collaboration: The Networks reported more than 25 agreements to 

promote sharing and collaboration in FY2005. Projects included the sharing of 

space, information technology expertise, educational programming, joint purchasing, 

and contracting for laboratory or diagnostic services. 

Access: By the end of FY2005, VISNs reported more than 20 programs that expand access to services for AI/AN veterans. For example, Network 19 reported nearly 300 telepsychiatry patient contacts, 84 veteran participants in traditional ceremonies or native healer consults, and the completion of a residential substance 

abuse treatment program by 10 patients. Other programs around the country include a dedicated AI coordinator to assist with nursing home placements, Tribal/reservation based CBOCs, telehealth home health care, telecardiology services, emergency room care agreements and reservation based housing for homeless AI/AN veterans. Network 18 reported an overall 17 percent increase in the number of AI/AN 

patients served in FY2005. 

Organizational Support: At the local level, organizational support frequently 

manifests as VHA sponsored health fairs, pow wow or homeless stand downs for AI/

AN veterans, often held on or near a reservation. VISNs reported holding or participating in more than 70 such events in FY2005. 

Health Promotion/Disease Prevention: Three Networks reported prevention oriented programs: OIF/OEF readjustment outreach in VISN 18 and 20 and health 

promotion programs in VISN 18 and 22. 

Two Year Review 

The Steering Committee (SC) met in April 2005 to review progress under the 

MOU, hear from veterans and Tribal leaders, and determine if changes were needed 

to the agreement. The SC recommended that the MOU and the programs under it 

continue unchanged. However, the SC expects to see a greater emphasis on communication, outreach and the sharing of program and benefit information with veterans 

and Tribes including information on housing programs and support for homeless AI/

AN veterans. In addition, the leadership of each organization has been asked to develop a joint policy for the coordination of health care for dual use veterans. Finally, 

the development of a new home health care demonstration for long term care elderly 

patients is expected.

ATTACHMENT 1

Examples of IHS/VHA Sharing and Collaboration Activities 

FY2005

Access: 

1. Telecardiology Services ............. SC, IHS at Rockhill ........................ 12 clients served to date. 

2. Patient diet counseling ............. NM, IHS Gallup .............................. IHS provided counseling for VA. 

3. Home based care ...................... AZ, LA ............................................ Telehealth enabled. 

4. Tribal staffed CBOC .................. OK, Choctaw Nation ...................... 1,000 vets; save 130 mile drive. 

5. ER diagnostic/treatment ........... OK, Choctaw Nation ...................... Saves 2 hour emergency trip. 

6. Health fair prevent screen ........ LA, Jena Band Choctaw ................ Enrolled vets w/ presumptive Dx. 

7. Mental Health Therapy .............. AZ, reservation based WY ............. 2 group; 63 indiv consults Q2. 

8. Telepsychiatry ............................ WY .................................................. @ 100 patient contacts, Q2. 

9. Residential SA treatment .......... UT .................................................. Eight patients completed. 

10. Co-management w/ CPRS ....... SD/ND; Pine Ridge, Ft. Yates, 

Eagle Butte.

IHS staff can view VA records for 

all shared patients. 

11. Homeless Housing ................... SD, Pine Ridge .............................. Building dedicated Nov 2005. 

12. Vet Centers .............................. AZ, SD, OK, AK .............................. Hopi, Navajo, Pine Ridge, Rosebud, Tahlequah, AK Native Villages. 

13. Shared FTE veteran coord ....... NC, Cherokee Hospital ................... 108 clients served FY2005.

Sharing & Collaboration: 

1. Radiology and Pathology ........... KS, Haskell Nation ......................... 100–200 reads/month. 

2. Space Lease .............................. WI, Ho-Chunk Nation ..................... 5,661 sq ft space leased. 

46

Examples of IHS/VHA Sharing and Collaboration Activities—Continued

FY2005

3. Tribal College affiliation ........... OK, Cherokee Nation ...................... Training for student RN, opt, rad. 

4. Laboratory contract ................... TX ................................................... $3,361 revenue generated Q2. 

5. PTSD education training ........... AK .................................................. Prepare IHS for OIF/OEF vets.

Organizational Support: 

1. Veteran Tours of VAMC ............. NC, Cherokee Hospital ................... Tours introduce AI vets to VA. 

2. Credentialing Tribal staff ......... NC, Cherokee Hospital ................... Smooth referral, access CPRS. 

3. Share patient edu material ...... VISN 12, Bemidji IHS ....................

4. Tribal veteran rep training ....... VISN 23, 19, 18, 12 ......................

5. Weekly talking circle ................. AZ .................................................. PTSD patients enrolled. 

6. Full Time AI Coordinator ........... AZ .................................................. Assist nursing home placement. 

VETERANS HEALTH ADMINISTRATION AND INDIAN HEALTH SERVICE COLLABORATION

FOR AMERICAN INDIAN/ALASKA NATIVES (AI/AN) 

On February 25, 2003, the Department of Health and Human Services (HHS) and 

the Department of Veterans Affairs (VA) entered into a Memorandum of Understanding (MOU) to encourage cooperation and resource sharing between the Indian 

Health Service (IHS) and the Veterans Health Administration (VHA). The goal of 

the MOU is to use the strengths and expertise of both organizations to deliver quality health care services and enhance the health status of American Indian and Alaska Native veterans. Through the Headquarters Advisory Group, numerous national 

programs have been initiated to serve AI/AN veterans. In addition, local activities 

take place between the Veterans Integrated Service Networks (VISN), VA medical 

facilities, and the tribes themselves. 

Outreach. At the national level, outreach activities have consisted of increased 

communications between VHA and IHS through the Headquarters Advisory Group 

and the Steering Committee, briefings such as the VA briefing on VA Seamless 

Transition Activities to IHS leadership, IHS participation in the VHA Symposium 

on ‘‘Caring for Veterans Returning from Recent Conflicts,’’ and the pending revision 

of the joint IHS/VA Web site. The Tribal Veterans Representative (TVR) Resource 

Guide and the TVR Facilitator Guide have been completed and will be distributed 

in November 2006. A video broadcast of the materials is also scheduled for release 

in November. At the local level, thirteen networks are engaged in a variety of outreach activities, including meetings and conferences with IHS program and tribal 

representatives, VA membership in the Native American Healthcare Network, VA 

participation in traditional Native American ceremonies, transportation support to 

AI/AN, etc. 

Education. VHA Employee Education Service (EES) is providing training programs to IHS staff and the tribal community. A password protected Web site has 

been established to provide IHS staff with electronic educational materials and to 

provide and track continuing education credits. In 2006, VHA delivered 145 training 

programs, of which 90 were made available using satellite technology and 55 using 

web based technology. These educational programs will be continued in 2007, and 

VHA will also provide selected IHS staff an opportunity to attend regional EES 

workshops on buprenorphine. 

Behavioral Health. The Behavioral Health workgroup developed a framework 

for AI/AN communities to assist returning Operations Iraqi Freedom and Enduring 

Freedom (OIF/OEF) AI/AN servicemembers and veterans reintegrate with their 

families and communities and readjust to civilian life. The objective is to promote 

a community health model that gives tools to Tribal communities and families to 

help returning veterans address emerging adjustment reactions, traumatic stress, 

and Post Traumatic Stress Disorder (PTSD), emphasizing recovery as the goal. The 

joint committee has developed a slide presentation to be used by outreach teams 

when addressing various Tribal veterans. There have been briefings using the slide 

presentation in Montana, with approximately 30 veterans now receiving services 

from VA. 

Expanded Health Care Services. At the local level, ten VHA networks are engaged in targeted initiatives aimed at providing a full continuum of healthcare services, such as health fairs, VA/IHS Advisories, Use of Health Buddy, and education 

and/or shared services in substance abuse, domestic violence programs, cardiac rehabilitation, dietetics, behavioral medicine, etc. 

47

Information Technology. VHA and IHS are collaborating on numerous information technology projects, including Medical record and data-sharing policy, a Bar 

Code Medication Administration (BCMA) project, Centralized Mail Out Pharmacy 

(CMOP) support, potential integration into IHS Integrated Behavioral Health package, potential use of VA information technology systems for some IHS sites, data 

networking and communication—exploring VA network operations for alternate 

connectivity for non-clinical applications (i.e. electronic lab services) and collaboration on hardware whereby approximately 100 CPUs will be sent to the Aberdeen 

Area. 

Patient Safety Program. The VHA National Center for Patient Safety (NCPS) 

has trained the newly appointed IHS patient safety manager in Root Cause Analyses and Healthcare Failure Mode and Effects Analysis and has provided a small 

library of core patient safety literature and various NCPS tools. 

Care Coordination. The VHA–IHS Shared Health Care Workgroup has drafted 

an Inter-Departmental Coordinated Care Policy, the goal of which is to optimize the 

quality, appropriateness and efficacy of the health care services provided to eligible 

American Indian and Alaska Native (AI/AN) veterans receiving care from both VHA 

and IHS or Tribes; and to improve the patient’s satisfaction with the coordination 

of care between the two Departments. 

Diabetes Prevention Programs. Three Diabetes Prevention programs have 

been initiated in San Diego, Greater Los Angeles, and Albuquergue. The goal of the 

program is to assist AI/AN veterans integrate healthy lifestyles, and therefore to 

prevent healthcare problems related to diabetes. Various components of the program 

include training Diabetes Prevention Program (DPP) lifestyle coaches, producing deliverable DVDs of the training sessions and distributing them to each AI site; providing sites with related equipment, including TVs, TV carts and DVD/VCR players 

and other related educational materials. 

Telemedicine. Another VA program that is very effective and popular with Indian and Alaskan Native Veterans is Telemedicine. It is proving to be extremely effective in the treatment of PTSD in Alaskan Native villages. VA and IHS are working to spread the use of telemedicine services by AI/AN veterans, which will allow 

VA to bring physical and mental health care to the tribes, especially those in remote 

areas of the country. 

Credentialing Program. VA and IHS are currently in a pilot test of the use of 

VetPro, VHA’s electronic credentialing system by the Phoenix Area Indian Health 

Service. The intent of this pilot is to demonstrate the value of sharing Federal information technology used for the credentialing of health care providers. The pilot 

began in May 2006. To date, 61 Licensed Independent Practitioners have been enrolled by the two IHS facilities and IHS appears enthusiastic about the VetPro process. Research. The Los Angeles VA Geriatric Research Education and Clinical Center 

has been funded for a research study entitled ‘‘VHA and IHS: Access for American 

Indian Veterans.’’ The study will describe dual utilization of VA and IHS services, 

including fragmentation or potential overlap of services, identify organizational and 

individual factors that impede or facilitate access to care, and generate recommendations on how VA and IHS can work together to improve access to health 

care. Traditional Healing. Some VHA facilities and Vet Centers have incorporated 

Traditional Healing Ceremonies along with modern methods of treatment and counseling. As a national initiative, VA has sent over 500 letters to tribal leaders to ask 

them to provide information on appropriate providers of Traditional Practices so 

that they may be called upon for religious/spiritual care of AI/AN veterans.

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS HEALTH ADMINISTRATION, 

Washington, DC, June 24, 2003. 

DEAR COLLEAGUES IN VETERANS AND INDIAN HEALTH: On February 25, 2003, the 

Department of Health and Human Services (HHS) and the Department of Veterans 

Affairs (VA) entered into a Memorandum of Understanding (MOU) to provide optimal health care for the more than 165,000 American Indian and Alaska Native veterans in the Nation. This MOU, signed by the Deputy Secretaries of VA and HHS 

on behalf of Secretary Anthony J. Principi and Secretary Tommy G. Thompson, offers many opportunities to enhance access to health services and improve the quality of health care for Indian veterans. The purpose of our letter is to provide guidance on the intent and potential applications of the MOU. We have enclosed a copy 

of the MOU for your reference. 

The MOU is designed to improve communication between the agencies and Tribal 

governments and to create opportunities to develop strategies for sharing informaVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00051 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
48

tion, services, and information technology. The technology sharing includes the VA’s 

electronic medical record system, bar code medication administration, and telemedicine. Also, VA and the Indian Health Service (IHS) will co-sponsor continuing medical training for their health care staffs. Significantly, the MOU encourages VA, 

Tribal, Urban, and IHS programs to collaborate in numerous ways at the local level. 

We expect that the most progress will be made where effective local partnerships 

are formed among the IHS, VA, and Tribal governments to identify local needs and 

develop local solutions. You are encouraged to establish a means for routine and 

periodic communication between local elements of VA and the IHS. At a minimum, 

such communication would serve to clarify and share information on which services 

are provided by each organization and to whom at each location. At its most effective, the communication would include a broader discussion of joint program initiatives in clinical service delivery, community-based care, health promotion, and disease prevention. The management and prevention of chronic disease is a challenge 

that confronts both Departments; creative solutions in case management, home and 

community-based care, and primary prevention activities will improve the health of 

those we serve. 

Collaborations already exist in many locations but the intent of the MOU is to 

expand these activities where they are and extend them to more communities and 

facilities. Examples of shared service arrangements already in place include the following: In some locations, specialists from VA provide cost-effective consultation to 

Indian health facilities; at others; telemedicine capabilities are shared to enhance 

access to otherwise unattainable services; and continuing education through access 

to veterans’ programs is another shared capability that has been developed in some 

areas. Other collaborative efforts remain to be developed and might include primary 

care for non-Indian veterans in exchange for hospital care for non-veteran Indians. 

The creation of joint community-based care and prevention is another area of collaboration where few models currently exist. 

Another principle embodied in the MOU is that collaboration and more creative 

and effective use of resources will meet the President’s management objectives. 

President Bush has clearly stated his management agenda to improve the efficacy 

and efficiency of Federal Government activities. Where there are opportunities to fill 

gaps or eliminate the duplication of effort, collaboration can help with the planning 

and deployment of resources in the most cost-effective and highest-quality manner. 

The MOU encourages the development of resource-sharing, within our current legal 

authority, to enhance the services provided to meet the missions of both Departments. It does not mean that each Department will begin to bill the other for services provided to the other’s beneficiaries, except where it is agreed to by both entities. It may mean, however, the development of responsible sharing of services to 

meet the needs of patients and communities. 

At the national level, the two Departments will continue their very productive collaboration in developing more effective information technologies. Collaboration has 

led to many advancements in electronic health record systems and quality improvement tools. The MOU should facilitate the engagement of local entities in both Departments that are able to influence national program development in these areas. 

In summary, the MOU expresses the commitment of both Departments to expand 

our common efforts to improve the quality and efficiency of our programs. It provides policy support to local planning and collaboration, and it charges local leadership to be more innovative and engaged in discharging our responsibilities. It is 

clear that the goal of the MOU is to improve both the quality and quantity of services provided to the populations we serve. Ultimately, it is a tool to elevate the 

health of our patients, communities, and the Nation. 

Sincerely yours, 

ROBERT H. ROSWELL, M.D., 

Under Secretary for Health. 

CHARLES W. GRIM, D.D.S., M.H.S.A., 

Assistant Surgeon General, 

Interim Director, Indian Health Service. 

MEMORANDUM OF UNDERSTANDING BETWEEN THE VA/VETERANS HEALTH

ADMINISTRATION AND HHS/INDIAN HEALTH SERVICE

I. PURPOSE

The purpose of this Memorandum of Understanding (MOU) is to encourage cooperation and resource sharing between the Veterans Health Administration (VHA) 

and Indian Health Service (IHS). The goal of the MOU is to use the strengths and 

49

expertise of our organizations to deliver quality health care services and enhance 

the health of American Indian and Alaska Native veterans. This MOU establishes 

joint goals and objectives for ongoing collaboration between VHA and IHS in support of their respective missions. 

II. BACKGROUND

The mission of the Indian Health Service is to raise the physical, mental and spiritual health of American Indians and Alaska Natives to the highest level. The IHS 

goal is to assure that comprehensive, culturally acceptable personal and public 

health services are available and accessible to American Indian and Alaska Native 

people. 

The mission of the Department of Veterans Affairs is to ‘‘care for him who shall 

have borne the battle and his widow and orphan.’’ Those words were spoken by 

Abraham Lincoln during his second inaugural address and reflect the philosophy 

and principles that guide VA in everything it does. The Veterans Health Administration six strategic goals are: put quality first until we are first in quality; provide 

easy access to medical knowledge, expertise and care; enhance, preserve, and restore 

patient function; exceed patient’s expectations; maximize resource use to benefit veterans; and build healthy communities. 

The IHS and the VA enter into this MOU to further their respective missions. 

It is our belief, that through appropriate cooperation and resource sharing both organizations can achieve greater success in reaching our organizational goals. 

III. ACTIONS

A. This MOU sets forth 5 mutual goals: 

1. Improve beneficiary’s access to quality healthcare and services. 

2. Improve communication among the VA, American Indian and Alaska Native 

veterans and Tribal governments with assistance from the IHS. 

3. Encourage partnerships and sharing agreements among VHA headquarters and 

facilities, IHS headquarters and facilities, and Tribal governments in support of 

American Indian and Alaska Native veterans. 

4. Ensure that appropriate resources are available to support programs for American Indian and Alaska Native veterans. 

5. Improve health-promotion and disease-prevention services to American Indians 

and Alaska Natives.

B. To further the goals of this MOU, VA and IHS agree to: 

1. Facilitate collaboration on effective healthcare delivery for American Indian and 

Alaska Native veterans and shared responsibility for implementation of appropriate 

health promotion and disease prevention efforts. Ensure that IHS and VA facilities 

develop and provide effective linkages between facilities to support health promotion 

for American Indian and Alaska Native veterans that benefit their communities. 

2. Identify needs and gaps between the VA and the IHS to develop and implement 

strategies to ensure optimal health for the American Indian and Alaska Native veteran population. 

3. Promote activities and programs designed to improve the health and quality of 

life for American Indian and Alaska Native veterans. 

4. Develop and implement strategies for information sharing and data exchange. 

5. Collaborate in the exchange of relevant programmatic communications and 

other information related to American Indian and Alaska Native veterans. 

6. Cosponsor and provide reciprocal support for Continuing Medical Education, 

training and certification for IHS and VA healthcare staff. 

7. Develop national sharing agreements, as appropriate, in healthcare information 

technology to include electronic medical records systems, provider order entry of prescriptions, bar code medication, telemedicine, and other medical technologies, and 

national credentialing programs. 

8. Create an interagency work group to oversee proposed national initiatives. 

9. Develop a common methodology to track VA and IHS interagency activities and 

report progress. 

IV. OTHER CONSIDERATIONS

A. All VA Medical facilities and the IHS will comply with all applicable Federal 

laws and regulations regarding the confidentiality of health information. Medical 

records of IHS and VA patients are Federal records and are subject to some or all 

of the following laws: the Privacy Act, 5 U.S.C. 552a; the Freedom of Information 

Act, 5 U.S.C. 552; the Drug Abuse Prevention, Treatment, and Rehabilitation Act, 

21 U.S.C. 1101, the Comprehensive Alcohol Abuse and Alcoholism Prevention, 

50

Treatment and Rehabilitation Act, 42 U.S.C. 4541, the Health Insurance Portability 

and Accountability Act of 1996, 42 U.S.C. 1301, VA’s Confidentiality of Certain Medical Records, 38 U.S.C. 7332; Confidential Nature of Claims, 38 U.S.C. 5701; Medical Quality Assurance Records Confidentiality, 38 U.S.C. 5705, and Federal Regulations promulgated to implement those Acts. 

B. Care rendered under this MOU will not be part of a study, research grant, or 

other test without the written consent of both the IHS and the VA facility and will 

be subject to all appropriate HHS and VA research protocols. 

C. The VA and the IHS will abide by Federal Regulations concerning the release 

of infonnation to the public—and will obtain advance approval from either VA or 

IHS before publication of technical papers in professional and scientific journals—

for articles derived from information covered by this MOU. The VA and the IHS 

agree to cooperate fully with each other in any investigations, negotiations, settlements or defense in the event of a notice of claim, complaint, or suit relating to care 

rendered under this VA/IHS MOU. 

D. No services under this MOU will result in any reduction in the range of services, quality of care or established priorities for care provided to the veteran population or the IHS service population. 

E. The VA may provide IHS employees with access to VA automated patient 

records maintained on VA computer systems to the extent permitted by applicable 

Federal confidentiality and security law. Additionally, the IHS will likewise provide 

VA employees access to Veteran IHS records to the same extent permitted by applicable Federal confidentiality and security law. 

F. Both parties to this MOU are Federal agencies and their employees are covered 

by the Federal Tort Claims Act, 28 U.S.C 1346(b), 2671–2680, in the event of an 

allegation of negligence. It is agreed that any and all claims of negligence attributable to actions taken pursuant to this MOU will be submitted to legal counsel for 

both parties for investigation and resolution. 

V. TERMINATION

This MOU can be terminated by either party upon issuance of written notice to 

the other party not less than 30 days before the proposed termination date. The 30 

days notice may be waived by mutual written consent of both parties involved in 

the MOU. 

VI. EFFECTIVE PERIOD

The VA and the IHS will review the MOU annually to determine whether tenns 

and provisions are appropriate and current.

LEO S. MACKAY, JR., 

Deputy Secretary of Veterans Affairs, 

Department of Veterans Affairs. 

CLAUDE A. ALLEN, 

Deputy Secretary of Health and Human Services, 

Department of Health and Human Services. 

Date: February 25, 2003.

Question 3: I understand from representatives of the Disabled American Veterans, 

based on a recent briefing at the Walter Reed Army Medical Center (WRAMC), that 

the average number of prosthetic limbs issued to amputees treated at WRAMC is 

six. These sophisticated artificial limbs enable severely wounded service personnel 

to run, climb, swim, lump and do other physical exercises and sports that were impossible for earlier generations of amputees. I understand that VA’s average prosthetics issue is three prostheses for a veteran amputee under your care. 

Question 3(a): Does VA have plans to modernize its prosthetic and orthotic programs in a similar way to that of WRAMC, and if so, what are those plans? 

Response: Yes, VA has begun a modernization process to upgrade existing computer aided design-computer aided manufacture (CAD–CAM) equipment in the 58 

prosthetics labs. In the personnel area, VA has mandated and has achieved full accreditation for all 58 of its Prosthetic and Orthotic Labs. Each lab has been mandated to have at least one Certified Prosthetist, Orthotist or an individual certified 

in both specialties. VA has also established training programs with private industry 

to learn more about the latest technology and fitting techniques. 

VA has established two national contracts to provide state-of-the-art upper extremity prostheses. To ensure convenience to the veteran amputee and access to the 

51

state-of-the-art prosthetic appliances, VA contracts out to private industry 95 to 98 

percent of the total limbs fabricated for all veterans. In addition, VA has established 

a rotation system with Walter Reed Army Medical Center and Brooke Army Medical 

Center to send VA Prosthetists, Physical and Occupational Therapists to their amputee centers to ensure continuity of care between VA and Department of Defense 

(DOD).

Question 3(b): If a veteran comes to VA today for newly invented prosthetic appliances or limbs, such as the ‘‘C-Leg,’’ or a prosthetic arm that would allow him to 

play golf or tennis, what is VA’s policy for providing those limbs and the necessary 

training to use them? 

Response: When a veteran comes to VA for a prosthetic appliance, VA provides 

the newest versions available and trains the veteran in its proper use. Prosthetists, 

physical or occupational therapists, and other rehabilitation specialists provide 

training relevant to the veteran’s specific needs as part of the rehabilitation process. 

If the patient has a lower extremity amputation and requires a C-leg, for example, 

VA offers training on how to walk on various surfaces, how to negotiate stairs, how 

to get back up after falling, how to care for the appliance, and how to don the device. For veterans with an upper extremity amputation requiring a myoelectric arm, 

for example, VA trains the veteran in how to don and care for the appliance, how 

to manipulate the hand, wrist, and elbow, and how to employ independent living 

techniques to care for themselves. This training is available whenever VA provides 

a prosthetic, whether the veteran is a new patient or not.

Question 3(C): How will VA respond when veterans who have been issued these 

high level appliances come to the Department’s Prosthetics and Sensory Aids Program for repairs and replacements? 

Response: When a veteran comes to VA for a repair or replacement of an appliance they received from DOD, they are provided repairs for that appliance or a replacement of equal or greater technology and provided the necessary training for 

use and maintenance.

Question 4: I am concerned that there are a great number of enrolled veterans 

who are at risk of Obstructive Sleep Apnea (OSA) who today are not being tested 

and diagnosed. I understand that the current backlog of sleep studies is quite high. 

While I understand that VA considers adding a large number of sleep study beds 

and contracting with community facilities as options to meet the current demand, 

what other innovative approaches for diagnosing OSA is the Department evaluating? 

Response. A number of VA sleep centers including, Houston and Los Angeles, are 

working to integrate a combination of in-laboratory and at-home testing into a comprehensive program. These programs are designed so we can continue to meet the 

national standards of practice for OSA diagnosis set forth by the American Academy 

of Sleep Medicine. VA will continue to evaluate the need for additional sleep centers 

and will expand to other facilities as the need arises. A description of the program, 

its operating procedures, guidelines, and implementation are currently being produced in the new volume of sleep clinics. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN D. ROCKEFELLER IV 

TO MICHAEL J. KUSSMAN, M.D., NOMINEE TO BE UNDER SECRETARY FOR HEALTH, 

DEPARTMENT OF VETERANS AFFAIRS

Question 1: Over 1 million active duty soldiers and over 400,000 Guard and Reservists have served in Iraq and Afghanistan, including 8,000 West Virginia service 

personnel and over 4,000 Guard and Reservists. Policymakers believe at least onethird or more soldiers will need mental health care at some point, and having met 

with many West Virginia soldiers, you believe this number could be even higher. 

The Vet Centers, created after the Vietnam War, are independent centers and provide quality counseling and care with the least bureaucracy in the VA system. Rumors suggest that VA is considering changing Vet Center so that each would report 

to a VA Medical Center, but this is a terrible idea, in my judgment. Dr. Kussman, 

I meet with returning West Virginia veterans privately, and they are strong advocates for the Vet Centers, and the independence of such centers. 

Question 1(a): What is your view of the Centers, and what will VA do to support 

the Centers and increase the staff and support necessary to fully care for the more 

than 1.4 million veterans who may need mental health care? 

Response: I believe Vet Centers play a unique role in VA’s services to returning 

combat veterans and I fully support maintaining them as a separate section within 

VHA. VA continues to expand into more communities with our Vet Centers, thus 

52

bringing our services closer to the veterans who need them and to help combat veterans successfully readjust to life at home. 

Since the beginning of Fiscal Year (FY) 2005, VA has created 26 new Vet Centers 

and added 72 staff, not including the 100 Global War on Terrorism (GWOT) outreach specialists authorized and now in place since Fiscal Year 2004 and Fiscal 

Year 2005. This represents a 26 percent increase in Vet Center staffing and a 13 

percent increase in the number of Vet Centers.

Question 1(b): What special arrangements are underway to prepare to serve the 

unique needs of female veterans, especially on the sensitive issue of military sexual 

trauma? 

Response: VA offers special training on women’s health care issues to the 100,000 

medical trainees who rotate through VA every year. We also provide 13 fellowships 

in health issues of women veterans, and a number of our clinical scholars pursue 

research projects on women veterans. VA recently created the Women Veterans 

Strategic Health Care Group (WVSHG). The WVSHG is closely examining the access to, and environment of care in, inpatient areas to recommend enhancements 

necessary to ensure adequate security and privacy on inpatient areas and comfort 

in outpatient waiting rooms and counseling centers. This will be accomplished in 

part through the annual plan of care/clinical inventory Web based survey sponsored 

by the WVSHG. In the past 3 years, this survey has shown significant improvements in the environment of care, specifically in the area of privacy. 

VA has made great strides in caring for women veterans over the past several 

years. We offer a number of programs specifically for women through the Center for 

Women Veterans. VA offers special counseling options for women recovering from 

trauma through the National Women’s Trauma Recovery Program. It should be 

noted that women receive better care on average in the VA system than from Medicare or from the best non-governmental provider. In fact, VA scores nearly 10 points 

better in breast cancer and cervical cancer screening than Medicare or the private 

sector according to the American Journal of Managed Care, thanks to our awardwinning electronic health record system. 

VA screens all veterans for military sexual trauma (MST). If a veteran reports 

military sexual assault or harassment, he or she is eligible for copay exempt health 

and mental health services for treatment of problems related to those experiences. 

Unless specifically established for women, programs serve both genders. There are, 

in absolute numbers, as many men as women who have experienced MST. 

Every VA facility has designated a MST coordinator, and Vet Centers also have 

specially trained sexual trauma counselors. Thirteen programs offer sexual-trauma 

specific treatment in a residential or inpatient setting, and at least two more are 

under development. In Fiscal Year 2007, VA established a Military Sexual Trauma 

Support Team to ensure VA is in compliance with mandated MST screening and 

treatment. This team also helps coordinate and expand education and training efforts related to MST and to promote best practices in the field.

Question 1(c): Do you think that VA should consider mandatory screening for 

mental health care as recommended by the Iraq and Afghanistan Veterans of America (IAVA)? 

Response: The post-deployment health assessment is conducted by DOD and includes some screening for mental health concerns, but we defer to DOD on those 

issues. VA participates in the post-deployment health reassessment (PDHRA) and 

conducts mental health evaluations. Returning Operation Enduring Freedom/ Operation Iraqi Freedom (OEF/OIF) veterans are screened for post traumatic stress disorder (PTSD) when they are first seen in VHA, at least annually thereafter for 5 

years, and at least every 5 years after that. Like all veterans seen in VA medical 

centers and clinics, returning veterans are also screened for depression and substance abuse on at least an annual basis. VHA policy requires physicians to conduct 

follow-up care for all positive screens, and provides treatment for all veterans found 

positive for indicators of PTSD, depression, substance use disorders, or other mental 

health conditions. These measures are taken to provide preventative care for patients and identify those in need of treatment.

Question 2: Under current law, Guard and Reservists who serve in combat have 

access to VA health care for 2 years after deployment and lifetime care if they can 

prove it is service-connected which is easier for physical injuries than mental health 

care. Combat veterans who apply for enrollment in VA health care before their twoyear post discharge period ends, remain enrolled and are eligible for hospital care, 

medical services and nursing home care. However, their priority group assignment 

and copay responsibilities will be based on the eligibility factors applicable at that 

period of time.

53

Question 2(a): Dr. Kussman, what is VA doing to improve the transition and outreach for Guard and Reservists, particularly on the mental health care issues? 

Response: National Guard members and reservists who served in combat, who 

meet the minimum active duty length of service requirement, and who are discharged or released under conditions other than dishonorable are treated the same 

as other combat-theater veterans. They are enrolled in Category 6 for 2 years and 

then placed in whichever enrollment category is appropriate, based on their particular situation. Like other combat-theater veterans, they may be subject to copayment requirements if placed in Category 7 or 8. But, importantly they still remain 

eligible for VA care and the medical care package. They are enrolled as Category 

6 veterans when they present to VA during the 2-year period after their discharge 

or separation and are not dis-enrolled. 

To ensure Guard members and Reservists are aware of these opportunities, VA 

uses its Vet Centers to facilitate transition and outreach for veterans, particularly 

for mental health issues. Vet Centers have provided outreach to 173,277 OEF/OIF 

veterans since October 2001 through the end of the second quarter Fiscal Year 2007. 

VA has hired 100 OEF/OIF combat veterans to provide outreach services to their 

fellow returning OEF/OIF veterans. Our Vet Centers have provided readjustment 

counseling to 54,451 OEF/OIF veterans in Vet Centers and have engaged in outreach to active duty, National Guard, and Reserve units demobilizing upon their return from combat. Vet Centers have participated in all 595 PDHRA screening 

events, including the pilot project and Vet Center staff members have facilitated 

10,578 referrals for readjustment counseling through the end of the second quarter 

Fiscal Year 2007.

Question 2(b): I strongly support legislation by Chairman Akaka to expand access 

for Guard and Reservists from 2 years to 5 years which will give them more time 

to seek care for mental health; will you work with us to implement such a policy? 

Response: VA would support an extension of the enrollment period from 2 to 5 

years. When OEF/OIF veterans seek care from VA they are placed in priority Category 6 and make no copayments for covered conditions. When the special treatment 

authority for combat-theater veterans was originally enacted, it was generally assumed that 2 years was sufficient. However, experience has shown that is not always the case. In caring for OEF/OIF veterans we have discovered the onset of 

symptoms and adverse health effects related to PTSD, and even traumatic brain injury (TBI), are often delayed, or do not manifest clinically, for more than 2 years 

after a veteran has left active service. As a result, many OEF/OIF veterans do not 

seek VA health care benefits until after their 2-year window of eligibility has closed. 

Without eligibility for enrollment in priority Category 6, many, i.e., those with higher incomes and non-service connected conditions, would not be eligible to enroll because they would be in priority Category 8. 

In addition, many OEF/OIF veterans are non-career military members who are 

unfamiliar with veterans’ benefits and the procedures for obtaining them. For that 

reason many fail to enroll in a timely fashion. Providing combat-theater veterans 

with an additional 3 years within which they can access VA’s health care system 

would help ensure none of them are penalized because of reasons beyond their control or because they have been unable to navigate VA’s claims system in time.

Question 3: Traumatic Brain Injury (TBI) seems to be a growing concern for many 

of our soldiers returning from combating. At previous hearings, witnesses have testified about the challenges in getting an accurate diagnosis, due to problems with 

hearing and vision issues. 

Question 3(a): What screening is being done now, and what plans are underway 

to expand such screening? 

Response: VA has implemented mandatory TBI screening of all OEF/OlF veterans 

receiving medical care within VA. Those who screen positive for TBI are offered further evaluation and treatment by clinicians with expertise in TBI. 

Patients with Polytrauma and TBI receive vision evaluations as part of their comprehensive rehabilitation management evaluation. Blind rehabilitation outpatient 

specialists serve as members of interdisciplinary polytrauma teams and provide 

thorough functional assessment of polytrauma veteran’s vision to ensure that functional vision problems are diagnosed and treated. 

Veterans receive basic eye examinations by ophthalmologists and/or optometrists 

in VA medical center eye clinics. Veterans documented with vision loss are referred 

to VA medical center low vision clinics or blind rehabilitation centers, where they 

receive clinical visual rehabilitation examinations by optometrists or ophthalmologists. 

VA does not routinely screen returning veterans for hearing loss; however active 

duty servicemembers receive a post-deployment health survey that addresses hearVerDate 0ct 09 2002 10:56 Sep 04, 2007 Jkt 000000 PO 00000 Frm 00057 Fmt 6633 Sfmt 6621 H:\RD41451\DOCS\37239.TXT SENVETS PsN: ROWENA
54

ing-related concerns. Audiology services are routinely provided for veterans injured 

on active duty and undergoing physical evaluation boards within military treatment 

facilities. Injured veterans transferred to the VA system of care are typically 

screened for hearing loss by an audiologist and more comprehensive evaluation and 

treatment is completed by an audiologist as warranted.

Question 3(b): What research is in development to care for TBI among our returning soldiers? 

Response: To advance the treatment and rehabilitation of soldiers returning with 

traumatic brain injury (TBI) and related neurotrauma, VA has issued a request for 

research proposals that focus on TBI; cervical spinal cord injury; co-morbid conditions such as PTSD and trauma to extremities; screening and diagnostic tools related to mild TBI, especially field-based; and continuity of care between DOD and 

VA. Applicants are asked to pay special attention to cooperative projects with DOD. 

Some exciting research projects currently underway include: (1) studying neural 

repair after brain injury to build a theoretical understanding of cognitive rehabilitation and creating targets for practical treatments to enhance quality of life; (2) exploring community re-integration for servicemembers with TBI (to promote seamless 

transition between servicemembers currently being treated, or who will one day be 

treated, in both DOD and VA medical facilities); and, (3) assessing whether there 

are differences in the cost patterns for rehabilitation among soldiers returning from 

OEF/OIF with combat-related TBI compared to those with non-combat-related TBI. 

Investigators are also examining how PTSD impacts future outcomes and costs associated with combat-related TBI. 

In addition, VA has established a Polytrauma and Blast-Related Injury Quality 

Enhancement Research Initiative (PT/BRI QUERI) coordinating center to promote 

the successful rehabilitation, psychological adjustment, and community reintegration of veterans. We have identified two priorities: (1) TBI with polytrauma, and (2) 

traumatic amputation with polytrauma. The primary target is OEF/OIF patients in 

VA, many of whom remain on active duty during their initial course of treatment. 

However, its activities will benefit all VA patients with complex injuries, regardless 

of service era and mechanism of injury. Finally, VA recently issued a special solicitation for research projects on the long-term care and management of veterans with 

polytrauma, blast-related injuries, or TBl. 

Question 4: Having candid communications is a priority for me, and I have been 

frustrated during recent hearing with standard testimony noting that VA appointments are quick and almost all veterans are seen in a timely manner. I meet regularly with returning West Virginia veterans, and this is not the story I hear. Dr. 

Kussman, how can we get direct, candid information about the true funding needs 

for VA health care? 

Response: VA’s actuarial model developed approximately 84 percent of the Fiscal 

Year 2008 VA medical care budget and VA has made every effort to account for the 

needs of veterans. The Model has had several key methodological improvements including development of separate enrollment, morbidity, and reliance assumptions 

for OEF/OIF veterans based on their actual enrollment and usage patterns. However, many unknowns can impact the number and types of services that VA will 

need to provide OEF/OIF veterans, including the duration of the conflict, when 

OEF/OlF veterans are demobilized, and the impact of our enhanced outreach efforts. 

VA is well-positioned to provide assistance to veterans returning from Iraq and Afghanistan. As a physician and a veteran myself, if there is ever a situation where 

patient care is in jeopardy due to inadequate funding, I will be sure to raise those 

concerns within the Administration.

Question 5: In 2005, when VA acknowledged a shortfall in the health care budget, 

the Secretary noted that part of the problem was a wrong estimate of the costs of 

care for the returning soldiers of $273 million. But an even larger amount of the 

shortfall was the miscalculation of the long-term care costs for our older veterans—

VA testified long-term care costs were $446 million short. 

Question 5(a): It is easiest to understand how the estimate could be off on the 

needs of the returning soldiers, but why was VA off by almost half a billion dollars 

on long-term care? 

Response: This was due to unrealistic assumptions in developing the budget estimates for VA long-term care nursing home care. The Fiscal Year 2005 supplemental 

budget request and the Fiscal Year 2005 budget amendment request corrected these 

errors. VA’s subsequent budget requests demonstrate an improved model of forecasting accuracy.

Question 5(b): How has the budget process been improved and what action is VA 

taking to ensure quality long term care for our aging veteran population? 

55

Response: The Fiscal Year 2007 and Fiscal Year 2008 budget requests included 

accurate estimates of VA’s long-term care costs and did not repeat the unrealistic 

assumptions and computational errors. VA continues to provide patient-centered 

long-term care services in the most independent setting suitable for a veteran’s medical condition and personal circumstances, especially in locations close to the veteran’s home and community-based settings. 

VA facilities may establish an enhanced use lease agreement in which VA leases 

space for a privately owned assisted living (AL) facility in return for affordable AL 

for veterans. This public-private partnership provides for supervised housing at an 

affordable rate structured to address the needs of the community, as well as the 

specific needs of veterans. VHA helps support veterans in assisted living settings 

through community residential care, medical foster homes, and home based primary 

care. Medical foster homes combine the adult foster home concept with VA home 

based primary care (HBPC), where VA finds people in the community willing to 

take veterans into their home and provide personal assistance and continuous supervision. Veterans pay for these services using their aid and attendance benefits 

from the Veterans Benefit Administration (VBA). The home based primary care 

team continues to provide health care, adaptive equipment, caregiver education, and 

oversight. We are operating medical foster homes in Little Rock, Tampa, and San 

Juan, and we are ready to expand to 20 additional sites.

Question 5(c): Will VA make long term care and nursing home care a priority for 

its construction projects? 

Response: VA will continue to make long term and nursing home care a priority 

for all veterans for whom such care is mandated by statute, and who need such care 

and seek it from VA. The current budget request will support continued expansion 

of veterans’ access to VA’s spectrum of non-institutional home and community based 

long-term care services while sustaining capacity in VA’s own nursing home care 

units and the community nursing home program and continuing to support modest 

growth in capacity in the State veterans home program. 

VA expects to meet a substantial part of the growing need for long-term care 

through such innovative services as care coordination/home telehealth. Care coordination in VA involves the use of health informatics; telehealth and disease management technologies to enhance and extend existing care; and case management activities. Home telehealth enables delivery of VA health care to veterans living remotely from VA medical facilities, including those in rural areas. 

RESPONSE TO WRITTEN QUESTION SUBMITTED BY HON. PATTY MURRAY

TO MICHAEL J. KUSSMAN, M.D., NOMINEE TO BE UNDER SECRETARY FOR HEALTH, 

DEPARTMENT OF VETERANS AFFAIRS

Question. Are there any external reviewers involved in the decisionmaking process 

for VA bonuses? 

Response: The Department of Veterans Affairs (VA) has four separate Performance Review Boards (PRBs)—one for VA personnel (employees who report to an Assistant Secretary, General Counsel, and other key staff and offices, usually in Central Office), one for the Veterans Benefits Administration (VBA), one for the Veterans Health Administration, and one for the Office of Inspector General (OIG). The 

first three are all composed entirely of VA employees, while the fourth is composed 

of three non-VA members (one from Housing and Urban Development, one from the 

Department of Labor, and one from NASA). This composition for an OIG PRB is 

common across government, since Offices of Inspector General are tasked with conducting an independent oversight role of their Department and tying their performance assessments to the Department could present a conflict of interest for personnel. 

Each agency is required to publish its PRB membership in the Federal Register. 

VA reviewed this listing for seven Cabinet-level Departments (Defense, Education, 

Health and Human Services, Homeland Security, Interior, Justice, and Treasury) 

and several agencies and administrations (Environmental Protection Agency, Government Services Administration, Small Business Administration, and the Nuclear 

Regulatory Commission) and found it is very rare for PRBs to include external 

members. For example, the Office of Personnel Management (OPM), which sets the 

rules for the bonus process, does not have an external member on its board. The 

only agencies VA could find that did include an external member for their PRB were 

relatively small—the Equal Employment Opportunity Commission, the Office of 

Government Ethics, and the National Transportation Safety Board. It should be 

noted that each of these agencies provides an oversight role similar to an OIG. 

56

VHA’s PRB includes the chair of each of the six national committees for VHA’s 

National Leadership Board, the chairs of the Performance Management Work 

Group, the Deputy Under Secretary for Health for Operations and Management, the 

Principal Deputy Under Secretary for Health, and the Chief of Staff. All of the committee members are VHA employees. The PRB determines the ratings of subordinate executives, SES pay adjustments, year-end performance bonuses, and priority 

rankings for rank awards for subordinate executives. Subsequently, a senior management committee composed of the Deputy Under Secretary for Health for Operations and Management, the Principal Deputy Under Secretary for Health, and the 

Chief of Staff, makes recommendations on all other executives’ ratings, SES pay adjustments, year-end performance bonuses, and the priority rankings for rank 

awards for subordinate executives, but they do not determine their own. The Under 

Secretary for Health makes recommendations on the Deputy Under Secretary for 

Health for Operations and Management, the Principal Deputy Under Secretary for 

Health, and the Chief of Staff. All recommendations go to the VA PRB for review 

and recommendation to the Secretary. No member of VA’s PRB acts on his or her 

own rating, bonus, or pay adjustment. 

RESPONSE TO WRITTEN QUESTION SUBMITTED BY HON. SHERROD BROWN TO

MICHAEL J. KUSSMAN, NOMINEE TO BE UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Question: Our vets returning from the Iraq and Afghanistan theaters of battle 

have faced enemies who have in many ways, fought in a manner different than any 

other we have faced in the past. I know that many other nations, particularly the 

Israelis, have reached out to the VA and that the VA has sent delegations and held 

meetings with foreign officials in the recent past. I would hope that you would keep 

those lines of communication open and to the extent that you can, expand on this 

relationship especially in the fields of brain trauma and stress disorders. Please 

comment on how you see the relationships developing, and what resources, if any, 

you might need to take advantage of such an opportunity. 

Response: Between January 15 and 19, 2007, a delegation from VA visited the Department of Rehabilitation, Ministry of Defense in Tel Aviv, Israel. The primary 

purpose of the visit was to examine how Israel deals with PTSD. VA also visited 

a TBI center and a Veterans’ Organization. VA observed that Israeli and U.S. clinicians take similar approaches to PTSD and TBI. 

VA welcomes continued discussions with the Israeli Ministry of Defense and is 

willing to consider funding collaborative, peer-reviewed research projects involving 

VA and Israeli investigators. We believe this cooperation will yield scientifically rich 

and highly relevant data to provide even better care to our Nation’s veteran population.

[Michael J. Kussman’s response to Questionnaire for Presidential Nominees follows:]

57


37239.001
58


37239.002
59


37239.003
60


37239.004
61


37239.005
62


37239.006
63


37239.007
64


37239.008
65


37239.009
66

UNITED STATES OFFICE OF GOVERNMENT ETHICS, 

Washington, DC, April 23, 2007. 

Hon. DANIEL K. AKAKA, 

Chairman, Committee on Veterans’ Affairs, 

U.S. Senate, 

Washington, DC. 

DEAR MR. CHAIRMAN: In accordance with the Ethics in Government Act of 1978, 

I enclose a copy of the financial disclosure report filed by Dr. Michael J. Kussman, 

who has been nominated by President Bush for the position of Under Secretary for 

Health, Department of Veterans Affairs. 

We have reviewed the report and have also obtained advice from the Department 

of Veterans Affairs concerning any possible conflict in light of its functions and the 

nominee’s proposed duties. Also enclosed is a letter dated April 11, 2007, from the 

agency’s ethics official, outlining the steps Dr. Kussman will take to avoid conflicts 

of interest. In addition to the steps indicated in the enclosed letter, Dr. Kussman 

informed the ethics official that he will divest General Electric and Pfizer in the immediate future. 

Based thereon, we believe that Dr. Kussman is in compliance with applicable laws 

and regulations governing conflicts of interest. 

Sincerely, 

ROBERT I. CUSICK, 

Director. 

Enclosures.

DEPARTMENT OF VETERANS AFFAIRS, 

OFFICE OF THE GENERAL COUNSEL, 

April 11, 2007, Washington, DC. 

Mr. ROBERT I. CUSICK, 

Director, Office of Government Ethics, 

Washington, DC. 

DEAR MR. CUSICK: In accordance with section 2634.605(c) of title 5, Code of Federal Regulations, I am forwarding the enclosed Public Financial Disclosure Report 

(SF–278) of Dr. Michael Kussman. President Bush has nominated Dr. Kussman to 

serve in the position of Under Secretary for Health of the Department of Veterans 

Affairs (VA). It is my opinion that Dr. Kussman’s report is complete and discloses 

no unresolved conflicts of interest under applicable law or regulation. 

Dr. Kussman has agreed pursuant to 18 U.S.C. § 208(a) that he will not participate personally and substantially in any particular matter that has a direct and 

predictable effect on his financial interests or those of any other person whose interests are imputed to him, unless he first obtains a written waiver under section 

208(b)(1), or qualifies for a regulatory exemption under section 208(b)(2) and 5 CFR 

§§ 2640.201–2640.203. Dr. Kussman understands that the interests of the following 

persons and entities are imputed to him: his wife; minor children; general partner; 

any organization in which he serves as an officer, director, trustee, general partner 

or employee; and any person or organization with which he is negotiating, or has 

an arrangement concerning, prospective employment. 

Dr. Kussman currently holds stock in General Electric and Pfizer. Dr. Kussman 

has agreed that he will divest himself of these stock interests within 90 days of his 

confirmation. Further, pending his divestiture of these assets, Dr. Kussman has 

agreed not to participate personally and substantially in any particular matters that 

will have a direct and predictable effect on the financial interests of either of these 

companies. 

Dr. Kussman also holds stock in Hewlett Packard. We have determined that it 

is not necessary at this time for him to divest this interest. However, Dr. Kussman 

has agreed that he will not participate personally and substantially in any particular matter that will have a direct and predictable effect on the financial interests of Hewlett Packard unless he first obtains a written waiver, pursuant to section 

208(b)(1), or qualifies for a regulatory exemption, pursuant to section 208(b)(2). 

These assurances resolve any concern about real or apparent conflicts of interest 

that may arise from Dr. Kussman’s report. Therefore, I have certified and dated the 

report. 

Sincerely yours, 

WALTER A. HALL, 

Assistant General Counsel 

and Designated Agency Ethics Official.

67

Chairman AKAKA. Thank you very much, Dr. Kussman. 

Let me note that the nominee has completed the Committee 

questionnaire for Presidential nominees and responded to my prehearing questions, all of which will appear in the hearing record. 

Also included will be a letter from the Office of Government Ethics 

acknowledging that he is in compliance with laws and regulations 

governing conflicts of interest. 

Before we go further here, there is a requirement that I swear 

in the nominee, and so, Dr. Kussman, I ask that you stand and 

raise your right hand. 

Do you solemnly swear that the testimony you are about to give 

the Veterans’ Committee is the truth, the whole truth, and nothing 

but the truth, so help you, God? 

Dr. KUSSMAN. Yes, sir. 

Chairman AKAKA. Thank you very much. 

At this time, I would like to ask our Committee Members for any 

comments or statements they would like to make before we ask 

questions. We will go to questions, Dr. Kussman. 

Let me say that as I spoke of this in my opening statement, 

about being an advocate for veterans in light of OMB control, I 

urge you to ensure that the best interests of veterans is behind 

each and every decision you make. How will you advocate for that 

approach as VA deals with pressure from OMB to limit spending 

on health care? 

Dr. KUSSMAN. Mr. Chairman, thank you for the question. 

As you know, I am a veteran and a retiree and that is what I 

am here to do. I represent veterans. When Mr. Nicholson asked me 

to be the Acting Under Secretary and we talked, and I was very 

flattered that he did so, I told him that—and he knew this already—that I tell the people I work for what I think is correct, not 

what they want to hear, and he told me very clearly he wouldn’t 

have it any other way. 

And so my passion is to fight for veterans, to tell the leadership, 

including OMB, what I think needs to be done in support of veterans. Those people who know me know that I already have done 

that in my capacity in the VA and I assure you that is what I will 

continue to do. 

Chairman AKAKA. I want you to address criticisms leveled at you 

that you have not actively worked to improve things as veterans 

move from Walter Reed to VA. Please describe your involvement 

with Walter Reed, including the specific allegation that you knew 

about the problems at Walter Reed through focus groups carried 

out in 2004. 

Dr. KUSSMAN. Yes, Mr. Chairman. Thank you for the question. 

I worked at Walter Reed, as you know, from 1996 to 1998. At that 

time, I was the Commander of the Walter Reed Health Care System, the hospital, not the installation. So even when I was there, 

I wouldn’t have had anything to do with Building 18 or the other 

residential areas around the post. 

I am very proud of my service at Walter Reed in 1996 to 1998. 

Walter Reed got the highest score it ever got on the Joint Commission survey when I was there and was recognized in DOD as the 

large military hospital that had the best patient satisfaction during 

those two years that I was there. Any issues that have occurred 

68

more recently in Walter Reed didn’t exist back in 1996 to 1998, the 

specific issue related to the focus group in 2004. 

In 2003, then-Secretary Principi asked me to co-chair with an individual from VBA a Seamless Transition Task Force to look at 

what the VHA and VBA were doing or not doing in support of 

servicemembers when they were transitioning. The first thing we 

did, and I was responsible for that, I think it was noted in the first 

panel, is call the commanders of the major installations, both Army 

and Navy, and was successful in getting VBA benefits counselors 

and social workers full-time in there to assist. That was unprecedented, having full-time VA people working within military facilities. 

About 9 months after we had started this, then-Chief of Staff 

Nora Egan for Mr. Principi asked whether or not we were doing 

our job, whether the servicemembers at Walter Reed, their families, knew who the VBA/VHA people who were there. A group was 

put together—I was really not part of that group—to do a sensing 

session that took place on one day. There were six servicemembers 

that were there and, I believe, six family members. The issues that 

they discussed were really related to the VBA and VHA service. 

There was very little discussion of what was going on nor were we 

asked about what was going on in relationship to Walter Reed. 

I am a big critic of myself, the biggest critic I know, and I have 

gone back and read this report several times. I have talked to the 

people who did the report and there really wasn’t anything there 

that could have been presumed to have been related to the issues 

that came up several years later. In fact, those conditions did not 

exist at Walter Reed in 2004. 

Chairman AKAKA. Thank you very much for that. We will have 

a second round here. 

Let me call on Senator Craig for his questions and comments. 

Senator CRAIG. Thank you very much, Mr. Chairman. 

Dr. Kussman, you have now spent many years at the highest levels of the VA health care system. Of course, prior to joining VA, 

you operated in the world of military medicine. VA and DOD, in 

spite of working under one President, have struggled over the years 

to work effectively together. From the perspective of the military, 

why has that relationship been so difficult to foster? That would be 

my first question. 

And then from your perspective as the potential head of the VA 

system, how do you think you can continue to improve cooperation 

of these two systems? 

Dr. KUSSMAN. Thank you, sir. The first part of the question was 

my perception why DOD——

Senator CRAIG. Why has it been difficult to foster a better relationship between the two? 

Dr. KUSSMAN. I think that on a personal basis, there are a lot 

of good relationships with DOD, but I believe that the perceived 

mission of the two organizations are different. One fights a war, 

one is a more specific health care system, and there have been 

challenges in that cooperation. 

With this Administration, we have moved far along with the 

partnering at multiple levels. There is Health Executive Committee 

chaired by myself and now Dr. Ward Cassells who took over for Dr. 

69

Winkenwerder. There is a Joint Executive Committee co-chaired by 

Dr. Chu and Deputy Secretary Mansfield. There is a Benefits Executive Committee co-chaired by Mr. Domingous, I believe, and Admiral Cooper, the Under Secretary for Benefits. We are together 

working common issues. We have developed a DOD–VA strategic 

plan and we are holding people’s feet to the fire to meet those requirements. So I think we are trying to break through the cultures 

that have existed and are moving along with that. 

As far as the second part of the question, what the VA can do, 

we are committed to doing that and I believe one of the things that 

I bring to the table is the knowledge of both sides, and when I go 

talk to people, and sometimes I am in danger of losing my guild 

card for DOD, but I bleed VA now as much as I bleed any green 

leftover from the Army, and when people come and ask me about 

things, I say frequently, stop. Remember who you are talking to. 

I understand your system. We move on from there. 

So I believe that with the Secretary’s leadership and the Deputy 

Secretary, I believe Secretary Gates is committed, Deputy Secretary England, we are going to move very rapidly to continue and 

improve the relationship between the two entities. 

SENATOR CRAIG. Thank you, Dr. Kussman. 

Every war produces, from a health care standpoint, a different 

kind of veteran. Can you talk a little bit about your views on the 

care and treatment we are providing the severely injured veteran 

and where you believe changes might need to be made in our approaches and our delivery system, if you are confirmed to lead the 

VA health care system? 

Dr. KUSSMAN. Yes, sir. You are absolutely correct, sir, that every 

war has its sentinel injuries. I believe there are three signature injuries. I believe that there are three actually in this war. One is 

PTSD, particularly related to the National Guard and Reserve, not 

to minimize the active component, but we have in this war, really 

in an unprecedented manner since World War II, have used and relied upon the National Guard and Reserve. So we have a great obligation to them. 

Second is TBI, and we can talk about that in just a second, for 

major, minor, and moderate TBI. 

The third thing that I look at is what we have described and put 

into the lexicon, polytrauma, or multiple trauma. This war has 

brought to us unprecedented quality of combat medicine. With the 

body armor and the far-forward delivery of care, with the forward 

surgical teams doing unprecedented surgery right on the streets of 

Baghdad, the survival of severely injured people have come back 

and they have really challenged the system. These issues are not 

arithmatic, they are geometric in their complications and we consider people with severe illness to have TBI, spinal cord, mental illness, blindness, and amputations, and sometimes some of these 

poor kids have had all of them. So how do we approach that multidisciplinary need? 

We have had our four TBI centers that were established in 1991 

in Palo Alto, Minneapolis, Richmond, and Tampa, in conjunction 

with the Defense and Veterans Brain Injury Study and Center at 

Walter Reed. That is partly why they were established, because we 

were in partnership with DOD, and they have been at the forefront 

70

of the delivery of TBI care in the country. They are staffed by the 

same people who staff all the civilian agencies, trained in the same 

places and using the same techniques. 

When the war got going, we realized that we needed to put together facilities that had a multi-disciplinary approach so it could 

take care of the full gamut of the injuries as I described, and what 

we did is build on our TBI centers. Unfortunately, people forget 

that they were originally TBI centers. They weren’t built as 

polytrauma centers, but they were expanded. We believe that we 

can provide the full depth and breadth of services. 

As related to TBI, we have known and DOD together do very 

well with severe traumatic brain injury as far as that evacuation. 

Those people get into the evacuation chain and come through 

Landstuhl, come to the Bethesda and Walter Reed and then come 

to us, and I think we are doing a very good job in treating them. 

The bigger challenge right now is mild to moderate TBI that is 

not diagnosed because the individual doesn’t know they had it. The 

scenario that I describe is that there is an IED that went off. There 

may be carnage around, people severely injured. A servicemember 

may have lost consciousness or banged their head or had lost consciousness for a second or two. The sergeant yells, ‘‘Is everybody all 

right?’’ and the kid says, ‘‘Yes, Sarge, I am fine.’’ It may happen 

more than once. It could happen three or four times. It could happen in multiple deployments. But they never surface in the medical 

evacuation chain. Nobody knows that they have TBI. 

They come back, and the question is the literature doesn’t tell us 

what to do with mild to moderate TBI. The literature that exists 

in the medical community is very anemic when it comes to this and 

is generally based on relatively mild head bumps related to football 

Friday night. I played basketball when I was a kid and I, not so 

much joking, but I am not too agile and I would get an elbow in 

the side of the head and see stars for a couple of seconds. The 

coach would say, ‘‘You OK?’’ I never left the game. I never played 

too well, either, but I never left the game. That probably is mild 

TBI. 

There is a lot of that that goes on, but it may very well be that 

the mild to moderate TBI that occurs in the blast injury that is one 

of the ways that the enemy has fought us causing the TBI may be 

different. There may be molecular changes that are different from 

a blast than a more common head bump, if you will. We are initiating research, both in the civilian community and also with DOD, 

to try to determine that, try to determine if there are tests and 

things that can be done to identify mild to moderate TBI. 

However, we are not waiting for that to happen. As you know, 

we have put in place a screen for every OIF/OEF person that comes 

to us, regardless of what the initiating diagnosis is, just like we 

have done with PTSD, military sexual trauma, substance abuse, 

and depression. We screen everybody for all those. We have been 

doing that for a long time. Now we have added a screen for TBI. 

If those questions are positive, we then refer the patient according 

to a clinical guidance process to neuro-cognitive testing. Frequently, there is no one test that can be done, but just treat the 

symptoms. 

71

It appears from the civilian literature that I described as anemic 

that anywhere from 70 to 90 percent of people will get better within 18 to 24 months, but that may be a different illness compared 

to the illness that we are talking about with the TBI that we are 

seeing because of the blast injuries and we are putting together a 

registry so we can then identify the people and follow them longitudinally to see what happens over 1 year, 5 years, 10 years, and to 

be sure that we are giving them all the things that we can do. So 

I believe that we are addressing the multiple levels of the TBI. 

From a PTSD perspective, the VA was a prime mover in the diagnosis and the description of PTSD. As you probably know, it 

wasn’t in the medical lexicon until 1980. We have led the country 

in the treatment of PTSD and have our major center for TBI in 

White River Junction and is seen as a national, if not international, center of excellence for PTSD. 

So we are constantly looking at how we treat people. We are ex- panding our capability with mental health. We spend almost $3 billion, a lot of it on this. It was mentioned earlier about the money. 

As you know, there was an issue of $100 million that didn’t get 

spent last year and that was because we have challenges hiring 

people to do that and getting them to go to areas in the country 

that we would need the assistance. Having said that, we have hired 

in the last couple of years over 1,000 new mental health personnel, 

to include psychiatrists, psychologists, and social

workers. 

Senator CRAIG. My time is way over, so I will stop. 

One—two comments. I just pinned a Purple Heart on a young 

man the other night out at Walter Reed whose life was saved and 

may well live a full life because of that street capability in Baghdad today that we are delivering to our men and women in uniform. 

Secondarily, I understand that we are, at least in the private sector, working on a device that might go on each individual soldier’s 

uniform to detect and measure impact or concussion, the volume of 

impact that a person might receive during one of those events. Are 

you aware of that, and does that have potential to at least begin 

to measure the amount of impact that might relate to this kind of 

trauma? 

Dr. KUSSMAN. Yes, sir. I have heard about it, but I really don’t 

know enough to comment. But clearly, that is an important thing, 

because what we really need to do is identify the people who have 

experienced a blast and then identify them so we can track them 

when they come and there would be an identifier with that to make 

sure that they get special attention than just the average person 

we are screening for. 

Senator CRAIG. Thank you, Dr. Kussman. Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you, Senator Craig. 

Senator Murray? 

Senator MURRAY. Yes. Thank you. Dr. Kussman, I wanted to 

start by raising an issue that affects every single thing we do in 

the Senate for veterans. Many Members of Congress, myself included, are extremely wary today of the information that the VA 

provides to us. As you know, the VA has a track record of being 

72

less than honest with Congress. I know you remember well back 

in 2005 when the VA told us consistently they had all the money 

they needed, blocked an amendment three times on the floor that 

Senator Akaka and I worked on to provide VA with money, and 

learned later, of course, that the VA was indeed short $3 billion. 

Well, as I mentioned a few minutes ago when we were here, I 

was astonished by an article written by Chris Adams of the 

McClatchy newspaper, and I want to quote it, ‘‘the VA has habitually exaggerated the record of its medical system, inflating its 

achievements in ways that make it appear more successful than it 

is.’’ In the context of the information we receive from the VA that 

we are all very wary of, that raises a lot of red flags for me and 

I wanted to know if you had read that report and if you had a comment on it. 

Dr. KUSSMAN. Yes, Senator Murray. As you and I talked about 

when I had the privilege of talking to you in your office, I agree 

that we have to work very hard on getting our information clear, 

concise. One of my goals is to look at our access standards, look at 

our appointment schedules, and correct anything that is in there 

that is not accurate. 

As far as the McClatchy report, I appreciate that report because 

I take any criticism or corrections very seriously to look at what 

we are doing. I am very forthright and honest about what I do and 

so I was actually—there were comments in there by the reporter 

that were very positive, as well, that the VA has transformed itself, 

is identified as a leader in health care. I think that there were correct issues that he raised of things that need to be articulated better and we are committed to do that. 

Senator MURRAY. I hope that part of your commitment is to give 

us a picture of reality, not of one that you just want to have us. 

Dr. KUSSMAN. I don’t believe in fantasies and I guarantee you 

that I will give you the best information that I know. 

Senator MURRAY. OK. I wanted to ask you also about this issue 

of bonuses. I am sure you are well aware of the issue. When you 

were acting VHA head, millions of dollars in bonuses were granted 

to senior managers, particularly those based here in Washington, 

DC. I know there are good reasons to do bonuses, but I was also 

perturbed yesterday to read a report by the Associated Press that 

says that 21 of 32 VA officials who sat on the board responsible for 

performance reviews and bonuses received more than half-amillion dollars in payments themselves. Would you comment on 

that? 

Dr. KUSSMAN. I don’t know specifically what the 21 were or 

which ones that the reporter is alluding to. I can just tell you, Senator, that to the best of my knowledge, our bonus process that is 

based on performance is consistent with what OMB’s policies are. 

I believe that the Secretary, because of this latest situation, has 

asked—I said OMB, I meant OPM—has asked OPM to come and 

look at our process to assure that we are doing the right things. 

Senator MURRAY. Does the VA’s Performance Review Board include any outside observers today? 

Dr. KUSSMAN. Outside the VA? I would have to go back and look. 

I don’t think so. 

Senator MURRAY. OK. Do you think that it should? 

73

Dr. KUSSMAN. I would have to look at that. 

Senator MURRAY. If you could get a response back to me, I would 

appreciate that. 

I also wanted to ask you about the VA budget shortfall that occurred back in 2005 because, as you know, the VA relied on 2002 

data to forecast medical expenditures and wound up $3 billion 

short. I was met by opposition from the VA every step of the way 

as we worked to try and deal with what we knew from the ground 

out there was a shortfall, and in fact, Secretary Nicholson wrote a 

letter to Senator Hutchison that denied at the time that VA needed 

any more money, right before they came back around and said they 

were indeed $3 billion short. 

You were VA’s number two medical leader at the time. Can you 

describe to this Committee any involvement that you had in that 

budget shortfall? 

Dr. KUSSMAN. I wasn’t directly involved in the development of 

the budget. Clearly, there were things that happened that were 

mistakes. We have tried to learn from that. As you know when we 

talked, I am now directly involved in the budget. The recommendation for 2008 was the first year that I had spent a lot of time and 

was directly involved in the development. I believe it is a good 

budget. It has things that are not in it that potentially were in 

there before. I believe that we have worked——

Senator MURRAY. Your VA request or what the Senate actually 

has included, which is about——

Dr. KUSSMAN. No, the VA request for 2008. 

Senator MURRAY. Well, I assume that you believe that the budget that the Senate passed with $3.5 billion would better serve the 

needs of the veterans than the request. 

Dr. KUSSMAN. We are very appreciative of dollars and we are a 

large agency and we will spend it on the best care of veterans. 

Senator MURRAY. Well, let me ask you a more specific question. 

Were you involved in any way with the writing of the letter by Secretary Nicholson that was sent to Senator Hutchison in April of 

2005? 

Dr. KUSSMAN. Not that I recall. 

Senator MURRAY. Let me ask you one other question. The Washington Post recently reported about high-level political meetings between White House officials and senior agency officials across the 

Federal Government, including the VA, and at one of those hearings, the Administrator of GSA asked how she could ‘‘help our candidates.’’ Those meetings raised a lot of serious concerns about possible violations of Hatch Act, which prohibit the use, as you know, 

of Federal funds for partisan political purposes, and they call into 

question the possibility of undue political influence at the VA, as 

well. Have you, Dr. Kussman, or anyone you know at the VA ever 

received a briefing or briefings from the White House that were political in nature? 

Dr. KUSSMAN. No, ma’am. 

Senator MURRAY. None? 

Dr. KUSSMAN. Not—I haven’t, or I don’t know of anybody who 

has. 

Senator MURRAY. And never heard of them, never been in a 

meeting—

74

Dr. KUSSMAN. I am not aware of that happening. 

Senator MURRAY. All right. As you heard me talk about in my 

opening statement, we are all pretty cautious about information we 

receive from the VA and I am really looking to find somebody in 

this position that we can trust, that will bring about a culture of 

change, that won’t just paint the happy-dappy picture but will actually tell us the reality, because we have a responsibility to make 

sure that those men and women who serve us have what they 

need. And if we are not getting accurate information, if we are 

being told a happy picture and not getting the reality, then we are 

not doing our jobs accurately, either, and it reflects on the performance of every one of us. How can you assure us that your going into 

this position will change that culture and really bring about a better, trustworthy, more honest information to this Committee so we 

can do the job we need to do? 

Dr. KUSSMAN. I am not sure how I can convince you other than 

to tell you that that is not my character. That is what I do. You 

and I have talked about this before. I am committed to working 

with you to correct any deficiencies or inaccuracies that we have. 

That is what I do. That is my passion. 

Senator MURRAY. Thank you, Dr. Kussman. 

Chairman AKAKA. Senator Burr? 

STATEMENT OF HON. RICHARD BURR,

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Thank you, Mr. Chairman. I am at a distinct disadvantage because I don’t read newspapers as widely as others. My 

fear is that if I read the articles about myself, it would probably 

lead me into the bathroom to slit my wrist if I believed everything 

that is in it. 

Mr. Chairman, I want to thank the Administration because they 

have, in my estimation, sent us a man that is incredibly qualified, 

unbelievably experienced, to take on, I think, one of the most difficult tasks that we could ask a nominee to do, not only to go into 

an agency that has a challenged background and shown tremendous progress, but one that is getting ready to go through a decade 

of significant challenges that I think most of us can predict exactly 

what those challenges will be like. 

I want to thank you, Dr. Kussman, for your willingness to do 

this. I want to thank the groups who were willing to publicly come 

in and support this nomination. 

Mr. Chairman, Dr. Kussman have had an opportunity to sit 

down and we have talked about every issue that I thought was relevant to hear from a nominee. We have explored the outpatient 

challenges of antiquated facilities with the full understanding that 

I have and that he has is that we can’t go out and build new hospitals everywhere we have got veterans. If we could do that, the 

delivery of care would be seamless. We wouldn’t have the physical 

challenges of somebody having to go from an outpatient entry point 

to a third-floor back room where we are now doing endoscopies because that is the only spot we have got. The reality is that we consistently make changes based upon the available funds. I want to 

thank you for working with the limitations, but also for giving me 

75

hope that we have got a vision of where we need to get from a 

standpoint of our VA facility. 

I have talked to him about the challenges of PTSD and 

polytrauma and how that is the makeup of the service personnel 

that we are going to see. It is significantly different from what we 

have seen. 

Mr. Chairman, I believe every nominee deserves to have a champion on the Hill. Maybe by default, I will be Dr. Kussman’s, and 

I want to explain to you why. It is because after I got through 

meeting with him, I left the room believing he gets it. He understands what this job is all about. For a Member that is involved 

about 60 percent of my time in health care on the private sector 

side, and just because of the nature of this Committee pulled into 

it from a committee jurisdiction, there are a lot of people in health 

care today that don’t get it. 

And not only does he get the health care piece, he gets the veterans’ piece. He gets the fact that these, in some cases kids, in 

some cases parents, in some cases friends, made a hell of a commitment for us and that we have an obligation to provide the best 

level and delivery of care that we can possibly do and that we can’t 

be shaded by the challenges that it presents to us, we can’t complain that every one of them is different. We have got to learn how 

to deal with it and to do it successfully. 

So I look at some of the issues that have been raised about this 

nomination. They have expressed that the VA is a bad system. 

Well, you know, we have beat that horse, and it is not perfect, but 

you know, when Business Week magazine did an article last summer on it, they said, you know, this is the best performing hospital 

system in the country. It far exceeds the two that I have got in 

Winston-Salem or the multiple systems that I have got in North 

Carolina, and most believe that our State has one of the best delivery systems in the country. 

The second belief was that Dr. Kussman’s service as co-chair of 

the DOD Seamless Transition Task Force, that in those focus 

groups, maybe somehow you should have known that Walter Reed 

had problems, since they were held at Walter Reed. As a matter 

of fact, the article was done by salon.com. Now, I am not—I don’t 

read salon.com, but I don’t necessary look to them for the cuttingedge news that happens day to day. And I am sure that it sells 

magazines to come to conclusions that people want to find something that is in the realm of ‘‘gotcha’’ because this is a town of 

‘‘gotcha,’’ but the reality is that if you should have known because 

you did it, Congress should have known. 

So if we are blaming you, we should be blaming ourselves and 

we probably should have blamed ourselves before we blamed anybody else, even the folks that were in charge of Walter Reed because this type of thing shouldn’t happen, and ultimately, when we 

are involved with sign-offs of our leadership, we put a tremendous 

amount of responsibility on them, but that also requires us to do 

a degree of oversight. I want you to know, we are going to do our 

oversight. I think you expect us to do our oversight and we are 

going to continue to do that.

76

We discussed the seamless transition from DOD to the veterans. 

I think that what is important with Dr. Kussman is he has, one, 

acknowledged the problem. Two, he has a desire to change. Three, 

he has a plan to transition. 

Now, DOD has to play a very, very important role in this and 

a commitment to technology and a commitment to the sharing of 

records. I can only speak from my conversation with Dr. Kussman, 

Mr. Chairman. He is more than willing to pick up the VA’s side 

of that transition. Unfortunately, we don’t have the jurisdiction 

over DOD about their willingness, but I am personally going to 

stay on the appropriate Committee Members to make sure that 

DOD, in fact, is a willing partner, but a willing partner at the level 

of commitment that I think Dr. Kussman and the VA is. 

Lastly, I want to end where I started. Dr. Kussman gets it. His 

focus is on veterans. It is on our children, our parents, our friends, 

and making sure that the commitment that we all made as a country to our veterans is to provide them with the best possible delivery of care for the rest of their lives. I, for one, believe that this 

is the man for whatever number of years he might be there can do 

an exemplary job at representing our best choice as the Medical Director at the VA. 

So I have no questions, Mr. Chairman, but I look forward to a 

speedy conclusion to his nomination. I thank the Chair. 

Chairman AKAKA. Thank you very much, Senator Burr, and I 

thank you so much for your comments about our nominee and look 

forward with you in trying to move it as quickly as we can. 

Dr. Kussman, if you are confirmed, the mental health needs of 

the returning servicemembers will rightly dominate so much of 

your agenda. Dr. Frese previously testified that the outside advisory body on mental health, which has been so vibrant, now seems 

dormant. As we know, the demand for care for invisible wounds 

continues to grow, and you have mentioned that. I note that if the 

supplemental is enacted, funding should not be a problem. What do 

you plan to do to improve mental health care? 

Dr. KUSSMAN. Mr. Chairman, if it is dormant, it won’t be dormant for long, so we will certainly go back and look at the comments that were made. 

Mental health—we are the largest provider of mental health service in the country. As I mentioned, we spend close to $3 billion 

a year and we will spend more now with your help. That does not 

include the Vet Centers, the readjustment counseling. That is a 

separate funding line. We are increasing that. That is critically important to us, led by Al Batres, who is one of my heroes. And we 

are increasing now—by next year, we will have 232 Vet Centers 

around the country. We are putting PTSD treatment teams in all 

our facilities and other groups of people even out into the CBOCs 

to be sure that mental health is available. 

What we need to do is looking—and I will extrapolate a little bit 

with my comments—besides PTSD is the issue of suicide and other 

things that are relevant to this age group. We have educated all 

our people about suicide. We have put suicide counselors in every 

facility. We are putting together a 24-hour suicide hotline. And 

working together, we want people who have a mental health issue 

to be seen right away, not have to wait any period of time, and the 

77

goal is that we will try to get people in within 24 hours to be assessed if they come for a mental health issue. 

We have some challenges of getting the resources where they 

need to be, but those are challenges that actually exist in the civilian community, as well, because there aren’t any resources out 

there. But I am committed to providing the world-class mental 

health care, PTSD and otherwise, for all our veterans. We will

either do it inside or we will buy it. 

Chairman AKAKA. Well, I have also heard, Dr. Kussman, concerns but have seen nothing official about changes to the readjustment counseling service. Are there plans to merge readjustment 

counseling service with VA health care? 

Dr. KUSSMAN. No. 

Chairman AKAKA. The law is that if a Vet Center is to be moved, 

the Veterans’ Affairs Committees must receive official notification 

of that fact, and I mention this because I understand that a Vet 

Center in Chicago may be moved. Please make sure that we have 

the appropriate notice. 

Dr. Kussman, in your response to my pre-hearing questions, you 

expressed your view that the VA health care system has become 

too decentralized as a result of its division into regional networks. 

You also indicated that this decentralization is a detriment to ensuring appropriate consistency and standardization. Will you 

please explain what your plans are for improving standardization 

of care through increased centralization? 

Dr. KUSSMAN. I believe any organization, particularly one that 

went through the tectonic shifts of the mid-1990s when we developed the VISN structure, has to continue to assess itself. Just parenthetically, we recently had a summit meeting last month to look 

at the 10–year evolvement of the VA from the mid-1996 and the 

millennium changes that took place and one of the things that we 

were talking about is as the pendulum shifts, there has always 

been in health care delivery or other agencies this constant balancing of centralization and peripheralization, establishing policies, 

procedures, and standards and then allowing people to implement 

those policies and standards. Health care is local. 

So I believe that—my personal opinion is that potentially the 

pendulum has swung a little too far. It needs to be looked at and 

brought back toward the center, and I think that will help standardization and consistency. That is part of my second issue of leadership, that we need consistence and standard. A veteran should 

have the same care and the same advantages whether they are in 

Maine or Manila and that at times, when you go around the system, sometimes you don’t find that. So that is one of the things 

that is a very important issue for me. 

Chairman AKAKA. VA TBI care, mental health care, and prosthetics have each been criticized in recent months for not being the 

best. My goal is to ensure that VA care of all kinds, especially care 

for war traumas, should be the best. How do you answer those who 

wish to contract out most VA care?

78

Dr. KUSSMAN. First of all, Mr. Chairman, let me say that I have 

the same passion you do. It has got to be the best. Shame on us 

if we don’t do that. I believe that with our TBI care, it is the best. 

Sometimes it may not appear that way to some patients. What I 

have initiated is a process where anybody who is unhappy or is 

concerned about the quality of care, we automatically get a second 

opinion from a reputable civilian agency to come in and look at it. 

I want that done for two reasons. One is if, God forbid, we are 

not doing the right thing, then we need to know about it and fix 

it. If we are doing the right thing, at least we owe it to the veteran 

and their families to tell them. But if they still want to go someplace else because they think that the care would be better, there 

are options to do that. 

I think in mental health, we are doing the same thing, and as 

I mentioned earlier, our outreach and money put against mental 

health. I will be the first one to acknowledge, when you mentioned 

prosthetics, early on in the war, we had some challenges. We do 

a lot of prosthetic work, as you know, and we probably do more amputations than any other health care system in the country. It is 

over 5,000 a year. But they tend to be more vascular and geriatrics, 

not anywhere near what this new generation of veterans needs. 

They want to go rock climbing and kayaking and play hockey and 

things. Being asked whether you can get off the floor is seen as an 

insult. There were instances like that early on. 

We have changed. We have sent our prosthetists and our people 

to Walter Reed and Bethesda and Brooke to train them and get 

them up to the same level. So we will buy anything for anybody 

for whatever they need. One of the issues is that sometimes there 

is experimental stuff with prosthetics going on at Walter Reed and 

that is the only place you can get it. We would obviously encourage 

people to go back there. 

But as far as outsourcing the care in the generality of things, I 

would be concerned. I think that we need to partner with the civilian community to get care as appropriate and we are looking at 

that. But one of the strengths that we have by keeping people in 

our system is to assure the quality, the integration, and the continuity of care with our electronic health record and things. So I 

think that we do need to partner with the civilian community, but 

to make it a common practice that would be of concern to me. 

Chairman AKAKA. Well, we also hear that the Brooke Army Medical Center is a premier rehabilitation facility for war injuries, and 

I am so glad you did mention about prosthetics and how far we 

have advanced on that and continue to do that. I look forward to 

see what you can do in keeping this operating. 

I really appreciate your responses, Dr. Kussman, and also your 

patience and your family’s, as well, and all those who are here. 

So in closing, I again thank all of our witnesses for being here 

today. We could not have had a truly informed hearing without 

your insight and your perspectives. I also want to again thank Dr. 

Kussman’s family for their presence here today. 

As you all know, every organization needs an unquestioned leader. It is not optimal for the Veterans Health Administration to 

have an acting leader for an indefinite period of time. With this in 

mind, I will work, I want to tell you, I will work to move Dr. 

79

Kussman’s nomination prior to our adjournment for Memorial Day 

recess, but we will see. 

I want to again say mahalo, thank you, and aloha to all of you. 

This hearing is adjourned. 

Dr. KUSSMAN. Mahalo, Mr. Chairman. Thank you. 

[Whereupon, at 12:38 p.m., the Committee was adjourned.] 

(81)

A P P E N D I X 

PREPARED STATEMENT OF HON. BERNARD SANDERS,

U.S. SENATOR FROM VERMONT

Thank you Mr. Chairman and thank you for holding this important hearing. I 

want to welcome Dr. Kussman and his family as well as the other witnesses we 

have with us today. Thank you for being here to share your views. 

Mr. Chairman, I don’t have to tell you that today’s VA faces enormous challenges. 

We have a backlog of over 400,000 claims waiting to be processed. 

We have the VA reportedly paying $3.8 million in bonuses to its employees while 

veterans are on waiting lists all across this country and Category 8 veterans are 

not allowed in at all. Some of those receiving bonuses are the very same people that 

were responsible for the over $3 billion VA budget short fall in 2005 as well as gaming the VA claims system so that it looked like claims were being processed faster 

than they were. 

We have the Institute of Medicine and National Research Council reporting on 

May 8th of this year that ‘‘[a] surge in the number of disability claims for PTSD 

has revealed inconsistencies in compensation levels awarded across the country, 

raising questions about the effectiveness of the VA’s current ways of assessing and 

rating this condition, and whether some veterans are getting payments that are too 

low, too high, or unmerited . . . It urged the VA to base compensation decisions 

on how greatly PTSD affects all aspects of a veteran’s daily life, not just his or her 

ability to be gainfully employed.’’

Reuters reports that ‘‘the Department of Veterans Affairs estimates 12 percent to 

20 percent of those who served in Iraq suffer from PTSD. A 2004 Army study found 

16.6 percent of those returning from combat tested positive for the disorder.’’

We have USA Today reporting on May 3 that ‘‘from 125,000 to 150,000 U.S. 

troops may have suffered mild, moderate or severe brain injuries in Iraq and Afghanistan.’’ As many note, that is a number far higher than what the official casualty figures of 26,000 tell us. 

The Associated Press reports that the Defense Department’s Task Force on Mental Health tells us in its study that it ‘‘found 38 percent of Soldiers and 31 percent 

of Marines report psychological concerns such as traumatic brain injury and posttraumatic stress disorder after returning from deployment... Among members of 

the National Guard, the figure is much higher—49 percent—with numbers expected 

to grow because of repeated deployments.’’

Army Times tells us ‘‘Suicides are up among combat vets, mental health issues 

are worse among those who deploy often and for longer periods, . . . ’’

For example the Army Times explained that Marine Commandant General James 

Conway of the military’s Mental Health Advisory Team recently reported: 

‘‘Soldiers and Marines who have faced the most combat situations, deployed for 

longer periods of time, and deployed more than once face more mental health issues, 

according to a survey of 1,320 soldiers and 447 Marines. Of those on a second, third 

or fourth deployment, 27 percent screened positive for mental health issues, compared to 17 percent of first-time deployers. And 22 percent of those in-theater for 

6 months or more screened positive for mental health issues, compared to 15 percent of those who had been there fewer than 6 months.’’

The list goes on and on, Mr. Chairman. 

My question today is does the VA, does Dr. Kussman recognize the challenges 

that the VA is up against? Will they stop all the stonewalling and the games with 

requesting low amounts of funding for the VA and work with the Congress to provide the services and benefits that our veterans need in a timely manner? We need 

a partner that will work us, not tell us that ‘‘we have it all taken care of.’’

The VA is filled with wonderful and dedicated employees, there is no doubt about 

that and they give great care to many veterans once they get into the system. 

82

But for too many the VA is a bureaucratic organization where red tape is the 

norm. As many have said, the VA needs to be an advocate for the veteran not an 

adversary. 

We have a lot of work to do, Mr. Chairman, and I look forward to hearing from 

our witnesses today about Dr. Kussman’s ability to meet these challenges. 

Thank you, Mr. Chairman. 

U.S. SENATE, 

Washington, DC, May 14, 2007. 

Hon. Daniel K. Akaka, 

Chairman, Committee on Veterans’ Affairs, 

U.S. Senate Washington, DC. 

DEAR MR. CHAIRMAN: It is my understanding the nomination of Dr. Michael 

Kussman to become the Under Secretary for Health in Department of Veterans Affairs is scheduled for May 16, 2007. Dr. Kussman is also a retired Brigadier General, U.S. Army (Ret.). He has an extremely impressive 10 page Curriculum Vitae 

which I have attached. In my view, he will make an outstanding Under Secretary 

for this vital function. I urge your support for his nomination. 

Aloha, 

DANIEL K. INOUYE, 

United States Senator.

Æ