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[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

                 DISCOVERING A MORE EFFICIENT PROCESS:
                  IMPROVING TIMELINESS AND ADEQUACY OF
                VA COMPENSATION AND PENSION EXAMINATIONS

=======================================================================

                             FIELD HEARING

                               before the

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 23, 2012

                               __________

                    FIELD HEARING IN TOMS RIVER, NJ

                               __________

                           Serial No. 112-58

                               __________

       Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                _____

                  U.S. GOVERNMENT PRINTING OFFICE

74-177                    WASHINGTON : 2012
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York

            Helen W. Tolar, Staff Director and Chief Counsel

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                    JON RUNYAN, New Jersey, Chairman

DOUG LAMBORN, Colorado               JERRY McNERNEY, California, 
ANN MARIE BUERKLE, New York          Ranking
MARLIN A. STUTZMAN, Indiana          JOHN BARROW, Georgia
ROBERT L. TURNER, New York           MICHAEL H. MICHAUD, Maine
                                     TIMOTHY J. WALZ, Minnesota

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                             April 23, 2012

                                                                   Page
Discovering a More Efficient Process: Improving Timeliness and 
  Adequacy of VA Compensation and Pension Examinations...........     1

                           OPENING STATEMENTS

Chairman Jon Runyan..............................................     1
    Prepared statement of Chairman Runyan........................    31
Hon. Timothy J. Walz, Democratic Member..........................     3

                               WITNESSES

Colonel Mike Warner, USA (Ret.), Chair, New Jersey Governor's 
  Council For Military and Veterans Affairs......................     5
    Prepared statement of Colonel Warner.........................    32
Mr. John Dorrity, Director, Ocean County Veterans Services.......     7
    Prepared statement of Mr. Dorrity............................    33
Mr. Gene O'Grady, The American Legion, Department Vice Commander.    10
    Prepared statement of Mr. O'Grady............................    34
Mr. Walter J. Tafe, Director, Burlington County Military and 
  Veterans Services..............................................    11
    Prepared statement of Mr. Tafe...............................    35
Mr. Michael E. Moreland, FACHE, Director, Veterans Integrated 
  Service Network 4 Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    21
    Prepared statement of Mr. Moreland...........................    36

Accompanied By:

Joseph Dalpiaz, Director of the Philadelphia VA Medical Center...    36
Robert McKenrick, Director of the Philadelphia VA Regional Office    36

 
                 DISCOVERING A MORE EFFICIENT PROCESS:
                  IMPROVING TIMELINESS AND ADEQUACY OF
                VA COMPENSATION AND PENSION EXAMINATIONS

                              ----------                              

                         MONDAY, APRIL 23, 2012

         U.S. House of Representatives,    
            Committee on Veterans' Affairs,
                         Subcommittee on Disability
                           Assistance and Memorial Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 11:19 a.m., at 
Ocean County College Auditorium, 1 College Drive, Toms River, 
New Jersey, Hon. Jon Runyan [Chairman of the Subcommittee] 
presiding.
    Present: Representatives Runyan and Walz.
    Dr. McGinty. I'm Dr. Jim McGinty, Executive Vice President 
of Ocean County College. And on behalf of the college 
president, Dr. Jon Larson, the Board of Trustees, the faculty, 
staff and students, it is my pleasure to welcome you to our 
beautiful and ever-expanding campus.
    We are very pleased we have been selected to act as the 
site for this morning's field hearing on Veterans Affairs.
    Before I turn to the podium, I would like to thank 
Congressman Jon Runyan for being here today. As a member of the 
House Committee on Veterans' Affairs and Chairman of the 
Subcommittee on Disability Assistance and Memorial Affairs, 
Congressman Runyan is most generously donating his time and his 
talents to listen to and ultimately to understand the many 
different issues that affect our veterans.
    I hope you enjoy the use of our facility in the Arts and 
Community Center and that you find today's field hearing both 
informative and productive. Thank you.
    Mr. Runyan. Thank you very much, Jim.

   OPENING STATEMENT OF CHAIRMAN JON RUNYAN, SUBCOMMITTEE ON 
           DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

    With that being said, good morning. Usually when we hold 
our DAMA Subcommittee hearings, we are sitting in Washington. 
Today I am honored and happy to be here at Ocean County 
College, in my home district.
    While we are far away from our national hearing room on the 
Hill and away from the C-SPAN cameras, this is still an 
official congressional oversight hearing of the House Veterans' 
Affairs Committee, and the hearing rules and hearing conduct 
apply in this venue. Therefore, I would respectfully ask that 
everyone be courteous to our witnesses and remain silent until 
the hearing is formally adjourned.
    In chairing the Subcommittee on Disability Assistance and 
Memorial Affairs, I have had the opportunity to work on the 
complicated issues surrounding the veterans benefit system, 
including the compensation and pension process. Through this 
experience, I have had the pleasure of working alongside my 
good friend, the Honorable Timothy Walz, who represents 
Minnesota's 1st Congressional District. I am happy to introduce 
him to you today and welcome him to Toms River.
    As many of you know, New Jersey has the 18th largest 
veteran population in the U.S. Over 60,000 veterans call the 
3rd Congressional District of New Jersey home. As many of you 
know, our district is home to the largest disabled veterans 
population in New Jersey, all of whom have sacrificed greatly 
for our Nation.
    We are also fortunate to be home to the Joint Base McGuire 
Dix Lakehurst. This installation is critical and related to 
veterans affairs.
    As we wind down two overseas conflicts, our military 
population will soon begin the process of transitioning to our 
veteran population. This transition will inevitably add 
additional stress to a process we are here today to discuss, 
examining the VA compensation and pension exam system. By 
bringing together all parties here today, from local veterans 
here in New Jersey to the VA itself, our objective is to make 
the process more efficient and ultimately to serve the needs of 
our veterans as best as we can.
    As I am sure all of you are aware, the C&P examinations are 
a major cause of delay in the VA claims adjudication process. 
My office has been following a host of problems dealing with 
the issues in the district and around the country. So we are 
here today to examine this problem, not from afar in 
Washington, D.C. but from right here in Ocean County, where so 
many veterans call home and who are affected by these delays.
    Currently, veterans in the southern counties of New Jersey 
receive C&P examinations through the Wilmington, Delaware or 
the Philadelphia VAMCs. All examinations at the Wilmington VAMC 
are conducted by VA staff. As best as we have been able to 
discern, VA relies too much on C&P examinations. Often there is 
sufficient medical evidence in the claims file alone to rate a 
disability based on VA and private treatment records.
    By unburdening the VA with all this current over-emphasis 
on C&P exams, the process should become more efficient. Also, 
greater access to exams could materialize. Based on these 
observations, I believe we can have these solutions moving 
forward.
    Before jumping ahead to what I believe are some solid 
solutions to these problems, I would like to welcome our 
witnesses here today who will be speaking in detail on ways to 
improve the system. It is my hope that through our mutual 
efforts, we can make the difference needed to increase access 
to C&P exams and unburden the claims process and make our lives 
and our veterans' lives easier.
    Again, I am delighted to be here with you today. I will now 
yield to the distinguished gentleman from Minnesota, my good 
friend, the Honorable Tim Walz.

  OPENING STATEMENT OF HON. TIMOTHY J. WALZ, DEMOCRATIC MEMBER

    Mr. Walz. Good morning, everyone. Thank you, and thank you, 
Chairman Runyan, for the invitation to this beautiful district 
and this beautiful facility. Thank you to our host here for 
putting this on. A special thank you to the majority and 
minority staffs for continuing to work to serve our veterans in 
a most professional manner. And a special thank you to all of 
you who took time out of a busy day, other things you could be 
doing. You chose to be here for one simple reason: you 
understand that this country's promise to our veterans is 
sacred, and to make sure that it is followed through with is 
not only our moral responsibility, it is our national security 
responsibility to prove to coming generations that if you 
choose to serve this Nation, this Nation will serve you and 
will do right by you.
    I have to tell you that serving on this committee is one of 
the greatest honors that I have ever been given. I spent 24 
years in the military myself, and I always tell a little story 
that is true. I went down to Walter Reed and was visiting a 
Marine, and they said this is Congressman Walz, he is a retired 
Command Sergeant Major. And a Marine said, oh, I'm really sorry 
about that. I thought he was talking to the Army guy. He said, 
no, I'm sorry you took the demotion to Congress there.
    [Laughter.]
    Mr. Walz. The fact of the matter is, though, that the 
service provided by this committee--and I will have to tell 
you, seeing a new congressman come in, and your congressman, 
Jon Runyan, he chose and asked to be on the VA Committee, and 
to be quite honest with you, not a lot of people do because it 
is a lot of hard work, and Jon is trying to get it right. He 
chose to be there, and since day one has decided that first and 
foremost the care of our veterans trumps everything else.
    So it is an honor for me to be here with him. It is an 
honor, and I think if you would see this, the Chairman 
mentioned there are no C-SPAN cameras. I wish they were on in 
the VA Committee more often. I think what you would see is the 
America that you think it could be, the idea of working 
together for a common goal of understanding that we have 
precious resources and it is right to deliver them in the most 
targeted, effective manner.
    I always say this to our friends from the VA. I am your 
staunchest supporter, but I will be your harshest critic, 
because if one veteran falls through the crack, it is one too 
many.
    This is a zero-sum proposition, and having these hearings, 
I cannot tell you, this is where the work is done. When you 
have someone, Chairman Runyan, and all the members of that 
committee, they are not there for the cameras. They sit there 
through the long hearings and learn the issues.
    And to the witnesses coming here, I come from a little 
different area. My district is Southern Minnesota. It is the 
whole northern tier of Iowa. My district starts right outside 
Sioux Falls, South Dakota and runs over to the Mississippi 
River in Wisconsin. It holds some of the most fertile farming 
land. We are the second-leading producer of hogs, corn, 
soybeans and turkeys, and we are also home to SAM, which I know 
you are so proud of, as we are. We are also home to the Mayo 
Clinic.
    With that being said, the diversity that is out there and 
the differences when I come to New Jersey, yes, you can see 
geographic differences, but I can tell you there are no 
cultural differences. We have some of the most patriotic 
people, just like you do, and young people willing to serve 
their nation, and we understand that the challenges of getting 
them care--and Mr. Runyan has been fabulous about talking about 
this.
    I said today, the teacher and the sergeant major in me, I 
hate to be late for anything, but you actually have stop lights 
out here, and we can turn left in Minnesota, by the way, to get 
to places, which is something a little different. But there is 
absolutely no difference culturally in the care of our 
veterans. So when these problems arise, I think you would see a 
sense of pride in what can be done, of working together, of 
trying to listen to the issues and come up with working 
solutions.
    And I will tell the witnesses before we get started that we 
are here to hear from you. That is the important part. We did 
one of these out in Minnesota back in 2007, and literally in 
the shadow of the Mayo Clinic, and we provided evidence, and at 
that time then sitting Chairman Filner received evidence, 
scientific evidence on the correlation between exposure to 
Agent Orange and Parkinson's disease. We had a cluster of six 
individuals out there who came together with no commonality in 
their lives, middle-aged men about 55 to 60 years old, all of 
them developing Parkinson's. Their commonality was their 
service to their country in Vietnam.
    And through that field hearing, and through that start as 
it moved up in a bipartisan manner, we added Parkinson's as a 
presumptive disorder of exposure to Agent Orange, along with 
ischemic heart disease and some others. That is the way it 
should be done.
    So thank you for having me here today. Thank you for each 
of you working to do better by our veterans and by our country, 
and I am proud to be here with my friend, who has done a great 
job of leading our Subcommittee on this and is moving things 
forward, Mr. Runyan.
    So with that, I yield back.
    Mr. Runyan. Thank you, Mr. Walz.
    And with that, I wanted to--we will do an introduction and 
official titles of the witness panel and begin with their 
testimony.
    So first we are going to be joined by Colonel Mike Warner, 
who is the Chair for the New Jersey Governor's Council for 
Military and Veterans Affairs.
    Then we will hear from Mr. John Dorrity, the Director of 
Ocean County Veterans Services.
    We will also hear from Mr. Gene O'Grady, Department Vice 
Commander for the American Legion.
    And finally, we will hear from Mr. Walter Tafe, the 
Director of the Burlington County Military and Veterans 
Services.
    Each of you will have 5 minutes to summarize your 
testimony. Your full written statement will be made part of the 
hearing record.
    With that being said, Colonel Warner, we will begin with 
you, with your oral testimony.

STATEMENTS OF COLONEL MIKE WARNER, CHAIR, NEW JERSEY GOVERNOR'S 
   COUNCIL FOR MILITARY AND VETERANS AFFAIRS; JOHN DORRITY, 
    DIRECTOR, OCEAN COUNTY VETERANS SERVICES; GENE O'GRADY, 
 DEPARTMENT VICE COMMANDER, THE AMERICAN LEGION; AND WALTER J. 
    TAFE, DIRECTOR, BURLINGTON COUNTY MILITARY AND VETERANS 
                            SERVICES

                    STATEMENT OF MIKE WARNER

    Colonel Warner. Thank you, Congressman Runyan and 
Congressman Walz. Thank you for the opportunity to testify on 
important issues pertaining to our country's veterans. My name 
is Michael Warner. I am a retired Army officer and service-
connected disabled veteran. My last assignment was commander at 
Fort Dix, New Jersey. Upon my retirement, I was appointed by 
Governor Whitman to the position of Deputy Commissioner for 
Veterans Affairs for the State of New Jersey. In that capacity 
I had the privilege to serve the veterans of New Jersey and 
manage the state's veterans programs. Those programs included 
the management of the largest state veterans cemetery in the 
United States, operations at three nursing homes, and oversight 
of New Jersey's veterans benefits programs, assisting veterans 
in the filing of their disability claims.
    I would like to comment on a couple of areas that are of 
direct concern to the Subcommittee. First, while it may not be 
particular to this particular hearing, I would like to comment 
in the area of the state veterans cemetery.
    I strongly encourage the Congress to authorize an increase 
in burial allowance for veterans in order to offset the 
increasing costs associated with the burial of veterans and the 
operations of the state veterans cemetery program.
    Similarly, I believe that it is important to authorize a 
burial allowance for the spouses of veterans interred at the 
state veterans cemetery. The U.S. Department of Veterans 
Affairs cemeteries and Arlington Cemetery inter spouses at no 
cost to the veteran. New Jersey provides for the burial of 
spouses at no cost to the veteran. However, the state veteran's 
family members interred at the state veteran cemeteries should 
receive the same consideration as the veteran family members 
interred at our national cemeteries.
    I would also testify that spouses of veterans are as much 
veterans of the military service as their servicemember. The 
family members serve by ensuring that the veteran can do his or 
her duty with the confidence that their family is being held 
together by the strong and capable hands of their spouses, many 
times on multiple separations for long periods of time.
    The other area I would like to comment on is the claims 
process, and specifically the accessibility of the C&P 
examination to the examiners. I believe that the process of 
conducting the C&P examination needs to be reevaluated. 
Currently, veterans are required to travel to their VA medical 
center to meet with the VA medical personnel and their C&P 
examination. For this area in South Jersey, that requires the 
veteran to travel to Philadelphia, Newark, New Jersey, or 
Wilmington, Delaware for their examination. This poses a 
hardship on many of our veterans, particularly our older 
veterans and their care providers.
    I believe that many of these examinations and interviews 
could be conducted at the community-based outreach clinics via 
teleconference or other methods, or by having the C&P examiners 
come to the CBOC. While the requirement to travel to the 
medical center may not be entirely eliminated, this approach 
would reduce the number of visits to the medical center that 
the veteran would be required to undertake. Bringing the C&P 
examiners and other professionals to the CBOC would be in 
keeping with the concept of bringing the VA to the veterans as 
much as possible, as opposed to requiring the veterans to 
travel to the medical centers for all services. It is not any 
more difficult to schedule a veteran for a visit to the CBOC 
than it is to schedule a veteran to a medical center for a 
visit. Frankly, it would also be good for the C&P personnel to 
get out of the VA medical centers and see veterans in their 
community.
    The process of claims also seems to be a never-ending 
problem no matter how hard we work to fix it. I have been 
dealing with this since I was the deputy commissioner in 1992. 
The process of claims has been an issue to veterans even before 
I was responsible for the state's program to assist veterans in 
filing their claims. In fact, there is a great article on the 
backlog of claims, almost 600,000, in the Friday edition of the 
National Journal. According to that edition, as I said, the 
backlog of claims is in excess of 600,000.
    I believe that one of the ways to reduce the time it takes 
to process veterans claims is to sort claims by difficulty and 
the number of primary conditions the veterans claim. For 
example, if claims with one primary condition were developed 
and submitted, the process of review would be very simple. The 
claims officer would only be required to review the 214, review 
the veteran's doctors' information, and then determine if the 
veteran's condition met one of the 15 presumptive conditions. 
If so, then approve the claim and determine the level of 
compensation.
    For example, if the veteran served in Vietnam and his 
physician has documented prostate cancer, he should be rewarded 
compensation without a full C&P review. Every veteran who 
served their country is presumed to have been exposed to Agent 
Orange. If the veteran later develops prostate cancer, it is 
presumed that the cancer is a result of the service in theater. 
There should be no need to drag out the process any longer 
unless there are other secondary conditions that have been 
claimed at some point. We need to trust the veteran and their 
physicians to not have to reexamine everything.
    In summary, the claims process would be significantly 
reduced for claims that had one primary condition and that 
condition is one of the 15 presumptive conditions. If these 
claims were assigned to one office and not mixed in with more 
difficult claims, they would be adjudicated quickly. There is 
no reason for these claims to dwell in the system for months or 
years, or many years. This approach would allow the C&P 
examiners to focus more of their time on more difficult claims 
that had to be reviewed.
    Thank you for the opportunity to discuss these important 
issues with you, and I will take any questions you may have for 
me.
    [The prepared statement of Mike Warner appears on p. 32.]
    Mr. Runyan. Thank you, Colonel Warner.
    Mr. Dorrity, you are now recognized for your testimony.

                   STATEMENT OF JOHN DORRITY

    Mr. Dorrity. Thank you, Congressman Runyan, and thank you, 
Congressman Walz. This is a very important discussion we are 
having this morning.
    I am just a vet. I would like to bring your attention to my 
executive summary as it pertains to Colonel Warner and 
testimony that I and others will be giving relative to 
presumptive conditions and time frames. Under B1, I have cited 
two subsections of 38 CFR that relate to this issue. Under B2, 
I have also cited a subsection of 38 CFR that relates to 
inadequate examinations. If I might, I would like to read my 
testimony into the record. Thank you, Congressmen.
    I have broken it down because I need chronology myself to 
follow myself some days.
    A1. When a veteran's request for disability entitlements is 
submitted to the Veterans Benefits Administration, or VBA, a 
process is enjoined that requires various steps in development 
of the claim in order to arrive at a decision.
    After acceptance of VBA and entry of the claim into the 
system, a rating specialist is assigned to the claim based 
usually on the veteran's last two digits of the claimant's 
claim number or through other factors of consideration relative 
to the policy and procedure of the particular VA regional 
office, or RO.
    Number 2. As development of the claim proceeds, an integral 
part of the process of adjudication is required and requested 
by that VBA employee who the claim is assigned to. That part of 
development is the employee's request of VHA, or the Veterans 
Health Administration, to arrange for a comp and pension, or a 
C&P examination, and either a contract provider but more 
usually at the VA medical center or VAMC in which the veteran 
resides. These evaluations are supposed to be objective and 
comprehensive. I will address the positives and negatives of 
this aspect of the process.
    B1. On average, between the time that VBA receives the 
claim and the C&P is ordered, at least 6 to 16 weeks have 
transpired. From the point of the last C&P issued, 
approximately 180 days passes before a decision is issued by 
VBA. If the claims issues are relatively uncomplicated, this 
time frame may be less. This brings the adjudicative process to 
approximately 1 year, give or take.
    I base this observation on my over 30 years of prosecuting 
veterans claims through the VA central office, or the CO, and 
the ROs might disagree with my assertion here.
    In terms of presumptive service-connected issues such as 
Agent Orange, POW, Persian Gulf, et cetera, this is purely 
inconsistent with filing decisions from VBA, the C&P process. 
With presumptive disabilities and supportive public or private 
medical evidence, the need for a C&P eludes me. C&Ps cost 
money, gentlemen. At a time when our Nation is feeling the 
noose tighten economically, it makes more sense, as long as all 
evidentiary requirements are met, to decide the claim without 
an unnecessary step of a costly C&P for presumptive service-
connected conditions.
    Number 2. In an effort to streamline the backlogged claims 
process, the Secretary of the VA has initiated information 
technology, or IT procedures. This is a laudable effort, with 
much thought and preparation on the part of the Secretary and 
his CO staff that I hope works.
    One of the efforts enacted by the CO of the VA is the 
Disability Benefits Questionnaire, or the DBQ. As a matter of 
fact, many of the VHA C&P clinicians, in conducting VA exams, 
or VAX's, as they are referred to, are struggling to complete 
these relatively simple forms and somewhat hampered by the 
process as it does not provide the examiner the ability to 
utilize their intellect and expertise in arriving at an 
objective finding.
    A case in point is my own C&P. It was conducted on 4/13/
2012, at which my examiner, one of my examiners, both of my 
examiners, but one in particular struggled for approximately 20 
minutes just to enact the DBQ program relative to my claim and 
my service-connected injuries. When I received and read my own 
results, I felt as though the examiners had someone else in the 
examination room as the VAX did not reflect any of the 
conversations between the examiners and myself. There is 
information that was not indicated on the results, the DBQs, 
that I know transpired in conversation between the examiners 
and myself.
    DBQs do not always provide for the objectivity required to 
arrive at a just decision for the veteran. Many times, because 
of this limited IT improvement, there is a lack of prudent, 
objective medical observation and testing that goes by the 
wayside as a matter of procedure in an effort just to complete 
the DBQ, as required by the CO's mandate.
    In older service-connected injuries, an x-ray, other than 
showing a fracture, is entirely inconclusive. In this regard, I 
feel that many inadequate C&Ps are conducted which leads to an 
incorrect decision on the part of VBA and prolongs the claims 
process for the veteran on orthopedic issues.
    Number 3. Another issue that we veterans contend with at 
C&P is the attitude of the examiner. As previously indicated, 
C&Ps are to be objective, as the entire claims process is 
purported to be. More often than not, I have seen upon review 
of the C&P subjectivity, not objective opinion, on the part of 
the VHA examiner. Although the C&P notification suggests that 
the veteran bring any other medical evidence relative to the 
issue, rarely, rarely do the examiners utilize this evidence in 
formulating their final report.
    Another case in point is audiology C&Ps. When an older 
veteran files a claim for, say, bilateral hearing loss and 
tinnitus, on more than half of the occasions I have had the 
examiner opine that the reason for the conditions is old age. 
This is not only discriminatory, but it's downright despicable. 
If the evaluator truly understands the nature of the process 
outside of their own little world of supposed expertise, then 
they would contend with the issue of the etiology of the 
acoustic trauma as indicated within the veteran's military 
exposure or military occupation and specialty, as MOS, or her 
MOS. A veteran who served in artillery, aviation, armor, or 
other units where the acoustic trauma is apparent are not 
afforded this objective review and conclusion.
    Many C&P examiners indicate that they have reviewed the 
veteran's record. Without the shipment of the file, voluminous 
or not, to the examiner's desk, this is an outright 
fabrication. Many VHA examiners do not have a clue in terms of 
the overall claims process due to lack of military service 
themselves. Therefore, they have no understanding or compassion 
in terms of the source of the veteran's initial exposure to 
loud noises. A combat veteran invariably is exposed to acoustic 
trauma on a daily basis. This is a given amongst any of us who 
have defended this Nation, our Nation.
    Number 4. On more than one occasion I have seen proof of 
the veteran's third party being billed for a C&P. I have some 
proof with me today. The problem with this erroneous aspect of 
C&P is that a third party payee, a private insurance carrier, 
et cetera, reduces the lifetime cap coverage afforded the 
individual through no fault of their own. If I am not mistaken, 
not only is a C&P a requirement of the adjudication process and 
not monetarily chargeable to anyone, but the veteran is 
afforded travel pay by VHA.
    This portion of the C&P process needs review as some 
diligent veterans who wait at the travel station receive their 
travel pay immediately. But those who send their travel pay 
reimbursement forms in are not quite so lucky. I have clients 
who have been made to wait more than 90 days for a 
reimbursement and others who submit the necessary forms and are 
never, never reimbursed. Clearly, irrespective of the fiefdom 
culture that emerges in large bureaucracies, a national 
standard of this component of the process is long overdue for 
review.
    C1. As a direct representative of veterans, I wish to 
suggest that all is not doom and gloom within the system. There 
are many good people within VBA and VHA. This issue and other 
problematic elements are endemic in any large agency. If we do 
not stay ahead of the curve on the problems of agency, then any 
initiative undertaken by any secretary of the VA is unlikely to 
bear fruit. I am in favor of the Secretary's present initiative 
and supported through my many interactions with my peers on the 
local, state, and national level. I speak to many that we need 
to embrace the technology and utilize it to our constituents' 
benefit.
    I would point out that in a Federal agency that employs 
nearly 300,000 employees, the Secretary would be well served to 
ensure that the culture, the culture of his agency is in sync 
with his mandates.
    Number 2. In the past I have CC'ed the House Veterans 
Affairs Committee any and all written complaints that I have 
received from individual veterans with respect to the problems 
of C&P, and will continue to do the same as long as I draw 
breath.
    Again, I thank you for this opportunity.
    [The prepared statement of John Dorrity appears on p. 33.]
    Mr. Runyan. Thank you, Mr. Dorrity.
    Mr. O'Grady, you are now recognized.

                   STATEMENT OF GENE O'GRADY

    Mr. O'Grady. Good morning to Chairman Runyan, and also to 
Congressman Walz. I would like to say thank you for selecting 
me, as I am a past student here at Ocean County College prior 
to my Army service, and being a member of the 3rd Congressional 
District.
    I am here to represent the American Legion on behalf of 
Atlantic, Burlington, Cape May and Ocean Counties. As a Vice 
Commander of the American Legion for this area, I understand 
how greatly affected our veterans are by the VA current 
compensation and pension claims processing.
    The examination process for claimants filing compensation 
or pension claims can be improved to allow for better 
timeliness in the adjudication process. This would require a 
liberalization of the Title 38 United States Code to allow for 
the examination to be conducted by a non-VA physician or by a 
VA physician furnishing outpatient care.
    When a claim is filed for service-connected compensation of 
conditions alleged to be related to military service, an 
examination in many cases is conducted to establish a nexus and 
to determine the extent to which the condition is disabling. A 
claim for non-service-connected pension requires an examination 
only when the claimant is below 65 years of age.
    While it may prove difficult to establish the relationship 
of the specific medical condition to military service in the 
instance where an original claim is being filed after an 
individual has separated from active duty for more than a year, 
the VA should explore the complex issue with a view towards 
accepting private medical evidence in lieu of conducting a 
compensation examination.
    In cases where service connection has already been 
established and the veteran is filing for an increased rating 
based upon a worsening of the condition, then some provision 
should be made to recognize medical evidence either from a 
private physician or from a VA physician in the instance where 
the veteran receives outpatient care at a VA facility.
    Requiring this specific examination for a service-connected 
condition is in many cases redundant and only serves to slow 
the claims process unnecessarily. The development of an 
alternative method for assessing and adjudicating medical 
conditions that a claim can be related to the military service 
and/or establishing the necessary degree of disability for non-
service-connected pension should expedite the claims process 
significantly.
    It is not suggested that the adequacy of determining the 
relationship of a medical condition to military service or the 
existing degree of disability should be compromised, but it is 
believed that alternatives to a specific compensation or 
pension exam exists, and that their feasibility for using 
claims should be assessed in order to improve the timeliness of 
the adjudication process.
    This may require the development of new forms that may be 
furnished, to be completed and returned by physicians who have 
been treating the veteran for the conditions claimed. It could 
also take the form of utilizing VA outpatient records in those 
cases where a veteran received medical care at a VA facility. 
VA physicians can be trained to include specific notes or 
references to the veteran's treatment record that will assist 
in adjudicating a claim.
    There are likely to be claims that will require 
compensation or pension examinations, but with the proper 
development I believe that those situations can be reduced 
significantly, with the result that timeliness can be greatly 
improved.
    I would like to thank you for allowing me to testify here 
today before your Subcommittee.
    [The prepared statement of Gene O'Grady appears on p. 34.]
    Mr. Runyan. Thank you, Mr. O'Grady.
    Mr. Tafe, you are now recognized.

                  STATEMENT OF WALTER J. TAFE

    Mr. Tafe. Good afternoon, Congressman Runyan, Congressman 
Walz. Thank you for inviting me to speak on this important 
subject. My name is Walter Tafe, and I'm the Director of 
Burlington County Department of Military and Veterans Affairs. 
Our office serves over 35,000 veterans. With our close 
proximity to Joint Base McGuire Dix Lakehurst, approximately 20 
percent of our clients are returnees from the global war on 
terrorism. I am here today to share my observations regarding 
the Veterans Affairs requirements for compensation and pension 
examinations. I don't come here to throw stones at the VA. I 
understand the backlog issues and hope to make meaningful 
testimony that will help all involved gain a better perspective 
of the veteran's point of view.
    Although I am sure this program was intended to speed the 
process by providing verification of a veteran's condition, in 
many cases it has the exact opposite effect. The reality is 
that the veterans face a wait of several months before seeing a 
doctor for a visit that is often no more than 10 minutes in 
conversation, with a doctor taking a cursory look at the 
medical records, and that's assuming that the regional office 
has sent the medical records to the regional hospital.
    Veterans leave this examination extremely frustrated. Many 
tell me they feel they've wasted several months waiting for an 
appointment that wasn't even a real medical examination.
    I would like to discuss several recommendations that I 
believe could have a dramatic impact on the process, reducing 
both the waiting time for C&P examinations and the backlog that 
is presently crippling the claims process.
    My recommendations are based on my conclusion that many, at 
least 50 percent of the C&P examinations conducted by the VA 
health care system, are unnecessary.
    Many of my clients are receiving their health care 
exclusively from the Veterans Administration health care 
system. This means the VA already has their complete medical 
history in their possession. When these veterans file a new 
claim or a claim for increase, they must first receive a C&P 
examination to verify the condition. The veteran waits several 
months to receive a C&P examination so that the VA doctor can 
verify the condition that was already diagnosed by a VA doctor. 
This makes absolutely no sense. It seems like the VA does not 
trust their own doctors to make a competent assessment and 
recommendation. Often these veterans interpret this as a means 
of delaying the process, and as a result it builds great 
animosity between veterans and the very department that is 
supposed to protect them.
    As I initially stated, approximately 20 percent of my 
current clients are only just returning to civilian life after 
serving on active duty. They are National Guard Reserve 
personnel being released from activation, or active duty 
military members separating or retiring. In these cases, the 
entire service medical records are available to the VA. These 
members normally file a claim within the first 3 months of 
separation. Many are combat wounded or have conditions 
diagnosed while on active duty and verified during their 
separation physical examinations.
    Even with a definitive medical exam at the close of their 
service, they must still wait months for a C&P exam 
appointment, and the only point is to verify the medical 
condition that is already a matter of record. These 
examinations could be completely eliminated if the VA and the 
DoD simply communicate with each other and share their 
information. I recommend that the military member's separation 
examination consist of the same verification procedure used by 
the VA, thereby reducing the redundancy of the claim.
    Another concern I share with others in my field is the 
requirement for full verification for every condition when the 
veteran is cared for by a private physician. I understand that 
in some cases verification by the VA of a condition is needed 
to be fully justified. However, for documented cases of Stage 4 
cancer, severe diabetes with insulin dependence, coronary 
artery disease and similar terminal conditions, a C&P seems 
unnecessary.
    Add the additional step of filing a claim and submitting a 
VA form allowing his or her doctor to release the information 
and records to the VA, the resulting delay can seem to be 
cruel.
    A case and example, former Marine Ron Guernon. He is 
presently temporarily service-related 100 percent for kidney 
cancer. Over a year ago, his condition worsened and his 
prognosis was determined to be terminal. At that time I filed a 
request for upgrade to permanent and total status. I also 
requested aide and attendance. He now resides in Spring Hill, 
Florida, where his wife, a registered nurse, provides his care. 
He also receives hospice care. His life expectancy is listed 
month to month.
    Despite the ongoing documentation of Mr. Guernon's 
deteriorating condition and the fact that all medical records 
have been given to the VA, the Tampa regional office requested 
he come for a C&P examination to determine whether his 
condition has worsened. This veteran is literally unable to 
travel due to his condition. This proud Marine absolutely is 
convinced that the VA is, and I quote, ``waiting for me to die 
so they don't have to bother.''
    While I'm sure this is not the case, Mr. Guernon is the 
perfect example of the crippling bureaucracy that is so 
significant in complicating our VA claims process. The VA is 
making some strides, and I applaud the new disability benefits 
questionnaire forms that have been produced for veterans to 
bring to their health care providers. These questionnaires were 
developed so the veteran could give it to his or her doctor to 
complete, providing all the medical information required to 
make a rating decision based on certain conditions. These 
questionnaires have been developed for almost all conditions a 
veteran can receive compensation for. If used correctly, they 
should begin the C&P process in most cases.
    In closing, I'd like to say it is my strong belief that the 
present C&P examination system is severely hindering rather 
than helping the veterans claim process. In most cases, 
examinations are not thorough and they leave veterans 
questioning why they waited several months for a 5-minute exam. 
The perception that C&P exams are a method of delaying and 
denying claims is rampant in the veterans community, and it is 
all the more potent when veterans like Mr. Juran share their 
stories.
    It is my sincere hope that these hearings will result in a 
thorough self-examination by VA personnel to evaluate the 
relevance of this requirement and eliminate unnecessary 
examinations. I thank you for your time and consideration of my 
testimony.
    [The prepared statement of Walter Tafe appears on p. 35.]
    Mr. Runyan. Thank you, Mr. Tafe.
    With that being said, we are going to open it up for a 
round of questions to everyone and be a little lenient with the 
time seeing as how there are only two members here and we 
usually have a panel up here.
    I really want to start with, obviously, the story Mr. Tafe 
just pointed out, and I know Mr. Dorrity just had his 
experience. I know, Colonel Warner, you just had your own C&P 
exam not too long ago, and I know you communicated with my 
staff a little bit about that. But could you talk about your 
experience with that and how a CBOC would improve access and 
improve the process also?
    Colonel Warner. Yes, sir. First of all, the C&P process 
requires multiple trips to Philadelphia to see the doctors, re-
see the doctors, audio tests for hearing two or three times, 
then fitting for hearing aids, and on and on. Some of those are 
not going to be eliminated. You can't eliminate things like 
that. But I do believe that we could use the CBOC to conduct 
more and take advantage of technology. A lot of these things 
would be--these visits would be eliminated by the veteran being 
able to either interface directly with the examiner or to use 
telecommunications where the veteran can sit and take advantage 
of state-of-the-art technology to have the interview conducted 
by telecommunication. I believe that that would eliminate it.
    My real concern is that too many times the veteran 
perceives that the interview process is adversarial, that the 
veteran is out to get over on the system and get something, and 
particularly for elderly veterans. I will give you an example 
of my father-in-law. My father-in-law is a veteran, was a 
veteran of World War II, Korea and Vietnam, and his entire 
dealing with his disability claim was not to get anything more 
for himself, was to establish a basis of understanding for his 
spouse, for my mother-in-law, because he was going to die of 
cancer. The entire process was so that she would be able to 
receive the compensation that she was due because of his 
disabilities.
    And so it wasn't that he wanted to get over. It was that he 
wanted to make sure that his wife was taken care of. 
Unfortunately, I think too many times it is seen as a get-over 
by the veteran.
    Mr. Runyan. Thank you.
    My next question is for Mr. Dorrity. Just dealing with the 
impact of delays of scheduling exams and the impact that that 
actually has on the family, Colonel Warner kind of touched on 
it as future, but as current, what could be done to actually 
help the DBQ process also?
    Mr. Dorrity. In order to help the DBQ process, I have seen 
the C&P examiners utilize them, and I have seen them experience 
difficulty. One of my doctors--and I have to allude to 
something that Walter said, five minutes in and out. Twenty 
minutes to get on the screen, and five minutes worth of 
discussion really provides for an inadequate VAX.
    I think that many of the forms, particularly in the area of 
the presumptives, really don't require a DBQ, the ischemic 
heart for one, the ALS, every condition that is listed. Why 
isn't a private board-certified diplomat in that specificity, 
why isn't their word good? They don't work for the VA. That's 
why? That's not good enough, that's not good enough.
    I have prosecuted over 100,000 claims, give or take, in 30 
years. I have had the distinct tragedy of watching probably 
close to 100 people die, die, while this lengthy process takes 
place. I think that we can do better. I know that we can do 
better.
    I know that we have mandates. I have been around since the 
first secretary was initiated, and that was--I am sorry. It was 
a Polish name. Sorry about that. But I have been around for a 
long time, and I have seen different secretaries take different 
initiatives which haven't come to fruition.
    Now listen, being someone who is a direct representative of 
veterans, I can tell you that there are a number of variables 
that fit into the equation of the backlog. One of the primary 
ones was in the late `90s. The Court of Veterans Appeals made 
one of the stupidest decisions going: No claim is well 
grounded. Do any of you remember that? Okay. So every 
legitimate claim that I sent in with proofs was bounced back as 
a denial.
    What I feel the DBQs are going to do, Congressman Runyan, 
is I think that on the front end--and I dispute the 600,000 
figure. I do. And I get my figures from the VA. I feel that on 
the front end it will probably lower the numbers some, but on 
the back end, the holds, the appeals, they are going to go 
through the roof. And I own--I, my office, owns probably 40 to 
60 percent of the appeals in this region. So here we have added 
on three-and-a-half more years in national time, in average 
national time to have an appeal heard before we get to sit in 
front of a judge, and they have heard everything that went 
before them. So the time frame kind of, sort of gets to 5 
years.
    And for older folks, like Colonel Warner's father-in-law, 
and like my 100 or so clients, they will be dead. They will be 
dead, like Walter's dad. What more do you need? What more do 
you need? What can I do to give you so that you adjudicate this 
claim properly, correctly?
    I would suggest that many of the C&Ps are totally 
inadequate. I know that they use archaic methods. One of the 
problems I have had in C&Ps that I have had and that I have 
seen--because I get my clients to release the C&P to me so I 
can read it--no diagnosis is issued. Now, what the hell am I 
there for, you know? If you can't confirm the diagnosis with 
some archaic x-ray, as opposed to an MRI, you have provided no 
service. You spent my tax dollars doing nothing, and this 
person is not going to--especially with orthopedics. They are 
degenerative in nature.
    So it is a problem that I don't have all the answers for. 
It is not a challenge, Mr. Secretary. A challenge is you and I 
trying to climb Mt. Everest. These are problems that have been 
around for a long time. You probably would make it. I wouldn't.
    They are problems that are endemic in a large system, and 
one of the secretaries--and I will invoke his name, Jesse 
Brown--he had a unique way of dealing with problems out in the 
field. He went out there, non-descript. I try to do that, and 
people know exactly who I am. But he was able to find areas, he 
was able to actually change the culture.
    And listen, don't think, as Walter indicated, that I am 
slamming the VA, VBA or VHA. I just want the process to work 
better. Thank you.
    Mr. Runyan. I think we all do.
    Mr. Dorrity. Yes.
    Mr. Runyan. One more question.
    Mr. Dorrity. Shoot.
    Mr. Runyan. And quickly, because I personally know you. I 
have known you a little longer than anybody.
    [Laughter.]
    Mr. Runyan. We talked about this before, but how common are 
the payment errors to third-party private insurance?
    Mr. Dorrity. Listen, they are happening every day. Medical 
care cost recovery is out of control. It has been out of 
control since the day it started. It is my understanding, 
unless I am wrong--and if I am wrong, I will eat my words--that 
if you are 50 percent, you are not paying the co-pays. I am 
seeing insurance companies send ELPs back to veterans, and the 
veteran will come in with the ELP and say--and I say, well, 
they didn't charge you. But what you need to do is call MCCR, 
and you need to correct this.
    One of the proofs I brought in to you today is one of my 
guys who I sent for a C&P, and he was denied. Okay. But now 
they are reducing his Social Security benefits to recover the 
MCCR costs that were charged for his comp and pension 
evaluation. Comp and pension is free. As a matter of fact, you 
get travel pay for comp and pension.
    I don't understand how it got to this point. One of the 
problems that we have locally with MCCR is people aren't always 
able to get in touch. That is part of the culture that we may 
be able to bring into line so that these occurrences don't 
happen.
    I am sorry to be so long-winded. I notified an insurance 
company many years ago about these overages and charges that 
they shouldn't be paying. But like everybody, they get a letter 
from a Federal agency saying you owe X amount of dollars, the 
first thing they do is they send a check, because who wants the 
IRS looking at them, or who wants a red flag up?
    I notified them. I got forwarded to an investigator. He 
said are you saying fraud? I said, listen, I don't think it is 
fraud. I think it is just a misunderstanding on the part of 
MCCR as to what is chargeable and what isn't. You know, that is 
why we have laws, 32,000 pages of them, but that is why we have 
them.
    So I believe that a review of MCCR and their billing 
process is appropriate, too. How often? That is a long way 
around the bush. Every day, every day, every stinking day.
    Mr. Runyan. Thank you for putting some light on that.
    Mr. Dorrity. Thank you.
    Mr. Runyan. I have a question for Mr. O'Grady, too. I know 
I am well over my time, but these are important discussions. 
Dealing with a private medical opinion and the C&P exam, to 
your experience, is there a difference? Is the private medical 
opinion usually right on with the C&P exam?
    Mr. O'Grady.With my own experience with going through a 
compensation assessment--I guess that is what they call it--for 
worker's comp, you have so many individual doctors that are in 
the process, and I think there are too many doctors that are 
involved. We should be able to take that outside doctor and use 
his opinion. If he can be treated properly and he is going to 
do the same exact evaluation, our veterans shouldn't have to 
start back at square one.
    It is the same process. These doctors are trained. They 
know how to do their evaluations. If we are using the same 
standard, that is it. If the VA has some super standard that 
they have to have, then we need to have our doctors on the 
outside find out about that, and hopefully that is going to 
speed up our process.
    But I think it is a similar process that they go through. 
It is just that the VA system seems to be redundant.
    Mr. Runyan. Thank you. And just one, maybe two, for Mr. 
Tafe. In your statement, you say about 50 percent of the exams 
are unnecessary. Can you elaborate on why you think that number 
is so high?
    Mr. Tafe. Sure. I think it is so high because there are so 
many instances when the VA is spending time verifying their own 
decisions that could be totally eliminated.
    I am in a very large retirement community, as you well 
know, and many of those veterans are already 50 to 100 percent 
rated. So their exclusive health care comes from the VA, and I 
just don't understand why the VA would diagnose someone, even 
with a terminal illness, and then require a C&P examination to 
verify their own decision. I don't understand that at all. I 
think it is extremely redundant.
    I also believe that those coming off of active duty, their 
records are so readily available, and some of them are 
diagnosed as combat wounded. I don't understand the reason for 
them to wait four to 5 months to go for a C&P examination, 
which is just five minutes in the door and out the door. In 
many cases, it is an adversarial meeting that takes place. I 
have people who receive C&P examinations for post-traumatic 
stress disorder who come back to me and say ``I'm never going 
back there again. I don't care if I get any money, I'm not 
going back. I will not do it.''
    So I think many of those cases, or almost all of those 
cases for post-traumatic stress disorder, have been verified 
and diagnosed by a VA doctor because that is the requirement 
now, either an outside provider or a diagnosis from a VA 
doctor. So I cannot understand the redundancy, at least in the 
environment that I am in, for continuously bringing them back 
to check the same thing that they have already checked.
    In my case in particular, I visited the Fort Dix clinic for 
a service-connected illness that I had a rating for. The VA 
doctor told me to go for a C&P examination. I had no intention 
of asking for an increase at all. The VA doctor said you have 
to go put in for an increase, and then I had to go wait 4 
months for the appointment to take place, go to Philadelphia 
and spend five minutes with the doctor to verify, and I was 
seeing a specialist at Fort Dix and saw a physician's assistant 
at the VA hospital. I don't understand that reasoning.
    Just one other thing that was mentioned earlier, and I just 
want to hit on it, if I had an oncologist who diagnosed Stage 4 
lung cancer, why would I have to go to the VA facility and have 
that verified by a physician's assistant who has no experience 
in the field? I think that those type of redundancies could be 
eliminated, and I do think it would have a dramatic impact on 
the number of cases that are backlogged.
    Mr. Runyan. I would agree with you because, obviously, in 
the case that you had in your testimony with Mr. Guernon, the 
Marine, he has been diagnosed with terminal kidney cancer, and 
yet they want an exam. I mean, common sense says why would I 
need an exam to----
    Mr. Tafe. And there is a feeling out there, because he is 
100 percent temporary, well, 100 percent is 100 percent. 
Permanent and total status for veterans in New Jersey is 
critical because his widow, unless he is determined to be 
permanent and total at the time of his death, his widow is not 
eligible for the tax exemption for her property tax. So it is a 
very critical thing that I don't even think is being understood 
on the other end of the C&P table because they have no idea 
what the individual state laws are. If his case isn't settled, 
it will be a dramatic impact on his wife for the rest of her 
life.
    So I think it is very important that they understand the 
ramifications of delay. This gentleman has been delayed for a 
year with a terminal illness.
    Mr. Runyan. Thank you, Mr. Tafe.
    With that, I will yield to the gentleman from Minnesota, 
Mr. WALZ.
    Mr. Walz. Thank you, Chairman.
    Thank you, each of you. I am very appreciative.
    It probably wouldn't surprise any of you, if we held this 
panel in Minnesota, we would hear very similar things.
    Mr. Dorrity, I hope every congressional district has 
somebody like you to be that conscience. Speak as long as you 
want on things.
    This is not a destination. It is a journey. And those of us 
who have been involved in this issue, we have been fighting it 
for decades. It is very frustrating, and I know the Chairman 
has expressed frustration, as he should, as we take these 
things on and we try and improve and we try and move forward, 
and it seems like we beat our head against the wall.
    It is our goal to try and get there, to do a more perfect 
union, if you will, and I think the things we need to keep in 
mind is--I think you all made that very clear, that the VA is 
there to serve our veterans. Everybody here has the same goal, 
care of our veterans that they have earned in the best possible 
way, and guarding the taxpayer dollars, as sacred as they are.
    With that being said, we have the best health care in the 
world. I say this. The VA medical centers are the best health 
care in the world. I represent the Mayo Clinic, so I do a lot 
on medicine, do a lot on that. The Mayo Clinic will tell you, 
if they have somebody with heart disease, they will send them 
to the VA medical center in Minneapolis for some of those 
things.
    And you know what? That is exactly what our veterans should 
deserve. When people tell me, why do they have that big, 
beautiful building, and the lawns are all mowed or whatever, 
and I say, what, do you want to send our veterans into a 
double-wide and tell them to get secondary care? Of course not.
    But with that being said, in a time of economic 
uncertainty, we have to be very pointed in how we are doing 
this. So I think this issue hit on several things, and I would 
come back to this table here, Chairman Runyan, his staff. I 
have talked about this until I am blue in the face. People are 
sick of it.
    But the systemic issue here for me is this seamless 
transition out of DoD into the VA, of combining resources and 
not allowing that Grand Canyon gap of dropping off and pulling 
them back. In this day and age of IT technology we have, it is 
absolutely ludicrous that we don't have that seamless. We are 
getting there.
    Now, the private sector doesn't necessarily have that 
electronic medical record either, but that is going to go a 
long way. But that is the implementation side. Each of you hit 
on something, and you are after my heart on this. I am a 
cultural studies teacher, the culture that is out there. And 
the VA, I know this hurts them when they hear this. I know it 
hurts people serving in the VA because many are veterans 
themselves and they care about their mission.
    When they hear that they believe the C&P exams are meant to 
delay the process or whatever, the thing I would tell the VA is 
if you think that is just what they think, their perceived 
reality, perceived reality is reality for our veterans. They 
believe it is happening, it gets out there, and you have to 
break that. You have to break where exactly that is.
    I am very, very frustrated as I see, as you said, the 
redundancy of this. Chairman Filner, former Chairman Filner, 
the Congressman from California, he always brought up a great 
point. He usually brought it up this time of year. Last year 
millions of Americans, or last week millions of Americans filed 
their tax returns. The IRS accepted that you were telling the 
truth, and then they went back and audited them. The VA assumes 
you are lying and then verifies them afterwards, and that is an 
attitude that is cultural that is in there.
    Now, we as taxpayers, these are all the false choices we 
always set up--and this is why I love this committee--it is not 
about a false choice. We want to get efficiencies. You are 
going to ask us to don't allow fraud, waste and abuse to 
happen. I think at times what happens, and I think C&P exams 
are an example of this, they are done with the intention of 
insuring that taxpayers are protected, but a perverse thing 
happens where it ends up not only causing problems but costing 
us more.
    I think we need to come to some type of agreement or some 
type of new way, and I am really glad the Chairman is hitting 
on this, that I think we are going to find a commonality on 
this. I think these examples you bring up--who in their right 
mind can defend what happened to Mr. Guernon? Who can defend 
that? No one is going to ask you to be able to defend that, but 
I can tell you it is not being done with maliciousness. It is 
being done with an intent on it is the letter of the law, not 
the spirit of the law. And somehow we, in a country of laws, 
have to get at that.
    So I wanted to ask just a couple of questions.
    Colonel Warner, this is an issue I struggle with. It is 
that choice between centralized control and uniformity versus 
decentralized efficiency amongst that. We are going to hear 
from VISN 4 folks. I represent VISN 23, which sets out in the 
Dakotas and the Upper Midwest. If you go and look at this, 
veterans know this. They know where to go to get a C&P exam to 
get a better rating and quicker service and things like that.
    My question to you, have you witnessed this amongst the 
states that there is a difference here that is either 
hindering--because my argument on this is if that young warrior 
comes back from Afghanistan and settles right down the road 
here in Mr. Runyan's district, or decides to go out into 
Southern Minnesota, they should get the equal care. They should 
get the same level of care. Do you think it is happening that 
we have these differences?
    Colonel Warner. I have not perceived this. I am not going 
to say that there is. I think that there is inherent in the 
system that there will be differences between rating officers 
and how they look at things, but I am not sure that there is a 
systemic issue between offices and that one office is an easier 
office than another office to go to.
    When I was the commissioner for veterans affairs, speaking 
to my counterparts, I am not sure that I experienced that. I 
think that the concern--and I will tell you, I think one of the 
concerns the VA has in the C&P process, by keeping it 
centralized at the VA medical center, is the fact that they do 
want to control it. Again, if they want to give a uniformity, 
then there is an underlying thing, is that is it, in fact, that 
the veteran truly has that claim.
    The only way, though, to address this and to increase the 
timeliness of adjudication is to decentralize the interview 
process. If you are a C&P officer and you are doing it in 
Philadelphia or Newark or Wilmington, and you are doing it 
there, causing the veteran to come to you, or doing it at the 
CBOC in Fort Dix but you are still interviewing and you can do 
it more timely, even going over telecommunications----
    Mr. Walz. Colonel Warner, or let me ask this to all of you, 
are you concerned about fraud in the system if we allow C&P 
exams to be done on the outside? Do you think there is that 
ability there, or are there redundancies in the system to be 
able to check against that?
    If the argument is we have to have the C&P exam done to 
make sure it is all kosher, it is all going through right, do 
you fear that having, whether it be the private sector--and 
this is all of us in this room, and the veterans know this. 
This is ongoing tension, that we have to do this right.
    The real fix isn't to have government do it all or the 
private sector do it all. It is that mix. There is a time and a 
place for fee-for-service. I see this in rural areas, where it 
makes sense to do fee-for-service. But many veterans groups get 
nervous when they say ``but the core mission of the VA medical 
center must remain intact.''
    Do you feel like in this instance, giving either private 
sector or CBOC, for goodness sake, makes sense to me because it 
is in their--I mean, Mr. Tafe made that argument. You can't 
argue with that. What about the private sector? Are you afraid 
that we will see that?
    Mr. Dorrity. No, I don't feel that we would see fraud. 
There is a statement that I used to know in Latin, and it said 
something to the effect that we don't judge a system by its 
possible abuse.
    Congressman, there is fraud all over the place. I like the 
CBOC idea. I realize that there are limitations to that with 
the teleconferencing.
    But fraud? No. When I detect fraud, I guess after my long 
years I can smell when stuff ain't right.
    Mr. Walz. That goes back to Mr. Filner's thing, that we 
will punish the entire veterans community for the perceived 
potential from a few, and that is the exact opposite of the 
IRS.
    Mr. Dorrity. You made a great illustration there.
    Mr. Walz. So you are not fearful of that? You think that--
--
    Mr. Dorrity. I am not fearful of fraud.
    Mr. Walz. Certainly not in the CBOCs, right?
    Mr. Dorrity. Not in the CBOCs certainly, and if we have a 
board-certified diplomate in a specific form of medicine, their 
license and everything else is on the line.
    Mr. Walz. Do you agree with that, too?
    Mr. Dorrity. One more thing. I have seen fraud in the VA. 
We have a contract out with some company in London, Kentucky, 
and the decisions I am getting, you would laugh, because I sit 
there and say, oh, gee----
    Mr. Walz. I want you to come back to that hearing, too, the 
contract thing. That is an entire other--that is a big giant 
can of worms.
    Mr. Dorrity. Rather than listing--let me just get this out. 
Rather than listing all of the disabilities, this company says 
``miscellaneous disabilities.'' Do you know what you did? You 
just pulled the due-process rug out from under the veteran, by 
law. But I will get off that.
    I don't see fraud as a greater hazard.
    Mr. O'Grady. I am not afraid of fraud. I think it will be 
the same as in every other segment of our population. You can 
provide the oversight and correct it when it happens.
    Mr. Tafe. I agree, Congressman, but I would say that there 
are times when there should be some verification, on secondary 
illness, secondary to an illness, where they very well may have 
to verify that through the CBOC or through the VA----
    Mr. Walz. You know, we made some changes. One of the things 
we have done in having these hearings over past congresses is 
that these initial claims, especially the catastrophic claims, 
approve them on the spot and get them paid, get them going, and 
then come back, and the ones that take the rest of the time 
that are a smaller portion of it and aren't going to impact the 
families' livelihood, aren't going to impact some of those, get 
after them later.
    I think, to tell you the truth, I think the real fix here 
is let's get that seamless nature done so it is easy and so you 
are out processing physical counts at your C&P and you are done 
and you move forward. In lack of that, let's use the CBOCs and 
approve those for the folks that are there, and to get further 
down, let's get to the good folks that are getting those.
    I think that the Chairman is right on this. I think the 
time for the C&P exam as being that detrimental to veterans has 
passed. I think there are other things that we can do in there, 
and I think technology gives us that ability. So I appreciate 
those insights.
    I yield back, Mr. Chairman.
    Mr. Runyan. I want to thank the gentleman, and I want to be 
conscious of everyone's time. We could probably have this 
conversation for the next month and still have plenty to talk 
about. But with that, I want to thank each and every one of you 
for your testimony and your time today. I appreciate it. You 
are now all excused. I want to welcome the second panel to the 
table.
    Colonel Warner. Thank you.
    Mr. Runyan. Thank you.
    The second panel consists of Mr. Michael Moreland, the 
Director of Veterans Integrated Service Network 4 for the 
Veterans Health Administration. He is accompanied by Joseph 
Dalpiaz, the Director of the Philadelphia VA Medical Center, 
and Robert McKenrick, the Director of the Philadelphia VA 
Regional Office.
    Each of you will have 5 minutes to summarize your 
testimony, and your full written statement will be made a part 
of the hearing record.
    Mr. Moreland, you can begin.

     STATEMENTS OF MICHAEL E. MORELAND, DIRECTOR, VETERANS 
 INTEGRATED SERVICE NETWORK 4, VETERANS HEALTH ADMINISTRATION, 
  U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JOSEPH 
    DALPIAZ, DIRECTOR, PHILADELPHIA VA MEDICAL CENTER, U.S. 
DEPARTMENT OF VETERANS AFFAIRS; AND ROBERT MCKENRICK, DIRECTOR, 
 PHILADELPHIA VA REGIONAL OFFICE, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

                STATEMENT OF MICHAEL E. MORELAND

    Mr. Moreland. Chairman Runyan and Ranking Member Walz, it 
is my pleasure to be here today to discuss how we provide high-
quality care to veterans in Southern and Central New Jersey. I 
am accompanied by Mr. Joe Dalpiaz, Director of the VA Medical 
Center in Philadelphia, and Mr. Robert McKenrick, the Director 
of the Philadelphia VA Regional Office.
    Today I will discuss the collaboration between VHA and VBA 
on compensation and pension examinations, and then review VHA 
services provided to New Jersey veterans.
    VHA and VBA work collaboratively to deliver compensation 
and pension examinations for veterans. VISN 4 ensures access 
through dedicated staff that provide coordination between VA 
medical centers and VBA regional offices, and also manages the 
Integrated Disability Evaluation System called IDES, or I-D-E-
S.
    In New Jersey's 3rd Congressional District, most veterans 
receive C&P examinations at the Philadelphia VA Medical Center, 
with a small number at the Delaware, Wilmington VA Medical 
Center, or in community-based outpatient clinics. Philadelphia 
also coordinates with a contract provider, QTC, for a small 
number of exams.
    At the Philadelphia VA, the average wait time between the 
date the appointment is scheduled and the date of the 
examination is between 13 and 16 days. Philadelphia has made 
tremendous progress in reducing the no-show rate for C&P exams, 
from 15 percent in 2009 to about 7.5 percent in 2012. 
Philadelphia's examination volume has increased by more than 20 
percent during the last year or so.
    The Philadelphia VA Medical Center has also increased staff 
capacity in 2011, and schedules C&P clinics on weekends and 
holidays for the convenience of veterans. A new sharing program 
has a physician traveling to the VA regional office to provide 
one-day medical-opinion-only turnarounds on some priority 
cases. Philadelphia also shaved 15 days off of the completion 
time for traumatic brain injury exams by providing follow-up 
neuropsychology exams on the same day as the initial screening 
for the veteran.
    At the Wilmington VA, the average wait time for the C&P 
examination is 10 to 14 days. Wilmington conducts all C&P exams 
on-site and is exploring options to use TeleHealth for certain 
examinations in community-based outpatient clinics. Wilmington 
has seen a 33 percent increase in C&P examination volumes 
between '09 and '11, and has a current no-show rate of about 
10.8 percent. Wilmington has improved its processes by adding 
staff at the C&P clinics and scheduling appointments on 
evenings and weekends. Wilmington is looking at opportunities 
to support the Dover Air Force Base and the Philadelphia VA 
Regional Office as part of the IDES process, and is exploring 
ways to increase TeleHealth usage to conduct behavioral health 
C&P examinations at their CBOCs.
    VA has a nationally established benchmark of 30 days for 
cumulative average processing time for C&P examinations, and in 
each month in FY 2012, both Philadelphia and Wilmington 
performed better than that benchmark, 25 days in Philadelphia 
and 20 days in Wilmington.
    The vast majority of examinations also surpassed the 
quality standards that VA has.
    Eighty-six percent of urban South New Jersey enrollees live 
within a 60-minute drive of the Philadelphia or Wilmington 
facility for inpatient care, while 100 percent of rural 
Southern New Jersey enrollees live within 90 minutes of 
inpatient care in the VA. VISN 4, therefore, is better than the 
current guidelines that 65 percent or more are to have that 
level of access. Outpatient care is provided by Philadelphia at 
the CBOCs in Gloucester County, Camden County, and Fort Dix in 
Burlington County. Wilmington serves New Jersey veterans at 
CBOCs in Northfield, Vineland, and Cape May, New Jersey.
    VISN 3 also operates facilities in New Jersey. Counseling 
and outreach services are also provided in the area at vet 
centers in Philadelphia, Pennsylvania and in Ewing, Lakewood, 
and Ventnor, New Jersey.
    Specific to New Jersey's 3rd Congressional District, VA 
provides care to veterans in Burlington and Camden Counties 
through services at the Philadelphia and Wilmington Medical 
Centers, as well as the CBOCs at Fort Dix and the Camden County 
Annex. In Ocean County, veterans receive care from VISN 3 
facilities.
    VA access standards indicate that 70 percent of veterans 
should be within 30 minutes of primary care. VISN 4 surpasses 
that requirement in Burlington County with 94 percent of 
enrollees living within 30 minutes, and in Camden County where 
100 percent of veterans meet the level of access. In VISN 3, 90 
percent of Ocean County veterans have access to primary care 
within 30 minutes.
    In conclusion, VHA and VBA are a strong team providing a 
full range of benefits in health care to Central and Southern 
New Jersey veterans. VBA and the Philadelphia Regional Office, 
together with VHA and VISN 4, furnish veterans with timely and 
accurate pension and compensation evaluations.
    Mr. Chairman, this concludes my testimony. My colleagues 
and I look forward to questions. I am the only one really 
giving a prepared statement.
    [The prepared statement of Michael E. Moreland appears on 
p. 36.]
    Mr. Runyan. Well, I thank you for your testimony, Mr. 
Moreland, and I will begin the questioning.
    I think Congressman Walz and I actually had this discussion 
on the floor of the House the other day. You said in your 
statement 100 percent of veterans in South Jersey are within 90 
minutes' drive of the closest VISN 4 facility. Is it up and 
down the Garden State Parkway on a Friday afternoon? Is it the 
drive time, or is it calculated by the mileage? Because I know 
when we get over into the western part of the state, into 
Burlington County, I can't get anywhere in a half-an-hour in 
Burlington County at 5 o'clock any day of the week. So what is 
the determining factor of that?
    Mr. Moreland. We use drive time, sir. But I think it is the 
average drive times. We don't focus in on the rush-hour drive 
times which, as you know, would be substantially larger. And 
just for clarity, that is access to inpatient care. We have 
much closer CBOCs in outpatient care. So we are really talking 
about 90 minutes to an inpatient facility with high-level 
specialty care.
    Mr. Runyan. And how about providing the transportation to 
disabled veterans? I know we have an issue in the county where 
a lot of times there is a legal issue where the county won't 
even pick them up because there is a liability issue.
    Mr. Moreland. It is interesting. Across the VISN, we have a 
lot of different situations depending on the county and, 
frankly, the state. Some counties are very supportive and 
provide payment to drivers. They provide vans. They provide a 
pretty extensive infrastructure to get veterans to the clinics; 
in other counties, not so much. And so we rely heavily on 
volunteers. The DVA, American Legion, VFW, they do a phenomenal 
job of supporting veterans getting to the facilities.
    We also run VA transportation to select areas. As you know, 
we have a bus coming out of deep southern New Jersey that we 
have used quite a bit, and that has worked really well, and we 
have, in fact, expanded that bus and expanded the services for 
that.
    But I don't deny that it is a challenge for people, on 
occasion, to get there. So we are working with the counties, 
the veterans' auxiliary organizations, and everyone else to 
make sure veterans get the service access they need.
    Mr. Runyan. And dealing with QTC and the process of the 
audiology and the mental health exams in the area, and that 
they have to travel to multiple locations, do you see that 
having to run around becomes a factor in the delay of the 
processing of the claims?
    Mr. Moreland. QTC is one of the contract vendors that we 
use, and there is a----
    Mr. Runyan. Well, not being centralized, though, and having 
to go from one office to the other office to get the claim so 
it is presentable.
    Mr. Moreland. Yes, that is one of the challenges always, is 
making sure that the exam meets the standards so that when I 
send it to VBA, it answers the question of the documentation, 
has all the clinical information. So, one of the reasons that 
we really like having VA staff do that is because they are 
trained and knowledgeable and able to do that.
    We are working with several different contractors. QTC is 
the one that is being used in Philadelphia, but we have three 
nationally, and the Pittsburgh VA is using a different vendor. 
To be honest with you, sir, I am encouraging us to use some of 
the contractors because I want to see how do they work, is it 
more convenient, do they give me a good quality product. I am 
using different vendors because I want to see if there is a 
difference between the contractors.
    So I think the decision is still out on how effective and 
how their service will be, and we are evaluating that data. You 
can take a look at it.
    Mr. Runyan. Okay. And in your statement you also stated the 
number of compensation and pension exams processed had 
increased in both Philly and Wilmington. Obviously, it is 
probably a rhetorical question. Can you explain the reasons for 
that?
    Mr. Moreland. Well, we have seen that not just in Philly 
and Wilmington. Across VISN 4 we have seen a large increase in 
exams, and I don't think I am overstepping my bounds to say 
that has been nationally, and there have been several reasons 
for that.
    Of course, we have the returning Iraq and Afghanistan vets, 
and so we have their service that needs to be provided. We are 
also in the midst of many people filing reclaims and additional 
claims. So there has just been a big influx, and we have 
increased our staff, increased our services, expanded our hours 
to do exams, and we are bringing in contractors to help with 
some of that variation in demand to make sure that we are able 
to meet needs.
    Mr. Runyan. And dealing with providing, obviously, a more 
efficient and veteran-friendly exams process, you may have 
stepped out several weeks ago when I was at the CBOC on the 
joint base, but I had asked the question in there, and you may 
not have the answer to it, but I want to make everyone aware of 
it and get it into the hearing record also, I asked a question 
about TeleHealth, and obviously Secretary Shinseki had asked 
the question also. Do we know the limitations of it and what we 
are capable of doing and what we are not capable of doing?
    But obviously, the conflicts that we are coming out of now, 
the mental health issues--and Secretary Shinseki was also very 
interested in the Parkinson's aspect of it, and he asked that 
question. I asked one about brain injuries and PTSD and all 
that kind of thing and the ability of a clinician to actually 
make a diagnosis over a teleconference, over a video 
teleconference, with the distraction of the technology in front 
of the veteran. I raised that question, and it wasn't truly 
addressed.
    Have you had that discussion or are you aware of it in 
looking at that? Because, obviously, this conflict we have been 
in the last 10 years, we are going to have a vast number of 
mental and behavioral health issues that I am afraid--and I 
have expressed this to Congressman Walz also--that we are not 
prepared for, because when we look at what we are dealing with, 
a lot of the stuff that we have is still dealing with the 
Vietnam era.
    Mr. Moreland. Several things. I think that there are 
opportunities to look at TeleHealth, and in some areas I think 
it is absolutely appropriate. It absolutely will work. I will 
mention in a second some of my personal experience with that. I 
think in other areas, we will have to wait and see. So we need 
to back up that effort with on-site physical review. So I don't 
think TeleHealth answers all of our concerns.
    But I have talked to the mental health leads at 
Philadelphia and Pittsburgh, our two largest mental health 
areas, and there are psychiatrists and psychologists there, and 
talked to them about their personal experience of exams via 
teleconference. Ten years ago, when I saw my first example of a 
psychiatry visit by TeleHealth, I frankly was uncomfortable 
with it, but in talking to the veteran, he was quite good with 
it. In talking to the psychiatrist, he was a little 
uncomfortable with it, but that was 10 years ago. People who 
have had the experience are getting very comfortable with this 
venue.
    And so I think that TeleHealth will continue to expand. It 
is a viable and very good option for certain conditions--not 
all, but for certain. So I am seeing us starting to expand 
that. We are doing quite a bit on mental health not only C&P, 
but we are doing a lot of treatment actually by video 
conference, and I have been surprised to find out that veterans 
sometimes can be more forthcoming with that little bit of 
separation by the video conference, but then they develop that 
good relationship with the provider. So I think it will work, 
sir.
    Mr. Runyan. I see that aspect of it, but I just worry about 
the clinical analysis of it sometimes, because whether that 
clinician in and of themselves has been trained in how to do 
that because it is a different way of delivering medical care. 
It is something that, as we move there and we try different 
aspects of our veterans' care, we have to be very conscious of 
that because it is a different delivery method and there are 
most likely different procedures and protocols around that to 
make sure no one falls through those cracks.
    That being said, I will yield to Mr. Walz.
    Mr. Walz. Thank you, Chairman.
    Thank you each for being here. More importantly, thank you 
for choosing to serve our veterans. Each of you possesses 
skills you could take to the private sector and probably make 
more money and have less of these questions. But you have 
chosen not to be, and for that I am thankful. It is important 
work you do. It is complex, and the thing that I am noticing, 
and this is what is so great about this Nation, the diversity 
that we have.
    When I hear rural New Jersey, I look out here and I don't 
see rural. Rural is my town where I had 25 kids in my 
graduating class and 12 were cousins. That is rural. That is 
the truth. I say it is like Lake Woebegone.
    But listening to the Chairman talk about this, it is an 
important issue, this issue of travel for our veterans, this 
issue of getting there. So we are looking at a very narrow 
issue today but an important one for veterans, because I think 
it does set up the cultural expectations. I think it sets up 
their experience.
    Older veterans, we all lived through this where you 
wouldn't go to a VA hospital because you were afraid of the 
care you would get. Now you are fighting to get in that thing, 
and that is a testament to the work you have done. But again, 
it is zero sum. We have to continue to force this.
    I would say you are also seeing more people because we made 
it clear that this Nation is going to serve those veterans. 
Five years ago we had to hold a hearing that clarified for the 
VA that they could advertise for services. Some of you remember 
that. And I said I wanted to see--we need a few good men in the 
Marines. We need those few good men and women when they come 
back to go to the VA if they need the care, and it isn't 
because they were victims, or it isn't because they want 
something for nothing. It is because these are our best and 
brightest who put themselves in a situation where the reaction 
to it is absolutely normal, to experience PTSD, to experience 
some of these issues.
    So I am really glad that you are incorporating this 
traumatic brain injury piece. It was a piece of a bill that I 
did last year incorporated into that. I am glad to see you are 
streamlining that.
    Do you believe that is being implemented? And again, I 
don't want to pit one VISN against another. I am trying to get 
a broader picture here with the Chairman. This is a great 
opportunity for me. Are they implementing those things, 
Director, do you think, on a broader basis?
    Mr. Dalpiaz. Yes, yes.
    Mr. Walz. Are they sharing best practices amongst each 
other?
    Mr. Dalpiaz. Yes, sir.
    Mr. Walz. Are we getting this right in this complexity of 
standardized rules issue? I mean, it does go back again to how 
far is 90 minutes, and I will confess today it was longer than 
90 minutes from Philadelphia this morning, for me, just as a 
veteran traveling the other way.
    But just with that being said, do we put you in a 
complexity of a box that doesn't allow you to adapt to your 
veterans, adapt to changing local areas? This is a case where 
many times we ask government to function more like a business 
and be more adaptable at times. Large businesses tend to not be 
as adaptable as smaller ones. We should take a hybrid of that.
    Do you have that ability to be able to adapt, or are the 
centralized rules kind of there for everybody?
    Mr. Dalpiaz. I think we have the ability to incorporate the 
private sector evaluation and build our treatment plan or build 
our analysis or build our evaluation or our decision around 
that. I believe we have the flexibility to do that.
    Mr. Walz. This is a real conundrum. They have their 
facilities. Their goal is providing that specialized care, and 
out of their budget comes the fee-for-service to reach down. 
And there is this belief for some of us out there, Minneapolis 
doesn't cordon their money, send it down to Laverne and 
Pipestone and those places or whatever, but it is not quite so 
simple.
    My point to each of you is focusing back on this issue of 
C&P exams. Are you fearful of fraud if we allow some of your 
contractors who have proven to be able to do this? Because my 
CBOCs are a combination of VA-run CBOCs, and Sterling Medical 
is the contractor that runs the others. They do a great job. I 
call them and provide the oversight, just like I do to you to 
them, and I trust those guys could do it.
    So I am asking. I know it is a tough question.
    Mr. Moreland. No, I think it is a good question. My concern 
is not with fraud. My concern is to assure good quality. So, 
for example, we have 44 community-based outreach clinics across 
VISN 4. About 15 or so of them are contract. I am an advocate 
of having a little bit of both because I think it provides some 
incentive and motivation for both of them.
    But I am not concerned about fraud. It is about quality. So 
if I can get a QTC, for example, to give me good quality exams, 
I am not worried about fraud. It is quality, because if I send 
a bad exam to VBA, it just delays the process, and I don't want 
to delay the process. So that is my goal.
    Mr. Walz. And speaking of the process, and I am a believer 
in this, and I think it is a complex issue. There are 310 
million people in this country, 20 million veterans, a million 
new veterans a year. It is complex on this. But I am always 
frustrated by the idea that if I sent you in a copy of my 
packet, I could trace it from when it left Minnesota via UPS, 
every place it was on there on my computer, and I know we are 
getting to that point.
    Can we get to where a veteran at least knows where their 
claim is at, knows where it is going to be, at least has some 
idea? These guys sitting behind you will tell you, I think it 
is that uncertainty of knowing that it is going to be rejected 
and then say, yeah, they always reject it.
    I think a fix on this--and I throw this out. I maybe should 
have asked the Colonel when he was up here from the state 
perspective a little more. I am a big fan of these county 
veteran service officers having more power to help push these 
claims and giving them access. Does that make sense? Do you 
think that is the way to go?
    Mr. Moreland. I will tell you that I view the whole thing 
as a team together. The veteran service officers from the 
different service groups are critically important in this 
process. The county veterans' officers are a critical piece to 
this.
    You know, when they--as a couple of the gentlemen 
mentioned, I am prosecuting and fighting for these cases. That 
is what I want because if I don't have the advocate for the 
veteran, then I can't assure that I am always looking to get 
better.
    You mentioned that we have the best health care anywhere. I 
am convinced we do. But if you are not trying to get better 
every day, you starting to fall back, and it is the same thing 
with the C&P.
    Mr. Walz. Yes, and especially from your perspective. This 
perception that you know is real, that you guys are just trying 
to delay these until they die, or you are told to kick them 
back and not approve them, that causes so much tension in this, 
especially assuming I see it from your side, I hear many of the 
claims adjusters say, ``For God sakes, man, I'm a combat 
veteran. These are my brothers and sisters in arms. I want to 
do what's right, but I can't because of this, and it needs to 
be there.''
    So I am trying to figure out how do we strike that proper 
balance, to go back to maybe some of the art, not just the 
science, of processing a claim. And I know I am biased on this. 
The benefit of the doubt always goes to the veteran. That is 
where I approach it from.
    But how do we do that?
    Mr. Moreland. And I am glad you mentioned about our staff. 
We have fabulous staff who are dedicated. You know, both these 
gentlemen and me, I went to work in the VA as a clinical social 
worker, sir, and my goal was to go to help veterans, and I have 
been in the VA for 32 years. So anyone that asks me why are you 
trying to hold up a claim, are you joking? I am not. But I 
don't disagree with you that there are people that may have 
that perception. So we have to get there and find those.
    I wrote down some names as they were talking today, and I 
always remind the veteran officers and the county people, if 
you have a name, if you have somebody who you think has a case, 
send an email, call me, go to Mr. Dalpiaz, got to the VBA and 
ask, and we will track them down. The gentleman in Florida, I 
am already going to track him down and find out what is going 
on with that case.
    So that is the only way I know to deal with the perception, 
is to find the real one and go fix it.
    Mr. Walz. What tool can we give you? Was I being overly 
optimistic in saying if we can get this seamless transition, 
that there is no darn reason you shouldn't help press that in 
your service and be ready to go? Is that the fix?
    Mr. Moreland. I think that is a big piece of the fix. The 
IDES is a wonderful growing-up system. So I now have staff in 
VHA, and in my office even, that are calling the military 
treatment facilities and saying, ``What's that guy's name? 
What's that lady's name? They need to have an exam.''
    And we are seeing it now in our medical centers, from the 
active duty as they are out-processing, and that has just got 
to continue to grow and make that more seamless, as you said.
    Mr. Walz. Okay. Well, again, I appreciate this. I think 
that is what we have to figure out, what is the direction. I do 
think--what is the best way to put this? Everybody in this room 
is here to serve the veterans. Large organizations can be 
cumbersome. We can have people believing they are doing the 
right thing, but in the long run I have seen places where we 
made sure we didn't have fraud, waste, and abuse, and in doing 
so we have caused lots of grief and created more waste. And I 
think it is being targeted, laser focused on that while moving 
the things we can.
    So again, thank you for the care of the veterans.
    I yield back to you, Mr. Chairman.
    Mr. Runyan. I thank the gentleman.
    Just your personal experience--and I am pretty sure that 
Congressman Walz, he probably doesn't have any more questions. 
I just have one thing, and I think Congressman Walz--I think 
Mr. Moreland brought it up, and it is government acting more 
like private business in adapting to their clientele. I brought 
it up to Secretary Shinseki back in a budget hearing.
    We talk about metrics and we talk about all the things that 
we are doing well. I think a lot of the time we miss the goal 
of customer service, which should be the primary metric. We can 
talk about how many claims we have filed, how many we have had 
to re-adjudicate and all that kind of stuff, but have you seen 
a movement at all, much like the private hospital system has 
kind of branched out and become more community-based and 
decentralized than the hospital, have you seen that?
    Mr. Moreland. One of the metrics that I look at every month 
is the patient satisfaction scores of both my VA facilities and 
their sister private-sector hospitals across the street. And so 
I am looking at their private-sector patient satisfaction 
results and mine, and in about five of the VA hospitals in VISN 
4, we actually do better than the community hospital across the 
street, which I think is something that most people don't know.
    When I look at the other five, three of them are doing 
essentially the same, and two of them are a little bit lower.
    So on one level I will say to you, Mr. Chairman, I think we 
are doing in many cases as well or better than the private 
sector. But I never wanted to compare myself to other people. I 
wanted to compare myself to what can I do best.
    So what we are really focused on is not only doing better, 
but getting to the best. So what we are doing is, through the 
Secretary's real big push with ICARE, his values, we are very 
much focused on having every veteran understand that we are 
here to serve you. So that is why we are running a public 
service announcement campaign right now across VISN 4 about 
quality indicators and how well we are doing. It is why we have 
a new one that is coming out very soon about Iraq and 
Afghanistan vets.
    Fifty-two to 55 percent of the returning vets have already 
enrolled in VISN 4, and I am really happy about that, but I am 
not happy because it is not 100 percent. So we are really 
working hard because I want 100 percent to come to us so that 
they can see us and find out that our public service is very 
good.
    Mr. Runyan. Mr. Walz, do you have anything further?
    Mr. Walz. No. Just again, I want to thank the staff, and I 
think that is exactly right, and I think it is important for us 
to keep in mind that that 100 percent, in the long run, serves 
this Nation so much better if we get them what they need, get 
them back to work, get them contributing. They are our leaders 
and our future.
    I want to thank you, Mr. Chairman, for the work you have 
done, for the Committee staff, both the majority and the 
minority staff.
    If you leave with anything, leave with the faith that 
although messy and ugly and, as Churchill said, the worst form 
of government ever, as democracy is, but better than every 
other one. It is messy and it is terrible, but there are good 
folks. There are good, dedicated servants. There are people who 
have served this Nation.
    We can get this right. And again, it is going to take us a 
long time, but we have to ask these hard questions.
    So I want to thank you all. You could have been elsewhere, 
but you were here, and for that I am grateful.
    I yield back, Mr. Chairman.
    Mr. Runyan. I thank the gentleman.
    I thank each of you for your time today and for taking our 
questions and your testimony.
    This completes our oversight hearing. In closing, I want to 
say stay tuned, New Jersey veterans, that the House Committee 
on Veterans' Affairs and my Subcommittee will continue to 
listen to your needs and work to fix the several issues we 
discussed here today.
    Mr. Walz, thank you for being here in New Jersey's 3rd 
Congressional District and helping make this important hearing 
possible. It has been my pleasure having you serve as Ranking 
Member throughout this hearing. I know our veterans and the 
Subcommittee benefit greatly from your dedication to military 
service, Congressman Walz, and again, thank you for your 
service to this great country.
    Do you have any other closing remarks?
    Mr. Walz. Nope, I am good.
    Mr. Runyan. I ask unanimous consent that the members have 5 
legislative days in which to revise and extend their remarks.
    Hearing no objection, so ordered.
    Once again, it is my pleasure to have you all with us here 
today, and I thank all of our esteemed witnesses for their 
testimony, and my good friend, Mr. Walz, for making a pit stop 
on his way back to Washington from Minnesota to be present here 
today.
    With that being said, this hearing is adjourned.
    Mr. Walz. Thank you, Chairman.
    Thank you all.
    [Applause.]
    [Whereupon, at 12:56 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Hon. Jon Runyan
    Good morning. Usually when we hold our DAMA Subcommittee hearings, 
we are sitting in Washington. Today, I am honored and happy to be here 
with all of you at Ocean County College in my home District.
    While we are far away from our normal hearing room on the Hill and 
the CSPAN cameras, this is still an official Congressional oversight 
hearing of the House Veterans Affairs Committee, and hearing rules of 
hearing conduct apply. Therefore, I would respectfully ask that 
everyone be courteous to our witnesses and remain silent until the 
hearing is formally adjourned.
    In Chairing the Subcommittee on Disability Assistance and Memorial 
Affairs, I have had the opportunity to work on the complicated issues 
surrounding the Veterans Benefits system, including the Compensation 
and Pension process.
    Through this experience, I have had the pleasure of working 
alongside my good friend, the Honorable Timothy Walz, who represents 
Minnesota's First Congressional District. I am happy to introduce him 
to you today and welcome him to Toms River.
    New Jersey has the 18th largest veteran population in the U.S. and 
over 60,000 veterans call the Third District of New Jersey home. As 
many of you know, our District is home to the largest disabled 
veterans' population in New Jersey--all of whom have sacrificed greatly 
for our country.
    We are also fortunate to be home to the Joint Base McGuire-Dix-
Lakehurst. This installation is critical and related to veterans' 
affairs.
    As we wind down two overseas conflicts, our military population 
will soon begin the process of transition to our veteran population.
    This transition will inevitably add additional stress to a process 
we are here today to discuss: examining the VA compensation and pension 
exam system.
    By bringing together all parties here today, from local veterans 
here in New Jersey to the VA itself, our objective is to make the 
process more efficient and, ultimately, to serve the needs of our 
veterans as best we can.
    As I'm sure all of you are aware, C&P examinations are a major 
cause of delay in the VA claims adjudication process. My office has 
been tracking a host of problems dealing with this issue in this 
district and around the country.
    So we are here today to examine this problem, not from afar in 
Washington DC, but right here in Ocean County where so many vets call 
home and who are affected by these delays.
    Currently, veterans in the southern counties in NJ receive C&P 
examinations through the Wilmington, Delaware or Philadelphia VAMCs. 
All examinations at the Wilmington VAMC are conducted by VA staff.
    As best as we have been able to discern, VA relies too much on C&P 
examinations. Often times there is sufficient medical evidence in the 
claims file alone to rate a disability based on VA and private 
treatment records.
    By unburdening VA with its current over emphasis on C&P exams, the 
process could become more efficient. Also greater access to exams could 
materialize. Based on these observations, I believe we can create 
solutions moving forward.
    Before jumping ahead to what I believe are some solid solutions to 
these problems, I'd like to welcome our witnesses here today who will 
be speaking in detail on ways to improve the system.
    It is my hope that through our mutual efforts, we can make the 
difference needed to increase access to C&P exams, unburden the claims 
process, and make your lives easier.
    Again, I am delighted to be with you today and I will now yield to 
the gentleman from Minnesota, and my good friend, the Honorable Tim 
Walz.

                                 
               Prepared Statement of Colonel Mike Warner
    Thank you for the opportunity to testify on important issues 
pertaining to our country's veterans.
    My name is Michael Warner. I am a retired army officer and service 
connected disabled veteran.
    My last assignment was Commander of Fort Dix, New Jersey.
    Upon my retirement, I was appointed by Governor Whitman to the 
position of Deputy Commissioner for Veterans' Affairs for the State of 
New Jersey. In the capacity, I had the privilege to serve the veterans 
of the New Jersey and manage the State's Veterans' Programs. those 
programs included management of the largest State veterans' cemetary in 
the United States, operations of three veterans' nursing homes, and 
oversight of New Jersey's veterans' benefits programs--assisting 
veterans in the filing of their disability claims.
    I would like to comment on two areas that are the direct concern of 
this subcommittee.
    First, in the area of State veterans' cemetaries, I strongly 
encourage the congress to authorize an increase in the burial allowance 
for veterans in order to offset the increasing costs associated with 
the burial of veterans and operations of the State Cemetary Program. 
Similiary I believe that it is important to authorize a burial 
allowance for the spouses of veterans interred in State veterans' 
cemetaries. U.S. Department of Veterans' Affairs cemetaries and 
Arlington cemetary inter spouses at no cost to the veteran. New Jersey 
provides for the burial of spouses at no cost to the veteran. However, 
State veterans' family members interred in State veterans' cemetaries 
should receive the same consideration as veterans' family members 
interred in our national cemetaries. I would also testify that spouses 
of veterans are as much veterans of military service as their 
servicemember. The family members serve by ensuring that the veteran 
can do his or her duty with the confidence that their family is being 
held together by the strong and capable hands of their spouses--many 
times on mutilple seperations for long periods of time.
    The other area I would like to comment on is the claims process, 
and, specifically, the accessability of the C&P examiners.
    I believe that the process for conducting the C&P examination needs 
to be reevaluated. Currently, veterans are required to travel to the VA 
medical center to meet with the VA medical personnel for their C&P 
examination. For this area and South Jersey, that requires the veteran 
to travel to Philadelphia, Newark or Willmington for their examination. 
This poses a hardship for many of our veterans, particularly, our older 
veterans and their care providers.
    I believe that many of these examinations and interviews could be 
conducted at the CBOC locations. While the requirement to travel to the 
medical centers may not be entirely eliminated, this approach would 
reduce the number of visits to the medical center the veteran would be 
required to undertake.
    Bringing the C&P examiners and other professionials to the CBOC 
would be in keeping with the concept of bringing the VA to the veterans 
as much as possible, as oppossed to requiring the veteran to travel to 
the medical center for all services. It is not any more difficult to 
schedule a veteran for a visit to a CBOC than it is to schedule the 
veteran to a medical center for a visit. Franky, it would also be good 
for the C&P personnel to get out of the VA medical center and see 
veterans in the community.
    The processing of claims also seems to be a never ending problem no 
matter how hard we work to ``fix'' it. The processing of claims has 
been an issue to veterans even before I was responsible for the State's 
program to assist veterans in filing their claims. In fact, there is a 
great article on the backlog of claims in the Friday edition of the 
``National Journal.'' According to the article, the backlog of claims 
exceeds 600,000.
    I believe that one of the ways to reduce the time it takes to 
process veterans' claims is to sort claims by difficulity and the 
number of primary conditions on the veteran's claim. For example, if 
claims with one primary condition was developed and submitted, the 
review process would be very simple. The claims officer would only be 
required to review the DD 214, review the doctor's information and then 
determine if the veteran's condition met one of the 15 presumptive 
conditions. If so, then approve the claim and determine the level of 
compensation. For example, if a veteran served in vietnam, and his 
physician has documented prostate cancer, he should be awarded 
compensation without a full C&P review. Every vietnam veteran who 
served in country is presumed to have been exposed to agent orange, and 
if the veteran later develops prostate cancer, it is presumed that the 
cancer is a result of his service in the theater. There should be no 
need to drag out the process any longer unless there are other 
secondary conditions that have been claimed. At some point, we need to 
trust the veteran and their physician.
    In summary, the claims process can be significantly reduced for 
claims that have one primary condition, and that condition is one of 
the 15 presumptive conditions. If these claims were assigned to one 
office and not mixed in with the more difficult claims, they could be 
adjudicated quickly. There is no reason for these claims to dwell in 
the system for months. This approach would allow the C&P examiners to 
focus more of their time on the more difficult claims.
    Thank you for the opportunity to discuss these important issues 
with you.
    Do you have any questions?

                                 
                   Prepared Statement of John Dorrity
    (A-1) When a Veteran's request for disability entitlements is 
submitted to the Veterans Benefits Administration (VBA), a process is 
enjoined that requires various steps and development of the claim in 
order to arrive at a decision. After acceptance at VBA, and entry of 
the claim into the system, a rating specialist is assigned to the claim 
based usually on the Veteran's last 2 digits of the claimant or through 
other factors of consideration relative to the policy and procedure of 
the particular VA Regional Office (RO).
    (2) As development of the claim proceeds, an integral part of the 
process of adjudication is required and requested by that VBA employee 
whom the claim is assigned to. That part of development is the 
employee's request of VHA to arrange for a C&P examination at either a 
contract provider or usually the VA Medical Center (VAMC), in which the 
Veteran resides. These evaluations are supposed to be objective and 
comprehensive. I will address the positives and negatives of this 
aspect of the process.
    (B-1) On average, between the time that VBA receives the claim and 
the C&P is ordered, at least 6-16 weeks has transpired. From the point 
of the last C&P issued, approximately 180 days passes before a decision 
is issued by BVA. If the claims issues are relatively uncomplicated, 
this time frame may be less. This brings the adjudicative process to 
approximately 1 year, give or take. I base this observation on my over 
30 years of prosecuting Veteran's claims although VA Central Office 
(CO) and the ROs might disagree. In terms of presumptive service-
connected issues (AGENT ORANGE, POW, PERSIAN GULF, etc.), this is 
purely inconsistent with timely decisions from BVA. With presumptive 
disabilities and supportive public or private medical evidence, the 
need for a C&P eludes me. C&Ps cost MONEY. At a time when our Nation is 
feeling the noose tighten economically, it makes more sense, as long as 
all evidentiary requirements are met, to decide the claim without an 
unnecessary step of a costly C&P.
    (2) In an effort to streamline the BACKLOGGED claims process, the 
Secretary of the VA has initiated information technology (IT) 
procedures. This is a laudable effort with much thought and preparation 
on the part of the Secretary and his CO staff, that I hope works. One 
of the efforts enacted by the CO of the VA is the Disability Benefits 
Questionnaire (DBQ). As a matter of fact, many of the VHA C&P 
clinicians conducting VA Exams (VAX), are struggling to complete these 
relatively simple forms and are somewhat hampered by the process as it 
does NOT provide the examiner the ability to utilize their intellect 
and expertise in arriving at an objective finding. A case in point is 
my own C&P conducted on 4/13/2012, at which my examiner struggled for 
approximately 20 minutes just to enact the DBQ program relative to my 
claim and service-connected injuries. When I received and read my own 
results, I felt as though the examiners had someone else in the 
examination room as the VAXs did NOT reflect any of the conversations 
between the examiners and myself. There was information that was NOT 
indicated on the results, DBQs, that I know transpired in conversation 
between the examiners and myself. DBQs do not always provide for the 
objectivity required to arrive at a JUST decision for the Veteran. Many 
times, because of this limited IT ``improvement'', through the lack of 
prudent, objective medical observation and testing goes by the wayside 
as a matter of procedure and in an effort just to complete the DBQ, as 
required by the CO's mandate. An ORTHOPEDIC injury, claimed by the 
Veteran, through the VHA examiner will dictate that an X-ray be taken, 
as part of the C&P. In older service-connected injuries, an X-ray, 
other than showing a fracture is entirely inconclusive. In this regard, 
I feel as though many INADEQUATE C&Ps are conducted which leads to an 
incorrect decision on the part of VBA and prolongs the claims process 
for the Veteran.
    (3) Another issue that we Veterans contend with at C&P is the 
ATTITUDE of the examiner. As previously indicated, C&Ps are to be 
objective (as the entire claims process is purported to be. More often 
than not, I have seen, upon review of the C&P, subjectivity NOT 
objective opinion on the part of the VHA examiner. Although the C&P 
notification suggests that the Veteran bring any other medical evidence 
relative to the issue, rarely do the examiners utilize this EVIDENCE in 
formulating their final report. Another case in point is AUDIOLOGY 
C&Ps. When an older Veteran files a claim for say BILATERAL HEARING 
LOSS and TINNITUS, on more than half of the occasion, I have had that 
examiner opine that the reason for the conditions is OLD AGE. This is 
not only discriminitory but downright despicable. If the evaluator 
truly understands the nature of the process outside of their own little 
world and supposed expertise, than they should contend with the issue 
of the etiology of the ACOUSTIC TRAUMA, as indicated within the 
Veteran's military exposure or MILITARY and OCCUPATIONAL SPECIALTY 
(MOS). A Veteran who served in the ARTILLERY, AVIATION, ARMOR or other 
units where the acoustic trauma is apparent are NOT afforded this 
objective review and conclusion. Many C&P examiners indicate that they 
have ``reviewed'' the Veteran's record. Without the shipment of a file, 
voluminous or not, to the examiner's desk this is an outright 
fabrication. Many VHA examiners do not have a clue in terms of the 
overall claims process due to a lack of military service themselves 
therefore, they have NO understanding or compassion in terms of the 
source of the Veteran's initial exposure to loud noises. A combat 
veteran invariably is exposed to acoustic trauma on a daily basis, this 
is a given amongst any of us who have defended our Nation.
    (4) On more then 1 occasion, I have seen proof of the Veteran's 3rd 
party being billed for C&P. The problem with this erroneous aspect of 
C&P is that a 3rd party payee (private insurance carriers, etc.) reduce 
the lifetime coverage afforded the individual through no fault of their 
own. If I am not mistaken, not only is the C&P a requirement of the 
adjudication process and NOT monetarily chargeable to anyone but, the 
Veteran is afforded TRAVEL PAY by VHA. This portion of the C&P process 
needs review as some diligent who Veterans wait at the travel station 
receive their travel pay immediately but, those who send their travel 
pay reimbursement forms in are not quite so lucky. I have clients who 
have been made to wait more than 90 days for reimbursement and others 
who submit the necessary forms and are NEVER reimbursed. Clearly, 
irrespective of the fiefdom culture that emerges in large 
bureaucracies, a national standard of this component of the process is 
overdue for review.
    (C-1) As a DIRECT representative of the Veteran, I wish to suggest 
that all is not doom and gloom within the system. There are many good 
people within VBA and VHA. This issue and other problematic elements 
are endemic in any large agency. If we do not stay ahead of the curve 
on the problems of agency, then any initiative undertaken by any 
Secretary of the VA is unlikely to bear fruit. I am in favor of the 
Secretary's present initiative and support it through my many 
interactions with my peers on the local, state and national level. I 
speak to many that we need to embrace the technology and utilize it to 
our constituent's benefit. I would point out that in a Federal agency 
that employs nearly 300,000 employees, the Secretary would be well 
served to insure that the ``culture'' of his agency is in sync with his 
mandates.
    (2) In the past, I have cc'd ththe HVAC any and all written 
complaints that I have received from individual Veterans with respect 
to the problems of C&P and will continue to do the same as long as I 
draw breath.

                                 
                   Prepared Statement of Gene O'Grady
    Good afternoon and thank you Chairman Runyan and Members of the 
Subcommittee for the opportunity to speak on behalf of our nations 
heroes on such an important issue. As Vice Commander of the American 
Legion for this area I understand how greatly affected our veterans are 
by the VA's current compensation and pension claims processing.
    The examination process for claimants filing compensation or 
pension claims can be improved to allow for better timeliness in the 
adjudication process. This would require a liberalization of Title 38 
United States Code to allow for the examination to be conducted by a 
non-VA physician or by a VA physician furnishing outpatient care.
    When a claim is filed for service-connected compensation (a 
condition(s) alleged to be related to military service) an examination, 
in many cases, is conducted to establish a nexus and to determine the 
extent to which the condition(s) is disabling. A claim for non-service-
connected pension requires an examination only when the claimant is 
below 65 years of age.
    While it may prove difficult to establish the relationship of a 
specific medical condition to military service in the instance where an 
original claim is being filed after an individual is separated from 
active duty for more than a year, the VA should explore this complex 
issue with a view toward accepting private medical evidence in lieu of 
conducting a compensation examination.
    In cases where service connection has already been established and 
the veteran is filing for an increased rating based upon a worsening of 
the condition then some provision should be made to recognize medical 
evidence either from a private physician or from a VA physician in the 
instance where a veteran receives outpatient care at a VA facility.
    Requiring a specific examination for a service-connected condition 
in many cases is redundant and only serves to slow the claims process 
unnecessarily. The development of an alternative method for assessing 
and adjudicating medical conditions that are claimed to be related to 
military service or for establishing the necessary degree of disability 
for non-service-connected pension would expedite the claims process 
significantly.
    It is not suggested that the adequacy of determining the 
relationship of a medical condition to military service or the existing 
degree of disability should be compromised but it is believed that 
alternatives to a specific compensation or pension exam exist and that 
their feasibility for use in claims should be assessed in order to 
improve the timeliness of the adjudication process.
    This may require the development of new forms that may be furnished 
to and completed and returned by physicians who are and have been 
treating the veteran for the condition(s) claimed. It could also take 
the form of utilizing VA Outpatient records in those cases where a 
veteran receives medical care at a VA facility. VA physicians can be 
trained to include specific notes or references to the veteran's 
treatment record that will assist a rater in adjudicating a claim.
    There are likely to be claims that will require a compensation or 
pension examination but with proper development it is believed that 
those situations can be reduced significantly with the result that 
timeliness will be greatly improved.

                                 
                  Prepared Statement of Walter J. Tafe
    Good afternoon. Thank you for inviting me to speak on this 
important subject. My name is Walter Tafe and I am the Director of 
Burlington County Department of Military and Veterans Affairs. Our 
office serves a community of over 35,000 veterans. With our close 
proximity to Joint Base McGuire-Dix-Lakehurst approximately 20 percent 
of our clients are recent returnees from the Global War on Terrorism.
    I am here today to share my observations regarding the Veteran 
Affairs (VA) requirements for Compensation and Pension (C&P) 
examinations. I don't come here today to throw stones at the VA. I 
understand the backlog issues and hope to make meaningful testimony 
that can help all involved gain a better prospective of the veteran's 
point of view. Although I'm sure this program was intended to speed the 
process by providing verification of a veteran's condition, in many 
cases it has the opposite effect. The reality is that veterans face a 
wait of several months before seeing a doctor, a visit that's often no 
more than a five to 10 minute conversation with a doctor who takes just 
a cursory look at the medical records--and that's assuming the regional 
office has sent the records at all. Veterans leave this examination 
extremely frustrated; many tell me they feel they've wasted several 
months waiting for an appointment that wasn't even a real medical exam.
    I would like to discuss several recommendations that, I believe, 
could have a dramatic impact on the process, reducing both the wait 
time for C&P examinations and the backlog that is presently crippling 
the claims process. My recommendations are based on my conclusion that 
many--at least 50 percent--of the C&P examinations conducted by the VA 
are unnecessary.
    Many of my clients are receiving their health care exclusively from 
the Veterans Administration health care system. This means that the VA 
already has their complete medical history in its possession. When 
these veterans file a new claim or a claim for increase, they must 
first receive a C&P exam to verify the condition. The veteran waits 
several months to receive a C&P examination so a VA doctor can verify a 
condition that was already diagnosed by another VA doctor. This makes 
absolutely no sense. It seems like the VA does not trust its own 
doctors to make a competent assessment and recommendation. Often, the 
veterans interpret this as a means of delaying the process; as a 
result, it builds great animosity between veterans the very department 
that is supposed to protect them.
    As I initially stated, approximately 20 percent of my current 
clients are only just returning to civilian life after serving on 
active duty. They are National Guard and Reserve personnel being 
released after activation, or active duty military members separating 
or retiring. In these cases the entire military service medical records 
are available to the VA. These members normally file a claim within the 
first 3 months of separation. Many are combat wounded, or have 
conditions diagnosed during active duty and verified during separation 
physical examinations. Even with a definitive medical exam at the close 
of their service, they must wait months to receive a C&P exam 
appointment--and the only point is to verify a medical condition that's 
already a matter of record. These examinations could be completely 
eliminated if the VA and DoD would simply communicate with each other 
and share information. I recommend that a military member's separation 
examination should consist of the same verification procedure used by 
the VA, thereby reducing the redundancy and expediting the claim.
    Another concern I share with others in my field is the requirement 
of a full verification process for every condition when a veteran is 
cared for by a private physician. I understand that in some cases 
verification by the VA of a condition is needed and fully justified. 
However, in documented cases of stage four cancers, severe diabetes 
with insulin dependence, coronary artery disease or similar terminal 
conditions a C&P exam seems unnecessary. Add the additional step of 
filing a claim and submitting a VA Form allowing his or her doctor to 
release all records to the VA, and the resulting delay can begin to 
seem cruel.
    A case in example: Former Marine Ronald Guernon. He is presently 
temporarily rated at 100 percent for service-connected colon and kidney 
cancer. Over a year ago his condition worsened and his prognosis was 
determined to be terminal. At that time I filed a request to upgrade 
his condition to permanent and total. I also requested Aid and 
Attendance. He now resides in Spring Hill Florida where his wife, a 
registered nurse provides care. He also receives hospice care. His life 
expectancy is listed as month-to-month. Despite the ongoing 
documentation of Mr. Guernon's deteriorating condition and the fact 
that all medical records have been given to the VA, the Tampa Regional 
Office requested he come for a C&P examination to determine whether his 
condition has worsened. This veteran is, literally, unable to travel to 
Tampa due to his condition. This proud Marine is absolutely convinced 
the VA is ``just waiting for me to die so they don't have to bother.'' 
While I'm sure this is not the case, Mr. Guernon is the perfect example 
of the crippling bureaucracy that is so significantly complicating the 
VA claims process.
    The VA is making some strides and I applaud the new ``Disability 
Benefits Questionnaires'' forms that have been provided for veterans to 
bring to their health care providers. These questionnaires were 
developed so a veteran can give it to his or her doctor to complete 
providing all the medical information required to make a rating 
decision on certain conditions. These questionnaires have been 
developed for almost all conditions a veteran can receive compensation 
for. If used correctly, they should negate the C&P process in most 
cases.
    In closing I would like to say it is my strong belief that the 
present C&P exam process is severely hindering, rather than helping, 
the VA claim process. In most cases the examinations are not thorough 
and leave veterans questioning why they waited several months for a 
five-minute exam. The perception that C&P exams are a method of 
delaying and denying claims is rampant in the veteran's community; and 
it's all the more potent when veterans like Mr. Guernon share their 
stories. It is my hope that these hearings will result in a thorough 
self-examination by VA personnel to evaluate the relevance of this 
requirement and eliminate unnecessary examinations. Thank you for your 
time and consideration of my testimony.

                                 
               Prepared Statement of Michael E. Moreland
    Chairman Runyan and Members of the Subcommittee, it is my pleasure 
to be here today to discuss VA's efforts to provide the best care 
possible to Veterans residing in Central and Southern New Jersey. 
Joining me today are Joseph Dalpiaz, Director of the Philadelphia VA 
Medical Center (VAMC) and Robert McKenrick, Director of the 
Philadelphia VA Regional Office (VARO).
    I will begin my testimony by furnishing an update on how VHA and 
the Veterans Benefits Administration (VBA) collaborate on compensation 
and pension examinations, to include the scheduling of those exams. I 
will also review VHA services provided to New Jersey Veterans.

Compensation and Pension Examinations

    VHA and VBA work together to deliver compensation and pension (C&P) 
examinations for Veterans. VISN 4 monitors and ensures access to these 
exams through dedicated staff that coordinate between VA medical 
centers and VBA regional offices. VISN staff also coordinate efforts 
related to the Integrated Disability Evaluation System (IDES) and 
provide additional resources when needed to VA medical centers. In the 
Third Congressional District of New Jersey, the vast majority of 
Veterans receive their C&P examinations at the Philadelphia VAMC, while 
a small number visit the Wilmington VAMC or a VA community-based 
outpatient clinic. In addition, VHA also coordinates some examinations 
through contract provider, QTC. This contract has allowed the 
Philadelphia VAMC to conduct additional clinical examinations. QTC has 
performed 38 audiology C&P examinations since November 2011. QTC 
conducts its examinations at sites closer to where Veterans live, 
including several locations in New Jersey.
    At the Philadelphia VAMC, the current average wait time between 
when an appointment is scheduled and the date of the C&P examination is 
between 13 and 16 days. In February 2012, the national average was 25 
days. The Philadelphia VAMC has made tremendous progress over the last 
3 years in reducing the rate of patient no-shows for these exams, 
cutting the figure in half from 15 percent in FY 2009 to 7.5 percent in 
FY 2012. This is particularly noteworthy as the total volume of 
examinations conducted at the Philadelphia VAMC has increased over the 
same time period by more than 20 percent (18,718 examinations in FY 
2009 and 23,132 examinations in FY 2011).
    The Philadelphia VAMC implemented several process changes and 
increased staff capacity and proficiency in FY 2011. The facility has 
restructured all C&P clinical appointment profiles to better manage the 
increasing complexity of examinations requested and is scheduling C&P 
clinics on weekends and holidays to enhance capacity and convenience 
for Veterans. A new physician sharing program has one physician travel 
from the Philadelphia VAMC to the Philadelphia VARO to provide one-day 
turnaround service on priority cases that do not require an on-site 
examination. Leadership at the Philadelphia VAMC reviews C&P 
performance measures on a weekly basis and develops strategies as 
appropriate to implement corrective action when necessary.
    One final innovation particularly helpful to Veterans of Operation 
Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/
OND) involves a revision to examinations conducted for traumatic brain 
injuries (TBI) to expedite the examination, thereby reducing the need 
for multiple reviews and simplifying the process for Veterans. 
Philadelphia determined that 70-80 percent of the Veterans presenting 
for TBI were not scoring well enough on their initial screen to avoid a 
second appointment with neuropsychology. Previously, this would require 
these Veterans to schedule a second appointment and return to the 
medical center at a later date. Philadelphia staff considered this a 
hardship for the Veterans, as a large number of the patients have a 
significant disability.
    To address the issue, Philadelphia changed their process for 
providing the TBI exam. They worked with neurology service to hold 
appointments available for the days that Veterans were scheduled for 
their initial TBI exam. If the Veterans scored low and required the 
second appointment, they would be scheduled later that same day to 
complete the neuropsychology exam, without the need for a return visit. 
This process has shaved approximately 5-15 days off the exam completion 
time and eliminated the need for return visits.
    At the Wilmington VAMC, the average wait time for a C&P examination 
is between 10 and 14 days. The Wilmington VAMC conducts all C&P 
examinations on-site, and is exploring options that would use 
telehealth to conduct certain types of examinations at community-based 
outpatient clinics in New Jersey and Delaware. The Wilmington VAMC has 
seen an even greater increase in the number of C&P examinations 
conducted between FY 2009 and FY 2011 than the Philadelphia VAMC, 
growing by more than 33 percent (4,902 examinations in FY 2009 and 
6,553 examinations in FY 2011). The Wilmington VAMC no-show rate has 
remained fairly constant and is currently at 10.8 percent for FY 2012.
    The Wilmington VAMC has also improved its processes. It has added 
staff in C&P clinics to allow greater flexibility in patient 
scheduling, including evening and weekend hours. The facility has 
identified a new C&P physician leader who works with the Philadelphia 
VARO on pending issues and to support collaborative problem solving. 
Wilmington VAMC is also looking at opportunities to support the Dover 
Air Force Base and the Philadelphia VARO as part of the IDES process. 
Finally, the Wilmington VAMC is exploring ways to increase the use of 
telehealth to conduct behavioral health C&P examinations at any of five 
community-based outpatient clinic locations this fiscal year.
    Both the Philadelphia and Wilmington VAMCs use a proactive, 
patient-centered approach to scheduling appointments by contacting 
patients and establishing appointment times that are as convenient as 
possible for Veterans. These facilities also make reminder calls to 
Veterans prior to their scheduled appointments to reduce the no-show 
rate. VA has established a national benchmark of 30 days for a 
cumulative average processing time for these examinations, and in each 
month of FY 2012, both the Philadelphia and Wilmington VAMCs exceeded 
the national benchmark (25-day average at Philadelphia and 20-day 
average at Wilmington). This represents a significant improvement for 
the Philadelphia VAMC, which had an average processing time of almost 
35 days in FY 2010. The vast majority of examinations conducted also 
pass all quality indicators for sufficiency and consistency between the 
available medical evidence and the examination report. Since FY 2009, 
the insufficiency rate at both Philadelphia and Wilmington was at or 
below 0.5 percent. VA's national benchmark for this figure is 1 
percent, with a smaller figure being better.

VISN 4 Overview: Central and Southern New Jersey

    Veterans Integrated Service Network (VISN) 4 consists of 10 VA 
medical centers and 43 community-based outpatient clinics (CBOCs), 17 
Vet Centers and one rural mobile clinic, which serve 104 counties 
throughout Pennsylvania, West Virginia, Delaware, New Jersey, New York, 
and Ohio. Almost 455,000 Veterans are enrolled in VA's health care 
system in VISN 4, and more than 318,000 unique Veterans received health 
care in VISN 4 during fiscal year (FY) 2011. Between FY 2010 and FY 
2011, we saw modest growth in the number of Veterans using VISN 4 for 
health care, despite a slight decline in the total number of Veterans 
enrolled. VISN 4 employs 13,144 people and has a total operating budget 
of $2.44 billion.
    In close proximity to the Southern New Jersey Veteran population, 
VA and VISN 4 operate medical centers in Philadelphia, PA and 
Wilmington, DE. As evidence of the accessibility of our inpatient 
services, 86 percent of urban Southern New Jersey enrollees live within 
a 60-minute drive of these facilities, while 100 percent of rural 
Southern New Jersey enrollees live within 90 minutes or less of these 
facilities. Approximately 82 percent of Veteran enrollees in Southern 
New Jersey live in urban areas, with the remaining 18 percent 
considered rural. The VA standard is that 65 percent of Veterans meet 
that level of access, which indicates that VISN 4 exceeds the current 
guidelines. To provide convenient outpatient care in Southern New 
Jersey, Philadelphia VAMC operates CBOCs in Gloucester County and Ft. 
Dix in Burlington County, as well as an annex clinic in Camden County. 
Wilmington VAMC serves New Jersey area Veterans at CBOCs in Northfield 
in Atlantic County, Vineland in Cumberland County, and Cape May in Cape 
May County. VISN 3 operates other VA facilities in New Jersey as well. 
Counseling, outreach and referral services are also provided to 
Veterans in the Southern New Jersey area in Vet Center locations in 
Philadelphia (two sites), Ewing, Lakewood, and Ventnor.
    Specific to the Third Congressional District of New Jersey, VA 
provides care to Veterans in Burlington and Camden Counties through 
services available at the previously-mentioned VAMCs in Philadelphia, 
PA, and Wilmington, DE, as well as the CBOC at Ft. Dix in Burlington 
County, and the annex clinic to the Philadelphia VAMC in Camden County. 
According to data published by the Joint Commission, a national 
hospital accreditation organization, these two facilities perform as 
well or better than their local private sector counterparts in all 
metrics for which there is sufficient data for comparison.\1\ In Ocean 
County, the majority of Veterans receive care from facilities located 
in VISN 3.
---------------------------------------------------------------------------
    \1\ See The Joint Commission, Quality Measure Set Comparison 
between Wilmington VA Medical Center and Christiana Care Hospital, July 
2010-June 2011. Available online: http://www.qualitycheck.org//
Consumer/SearchQCR.aspx. See The Joint Commission, Quality Measure Set 
Comparison between Philadelphia VA Medical Center and Pennsylvania 
Hospital, July 2010-June 2011. Available online: http://
www.qualitycheck.org//Consumer/SearchQCR.aspx.
---------------------------------------------------------------------------
    An estimated 61,000 Veterans reside in Burlington and Camden 
counties. In FY 2011, 19,455 Veterans from Burlington and Camden 
Counties were enrolled in VA's health care system. For that same time 
period, the medical centers in Philadelphia and Wilmington treated 
5,586 unique patients from Burlington County and 5,721 from Camden 
County.
    VA has established a standard that 70 percent of Veterans have 
access to primary care within a 30 minute drive of their residence. 
VISN 4 surpasses this requirement in Burlington County, where 94 
percent of total enrollees live within 30 minutes of primary care, and 
in Camden County, where 100 percent of Veterans have this ready access. 
In VISN 3, approximately 90 percent of Ocean County Veterans have 
access to primary care within 30 minutes.
    The Philadelphia VAMC is an acute care, teaching hospital, 
providing comprehensive patient care services, including primary care, 
tertiary care, and long-term care in areas of medicine, surgery, 
psychiatry, rehabilitation, neurology, oncology, dentistry, and 
geriatrics. A wide range of specialty care services are offered to 
Veterans at Philadelphia, such as substance use disorder treatment; 
mental health care, including evidence-based treatment for post-
traumatic stress disorder (PTSD); hemodialysis for Veterans with kidney 
disorders; skilled nursing home care; respite care; Home-Based Primary 
Care; laser surgery; and other intensive care programs. High-tech 
diagnostic services such as computerized tomography (CT) and magnetic 
resonance imaging (MRI) complement the treatment modalities. In May 
2012, the medical center will open an outpatient dialysis center for 
Veterans, and already operates a Women's Health Clinic providing 
primary and gender-specific specialty care to female Veterans. The 
facility's 240-bed Community Living Center serves the metropolitan 
Philadelphia area and provides extended care, rehabilitation, psycho-
geriatric care, palliative care, and general nursing home care to area 
Veterans.
    Philadelphia also operates several Centers of Excellence, 
including:

      The Mental Illness Research, Education and Clinical 
Center (MIRECC), which focuses on improving the identification of 
substance abuse and other mental health problems in Veterans;
      The Center for Health Equity Research and Promotion 
(CHERP), which works to reduce disparities and promote equity in health 
care among vulnerable groups of Veterans; and
      A Parkinson's Disease Research, Education and Clinical 
Center (PADRECC), one of six such facilities that strive to improve 
care for Veterans suffering from Parkinson's disease and other related 
movement disorders.

    The acute care facility in Wilmington, DE is a teaching hospital 
that provides a full range of patient care services. Comprehensive 
health care is provided through primary care and long-term care in 
several areas of medicine, including surgery, psychiatry, physical 
medicine and rehabilitation, neurology, oncology, dentistry, 
geriatrics, and extended care. Wilmington VAMC also provides 
comprehensive primary care for women Veterans.

Conclusion

    VHA and VBA are a strong team providing a full range of benefits 
and health care to Central and Southern New Jersey Veterans. VBA and 
the Philadelphia VA Regional Office, together with VHA and VISN 4, 
strive to furnish Veterans with timely and accurate compensation and 
pension evaluations. VISN 4 is committed to ensuring access to 
comprehensive health care through primary, acute inpatient, and long-
term care in areas of medicine, surgery, psychiatry, physical medicine 
and rehabilitation, neurology, oncology, dentistry, geriatrics, and 
extended care. Mr. Chairman, this concludes my testimony. My colleagues 
and I look forward to answering any questions you may have. Thank you.

                                 
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