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94–132 PDF 2016

S. HRG. 114–233 

THE FISCAL YEAR 2016 BUDGET FOR 

VETERANS PROGRAMS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

FEBRUARY 26, 2015 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

RICHARD BLUMENTHAL, Connecticut, Ranking 

Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JON TESTER, Montana 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

TOM BOWMAN, Staff Director 

JOHN KRUSE, Democratic Staff Director 

(III) 

C O N T E N T S 

FEBRUARY 26, 2015 

SENATORS 

Page 

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

Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from Connecticut ... 3 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 44 

Brown, Hon. Sherrod, U.S. Senator from Ohio ..................................................... 47 

Cassidy, Hon. Bill, U.S. Senator from Louisiana .................................................. 50 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 53 

Prepared statement .......................................................................................... 53 

Sullivan, Hon. Dan, U.S. Senator from Alaska ..................................................... 56 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 59 

Rounds, Hon. Mike, U.S. Senator from South Dakota ......................................... 62 

Sanders, Hon. Bernard, U.S. Senator from Vermont ........................................... 64 

Hirono, Hon. Mazie K., U.S. Senator from Hawaii ............................................... 67 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 203 

WITNESSES 

McDonald, Hon. Robert A., Secretary, U.S. Department of Veterans Affairs; 

accompanied by Carolyn M. Clancy, M.D., Interim Under Secretary for 

Health; Hon. Allison A. Hickey, Under Secretary for Benefits; Ronald E. 

Walters, Interim Under Secretary for Memorial Affairs; Hon. Helen 

Tierney, Assistant Secretary for Management and Chief Financial Officer; 

and Stephen W. Warren, Executive in Charge and Chief Information Officer, Office of Information and Technology ......................................................... 4 

Prepared statement .......................................................................................... 9 

Response to prehearing questions submitted by Hon. Johnny Isakson ....... 31 

Response to request arising during the hearing by: 

Hon. Sherrod Brown ..................................................................................... 49 

Hon. Patty Murray ........................................................................................ 54 

Response to posthearing questions submitted by: 

Hon. Johnny Isakson .................................................................................... 70 

Hon. Richard Blumenthal ............................................................................ 134 

Hon. John Boozman ...................................................................................... 159 

Hon. Bill Cassidy .......................................................................................... 165 

Hon. Jon Tester ............................................................................................. 166 

INDEPENDENT BUDGET REPRESENTATIVES

Blake, Carl, Associate Executive Director for Government Relations, Paralyzed Veterans of America ................................................................................... 168 

Prepared statement .......................................................................................... 170 

Ilem, Joy, Deputy National Legislative Director, Disabled American Veterans 174 

Prepared statement .......................................................................................... 175 

Kelley, Raymond C., Director, National Legislative Service, Veterans of Foreign Wars of the United States ........................................................................... 181 

Prepared statement .......................................................................................... 183 

OTHER VETERANS SERVICE ORGANIZATIONS

de Planque, Ian, Director, National Legislative Division, The American Legion ........................................................................................................................ 185 

Prepared statement .......................................................................................... 186 

Page

IV 

Weidman, Richard, Executive Director for Policy and Government Affairs, 

Vietnam Veterans of America ............................................................................. 190 

Prepared statement .......................................................................................... 191 

APPENDIX 

Independent Budget; report ..................................................................................... 207 

(1) 

THE FISCAL YEAR 2016 BUDGET FOR 

VETERANS PROGRAMS 

THURSDAY, FEBRUARY 26, 2015 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 9:33 a.m., in room 

418, Russell Senate Office Building, Hon. Johnny Isakson, Chairman of the Committee, presiding. 

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

Rounds, Tillis, Sullivan, Blumenthal, Murray, Sanders, Brown, 

Tester, Hirono, and Manchin. 

OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 

U.S. SENATOR FROM GEORGIA 

Chairman ISAKSON. I will call to order this meeting of the Veterans’ Affairs Committee of the U.S. Senate and welcome everybody on a snowy, cold Washington day. 

We are glad to have you, Mr. Secretary, Dr. Clancy, and all the 

members of your staff here, and glad to have the veterans service 

organizations in to talk about VA’s budget request and the current 

pending budget for the U.S. Department of Veterans Affairs. 

I am going to open—we changed the rules a little bit. We are 

going to have an opening statement by the Chairman and an opening statement by the Ranking Member. Then we are going to let 

any other Member who wants to make a public statement make a 

closing statement so we can go straight to your testimony and give 

you all the time that you need to do so. We will receive questions 

based on the early-bird rule and we will alternate between Republican and Democrat in that order so we will be fair and equitable 

and everybody here gets a chance to ask questions. 

I am going to be liberal with the time, because I think this is a 

very important hearing and it is very important for us to understand the Department’s request. It is equally important for the Department to understand what we really want to see out of the Veterans Administration, so thank you for being here. 

Secretary MCDONALD. Thank you, Mr. Chairman. 

Chairman ISAKSON. I thought last night, when I prepared for 

what I might say this morning, about the last 2 years on the Committee, because it has been a rough 2 years in a lot of ways for the 

VA; a rough 2 years for us. There have been a lot of increases in 

money to VA. There have been increases in parameters. The Veterans Choice bill has passed and we are trying now to implement 

that. We have had the challenges with mental health, particularly 

2 

with veterans’ suicide rates. We have had a lot of other problems 

with construction and other departments within the Department. 

So, you could look back and say, this thing is a mess. The fact 

of the matter is that you have—with your estimate for employees 

in fiscal year 2017, you are going to have 305,000 employees in the 

Veterans Administration health care, just the health care system 

alone. That is a big organization, exceeded only by the United 

States military in its totality as the largest employer in government. So, you have a big organization that could be—and sometimes is—unwieldy. 

We, as a committee, want to try to make it work as seamlessly 

as possible. We want the funding to be appropriate, but not in the 

excess; and, we want our attitude and the attitude of the Department to be equally focused on the veteran and the veterans’ health 

care, not on ourselves. 

To that end, I did a little math last night—I am a Georgia graduate, so I might be corrected by some of these people that went to 

higher institutions than that—but I was trying to figure out the 

ratio of employees to the number of beneficiaries in the VA. There 

are 6.5 million veterans—I believe that is the right number—who 

are using VA health care. Is that correct? 

Secretary MCDONALD. That is very close. Yes, sir. 

Chairman ISAKSON. OK. And, there are going to be 305,000 employees in veterans’ health systems if you get the number of employees you want in 2 years? 

Secretary MCDONALD. That is correct. Yes, sir. 

Chairman ISAKSON. That is a ratio of 21 veterans to every one 

employee in the VA. That is pretty good—that is a lot better than 

the pupil-teacher ratio you have in public education today. So, I am 

not sure that we have a shortage of employees nearly as much as 

we have not every oar in the water rowing in the same direction 

in terms of those that are following you and your leadership, or in 

terms of us and the support we are giving to you. 

I am troubled by the lack of detail in some of your request, and 

I want to get into that in the Q and A portion, because I know 

there is a request for 5,000 more employees in the VA over the 

next couple of years. I understand why it is being asked for, but 

I ask the question, if the ratio is 21-to-1 now, are we going to lower 

it to 19-to-1; and is that going to improve anything, because more 

is not necessarily better in any business. In fact, sometimes more 

can be more cumbersome than it can be healthy. 

Second, as I told The American Legion yesterday—we have had 

a hearing with the Legion, we had the Disabled American Veterans 

hearing—and in both hearings, the VSOs made it clear that while 

they understood Veterans Choice, they wanted to make sure we understood that they did not want Veterans Choice to replace VA 

health care. 

So, I want to repeat what I told the Commander from Kansas 

and Nebraska yesterday at the end of the meeting. We need the 

VSOs and the Veterans Administration putting their heart and 

soul behind making Veterans Choice work, not as a replacement for 

VA health care, but as a force multiplier for VA health care, and 

to be the VA health care of the 21st century. Veterans Choice was 

not designed to be a replacement. It was designed to be a help us 

3 

deal with the problem that existed in the administration in the delivery of health care, in appointments, in timeliness, and in proximity to specialized care that veterans oftentimes need. 

So, one of the things you are going to hear me say over and over 

and over again, which I hope the Veterans Administration employees and the VSO leaders are listening to this, they need to get onboard and start going forward. There is an old saying that a radio 

disc jockey in Atlanta had. ‘‘Them that’s going, get in the wagon. 

Them that ain’t, get out of the way.’’ That is what we need to do 

on Veterans Choice. We need to make it work to address the problems that the VA health care has experienced and get health care 

to our veterans in the most timely and seamless way we can. I am 

dedicated and committed in my service as Chairman to doing just 

that. 

As I close my remarks—I have got coins for the Members, by the 

way, which they will be getting when we come back next week, 

that have the IDWIC acronym on it, ‘‘I Do What I Can’’ to help 

with veterans health care. We want you to do what you can to 

make it work for us. We welcome you today. We look forward to 

your testimony. 

I am pleased to now turn to the Ranking Member, Senator 

Blumenthal. 

OPENING STATEMENT OF HON. RICHARD BLUMENTHAL, 

RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thank you, Mr. Chairman, for that very 

eloquent opening statement. 

I am very eager to turn to our witnesses and to our colleagues 

for questions, but let me just state right at the outset, Secretary 

McDonald, I have welcomed many of the steps that you have taken 

as a beginning toward MyVA, meaning all of our VA, and you were 

hired to do a very dramatic turnaround. And, as with many tremendous challenges, that turnaround will take time and very likely 

stronger action than you have been willing to devote so far. 

The Congress responded to the debacle of delays and inadequate 

health care in some facilities by approving a measure that also is 

still a work in progress. The Choice Act has been shockingly underutilized, as you and I have discussed. The reasons are uncertain 

and unknown at this point. 

What is really necessary now is better data and stronger information. That has been one of the downfalls of VA to this point: the 

lack of reliable, accurate, truthful information. It was the downfall 

of your predecessor. Very simply, certain people in the VA lied to 

us. 

So, the oversight function of this body is tremendously important 

to our work like demanding reliable, accurate data and information 

for your decisions. As you know from being a very successful chief 

executive in the private sector, decisions are only as good as the 

information that underlies it, which is why I have posed some 

questions to you in the last couple of weeks. You have been very 

forthright and forthcoming in seeking to respond to them. I recognize that some of them will require time to answer. 

I am hoping that we can answer them in order to better know, 

for example, about some of the factors that are contributing to the 

4 

underutilization of the Choice program, the illogical 40-mile interpretation—the American Legion Commander characterized it yesterday as ‘‘crazy,’’ the confusing clarification around the geographic 

barriers and the definition of the term ‘‘facilities’’ in a meaningful 

way. Beyond the health care issue, there are all kinds of questions 

as to the backlog of disability claims, GI Bill benefits for education, 

physical facilities, and infrastructure. These challenges are more 

important than ever. 

I look forward to your testimony today on what the VA is doing 

and also how it can better connect with the Department of Defense. 

One of the still important problems is the disconnect in so many 

respects, whether it is information technology, or drug formularies. 

I spent some time yesterday talking to General Chiarelli about the 

formulary issue, which he has very pointedly and importantly 

raised. 

There are a variety of challenges ahead that this budget seeks 

to address, and I welcome the partnership between your team and 

the Congress in seeking to address them and, finally, doing more 

about not only health care in general, but mental health in particular. The Clay Hunt SAV Act was a proud achievement of this 

Committee on a very bipartisan basis, and I want to thank again 

the Chairman for putting it so high on the list of priorities for this 

Committee to address. 

Thank you very much, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Blumenthal. 

We are going to recognize the Secretary. I told the Secretary before the hearing that I am not going to run the clock on him. I will 

gavel him down if he starts repeating himself, but this is very important testimony and a very important budget request. I want to 

give you the time to make your request and make your points. You 

are recognized for your presentation. 

STATEMENT OF HON. ROBERT A. MCDONALD, SECRETARY, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 

CAROLYN M. CLANCY, M.D., INTERIM UNDER SECRETARY 

FOR HEALTH; HON. ALLISON A. HICKEY, UNDER SECRETARY 

FOR BENEFITS; RONALD E. WALTERS, INTERIM UNDER SECRETARY FOR MEMORIAL AFFAIRS; HON. HELEN TIERNEY, 

ASSISTANT SECRETARY FOR MANAGEMENT AND CHIEF FINANCIAL OFFICER; AND STEPHEN W. WARREN, EXECUTIVE 

IN CHARGE AND CHIEF INFORMATION OFFICER, OFFICE OF 

INFORMATION AND TECHNOLOGY 

Secretary MCDONALD. Thank you, Chairman Isakson and thank 

you, Ranking Member Blumenthal, Members of the Committee. 

Thanks for the opportunity to discuss VA’s 2016 budget and 2017 

advance appropriations requests. I appreciated the opportunity to 

speak with many of you during the past few weeks to gather your 

questions and to be able to try to address them. We appreciate the 

partnership. 

We also appreciate the President’s and Congress’ steadfast support for veterans, their families, and survivors, as well as the assistance of Veterans Service Organizations. 

As VA emerges from one of the most serious crises the Department has ever experienced, we have before us a critical opportunity 

5 

to improve care for veterans and build a more efficient and more 

effective system. With your support, VA intends to take full advantage of this opportunity. 

Members of this Committee and VSOs share my goal to make VA 

a model agency with respect to customer experience, an example 

for other Government agencies. With efficient and effective operations, we look to be comparable to the top private sector businesses in order to best meet the Nation’s obligations to all 

veterans. 

The cost of fulfilling our obligations to veterans grows over time 

because veterans’ demands for services and benefits continue to increase even after wars end. 

This chart (see Veterans Receiving Service-Connected Disability 

Compensation on pg. 8 of 23) shows that 22 percent of Vietnam 

veterans were receiving service-connected disability claims in 2014, 

four decades after the war ended. We expect the percentage will 

continue to increase. 

It is worth remembering that today, almost 150 years after the 

Civil War, VA is still providing benefits to the child of a Civil War 

veteran. 

We still have troops in both Iraq and Afghanistan, yet in the last 

decade, we have already seen a dramatic increase in the demand 

for benefits and care. This chart (see Percent of Veterans Receiving 

Disability Compensation on pg. 10 of 23) shows that from 1980 to 

2000, the percentage of veterans receiving VA compensation was 

stable at about 8.5 percent. But in just the last 14 years, since 

2001, the percentage has dramatically increased to 19 percent. 

Simultaneously, the number of claims and medical issues in 

claims has soared. Look at this chart. As this chart shows (see 

Claims and Medical Issues Completed on pg. 15 of 23), in 2009 

VBA completed almost 980,000 claims. In fiscal year 2017, we 

project we will complete over 1.4 million claims. That is a 47-percent increase. 

But there has been a more dramatic growth in the number of 

medical issues in claims, 2.7 million in 2009 and a projected 5.9 

million in 2017. That is a 115-percent increase in just 8 years. 

Now, these increases were also accompanied by a rise in the average degree of veterans’ disability compensation. For 45 years, 

from 1950 to 1995, the average degree of disability was 30 percent. 

Since 2000, the average degree of disability has risen to 47.7 percent, nearly 50 percent, as this chart (see Average Degree of Disability on pg. 10 of 23) shows. 

While it is true that the total number of veterans is declining— 

and the total number of veterans is declining—the number of those 

seeking care and benefits is increasing. 

Fueled by more than a decade of war, Agent Orange-related 

claims, an unlimited claims appeal process, increased medical 

claims issues, far greater survival rates of those wounded, more sophisticated methods for identifying and treating veterans’ medical 

issues and demographic shifts, and as we said, the population is 

aging, veterans’ demand for services and benefits exceeded VA’s capacity to meet them. It is important that Congress and the American people understand why that is happening. 

6 

The most important consideration is that America’s veterans are 

aging, and their health care requirements and demand for benefits 

increase as they age and as they retire. 

Look at this chart (see Number of Living Veterans on pg. 9 of 

23). This chart reveals an astounding shift. Just 40 years ago, only 

2.2 million veterans were 65 years old or older. That is 7.5 percent 

of the population, and you can see that in 1975 based on the size 

of the red bar. 

But look at 2017. We expect 9.8 million veterans will be 65 years 

or older. That is 46 percent of veterans. Just look at the size of the 

red bar from 1975, the year I graduated from West Point, to what 

we project in 2017. So, we now serve an older population with more 

chronic conditions who are less able to afford private care. 

Currently, 11 million of the 22 million veterans in this country 

are registered, enrolled, or use at least one VA benefit or service. 

More are demanding VA services and care than ever before. 

The requirement for women veterans and mental health care has 

increased dramatically. Over 635,000 women veterans are now enrolled for health care, and over 400,000 actively use VA. That is 

double the number using the VA in the year 2000. Annual increases in women veterans seeking care are about 9 percent, and 

this trend will continue. Our Women Veterans Call Center now 

connects with about 100,000 women veterans per year. 

In 2014, over 1.4 million veterans with a mental health diagnosis 

enrolled in VHA, and we had 19.6 million mental health outpatient 

encounters. Those are increases of 64 percent and 72 percent, respectively, since the year 2005. 

Since its inception in 2007, the Veterans Crisis Line has answered over 1.6 million calls and assisted in over 45,000 rescues. 

As veterans witness the results of the positive changes VA is making and as the military downsizes, the number of veterans choosing 

VA services will continue to rise. It should, and they have earned 

it. 

We are listening hard to what veterans, Congress, employees, 

and VSOs are telling us. What we hear drives us to a historic department-wide transformation, changing VA’s culture and making 

veterans the center of everything we do. We call it MyVA, and it 

entails many organizational reforms to better unify the Department’s efforts on the behalf of veterans. 

These are the strategies at MyVA. We have them listed in our 

written testimony as our five major themes. 

First, We are working to improve the veteran experience so that 

every veteran has a seamless, integrated, and responsive customer 

service experience every single time. We are working with the very 

best companies in customer experience in the private sector to do 

that. 

Second, we are improving employee experience by eliminating 

barriers to customer service and focusing on our people and culture 

so we can better serve veterans. We have no hope of taking care 

of veterans unless we take care of our employees. 

Third, improving our internal support services, which is where 

we think we can improve our productivity dramatically and, therefore, get more resources to serve veterans. 

7 

Fourth, establish a culture of continuous improvement to identify 

and correct problems faster and, importantly, replicate solutions at 

all facilities. 

And, number 5, enhance strategic partnerships. Strategic partnerships, like the Choice Act, as the Chairman said, are a force 

multiplier, and we want to take advantage of that. 

MyVA revolutionizes culture and reorients VA around the needs 

of veterans, measuring success by veterans’ outcomes as opposed to 

internal metrics. Reorganizing the Department geographically is a 

first but substantial step in achieving this goal. 

In the past, VA had nine disjointed geographic organization 

structures, one for each of our nine lines of business. Our new unified organization framework has one national structure, as shown 

on this chart (see pg. 5 of 23). The new structure has just five regions, aligning VA’s disparate organization boundaries into a single 

framework. You will notice this framework and these boundaries 

are by State lines, which they were not previously. This facilitates 

internal coordination and collaboration among business lines; it 

creates opportunities for local level integration, pushing responsibility lower in the organization. It promotes effective customer 

service. Veterans will see one VA rather than individual, disconnected organizations. 

Last, MyVA is about ensuring sound stewardship of taxpayer dollars. We will integrate management improvement systems such as 

Lean Six Sigma across operations to ensure we balance veterancentric service with operational efficiency. But we need the help of 

Congress. VA cannot be a sound steward of the taxpayers’ resources with the asset portfolio we currently carry. No business 

would carry a portfolio like the one we have. Veterans deserve better. It is time to close VA’s old, substandard, and underutilized infrastructure. We have 900 VA facilities that are over 90 years old 

and more than 1,300 that are over 70 years old. VA currently has 

336 buildings that are vacant or less than 50 percent occupied. 

That is 10.5 million square feet of excess, costing an estimated $24 

million annually to maintain. These funds could be used to hire 

roughly 200 registered nurses for a year or to pay for 144 primary 

care visits for veterans or to support 41,900 days of nursing home 

care for veterans in community living centers. We need your support to do the right thing. 

MyVA reforms will take time, but over the long term, they will 

enable us to better provide veterans the services and benefits they 

have earned and that our Nation has promised them. Our 2016 VA 

budget will allow us to continue transforming the intent of MyVA. 

It requests $168.8 billion—$73.5 billion in discretionary funds and 

$95.3 billion in mandatory funds for benefit programs. The discretionary request is an increase of $5.2 billion, which is 7.5 percent 

above the 2015 enacted levels. This will provide resources to continue serving the growing number of veterans seeking care and 

benefits. The budget will increase access to medical care and benefits for veterans. It will address infrastructure challenges, including major and minor construction, modernization, and renovation. 

It will end the backlog of claims and will end veterans’ homelessness by the end of 2015. It will fund medical research and prosVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6601 Z:\ACTIVE\022615.TXT PAULIN
8 

thetics research; and it will address IT infrastructure and modernization needs. 

The resources required in the 2016 budget request are in addition to those Congress provided last year in the Veterans Choice 

Act. The VA has fully implemented this act and will be expanding 

our outreach and providing more information to veterans with a 

nationwide public service announcement, which I would be happy 

to show you sometime today during the hearing if the Committee’s 

time permits. 

We do not know at this time how many veterans will use the provisions of the act to seek non-VA care or how much that care will 

cost. As this chart demonstrates (see pg. 11 of 23), there is a high 

degree of uncertainty about resources required. Our current estimates range from a demand low of about $4 billion to a high of 

about $13 billion over the 3-year program. 

We will need flexibility within our budget to ensure that we have 

the right resources at the right places at the right time to provide 

veterans the timely care they need, regardless of wherever they 

choose to receive it. 

As an example of this flexibility, we are currently exploring options to review the 40-mile provision, as we have talked, of the 

Choice Act to get more veterans the care that they want and need. 

I look forward to and I want to continue to work with the Committee Members on the redefinition of this 40-mile limit and work 

with other Members of Congress and veteran stakeholders on this 

critical issue as we gain more information about how veterans are 

using the Choice Act. 

We meet today at a historically important time for VA and the 

Nation. Next Wednesday, March 4, will mark the 150th anniversary of President Lincoln’s solemn promise to care for those who 

have borne the battle and for their families and their survivors. 

That is VA’s primary mission. It is the noblest mission of supporting the greatest clients of any agency in the country. 

Mr. Chairman, Members of the Committee, thanks again for your 

support for veterans, for working with us on these budget requests, 

for your patience in listening to my presentation, and for making 

things better for all veterans. We look forward to your questions. 

[The prepared statement of Secretary McDonald follows:] 

9 

PREPARED STATEMENT OF HON. ROBERT A. MCDONALD, SECRETARY, U.S. 

DEPARTMENT OF VETERANS AFFAIRS


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RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON TO U.S. 

DEPARTMENT OF VETERANS AFFAIRS

Question 1. The Secretary has undertaken an ambitious goal to reorganize the Department of Veterans Affairs (VA) into a more veteran centric organization. This initiative, called MyVA, intends to put the veteran first and give them the opportunity 

to choose how and where they are served. In addition, it is intended to integrate 

VA to increase productivity and efficiency across the Department. 


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a. In total, how much funding is requested for the MyVA initiative for fiscal year 

(FY) 2016 and for FY 2017? 

b. If VA’s budget is adopted, how many additional employees in total would be 

hired in relation to the MyVA initiative? 

c. Please provide the breakdown of where those employees would be located, including how many would be located at VA’s Central Office and how many would be 

located in the field. 

d. Please provide a breakdown of what categories of positions those employees 

would fill. 

VA Response (a-d). The 2016 Budget requests: (1) $3.5 million and 15 Full-Time 

Equivalent (FTE) employees for MyVA in the General Administration account, and 

(2) $76.3 million and 204 FTE supported from within the existing VA budget as reimbursable funded activities. As the process continues and the specific policy and 

program changes are identified, the Department will submit budget requests for implementation, beginning in FY17. 

Question 2. Within the Medical Support and Compliance account, VA is request- ing 5,006 new Full-time equivalent (FTE) employees and an increase of $283.7 million to support the Secretary’s MyVA initiative. These new FTE would be in the 

field at the VA medical centers (VAMCs) and Veterans Integrated Service Networks 

(VISNs). 

a. Please describe the analysis performed to determine whether 5,006 new FTE 

were needed as opposed to whether the duties of these new FTE could be performed 

as ancillary duties of existing employees. 

Response. The Medical Support and Compliance FTE growth is not associated 

with the Secretary’s MyVA initiative. 

The additional positions are being added to the Medical Centers and VISNs to 

support and fulfill the Secretary’s vision of becoming a more Veteran-centric organization and to be able to provide top-level customer service in a more efficient manner to our Veterans. These personnel will support healthcare workers in order to 

deliver the healthcare services that our Veterans expect. 

Although the FY 2016 Revised Request estimate of 54,020 FTE is 5,006 more than 

the original FY 2016 Advance Appropriation estimate, it is only 1,206 more than 

the FY 2015 Current Estimate. The FY 2015 Estimate is largely based on FTE Operating Plans submitted by the Veterans Integrated Service Networks, and reflects 

a concerted effort to provide more support staff to VA clinical staff to enhance Veterans access to health care. The FY 2016 Revised Request increase of 1,206 FTE 

above the FY 2015 Current Estimate is a 2.3% increase, which is in line with VA’s 

estimated increase in health care demand. 

b. Please provide the full list of 5,006 positions, job descriptions, and the General 

Schedule or Title 38 pay grade(s). 

Response. See table below. It should be noted that these staffing levels do not reflect the additional medical and clinical support staff added under the Veterans 

Choice Act to increase Veterans’ access to medical care, which is accounted for separately in the budget. 

Description 

2016 

Advance 

Approp. 

Revised 

Request 

Increase/ 

Decrease 

Physicians ........................................................................................................................... 611 651 40 

Dentists ............................................................................................................................... 15 10 (5 ) 


94132q1VA2a.eps
33 

Description 

2016 

Advance 

Approp. 

Revised 

Request 

Increase/ 

Decrease 

Registered Nurses ............................................................................................................... 2,960 3,365 405 

LP Nurse/LV Nurse/Nurse Assistant .................................................................................... 90 105 15 

Non-Physician Providers ..................................................................................................... 235 227 (8 ) 

Health Technicians/Allied Health ........................................................................................ 1,206 1,119 (87 ) 

Wage Board/Purchase & Hire ............................................................................................. 903 993 90 

All Other 1 ........................................................................................................................... 42,994 47,550 4,556 

Total ........................................................................................................................... 49,014 54,020 5,006 

1 All Other Category includes: Medical Records Clerk/Technician, Budget/Fiscal, Contract Administrator, Supply Technician, Medical Support 

Assistant, Administrative Support Clerk, Administrative Specialist, Police, Personnel Management Specialist, Management and Program Analyst, 

and other staff that are necessary for the effective operations of VHA Medical Support and Compliance 

c. Would the new FTE report to the VAMC and/or VISN directors? If not, please 

provide the reporting structure for these positions. 

Response. The majority of these new FTE will be supporting health care workers 

at VA medical centers and would report through their supervisory chain to the local 

Medical Center Director. Other FTE would be added for VA Consolidated Activities, 

such as Consolidated Mail Outpatient Pharmacies and Consolidated Patient Account 

Centers. 

Question 3. The President’s budget request indicates that ‘‘[i]n the coming months, 

the Administration will submit legislation to reallocate a portion of Veterans Choice 

Program funding to support essential investments in VA system priorities in a fiscally-responsible, budget-neutral manner.’’ How much of the Veterans Choice Program funds, and to which programs, does the Administration propose to reallocate? 

Response. It is too early in the implementation of the Veterans Choice Program 

to provide a detailed answer. VA is assessing Veterans’ utilization of the Choice Program while also examining where the Veterans Choice funding could be utilized to 

meet the demand for Veterans services in VA’s base program. VA’s highest priority 

is ensuring that Veterans have timely access to high quality care. VA will work with 

Congress on any legislative proposal to ensure that budgetary resources are allocated in a way that maximizes Veteran access to care and services. 

Question 4. The budget request includes an increase of $1.3 billion to the FY 2016 

advanced appropriations for medical care. The majority of the increased funding 

would be for initiatives that are not included in the Enrollee Health Care Projection 

Model. 

a. Please explain in detail what changed with these initiatives since the FY 2016 

advanced appropriations request was sent to Congress in March 2014? 

Response. See the attachment. The primary drivers of the increase were increased 

demand for health care services (which included the cost of new lifesaving Hepatitis 

C treatments), increased demand for Caregivers stipends, an increased estimate for 

the cost of activation of new health care facilities, increased investment in programs 

to assist homeless Veterans (largely increased HUD-VASH vouchers) and increased 

investment in non-recurring maintenance. 

34 


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36 

b. What metrics does VA use to ensure it is requesting the total amount needed 

for these initiatives when the budget request is sent to Congress? 

Response. The FY 2016 advance appropriation funding level included in the FY 

2015 Budget submission focused on providing essential initial funding for the advance appropriations year to ensure continuity of veterans’ health care services. 

Each year, Medical Care funding, including funding for all non-modeled activities, 

is revisited during the budget process for the next submission and is revised to reflect updated information on funding requirements and budgetary resources, including unobligated balances. 

Question 5. The budget request for the FY 2016 medical care appropriations and 

the FY 2017 advanced appropriations request include a cost shift of $452 million 

and $733 million, respectively, due to veterans using the Choice Program. Please 

explain the metrics used to determine the amount for FY 2016 and FY 2017 and 

the number of veterans it is estimated to provide care through the Choice Program. 

Response. The Veterans Choice Program (VCP) may provide a measure of shortterm relief from the pressure of escalating health care requirements as some current 

patients in the VA system elect to receive their care through the program. The 2016 

and 2017 requests for the Medical Care appropriations assume that some veterans 

who would otherwise receive care in the VA health care system will now receive 

that care through the VCP, instead. This introduces a shift of health care costs from 

the discretionary program to the new mandatory source of funding in the Veterans 

Choice Fund, thereby reducing the discretionary appropriations request by the same 

amount. The assumed cost-shift is $452 million in 2016 and $733 million in 2017. 

These estimates were developed prior to having program experience and will need 

to be revalidated going forward. 

Key assumptions that were used in the cost-shift model prior to program implementation: 

• Consistent with the Regulatory Impact Analysis (RIA) for the Veterans Choice 

Program Interim Final Rule, we split the population into the two cohorts—(1) veterans living more than 40 miles from a VA facility (or meeting the other geographic 

criteria); and (2) veterans waiting more than 30 days for their scheduled appointment. 

• In general, we used the same assumptions that were published in the RIA, 

wherever possible. 

• One of the most sensitive factors involves the assumption about how many eligible veterans will participate in the VCP. It’s difficult to predict veterans’ behavior 

in response to this new choice, so we used a range of rates, from low to high. 

As VA gains program experience we will revisit the methodology used to develop 

the cost shift estimate. 

Question 6. During a House Veterans’ Affairs Committee hearing on January 21, 

2015, Deputy Secretary Gibson stated that the interim 90-day contract for the Denver VA Medical Center has been funded with $70 million. Please provide a detailed 

expenditure report for the $70 million, including when it will be depleted. 

Response. This interim contract for $70 million includes a $20 million allowance 

to settle subcontractor liabilities, and $50 million for continued work on the project 

on a cost reimbursable basis. The $50 million is currently funding critical activities 

on the construction site. VA has added an additional $30 million for continued work 

on the construction for a total of $80 million. The $80 million is estimated to fund 

construction activities through March 29, 2015. If additional funds are not added to 

the contract VA will be forced to stop work on the site and begin to demobilize the 

contractor. 

Question 7. VA indicated that the interim Denver contract will require an additional $300 million. Please provide a comprehensive list of the major construction 

projects that will have funds transferred to the Denver VAMC to pay for this increase and the specific amount taken from each project. 

Response. The following table shows the source of the funding for the reprogramming actions to date: 

Source Amount 

VHA Working Reserve (No Bid Savings) ................................................................................................................... $27,109,829 

Physically Complete Projects (Bay Pines, FL—Outpatient Clinic (Lee County); Columbia, MO—Operating Suite 

Replacement; San Juan, PR—Seismic Corrections; Tampa, FL—Upgrade Essential Electrical Distribution 

System; Murfreesboro, TN—Psychiatric Care Facility) ........................................................................................ 3,897,215 

Funds Transferred from Line items: 

Facility Security ............................................................................................................................................... 8,401,000 

37 

Source Amount 

Asbestos .......................................................................................................................................................... 12,951,956 

Judgment Fund ................................................................................................................................................ 3,240,000 

VBA APF ........................................................................................................................................................... 1,000,000 

Total ........................................................................................................................................................ $56,600,000 

VA has not finalized which projects will have funds transferred to the Denver 

project to pay for the next increase which is projected to continue progress on the 

project until USACE has developed its cost estimate and entered into a long-term 

contract with Kiewit-Turner Construction. 

Question 8. The FY 2016 budget request has TBD listed for the total estimated 

cost and future requests for the Denver VA Medical Center. Given that the facility 

has already had $825 million allocated to it, when will a new total estimated cost 

for the facility be complete? 

Response. VA and the Army Corps of Engineers (USACE) are working collaboratively on the current short-term contract with Kiewit-Turner Construction, with 

the expectation of a long-term contract being negotiated by the USACE. USACE 

continues to develop a cost estimate to complete the effort and is tracking for a contract award summer 2015. As additional steps are taken USACE and VA will continue to update our stakeholders. 

Question 9. For FY 2015, the West Los Angeles major construction project received a $35 million appropriation but was not authorized. The Long Beach major 

construction project received $101.9 million in appropriated funds but was not authorized. The FY 2016 budget requests authorization again for these projects, 

though it seems to reflect that the FY 2015 funds have been received and possibly 

spent. What is the status of the FY 2015 funds for the West Los Angeles and Long 

Beach projects? 

Response. Congress did not pass legislation to authorize any of the major construction projects in FY 2015, including Long Beach, San Diego, San Francisco, 

West LA, and Canandaigua. VA is asking Congress to pass legislation to authorize 

these five projects expeditiously, in addition to the six new authorization requests 

for major construction projects are included in the FY 2016 Request. 

None of the FY 2015 funds appropriated for the five projects have been spent, because the projects require authorization prior to obligation and expenditure. 

The FY 2015 funds for West LA and Long Beach have been moved to the project. 

VA is awaiting Congressional authorization action before awarding a construction 

contract for either project. Currently, VA plans to make awards by September 30, 

2015, subject to receipt of authorization. 

Question 10. Women veteran gender-specific health care increased $34.3 million 

or 8.3 percent between FY 2015 and FY 2016. Please break out the amount allocated to each category included under gender-specific health care for fiscal years 

2014, 2015, and 2016 as well as projections for FY 2017. 

Response. See the following table. 

Question 11. What percentage of women veteran specific care is provided at VA 

facilities and what percentage is provided through non-VA care? Please break out 


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38 

each category included under gender-specific health care for fiscal years 2014, 2015, 

and 2016 as well as projections for FY 2017. 

Women Veterans: Gender-Specific Medical Care 

(Share of total care provided at VA Facilities and by Non-VA providers) 

Question 12. At a hearing before the House Committee on Veterans’ Affairs on 

February 11, 2015, VA testified that there has been a 25 percent increase in productivity per employee with respect to claims processing. 

a. Please provide the Committee with the details of how that statistic was calculated, including the number of claims completed per employee for the relevant 

time periods, the time period over which that change was measured, and the categories of employees that were included (for example, quality review teams, non-rating staff, appeals staff, fiduciary staff, management, etc.). 

Response. The 25-percent increase in productivity is calculated by dividing the 

number of compensation and pension (C&P) claims completed in FY 2014 by the 

number of direct C&P full-time equivalents (FTE) in FY 2014, and then comparing 

this ratio to the same figure from FY 2012. In addition to claims processing personnel, Direct FTE includes all employees supporting C&P programs, such as fiduciary employees, national call center employees, outreach personnel, military services coordinators, etc. except for management support, which typically comprises 11 

percent of all C&P field staff. 

However, a more accurate representation of VBA’s increase in productivity is at 

the issue-level rather than the claim-level. Calculating productivity by the more 

simplistic output of ‘‘number of claims’’ does not reflect the increase in workload 

VBA has experienced since 2009. From 2009 to 2014, VBA’s productivity at the 

issue-level increased by 67 percent. 

b. In calculating that statistic, were claims completed during overtime included 

in determining productivity per employee? If so, what percent of claims were completed during overtime? 

Response. All rating-related C&P medical issues were included in the calculation 

of productivity per employee. Overtime has historically been an important management tool for VBA, although at levels generally lower than what has been used over 


94132q1VA11.eps 94132q1VA12a.eps
39 

the past three years. In FY 2014, VBA estimates between 504,000 and 588,000 medical issues were completed due to overtime. 

c. Please provide that statistic—productivity per employee—calculated in the 

same manner for the prior 10 years. 

Response. The table below provides productivity figures per direct FTE at the 

issue-level since 2009. Issue-based data prior to 2009 is not readily available. 

FY 

Completed 

Claims 

Issues 

Completed 

Average 

Issues 

Claimed 

Direct 

C&P FTE 

Issues Per 

Direct FTE 

2009 .................................................................................. 977,219 2,744,962 2 .8 11,868 231 .3 

2010 .................................................................................. 1,076,983 3,808,712 3 .5 13,555 281 

2011 .................................................................................. 1,032,677 3,284,234 3 .2 14,039 233 .9 

2012 .................................................................................. 1,044,207 4,128,321 4 .0 14,119 292 .4 

2013 .................................................................................. 1,169,085 5,703,976 4 .9 14,473 394 .1 

2014 .................................................................................. 1,320,870 5,528,656 4 .2 14,307 386 .4 

d. If VA’s FY 2016 budget is adopted, what is the expected productivity per employee during FY 2016 using the same manner of calculation? 

Response. If the average number of medical issues per claim remains at 4.2 issues 

per claim, VBA expects productivity to increase to 397.5 issues per employee in FY 

2016. 

Question 13. Over the past few years, VA has used overtime to help process disability claims. 

a. Please provide the amount spent on overtime for claims processing staff during 

FY 2014, the amount expected to be spent on overtime during FY 2015, and the 

amount requested for overtime for FY 2016. Response. In FY 2014, VBA spent $132.9 million in overtime pay, including $122.8 million for the compensation and pension claims processing, $6.2 million for 

education claims processing, and $3.9 million on all other programs. The FY 2015 budget request included $65 million for overtime, and at the start 

of the fiscal year VBA applied a portion of carryover funding to increase the overtime budget to $83 million. In January 2015, VBA reinstituted mandatory overtime 

for compensation and pension claims processing. To date, VBA has spent $40 million 

on overtime in FY 2015, including $37 million for compensation and pension claims 

processing, $1.9 million for education claims processing, and $1.1 million for all 

other programs. VA is assessing funding alternatives to sustain current levels of 

overtime for claims processing. 

b. What portion, if any, of the overtime hours during FY 2014 were used to handle 

non-rating work or appeals? 

Response. Eliminating the rating claims backlog remains one of VA’s top priorities. Therefore, in FY 2014 and FY 2015, overtime has not been utilized to process 

non-rating work or appeals. 

c. To date during FY 2015, what portion of overtime hours have been used to handle non-rating work or appeals? 

Response. Eliminating the rating claims backlog remains one of VA’s top priorities. Therefore, in FY 2014 and FY 2015, overtime has not been utilized to process 

non-rating work or appeals. 

Chairman ISAKSON. Thank you, Mr. Secretary, and thank you for 

the timeliness of your remarks. 

I will be brief in my questions, but to the point. In 36 years in 

legislative office, in one office or another, either in the State or the 

Federal Government, I have seen lots of consolidations and lots of 

reorganizations. More often than not, it means more government 

and more employees, less efficiency, and does not work. So, do you 

think consolidating the regions from nine to five will produce more 

efficiency and less burden in terms of employees? 

Secretary MCDONALD. Yes, sir. Right now, the average employee 

at the lowest level working with veterans—and I have gotten this 

from the roughly 100 facilities I have visited so far—they feel they 

are a prisoner of a system that they cannot control. So, many of 

the ideas we are coming up with in MyVA are really the ideas of 

the employees who are trying to better serve veterans. 

40 

What they see today is there are nine lines of business. Each has 

their own geographic map. If you talk to one VA employee in one 

facility, they will not be able to direct you, largely, to the other 

eight lines of business. We have got to stop that. 

MyVA is about reorganizing and getting more resources working 

with veterans. I do not expect it will be an increase in head count 

for the Department over time. In fact, I expect it will be a productivity improvement. That is one of the reasons we are going to 

shared services, where many companies have gotten significant 

benefit. 

We plan to take those resources that we are able to gain through 

shared services and apply them for better customer service. Whether or not that reduces head count overall, I do not know yet, but 

our intention is certainly not to raise the head count of the Department. 

Chairman ISAKSON. Well, I want to make sure the goal is 

achieved in improving services and unifying the VA and the VA 

employees but does not end up resulting in more payroll, more employees, and more bureaucracy. I think streamlining the VA is important to accomplish. 

Secretary MCDONALD. Mr. Chairman, that is all of our goal. 

Chairman ISAKSON. OK. On concurrent—I am going to show my 

ignorance here, show my memory loss in my older age—but, we 

changed concurrent receipt a few years ago because veterans with 

disability were not able to get retirement, is that not correct? And, 

we changed it to where if you had 50 percent disability or more, 

you were eligible for both the disability payment as well as your 

retirement, is that correct? 

Ms. HICKEY. That is correct, Chairman. 

Chairman ISAKSON. Then, if I look at this chart that you handed 

out about the average degree of disabilities increasing since 2000, 

that corresponds with the time we changed the law, if I remember 

correctly. So, by moving the eligibility threshold for joint receipt of 

retirement and disability to 50 percent disability determination, 

did that have a force effect to raise the number of determinations 

that were raised to 50 percent or higher? 

Ms. HICKEY. I think, Chairman, the way I would answer that is 

there are multiple trigger points in the march up on the levels of 

percentage of disability. Certainly, at 30 percent, you achieve the 

opportunity to apply for dependency, meaning you get additional 

funds for having family members. At 50 percent, you get the access 

to health care. When you get upwards into the 70 percent marks, 

you start becoming more eligible for something called ‘‘individual 

unemployability,’’ which raises you effectively up to the 100 percent. There are different threshold marks in there that are—where 

new benefits are triggered as a result of increases. 

But, I will tell you that, clearly, in at least my data analysis, the 

number 1 issue that is driving the volume of work, that 5.5 million 

medical issues that you saw on the chart, is the number of medical 

issues that people are filing per claim—— 

Chairman ISAKSON. Right. 

Ms. HICKEY [continuing]. Has dramatically increased. 

Chairman ISAKSON. Well, I supported concurrent receipt and 

what we did, and I think it was the right thing to do, but I think 

41 

your answer confirms the fact that as you ratchet up the threshold 

to qualify for benefits, inherently, you are going to raise the cost 

of the services that you offer, and I am going to—— 

Ms. HICKEY. Chairman, I would also say, inherently, you are 

probably also meeting a need for a more disabled veteran that 

needs that need, as well. 

Chairman ISAKSON. Exactly. That is exactly correct. 

My time is almost up, so I will end with a comment. Secretary 

McDonald, I was delighted that in your entire presentation, which 

was not timed or limited, you did not talk about moving money 

from VA Choice to non-VA health care or to regular VA health 

care, which was originally a proposal you talked about. Is that still 

in the budget request? 

Secretary MCDONALD. Mr. Chairman, the—I found a better way 

to articulate, I think, what I am talking about. What I am talking 

about, a choice. What we have done is we have implemented choice 

for the veteran, and what we want in VA is for the veteran to be 

able to make that choice. All I am asking for is flexibility that if 

the veteran does make a choice, that I have the funds available to 

be able to pay for their care so that we do not have what occurred 

in 2014. 

We have over 70 line items of budget that do not allow us to 

move money from one line item to another. A company would never 

be run that way. Imagine at your home, if you had two checkbooks, 

one checkbook for gasoline, one checkbook for food. The price of 

gasoline falls by half while you are hungry and you need more food, 

but you cannot move money from the gas account to the food account even though that would be appropriate for your family. That 

is the situation we face. 

We look forward to working with you and making sure you are 

totally aware of the data that we have so we can make sure the 

money is there for veterans. 

Chairman ISAKSON. Well, you are moving in the right direction 

and I appreciate the articulation of the request. 

Senator Blumenthal. 

Senator BLUMENTHAL. Thank you. 

As I outlined earlier, Secretary McDonald, the Choice Card Program basically seems to be not working. I think you and I, in our 

conversations, have talked about the potential reasons that it is so 

underutilized. A small fraction of the veterans who are eligible to 

use it, in practical terms, are doing so. The 40-mile rule may be 

a cause. But, I wonder what the VA is going to do about it and 

what plans you have to act on the current real gaps and deficiencies in that Choice Program. We are now into the sixth month 

of a 3-year program, so there should be more to show for it. 

Secretary MCDONALD. Let me try to address it, and then, also, 

if Carolyn has anything to add, she may want to add. 

First of all, I would like to congratulate the Committee and the 

Members of Congress for the Choice Program. I think it is a great 

program. Even though we have been at this some time, we need 

to remember that the last cards went out in January and it is right 

now the end of February, so it is early yet. But, as the Ranking 

Member mentions, and we spoke about last night, we are working 

42 

hard to make sure we gather data to really understand and drill 

down into what is going on. 

So far, we have gotten about a half million calls, but that has 

translated only into about 30,000 appointments or clearances. That 

seems like an awfully low ratio to us. 

Second, we worked together to put in the geographic barrier as 

an allowance. It would allow the Secretary to allow someone to 

take advantage of the program. So far, we have only had less than 

50 people take advantage of that. 

Senator BLUMENTHAL. It is 44, you told me. 

Secretary MCDONALD. Forty-four is the exact number. I said—we 

do not know exactly why, so we need to figure that out. 

We are doing a number of things. One, we have gone back to our 

third-party administrators and we said, here is some new data that 

we need, because initially, we set up the relationship to give us 

data, but now we are discovering the data that we need to understand this situation. So, we are doing that. Hopefully, over time, 

we will better get that data, and then we will put together an algorithm that we will share with you and alternatives that will show 

how we should redefine that 40-mile restriction and reinterpret it 

so that more veterans can take advantage of the Act. 

Senator BLUMENTHAL. But, if I may interrupt—— 

Secretary MCDONALD. Yes, sir. 

Senator BLUMENTHAL [continuing]. You know, I think data is important, but meanwhile, the clock is ticking and real money was 

authorized for this program. So, I think there is a sense of urgency 

in the Committee. As I mentioned when you and I were talking, 

if this were a product at Proctor & Gamble that had a 0.37 percent 

purchase rate as compared to what you expected, if its marketing 

simply was not working, you would begin acting right away, and 

I hope that you will take—— 

Secretary MCDONALD. We—— 

Senator BLUMENTHAL [continuing]. Very strong and urgent action. 

Secretary MCDONALD. I certainly agree with you. Hence, one of 

the things we have done is—we have got to do a better job of marketing the program. So, we are making calls. We are sending out 

brochures, and we have got a Public Service ad. I do not know, Mr. 

Chairman and Ranking Member, if you would like to see it, but we 

have posted an ad that we recently created which is already out 

there on YouTube getting hits right now—— 

Senator BLUMENTHAL. I have seen it, and I would like to see it 

again, but not on the time that I have for questioning. 

Secretary MCDONALD. OK, sir. [Laughter.] 

Senator BLUMENTHAL. Let me go to—— 

Secretary MCDONALD. Anyone who wants to see it, we want to 

make sure that you get the opportunity. 

Senator BLUMENTHAL. Let me quickly go to—— 

Secretary MCDONALD. And, put it on your own Web sites, please. 

Senator BLUMENTHAL. Sorry, again, for interrupting—— 

Secretary MCDONALD. That is OK. No, no. 

Senator BLUMENTHAL [continuing]. But, I want to be respectful 

of my colleagues’ time. The Inspector General—the budget actually 

requests an amount of funding that would reduce the number of 

43 

full-time positions, which I think is unacceptable. We have yet to 

see the Inspector General report on the debacle that inspired the 

Choice Program. That delay, in my view, is inexcusable. I requested that the Federal Bureau of Investigations be involved, because I said at the time that the Inspector General lacked sufficient resources to do a prompt and effective job—nothing personal 

or professional about his qualifications, but resources, as I know 

from my law enforcement experience, are critical. To increase the 

budget by so small a factor, 0.3 percent, where there is actually a 

reduction in full-time positions, I think, is unacceptable. Would you 

comment. 

Secretary MCDONALD. Yes, sir. You are right. that was an administrative error. We have gone back and talked to the Inspector 

General, and when he testifies in front of you, he is going to ask 

for a $15 million increase. We support him 100 percent on that. 

Right now, we have got a number of investigations that are ongoing, and the sooner we get these done, the happier we all will be. 

Senator BLUMENTHAL. Finally—I have a lot more questions, but 

very little time—on the issue of medical research, particularly into 

mental health, my understanding is that there has been no requested increase for that research. Am I correct? 

Ms. TIERNEY. For mental health, I will have to check, but overall, 

the research budget goes up $33 million in our 2016 request. 

Senator BLUMENTHAL. Well, for the VA’s National Center for 

Post Traumatic Stress Disorder, which, as we all know, is the signature wound of these 13 years of war, the funding is stagnant. 

For centers like the Health Care System Medical Care Center 

Campus at Westhaven, which is doing enormously promising and 

critically important work, to leave this funding stagnant, in my 

view, again, is unacceptable. 

Ms. TIERNEY. Yes, sir. I think Dr. Clancy can probably better address this. When we ran the model, we found that we are having 

less very seriously injured people in the war coming back and our 

costs are stabilizing in that arena, but let me turn it over to Dr. 

Clancy. 

Senator BLUMENTHAL. Well, if I may say, with all due respect, 

your injuries may be stabilizing because you are not recognizing 

them—— 

Ms. TIERNEY. Thank you. 

Senator BLUMENTHAL [continuing]. And acknowledging their existence. The military itself says that 30 to 50 percent of our returning and separating men and women suffer from these invisible 

wounds of war. We just passed new law, the Clay Hunt SAV Act, 

recognizing the importance of providing mental health care. The research into how to treat it is even more important, or at least as 

important as providing funds for the treatment, because we are 

now using pharmaceutical drugs that are actually counterproductive, according to the experts in this area. So, may I suggest 

respectfully that the research funds be increased for this purpose. 

Chairman ISAKSON. Thank you, Senator Blumenthal. 

I might interject, since mental health was raised, I want to congratulate VA on the recognition they received at the Academy 

Awards for the VA Mental Health Hotline. I think you have made 

44 

a major move forward in getting the VA accessibility to someone 

in a state of crisis, and you are to be commended for that. 

Secretary MCDONALD. Mr. Chairman, we would love to share 

that video with anyone who wants to see it. 

Chairman ISAKSON. There is going to be a time, but it is going 

to be after everybody has their questioning. 

Secretary MCDONALD. I am sorry. I meant the HBO program. 

Chairman ISAKSON. Oh, OK. Good. 

Senator Moran. 

STATEMENT OF HON. JERRY MORAN, 

U.S. SENATOR FROM KANSAS 

Senator MORAN. Mr. Chairman, thank you very much. Thank 

you for your opening statement as well as Senator Blumenthal’s. 

Mr. Secretary, nice to see you again. I was thinking that in the 

time that you have been the Secretary of the Department of Veterans Affairs, I have had more opportunity to have conversations 

with you than any other Cabinet Secretary. I appreciate that. I will 

see you in the Appropriations Committee on this topic again in a 

few weeks. Yet, I do not feel like the circumstances that I keep explaining and expressing concern about are being expressed. 

Therefore, the problem is that while I have more time to speak 

to you than I have had with any other Cabinet Secretary, I must 

be failing in my ability to deliver the message that I want to deliver because I have no doubt that you care about the results that 

I am seeking. So, I am going to try one more time to express to 

you as the Secretary, and to members of your team, where I think 

we are still failing in hopes that my communication skills this time 

are sufficient to get change at the Department. 

You would expect me to talk about the 40-mile issue, and I will, 

but it is broader than that. What troubles me, and again, I know 

you have been in office a short period of time, but I will tell you, 

the complaints that I receive from veterans in Kansas about the 

quality of the service, the timeliness of their being seen by a physician, their ability to access care, is no less today than it was a year 

ago. 

I would tell you that the success of claims, that while your numbers indicate that the length of time for which claims over 125 days 

are pending is improving, the number of veterans who come to me, 

to my staff, asking for helping with a long pending claim is no 

different. 

I worry that we are setting the stage for another kind of scandal, 

similar to the one about the fake list, the waiting list, because your 

numbers are affected by claims that are being appealed. And, I 

think one of the things that is happening at the VA is, while you 

have shortened the number of claims that are pending, they are 

now just in a different category, waiting appeal, and the end result 

is our veterans are still waiting. 

There is no sense of the employees at the Department of Veterans Affairs that I visit with in hospitals and facilities across Kansas, that there is any more direction from the Department of Veterans Affairs in Washington, DC, directed to them and how to 

manage their operations, or any more freedom to make decisions 

at home than there was before. In a sense, there is no change that 

45 

emanates from Washington, DC, so that folks who are on the front 

line of delivering care to veterans feel like they know better what 

to do or have flexibility to make the decision about what they 

should do. 

There is no sense, to my knowledge—I mean, you can convince 

me—that there has been accountability since the scandals of a year 

ago, that we are still waiting for the Department of Veterans Affairs to handle employees who conducted themselves inappropriately, perhaps illegally. 

When I raise topics of concern about a specific veteran in a setting like this, my veteran gets attention, which I appreciate, but 

I can tell you, as soon as the spotlight is over, that veteran is back 

to the same position he or she was in before I raised their claim 

with the Department of Veterans Affairs. So, they get a moment 

of reprieve, but it does not last. 

Further, Mr. Secretary, when it comes to the 40 mile issue—that 

background, I hope, suggests to you where I am coming from in my 

skepticism about the Department’s implementation of the Choice 

Act—and 40 miles is a significant component of that, but not the 

only aspect. It is not just the 40 miles, within the 40 miles, and 

it is, I do not know, 42 Senators that are in this. I am not the mile 

guy. Forty-two Senators sent you a letter indicating our preference 

about how this should be implemented and related to—this is Senator Collins’ letter—related to as the crow flies as well as to whether a facility that does not provide the service that a veteran needs 

should be counted as a facility. The problems are beyond—in the 

implementation of the Choice Act—are beyond just that 40-mile 

issue. 

When a veteran signs up—and you indicated a half-a-million veteran calls—the problem is, when they call, they are often told they 

do not qualify. ‘‘You are not on our list.’’ But, then, there is nothing 

the veteran can do about it to say, ‘‘Wait a minute. I should be. I 

am.’’ There is no appeal process for a veteran who should be on the 

list to get on the list. 

You are requiring prepayment of copayments, causing veterans 

to pay more money for their health care if they choose the Choice 

Act, in a sense, discouraging that choice. 

In addition to that, trying to get community providers signed up 

for services—I have been trying for months to get community mental health centers to be able to be one of the providers of those 

services—unsuccessfully. We have a provider who says, ‘‘I am going 

to lose money, but I have decided I want to do this, but I cannot 

get the VA to even approve me to be a provider under the Choice 

Act.’’ 

So, the concern I have is that the VA has a mentality against 

outside care, even in the circumstances where one cannot get service within 30 days or within 40 miles, and that is highlighted by— 

just a couple more points, Mr. Chairman—that is highlighted by 

the fact that when we attempted to implement the ARCH Program, 

the VA was not at all interested in seeing, in my view, its success. 

In fact, we came across an e-mail from the VA in DC instructing 

the VA in Wichita not to promote, market, or encourage participation in ARCH, suggesting to me that there is this approach or attitude against outside care. 

46 

Finally, Mr. Secretary, while you have been available, and, in 

fact, you asked Deputy Secretary Gibson to come see me, the President’s budget request—you are going to artfully change your words 

a bit today, and I appreciate that—but, the suggestion that the 

money could be used for higher priorities within the VA is troubling to me because it, again, demonstrates the lack of interest in 

this program. 

When Deputy Secretary Gibson came to see me, he told me we 

could not do the 40 miles because we could not afford it. Now, I 

am told we need to move the money out because it is, in a sense, 

not a priority. But, then, I will tell you, a few days later, Dr. 

Tushman was in our office indicating that the only cost estimates 

of the Choice Act were on the back of a napkin. We do not have 

the information to determine what the costs are. 

So, we are told it is expensive by the Deputy Secretary. We are 

told by the number 2 person at VA health, we do not really have 

numbers. 

I try to be very optimistic, and all this is couched in terms of I 

thought and want great things to happen with your arrival at the 

Department. I thought Congress finally got its act together. We actually could function. Republicans and Democrats come together 

and pass a piece of legislation that has value and I want to see its 

success. 

Mr. Chairman, thank you. 

Chairman ISAKSON. That was over time, but that merits a 

response. 

Secretary MCDONALD. It does. I am going to try to do the best 

I can, Senator Moran. If I am missing something, let us get together later and talk about it. 

We are for the Choice Program, and we are for outside care. Over 

the last 12 months or so, we have had roughly 500,000 appointments in outside care which is up 48 percent—not Choice but outside care. So, we already have a process for outside care. The difference is that this is outside care we suggest to the veteran, not 

that the veteran suggests to us. 

So, we already have a culture of outside care, and while I cannot 

say every employee would tell you that outside care is a good thing, 

I can tell you the leadership believes that it is the only way to go. 

We have got to have a combination of VA care and non-VA care to 

properly care for our veterans. There is no question about that. 

When the law was passed and the law was designed, nobody 

knew—and, arguably, as we talked with the Ranking Member—we 

still do not exactly know how many veterans are going to choose 

to use it. So, we are in a period of uncertainty, but we are trying 

to get as much certainty as we can so we can go back as quickly 

as possible and change the definitions of the 40 miles, change the 

definitions of the geographic barrier, in order to get more people in 

the program. We want more people in the program, and I think if 

you see our public service ad, you will see demonstrated that is our 

intent. Yet, we have got to figure out why they are not there. And 

just like you would in marketing anything, we have got to figure 

out how to get people in. 

So, we want to get people in, but if the situation exists that they 

do not go in, all I am saying is that at some point we will share 

47 

with you how many people are in. We will do the best we can to 

get them in. But, if they do not go in, what we do not want to do 

is lose the budgetary flexibility if those people stay in VA, because 

we made assumptions as to how many people would leave VA care, 

and we took that money out of the VA budget. That was the only 

point I was making. It is a point of flexibility. 

Relative to facilities in Kansas, I need to get there. You know, 

as you know, I gave out my cell phone number publicly. I get calls, 

I get e-mails, I get texts every single day. I am seeing a change. 

I am still getting a lot of complaints, but I am seeing a change. The 

Veterans Service Organizations are telling me they are seeing a 

change. But if you are not seeing a change in Kansas, that does 

not do the people in Kansas any good. So, we will get out there, 

and we will take a look. We will work with you. 

Senator MORAN. Mr. Secretary, thank you for working with me. 

We would love to have you in Kansas. I look forward to your support of the 40-mile-fix legislation that I know the Chairman has 

visited with you about. 

And the final thing I would say is that when Secretary Shinseki 

resigned, one of the things that stuck with me in his comments 

was, ‘‘I was too trusting of some, and I accepted as accurate reports 

that I now know to be misleading.’’ Make certain that what you are 

telling me today is backed up by facts as you can know them, not 

by the culture or the circumstances that you find with the people 

that surround you. 

Secretary MCDONALD. Yes, sir. I would like to invite you and 

other Members of the Committee to join us for our daily stand-up, 

which is where we go through all of our data. We had the Ranking 

Member and the Chairman there, and I think you would find it to 

be very helpful. 

Chairman ISAKSON. I think we have already got a date set in 

June for the next opportunity for a town—— 

Secretary MCDONALD. I am thrilled. Let us do the stand-up and 

the town hall together. That would be great. 

Chairman ISAKSON. In fairness to all the Members, I am very liberal with the gavel because the questions and the comments have 

been excellent, but there is a point of patience that I will use 

to—— 

Senator MORAN. I feel sufficiently chastised, Mr. Chairman. 

[Laughter.] 

Chairman ISAKSON. I started with Mr. Blumenthal, and you just 

added on. 

Senator Brown? 

Senator BROWN. Thank you for starting the new impatience rule 

with me, Mr. Chairman. [Laughter.] 

HON. SHERROD BROWN, 

U.S. SENATOR FROM OHIO 

Senator BROWN. Thank you, Mr. Secretary, and thank you for 

your outreach and your accessibility. We have all commented on 

that and all appreciate that. 

We spoke yesterday about the Ohio NPR affiliate which raised 

health concerns related to post-Vietnam dioxin exposure to reservists who flew or worked on C–123 aircraft, as you know. They do 

48 

not fall under the Agent Orange presumptive eligibility construct. 

I want to acknowledge the VA’s efforts regarding the Institute of 

Medicine’s recent report. Can you assure me that this will happen? 

And give us the timetable, if you would. 

Secretary MCDONALD. Yes, sir. We asked the Institute of Medicine to do that analysis. The analysis came back positive. We have 

looked at it, and we have looked at ways to identify the people, and 

we are expecting to make an announcement next week. Gen. Allison Hickey, Under Secretary of Benefits, will be making that announcement next week. 

Senator BROWN. OK. Good. Thank you. 

The Department I know has made ending the claims backlog by 

the end of this year a priority. My growing concern is that expediting claims processing has led to an increase in veterans filing 

appeals to their claims, which in turn makes dealing with the backlog more difficult. The Cleveland regional office, as we have discussed, continues to have a backlog numbering in the thousands of 

claims. The budget request has $85 million to hire 770 new staff. 

Could you walk us through what will happen with the new staff, 

what their function will be, how quickly this happens, and how it 

affects the backlog? 

Secretary MCDONALD. Yes, sir, I will; plus I will ask Allison to 

comment. I want to just give a short overview. 

If you remember, when we put in our request for the Choice Act, 

we had people in the Choice Act that would work in VBA to work 

on claims and to work on non-rating claims, which is part of the 

backlog issue. When the Choice Act was passed, that was stripped 

out. We have had people working mandatory overtime in order to 

get more and more claims done. We have also converted most of 

the claims now to digital, and as a result, we are able to have a 

national work stream. 

We are at the point where we really need the people if we are 

going to continue to make progress against the claims and the 

appeals. 

Allison? 

Ms. HICKEY. Let me just start by very quickly giving you all a 

larger update since we last met. The inventory for all of our claims 

is down 45 percent. The backlog is down, this morning, 64 percent, 

from 611,000 to 222,000. The quality is up 9 percentage points, up 

to 92 percent at the claim level, and at the medical issue level 96 

percent. Believe it or not, despite the fact that there are a volume 

of appeals increases, not the rate; the rate has remained steady for 

more than 20 years. In fact, last year it actually went a little bit 

lower, but not enough that I am going to statistically quibble anything about that. But it has held steady at 11 percent. 

But remember the chart that we showed you where we did 9 million versus 1.3 million record-breaking—or 900,000 4 years ago 

versus 1.3 million this last year, which is record-breaking for us; 

11 percent against 1.32 million is many more. 

Here is the situation for appeals: despite the fact we have increased our production against it by 35 percent last year, we still 

have two solutions to appeals. One is change the law. I recognize 

there is little appetite for it, but I have submitted the legislative 

request regardless. The second is throw a whole lot more people at 

49 

it. So, those are the only two provisions I have, neither one of 

which I control. Why? Because it is so wired, this appeals process 

is so wired in law. It is not like the claims process where I could 

do 45 initiatives to drive that excellent takedown in the claims 

backlog. I cannot do it. 

There is one idea out there—and I am extremely appreciative to 

the VSOs, specifically DAV who took the leadership, and all the 

rest who signed on, for the fully-developed appeals process. That 

will help at the margins. It still requires a legislative fix, which we 

will need that in order to proceed forward. 

But at the end of the day, beyond that, two things will fix the 

appeals process—legal changes to it or a whole lot more people— 

and we have submitted that in this budget. There is in this budget 

request for appeals, for non-rating, and for fiduciary, all—which 

was a byproduct of a successful increase in production and productivity as a result of the transformation. 

Senator BROWN. One last brief question, Mr. Chairman. I know 

from representing you in the Senate that P&G is one of Ohio’s 

great companies in labor-management relations, which was always 

so important to you and that you honored your workers and labor— 

union and non-union alike. I have been very impressed with your 

reaching out both to AFGE and other unions, their leadership and 

rank-and-file. My question—and we all welcome your comments at 

the beginning of your testimony in terms of upgrades and new construction and modernization of the physical facilities. My question 

is simple: will you continue to utilize project labor agreements in 

VA construction, in all VA construction? 

Secretary MCDONALD. I am not an expert in that topic, but if— 

you said ‘‘continue.’’ If we have been doing it, certainly we would. 

I have reached out to our labor union leaders, and I have spoken 

at their national conventions. I honestly believe—65 percent of our 

employees are union members. We cannot get this change done 

without the employees leading it, because who better to know what 

we need to change than those working with veterans every single 

day? As a result of that, we have a very strong relationship with 

J. David Cox, the AFGE president, and others. We are working 

hard to do that. We will get back to you on that. 

Senator BROWN. OK. Thank you for that. 

[The information referred to follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. SHERROD BROWN TO

HON. ROBERT MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. Yes. VA is required to determine, through market research and Impact 

Studies, if Project Labor Agreements (PLA) are appropriate for construction procurements at or above $25 million. When beneficial, VA provides the option for contractors to submit a proposal with PLA and/or without PLA. 

Senator BROWN. One more point about that. The unions—the 

AFGE and the other VA unions you negotiate with and work with 

are not typically the unions that my question would be involved 

with. These are construction trades that actually build the facilities, as you know from expansions at Procter & Gamble over the 

years. I appreciate your track record on this. I just want to see it 

continue, and I want to see it everywhere. We had some problems 

in VA before about the pay of workers, the unionization rate of 

50 

those workers, and I think it affected the quality of construction. 

I know how much you care about that. 

Secretary MCDONALD. I need to dig into that more. I will learn 

from it and get back to you. 

Senator BROWN. Thank you. 

Ms. HICKEY. Senator Brown, if I can make one more comment; 

Cleveland is doing phenomenally well. Their backlog is down 80 

percent. Their quality is up into one of the highest in the Nation 

at both claims level and issue level. 

Senator BROWN. Thank you. 

Chairman ISAKSON. Senator Cassidy. 

HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA 

Senator CASSIDY. Thank you. Clearly, patient access to care is 

important. You have impressive statistics about the total number 

of visits. Are no-shows—when somebody has an appointment 

scheduled but does not show up—are those included in your total 

number of visits? 

Secretary MCDONALD. Yes, but I want—you are making a great 

point. No-shows is a really big issue. 

Senator CASSIDY. So, really, we cannot interpret the number of 

outpatient visits you list unless we know the percent of those in 

which the patient did not actually show up. Do we know the percent of those total number of visits? 

Secretary MCDONALD. Yes. I was going to say, one of the things 

we review every morning is the no-shows. 

Senator CASSIDY. So, what is that percent of total visits which 

are ‘‘no-shows?’’ 

Ms. HICKEY. It depends on the facility and the type of appointment—— 

Senator CASSIDY. I totally accept that. That is my next question. 

Globally, what would you say of the—I think you had 80—some incredible number. What percent, 20 percent, 10 percent, 30 percent? 

Dr. CLANCY. I would say it is probably more in the ballpark of 

20 percent. I was literally on the phone with a physician the other 

day from the great State of Montana, I might note, who said that 

actually they had started calling and had reduced it quite a bit. He 

was orthopedics, down from thirty—— 

Senator CASSIDY. I get that. So, the next question is: are these 

generally distributed throughout the system and institutions? Or 

can you pinpoint institutions in which these no-show rates are particularly egregious? 

Dr. CLANCY. It is not quite that pinpoint-able. Interestingly, veterans who come from rural areas have a much lower no-show rate, 

and the more rural, the highly rural have the lowest no-show rates; 

rural a little bit higher than that, and urban actually have—— 

Senator CASSIDY. Now, let me ask, because when you mentioned 

your daily stand-up of looking at data, really, unless you can bring 

it down to ‘‘This facility has a no-show rate of 30 percent, not improving, and this one has 30 percent but is down from 50, and this 

one was 10 but now it is 30.’’ The same 30 percent rate has far different meaning in that context. So, I am asking, in your stand-up 

meetings, are they worth—and I do not mean to be disrespectful, 

51 

but unless you are able to interpret it in that means, what value 

are they? 

Dr. CLANCY. No. That is exactly what we are working on with 

facilities, and I think as the Chairman and Ranking Member can 

tell you, the day they came we actually had one facility online. We 

had two lined up, but we ran out of time. And that is the kind of 

deep dive that we are doing with facilities to help them figure this 

out. We also have some electronic tools to help them. 

To get back to your initial question, we look at both pending appointments as well as completed appointments, so we are actually 

reflecting on the completed appointments who showed up. 

Secretary MCDONALD. This is the chart, Senator Cassidy. It 

shows missed—we call it ‘‘missed opportunities.’’ And as Carolyn 

says, it breaks it out by rural, urban, highly rural—I am sorry Senator Moran is not here—and it also breaks it out by specialty. And 

as you can see, as you would expect, mental health is—— 

Senator CASSIDY. Is that in here? 

Secretary MCDONALD. No, sir. This is our daily stand-up—— 

Senator CASSIDY. My eyes are 57 years old, man. I cannot see 

that. 

Secretary MCDONALD. Well, come on over. We would love to go 

through this with you and get your advice. 

Senator CASSIDY. Sounds great. 

Dr. CLANCY. We would be delighted to give you a briefing. 

Senator CASSIDY. Now, once I sat on a plane next to someone 

who—a physician, who told me he was in charge of a ‘‘turnkey operation’’ in which the VA contracted for him to go, I think, to the 

Thibodaux area in Louisiana. It was an outside group. They set up 

all the nurses, all the docs. They rented the space, started seeing 

patients, and they were held accountable for quality by the VA. 

Poor quality, boom, you are out of here. Poor turnover, boom. But 

good, you stay. Now, I have not seen him since, do not know if that 

clinic is still turnkey. But do we have a sense—if that is a model 

VA uses, do we have a sense of both the no-show rates in those 

clinics versus the VA traditional facility and the productivity of 

those clinics versus a regular facility? I see Ms. Tierney nodding 

her head. 

Dr. CLANCY. We have about 850 community-based outpatient 

clinics, or CBOCs, and then we have a couple hundred that are 

contract. My general impression is that the quality and timeliness 

has been variable in those contract operations, and we are actually 

looking into that right now. I would be happy to follow up with 

you. 

Senator CASSIDY. If you could, because it really—I mean, the 

question is: do you have a model where there is accountability by 

contracts and you lose the contracts if you fail to perform, whether 

that is better than a traditional VA model? Our endpoint is not 

preservation of VA. Our endpoint is preservation of the veteran, 

and so we need to look for that best model. 

Dr. CLANCY. Absolutely. 

Secretary MCDONALD. We are going through that now. We believe we have to take responsibility for wherever the veteran gets 

the care. 

52 

Senator CASSIDY. Now, there has been a lot of talk about the veteran’s electronic medical record (EMR). Do you have a sense of the 

average time a physician in the VA system spends entering data 

per clinic visit? Because, obviously, I think Epic says it is 17 minutes per visit, which is obviously not the time you are looking into 

the veteran’s eyes to find out if he or she is depressed. So, do you 

have—you do not have that? 

Secretary MCDONALD. I do not have it with me, but we will get 

it and get it to you. We certainly look at that, and certainly as I 

go around to our different facilities, I hear our providers talk about 

the need for people to put that data into the medical record. 

Senator CASSIDY. I get you. I will tell you that talking to my physician colleagues, I get a sense that they spend a lot of time on 

your EMR and not as much time looking into the eyes and saying, 

‘‘Are you depressed?’’ 

Secretary MCDONALD. That is true, but for benefit of the other 

Committee Members—because I know you know this—the EMR 

also signals questions that the doctor should ask. If, for example, 

a doctor wants to prescribe a drug, the record might say back, 

‘‘Well, watch out, the compatibility of that drug with another 

drug’’—— 

Senator CASSIDY. So, next, can I finish up? Because the Chairman was so generous with time. There is a GAO report on the improvements needed in monitoring antidepressant use for major depressive disorders and increasing accuracy of the suicide data that 

I am sure you are familiar with from November 2014, showing 

major deficiencies in the VA’s database as regards veterans suicide. 

I think I heard a report, but I am saying it off the top of my mind, 

22 veterans commit suicide a day. That may be an overstatement. 

I am saying it off the top of my head. 

Now, here they found a number of deficiencies in data collection. 

Theoretically an EMR would have done it automatically, but indeed 

it does not. Can I ask you specifically what is being done to address 

this issue? 

Dr. CLANCY. We have follow-up plans with the facilities and networks that have the greatest opportunities for improvement. An 

EMR can remind clinicians what is the right thing to do. As you 

probably know from your own practice, there is no guideline or recommendation that is 100 percent right for 100 percent of patients. 

So, what we are trying to figure out is to what extent are people 

making appropriate decisions and to what extent are they actually 

just not paying attention. 

Senator CASSIDY. This is also about data collection, though, for 

example, date of death being wrong on the form as to the day the 

veteran committed suicide, as just a simple sort of, ‘‘Man, somebody did not do this right’’ sort of thing. 

Dr. CLANCY. Yes. 

Senator CASSIDY. I am over time. Thank you very much. Thank 

you for your service. 

Chairman ISAKSON. Thank you, Senator Cassidy. It is nice to 

have a doctor on the Committee. 

Senator Murray? 

53 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Mr. Chairman, thank you very much, and welcome to all of our witnesses. Mr. Secretary, it is really good to see 

you again. I do have an opening statement I would like to submit 

for the record. 

Chairman ISAKSON. Without objection. 

Senator MURRAY. Thank you. 

[The prepared statement of Senator Murray follows:] 

PREPARED STATEMENT OF SENATOR PATTY MURRAY

Mr. Chairman, thank you for holding this hearing. 

A budget is a statement of our values and priorities. And as the daughter of a 

World War II veteran, I believe making sure our country keeps the promises we’ve 

made to our Nation’s heroes should be at the top of our list of priorities, all of the 

time. Taking care of our veterans when they come home is a fundamental part of 

who we are as a Nation. 

It is part of the cost of going to war. And making sure the VA has the tools and 

resources it needs to provide care and support our veterans is critical. 

I was very pleased to see the President submit a strong budget request for VA 

this year. In particular I am pleased to see VA requested an increase of $34 million 

for gender-specific health care for women veterans. 

Also, I continue to hear from veterans about delays in processing certain types 

of claims in the Seattle Regional Office, so VA’s request to hire another 770 employees nationally to help bring down those processing times is very important. 

However, the President’s budget request also includes areas where we are not investing strongly enough. With the continuing high rates of suicide among veterans, 

and long wait times, we need to increase funds for mental health care. I am also 

concerned that the request for the IG is insufficient. Especially at this critical time 

when so much oversight of VA hospitals is needed, we cannot afford to cut the Office 

of Inspector General, which has been so vital in making sure veterans get the timely, quality care we expect. 

Even with an overall strong budget request, effective management and oversight 

is critical to the Department providing for our veterans the way we expect. 

Mr. Secretary, from your experience in the private sector you know as well as 

anyone here how difficult it is to change the culture of a large organization. But 

change is essential. VA has struggled with these types of efforts in the past, so you 

certainly have your work cut out for you to make sure this time we are successful. 

You are asking the right kinds of questions—how to move the Department’s focus 

from the bureaucracy to focus on the veteran’s experience—and taking a fresh look 

at how business services are delivered. Human resources, contracting, I.T., and construction have all been major problems for the Department for many years. I hope 

you will stay focused on how to bring real reform to those offices. 

Mr. Secretary, I am also looking forward to working with you on some important 

legislation to improve the health care services for our veterans. 

I recently introduced S. 469, the Women Veterans and Families Health Services 

Act, which will expand critical fertility services to injured and ill servicemembers 

and veterans to help them realize their dreams of having a family when they otherwise might not be able to because of an injury in the line of duty. And I was very 

pleased to work with Senator Heller to introduce S. 471, the Women Veterans Access to Quality Care Act. That bill would greatly improve access to gender-specific 

care for women veterans, and ensure VA is accounting for the needs of the growing 

population of women in the construction planning process. 

Implementing the Veterans Access, Choice, and Accountability Act will also be a 

critical issue this Congress. The $5 billion we gave to build and strengthen VA for 

the long-term is already making a difference. In my home state of Washington, two 

medical centers have already announced they will hire a total of 324 new medical 

care staff in the Puget Sound and Portland/Southwest Washington regions. 

As for the Choice Program, I understand there are some initial problems implementing the program, and I hope you will act quickly to resolve them. But it’s also 

time to start planning now for what the future of non-VA care will look like. 

There are now several different major authorities VA can use to purchase care 

outside the system. They are often duplicative and inefficient, and they are not consistent with each other. 

54 

The Choice Program was a temporary, emergency authority. When it expires, VA 

needs to have a reformed program in place to help veterans access care outside VA 

in a way that: complements services provided by VA, provides coordinated care with 

strict quality of care requirements, has consistent processes and eligibility rules, 

and is cost effective 

Finally, I would also like to thank our representatives from the veterans service 

organizations. Your hard work each year, especially on the Independent Budget, is 

very important for us as we work to make sure there are adequate resources to provide veterans the benefits and care they have earned. 

Thank you, Mr. Chairman. 

Senator MURRAY. Secretary McDonald, as you know, and you 

said in your opening statement, the population of women veterans 

is increasing dramatically. It has doubled since 2001. I was really 

pleased to work with Senator Heller to introduce the Women Veterans Access to Quality Care Act to make sure that the VA does 

have the services and facilities to meet the needs of women 

veterans. 

One of the key provisions of that bill is requiring obstetrics and 

gynecology to be available at every medical center. I wanted to ask 

you what resources and staff, including support staff, will you need 

to meet that kind of requirement. 

Secretary MCDONALD. Thank you, Senator Murray. We are very 

much in favor of that approach. We are in the process of putting 

women’s clinics all over the country. We have a new one here in 

Washington, DC, and I would like to invite the Members of the 

Committee to visit it. It is in our Washington, DC, facility. It is a 

women’s clinic. 

As you know, I have been out to about 12 medical schools, talked 

to deans. We are hiring and we need to hire more gynecologists. 

Senator MURRAY. Do you know how many you would actually 

need to do this? 

Secretary MCDONALD. The exact number? I do not have an exact 

number. I can tell you that in the past 9 months or so, we have 

hired about 8,000 people. Of that, about 1,000 are doctors, but I do 

not know how many of them are gynecologists. We can get back to 

you with that number. 

Senator MURRAY. OK. If you can get that back to me. 

[The information referred to follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. PATTY MURRAY TO

HON. ROBERT MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. From April 1, 2014, to March 31, 2015, VHA’s net onboard for providers 

was over 1,017 physicians (4.5% increase). Of those, 13 were gynecologists (11.7% 

increase). 

Senator MURRAY. I also wanted to bring up that the VA policies—it is way past time to bring the VA policies up to date with 

modern medicine and allow the VA to provide better fertility treatment, including in vitro fertilization, for seriously injured veterans 

who want to start a family. This is a high priority for me. I think 

it is a high priority for our veterans, and I want to work with you 

to get that done, as well. So, I will be talking to you more about 

that. 

Secretary MCDONALD. We are working on that. 

Senator MURRAY. OK. I want to hear from you, what are you 

doing to work on this? 

55 

Dr. CLANCY. My staff briefed me recently in terms of how many 

women might be eligible and what would be the specific requirements—— 

Senator MURRAY. Well, it is women and men. 

Dr. CLANCY. Yes. And also compared what the Department of Defense covers versus what we cover, or actually do not at the moment. So, I sent them back with some more questions, which we 

would be happy to follow up with you. 

Senator MURRAY. OK, and I will submit some questions on this, 

but I think this is absolutely critical for our men and women who 

serve overseas and lose their capability, then we have to make sure 

they can start a family. So, I will be focused on this. 

I also wanted to talk to you about the legislation that I introduced last year to expand the caregiver support services to VA, to 

all eras of veterans. I am going to be introducing that again this 

year, and I want to be sure we are all working together to 

strengthen that program so it will be ready to take on the additional workload. 

VA’s budget request says that in fiscal year 2015 you cannot hire 

any new caregiver support coordinators to help with the overwhelming demand, and I hear already at some facilities that providers refuse to help with doing initial evaluations or home visits. 

To me that is just unacceptable. I wanted to ask you what you are 

doing to bring in more caregiver support coordinators. 

Secretary MCDONALD. Let me start, and then I will ask Carolyn 

to comment. 

We are very much in favor of improving our caregiver operation. 

In fact, in the last week, I met with Senator Dole of the Elizabeth 

Dole Foundation. We are working very closely with her. 

First, what we have agreed to do is to set up a special advisory 

committee for the Secretary on caregivers. We do not have that, 

and I think we would benefit greatly from having that—working 

with her, incidentally, working with her foundation. 

Second, we are talking about having a caregiver summit, something where we could get everybody together, and we are working 

together—— 

Senator MURRAY. For all eras or just—— 

Secretary MCDONALD. All eras. All eras, because, again, Post9/11 is not enough. 

Senator MURRAY. Yes. 

Secretary MCDONALD. We want to work together with you on 

this. 

Senator MURRAY. OK. Well, I want to stay in touch with you on 

that. Please keep me up to date on what they are doing. 

Finally, I want to talk to you about a homestate issue, the Spokane VA emergency room. They have seen a dramatic cutback in 

operations simply because of staffing problems. I have to tell you, 

as the daughter of a World War II veteran, this is unacceptable to 

me. It is a very serious problem for veterans in that area, and we 

have got to get it back to full-time operation. I wanted to ask you 

today, When will the emergency room at the Spokane VA start operating 24 hours a day again? 

Dr. CLANCY. Senator, we have had significant recruiting problems. We had originally hoped to open it to 24/7 in April, and it 

56 

is now looking like that is going to get pushed back a few months. 

However, I met with some colleagues from the American Legion 

just a couple of days ago at their meeting, and they have actually 

been out speaking to some of the other hospitals in town who may 

be able to help us out. 

The other area where we need help, I think, recruiting emergency physicians is a legislative change that would allow us to accommodate what many people who go into emergency medicine 

want, which is greater flexibility for hours than the current Federal H.R. policies allow. 

Senator MURRAY. OK. Are you looking at every option? Because 

we—— 

Dr. CLANCY. Yes. 

Senator MURRAY [continuing]. Have heard recruiting forever. So, 

temporary providers, bringing in doctors from other facilities, absolutely everything, because this is a critical need in that community. 

Dr. CLANCY. I would agree with you, and we are looking at all 

options, yes. 

Senator MURRAY. OK. I want to follow up with you on that so, 

let me know when and how and when we are going to see that 

open again. 

Thank you. 

Chairman ISAKSON. Thank you, Senator Murray. 

For the benefit of the Members, the order for questions will be 

Sullivan, Tester, Rounds, Sanders, and Hirono, unless somebody 

who was here comes back. Anybody argue with that? Is that OK? 

[Nodding in agreement.] 

Senator Sullivan? 

HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA 

Senator SULLIVAN. Thank you, Mr. Chairman. 

Mr. Secretary, your team, thanks for your testimony today and 

your service. You know, I think there are a couple things going on 

here that give a sense of frustration from the Members on some of 

the big issues that I know you are working hard on, and it goes 

without saying that in many ways it is just a strong passion all of 

us feel in a very strong, bipartisan sense. You have the disabled 

vets in town all week, and you see that, you see what they have 

sacrificed with regard to our country. It is hard not to get passionate about this. I know you guys are passionate about this and, 

as you can imagine—you and I have talked about it—in Alaska we 

are quite passionate about it. We proudly wear the title of the 

State that has the most veterans per capita of any State in the 

country. 

A lot of what Senator Moran talked about I share in terms of the 

frustration. And you mentioned getting out to Kansas. I would welcome a commitment from you to come visit Alaska, given, you 

know, our challenges there. While we were just on recess, I was actually out in our new veterans’ facility there on Joint Base Elmendorf-Richardson, and had a briefing from your team, which was 

quite informative. They did an outstanding job. 

We would love to get a commitment from you to come visit our 

great State this year, if possible, with your team and look at some 

of those issues. 

57 

Secretary MCDONALD. I would love to visit Alaska. I served there 

and I would love to come back. 

Senator SULLIVAN. OK, Outstanding. Then we will do that. 

I wanted to also follow up on the appeals process. You know, a 

big issue that I think would be helpful in terms of your team testifying in front of this Committee, if you can give us a very regular 

update on the backlog, both in terms of the existing backlog and 

the appeals. You know, I think in many ways that has been kind 

of a symbol of some of the challenges, some of the problems. You 

can put a finger on it in terms of the numbers, and I think there 

is concern in the Committee of kind of having that bulging backlog 

kind of just move over to the appeals. 

Ms. Hickey, I know you were talking about the express appeals 

process. I know a number of us are looking at legal ways in which 

to move that. You mentioned that it would just possibly move on 

the margins. We do not want to move on the margins. We want to 

address this in a fulsome way. 

Can we get your commitment to work with us on what would be 

some of the ideas that we are working on to address that? We do 

not want the backlog to be kind of a whack-a-mole issue. That 

would be very devastating, I think, for our veterans. It is really important that we put a lot of smart minds, not just money but 

minds, to this. I would like your commitment on working with us 

on that. 

Ms. HICKEY. Senator, I am more than willing to give our commitment. We have done that repeatedly. And we keep thinking about 

solutions. We have new, fresh minds to bring to the table as well. 

This is one that will require the Congress’ active participation—— 

Senator SULLIVAN. Good. 

Ms. HICKEY [continuing]. Because of what I have described, 

which are issues that are beyond our control. 

Senator SULLIVAN. Great. Then we will—I know that the Members of this Committee are very interested—— 

Secretary MCDONALD. Senator Sullivan, may I also add that we 

will work with your staff on this. We put our data online every 2 

weeks, so it is open to Members of the Committee, and we are 

doing that for a reason. I know there have been questions about 

our data, but it is online every 2 weeks. Your staff can get it and 

download it, and you can call us and ask questions. We are trying 

to be as transparent as possible. 

Senator SULLIVAN. OK, great. 

Ms. HICKEY. And in this case, I will tell you actually our data 

is up every Monday. It is in the Monday morning workload report. 

Congress last year asked us to add appeals information to that. We 

did. It is in there. And I also have numbers of VBA stat sessions 

that we run every month, which I would invite you or your staffs 

to participate in some of those. We do very deep dive data conversations with our RO directors and go through each and every 

line of what they are doing and their performance. 

Senator SULLIVAN. Great. We look forward to working with you 

on that. 

I have two questions, and they are for you, Mr. Secretary. You 

know, when you and I talked, you mentioned that the budget of the 

VA has increased pretty dramatically over the last several years. 

58 

I forgot the number. I think you said something along the lines of 

60 percent over the past 6 years. That may be a ballpark figure. 

So, my two questions are—and they are unrelated, but I just want 

to get them in under the buzzer here so I do not get reprimanded 

by the Chairman. 

First, given your background, do you think the problems are 

money versus culture? I mean, you can throw money at an organization, drown it in money, but if you do not have the culture to 

solve the problem, you are never going to solve the problem. 

Second, you talked about in your budget how we could end veterans’ homelessness. The term ‘‘homeless veteran’’ is a term that 

I just choke on. I hate the term. I would love to get rid of it in the 

English language. If you have a plan on ending veteran homelessness, we are all ears. 

Secretary MCDONALD. Well, let me go for homelessness first. We 

are committed to ending veteran homelessness by the end of this 

year. We do have a plan, and the plan is putting veterans in homes 

first. There is not a lot of debate about this any longer. The science 

in homelessness now is getting the veteran in a home first and 

then providing all the treatment for them. If you do not get them 

in a home first, you run into Maslow’s hierarchy of needs kinds of 

issues. It is best to get that out of the way. Get them in a home. 

We have programs to do that. We have several programs, more 

than a dozen programs to do that. 

The most important thing is community involvement. That is the 

reason I went out to Los Angeles. I ended a lawsuit that we had 

there. I got the community together. Everybody has a role. We in 

the Federal Government can provide a HUD-VASH voucher, but if 

we do not have a local landlord willing to rent at that rate, we cannot get the veteran in the home. 

Senator SULLIVAN. Got it. 

Secretary MCDONALD. So, it requires a 360-degree solution. We 

know that we can do it. The mayor of New Orleans committed to 

end homelessness, and in 6 months we had done it. 

Now, admittedly, there are not as many people homeless in New 

Orleans as there are in Los Angeles, but we know we can do it and 

we know how to do it. We would be happy to work with you on it. 

Senator SULLIVAN. Great. Thank you. 

Secretary MCDONALD. I forgot the second—— 

Senator SULLIVAN. Culture versus money. 

Secretary MCDONALD. Culture. Obviously, culture is the most important thing. In my leadership experience, the way we are approaching this is we have got to change the culture. We have to 

change the systems, if you know what I mean by—the repetitive 

processes, because many of our employees feel like they are prisoners of a system that is not right. We have to change the strategies, and we are doing that. 

Partnerships is a strategic change; and we have to change leadership. Over 90 percent of our medical centers have either new 

leaders or new members of the leadership team. 

In fact, what I worry about as I am trying to go out and recruit 

is all the bad press that we are getting; it makes my recruiting job 

very difficult. And, if Congress is to pass laws that affect VA employees only, it makes my recruiting job even more difficult. 

59 

We are trying to show that we have a plan, there is a good reason to join us, and we are getting a lot of takers. As I said, our 

employment is up. So, we are making progress. 

Senator SULLIVAN. All right. Thank you. 

Thank you, Mr. Chairman. 

Dr. CLANCY. May I make one addition from your State. 

Chairman ISAKSON. Quickly, if you will. 

Dr. CLANCY. Yes. In the short term we do need resources because 

a lot of our clinicians, who are terrific, are actually limited to one 

room per clinician, which means that affects productivity and how 

many veterans can be seen and so forth. So, I was thinking about 

the Nuka system in Alaska which has been a huge inspiration for 

us, but we believe that some part of their success was their ability 

to create a very, very different space. MyVA and the shared services that the Secretary is bringing about will help us get to a place 

that we can do that more efficiently and expeditiously. 

Chairman ISAKSON. Senator Tester. 

HON. JON TESTER, U.S. SENATOR FROM MONTANA 

Senator TESTER. Yes, thank you, Mr. Chairman. I want to thank 

the Secretary and your team for being here today. 

I have been particularly proud of this Committee, to serve on it, 

and particularly proud of the work the previous Congresses have 

done. When I first got here, you had discretionary funding in the 

VA; now it is mandatory. You had year-to-year funding; now we 

have got forward funding. We plussed up the budgets. We have had 

some great Secretaries from Peake to Shinseki to yourself, and I 

appreciate that. And to add to that, in Montana, I will tell you, you 

have some great people on the ground. The veterans who get 

through the door love the health care they get for the most part. 

There are a few exceptions to that. And the reason they love the 

health care they get is because of the health care professionals that 

are on the ground. They like it better than the private sector. That 

is why you do not see a lot of referrals out because they want to 

see their doc within the VA. 

That being said, we have got a problem, and that problem has 

to do with vacancies. The Director for VA in Montana had been an 

Acting Director for so long that he is no longer there because the 

Acting Director time ran out, 240 days. It is a huge issue. We have 

talked about it multiple times before. It is parochial in nature, but 

I think it is bigger than that. I think it happens in far, far too 

many regions. In fact, Dr. Clancy and Mr. Walters are Acting. 

When can we see a full-time Director in Montana? And when can 

we see nominees for the two positions Dr. Clancy and Mr. Walters 

have? 

Secretary MCDONALD. We are hoping to get the full-time Director 

in Montana within days. 

Dr. CLANCY. I was just checking my e-mail. We are actually expecting some word today, so—— 

Senator TESTER. Word today? 

Dr. CLANCY. Yes. 

Secretary MCDONALD. We were hoping to have it by—— 

Dr. CLANCY. We have a great candidate. That is not the issue. 

It is some paperwork that is beyond VA. 

60 

Senator TESTER. OK. 

Secretary MCDONALD. I also have worked with the President. We 

have nominations coming to the Senate very shortly. You will probably get some nominations next week. 

Senator TESTER. OK. That will be good. 

You had talked in your opening statement, Mr. Secretary, about 

antiquated infrastructure, the fact that we need new buildings, 

which I agree with. 

At Fort Harrison, we have a new acute psychiatric wing. I was 

there for the grand opening. Dr. Clancy’s predecessor was there 

when we cut the ribbon on the tape. Everybody was happy about 

it. It was going to take care of issues that dealt with PTSD and 

alcoholism and drugs. That facility—‘‘closed’’ is not the right word, 

but it is not taking any patients; a fact, we have been dealing with. 

A disabled vet with PTSD was turned away because that facility 

was no longer accepting patients. The county spent $2,400 to send 

him—but the bigger problem is that the facility was built—it is 

brand new, yet we do not have the staff. You just said hiring is up. 

You have got the best staff in the country in Montana. Why can’t 

we get some people to Montana to help these folks out? Why can’t 

we get that facility open? 

Secretary MCDONALD. I am hoping to learn more about that 

when you and I go to Montana, and I am hoping during our trip 

we can do some recruiting. 

Senator TESTER. I appreciate that. The problem is that I do not 

know—we talked about culture, we talked about money. I think 

you guys are great. I think the people you have got on the ground 

in Montana are great. What is going on in the middle? Why don’t 

we have aggressive recruitment going on with the folks down in 

Denver, in our region, and regions in the country? 

Secretary MCDONALD. They are aggressively recruiting. 

Senator TESTER. I do not see it. 

Secretary MCDONALD. But we do not see it in your result, so I 

have to get into it and learn about it. 

Senator TESTER. OK. 

Secretary MCDONALD. Make a difference. 

Senator TESTER. All right. I have a question. There is a group 

out there—it is my understanding a group called ‘‘Concerned Veterans of America’’—that is putting forth a proposal today to reform 

the VA, among other things. It would restrict the VA to only service-connected veterans. Could you give me your thoughts on that? 

Secretary MCDONALD. Well, as you know, the Department of Veterans Affairs is committed to providing veterans the best care they 

can get. They have earned it, and we want them to get it wherever 

they want, whether it is in the VA or outside the VA. The veteran 

is the core of our mission, and it is fundamental of our purpose of 

MyVA, the reorganization we are doing. 

Unfortunately, many of the proposals that are coming up today 

advocate contracting out what we consider to be a sacred mission 

of those who have borne the battle. So, it is important—we think 

there is an important role for outside care in veteran health to supplement our own VA care. But, frankly, we do not think that 

should diminish or obscure the role and the importance of VA’s 

health care program. That is what we worry most about. Reforming 

61 

VA health care cannot be achieved by dismantling it or by preventing veterans from receiving the specialized care and services 

that can be received only from VA. 

Our goal continues to be to provide timely, quality care and benefits, and we want to work to improve access, wait times. We want 

to find partners to help us. But we do not want to dismantle the 

VA. 

Senator TESTER. One last question, if I might, Mr. Chairman. I 

need you to provide me an update of the situation in Tomah VA 

medical center in Wisconsin. It is not my State, but it is very, very 

important. It is my understanding that Senator Baldwin had asked 

you for a VA investigation last June. It is also my understanding 

that the VA waited until January to launch that investigation. 

Why? 

Dr. CLANCY. The Inspector General actually delivered a report to 

the facility last spring and essentially told them not to share the 

report with anyone, so we did not have awareness of that for a 

number of months later. 

Senator TESTER. Why would they do that? 

Dr. CLANCY. They subsequently published it on February 6, and 

they did not find very much to act on. They had reviewed the practices of some clinicians whose practices were reported to be under 

concern. They simply did not come up with any hard findings to act 

on at that point in time. But, we did not have awareness of that 

until sometime in January. 

I am told that sometimes they close reports when it is more or 

less a negative report. I am just trying to explain the timeline. 

Right now we have completed the first phase of an in-depth clinical 

review with a second phase that has just launched, and the Office 

of Accountability and Review is also vigorously evaluating reports 

of retaliation and bullying by this one physician, who also happens 

to be the chief of staff. The clinicians in question are not seeing patients. They are on administrative detail, and they are also not 

able to prescribe any kind of medications for patients. 

We are taking this very seriously. We are reinforcing our effort 

systemwide to promote the safe and effective use of opioids. You 

want pain management, but at the same time we know that opioids 

come with a very big price tag in terms of side effects. So, we are 

not waiting for all the investigations to be done to be able to move 

forward on improvements we can make right now at Tomah and 

elsewhere. 

Senator TESTER. Fifteen seconds. I have been on this Committee 

since I got to the Senate. I believe in the people who serve this 

country, just as Senator Sullivan talked about. We have great service on the ground, but I am more concerned today than I have ever 

been in the past about what is going on in Montana’s VA, and that 

is what I am most familiar with. We have got to do better. I think 

everybody on this Committee is here to help you do better, but 

something is wrong. I am telling you because it is a good outfit; 

people should want to go to work there. 

Thank you. 

Chairman ISAKSON. Following up, I want to thank Senator Tester for bringing up the Tomah issue. For the record, so everyone 

62 

knows, the House Committee is going to Tomah, as I understand 

it—is that not correct? 

Dr. CLANCY. Yes. 

Chairman ISAKSON [continuing]. On a site visit, and we are trying to coordinate with them to do as much outreach as we can. Our 

second hearing after the hearing on the 40-Mile Rule will be on 

Tomah and on the overprescription of opiates. 

With regard to the IG, I have great respect for the IG. I think 

the IG provides a tremendous benefit to the Committee. But, that 

benefit is only utilized when we have the reports. I had the same 

question the Senator raised with regard to why those reports were 

not in the hands of the Committee as well. I will be working with 

the IG to see to it we have more transparency on those reports for 

the Members of the Committee. We may have to embargo them for 

reasons that you mentioned, Dr. Clancy. But I think it is important 

that the Committee know and not get caught by surprise. 

Secretary MCDONALD. Mr. Chairman, may I make a very brief 

comment? Concerning the report that is going to come out today 

that you asked about, Senator Tester, I have not gone through the 

details of the report, but I also want to—my statement is not—I 

want to make sure that you know that I am reaching out to a 

member of that committee to try to find out what there is to learn 

about it, and I am open to any ideas anybody has. So, I just want 

to make sure that you understand we are open to other people’s 

ideas. 

Chairman ISAKSON. Senator Rounds. 

HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA 

Senator ROUNDS. Thank you, Mr. Chairman. 

I would share that we had a very good meeting yesterday with 

the South Dakota delegation and I appreciated your time and your 

efforts in visiting about the Black Hills facilities, including the hospital at Hot Springs. First, I want to just briefly touch on that 

issue and then I would like to delve into a couple of other items. 

First of all, would you be able to assure the Committee that the 

items in the fiscal year 2016 budget request regarding the Black 

Hills Health Care System are not an indication of a pre-determined 

decision for the Hot Springs Hospital? 

Secretary MCDONALD. Yes, sir, Senator Rounds. As we talked 

yesterday, the money that was in there for Rapid City is what we 

need to do at Rapid City. There is no indication of any decision 

being made on Hot Springs. I have made no decision. We are still 

collecting data and the study is still being done, and that is why 

we met with you. 

Senator ROUNDS. Thank you, sir. 

Look, I have listened as each member around here has invited 

you to come in, and I know that we have talked about coming to 

South Dakota. You have got more things on your plate than I can 

imagine, and yet there seems to be kind of an underlying current 

here, and that is that you have stepped into a position in which 

you have got a huge and very unwieldy agency/administration. You 

have started with a reorganization, and you have got MyVA, and 

I notice that you have got some charts laid out for us in here. 

63 

When you take a look at the organizational chart that you have 

inherited—I had one of your employees come up to me and lay out 

what they had kind of charted out. They had 13 layers that they 

had been able to count. You cannot run an organization that has 

got that kind of a program. So, number 1, it looks like, what both 

Senator Tester and Senator Sullivan are talking about, the issues 

way down deep, they suggest that it is culture. I kind of go a little 

bit deeper and think that you can have real good people working 

in an organization, but if the organizational system, the layout, the 

map for getting approval and so forth and making changes does not 

work, you can have good people that just get frustrated and pretty 

soon, they do not want to be there. You have got folks on the 

ground, doctors that do a great job with individual veterans coming 

in, and yet the frustration that they have with trying to get 

changes made that they think would make it better, they become 

part of the issue that you are walking into. 

Can you talk a little bit about the organizational structure and 

what you would like to see done; what progress you have been able 

to make with regard to the organization; and how that may impact 

the ability for those folks that are at ground level to be able to 

respond. 

Secretary MCDONALD. Your insight is absolutely right. As I went 

around to the roughly 100 facilities I have been at, the number 1 

feedback I get from the lowest-level employee is, ‘‘I am a prisoner 

of a system I cannot change.’’ So, what we are trying to do is 

change the culture. We are trying to empower people to know that 

they can create change. 

We have stood up teams across the country that have people 

with similar interests in working on various issues. We are teaching them Lean Six Sigma technology so that they can make 

changes to the processes they work. 

Second, I have met with all the union leaders and I have said— 

65 percent of our employees are unionized—that it is their job to 

help us empower these people, and they have all been right on with 

that. 

Third, one of the things we do not do well is we are not a connected organization. We have vertical silos in our nine lines of 

business, but we also have horizontal silos, if I can say it that way. 

That is one of the reasons we had to go from the nine geographic 

maps, as a first step, to one. That is a big enabler. Now, we can 

take on other things that we could not take on. All of these things 

have to be sequenced. 

The next point would be that in addition to changing the maps, 

it is important that we change the organizational structure. Today, 

when I go to the human resources leader of VA and say, I would 

like the names of our top 50 development candidates, she cannot 

produce that because our functions are not connected from top to 

bottom in the organization. 

Senator ROUNDS. It does not work. 

Secretary MCDONALD. Companies do not run this way. So, we 

have got to build those connections in. We are in the process of 

doing that. 

I am as frustrated—we are as frustrated as all of you are that 

it takes time to create these changes, because the changes all have 

64 

to be sequenced; and we have to make sure the employees are involved in creating those changes, that it is just not top-down, because we have got to get at the stick. 

I am bringing in the very best people I know from the private 

sector to help us. We brought a Chief Customer Service Officer in. 

We have brought in a person to work on strategic partnerships. I 

am setting up an external advisory board, and you will recognize 

many of the names on that board. They are people who have done 

this before in the private sector. It is all going to accelerate our 

process and our progress. 

Senator ROUNDS. Can you give me a timeline? 

Secretary MCDONALD. I wish I could. We are going to make substantial progress in the next year. 

Senator ROUNDS. OK. 

Secretary MCDONALD. I think in the next year, you are going to 

be able to—I do not think there will be anyone who will not see 

the progress. And, you certainly will not be seeing the same structure we are in today. 

Senator ROUNDS. Thank you. 

Secretary MCDONALD. You are welcome. 

Senator ROUNDS. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Rounds, very much. 

The record should note the patience of former Chairman Sanders. I appreciate your patience, and it is now your time for questions. 

HON. BERNARD SANDERS, U.S. SENATOR FROM VERMONT 

Senator SANDERS. You are going to give me 15 minutes for that, 

right? 

Chairman ISAKSON. I am not that appreciative, no. [Laughter.] 

Senator SANDERS. Thank you, Mr. Chairman. Let me also thank 

the Secretary and his staff for being here. 

A funny thing happened on Tuesday. The Chairman and I and 

other Members of the Committee were there to hear testimony 

from the DAV, who do an extraordinary job representing disabled 

veterans. Well, it turns out that when I asked Commander Hope 

of the DAV his views about VA health care, what he said is that, 

by and large, the care was very, very good. In fact, he thought, representing his membership, that it is probably better than private 

care. 

So, the first point I want to make is that you run 151 hospitals. 

I suspect in every single one of them, there are problems today. I 

suspect on any given day, the media will put those problems on the 

front pages. You run 750 CBOCs. You run Vet Centers. You have 

6.5 million people coming in a year. And, if you had 90 percent satisfaction, you would have a hell of a lot of people who would be dissatisfied. So, you run an enormous operation. 

But, I think it is fair to say, in my view, talking to the service 

organizations, that, by and large, given the context of health care 

in America, which has enormous problems, that the VA does a 

pretty good job for those folks who get into the system. 

Let me go on the record as to suggest—this is no great secret 

that we live in a political world—there are some very conservative 

organizations who do not believe in government. Some of them are 

65 

funded by the Koch Brothers. They do not believe in Social Security. They do not believe in Medicare. They do not believe in the 

VA. They want to dismember the VA. 

Let me go on record to tell you that I will fight any effort to dismember the VA, because I think when you talk to the veterans of 

Vermont or the service organizations all over this country, as I do 

often, they say, you know what, there are problems—and I share 

the concerns that all Members here have raised, as we want to 

make it a better system—but, by and large, you have got a pretty 

good, cost-effective system. 

Number 2, in the bill that Senator Isakson and I and others 

worked very hard on, we put $5 billion into, in fact, strengthening 

the VA. Now, what I am hearing from you and from other members, you are having a hard time recruiting physicians, and you 

know why? Because in this country—forget the VA—we have a 

huge crisis in primary health care physicians. I was told—Jon Tester told me something I never knew. He explained that in Montana, 

and I suspect in other rural States, in some hospitals they do not 

have any doctors? I had never heard that in my life. In Kansas, you 

have that problem, I believe, Senator Moran, right? It’s unbelievable. 

Now, one of the things that I insisted be in that bill is debt forgiveness to make it possible to recruit doctors. Tell me what you 

are doing, and the difficulties that you are facing—and it is not just 

you, it is the Nation—and if you think it is bad today, it is going 

to be a lot worse 15 years from now. So, what are we doing to get 

young people out of medical school into the VA and into primary 

care, for example? 

Secretary MCDONALD. You are absolutely right. The debt forgiveness provision in the Choice Act is a huge enabler, and the debt 

provision in the Clay Hunt Act is a huge enabler. What we have 

done is we have made sure that our recruiting team is going out 

and talking about that. I can tell you from the roughly 12 medical 

schools I have been to—you and I were together in Vermont—that 

this is making all the difference in the world. It is a huge enabler. 

The average medical school student, my understanding, graduates 

with about $150,000 to $180,000 in debt. The Committee and the 

Congress doubled the former VA debt forgiveness, so it is making 

a huge difference. It is one of the reasons November was our peak 

recruiting month. So, we are getting better and better as we get 

the word out. 

Senator SANDERS. But, my point is, this is not just a crisis for 

the VA. This is a crisis for the United States of America. All right. 

Issue number 3. In the last 2 years, I think the major concern 

is that many veterans were on horrendously long waiting periods, 

all right. In fact, that precipitated a major crisis within the VA. 

How are we doing in shortening, if we are, the waiting periods? We 

do not want veterans to be waiting in lines for months. Are you 

making any progress on that? 

Secretary MCDONALD. Wait times are down about 18 percent nationally, and on average, are roughly 30 days. But, of course, that 

is an average, and we have wide variation, as you can imagine, by 

location and by specialty. Anything you want to add? 

66 

Dr. CLANCY. I think one big, big point that has changed, Senator 

Sanders, is that we are literally looking at data almost on a daily 

basis to identify, as one of your colleagues pointed out earlier, 

where there are very specific problems; what we can do about that. 

One of the big assets we actually have is a very large footprint in 

telehealth. So, when Denver had huge problems in mental health 

waiting times, Salt Lake City could step in and help them bring 

those wait times down. 

Senator SANDERS. What about Phoenix? 

Dr. CLANCY. Phoenix is improving. In fact, we were hoping to 

make a visit with the Chairman and Senator McCain literally tomorrow, but we are going to have to postpone that because of other 

Senate business here, but look forward to doing that. We have a 

very good Acting Director in there. We are recruiting hard for a 

permanent—— 

Senator SANDERS. But, we are making some progress—— 

Dr. CLANCY. Absolutely. 

Senator SANDERS [continuing]. In some of the worst areas of the 

country. You are focusing on those—— 

Dr. CLANCY. Yes. 

Senator SANDERS [continuing]. Where the waiting times were the 

longest. 

Next, let me concur with Senator Murray about the caregivers 

program. I think Congress several years ago developed that program for post-9/11 veterans. I think sometimes, Mr. Chairman, we 

forget that there are people out there, often wives, sisters, others, 

family members, who have devoted a large part of their lives to 

taking care of disabled veterans. So, we made progress. I would 

hope that we expand that program and I hope you, Mr. Secretary, 

will work with us. 

Another area where I think we need a lot of work, we have in 

this country not only a primary health care crisis, we have a dental 

crisis. It is a huge issue. Right now, you do dental work for serviceconnected veterans, and I, when I was Chairman, went around the 

country and talked to a lot of folks. There is a need, I think, to expand that program. Would you comment on that, Dr. Clancy or Mr. 

Secretary? 

Dr. CLANCY. You are right that we only provide dental services 

to a very small proportion of the veterans that we serve. We are 

looking at partnerships. We also have a low-cost dental insurance 

product that we have made available. But, we facilitate veterans 

getting access to this—it is a kind of partnership—and would be 

looking to expand in any way that we could work with you on. 

Senator SANDERS. OK. The last point that I would make, we 

have talked in this Committee a lot about opiates and the side effects that opiates have. The VA, I think, has been—along with the 

DOD, actually—leaders in this country in terms of moving to complementary and alternative medicine. Dr. Clancy, can you give me 

a report on that very briefly? Are we expanding the program? If 

people want to come in and get acupuncture, meditation, yoga, are 

they able to do that increasingly? 

Dr. CLANCY. Yes. First of all, we are expanding that, period. Second, as part of the issue of pain management and adaptation, oftentimes for a number of veterans, those modalities are very helpVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00070 Fmt 6633 Sfmt 6601 Z:\ACTIVE\022615.TXT PAULIN
67 

ful augmentations and help some veterans actually transition to 

lower doses or actually off opioids altogether. It does not happen 

instantaneously. But, I can tell you that we are now looking at the 

practices of individual clinicians and teams so we know where we 

can provide the most assistance, who is having the most challenges. We have got some virtual training that has demonstrated 

some phenomenal results in Ohio and we are planning to spread 

that out elsewhere. 

Senator SANDERS. All right. Thank you very much, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Sanders. 

Senator Hirono. 

HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII 

Senator HIRONO. Thank you, Mr. Chairman, and Mr. Secretary, 

it is good to see you again. 

I have a couple of questions relating to the Choice Card Program. 

I realize that there are some communication issues regarding that 

card with the veterans who receive them not quite understanding 

what it means, so I expect that you are addressing those kinds of 

issues. 

I did have one matter that was brought to me regarding the veterans who use the Choice Card when they go to see an outside doctor for a brace or a durable medical device, there is a catch–22 

there, because the VA has not updated their policy and only issues 

items like a knee brace to veterans who have an order from a VA 

doctor. So, even if they get to an outside doctor who prescribes such 

items, they cannot get them. So, are you making the necessary 

changes so that the veterans can get the prosthetics and other devices that they need? 

Secretary MCDONALD. I was unaware of that problem, so I would 

like to—we would like to follow up with you and get into that—— 

Senator HIRONO. Thank you. 

Secretary MCDONALD [continuing]. And make sure we address it. 

Senator HIRONO. I realize that the VA is the second-largest department in the entire Federal Government and so there are huge 

complexities involved in the challenges that you are facing, so I 

want to add my support to what you are doing to change your culture, to change your organizational structure. I realize it cannot be 

easy with the thousands and thousands of employees that you 

have, so I commend you, all of you, for the efforts that you are undertaking. 

When I met with you, Mr. Secretary, you said that eliminating 

veterans’ homelessness is a top priority and that you expect to 

eliminate homelessness among veterans by the end of this year. 

You are working in particular with 25 identified cities where there 

is a high veteran homeless population, Honolulu being one of them. 

Can you describe particularly how you are doing it, including—by 

the way, I think you mentioned the HUD-VASH voucher program, 

but the new budget that was submitted, I think, does not set aside 

vouchers specifically to address veterans’ housing. So, that may 

have a negative impact on your ability to get the veterans into 

housing in these cities. 

68 

So, could you just describe for me what you are doing. For example, in Honolulu, you are working with the mayor of the city and 

county. What is your expectation of what he is supposed to be 

doing? 

Secretary MCDONALD. The most important thing from our side is 

our medical center directors need to know those mayors and partner with those mayors. They cannot wait for me or for Carolyn to 

go out there to do it. So, we have asked every one of our medical 

center directors to make sure they are partnering with those mayors and working with the mayors to make the commitment to end 

homelessness by the end of this year. 

Then, we are bringing the tools to bear. You have mentioned a 

couple of them. The HUD-VASH vouchers is one tool. Another tool 

is a wonderful program called SSVF, which is about supporting 

families. We had—we need some work by Congress to—we had 

about half-a-billion dollars in the budget for the SSVF program. 

Only $300 million of it was authorized. We need the other $200 

million to be able to complete the program. So, we will be working 

with you on that. But, that is a wonderful program. It allows us 

to work with a local partner in order to get the families into housing, and it is the local partners that become very important. 

So, those are the steps we are taking. I have not been to Honolulu yet in this capacity, although I have been there many times 

before, and always enjoyed it—— 

Senator HIRONO. I extend the invitation. 

Secretary MCDONALD [continuing]. But, I would—the issue that 

we are seeing is, for example, I was with the Mayor of New Orleans the other day. We were holding a conference here and we were 

teaching mayors how to get this done and we acknowledge one of 

the things that is a problem is if you have a good climate, chances 

are good when you house the homeless veteran, you are going to 

have more homeless veterans because they are going to good climates. As a result of that, I worry a little bit about Honolulu—— 

Senator HIRONO. Yes. 

Secretary MCDONALD [continuing]. Places like Honolulu, New 

Orleans, Los Angeles, San Diego. So, I would like to get together 

with you and talk more about this. 

Senator HIRONO. I believe that Hawaii has the highest per capita 

number of homeless, not just veterans—— 

Secretary MCDONALD. Not just veterans—— 

Senator HIRONO. Yes. That is an issue. 

You mentioned, regarding homelessness, that it is a whole community approach. So, do you have some kind of a media program 

that you are running that says to a community like Honolulu that 

we are all coming together to eliminate homelessness in our communities? 

Secretary MCDONALD. Yes. In fact, we have a road map, a plan, 

that we work with each mayor and community on. That was what 

I was doing in Los Angeles. We had a press conference. I did a 

‘‘Meet the Press’’ segment on that and the work that we did. So, 

yes, that is part of the plan, and we can sit down with the mayors 

that you want us to and go through that plan. 

Senator HIRONO. I am wondering if there is a PSA or something 

that can be shown in all of these cities. Do you have such a thing? 

69 

Secretary MCDONALD. Yes. That is a great idea. 

Dr. CLANCY. I guess that I would just build on the Secretary’s 

leadership in striking a deal with partners in Los Angeles, because 

we are planning to use that as a model that we can then export 

lessons learned. So, we need people at our facilities working very 

hard to meet the veterans’ health care needs and so forth and 

reaching out to make sure that they get the right kinds of supportive services. But, we also very, very much need community 

partners. So, we have got a terrific individual leading this effort in 

Los Angeles with the idea that he will then bring those lessons 

learned rapidly to the other cities facing the greatest challenges, 

because the Secretary has made it very, very clear there is no way 

that we accomplish our stated goal in 2015 of getting close to functional zero without a renewed effort, stepping on the gas, if you 

will. 

Senator HIRONO. Thank you. 

Ms. HICKEY. And, Senator, if I might add, it is not just the 

health. It is an all of VA response, because I have two rather significant pieces that would contribute to the homeless mission. One 

is the very biggest program on prevention that exists out there, 

which is related to our Home Loan Guarantee Program. In the last 

4 years, we have kept 400,000 veterans and servicemembers from 

foreclosure. So, we have kept them in their homes by interjecting 

up front, as soon as we see—because we are in a paperless environment, we can see the data, see you have missed your mortgage payment, hear from a VSO or from you directly that you are in trouble—we immediately throw our great loan guarantee folks at that 

problem and see what we can do to renegotiate the loan, keep you 

in your home. That is the ambition of that. 

Senator HIRONO. Thank you. 

Ms. HICKEY. The second thing is, in our claims process and in 

our appeals process, we have provisions for expediting homeless 

veteran’s both claims and appeals. We do that rather regularly and 

that is another way we try to get additional resources into their 

hands by the nature of what we can do on the claims side or on 

the benefits side. 

Senator HIRONO. Thank you. 

Secretary MCDONALD. May I add one more, Mr. Chairman, Senator Hirono, because I am really glad you are on this topic: Veterans Courts. A ticket to a homeless person means incarceration; 

so what we are working to do is set up Veterans Courts all over 

the country so that we avoid incarceration. We know that if we 

avoid incarceration, we avoid homelessness. So, this becomes another breakthrough for us to stop veterans’ homelessness. 

Senator HIRONO. Thank you very much. Keep up the good work. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Hirono. On that point, 

that is another place where we have far more vacancies than we 

need right now, because the importance of coordinating with a Veterans Court for that veteran is critical and that communication 

needs to be seamless and timely between the VA and the judge in 

charge of that court. 

As you can evidence by both the attendance and the longevity of 

the questioning and the quality of the questioning, there is no 

70 

agency of the government that has more challenges to meet than 

the VA. I think I speak for the entire Committee, although only 

one Member is left here with me right now, and that is to say we 

have your back. You have our support. But, it is neither timeless 

nor unlimited. Now that we have isolated the problems before us 

on Choice, on facilities, on flexibility in funding, all the things you 

have talked about, it is time for us to put our shoulder to the grindstone and get the job done. We will not let the detractors tear us 

down nor let the protractors protract it out, but instead work together to improve the VA and make the VA better than it has ever 

been before. 

With that said, we will go to our second panel. This hearing is 

not adjourned, but we will have an intermission. 

Secretary MCDONALD. Thank you, Mr. Chairman. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 1. In response to pre-hearing questions regarding the analysis performed 

to determine whether the 5,006 new full-time equivalent (FTE) employees under the 

Medical Support and Compliance account are needed as opposed to whether the duties could be performed as ancillary duties of existing employees, the Department 

of Veterans Affairs (VA) stated: 

The Medical Support and Compliance FTE growth is not associated with 

the Secretary’s MyVA initiative. 

The additional positions are being added to the Medical Centers and [Veterans Integrated Service Networks (VISNs)] to support and fulfill the Secretary’s vision of becoming a more Veteran-centric organization and to be 

able to provide top-level customer service in a more efficient manner to our 

Veterans. These personnel will support healthcare workers in order to deliver the healthcare services that our Veterans expect. 

(Emphasis added.) 

On December 18, 2014, VA briefed staff on the MyVA initiative. According to 

slides handed out at that briefing, MyVA is about: 

[E]mpowering employees and helping them deliver excellent customer service to improve the Veteran experience*** [and] rethinking our internal 

structures and processes to become more Veteran-centric and productive. 

(Emphasis added.) 

a. Please describe the analysis performed to determine whether the 5,006 new 

FTE under the Medical Support and Compliance account are needed as opposed to 

whether the duties could be performed as ancillary duties of existing employees. 

Response. The Medical Support and Compliance (MSC) full-time equivalent (FTE) 

growth is not directly associated with the Secretary’s MyVA initiative. 

VA medical centers and Veteran Integrated Service Networks (VISN) are adding 

additional MSC positions to support and fulfill the Secretary’s vision of becoming 

a more Veteran-centric organization and to provide top-level customer service in a 

more efficient manner to our Veterans. As a result, some of the following positions 

will be increased: personnel management specialist, police, contract administrator, 

voucher examiner, claims assistant, emergency management series, medical records 

clerk/technician, health systems specialist, administrative officer, and security clerical and assistants . These positions directly support the Department of Veterans 

Affairs’ (VA) objective to manage and improve VA operations to deliver seamless 

and integrated support. The additional personnel will support the delivery of health 

care services that our Veterans expect. Though not originated as part of MyVA, the 

FTE growth will improve the service VA provides to Veterans, and will therefore 

support MyVA efforts. 

Although the FY 2016 Revised Request estimate of 54,020 FTE is 5,006 more than 

the original FY 2016 Advance Appropriation estimate, it is only 1,206 more than 

the FY 2015 Current Estimate. As displayed in the table below, VA anticipates 

growth in FY 2015 Medical Support and Compliance FTE. The FY 2015 Current Estimate of 52,814 FTE is 3,800 more than the FY 2015 Budget Estimate and 2,491 

more than the FY 2014 Actual FTE. The FY 2015 Current Estimate is largely based 

on FTE Operating Plans submitted by the VISNs, and reflects a concerted effort to 

71 

provide more support staff to VA clinical staff in order to enhance Veterans’ access 

to health care. The FY 2016 Revised Request increase of 1,206 FTE above the FY 

2015 Current Estimate is a 2.3 percent increase, which is in line with VA’s estimated increase in health care demand. 

b. Please describe, in detail, the difference between the MyVA initiative as it was 

defined to staff on December 18, 2014, and the duties to be performed by the 5,006 

new FTE in Medical Support and Compliance. 

Response. The requested Medical Support and Compliance (MSC) resources would 

focus exclusively on medical centers and VISNs. Though not originated as part of 

MyVA, the FTE growth will improve the medical support VA provides to Veterans, 

and will therefore complement MyVA’s broader, enterprise-wide efforts. 

‘‘MyVA’’ is our enterprise-wide transformation from VA’s current way of doing 

business to one that puts the Veterans in control of how, when, and where they 

wish to be served. It will modernize VA’s culture, processes, and capabilities to put 

the needs, expectations, and interests of Veterans and their families first. MyVA 

represents an opportunity to affect fundamental changes in VA’s systems and structures to align with our mission and values. The MyVA vision is to provide a seamless, unified Veteran Experience across the entire organization and throughout the 

country. 

Our plan has three integrated elements, or horizons. First, we plan to leverage 

those existing programs and initiatives that are delivering better services and benefits to Veterans. There is already a great deal of positive transformation taking 

place in VA and those efforts must be exploited and leveraged. 

While these efforts provide a solid base to build from, the improvements are not 

sufficient. Thus, the second horizon of the transformation concentrates on a relatively small set of catalytic efforts focused on five initial priorities. They will accelerate the transformation now underway: expect to see significant and demonstrable 

progress in these targeted areas between now and the end of 2016. These initial priorities include: 

• Improving the Veterans experience. At 

a bare minimum, every contact 

between Veterans and VA should be 

predictable, consistent, and easy. But 

we’re aiming to make each touch point 

exceptional. 

• Improving the employee experience. 

VA employees are the face of VA. They 

provide care, information, and access 

to earned benefits. They serve with 

distinction daily. 

While improving the Veteran and employee experiences are central to our efforts, 

three complementary efforts will help build more robust management systems, enhance productivity, and deliver more effective results. 


94132q1VA2a.eps 94132q3VA1b.eps
72 

• Achieving support services excellence will let employees and leaders focus on assisting Veterans, rather than worrying about ‘‘back office’’ issues. 

• Establishing a culture of continuous performance improvement will apply lean 

strategies to help employees examine their processes in new ways and build a culture of continuous improvement. 

• Enhancing strategic partnerships will allow us to extend the reach of services 

available for Veterans and their families. 

The third horizon is optimizing and scaling successful initiatives from the previous horizons, and growing small wins into big ones. This horizon will extend into 

and beyond 2017. 

Since the December 18th briefing that is referenced in the question, the MyVA 

staff has discussed this transformational effort several times with members and congressional staff. Specific meetings include: 

• 1/26/15—HVAC/SVAC/HAC/SAC Staff (teleconference) 

• 1/26/15—VA 101 Brief to House Hill Staffers 

• 2/6/15—SVAC MLA’s 

• 2/19/15—VA 101 Brief to Senate Hill Staffers 

• 4/17/15—HVAC & SVAC Staff Update 

• 4/28/15—Rep. Amodei (R-NV) Member-level brief 

• 5/8/15—Sen. Crapo (R-ID) Staff-level brief 

• 7/17/15—SVAC/HVAC Staff Update 

On July 30, 2015, VA released the MyVA Integrated Plan that describes the 

MyVA effort in more detail. It can be accessed at: http://www.va.gov/opa/myva/docs/ 

myva—integrated—plan.pdf 

Question 2. In the fiscal year 2016 budget, VA indicates that it is leveraging 

eBusiness initiatives to create ‘‘efficiencies in the billing and collections process’’ for 

the Medical Care Collections Fund (MCCF). These initiatives include: ‘‘Medicareequivalent Remittance Advices; insurance verification; inpatient/outpatient/pharmacy billing; and payments, including Electronic Funds Transfer.’’ 

a. Please describe in detail each initiative and how each has improved MCCF’s 

billing and collections process. 

b. What metrics does VA use to determine the performance of each initiative in 

increasing collections of MCCF? 

Response. Fiscal Year 2016 eBusiness Initiatives for the Medical Care Collections 

Fund (MCCF). The MCCF Electronic Data Interchange (EDI) Development builds 

the transaction platform infrastructure to bill third party payers for non-service-connected care provided to veterans. The development initiatives address changes in 

transaction processing standards in the insurance and banking industry, those that 

are mandated in published regulations as well as those defined by Designated 

Standards Maintenance Organizations. The internal VA transaction structure must 

conform to current transaction standards to be able to securely communicate electronically with the commercial healthcare industry in order to collect revenue. In 

addition to mirroring the technology of the commercial healthcare industry, VA 

must also update internal functionality to reflect new and emerging needs as a result of years of iterative changes such as tracking system problems and transaction 

irregularities, as well as, updating reporting structures within VistA to support internal VHA organizational changes. Specifically, now that VA has moved to a consolidated revenue structure for billing and collections, the configuration of reporting 

within the VistA system must be modified to provide new and varied configurations 

for EDI system status and data analysis. 

Medicare-equivalent Remittance Advices (eMRA). While the eMRA initiative is an 

integral part of the MCCF EDI transaction platform, there is no development needed or planned for FY 2016. VHA transmits over 4.5 million eMRA requests to Medicare which is essential for billing Medicare secondary payers. eMRA is a mature and 

stable part of the VistA transaction platform with no development funding needs anticipated at this time. 

Insurance Verification. The electronic Insurance Verification (eIV) module in 

VistA provides verification of patient health insurance and Medicare eligibility, providing the essential data elements to process a claim. VHA transmitted over 9.5 million electronic eligibility transitions (HIPAA X12 270) in the last fiscal year (FY 

2014). Medicare eligibility was added and increased growth 31% since FY 2010. 

Real-time electronic verification occurs in seconds (electronic inquiry, response, and 

auto-update the information in the patient insurance file). Volume metrics will continue to be collected through the testing phase in FY 2016, into FY 2017 for national 

deployment, and continue until the insurance identification/verification processes 

reach a plateau in the MCCF EDI transaction platform. 

73 

• A savings of over $6 million over the next decade will be realized by the Medicare Direct Connection (between VA and CMS), which eliminated the need to pay 

clearinghouses to process the Medicare eligibility inquiry for MCCF. • Monthly cost savings are tracked and will be tracked through FY 2016 and beyond. Since the first direct transmission in August 2014, a total of 2,094,184 Medicare inquiries were processed, saving $229,588 in transaction fees. • Future savings of over $7 million a year will be realized when the current ‘‘commercial off-the-shelf’’ (COTS) insurance intake and verification product is replaced 

with VA owned, GUI software, which is currently in development. The testing phase 

for this project is expected to begin in FY 2016, with savings to be realized after 

full deployment. Insurance card images stored on a data storage platform (SSOi) 

connecting all VA medical centers (VAMCs) and Community Based Outpatient Clinics (CBOCs) (approximate 6,000 users) is in current development—costs in supplies, 

manpower and time has not yet been realized. 

Inpatient/Outpatient Medical Billing. The electronic submission of standard electronic Institutional and Professional inpatient and outpatient claims to third-party 

payers increases the speed of the billing and adjudication of claims, resulting in 

faster collections and fewer rejections. Automation of billing processes enables accurate billing to plans paying secondary to Medicare and other third party payers who 

are considered primary payers. The eBilling initiative is focused on industry compliance, and not efficiencies. Over 15 million electronic billing transactions occur annually (including over 4.5 million eMedicare Remittance Advice requests to Medicare). 

With electronic billing, communication methods are used to interact with over 1,600 

payers in a standard language, making messaging about health care efficient and 

determination of payment fast and accurate. FY 2016 includes updates to Health 

Care Services Review (HCSR) transactions (ASC X12 278) based upon industrymandated biennial review and to ensure VHA systems implement a streamlined 

work flow between transactions and Utilization Review (UR) staff. A performance 

metric for the 278 transaction will target a processing metric to third-party payers 

of less than 5% rejects requiring manually submitted reviews for all transactions 

processed. Updates to Health Care Claims Attachments transactions are planned in 

FY 2016, based upon industry-mandated biennial review and/or gaps identified in 

the implementation of attachment transactions across payers. These updates will include the ability for the end user to see the attachment that is associated with the 

claim and payment, thus eliminating the mailing of a paper copy of the required 

documentation. Claims Attachments is targeted to process to third-party payers 

with less than 5% of those transmitted returning with additional requests for manually submitted attachments. 

Pharmacy Billing. Electronic pharmacy (ePharmacy) billing is the automated submission of real-time electronic VA Outpatient Pharmacy claims to third-party payers/Pharmacy Benefit Managers (PBM). All of the work in support of pharmacy 

transactions is industry standard compliance. Quarterly updates from the National 

Council for Prescription Drug Programs (NCPDP) are planned through FY 2016 to 

maintain electronic connectivity to PBMs which do not accept paper claims. An 18- 

second response time has been achieved for these real-time transactions. VHA submits over 11.7 million ePharmacy transactions annually from 265 VHA pharmacies. 

Four million prescription fills and claims are processed annually, without manual 

intervention. Drug profile information, contained in the adjudication received from 

the PBM, includes drugs prescribed and obtained outside of VA and paid for by the 

PBM, increasing patient safety. Days to Bill for NCPDP transactions in this fiscal 

year-to-date is 11.9 days, and will continue to be tracked through FY 2016 to assure 

there is no degradation in processing times. (Historically, the Days to Bill paper 

claims average was 148.7 days.) 

Payments. The electronic payments (ePayments) process is comprised of the receipt of HIPAA-mandated Electronic Remittance Advice (ERA) and Electronic Funds 

Transfer (EFT) transactions. Over $1.6 billion is received annually through EFTs 

from over 150 third-party payers and over $2 billion in ERA transactions is posted 

annually through electronic accounts receivable processing. Payments processing by 

EFT has already been developed and deployed for VA prior to the January 1, 2014 

Patient Protection and Affordable Care Act of 2010 (ACA) compliance deadline, 

which mandated use of the EFT across the industry. Over 70% of all payments are 

currently received via EFT versus a paper check. Having 70% of all revenue processed through EFT by FY 2017 is a Revenue Collections Management objective set 

by the Commissioner of the Department of the Treasury’s Bureau of the Fiscal Service. VA’s FY 2015 EFT measurement already exceeds U.S. Treasury’s EFT throughput goal. This metric will continue to be monitored through FY 2016 and beyond. 

Auto-posting and auto-decreasing of third-party claim payments creates an efficiency with minimal manual intervention in the payment posting process, thus inVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00077 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
74 

creasing accuracy and speeding the close of health care claims receivables. Metrics 

will be developed to track the percentage of auto-posting and exceptions. 

Question 3. VA has started to integrate mental health into primary care through 

its Primary Care Mental Health Integration (PCMHI) initiative. According to the 

budget justification, the Veterans Health Administration (VHA) has increased the 

penetration rate of PCMHI to 15 percent overall. 

a. Please describe in detail the implementation plan, including key milestones and 

estimated completion dates for each milestone. 

Response. VA began formal implementation of Primary Care-Mental Health Integration (PCMHI) by providing initial funding during fiscal year (FY) 2007 to 92 facilities that expressed interest. Since FY 2009, all VA medical centers and large and 

very large community-based outpatient clinics (CBOC) have been required, under 

the Uniform Mental Health Services Handbook, to have fully operational programs. 

Substantial growth and development of PCMHI has continued throughout, as evidenced by the following milestones and goals: 

• From FY 2007 to the present, PCMHI has been supported by ongoing educational seminars and events and facility-based consultation by national subject 

matter experts, with the more recent addition of intensive, evidence-based facilitation through the Office of Mental Health Operations. • In FY 2010, additional enhancement funding was provided to facilities with 

identified need. • Access to mental health services occurs through various pathways including 

PCMHI encounters. As of the third quarter of FY 2015, 23.4 percent of all Veterans 

enrolled in VA primary care had mental health encounters including both specialty 

mental health and PCMHI use. • As of the first quarter of FY 2015, 92.1 percent of sites required to have PCMHI 

embedded in Patient Aligned Care Teams (PACT) have established programs. This 

is an increase from 87.9 percent during the first quarter of FY 2014. • The extent of PCMHI practice has grown steadily, from 183,048 encounters and 

a penetration rate (percentage of PACT patients who have a mental health encounter within the primary care clinic) of 2.2 percent during FY 2008, to 991,773 encounters and a penetration rate of 6.8 percent during FY 2014. In the first 4 months 

of FY 2015, 156,622 Veterans seen in primary care had at least one visit with an 

integrated mental health clinician, compared to 342,081 during all of FY 2014. • The overall PCMHI penetration rate increased by 15 percent overall from FY 

2013 to FY 2014 (from 5.9 percent to 6.8 percent). This reflects the percentage of 

the primary care population receiving mental health services as part of routine primary care. Many facilities have penetration rates in the 10–12 percent range, and 

as continued maturation of inter-professional care within PACT occurs we expect 

penetration rates to continue to increase • An ongoing goal of the PCMHI program is to ensure that services are available 

on a same-day basis to a primary care appointment, when a new Veteran’s needs 

are identified. To date, in FY 2015, 34 percent of Veterans new to PCMHI services 

were seen on the same day, compared to 29.9 percent at this time in FY 2014 [note: 

this is a cumulative rolling average]. 

• An additional goal is ongoing enhancement of our electronic platforms to support longitudinal follow-up and telephone care management. To that end, the Behavioral Health Laboratory (BHL) software that supports these functions has been 

installed at 98 VA facilities (approximately 75 percent of currently eligible sites) as 

of March 2015. Training and field support for its use are ongoing, and software enhancements are in development for FY 2016 to promote flexibility of use for both 

care management and for measurement-based mental health care more broadly. 

b. Please describe the oversight conducted to ensure the mental health providers 

assigned to a Patient Aligned Care Team are provided office or treatment space 

within the primary care setting. 

Response. One requirement of PCMHI programs is the co-location of mental 

health clinicians within the primary care setting. Given current space constraints 

in many facilities, not all are yet co-located. Questions related to co-location of providers are addressed in the Office of Mental Health Operations site visit process. 

Additionally, the PACT space design process now specifies identified space for colocated mental health providers within primary care in all new and renovated space 

configurations. Finally, continued development and maturation of both care management platforms and telehealth technologies will advance the extent and quality of 

care in a manner that is less dependent on fixed infrastructure. 

Question 4. Hepatitis C is more prevalent in VA’s population than in the general 

population. In 2013, VA estimated there were 174,000 veterans with Hepatitis C or 

about three percent of VA’s unique patient population. In recent years, new pharmaVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00078 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
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ceuticals have been approved that will cure Hepatitis C within a few weeks and 

without the devastating side effects of previous medications. According to the budget 

justification, VA has developed a model to determine the funding needed for these 

new Hepatitis C drugs. 

a. Please describe in detail the model developed and the assumptions within the 

fiscal year 2016 and fiscal year 2017 budget requests. 

Response. The Department of Veterans Affairs (VA) developed an actuarial model 

(Hepatitis C Model) that projects the number of enrolled Veterans infected with the 

Hepatitis C virus (HCV), the number of treatments for this population, and the 

costs associated with HCV drug treatments. This model includes data on estimated 

HCV prevalence rates in VA, demographics, genotype, advanced liver disease status, 

course of treatment, estimated number of treatments per week, treatment duration, 

average treatment cost per week by duration, assumed relative mortalities, probabilities for Sustained Virological Response (SVR), number of retreatments, and reinfection rates. Shifting prevalence of HCV in the VA population was also modeled 

in a manner consistent with enrollment projections from the VA Enrollee Health 

Care Projection Model (EHCPM). Recent trends were used to project behaviors regarding HCV infection rates and screening increases. 

To estimate the additional drug acquisition costs associated with providing HCV 

drug treatments from FY 2014 to FY 2017, the average cost per treatment was applied to the total number of treatments expected to be performed each fiscal year. 

The assumed cost for each course of treatment was provided by VA’s Pharmacy Benefit Manager (PBM) in July 2014. The costs per treatment were assumed to stay 

constant over time. New treatments that became available starting in FY 2015 were 

assumed to be cost-neutral with regards to known treatments at the time the cost 

assumptions were developed. 

The projection model includes prescription drugs that are currently available. 

• The primary treatment regimens that are currently being prescribed include: 

sofosbuvir/ledipasvir ± ribavirin 12-week; 

ombitasvir/paritaprevir/ritonavir/dasabuvir ± ribavirin 12-week; 

sofosbuvir/ledipasvir 8-week; 

sofosbuvir/ledipasvir 24-week; and sofosbuvir/ribavirin 24-week. 

• The treatment regimens that became available in October 2014 include: 

sofosbuvir/ledipasvir 8-week; 

sofosbuvir/ledipasvir 12-week; and 

sofosbuvir/ledipasvir 24-week. 

• The treatment regimens that became available in December 2014 include: 

ombitasvir/paritaprevir/ritonavir/dasabuvir ± ribavirin 12-week and 24-week. 

• Future regimens include Daclatasvir and Sofosbuvir 12-week and 24-week. 

The initial treatment projections from FY 2015 through 2023 were developed to 

target approximately 13,000 treatment evaluations annually, based on treatment 

starts in FY 2014. The estimated capacity within VA to treat HCV patients at the 

time of approval of new treatment regimens by the Food and Drug Administration 

was based on the number of treatment starts in FY 2014, which was low due to 

long and arduous treatment regimens available at the time. This estimated capacity 

was considered as a constraint on the model when projecting the 13,000 treatment 

evaluations. The variation in projected treatments and costs between different Veteran Integrated Service Networks (VISN) was related to the underlying patient demographics within each VISN, differences in HCV provider treatment capacity, improved infrastructure leading to differences in the numbers of Veterans started on 

treatment, and differing approaches within VISNs to prioritization of patients at different disease. Of note, a VA-wide prioritization plan based on disease stage was 

implemented in May 2015 after FY 2015 funds to treat HCV were exhausted in 

nearly all facilities. 

Hepatitis C Model Projection Methodology and Assumptions 

The Hepatitis C Model projects the HCV infection status of enrollees year-overyear in a manner consistent with clinical assumptions and enrollment estimates in 

each year. The model projects the following Hepatitis C statuses for enrollees in 

each projection year: 

• Uninfected—Veteran enrollees who have not contracted HCV 

• Undiagnosed Infected—Enrolled veterans with HCV who have not yet been diagnosed as HCV positive 

• Diagnosed Infected—Enrollees infected with HCV who have been diagnosed and 

are candidates for treatment 

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• Infected Non-Candidates—Enrollees infected and diagnosed with HCV but, 

through VHA evaluation, have been deemed not suitable for treatment or have declined treatment • SVR—Enrollees who have effectively been ‘‘cured’’ through treatment 

In each year of the projections, treatments occur only within the Diagnosed Infected population and are isolated to those enrollees who are considered treatment 

candidates. It is assumed that approximately 30% of all enrollees are not considered 

candidates for treatment for a variety of reasons, including clinical reasons and by 

individual choice. If a patient receives treatment in a given year and fails to attain 

SVR, the patient remains eligible for treatment in a future year. However, if after 

two years of attempted treatment the patient still fails to attain SVR, the patient 

is no longer a candidate for treatment in the third year. It is possible that an HCV 

patient may transition into the Diagnosed Infected population and receive treatment 

in the same year. 

In order to determine when a transition for treatment occurs, along with other 

assumptions, a stochastic model is used to assign patient statuses based on a probability distribution. Transitions and treatments for each individual are determined 

by choosing a random ‘‘seed’’ number that dictates which of the available outcomes 

is assumed to occur. Although this methodology is built upon a random process, the 

large size of the modeled population ensures that the proportion of individuals transitioning to each particular status will approximately equal the assumed probability 

of that event occurring. The model is also run 30 times and average results are used 

in order to reduce the variability in results due to random fluctuation. 

b. What are the long-term savings to VA in curing Hepatitis C? 

Response. The Veterans Health Administration (VHA) is assessing the short- and 

long-term impact on overall health costs associated with treatment of Veterans’ 

Hepatitis C. To assess these costs, VHA evaluated 14,206 Veterans who received 

therapy beginning in FY 2005 with at least 5 years of time after finishing treatment. At 5 years post-treatment, patients with SVR (vs. no SVR) had an average 

adjusted mean cost savings of $5,200 per patient overall, $15,705 in cirrhotics, and 

$3,501 in non-cirrhotics. The unadjusted mean cost savings was $17,962 per patient 

overall, $22,857 in cirrhotics, and $14,204 in non-cirrhotics using a 5-year follow up 

period, means VHA is not currently able to assess the impact of newer Hepatitis 

C medications on long-term savings. In the general population, the best available 

study shows an adjusted cost savings of $2,648 per year in a similar large sample 

of managed care patients with SVR vs. no SVR (Manos MM et al. Journal of Managed Care Pharmacy, July/Aug 2013). 

Question 5. In part, the President’s Executive Order (E.O.) 13625, ‘‘Improving Access to Mental Health Services for Veterans, Servicemembers, and Military Families,’’ directed VA to work closely with the Department of Defense (DOD) and the 

Department of Health and Human Services (HHS) to improve research on suicide 

prevention. To carry out this E.O., VA, DOD, and HHS have partnered to implement the Cross Agency Priority Goal (CAP Goal) and the 19 new Executive Actions 

announced in August 2014 to ‘‘improv[e] access and reduc[e] barriers to mental 

health care.’’ Please describe in detail how VA intends to implement the CAP Goal 

and the 19 new Executive Actions. 

Response. The Departments of Veterans Affairs (VA), Defense (DOD) and Health 

and Human Services (HHS) have been working closely together to enhance mental 

health services to Veterans, servicemembers and military families. Accomplishments 

resulting from the President’s 2012 Executive Order (#13625) are highlighted below: 

• Implemented a joint DOD/VA national suicide prevention campaign and increased Veterans Crisis Line staffing by 50 percent. 

• Established the National Research Action Plan and invested $107 million into 

two joint research consortia on Post Traumatic Stress Disorder (PTSD) and the 

Chronic Effects of Neurotrauma. 

• Completed VA pilot partnerships with 24 community-based mental health and 

substance abuse disorder treatment providers. 

• Expanded outreach campaigns to raise awareness and reduce the stigma associated with seeking mental healthcare. 

• Launched training in military culture competence for VA, DOD, and community 

healthcare professionals. 

• Established the Interagency Task Force to coordinate and oversee interagency 

mental health activities, resulting in annual interagency recommendations for improvement. 

• Added 1,669 mental health clinical providers and 973 peer support staff in VA. 

• Established policies and implemented a process for connecting Veterans in crisis 

to a mental health worker within 24 hours. 

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Interagency work in this area has continued under the auspices of the Cross 

Agency Priority Goal (CAP Goal) on servicemember and Veteran mental health, 

which was announced in March 2014. Immediately following the announcement of 

the CAP Goal, each of the three departments identified action officers and subject 

matter experts to develop 3-year work plans consisting of actionable milestones and 

performance indicators (metrics). Action officers for each department meet weekly 

to discuss progress on the milestones and indicators. Progress is tracked and reported quarterly on the public facing Web site www.performance.gov. Detailed updates on the CAP Goal activities are provided on a quarterly basis to executive 

branch leadership and posted publicly on performance.gov. Notable highlights from 

the progress of the CAP Goal efforts include the following: 

• Visits to the Make the Connection outreach campaign Web site continue to 

trend upward (722,698 so far in FY 2015) and are on track to substantially exceed 

the targeted 10% increase for this year.Established an interagency workgroup to 

identify, expand, and promote DOD, VA, and HHS efforts to reduce negative perceptions associated with seeking mental health care and increase awareness of resources. • ‘‘These Hands’’ public service announcements (PSA) for the Veterans Crisis 

Line/Military Crisis Line are in the top 5 percent of PSAs being aired nationally. • Views of the VA Community Provider Toolkit (www.mentalhealth.va.gov/ 

communityproviders/) also continue to increase and content continues to be enhanced to meet the needs of clinicians who are serving Veterans in the community. 

Further building upon the activities of the EO #13625 and the CAP-Goal, VA, 

DOD, and other Federal agencies have taken a number of steps in response to the 

President’s August 2014 Executive Actions (EA). Similar to the CAP-Goal, the Departments have identified Action Officers and subject matter experts for each of the 

19 items and collaborative work is underway. Highlights of interagency EA progress 

to date include the following: 

• DOD’s inTransition contract is in the process of being modified to establish an 

automatic enrollment for Servicemembers preparing for transition to Veteran status. • Military Culture Competence training is being disseminated to community providers in coordination with the White House Joining Forces initiative. • VA and IRS are providing Operation Save suicide prevention training to volunteer tax preparers who are working with Veterans. • DOD, VA, and HHS are working together to address risk of opioid overdose risk 

by increasing the availability of naloxone, a medication that reverses the effects of 

opiates. VA policy was revised in February 2015 to ensure that Servicemembers 

transitioning to VA care will maintain access to medication prescribed by DOD providers. 

Question 6. VHA has pointed to its use of and training in evidence based 

psychotherapies (EBPs) and, according to the budget justification, has provided 

training to more than 7,500 providers. The justification also states: ‘‘VHA will expand its efforts to * * * evaluate the impact of training in and delivery of these 

therapies.’’ Please describe in detail the metric used to evaluate the training and 

delivery of EBPs. 

Response. VHA’s competency-based EBP training model includes two key components designed to create mastery and promote successful EBP implementation: (a) 

participation in an in-person, experientially-based workshop, and (b) ongoing telephone-based clinical consultation on actual therapy cases with a training program 

consultant who is an expert in the particular EBP. Ongoing formative and 

summative program evaluation is a central component of the VA EBP training programs and focuses on both staff and Veteran outcomes. Additionally, alternative 

training methods are being piloted and will be evaluated against the current training standards. 

Therapist Outcomes—For evaluating EBP therapists-in-training, the EBP training 

programs use survey measures to collect data at several points in time: before and 

after training; and during, immediately after, and six months after the consultation 

phase. Variables assessed include: therapists’-in-training ratings of (1) the trainers; 

(2) training program quality; (3) self-rated knowledge and skills acquisition; (4) intent to apply skills to their practice; (5) self-efficacy in applying EBP skills; (6) attitudes regarding use of the EBP; and more. In addition, expert EBP consultants assess the outcomes of therapists-in-training by using an EBP-specific competency rating scale to rate actual sessions. These ratings provide reliable and detailed feedback on their EBP skills. 

VHA program evaluation has shown that this intensive consultation, combined 

with ratings of actual clinical cases, is crucial to improving provider competencies. 

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Consultation improves therapists’ sense of efficacy in delivering EBPs that are not 

evident when therapists only attend a workshop. 

Veteran Outcomes—The EBP training programs also assess Veterans’ responses to 

EBPs. To date, the VHA EBP program evaluation data indicate that Veterans’ improvements in target symptoms have been in the medium-to-large or large range for 

Post Traumatic Stress Disorder, insomnia, depression, and chronic pain. These results are quite promising considering they come from Veterans, often with complex 

or chronic problems, who are being treated by EBP therapists-in-training. Program 

evaluation for some of the newer EBP training programs, which focus on treating 

substance abuse and building motivation to change problematic behaviors, are fully 

underway, but results are not yet published. 

Beyond symptom relief, Veterans have also shown significant improvement in 

their quality of life (both psychologically and physically) and in their therapeutic alliance scores, indicating that Veterans agree with their therapists on the goals and 

tasks of therapy and feel a bond with their therapists. VHA data indicate completion rates of around 70 percent across treatments, relative to the mean completion 

rate of 54 percent reported in studies of psychotherapy with the general population. 

These findings indicate a high degree of Veteran acceptance of these therapies, 

which may be in part due to the strong emphasis the training programs place on 

building strong working alliances between the trainers and their Veteran patients. 

Increasingly, researchers are focusing on the effects of EBPs on reducing medical 

utilization and health care costs. For example, completion of EBPs for Post Traumatic Stress Disorder has demonstrated a 30 percent reduction in mental health 

service utilization and about a 40 percent reduction in health care costs in the year 

following treatment. Studies from the National Health Service in the United Kingdom have demonstrated that EBP treatment for a wide variety of mental health 

conditions results in net savings to the system above and beyond the costs of training. 

Delivery of EBPs—Previously, there was no mechanism for tracking the delivery 

of EBPs using administrative data. In the first two quarters of fiscal year 2015, 

VHA released nine sets of documentation templates for the EBPs that treat Post 

Traumatic Stress Disorder, depression, serious mental illness, insomnia, and relationship distress. Six more sets are planned for release at the beginning of next fiscal year. These documentation templates are for the EBPs that treat chronic pain 

or substance use, increase motivation to change, and track the offering of EBPs to 

Veterans. For the first time, VHA can directly measure the delivery of the EBPs 

that have documentation templates. 

A beta version of a national dashboard was just released that documents the number of unique Veterans who have had two or more sessions of an EBP since the templates were deployed. Currently, the EBP utilization data, available at the national, 

VISN, and facility levels, can be viewed by any VA staff member. EBP data is displayed in near real time. New parameters and reporting capabilities will continue 

to be added as data definitions are developed and refined. The release of the EBP 

documentation templates and the deployment of the national EBP dashboard will 

greatly increase VHA’s ability to focus implementation efforts at sites with low EBP 

delivery and to learn the best practices from high achieving sites. 

Improving Access to EBP Training—The EBP training programs are piloting alternative training methods that rely less on national in-person workshops. During 

the piloting phase, the training programs will be evaluating whether the alternative 

training methods are as effective in terms of therapist and Veteran outcomes as the 

in-person workshops that have demonstrated efficacy. 

Recent restrictions on employee travel and conferences have impacted VHA’s ability to train providers. In order to adequately train the VHA mental health workforce, as well as improve the implementation and sustainability of EBPs, alternative 

training methods must be developed. Since 2007, VHA has trained over 9,000 

unique VA staff in one or more EBP. Nevertheless, there is ongoing demand for 

EBP training due to new staff joining VA, staff turnover, and changes in job assignments. 

In order to better meet this demand, two models are being piloted and evaluated. 

One is a regional training model whereby the national EBP training program train 

staff adept in an EBP to become trainer/consultants. These trainer/consultants then 

conduct local or regional trainings and provided the follow-up consultation within 

their VISNs. This model is responsive to local needs and schedules but has the disadvantages of trainers/consultants having to get local permission to block their clinical schedules to provide training and consultation; and local facilities having to 

fund travel within their regions. In the current national model, the EBP training 

programs reimburse VA sites for the percentage of time staff devote to national 

training efforts and pay for training participant travel. 

79 

The other training model being piloted uses a blended learning strategy whereby 

the didactic portions of the workshop are presented in web courses, the experiential 

role-play training is conducted over video conferencing technology in small cohorts 

led by an EBP expert, and consultation is provided as it is currently (by nationallyfunded consultants who provide expert ratings of actual clinical cases and give feedback to training participants on small group conference calls). 

In short, VA uses a wide variety of metrics to track the number of therapists 

trained in EBPs, the therapist and Veteran outcomes with EBP training cases, the 

efficacy of EBP training methods, and, now, the numbers of Veterans engaged in 

various EBP treatments. In the near future, VA plans to assess the offering of 

EBPs, completion rates, and, eventually, clinical outcomes for Veterans in EBP. 

Question 7. The revised estimate for the fiscal year 2016 advance appropriations 

request for the Medical Support and Compliance appropriations account indicates 

a $114.6 million decrease for VISN headquarters and a $37.3 million increase for 

VHA Central Office (VHACO). 

a. What accounts for the change in funding for the VISN headquarters and 

VHACO? 

Response. The 2016 Revised Request adjusts the estimate for the latest actual obligations (2014), as opposed to the 2016 Advance Appropriation estimate (based on 

the 2013 actual obligations). The 2016 Revised Request for the VISN Headquarters 

reflects the funding necessary to maintain the 2014 current service levels, allowing 

for inflation; the proposed pay raise from 1 percent to 1.3 percent; and changes in 

full-time equivalent employees (FTE). The 2016 Revised Request for the VHACO reflects the funding necessary to maintain the 2014 current service levels, allowing 

for inflation; the proposed pay raise from 1 percent to 1.3 percent; and FTE held 

steady at the 2014 level. 

b. If the changes are due to the overall increase or decrease in FTE, please describe in detail the justification for the increase or decrease and whether the increase or decrease is a shift of FTE between VISN headquarters and VHACO. 

Response. Sixty-eight percent of the funding for Medical Support and Compliance 

will go toward VAMCs, Other Field Activities, and VISN Headquarters. The majority of the funding increase is due to additional staffing requirements for field activities at the VA medical centers and VISNs. The additional positions are being added 

to the Medical Centers and VISNs to support and fulfill the Secretary’s vision of 

becoming a more Veteran-centric organization, and to be able to provide top-level 

customer service in a more efficient manner to our Veterans; as a result, some of 

the positions we are increasing are: Police, Personnel Management Specialist, Contract Administrator, Voucher Examiner, Claims Assistant, Emergency Management 

Series, Medical Records Clerk/Technician, Health Systems Specialist, Administrative Officer, Security Clerical & Assistance. These personnel are in direct support 

of VA’s objective to manage and improve VA operations to deliver seamless and integrated support. These personnel will support healthcare workers in order to deliver 

the healthcare services that our Veterans expect. FTE estimates for VHA Central 

Office and VHA National Consolidated Activities remain steady at their 2014 levels. 

Question 8. VA’s goal is to end veteran homelessness this year. If that goal is not 

met, what is the plan for funding homelessness programs for fiscal years 2016 and 

2017? If that goal is met, will funding need to be shifted to sustain preventative 

services? If so, how? 

Response. The goal of ending Veteran homelessness will be measured according 

to the January 2016 Point in Time count, the results of which are expected by summer 2016. Given the timing of this information, we do not anticipate deviating from 

the current requested budgets for fiscal years 2016 and 2017. Available funding has 

been prioritized among our programs to achieve three objectives: 

• Maintain current case management services and provide interventions as needed to those high-risk/high-need Veterans we have been able to house, so that they 

do not return to homelessness; 

• Ensure resources are available to identify Veterans at-risk for homelessness, 

and prevent these Veterans from falling into homelessness; and 

• Provide immediate access to housing to Veterans who fall into homelessness so 

that they are moved as rapidly as possible to safe and stable settings, putting them 

on a path to permanent housing. 

Medical Facilities 

Question 9. The fiscal year 2016 advance appropriations for medical facilities have 

been revised significantly in this year’s budget request. Numerous subaccounts, such 

as plant operations, leases, and operating equipment maintenance, and repair, each 

have a revised estimate of more than $200 million below the advance appropriaVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00083 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
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tions. Conversely, recurring maintenance and repair and non-recurring maintenance 

each have a revised estimate of more than $200 million above the amount provided 

in advance appropriations. 

a. Why were the fiscal year 2016 advance appropriations inaccurate? 

Response. The 2016 advance appropriations estimates for plant operations, leases, 

operating equipment maintenance and repair, and recurring maintenance and repair reflect the most recent available obligation data (2013 actuals). The estimates 

have been updated to reflect the latest actual obligations (2014) and an inflationary 

increase over the 2015 Current Estimate. Non-recurring maintenance estimates 

were revised to address high priority emerging capital needs, as identified through 

the Strategic Capital Investment Planning (SCIP) process. 

b. Please detail the process used to identify the advance appropriated funds necessary for medical facilities. 

Response. The 2016 advance appropriation took into account the latest actual obligations (2013); estimates for Obligations by Functional Area (Engineering and Environmental Management Services, Plant Operations, etc.) and Obligations by Object 

Class (utilities, rent, etc.); capital needs as identified through the SCIP process 

(NRM); a one percent pay raise; and adjustments to funding availability (transfers 

to Joint DOD/VA Medical Facility Demonstration Fund and reimbursements). 

Question 10. The Non-Recurring Maintenance (NRM) subaccount is $708 million 

for fiscal year 2016, an increase of $247.4 million over the amount provided in advance appropriations. The budget request indicates that this is offset by a decrease 

of $311.4 million for leases based on revised estimates. 

a. What accounts for the $247.4 million increase in NRM? 

Response. VA’s NRM project list is greater than $9 billion. The requested increase 

in NRM in FY 2016 above the Advance Appropriation amount is an attempt to address more of these NRM projects within the total requested resources in the President’s Budget. 

b. What accounts for the $311.4 million decrease in leases? 

Response. The Veterans Choice Act Section 801 provided funding for leases. VA 

projects that $313 million of Section 801 funding will be used to support new leases 

in 2015 and 2016 and this amount was reduced from our request. Also prior to this 

year’s budget submission, VA estimated medical facility lease costs based on historical trends in the object classes in which lease obligations are recorded. Beginning 

with this budget, VA has moved to a specific requirement by lease rather than relying on overall trends. 

Question 11. The NRM subaccount is projected to increase by $71.8 million or 11.2 

percent between fiscal year 2015 and fiscal year 2016 and decrease by $247.4 million or 35 percent between fiscal year 2016 and fiscal year 2017. 

a. The advance appropriation each year for the NRM subaccount is $460.6 million 

and each year the revised estimate is significantly higher. What metrics does VA 

use to determine the NRM funding request? 

Response. VA’s total capital investments are balanced across NRM, Major Construction and Minor Construction by the Strategic Capital Investment Plan (SCIP) 

process, and are balanced within the total requested resources in the President’s 

Budget Advance Appropriation request. 

b. Why does the 2017 advance appropriations request only include Object Class 

32 while the actual expenditures include Object Classes 10, 21–26, 31, 32, 41, and 

43? 

Response. Reported actual obligations for 2014 include errors in the VA Financial 

Management System that were made too late in the year to identify and correct before the required fiscal year close out activities made those errors a part of the official financial record. VA’s budget request does not assume that those errors will be 

repeated in future years. 

Question 12. According to the fiscal year 2016 budget, VA will spend $598 million 

to activate medical facilities in fiscal year 2016. And, the estimate for activations 

for fiscal year 2016 increased by $468 million over the amount provided in advance 

appropriations. 

a. Please break out the $598 million by appropriations account. 

VA Response: 

Medical Services: $443 million 

Medical Support & Compliance: $54 million 

Medical Facilities: $101 million 

b. Please provide a full list of the facilities that will be activated with these funds, 

with the amount of funding estimated for each facility broken down into non-recurring and recurring costs. 

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Response. See attached. 


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c. Please provide a detailed explanation for the $468 million increase above the 

advance appropriations amount for medical facility activations for fiscal year 2016. 

Response. See attached. 


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Question 13. VA cost estimates for new activations are $28 per square foot for 

leases and new construction and $6,600 per new employee. 

a. Please provide a detailed breakdown of these cost estimates. 

Response. The $28 per square foot is a GSA standard for office space IT activation, we have no further breakdown. The $6,600 breakdown is as follows: 

Estimated 

Cost Cost Element 

$1,000 Computer 

$1,200 License for Computer Software 

$1,200 VOIP Phone 

$800 Blackberry 

$1,200 Blackberry Sustainment ($100/mo x 12 mos) 

$200 Softphone Hardware/Software 

$200 Softphone License 

$100 Network Support ($100 per port) 

$200 Wiring Infrastructure ($200 per jack) 

$250 Storage and Server 

$250 Email and security license 

$6,600 Total 

b. How do these cost estimates compare to the private sector? 

Response. We have no reliable source of information for comparison to the private 

sector. 

Question 14. Please detail the status of each of the 27 leases included in Public 

Law 113–146, the Veterans Access, Choice, and Accountability Act of 2014 (Choice 

Act). Please provide a timeline for completion of Phases 1–4 of the leases. 

Response. The table below shows the status and timeline for each of the 27 leases 

included in the Choice Act. 

89 

Question 15. The Congressional Budget Office scored the leases in section 601 of 

the Choice Act as direct spending. However, VA indicated 4 of the 27 leases are 

being funded through the $5 billion provided to increase veterans access to care in 

section 801 of the Choice Act. Please provide a breakdown of the funding source for 

each of the 27 leases. 

Response. Of the 27 Major leases authorized in Section 601 of the Choice Act, 4 

are new leases (Lake Charles, LA in FY 2016; Johnson County, KS in FY 2017; 

Phoenix, AZ in FY 2017; and Honolulu, HI in FY 2018) supporting access improvements and have supporting funding identified in the plan developed for the Section 

801 funds. The remaining 23 are replacement or Research leases with support from 

within existing VHA appropriated funding streams. 

Question 16. In the fiscal year 2016 budget, VA requested legislative language to 

pursue additional types of Enhanced-Use Lease (EUL) agreements beyond creating 

supportive housing. At least two VA Inspector General Reports in 2012 and a Government Accountability Office (GAO) report in August 2014 show that VA needs to 

improve how it tracks and monitors its current EUL agreements. 

a. What changes has VA made to its tracking and monitoring of EUL agreements? 


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Response. VA has developed an agile and modernized tracking program and has 

made improvements to the oversight and monitoring of EUL agreements after the 

Inspector General (IG)’s report in 2012. VA has issued detailed and holistic guidance 

for the oversight and monitoring of the EUL portfolio during the post-transaction 

stage of the EUL lifecycle. This includes defining roles and responsibilities of EUL 

stakeholders, both corporately and locally at the site where the EUL resides, as well 

as defining recurring reviews for compliance and paths for escalation should issues 

arise with a particular EUL. In addition, VA has developed a new technology system 

(Enhanced Use-Lease Information System) to help in the tracking and monitoring 

of operational EULs. This technology enables improved collaboration with on-site resources and serves as a common source of information for recurring compliance 

tracking. 

In addition to the improved oversight and tracking, VA also developed a new 

methodology for estimating the benefits and costs associated with the EUL program. 

This methodology has been in use for the past three years and the results of the 

methodology are published annually in VA’s Congressional Budget Submission (Volume IV, EUL Consideration Report). This report provides a transparent view of the 

benefits to VA, Veterans, and local communities as a result of these EUL projects. 

As a result of these improvements, all recommendations in the IG’s report have 

been closed out. In regards to the GAO report in August 2014, it focused on landuse agreements, but excluded EULs from the audit. References to EUL in that report were only used to illustrate how the EUL oversight program is structured, but 

GAO did not actually assess the EUL program. 

b. Would the system be able to handle an influx of new EULs should this legislative language become law? 

Response. Yes. The enhancements made to the EUL oversight and monitoring 

process are fully scalable to accommodate new EULs. In addition, the Enhanced 

Use-Lease Information System is fully operational and capable of handling the influx of new EULs, should this legislative language become law. 

Long-term care 

Question 17. More than half of the veterans seeking healthcare through VA are 

over the age of 65. As the veterans population continues to age, the Department will 

be faced with challenges of chronic health conditions as well as increasing demand 

for long-term care services. The fiscal year 2016 budget again requests $80 million 

for State Veterans Homes grants, $10 million below the fiscal year 2015 appropriated level. How will the decrease in construction funding impact the availability 

of beds for veterans seeking long-term care through State Homes? 

Response. The FY 2016 VA state home construction grant program funding request of $80M is unchanged from the FY 2015 request. The decrease in construction 

funding will have no impact on the current level of available state beds. However, 

required funding supporting FY 2016 new bed construction is not fully predictable 

until States have completed their application for the FY 2016 Priority List. States 

had until April 15, 2015, to submit new applications. VA may have funds for 1–2 

new construction projects in FY 2016 dependent upon an appropriation of $80M and 

the total cost of FY 2016 safety projects. The availability of these new beds will be 

realized following completion of construction. This is typically a 2–3 year process 

based on project size and complexity. 

Women Veterans 

Question 18. The Mental Health Medical Care account for fiscal year 2016 is $7.5 

billion. Please break out the amount allocated for women-only programs. 

Response. The total mental health medical care amount for women Veterans in 

fiscal year 2016 is estimated at $700 million. 

CONSTRUCTION AND CAPITAL ASSETS

Question 19. The fiscal year 2016 budget request includes $1.14 billion for major 

construction projects, to include nine VHA projects. The fiscal year 2015 total estimated cost of the Long Beach, CA, project was $287.1 million. The fiscal year 2016 

total estimated cost for the project is now $317.3 million. What accounts for the 

$30.2 million increase? 

Response. The construction cost increase on the Long Beach, CA project is due 

to building area increases to meet updated design criteria for the Community Living 

Center and additional cost escalation as the project waits for full construction funding. 

Question 20. Of the nine VHA major construction projects requested, all but one 

project will need future funding in order to be completed. Please detail each of the 

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remaining eight projects, including a breakdown of future budget requests and projected completion dates. 

Response. The completion dates of these projects are dependent on when funding 

is received. 

Question 21. The Advance Planning and Design Funds for VHA is projected to increase by $23.7 million or 34 percent between fiscal year 2015 and fiscal year 2016. 

What accounts for the $23.7 million increase? Please detail the specific projects included in this increase. 

Response. VA’s request for the Advanced Planning and Design Fund (APDF) line 

item is based on the estimated need to support a project and other requirements 

through this fund. The APDF provides funding for schematic design, design development, and construction document phases up to 100 percent of design for major construction projects. This allows VA to complete 35 percent of total design prior to requesting construction funds. It can be used to prepare facility master plans, historic 

preservation plans, conduct environmental assessments and impact studies, energy 

studies or audits, and design and construction-related research studies including 

post-occupancy evaluations. The funds are also utilized to maintain construction 

standards, such as: design guides and standards, specifications, and space criteria. 


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The table below reflects the anticipated use of the APDF in fiscal year (FY) 2016: 

Location/Project Description 

Planned 

Amounts 

($000) 

American Lake, WA—Buildings 81, 81AC and 18 Seismic Corrections ................................................................. 6,000 

Bay Pines, FL—Phase 4 Renovation ....................................................................................................................... 1,650 

Livermore, CA—Realignment and Closure, Palo Alto ............................................................................................. 5,500 

Long Beach, CA—Mental Health and Community Living Center ........................................................................... 300 

Louisville, KY—New Medical Facility ....................................................................................................................... 2,000 

Omaha, NE—Replacement Medical Facility ............................................................................................................ 2,000 

Palo Alto, CA—Ambulatory Care and Polytrauma Rehab ....................................................................................... 2,000 

Portland, OR—Retrofit and Renovation .................................................................................................................. 17,000 

Roseburg, OR—Seismically Upgrade and Renovate Building 2 and Replace Building 1 ..................................... 5,000 

San Francisco, CA—Seismic Retrofit Buildings 1,6 and 8/Replace Building 12 .................................................. 200

San Juan, PR—Seismic Corrections ........................................................................................................................ 100 

St Louis, MO—Bed Tower Replacement .................................................................................................................. 5,380 

Tampa, FL—Polytrauma Renovation/New Bed Tower .............................................................................................. 3,200 

West Los Angeles, CA—Seismic Upgrade to 12 Buildings ..................................................................................... 3,200 

Pre-planning for Strategic Capital Investment Planning Projects .......................................................................... 5,000 

Historic Preservation, Environmental, Value Management, and Cost Estimating Services (Various Projects) ...... 10,000 

Facilities Standards and Criteria ............................................................................................................................. 11,700 

Integrated Strategic Master Plans (Various Locations) ........................................................................................... 38,000 

Total ................................................................................................................................................................. $118,230 

Question 22. The fiscal year 2016 budget requests $5 million for claims analyses, 

a $3 million or 150 percent increase over fiscal year 2015 levels. Please provide a 

list of the number of claims filed against VA for fiscal year 2014 and to date in fiscal 

year 2015. What specifically accounts for the $3 million increase? 

Response. The table below lists the claims filed against VA during FY 2014 and 

year-to-date for FY 2015. 

VA Major Construction Claims 

Project 

Number of 

Claims 

FY 2014 

Abraham Lincoln National Cemetery, IL .................................................................................................................. 2 

Pittsburgh Consolidation Building 29 Ductwork ..................................................................................................... 1 

Orlando New Medical Center ................................................................................................................................... 4 

Las Vegas Photovoltaic System ............................................................................................................................... 1 

Palo Alto ................................................................................................................................................................... 1 

Total ..................................................................................................................................................................... 9 

FY 2015 

Fort Jackson National Cemetery .............................................................................................................................. 1 

New Medical Center, Aurora, CO ............................................................................................................................. 140 

Total ..................................................................................................................................................................... 141 

Prior to the FY 2015 request, VA had not requested funds for this line item since 

FY 2009. VA’s use of this line item had remained relatively limited from FY 2009 

through FY 2013, averaging $98,000 per year. In FY 2014, VA used $2.2 million, 

and in FY 2015 to-date, VA has spent over $2 million. The growth in VA’s request 

from 

FY 2015 to FY 2016 is directly related to the recent increase in claims from the 

Denver Replacement Medical Center. 

Question 23. In Secretary McDonald’s testimony, he indicated one of his top priorities is to ‘‘right-size’’ VA’s capital asset portfolio. He indicated that VA currently 

has 336 buildings that are vacant or less than 50 percent occupied, which costs VA 

$24 million annually to maintain and operate. 

a. Please provide a list of facilities VA intends to close. 

Response. The 336 buildings referenced by Secretary McDonald in his testimony 

do not represent facility closures. These are individual buildings, located at VA medVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00096 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
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ical centers across the county, that are no longer in use. Disposal of these individual 

buildings would not impact Veteran Services being delivered at that particular facility, but would generate significant cost savings. 

At this time, there are no plans to close any VA facilities. VA is conducting a review of its facilities and considering options such as possible realignments. These 

realignments may result in a partial or full closure of a facility. VA stakeholders 

will be offered a briefing once the plan becomes final. 

b. How does VA plan to dispose of excess space while ensuring that it does not 

affect veterans’ access to care? 

Response. As stated above, the 336 buildings referenced by Secretary McDonald 

that are presently vacant or less than 50% occupied do not represent any planned 

facility closure. Rather these are individual buildings which are, through a combination of age, location, need, and layout, no longer suitable for regular use by VA. 

Given this fact, the disposal of these excess buildings should have no impact on provision of services to Veterans as these assets are not being utilized to provide services at this time. 

In cases where VA has multiple buildings that are underutilized (i.e. building is 

larger than need, so only a part of the building is necessary), efforts can be undertaken to consolidate the services to a single building, allowing for disposal of one 

or more buildings. This disposal would only occur after consolidation occurs, so 

again, no impact to Veteran services would be anticipated. The vacant buildings 

that are no longer needed for patient care will either be planned for demolition, 

given to a third-party developer to convert to homeless housing via VA’s Enhanced 

Use Lease (EUL) process (subject to congressional authority), or they will remain 

mothballed due to historic preservation considerations. Many of these buildings are 

too old to efficiently house administrative services, let alone clinical services that 

require additional floor load, heating and ventilation requirements, upgraded electrical and plumbing, etc. Therefore, disposal of these individual buildings would not 

impact Veteran’s services being delivered at any respective facility with these buildings. 

VETERANS BENEFITS ADMINISTRATION

Question 24. In the fiscal year 2016 budget, VA requested an additional 320 employees to handle non-rating work. 

a. Please provide the calculations used by VA to determine that 320 was the correct number of non-rating staff to request. 

Response. VBA is grateful for the funding received in the FY 2015 and 2016 appropriations to support 420 additional non-rating FTE. VBA completed a record 3.1 

million non-rating claims in FY 2015, which was a 16 percent increase over nonrating claims completed in FY 2014, and a 37 percent increase over non-rating 

claims completed in FY 2013. The additional 320 FTE in FY 2016 will enable VBA 

to continue to reduce the non-rating inventory to below 800,000 and the average 

time a Veteran is waiting for a non-rating decision from 345 days at the end of FY 

2015 to an average of 280 days. 

b. How many employees, in total, were dedicated exclusively to non-rating work 

during fiscal year 2014 and how many employees, in total, will be dedicated exclusively to non-rating work during fiscal year 2015? 

Response. At the end of FY 2014, 789 employees were assigned to non-rating 

teams, including 200 temporary employees. VBA is in the process of hiring additional temporary non-rating employees utilizing the increased funding for FTE received in 2015. This will increase the number of staff dedicated to non-rating claims 

work to 1,009 in 2015. Receipt of VBA’s FY 2016 request for funds to support an 

additional 320 non-rating FTE will allow VBA to retain these temporary employees, 

convert them to permanent positions, and also further increase non-rating staffing 

levels. These additional resources are expected to enable VBA to achieve a steady 

state of approximately 500,000 pending non-rating claims/actions in FY 2017. 

c. During fiscal year 2014 and to date during fiscal year 2015, were non-rating 

employees required to work on the disability claims backlog during regular hours 

or overtime hours? If so, how many non-rating employees were used for that purpose and, on average, how many regular hours and how many overtime hours per 

month were worked for that purpose? 

Response. All employees regardless of team assignment were required to work disability rating claims during their mandatory 20 hours of overtime each month. During fiscal year 2014, VBA’s 854 non-rating full time equivalent employees (FTE) 

worked approximately 19 hours of overtime per month, and in fiscal year 2015, 

1,059 FTE worked an average of 15 hours per month. This 20-hour per month manVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00097 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
94 

datory overtime requirement was in place from January to August 2015, with optional overtime offered in other months. 

Often rating-related and non-rating related work are completed concurrently. In 

these cases, employees are directed to take credit for rating-related work instead of 

non-rating work, because the rating-related work credit is assigned the greatest 

point value in VBA’s performance management system. Employees are instructed to 

work all associated actions on a pending claim, but may not take dual credit for 

both rating and non-rating work accomplished by the same action. On average, disability rating claim work was approximately 20 to 25 percent of our non-rating 

FTEs’ work completed in fiscal years 2014 and 2015 during their regular tour of 

duty, which averages to 22 to 28 hours per month per employee. 

d. What metrics does VA use to determine the actual and expected productivity 

per employee for non-rating staff? 

Response. Non-rating claims generally include adjustments to existing compensation and pension awards that are processed after the initial award of benefits. As 

more rating claims are processed in FY 2015 and more Veterans begin receiving 

compensation and pension benefits, there will be a similar increase in non-rating 

claims. 

In addition to completing 1.32 million disability rating claims in Fiscal Year 2014, 

VBA also completed 2.7 million non-rating claims and other administrative actions, 

a 30 percent increase from FY 2012. Productivity increased from 147.2 non-rating 

claims/actions per FTE in FY 2012, to 188.7 claims/actions in FY 2014. Using the 

FY 2015 staffing level of 14,765 direct FTE, VBA’s non-rating production is currently 206.8 claims/actions per compensation and pension direct FTE. In addition 

to claims processing personnel, direct FTE includes all employees supporting compensation and pension programs, such as fiduciary employees, national call center 

employees, outreach personnel, military services coordinators, etc. This does not include management support, which typically comprises 11 percent of all compensation and pension field staff. 

VBA continues to focus on the body of non-rating work while we simultaneously 

eliminate the rating claims backlog As VBA hires additional staff to address nonrating work, VBA will track non-rating productivity as well as monitor the inventory of these claims as the primary metrics for our improvement efforts. 

e. Using those metrics, what was the productivity per non-rating employee during 

fiscal year 2014 and what is the productivity per non-rating employee to date during 

fiscal year 2015? 

Response. VBA does not budget field FTE solely for rating or non-rating work. 

Production per FTE is based on all compensation and pension employees assigned 

to each regional office’s claims processing workforce. Please see the chart below with 

FY 2015 FTE prorated for five months (14,479 direct FTE ceiling divided by 12 

months and then multiplied by five months): 

FTE 

Non-Rating Claim and 

Administrative 

Actions Completed 

Non-Rating 

Production 

per FTE 

FY 2014 ................................................................................................... 14,307 2,699,264 188 .7 

FY 2015 (February) ................................................................................. 6,033 1,247,695 206 .8 

f. What would be the expected level of individual productivity for non-rating staff, 

if the fiscal year 2016 budget is adopted? 

Response. VBA forecasts that the additional 320 non-rating employees would complete 145,000 to 165,000 non-rating claims/administrative actions in FY 2016. However, the number of non-rating claims completed per FTE will initially decrease because of the hours devoted to training the new employees and the lower production 

levels of these employees due to their inexperience. Production per FTE for budgetary purposes is based on all compensation and pension FTE assigned to claims 

processing in all regional offices, not just FTE processing non-rating claims. In FY 

2016, VBA expects non-rating claim production per FTE to decrease slightly from 

the current average of 206 non-rating claims/actions per compensation and pension 

FTE. 

g. What would be the expected timeline for bringing these new non-rating employees on board, if the fiscal year 2016 budget is adopted? 

Response. The 320 additional non-rating FTE will be hired in the first quarter of 

FY 2016. 

95 

h. How would these new non-rating employees be allocated among the regional 

offices? 

Response. The new non-rating employees will be placed in a few regional offices 

based on available seating. However, these additional employees will be a national 

resource focused on challenged workload areas within the non-rating workload of all 

regional offices, such as drill pay adjustments and dependency claims. 

i. Please provide any goals or milestones the Veterans Benefits Administration 

(VBA) has established for reducing the number of pending non-rating work items, 

including an estimation of when the level of pending work will be reduced to a level 

that VBA considers acceptable. 

Response. VBA’s success in completing rating decisions has driven an increase in 

non-rating claims. Despite completing a 20-year record number of non-rating claims 

in FY 2014, this work continues to grow. In FY 2015, VBA expects to receive 2.9 

million non-rating claims and other administrative review actions, an increase of 7.4 

percent over 2014 (2.7 million) and 20.8 percent over 2013 (2.4 million). These additional resources are expected to continue to reduce the non-rating inventory in FY 

2016 and enable VBA to achieve a steady state of approximately 500,000 pending 

non-rating claims/actions in FY 2017. 

j. During the remainder of fiscal year 2015 and during fiscal year 2016, will regional offices be permitted to use overtime hours to deal with non-rating work? 

Response. FY 2015 compensation and pension overtime efforts are focused on the 

following priorities: backlog rating claims, priority rating claims (Medal of Honor recipients, prisoners of war, homeless Veterans, Veterans with hardship, terminally 

ill Veterans, fully developed claims, etc.), and functions in support of continued 

transformation into a paperless environment, such as centralized mail. For the remainder of FY 2015, VBA will continue to focus on the abovementioned priorities 

during overtime efforts. In FY 2016, overtime use will be reassessed by VBA leadership. 

k. During fiscal year 2016, does VBA intend to use the services of any contractors 

to assist with non-rating work? If so, how much is expected to be expended on those 

contractors and what level of productivity is expected to be achieved as a result of 

use of those contractors? 

Response. On April 21, 2014, VA awarded a contract for assistance in entering 

data from paper-based dependency claims into VA’s electronic rules-based processing system. The contractor enters the information from the paper-based dependency claims just as a claimant would enter information if filing the claim online 

using eBenefits. The performance period is one base-year and two option-years. During FY 2016, VA will continue to utilize the contract to assist in reducing the inventory of dependency claims. In FY 2016, funds for this contract total $3.1 million, 

with approximately 400,000 dependency claim reviews projected to be completed by 

the contractor. Because not all claims reviewed by the contractor can be fully processed to completion through VA’s online rules-based processing system, manual 

processing of the more complex dependency claims is still required. 

Question 25. In the fiscal year 2016 budget, VA requested an additional 200 employees to work on appeals. 

a. Please provide the calculations used by VA to determine that 200 was the correct number of appeals employees to request. 

Response. VBA is grateful for funding in FY 2015 and FY 2016 to hire another 

300 appeals FTE. However, these additional FTE are not sufficient to address the 

existing or future appeals workload. Under the appeals framework established by 

current law, Veterans are waiting far too long for final resolution of their appeals. 

Legislation is needed to streamline and modernize the appeals process. The 300 

FTE will assist VA in closing the gap, but without legislative change or significantly 

greater increases in staffing, VA will face a soaring appeals inventory, and Veterans 

will wait even longer for a decision on their appeal. 

In the FY 2017 President’s Budget, VA sets forth a plan to provide most Veterans 

with a timely and fair decision on their appeal within one year of filing the appeal. 

VA looks forward to working with Congress to secure the required resources to address the current appeals workload and the legislative changes needed to provide 

Veterans with a modern appeals process. 

b. How many employees, in total, were dedicated exclusively to appeals during fiscal year 2014 and how many employees, in total, will be dedicated exclusively to 

appeals during fiscal year 2015? 

Response. In FY 2014, VBA had 11,290 claims processors on board, of which 950 

employees were dedicated to processing appeals in regional offices and 190 employees at the Appeals Management Center. In FY 2015, VBA is dedicating the same 

level of resources to appeals. Additionally in FY 2014 all of the Board of Veterans’ 

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Appeals 631 employees were dedicated to processing appeals and in FY 2015all 642 

employees were dedicated to processing appeals. 

c. During fiscal year 2014 and to date during fiscal year 2015, were appeals employees required to work on the disability claims backlog during regular hours or 

overtime hours? If so, how many appeals employees were used for that purpose and, 

on average, how many regular hours and how many overtime hours per month were 

worked for that purpose? 

Response. In FY 2014 nd FY 2015 appeals processors have been focused on appeals workload. During this same period all appeals processors were on mandatory 

overtime and required to complete 20 hours of overtime per month. 

d. What metrics does VA use to determine the actual and expected productivity 

per employee for appeals employees? 

Response. Production per FTE is based on all compensation and pension employees assigned to regional offices. As VBA continues to receive and complete recordbreaking numbers of disability rating claims in recent years (1.32 million claims 

completed in 2014), the volume of appeals increases concomitantly. Using the FY 

2015 staffing level of 14,765 direct FTE, VBA’s appeals productivity is currently 

11.4 appeal actions (e.g., statements of the case, appeal certifications) per FTE. As 

VBA hires additional FTE to address appeals, VBA will track production, inventory, 

and average days pending as the primary metrics of improvement efforts. 

e. Using those metrics, what was the productivity per appeals employee during 

fiscal year 2014 and what is the productivity per appeals employee to date during 

fiscal year 2015? 

Response. The complex appeal process defined in law involves multiple reviews 

of the evidence considered in the original decision as well as any new evidence received during the appeal. Please see the chart below for VBA’s total completed appeal actions (e.g., statements of the case, appeal certifications) and appeals productivity: 

VBA FTE 

Appeal Actions 

Completed 

Appeals 

Productivity 

FY 2014 ............................................................................................................... 14,307 176,991 12 .4 

FY 2015 (February) ............................................................................................. 6,033 69,073 11 .4 

f. What would be the expected level of individual productivity for appeals staff, 

if the fiscal year 2016 budget is adopted? 

Response. VBA’s key metrics for measuring appeals processing is the completed 

appeal actions, inventory of notices of disagreement (NODs), and the average days 

pending for this workload. In the first year, VBA projects the completed appeal actions and appeal resolutions will increase, while productivity per FTE will slightly 

decrease as the new appeals employees become familiar with the entire appeals 

process. By the end of the second year, productivity per FTE will return to the current level, approximately 11 completed appeal actions per compensation and pension 

direct FTE. As previously noted, productivity per FTE is based on all compensation 

and pension employees assigned to regional offices, not just FTE processing appeals. 

To increase efficiency, VBA is working closely with the Board of Veterans’ Appeals, Veterans Service Organizations, and Congress to identify legislative solutions 

to simplify the appeals process and improve the timeliness of appeal decisions. 

g. What would be the expected timeline for bringing these new employees on 

board, if the fiscal year 2016 budget is adopted? 

Response. In February of FY 2015, VBA had 11,290 appeal claim processors on 

board, including approximately 950 employees dedicated to processing appeals in regional offices and 190 employees at the Appeals Management Center. VBA is in the 

process of adding 100 appeal claim processor FTE in FY 2015, and as soon as full 

funding is provided in FY 2016, VBA will hire 200 additional appeal claim processor 

FTE. 

h. How would these new appeals employees be allocated among the regional offices? 

Response. VBA’s Resource Allocation Model (RAM) is a systematic approach to 

distributing field resources each fiscal year. RAM utilizes a weighted model to assign compensation and pension FTE resources based on regional office workload 

which takes into account the following factors: 

• number of rating claims pending 

• number of rating claims received, 

• number of non-rating claims received 

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• and the number of appeals 

Starting in FY 2014, RAM incorporated additional variables that align with VBA’s 

transformation to a paperless environment, where receipts can be assigned and 

managed at the national level. These variables include: 

• station efficiency (claims completed per FTE) 

• quality 

• each regional office’s processing capacity 

VBA uses the model as a guide and makes adjustments for special circumstances 

or missions performed by individual regional offices. Special missions include: 

• Appeals Management Center 

• Benefits Delivery at Discharge processing 

• Integrated Disability Evaluation System (IDES) processing 

• Quick Start processing 

• National Call Centers (NCCs) 

• foreign claims processing 

• radiation processing 

• Camp Lejeune Contaminated Water (CLCW) processing 

• and Pension Management Centers (PMCs). 

i. Please provide any goals or milestones VBA has established for reducing the 

number of pending appeals, including an estimation of when the level of pending 

work will be reduced to a level that VBA considers acceptable. 

Response. Over the last 20 years, appeal rates have continued to hold steady at 

between 11 and 12 percent of completed claims. As VBA continues to receive and 

complete record-breaking numbers of disability rating claims in recent years (1.3 

million claims completed in FY 2014), the volume of appeals increases concomitantly. The number of statements of the case and other appellate actions completed 

by VBA on Veterans’ appeals has increased 31 percent since 2011, from 135,000 actions to 177,000 actions. VBA currently has approximately 290,000 pending appeals. 

VBA is working to reduce its pending appeals inventory to less than one year of 

receipts by the end of FY 2017. In addition, VA is engaging with its key partners 

and stakeholders to define and establish the levels of service delivery that Veterans 

should be able to expect in the appeal process and determine what legislative and 

resource changes would be needed to meet those expectations. 

j. During the remainder of fiscal year 2015 and during fiscal year 2016, will regional offices be permitted to use overtime hours to handle pending appeals? 

Response. In FY 2015 appeals processors were dedicated to working appeals only 

during regular hours. VBA utilized overtime in both a voluntary and mandatory capacity at various times in FY 2015 for all claims processors, including those working 

appeals. However, during overtime, appeals processors were focused on the following 

prioritization targets: backlog claims and priority claims (Medal of Honor recipients, 

prisoners of war, homeless Veterans, Veterans with hardship, terminally ill Veterans, fully developed claims, etc.). Overtime use in FY 2016 is being reassessed by 

VBA leadership. 

Question 26. In the fiscal year 2016 budget, VA requests an additional 85 fiduciary field examiners. 

a. Please provide the calculations used to determine that 85 was the correct number of fiduciary employees to request. 

Response. In FY 2014, VBA’s fiduciary program protected more than 172,800 

beneficiaries, which is a 41 percent increase in the number of beneficiaries from 

2011 (122,271). An increase in the total number of beneficiaries receiving VA benefits and an aging population are the primary causes for this program growth. With 

this dramatic increase, the fiduciary program’s current staffing levels are inadequate to properly oversee all beneficiaries. If sufficient resources are not provided, 

beneficiary protection will be compromised with increased intervals between visits. 

From 2011 to 2014, the field FTE allocation increased 22 percent (703 FTE to 855 

FTE); however, staffing has not kept pace with program growth. Even though fiduciary hubs are completing more work through FTE increases and recent efficiencies, 

the backlog of pending field examinations continues to grow. The following chart reflects the 19 percent growth in completed field examinations and the 16 percent 

growth in pending field examinations experienced between 2012 and 2014. 

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In July of FY 2014, VBA notified Congress of a need to hire 1,618 FTE, including 

307 FTE to address the increase in fiduciary workload. VBA is grateful for funding 

in FY 2015 to hire 50 fiduciary FTE and is asking for funding in FY 2016 to hire 

an additional 85 fiduciary FTE. 

b. This information is included in the budget request for fiscal year 2016: ‘‘In 

May 2014, VBA began the process of evaluating the current performance standards 

for field personnel by conducting a work measurement study of all fiduciary work 

tasks. This study is under contract and should be completed in June 2015.’’ Once 

that study is complete, will VBA re-evaluate the required number of employees for 

fiscal year 2016? 

Response. Yes, VBA will use data collected through the Work Measurement Study 

(WMS) to refine fiduciary program resource requirements. The fiduciary program 

has experienced tremendous growth and significant revisions to policies and procedures. The WMS is capturing work performance in the new fiduciary environment. 

With the information provided through the WMS, VBA will more accurately define 

and quantify the time involved in completing fiduciary program work. 

Question 27. In volume 3 of the fiscal year 2016 budget request, a chart on page 

VBA–205 indicates that, in fiscal year 2013, VBA received 168,745 work items labeled as ‘‘compensation rating other’’ and, in fiscal year 2014, VBA received 568,057 

work items with that label. That chart also reflects that, in fiscal year 2013, VBA 

received 1.1 million work items labeled as ‘‘compensation non-rating other’’ and, in 

fiscal year 2014, VBA received 666,898 work items with that label. 

a. What factors account for the large change in the number of these types of work 

items received in those years? 

Response. The two tables referenced from the FY 2016 budget request regarding 

claims received and completed both have errors. In the FY 2015 budget request, 

similar tables attempted to explain the distribution of claims received and completed in different categories to provide a different perspective of VBA’s workload. 

This year’s budget table incorrectly kept the row descriptions and FY 2013 column 

from last year’s budget narrative. The corrected tables to replace the ones on page 

VBA–205 are provided below: 

Received Claims 2013 2014 

2015 

Estimate 

2016 

Estimate 

Compensation Rating ......................................................................... 897,396 963,834 1,135,905 1,231,617

Compensation Non-Rating .................................................................. 484,735 568,057 632,360 651,331 

Compensation Controlled End Products ............................................. 642,573 731,274 807,070 830,759 

Compensation Other End Products .................................................... 584,742 666,898 710,454 731,767 

Total Compensation Workload ................................................... 2,609,446 2,930,063 3,285,789 3,445,474 

Completed Claims 2013 2014 

2015 

Estimate 

2016 

Estimate 

Compensation Rating ......................................................................... 1,017,513 1,145,607 1,212,597 1,230,819 

Compensation Non-Rating .................................................................. 410,775 528,495 694,228 708,113 

Compensation Controlled End Products ............................................. 572,620 727,443 656,180 666,804 

Compensation Other End Products .................................................... 554,974 633,614 713,225 729,944 


226TAB26a.eps
99 

Completed Claims 2013 2014 

2015 

Estimate 

2016 

Estimate 

Total Compensation Workload Actions ...................................... 2,555,882 3,035,159 3,276,230 3,335,679 

b. Were there any changes in how VBA categorizes this work? 

Response. As noted in the response above, the tables in the FY 2016 budget request are different from those shown in the FY 2015 budget request. VBA reverted 

to the traditional four groupings of compensation work products, as defined in the 

narrative found on page VBA–205. The figures presented in the above tables are 

corrected based on the same definitions. 

c. Please enumerate the specific types of work included in each category. 

Response. The FY 2016 budget narrative, on page VBA–205, discusses the four 

groupings of compensation work, including: 

1. Compensation Rating: Original disability claims with eight or more contentions 

or medical conditions or with seven or fewer contentions; supplemental disability 

claims; as well as requests for future medical exams 

2. Compensation Non-Rating: Dependency determinations that impact the entitlement of the Veteran or his dependents/family members; and other adjudicated decisions that impact entitlement to other VA or Federal programs 

3. Compensation Controlled End Products: Controlled correspondence with a Veteran or beneficiary not requiring additional rating or authorization decisions; required reviews of claims; and corrections of claims 

4. Compensation Other End Products: Verification of continued eligibility or status; Freedom of Information Act and Privacy Act requests; special correspondence 

involving Members of Congress or other U.S. Government agencies; notices of upcoming determinations or reviews that could affect a Veteran’s status; eligibility for 

vocational rehabilitation services; and other administrative actions 

Question 28. In response to pre-hearing questions, VA stated that $122.8 million 

had been expended on overtime hours during fiscal year 2014 to process compensation and pension claims and that VBA has expended $37 million for that purpose 

to date during fiscal year 2015. 

a. How much is VA requesting for fiscal year 2016 for overtime hours to process 

compensation and pension claims? 

Response. Of the $55 million requested for overtime in FY 2016, VBA currently 

anticipates using approximately $47 million to fund overtime for compensation and 

pension claims processing. 

b. Please provide the number of claims (not issues) completed during overtime 

hours during fiscal year 2014 and the number of claims (not issues) expected to be 

completed during overtime hours during fiscal years 2015 and 2016. 

Response. VBA completes an estimated 1,700 rating claims for every $1 million 

of invested overtime funding. Based on this calculation, in FY 2014, an estimated 

208,000 claims were completed due to the additional overtime funding. In FY 2015, 

VBA estimates completing an additional 127,500 claims with the budgeted $75 million overtime funding. In FY 2016, VBA budgeted approximately $50 million for 

overtime directed toward the completion of disability claims. This will allow VBA 

to complete an additional 85,000 claims in FY 2016. 

Question 29. In November 2014, GAO issued a report outlining certain shortcomings with VBA’s quality assurance program related to claims processing. What 

changes are planned in response to that report, what is the timeline for implementing those changes, and what level of funding is requested for fiscal year 2016 

in relation to those changes? 

Response. In response to GAO’s recommendations, VBA is making numerous 

changes to the quality assurance program, including: 

• Beginning with claims completed in January of FY 2015, VBA executed a revised sample methodology that uses each regional office’s output and claims processing accuracy to determine the number of cases reviewed. No additional funding 

is required at this time. 

• Claims are being reviewed based upon the regional office that worked the claim, 

which eliminates deselection of claims that are transferred to another regional office 

for processing. Reporting of these claims will include the confidence intervals for 

each regional office. VBA will ensure this work, known as ‘‘brokered work,’’ is not 

underrepresented in quality reviews. No additional funding is required at this time. 

• VBA is currently drafting an abstract describing our sampling, assessment criteria, accuracy calculation, and reporting methodologies for claim and issue-level acVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00103 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
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curacy. This abstract will accompany future performance documents and public reports to explain key differences between the claim-based and issue-based accuracy 

rates. 

• VBA is utilizing a Knowledge Management portal to make all guidance and reference materials available to claims processors. This portal will include the Adjudication Procedures Manual, M21–1, as well as other interim guidance in one 

searchable location. This project is being funded with existing resources and is expected to become functional within the current fiscal year. 

• VBA is currently designing a new system that will incorporate all types of quality reviews, to include local regional office reviews, Systematic Technical Accuracy 

Review (STAR), and consistency studies, which will capture data at various stages 

of the claims process. This system will provide VBA with increased data analysis 

capabilities for accuracy review and improved tracking of error trends. 

Question 30. In recent years, Congress has provided funding for a number of initiatives to improve VBA’s ability to handle its claims workload, including the Veterans Benefits Management System, eBenefits, and the Stakeholder Enterprise Portal. 

a. Are there any initiatives that are not yet having the expected impact on productivity? If so, please quantify the future increases in productivity expected as a 

result of these initiatives. 

Response. VBA is retraining, reorganizing, streamlining business processes, and 

building and implementing technology solutions based on the newly redesigned processes to improve benefits delivery. VBA expects several transformation initiatives, 

as described below, to continue increasing the number of claims and issues completed per FTE. It is difficult to extract the impact of each transformation initiative 

from the combined people, process, and technology models that are being concurrently implemented to determine individual initiatives’ contribution to productivity 

outcomes. 

VBA’s transformation progress is the result of an integrated series of initiatives 

designed to eliminate the backlog. The FY 2016 budget will allow VBA to continue 

building on the success of the following initiatives: 

Veterans Claims Intake Program (VCIP): VCIP streamlines processes for receiving digital records and data into the Veterans Benefits Management System 

(VBMS) and other VBA systems, transitioning VBA from a paper-based claims environment to a digital operating environment. It scans paper claims, converts them 

into digital format, and extracts important data for input into electronic folders. 

VCIP has converted and uploaded more than 1.3 billion images from paper. In addition to supporting scanning operations for incoming claims, VBA’s FY 2016 request 

of $140.8 million will allow the digital intake of military, income, and employment 

records from other Federal agencies and private providers. This will broaden electronic evidence exchange for processing all types of claims more accurately and more 

rapidly by building additional interfaces for Official Military Personnel Folders 

(OMPF) from DOD and interfaces with health networks, hospitals, and private clinicians. 

Centralized Mail: Centralized mail consolidates inbound paper mail from VA’s 

ROs to a centralized intake site. This initiative expands VBA’s capabilities for scanning and conversion of claims evidence, increases electronic processing capabilities, 

and assists in converting 100 percent of received source materials to electronic format. VBA has deployed centralized inbound mail for all ROs. The FY 2016 budget 

request of $18.3 million provides resources to sustain operations at all 56 ROs and 

positions VBA to expand centralized mail operations to other lines of business and 

centralize outbound correspondence to Veterans. 

Veterans Benefits Management System: VBMS, as VBA’s key business transformation initiative, provides a paperless claims-processing environment and improved business processes to support timely, high-quality decisions for Veterans and 

their dependents. National deployment of VBMS was completed June of FY 2013 

and provides access to over 28,000 end users. VBMS allows VBA to centrally manage the claims workload at the national level and direct cases electronically across 

its network of ROs to more efficiently match claims demand with available processing capacity. VBA went from touching 5,000 tons of paper annually to now processing 95 percent of the claims inventory electronically in VBMS. VBA has now 

completed over 1.32 million claims in VBMS. In FY 2015, VBMS is focused on delivering the National Work Queue (NWQ) and reducing reliance on legacy systems. In 

FY 2016, VBMS enhancements will focus on the Integrated Disability Evaluation 

System, appeals, and pension. 

National Work Queue: VBA will distribute claims electronically from a centralized 

queue based on RO capacity using the electronic NWQ, a national workload manVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00104 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
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agement strategy. With all claims placed in the electronic NWQ, Veterans’ claims 

will be automatically directed across all ROs to efficiently match claim demand with 

available expertise and processing capacity regardless of RO jurisdiction, delivering 

benefits to Veterans more quickly and accurately. The electronic inventory provides 

real-time updates, no matter where the claim is assigned for processing. Veterans 

are still able to receive assistance with their claims by visiting their RO for personal 

assistance at the public contact sites, going on-line through eBenefits, and utilizing 

VBA’s National Call Centers. In FY 2016, VBA is requesting $3.2 million to provide 

the requisite funding to resource and support 13 employees to manage the NWQ 

across the VBA enterprise. 

Veterans Relationship Management: The VRM initiative continues to facilitate an 

increasingly more Veteran-centric digital operating environment. VRM is delivering 

a scalable, enterprise-wide, services-based technology environment that will be the 

foundation for how Veterans are served and how benefits and services are delivered. 

This new model will provide VA an integrated services delivery platform with the 

approach of placing the Veteran at the center of the service with all business requirements and design being driven from the Veteran perspective. 

Components of VRM include eBenefits, the Stakeholder Enterprise Portal (SEP), 

Customer Relationship Management solutions, Digits-to-Digits, Knowledge Management, and Veterans Online Application Direct Connect. Through the eBenefits portal, Veterans can submit claims for benefits, administer their accounts, and receive 

status updates. The eBenefits Web portal standardizes claim intake and enables collaboration with VSOs to assist Veterans with all interactions with VA. VA continues 

to expand the capabilities available through the eBenefits portal as more Veterans 

use the site. Today eBenefits has 4.4 million registered users and over 48 million 

visits annually. VBA’s FY 2016 request for $13.8 million, in addition to the $67 million requested for VRM in the Office of Information Technology, will support ongoing operations and continued efforts to pilot and deploy new solutions for VBA mobile applications that expand access to self-service tools and benefits/services information in VBA portal environments; develop new service features in SEP for medical providers, loan officers, fiduciaries, and funeral directors; and integrate 

VetSuccess with Career Center for Veterans, enabling searches for jobs posted by 

unique employers targeting Veterans. 

b. What metrics does VA utilize to determine whether overall efficiency is improving as a result of those investments? Do those metrics take into account the percent 

of work completed during overtime rather than during regular hours? 

Response. Through VBA’s claims transformation initiatives, the number of claims 

completed per compensation and pension direct FTE increased 25 percent from 2012 

to 2014. An even more accurate representation of VBA’s increase in productivity is 

seen at the medical issue-level rather than the claim-level. From 2009 to 2014, 

VBA’s issue-level productivity increased by 67 percent. 

It is difficult to extract the impact of each transformation initiative from the combined people, process, and technology models that are being concurrently implemented to determine individual initiatives’ contribution to productivity outcomes. 

The productivity metrics include work completed on overtime. 

Question 31. The fiscal year 2016 budget request includes a proposal to limit the 

circumstances under which VA is required to provide a medical examination for a 

veteran seeking disability compensation. Under that proposal, an examination 

would be provided by VA only if there is ‘‘objective evidence establishing that the 

Veteran experienced an event, injury, or disease during military service.’’ VA estimates that this change would lead to cost savings of $438 million over 10 years. 

a. Please provide any available statistics on how frequently disability claims are 

ultimately granted in the circumstances where an examination has been provided 

even though the veteran did not have such objective evidence. Alternatively, please 

provide any statistics on how frequently a claim is ultimately denied under those 

circumstances. 

Response. VA does not maintain data regarding grant rates based on specific evidence that may or may not have been present. After separation from service and 

with the passage of time, the rate VA denies service-connected disability significantly increases. In FY 2013, VA denied 42 percent of issues for conditions that 

were not caused by service for Veterans who submitted claims within one year of 

discharge; 66 percent of issues submitted by Veterans who filed a claim between 10 

and 20 years after discharge were denied on this basis. While claimants from both 

categories were provided medical examinations to support their claims, the disproportionate number of denials seen when a claim is filed longer after separation 

suggests a large portion of medical examinations were scheduled unnecessarily. 

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b. Please provide the calculations and assumptions used to determine the estimated cost savings of this initiative. 

Response. The methodology to calculate cost savings was based on data showing 

claims with an exam request that were denied because a disability was not incurred 

in or caused by service or because there was no diagnosis. Based on this data, VA 

assumed 30 percent of an estimated 166,000 exams would result in a denial of 

claimed conditions being associated with Veterans’ military service. An estimated 75 

percent of these denied exams could be presumed as savings under this proposal 

since an exam would not be warranted. 

GENERAL ADMINISTRATION

Question 32. The Office of Small and Disadvantaged Business Utilization’s 

(OSDBU), Center for Verification and Evaluation (CVE) is charged with verifying 

veteran businesses looking to take advantage of veteran specific VA contracting 

preferences. There have been legislative proposals presented to move CVE outside 

of VA or to another office under the Secretary. 

a. What are VA’s views of proposals to move CVE to another Federal agency and 

is the current organization best positioned to verify veteran businesses? 

Response. VA does not support moving CVE to another agency. CVE is responsible for verifying the eligibility of VOSBs for the VA Veterans First procurement 

preference program under 38 U.S.C. § 8127. We do not believe it appropriate to have 

important elements of a VA program performed by other agencies. CVE is best positioned to verify Veteran businesses as it resides in the Office of Small and Disadvantaged Business Utilization, the organization responsible for promoting Veteran access to contracting opportunities within VA. Since the primary benefit of 

verification is to establish eligibility for VA contracting opportunities, having the 

CVE verification function within OSDBU appropriately places these closely related 

functions together. 

b. Additionally, it has been suggested that other agencies do not have the infrastructure in place to verify veteran businesses. What analysis has VA performed on 

the budgetary implications of instituting a governmentwide certification program for 

veterans in terms of cost and FTEs required? 

Response. There are no comparable authorities and thus no comparable programs 

within the Federal Government. VA’s verification program is unique among government programs, although the closest comparable programs are found within SBA. 

SBA has an SDVOSB program and the 8(a) business development program. However, while the SBA’s SDVOSB program has similar regulations to VA’s, entry into 

the program is based on self-certification rather than an up-front verification of eligibility of all applicants. SBA reviews SDVOSB eligibility only if a protest is filed 

by an interested party against a prospective awardee, and only a very small percentage of SDVOSBs are ever actually reviewed to ensure compliance. 

Second, while the 8(a) program does review its applicants before granting admittance to the program, the requirements are different, and concerns ‘‘age out’’ of the 

program. For example, since the 8(a) program provides business development assistance, the program requires applicants to show potential for success. Government 

and private sector contracts are awarded to an 8(a) firm as part of the participant’s 

business plan for development. These criteria have no counterpart in the VA 

verification program. The 8(a) program therefore not only sees far fewer applications, but it also deals with a significantly smaller database of participants at any 

time. 

By contrast the VA has increased its infrastructure capacity, to include professional development and training as well as contract and legal support. VA has also 

refined and documented its processes. VA’s current processes are appropriate for 

replication and scale. VA has not done analysis of the budgetary implications of a 

governmentwide verification program as the Administration has not established a 

position on such a program. Should a decision be made on governmentwide 

verification, we believe that it would be most cost-effective to scale up the CVE program by obtaining additional personnel to cover the workload and apply alreadyexisting processes and criteria, rather than creating new infrastructure in other 

agencies. 

c. Does VA have the capability to administer a governmentwide certification program or would a more effective verification program be housed outside of VA? 

Response. VA’s VOSB verification program has the capability to rapidly increase 

and support the scale of a governmentwide program expansion. VA could obtain additional personnel to cover the workload and apply already-existing processes and 

criteria, whereas other agencies would have to develop these capabilities. 

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d. What estimates does VA have of the current cost per applicant to CVE and 

what are VA’s estimates of those costs government wide? 

Response. The estimated average cost to process one application through CVE in 

FY 2015 is $1,242. We do not have an estimate of these costs governmentwide. As 

noted previously, no other agency has a similar verification function that can be 

used as a comparison. 

Question 33. The chart, ‘‘Summary of Employment and Obligations,’’ for the Office 

of Acquisitions and Logistics Supply Fund does not include FTE information specifically for CVE. 

a. Please provide the Committee with the FTE requirements for CVE for fiscal 

year 2016 and the preceding three years. 

Response. The number of Federal FTE in CVE for the period 2013–2016: 2013: 

16 2014: 17 2015: 17 (one position vacant) Projected 2016: 21 (Requested addition 

of 4 Federal staff to review evaluations). 

b. Please provide the Committee with a detailed budget for OSDBU and CVE. 

Response. The FY 2015 Budget for OSDBU and CVE is provided below: 

2015 Approved Budget 

As of 05/07/2015 

(000s of dollars) 

CVE All OSDBU 

FTE ................................................................................................................................................. 17 42 

Obligations: 

FTE ............................................................................................................................................ $2,471 $6,660 

Professional Services ................................................................................................................ $7,387 $17,214 

Travel ........................................................................................................................................ $30 $102 

Training ..................................................................................................................................... $15 $54 

Printing and reproduction ........................................................................................................ $1 $30 

Contract Support ...................................................................................................................... $5,843 $7,183 

Supplies and materials ............................................................................................................ $8 $48 

Equipment ................................................................................................................................. $2 $80 

Rents ......................................................................................................................................... $301 $523 

Security ..................................................................................................................................... $20 $52 

Total obligations .................................................................................................................. 1 $16,078 2 $31,946 

1 CVE budget includes an increase in budget authority of $4.511 million for contract support and professional services since January 2015. 

2 OSDBU budget reflects the increases in CVE budget and an additional authorization for non-CVE items of $1.736 million 

INFORMATION TECHNOLOGY

Question 34. In the fiscal year 2016 budget, VA is proposing raising from $1 million to $3 million ‘‘the threshold at which a request is required [to] be made from 

both Houses of Congress prior to the transfer of funds between projects.’’ 

a. Please provide further explanation for this request and what specific projects 

would require a transfer of funds. 

Response. Under current law, VA’s IT Systems appropriations account is divided 

into three subaccounts—pay/administration, operations and maintenance, and development. The development subaccount is further divided into a number (roughly a 

dozen) project lines. Each subaccount and each project line are assigned a certain 

amount of funds. During the course of the year as funds are executed, an under execution of funds may occur for a variety of reasons; proper stewardship suggests that 

these under-executed funds be reprogrammed to other high priority needs. Historically, the annual appropriations act has included language requiring that VA request and receive the approval of the Committees on Appropriations of both Houses 

of Congress before reprogramming funds among the three subaccounts and/or shifting funds among development projects. The requirement has remained constant over 

the years, while the IT Systems appropriations account has grown significantly. 

This modest increase in the threshold at which permission must be sought for reprogramming will allow for more effective management of resources within the IT 

Systems Account. 

b. Please provide a list of all transfer of funds VA has requested for Information 

Technology (IT) projects for the past two fiscal years. 

Response. The Re-programming letters for both FY 2013 and FY 2014 are attached, and include a list of projects that required funding transfers. 

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Question 35. VA has requested $1.828 billion to maintain the current IT infra- structure. Of that, $376.2 million is for IT support contracts. This is approximately 

a $106 million increase from fiscal year 2015. Please provide the Committee with 

a breakdown of current and expected support contracts’ vendors and costs. 

VA Response, VA is making significant investments to improve IT infrastructure 

to support the new IT capabilities developed over the past 5 years. While the budget 

for IT Support Contracts increases in FY 2016, it is worth noting that the Department continues to strive for providing the most effective and efficient support of its 

infrastructure used to move data around the country as is possible. The Department 

also continues its efforts to improve transparency and accuracy in the classification 

of funds used to support the IT infrastructure of VA. In developing its 2016 budget, 

VA also sought to improve accuracy and transparency—some items in FY 2015 were 

IT support contracts, but were not correctly classified as such. In developing the FY 

2016 budget, IT infrastructure contracts are properly classified, with the effect that 

other lines in the IT infrastructure category showed decreases between FY 2015 and 

2016. The IT Support contracts that will be supported by the $376.2 million request 

in FY 2016 are expected to require obligations on the same order in FY 2015. 

The list of contracts for FY 2015 is below. This list is divided into two parts. The 

first part identifies six large contract items for $112 million. The second list documents some 289 small contracts, most of which are on the order of a few hundred 

thousand dollars each—the total of these is just over $264 million. The vendors that 

would address these contracts in FY 2016 will be determined through competitive 

processes consistent with Federal Acquisition Regulations. 

Large Contracts Planned Total 

Contracts 

Required 

CRISP Surge .................................................................................................................................... $12,106,232 1 

Help Desk ........................................................................................................................................ $52,984,797 2 

PAID to the new HRIS SSC ............................................................................................................. $11,350,356 1 

Testing Service Support .................................................................................................................. $23,689,992 1 

VBMS ............................................................................................................................................... $12,000,000 1 

Total ....................................................................................................................................... $112,131,377 6 

Other IT Support Planned Total 

Contracts 

Required 

Electronic Health Record Interoperability ....................................................................................... $13,913,082 8 

Health Administrative Systems—INTER ......................................................................................... $759,456 1 

Health Administrative Systems—MED ........................................................................................... $5,794,924 12 

Health Provider Systems/Access to Care ........................................................................................ $568,542 2 

Human Resources Information System (HRIS) ............................................................................... $9,224,688 9 

IT Support Contracts—BENE .......................................................................................................... $22,162,653 18 

IT Support Contracts—ENT ............................................................................................................ $16,565,356 14 

IT Support Contracts—MED ........................................................................................................... $88,204,720 128 

Memorials Development .................................................................................................................. $2,000,000 7 

New Models of Health care ............................................................................................................ $17,123,453 12 

Veterans Benefits Management System (VBMS) ............................................................................ $38,151,800 20 

Veterans Relationship Management (VRM) .................................................................................... $49,732,864 58 

Total ....................................................................................................................................... $264,201,539 289 

Question 36. GAO recently outlined how Federal IT investments have historically 

been plagued by failures and cost overruns resulting in billions of dollars of taxpayer money wasted. Specifically, GAO cited VA’s Financial and Logistics Integrated Technology Enterprise program and VA’s Scheduling Replacement project as 

examples of waste. Please detail what specific steps VA has taken to incorporate 

GAO’s recommendations for successful IT management. 

Response. In order to address systemic IT project delivery challenges, VA established the Project Management Accountability System (PMAS) in June 2009. PMAS 

establishes a discipline which ensures the customer, IT project team, vendors, and 

all stakeholders invested in an IT project focus on a single compelling mission— 

achieving on-time project delivery. PMAS facilitates relationships which ensure cusVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00136 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
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tomer needs are met, minimizes waste in IT investments and reduces project management and technical risks. Additionally, PMAS rebalances IT requirements with 

available staffing, focuses IT efforts by funding only projects with adequate resources, and enables VA to intervene in projects as soon as problems arise. In other 

words, under PMAS, VA can easily determine that if VA IT projects are going to 

fail, they will fail early and fail fast, allowing VA to more immediately correct or 

close IT projects which are not succeeding. 

PMAS also allows VA to actively address the nine critical factors highlighted by 

GAO in GAO–15–290 ‘‘High Risk Series: An Update.’’ As shown in the following 

table, VA’s Information Technology (IT) management methodology directly addresses the nine critical factors identified by GAO to support the objective of improving 

the management of large-scale IT acquisitions across the Federal Government: 

VA’s Implementation of GAO’s Nine Critical Factors 

GAO’s Nine Critical Factors VA’s Implementation Steps 

(1) Program officials actively engaging 

with stakeholders 

• VA delivers IT capabilities through its Integrated Project Team (IPTs); IPTs 

include the project staff, the business sponsors and stakeholders working 

together and sharing responsibility for delivering IT capabilities on time 

• Senior leaders review the work of the IPTs at all Milestone Reviews, which 

are gateways for continued development 

• In VA, our term for program officials is ‘‘senior leaders′′. Senior leaders constantly interact with stakeholders, which are a part of our project teams and 

business sponsors 

• Senior leaders also engage with stakeholders when projects experience risk 

that could prevent an on time delivery; project managers and senior leaders 

meet weekly to mitigate risk to get a project or increment back on schedule 

(2) Program staff having necessary 

knowledge and skills 

• VA ensures all IT Project Managers have completed the Federal Acquisition 

Corp Project/Program Management (FAC P/PM) certification course and also 

provide them with opportunities and support to earn their requisite annual 

continuing learning education credits. 

• In VA, senior leaders review the composition of all IPTs and do not approve 

the project to proceed unless the IPT and project team are staffed with individuals that have the necessary knowledge and skills to deliver the agreed 

to IT capability on time 

• VA’s Office of Information & Technology (OI&T) provides a resource management process that enables project teams to request staff members with the 

requisite knowledge, skills and experience to make the IPT successful 

(3) Senior department and agency executives supporting the programs • VA’s Chief Information Officer (CIO) and all Deputy Chief Information Officers (DCIOs) invest significant time each week to ensuring its IT management framework is being fully and completely executed 

• Weekly, senior leaders review and approve projects which believe they are 

ready for the next phase of development 

• Weekly, senior leaders also support the risk mitigation process by participating in and providing the intervention/resolution requested to reduce risk 

• VA CIO reviews the progress of execution weekly and monthly and authorizes 

changes to the policy and process as needed 

(4) End users and stakeholders involved in the development of requirements • The business sponsor/customer creates and approves a Business Requirements Document before starting IT development 

• Milestone Review Board will not approve a project to move forward without a 

signed BRD 

• Stakeholders, business sponsors and any designated end users are all members of the IPT 

• Milestone Review Board will not approve a project to move forward without 

an effective IPT 

(5) End users participating in testing 

of system functionality prior to end 

user acceptance testing 

• Business sponsors and end users participate in reviews of code prior to also 

participating in User Acceptance Testing (UAT), which is an essential part of 

VA’s process for delivering IT capabilities 

• The Agile methodology, which is embedded in VA’s IT delivery approach, requires—and VA enforces-near continual participation of end users and business sponsors as part of the sprint delivery process 

134 

VA’s Implementation of GAO’s Nine Critical Factors 

GAO’s Nine Critical Factors VA’s Implementation Steps 

(6) Government and contractor staff 

being stable and consistent 

• VA has re-structured the method by which it staffs projects. VA uses a competency model to ensure timely, efficient and consistent staffing of all 

projects. 

• Projects are not allowed to start or continue work if they do not have all required staff assigned to a project 

• VA also requires all projects to have stable, consistent staffing of all IPTs 

• Milestone Reviews review the composition of all IPTs and inquire as to 

whether the project manager is having any issues with IPT staff composition 

• Project managers can seek immediate help for any loss of resources via the 

risk mitigation process 

• OIT’s staffs projects via a resource management board to ensure the fair 

and consistent assignment of staff to projects 

(7) Program staff prioritizing requirements • VA’s IT delivery framework requires the IPT members to work together to develop an agreed set of requirements; establishing the priorities for these requirements is an essential element of this process and for creating and approving the BRD 

• IPTs constantly review their agreed set of requirements and ensure over time 

that priorities remain correct 

• Use of the Agile framework also enforces the consistent prioritization and reprioritization (as necessary) of requirements 

(8) Program officials maintaining regular communication with the prime 

contractor 

• IPTs are the organizational entity for ensuring program officials have regular 

communications with the prime contractor; representatives of the prime contractor attend IPT meetings and are responsive to the project manager to 

provide contractual deliverables 

• At a minimum IPTs meetings are held bi-weekly; but most are held weekly 

(9) Programs receiving sufficient funding • No project can start or continue work unless it has sufficient funding for 

success 

• If funding is lost mid-development, the project is paused until a determination can be made to either restore funding or cease work 

• No project is expected to be successful and make on-time deliveries if funding is not sufficient 

The preceding table defines the steps that VA has taken to incorporate GAO’s recommendations for successful IT management. 

By following these steps, over the past five years (FY 2010—March, FY 2015), VA 

has achieved an on-time delivery rate of 83% (through the end of March 2015), and 

an overall delivery rate of 92%. As noted in GAO–14–361 Report ‘‘Information Technology: Agencies Need to Establish and Implement Incremental Development Policies’’ released on May 8, 2014, GAO reviewed five agencies’ incremental development 

approaches. Of the agencies surveyed, VA was the only Federal agency to meet all 

three evaluation factors, which were delivery of functionality every 6 months, welldefined functionality, and defining a process for enforcing compliance. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO U.S. DEPARTMENT OF VETERANS AFFAIRS

HEALTH CARE

Non-VA Care 

Question 37. What tangible steps has VA taken to ensure coordination of non-VA 

care options, particularly in conjunction with the new Choice Program that to date 

has seen low utilization? 

Response. The Chief Business Office Purchased Care (CBOPC) will continue biweekly calls with VA Medical Center staff and the Choice/Patient-Centered Community Care Third Party Administrators (TPAs) that address usage, utilization strategies, and communicating newly implemented work flow processes associated with 

both programs. CBOPC has increased the frequency of direct communications and 

onsite visits with VA medical centers (VAMCs) that have low utilization of Choice 

and PC3. In addition, CBOPC is communicating with VAMC Directors to keep them 

135 

informed of PC3/Choice provider network efforts, cost benefits, and barriers to current utilization. 

Public Law 114–41, the Surface Transportation and Veterans Health Care Choice 

Improvement Act of 2015, included amendments to the original Veterans Choice 

Program as well as instruction for VA to review the statutory authorities VA has 

for purchasing Veteran healthcare in the community and to recommend a plan to 

consolidate these programs into a single program to be known as the ‘‘Veterans 

Choice Program.’’ With this initiative VA assigned a special team of subject matter 

experts to develop the plan for submission to VA leadership, OMB and ultimately 

Congress. The outcome of this work is expected to provide a more streamlined authority for VA to purchase any care in the community. 

Question 38. What level of funding included in the President’s budget request 

would be used to ensure VA is adequately communicating with veterans and providers about the availability of non-VA care options and how they work? How are 

veterans who don’t meet the eligibility criteria for the Choice Program informed of 

other fee-basis care options? 

Response. At this time, how much of the President’s budget is used to communicate with Veterans and providers regarding non-VA medical care is unknown. 

However, CBOPC ensures that communication is available to providers and Veterans. One avenue of such communication is the CBOPC Web site, http:// 

www.va.gov/PURCHASEDCARE. The CBOPC Web site provides information for 

non-VA medical care providers on the submission of claims and other pertinent information for their offices and also contains many references for Veterans, including 

how to request non-VA medical care. Additionally, VA facilities have pamphlets and 

brochures that also describe non-VA medical care options. 

Veterans who do not meet the Choice eligibility requirements may be referred for 

non-VA medical care if the care needed is not available at the VA facility. Once a 

Veteran has been referred for non-VA medical care, the local Non-VA Care Coordination Office (NVCC) will make contact and work with the Veteran to identify a 

non-VA provider. Once the non-VA provider has been identified, the local NVCC office will coordinate with Veteran and the non-VA medical provider to schedule an 

appointment for the needed medical care. The NVCC office will continue to coordinate with the non-VA medical care provider and the Veteran for any additional 

needed medical care, whether through the non-VA provider or the VA facility. 

Question 39. Given the intense spotlight placed on exceptionally long-wait-times 

thousands of veterans faced across the country last year, what is VA doing to ensure 

local VHA staff are better informed about how and when to use non-VA care? 

Response. A Choice intranet site has been developed that includes training material and a resource toolkit for VA employees. The resource toolkit includes recorded 

training sessions, fact sheets, Frequently Asked Questions (FAQs), and information 

for Veterans, Veteran Service Organizations, and the Public. Additionally, each VA 

health care facility has designated Choice Champions to provide VA staff and Veterans with information and guidance on the Choice Program. To support the Choice 

Champions, a Pulse Web site was created to provide a forum for discussing questions and issues relating to Choice Program implementation; a monthly call has 

been established (starting in April 2015, it will be bi-weekly); and a Choice Champions email group was developed to also address outstanding issues and to disseminate timely information. 

In addition, Veterans Health Administration (VHA) staff can find information 

about the use of non-VA medical care on the CBOPC’s National Non-VA Medical 

Care Program Office (NNPO) intranet site. Included on that site are policies, procedures, training, memorandums, fact sheets, handbooks, directives, and access to a 

Question and Answer (Q&A) database. Also located on the NNPO intranet site are 

copies of the bi-weekly publication, The Bulletin, which contains articles specifically 

for non-VA medical care staff at VHA health care facilities. Moreover, NNPO conducts monthly calls with non-VA medical care staff and also provides visits to VA 

health care facilities to support Non-VA Medical Care Managers and Business Operations through process improvement plans, training, data analysis, and communication tools. 

Finally, a Patient-Centered Community Care (PC3) intranet site is available for 

VHA staff that includes presentations, training, fact sheets, and reference guides. 

Bi-weekly meetings are held with designated VHA staff aimed toward education and 

promoting the use of PC3. 

Formularies 

Question 40. For soldiers transitioning from active duty, continuity of health care, 

particularly as it relates to treatments for mental health conditions can be extremely important. The VHA Directive issued on January 20, 2015, indicates that 

136 

VA providers are not to discontinue mental health medications based solely on ‘‘differences between the VA and DOD drug formularies, VA Criteria-for-Use, or the 

cost of the drug.’’ 

a. Does VA have the necessary resources to implement this directive by the 

March 13, 2015, and to provide appropriate oversight to make sure that clinicians 

are conforming to the policy? 

Response. Yes, VA has the necessary resources. The Directive describes longstanding VHA practices which have been in place since approximately 2006, so in 

essence the Directive is already implemented. VHA recently conducted an in depth 

analysis of its practices to continue mental health and pain medications in Servicemembers transitioning from DOD to the VA healthcare system. This review found 

very few exceptions where the practice that is now policy was not being followed 

(21 exceptions of 2,000 Servicemembers evaluated). VA plans to periodically repeat 

the analysis to ensure that the Directive is being followed. 

b. Does VA anticipate significant increased expenses due to paying for these treatments which may be more expensive than what the clinician would prescribe for a 

veteran who is outside of the transition period? 

Response. For the specific population impacted by the Directive (i.e., Servicemembers transitioning their care from DOD to VA who are receiving mental health 

medications from DOD) VA does not expect significant increases because our practice has been to continue those medications when clinically safe and appropriate. VA 

would only anticipate large increases in expenses if this policy were expanded to 

other drug classes and to all VA beneficiaries (i.e., not just transitioning Servicemembers who are receiving mental health medications from DOD). 

Accountability 

Question 41. If VA were given the authority to make a change to the Title 38 Appointment and Compensation System for Medical Center and Network directors, 

how does the Department intend to ensure these individuals are meeting VHA’s performance goals? 

Response. The Department of Veterans Affairs (VA) intends to ensure Medical 

Center Directors and Network Directors meet Veterans Health Administration’s performance goals through the existing performance management process. A Title 38 

appointment for senior executives will not change the current Performance Management System. VHA’s current Title 38 executives are held to the same performance 

standards as members of the Senior Executive Service (SES). 

The Deputy Under Secretary for Health for Operations and Management conducts 

quarterly reviews with Network Directors to evaluate their performance and the 

performance of their organizations against desired outcomes consistent with the senior executives’ performance plans. These reviews include assessment of leadership’s 

capacity to promote and support effective governance, integrity, and high reliability. 

Other focus areas include: Quality Improvement, Patient Safety, Environment of 

Care, Veteran Experience, Customer Service and Workforce Training/Readiness. 

VHA conducts a comprehensive performance review annually of each senior executive, including SES and Title 38 SES Equivalents, in accordance with VA Handbook 

5027 and the VA SES and Title 38 SES-Equivalent Performance Management Systems policy. VHA complies with law and Department policy related to executive performance evaluation. The SES or SES Equivalent prepares an assessment, which 

documents their accomplishments throughout the performance year; the supervisor 

provides an evaluation, and the Reviewing Official conducts a second level review 

to rate the executive’s performance. VHA’s Performance Review Committee reviews 

all VHA evaluations and makes rating recommendations to the VA Performance Review Board (PRB). The PRB reviews all VA SES and SES Equivalent performance 

appraisals and makes rating recommendations to the Secretary, who has final decision authority of the rating of record. 

Question 42. Why has VA not set out more ambitious projections for itself in the 

strategic framework outlined by VHA’s National Leadership Council, especially as 

it relates to satisfaction measures of veterans? 

Response. The Department of Veterans Affairs (VA) is implementing an historic 

department-wide transformation, changing VA’s culture and making the Veteran 

the center of everything we do. Transformation must start with organizational reforms to better unify the Department’s efforts on behalf of Veterans. These reforms, 

which will take time, center on the ICARE values. These reforms include the Department’s ‘‘MyVA’’ initiative, which reorients VA around Veteran needs and empowers employees to assist them in delivering excellent customer service to improve 

the Veteran experience. VHA’s Blueprint for Excellence is aligned with the Department’s Strategic Plan and supports the ‘‘MyVA’’ initiative. The Blueprint lays out 

themes and supporting strategies for the transformation to improve the performance 

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of VA health care now and offers a common framework for action with VHA’s Strategic Plan. The overarching principle is our focus on the Veteran experience. 

While VA is in a process of transformation, VHA is in the process of developing 

performance measures and targets for 1) Veteran experiences of Access to routine, 

urgent, and specialist care; 2) self-management support; and 3) overall rating of 

their inpatient and outpatient care and their VA provider. To achieve a high level 

of performance, much work has to be done over a sustained period of time to ensure 

we hire the right numbers of staff, build the right networks of community-based 

providers, train our staff using the correct core values and skills, and ensure the 

supporting infrastructure that guarantees a high degree of reliability. Furthermore, 

how Veterans rate their experience will also depend on the trust they place in us. 

We recognize that rebuilding that trust takes time and we are committed to providing high quality, proactive, personalized patient-drive care to Veterans and strive 

to improve our services. 

Antibiotic Resistance 

Question 43. In January 2014, VA issued a Directive requiring VA medical facilities to implement antimicrobial stewardship programs. Addressing the urgent, growing problem of antimicrobial resistance will require both the development of new antibiotic products and the stewardship of existing products. VA facilities, as well as 

private sector facilities, must implement meaningful stewardship programs to do 

their part in avoiding unnecessary and very difficult to treat infections. 

a. What is the current status of the VA directive on antimicrobial stewardship 

programs, and are there any plans to share data and lessons learned from stewardship programs among facilities and with other stakeholders? 

Response. The Antimicrobial Stewardship Programs Directive (VHA Directive 

1031) requires all VHA facilities to implement, maintain and evaluate an Antimicrobial Stewardship Program. A national field survey has been developed to determine compliance with Directive 1031 and is awaiting final approval from 10N for 

dissemination. Data and resources are shared through educational webinars and 

made available on a VHA SharePoint site for use by antimicrobial stewardship 

champions in the field. 

b. Does VA have resources available to address any changes that may be necessary within facilities based on what is learned from stewardship programs? 

Response. This initiative has no designated funding and relies on a core group of 

highly productive field volunteers, the National Antimicrobial Stewardship 

Taskforce. There is no fenced facility-specific funding for stewardship; such funding 

would fall under the facility’s general medical resources as part of patient care. 

Women Veterans 

Question 44. As more and more women are becoming veterans, it becomes even 

more important that VA provides gender-specific services such as obstetrical and 

gynecology specialty care. However it is also important that VA services generally 

available are appropriate for women. For instance, primary care, cardiology and 

mental health options must be equally available to women as they are to men. How 

will the funding in the President’s budget request ensure that all appropriate services available within VHA are accessible to women and that primary care providers 

are counseling women veterans about risks specific to women such as potential risk 

of birth defects associated with prescribed medication? 

Response. To provide the highest quality of care to women Veterans, VA offers 

women Veterans assignments to trained and experienced Designated Women’s 

Health Providers (DWHP) who can provide general primary care and gender-specific 

primary care in the context of a longitudinal patient/provider relationship. Today, 

DWHPs are available at 95 percent of VA medical centers (VAMC), and 84 percent 

of community-based outpatient clinics in comparison to 2009 when women’s health 

providers were at only 33 percent of VAMCs. VA plan is that whenever a woman 

Veteran enters the health care system, she will have access to a DWHP. To meet 

this plan, VA must ensure that all new primary care hires are proficient in the care 

of women as well as men. VA is continuing to train and update skills of current 

VA primary care and emergency providers in the care of women. Since 2008, VA 

has provided intensive training to over 2,000 women’s health providers and provided 

over 50 different online, accredited women’s health classes, which can be taken 24/ 

7 to enhance the flexibility of learning opportunities for employees. The combination 

of educational offerings provides not only basic training in women’s health but advance courses so that providers and other staff can keep their skills and knowledge 

up-to-date. 

VA is raising awareness of cardiovascular risk in women Veterans through collaboration with the American Heart Association’s Go Red for Women Movement. 

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VA’s national Women’s Veterans Cardiovascular Work Group, published the State 

of Cardiovascular Health in Women Veterans Report and in February, 2015 encouraged all sites to develop specific cardiovascular risk reduction programs for women 

through a national Go Red Challenge. 

VA is raising awareness of preconception care for women Veterans and VA providers by expanded training in preconception care to providers serving high risk 

women and developing the Preconception Care mobile application for providers as 

a tool to enhance and support the integration of preconception care into primary 

care. By addressing health and wellness before pregnancy, preconception care is an 

essential component of well women care during the childbearing years. 

VA has developed a national curriculum for primary care and mental health providers addressing topics including the effects of pregnancy and menopause on women’s mental health and the effects of psychiatric medications on reproductive health. 

Additionally, VA has developed a national pharmacy order check that alerts providers of potentially teratogenic medications through the computerized electronic 

medical record. Later this year, a national Information Technology project, the Notification of Teratogenic Drugs Project, will launch that will enhance the current computerized order check. This will provide enhanced electronic record functionality for 

providers to improve patient safety when prescribing high risk medications to 

women of reproductive age. 

Question 45. Military Sexual Trauma (MST) has gained increased recognition over 

recent years. VA estimates that of veterans receiving VA health care, approximately 

one in four women and one in a hundred men report experiences of MST during 

their military service. How much does VA anticipate spending on treatment associated with MST? Please describe how this funding would be utilized to adequately 

train all appropriate staff, including schedulers and support staff on sensitivity related to MST. 

Response. VA’s data on the prevalence of MST comes from its universal screening 

program, which includes all Veterans seen for any VA health care. It is important 

to note that not all Veterans who disclose MST during screening need or are seeking 

MST-related treatment, as many recover from their experiences without professional 

care. Of those Veterans who are experiencing difficulties, their presenting problems 

include a wide range of both mental and physical health conditions. As such, the 

types and costs of MST-related care will vary based on the specific health conditions 

for which Veterans decide to seek treatment. The treatment provider makes the determination whether a particular episode of care is MST-related for a particular 

Veteran; this is indicated on a case-by-case basis in a Veteran’s medical record. 

Therefore the cost of providing MST-related care is incorporated into broader health 

care costs for each VA healthcare system; it is not feasible to treat MST as a separate line item. 

In FY 2014 VA reviewed Veteran utilization and cost data for treatment episodes 

judged to be MST-related between FY 2009 and FY 2013, in order to estimate the 

total costs of VA outpatient and inpatient care provided in those years. Projections 

for future costs in years FY 2014-FY 2016 were also made based on utilization in 

past years. These cost estimates (which include treatment for both female and male 

Veterans) are provided in the table below. 

Military Sexual Trauma Related Care 

Year 

Number of Male 

and Female Veterans Receiving VA 

MST-Related Care 

Obligations 

FY 2009 ....................... 65,264 $207,599,000 

FY 2010 ....................... 72,548 $256,193,000 

FY 2011 ....................... 80,688 $283,563,000 

FY 2012 ....................... 88,990 $308,156,000 

FY 2013 ....................... 96,807 $319,363,000 

FY 2014* ..................... 104,760 $346,913,000 

FY 2015* ..................... 112,814 $368,637,000 

FY 2016* ..................... 120,816 $389,527,000 

* Years FY 2014 through FY 2016 are based on projections of future 

costs and therefore may be different than actual costs incurred in 

those years. 

MST-related education and training for VA staff MST training initiatives occur 

at both the local and national level. At a local level, every VA health care system 

has a designated MST Coordinator who serves as a contact person for MST-related 

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issues and can help Veterans access VA services and programs. MST Coordinators 

help ensure that local staff members receive mandated MST education and training, 

and provide training as needed in clinics throughout the health care system to ensure that staff members have the needed knowledge and skills to work effectively 

with MST survivors. For example, MST Coordinators host Grand Rounds and other 

educational presentations, distribute informational materials, and provide clinical 

consultation. These training duties are collateral to being full-time clinicians, so 

their salary support comes from their primary role within their local VA health care 

system. 

Nationally, all VA mental health and primary care providers are required to complete mandatory training on MST. Mental health providers complete a web-based 

training on MST that provides a comprehensive review of issues relevant to provision of mental health care to MST survivors. Primary care providers must complete 

a web-based training that reviews a range of issues including health conditions associated with MST, screening sensitively for MST, how MST can affect a Veteran’s 

experience of healthcare, how to appropriately adapt care to address the needs of 

MST survivors, and VA documentation requirements. 

VA’s national Mental Health Services program office funds a national MST Support Team which is, in part, charged with coordinating and expanding national 

MST-related training initiatives. For example, the team hosts monthly continuing 

education calls on MST-related topics that are open to all VA staff and available 

online afterwards. Since 2007, the MST Support Team has hosted an annual training focused on MST-related program development as well as the provision of clinical 

care to Veterans who experienced MST. The MST Resource Homepage is a VA 

intranet community of practice Web site where VA staff can access MST-related resources and materials, review data on MST screening and treatment, and participate in MST-related discussion forums. In addition, all VA staff have access to an 

online independent study course on MST and other Web-based training materials. 

The MST Support Team has also partnered with VA rollouts of empirically-supported treatments for PTSD, depression, and anxiety to include MST-specific information. These national initiatives train therapists in evidence-based practices such 

as Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), Acceptance & 

Commitment Therapy (ACT), and Cognitive Behavioral Therapy (CBT). Conditions 

targeted by these treatments are strongly associated with MST, meaning these national initiatives have been an important means of expanding MST survivors’ access 

to cutting-edge treatments. 

The MST Support Team also conducts an ongoing National Review of the Accessibility of MST Coordinators. This program is an innovative ‘‘secret shopper’’ initiative 

to survey the experiences a Veteran would be likely to have in attempting to reach 

an MST Coordinator via telephone. This initiative was expanded in FY 2014 in 

order to help maintain improvements and continue progress toward the goal of ensuring Veterans are able to reach the MST Coordinator at every health care system. 

The latest round of this review is currently underway. In conjunction with the review, MST Coordinators are encouraged to provide training to frontline staff, such 

as clerks and telephone operators, on how to appropriately and sensitively assist 

MST survivors. The MST Support Team has developed handouts and tips sheets to 

support MST Coordinators in these efforts. 

Also, in conjunction with Sexual Assault Awareness Month (April) 2015, the MST 

Support Team is releasing a new MST sensitivity training video titled, ‘‘You can 

make a difference: Honoring Veterans who experienced MST.’’ To underscore the importance of being sensitive to the needs of MST survivors, Secretary McDonald provides an introduction to the video; Veteran Ruth Moore also appears in the video 

to share her perspectives on how every VA staff member can assist Veterans who 

experienced MST. The video and associated training materials are applicable to all 

VA staff but particularly designed to target frontline staff. MST Coordinators will 

use the video in awareness-raising events during Sexual Assault Awareness Month, 

as well as in ongoing efforts related to the National Review of the Accessibility of 

MST Coordinators and training of frontline and support staff more generally. 

BENEFIT PROGRAMS

Disability Compensation Claims System 

Question 46. Provide the methodology utilized to allocate personnel and resources 

to the regional offices and specifically address any refinements made to this methodology in the past fiscal year. In discussing refinements made over the past fiscal 

year, please specifically address VBA’s Office of Strategic Planning efforts to design 

a workforce capacity model. 

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Response. Please see the attached VBA Workforce Analysis submitted to Congress 

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Question 47. In 2009, VA began an effort to update the VA Schedule for Rating 

Disabilities. 

a. Provide an itemized list of funding expended in FY 2015 on the rating schedule 

modernization. 

Response. For FY 2015, VBA budgeted $3.1 million to update the VA Schedule 

for Rating Disabilities (VASRD), including $956,000 for pay and benefits, $30,000 

for travel, $2.0 million for an earnings loss study, $46,000 for rent; and $54,000 for 

supplies and other services. 

b. Provide an itemized list of the requested funding in FY 2016 for the rating 

schedule modernization. Also, include the number of FTE assigned to or supporting 

this modernization effort. 

Response. For FY 2016, VBA requests $3.1 million to update VASRD, including 

$960,000 for pay and benefits, $30,000 for travel, $2.0 million for an earnings loss 

study, $46,000 for rent, and $54,000 for supplies and other services. Five employees 

are currently assigned to support the VASRD modernization effort. 

c. Provide the Project Management Plan, the VASRD Update Operating Plan and 

project schedule for the rating schedule modernization. 

Response. Please see the attached Project Management Plan. VBA does not have 

a VASRD Operating Plan. Table 2 in the Project Management Plan shows the 

stages of concurrence for each body system. Since the Plan was last updated, proposed rulemakings for several systems have been published. VA understands the 

importance of updating the Rating Schedule and will ensure the completion of updates as each system proceeds through concurrence. 

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d. Does the FY 2016 request include any funding to support updates that will 

need to be made to IT solutions, including VBMS, disability benefit questionnaires, 

rules-based calculators, or other initiatives based on the current VASRD? How much 

funding does VA anticipate these updates will require upon publication of final rules 

for the various body systems? 

Response. Yes, the FY 2016 request includes funding to support updates that will 

need to be made to IT solutions, including VBMS, related to the VASRD modernization project. This funding is included in OIT’s budget request for sustainment of IT 

systems. 

Question 48. Provide the number of FTE assigned to or supporting VA’s accreditation program. Also, provide the following information for calendar years 2014. 

Response. The Office of the General Counsel’s (OGC) accreditation program currently has six full-time employees (two permanent GS–7 employees, two temporary 

GS–7 employees, one permanent GS–8 employee, and one permanent GS–11 employee) assigned to the accreditation program as well as three-fourths of a Deputy 

Chief Counsel position (formerly titled as Deputy Assistant General Counsel) and 

approximately one-tenth of a Chief Counsel position (formerly titled Assistant General Counsel). In calendar year 2014, the program had three full-time employees 

(one GS–7, one GS–8, and one GS–11 (from June 2014 to December 2014)) assigned 

to the accreditation program as well as approximately one-third of a GS–15 Deputy 

Assistant General Counsel position and approximately one-tenth of an Assistant 

General Counsel position. In addition, the Veterans Benefits Administration detailed one employee to the program for the entire calendar year of 2014, and temporarily detailed approximately eight other employees, for periods lasting at least one 

month, to the program to assist with the backlog of accreditation applications in calendar year 2014. VA has also utilized legal externs working with OGC to assist with 

the program. 

a. The number of individuals per year who have sought recognition to represent 

individuals before VA broken down by representatives of service organizations, attorneys or agents. 

Response. VA’s accreditation matters are tracked within OGC’s recordkeeping 

database, GCLAWS. The GCLAWS database is primarily a recordkeeping and casetracking database for legal matters, and is somewhat limited in its ability to track 

certain types of information for VA’s accreditation program in a way that permits 

reliable targeted searches of statistical programmatic data for that program. For example, this database tracks accreditations and suspensions/cancelations, but does 

not specifically track other data, such as the number of accreditation applications 

received per year, the number of applications denied, or the number of applications 

withdrawn or abandoned. From the information available, we are able to estimate 

the number of applications received per year from the number of accreditation applications granted per year. With respect to attorneys and service organization representatives, the number of applications granted closely approximates the number 

of applications received, because very few applications are denied in these categories, for reasons discussed in paragraph (c) below. Accordingly, the estimates provided below are based on the number of attorney and service organization representative applications granted in calendar year 2014. Additionally, we have estimated 

the number of agent applications based on the number of cases attributable to the 

one VA employee who was assigned exclusively to agent applications for calendar 

year 2014. 

Accreditation Applications Received in Calendar Year 

Calendar Year 

VSO 

Representatives Attorneys Claim Agents Total 

2014 ............................................................................................. ∼3,150 ∼1,940 ∼680 >5,000 

b. Of those requests for recognition, how many were granted and how many were 

denied? 

Response. In FY 2014, VA granted accreditation to 1,940 attorneys, 47 agents, 

and 3,150 service organization representatives. 

Regarding the number of service organization representatives accredited, we note 

that a service organization representative may be accredited with more than one organization. This figure represents the number of service organization representative 

accreditations granted, not the number of individuals accredited. 

Regarding the number of agent applications, as explained in greater detail in response to question (c), the processing of an application for accreditation as an agent 

has several additional steps compared to processing of an application for accreditaVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00158 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
155 

tion as a service organization representative or attorney. Some of these steps were 

implemented at the beginning of calendar year 2014 in response to the Government 

Accountability Office’s (GAO) observations in its 2013 report VA Benefits: Improvements Needed to Ensure Claimants Receive Appropriate Representation. Specifically, GAO noted that VA’s then-existent process for accrediting agents relied on (1) 

applicants to self-report background information without independent verification, 

and (2) character references that did not provide relevant information. By the beginning of calendar year 2014, VA had modified its process for accrediting agents to 

incorporate background checks and direct questions to the applicants when potential 

areas of concern are identified regarding the applicant’s criminal or employment history as well as the applicant’s motivation for seeking accreditation by VA. In some 

cases agent applicants withdraw or abandon their applications because they realize 

that they initially applied for VA accreditation for some purpose other than to represent veterans on their VA benefit claims. In other cases the additional steps yield 

valuable information that informs OGC’s accreditation decision. VA does not currently track the number of applications that are denied in comparison to the number of applications that are closed because they are withdrawn or abandoned. In addition, because the accreditation process for agents takes more than a year, some 

of the applications received in calendar year 2014 are still pending. 

c. On average, how long does it take VA to process a request for recognition? 

Response. Applications for accreditation as a service organization representative 

are generally processed in less than 60 days, applications for accreditation as an attorney are processed in 60–120 days, and applications for accreditation as an agent 

take over one year to process to completion. Agent applications take considerably 

longer to process because there are several additional steps, such as the frequent 

need to obtain additional information or clarification from the applicant, conducting 

a background check, checking character references, and scheduling schedule and reviewing the agent exam. As part of the initial application, the character and fitness 

qualifications of service organization representatives are attested to by the certifying official of the organization and the character and fitness qualifications of attorneys are presumed based on good standing with the state bar. However, there is 

not an equivalent vetting process inherent in the application for agents and, therefore, VA must specifically examine the character and fitness and qualifications of 

each of these applicants. 

d. How many individuals had their recognition suspended or canceled? 

Response. The following table shows the number of cancelations that occurred in 

FY 2014. The accreditation database does not track disciplinary history, but rather 

whether the person is currently accredited. Two of the attorney cancelations were 

due to action taken by VA in response to a complaint. By regulation, service organizations are permitted to request cancelation of the accreditation of one of their representatives at any time, with or without stating a cause. If the cancelation is due 

to misconduct or incompetence of the representative, the regulations require the organization to inform VA of the reasons for the cancelation. Three of the cancelations 

of service organization representatives were for a stated cause. The remainder of the 

cancelations shown below were either at the request of the individual (such as an 

attorney or agent retiring) or at the request of the service organization without a 

stated cause (such as when an accredited veteran service organization representative’s employment ends). 

Attorneys .................................................... 126 

Agents ....................................................... 4 

Service Organization Representatives ....... 1318 

e. How many complaints were filed against individuals who are recognized to represent claimants before VA, how many were found to have merit, and how many 

were referred to the Inspector General, a law enforcement agency, or other similar 

enforcement entity and how many of the referred cases resulted in further enforcement, disciplinary or legal action? 

Response. VA received 47 complaints regarding individuals and organizations assisting individuals with claims for VA benefits. The complaints implicated the activities of approximately 44 accredited individuals and 34 individuals and organizations 

that are neither accredited recognized nor recognized by VA but are alleged to be 

assisting individuals with VA benefit claims. Some complaints implicated multiple 

individuals and organizations. 

The majority of these individuals (21 accredited individuals and 23 unaccredited 

individuals and organizations) were brought to the attention of VA based on their 

156 

use of the same marketing materials to market financial products to potential VA 

pension applicants residing in California. VA referred this matter to the California 

Attorney General and the California Insurance Commissioner for any action they 

deemed appropriate under state law. 

VA referred two matters involving using the VA logo to market financial products 

to Veterans to law enforcement. One matter was referred to the California Insurance Commissioner for any action he deemed appropriate under state law and the 

other was referred to the VA Office of the Inspector General. 

In two matters, VA sent cease and desist letters and, based on subsequent information provided to us, determined that no further action was required. 

Regarding three matters, VA has been unable to take further action because the 

complainant has not provided VA with a privacy release authorizing the release of 

information to the subject of the complaint. 

The remaining complaints are pending. In the cases involving accredited individuals, VA is currently gathering additional information and determining whether disciplinary proceedings will be necessary. For cases involving individuals who are not 

accredited, it is VA’s general practice to send a cease and desist letter and, if VA 

concerns remain unresolved, to refer the matter to appropriate state authorities. 

Education Benefits and Implementation of Executive Order 13607 

Question 49. I understand that there is a large backlog of complaints pending in 

the GI Bill Feedback System. Does VA have the necessary resources to respond to 

all the complaints about educational institutions registered in the GI Bill Feedback 

System by veteran students? How does VA plan to resolve this backlog? Is VA sharing complaints registered with the GI Bill Feedback System with Federal and state 

law enforcement agencies when the complaints are received? 

Response. The GI Bill Feedback System was implemented in January 2014 without additional FTE or funding resources. Despite this limitation, VA has handled 

over 2,700 complaints from education beneficiaries and has closed 1,900 complaints. 

Approximately 850 complaints are currently open and active, including 480 complaints with responses from schools that have not been matched to the original complaints for closure. The remaining 370 complaints are awaiting a response from the 

school. This is a significant improvement from the 1,100 open and active complaints 

in January 2015 when additional staff was assigned. VBA expects improvements to 

continue and will continue to actively monitor workload to determine if additional 

resources are necessary. VA provides complaints to Federal and state law enforcement agencies through the Federal Trade Commission’s Consumer (FTC) Sentinel 

System. 

Question 50. Is VA receiving updates from Federal and state law enforcement on 

their investigations and legal actions to stop predatory practices against veterans? 

If VA is receiving such updates, is VA identifying patterns of deception and predatory practices against veterans? How is VA protecting veterans from those practices? 

Response. VA is routinely receiving updates from DOD and the Department of 

Education on their compliance activities and findings, but VBA’s Education Service 

is not receiving updates directly from Federal and state law enforcement with the 

exception of activities that can be viewed through Consumer Sentinel. VA will suspend and/or withdraw any institution’s eligibility for VA education benefits when it 

is found in violation of any element of the statutory approval requirements, which 

generally refer to deceptive, erroneous, false and misleading advertising practices. 

There are no references in the statute to ‘‘predatory practices.’’ 

Question 51. Executive Order 13607 directs VA to institute uniform procedures for 

referring potential matters for civil or criminal enforcement to the Department of 

Justice and other relevant agencies. Has VA implemented these procedures? 

Response. Yes, VA has implemented these procedures through the GI Bill Feedback system and its direct connection to FTC’s Consumer Sentinel database. Criminal matters are referred to VA’s Office of Inspector General. 

HOMELESS VETERANS

Question 52. Describe the methodology and criteria utilized to determine whether 

and where to expand the domiciliary care for homeless veterans program. 

Response. The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) methodology for determining where a Domiciliary Care for Homeless 

Veterans (DCHV) program should be located emphasizes two primary criteria. First, 

the location should be an urban center with a significant homeless Veteran population. Second, the location should have few, if any, VHA residential treatment programs. As part of the VA Secretary’s Transformation 21 (T21) plan to end homelessness among Veterans, VHA identified five urban centers with significant homeless 

157 

Veteran populations and no residential treatment programs. These locations included Philadelphia, Atlanta, Miami, Denver and San Diego. 

A suitable location to lease in Miami was not found after numerous solicitations 

and the DCHV was subsequently moved to West Palm Beach, FL as part of a minor 

construction project. Philadelphia, Atlanta, Denver and San Diego are operational 

and the West Palm Beach building is under construction. 

The need to further expand or reduce DCHV beds may be initiated by a Veterans 

Integrated Service Network (VISN) based on a regional review of current and projected treatment needs using available projection models. In accordance with VHA 

policy, VISNs are required to submit a Business Plan that justifies a need to develop or reduce DCHV beds, which must be approved by the Under Secretary for 

Health (USH). VISN 8 submitted a proposal to develop a 40-bed DCHV in San Juan, 

PR. This proposal was approved and leased space is currently being solicited. 

Question 53. Describe how staff in VA’s new Homeless Veteran Community Employment Services will interface with staff from the Department of Labor’s Homeless 

Veteran Reintegration Program. 

Response. The Homeless Veteran Community Employment Services’ (HVCES) 

community employment coordinators (CEC) work with Department of Veterans Affairs (VA) and non-VA partners to identify local gaps in current competitive employment services and to develop new employment opportunities targeting homeless and 

formerly homeless Veterans. It is expected that CECs develop collaborative relationships with Department of Labor’s Homeless Veteran Reintegration Program staff at 

all sites where these programs co-exist to prevent duplication of services and improve employment outcomes for Veterans exiting homelessness. 

CONSTRUCTION AND LONG RANGE CAPITAL PLAN

Question 54. Provide a list of priority weights for the major criteria and sub-criteria used to inform the FY 2015 Strategic Capital Investment Plan decision plan. 

Response: 

Question 55. The budget request contains a legislative proposal to allow VA cemeteries to lease air rights above VA cemeteries. Please provide a list of the cemeteries 

that would be able to lease air rights, along with the total square footage available 

above each. 

Response. Under the proposal, all cemeteries would be allowed to lease air rights. 

NCA has no intention of encouraging air space usage over cemeteries. 


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INFORMATION TECHNOLOGY

Question 56. Provide a list of criteria utilized to prioritize information technology 

investments, along with a description of the prioritization process. 

Response. All items within the information technology account were put through 

a two-stage prioritization process. The first stage consisted of prioritization based 

on a three-dimensional taxonomy. The second stage consisted of prioritization based 

on further defined categories and how investments supported the Secretary’s Agency 

Priority Goals (APGs). Both stages are characterized below: 

Stage 1: Consistent with the Secretary’s direction, the taxonomy was focused on 

three major dimensions: Veteran centered outcomes, direct or indirect benefit to the 

Veteran, and whether these benefits were quantifiable, qualitative, or neither. Due 

to the focus on Veteran- centered outcomes, activities categorized as indirect or that 

were not categorized were not funded. The taxonomy is shown below. 

1. Quantified, direct Veteran centered outcome 

2. Qualified, direct Veteran centered outcome 

3. Direct Veteran centered outcome (asserted, but not quantified, not qualified, 

nor well described) 

4. Quantified, indirect Veteran centered outcome 

5. Qualified, indirect Veteran centered outcome 

6. Indirect Veteran centered outcome (asserted not quantified, not qualified, nor 

well described) 

7. Not prioritized 

Stage 2: Within each of the prioritization criteria above, a further refinement was 

applied and is shown below in priority order. This priority is based on the Secretary’s direction regarding the three current APGs and how an investment supported each. 

Question 57. Please provide a copy of timeliness standards and any guidelines associated with veteran notifications of data breaches involving PII or health data. 

Response. We are required by the HIPAA Breach Notification Rule to notify Veterans within 60 days of discovery of any breach involving unsecured protected 

health information, and VA Handbook 6500.2 requires VA to make notification within 30 days from the date the incident occurred for other breaches. We currently average 28 days to make notification. 

Question 58. What actions is VA taking to actively recruit additional VLER 

Health partners to enhance access to clinical data and improve clinical decisionmaking abilities for veterans? 

Response. The Department of Veterans Affairs (VA) is actively seeking additional 

Virtual Lifetime Electronic Record (VLER) Health partners resulting to improve 

clinical decisionmaking abilities for Veterans. VLER Health leadership understands 

and believes that pursuing additional VLER Health non-VA partners is vital to improving clinical decisionmaking abilities for Veterans. Our Exchange team has established nearly 40 partners from across the country. Our Direct team is working 

toward adapting use cases for sharing health data between VA facilities and Veteran State Home federally Qualified Health Centers, long term care facilities, and 

mental health providers. Our Regional Health Information Exchange team is adopting and publishing a coherent and reproducible Health Information Exchange approach for engaging states, regions, and communities. 

When researching potential new partners, every state in the Nation is looked at 

from a variety of viewpoints and considerations including: (1) Looking for the highest Veteran enrolled states; (2) Reviewing top purchased care sites for VA from 

across the Nation; (3) Reviewing coverage for VA’s Rural Health locations; (4) ComVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00162 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN

94132q3VA56.eps
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paring VAMC recommended list of potential partners; (5) Considering potential 

partner referrals from HealtheWay and Social Security Administration; (6) Reviewing potential partners that reach out to VA directly; (7) Reaching out to Health Information Service Providers (HISPs) as well as non-VA clinical partners; and (8) Increasing outreach and awareness to non-VA partners via communications. 

Bottom line: Adhering to an evaluation process that selects future partners with 

the greatest likelihood of success by considering: (1) areas of greatest need; (2) Veterans Affairs Medical Center (VAMC) and partner collaboration; and (3) Health Information Exchange (HIE) technical capabilities, is critical to improving Veteran 

care. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHN BOOZMAN TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 59. Secretary McDonald, private medical providers and hospitals in Arkansas are having a very difficult time receiving reimbursement for providing emergency medical care to veterans. In Arkansas, we have cases that date back to 2012 

and for some of our smaller community hospitals, this is a serious financial burden. 

My office has also received calls from the Louisiana Hospital Association where they 

are experiencing similar problems and this appears to be problem throughout VISN 

16. What can be done to help these hospitals and medical providers close out these 

claims? 

Response. The Veterans Health Administration’s (VHA) Chief Business Office 

(CBO) has been focused on improving the timeliness of claims processing. In December 2014, less than 36 percent of the Veterans Integrated Service Network (VISN) 

16 non-Veterans Affairs (VA) medical care claims had been pending for less than 

30 days. As of February 2015, that number has improved to 50 percent. Currently, 

VISN 16 is processing approximately 55 percent of their claims within 30 days, and 

we expect this number to continue to improve. 

On November 12th and 14th, 2014, CBO’s Purchased Care (PC) leadership met 

with members of the Louisiana Hospital Association (LHA) onsite in Louisiana to 

discuss the recent consolidation, corrective actions, and sustainment plan. Additionally, a focused review of provider high dollar accounts was completed and contact 

information for ongoing issues was provided. CBO’s PC leadership also addressed 

the backlog of claims, customer service issues, provider remittance reports, and 

backlog of reconsiderations/appeals. 

A Tiger Team visited VISN 16 the week of November 17–21, 2014. This team addressed the claims payment backlog, operational issues, and corrective actions required to improved vendor relations and claims processing timeliness. Since this 

visit and implementation of a backlog reduction strategy, VISN 16 has continued 

to process more claims than received and has made ongoing improvements in their 

overall claims inventory, as described above. In addition, a review of customer service and provider relations was conducted by CBOPC Customer Service Center (CSC) 

leadership. A plan to consolidate the VISN 16 Customer Support Staff was implemented and this staff is now aligned directly under the CBOPC CSC structure. Continued training and customer service expectations are being provided to staff to further assist with provider and veteran relations. 

a. I bring this situation to your attention because I believe it has ramifications 

that extend well beyond hospitals being reimbursed for emergency medical care. The 

Choice Act relies upon the private sector to accept and treat veterans and if these 

hospitals are experiencing this much difficulty getting reimbursed, they may decide 

that dealing with the VA and treating veterans under the Choice Act is not worth 

it because of the financial uncertainty that it might entail. Do you share this 

concern? 

Response. The Department of Veterans Affairs (VA) shares this concern. VA contracted with Health Net Federal and TriWest Healthcare Alliance to implement the 

Choice Program. Health Net Federal and TriWest Healthcare Alliance reimburse 

the contracted provider within their networks for the services performed under 

Choice. Health Net Federal and TriWest Healthcare Alliance, in accordance with 

their contracts, then invoice the VA for services performed by the contracted 

providers. 

Question 60. Dr. Clancy, I am concerned about the projected deficits within the 

VAMCs. I am being told that within the Fayetteville, AR, VAMC they are projecting 

a $22M deficit and VISN 16 as a whole is projecting a $220M deficit for this fiscal 

year. To your knowledge is this accurate? 

a. What is the reason that these VAMCs are projecting deficits and what can be 

done to address these shortfalls? Is this due to VA projecting that the Choice Act 

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would be used at a higher rate and therefore less funding would be needed for 

VAMCs because more veterans would be seeking outside care? 

Response. As of August 19, 2015, VISN 16 has no projected deficits at any of its 

VAMCs, including Fayetteville. VHA will continue to work with VISN 16 to ensure 

that all resource needs are met to prevent unnecessary delays in Veteran care. 

Including the funding provided by the Veterans Access, Choice and Accountability 

Act, VISN 16 has received a funding increase of 7.2 percent in FY 2015. This increase in funding contrasts the 5.8 percent increase realized in the entire VHA FY 

2015 budget. The Acting VISN 16 Director is to provide a detailed analysis of why 

VISN 16 has such a large shortfall in view of the funding increase received this 

year. VHA intends to report those findings back to the Committee once the data is 

received and reviewed. 

VISN and Medical Center Directors have a very challenging mission balancing 

funding requirements in light of new patient care practices, advances in medical 

technology, accounting for non-VA care, and supporting an aging infrastructure. 

VHA is working closely with VISN leadership to ensure that each VISN has the 

most appropriate funding based on Veterans’ demand for health care in their region. 

b. As of now, do you anticipate submitting a reprogramming request to Congress 

in which you will request transferring money from Choice Act accounts into the 

medical care account? 

Response. With respect to the $5 billion appropriated by section 801 of the Choice 

Act, VA does not currently anticipate deviating from the spending plan that it previously submitted to Congress. 

With respect to the $10 billion appropriated by section 802 of the Choice Act, 

there is no legal authority that would permit VA to transfer funds from the section 

802 Veterans Choice Fund to the medical care appropriations accounts, even with 

Congressional approval. 

c. The FY 2016 budget request for VA in the Medical Care account is $58.662B 

which is 5.12% above the FY 2015 appropriated amount. Is this increase intended 

to address these projected deficits within the VAMCs? 

Response. Compared to the enacted 2016 advance appropriations level, as requested in the 2015 President’s Budget, this year’s 2016 request for VA health care 

services is $1.299 billion higher. This request for additional funding is necessary to 

ensure the delivery of high-quality and timely health care services to veterans and 

other eligible beneficiaries. For the first time, VA is requesting an increase above 

the enacted advance appropriation in all three Medical Care accounts: $1.124 billion 

in Medical Services, $105 million in Medical Facilities, and $70 million in Medical 

Support and Compliance. 

The total net increase of $1.299 billion is due to the following factors: 

• Ongoing health care services estimate increased by $599.9 million, driven largely by estimates of the cost of new Hepatitis C treatments and updated actuarial 

trends based on the latest actual data. 

• A reduction in projected base appropriations health care costs due to enactment 

of the Veterans Choice Act; VA estimates that $452 million in requirements will 

shift from the regular program as Veterans who would otherwise receive care in the 

VA health care system instead choose to participate in the new Veterans Choice 

Program, as established in the Veterans Choice Act and funded by section 802 of 

the Act. 

• Long-Term Services and Supports estimate has increased by $51.1 million, reflecting trends in the most recent actuals and the continued investment into noninstitutional settings. 

• Ongoing health service programs not projected by the EHCPM increased by 

$221.6 million. The Caregivers program cost estimate increased by $249.4 million, 

driven largely by an increase in the projected number of Caregivers receiving stipend payments. The combined sum of the estimates for CHAMPVA, reimbursement 

to the Indian Health Service and tribal health programs, caring for eligible Camp 

Lejeune Veterans and families, and readjustment counseling decreased by $27.8 million based on updated actuals and revised assumptions in workload for Camp 

Lejeune and Indian Health Service. 

• VA programs to end Veterans’ homelessness increased by $128 million, for a 

total of $1.393 billion. The increased estimate allows VA to fully support projected 

utilization in its homeless programs, including the Supportive Services for Veterans 

Families (SSVF) program and the Department of Housing and Urban DevelopmentVA Supportive Housing program (HUD-VASH). 

• Healthcare Infrastructure Enhancements increased by $666.9 million. Facility 

activation costs have increased by $468.2 million over the initial advance appropriation estimate of $130 million to $598.2 million; the initial estimate was based on 

161 

construction delays that have caused under-execution of activations in recent years. 

However, VA has made progress in resolving these issues, and as a result has increased confidence that the additional funding will be required in FY 2016. The cost 

estimate of supporting the Veterans Integrated System Technology Architecture 

(VISTA) evolution project has been revised downward from $208.3 million to $159.6 

million. Estimated non-recurring maintenance obligations grew from $460.6 million 

to $708.0 million, to address high-priority emerging capital needs as identified 

through the Strategic Capital Investment Planning (SCIP) process; this increase excludes funding provided by the Veterans Choice Act. See Volume 4, Chapter 7 for 

additional information on the SCIP process and the NRM program. 

• The cost of VHA proposed legislation remains nearly unchanged with an estimated cost decrease of $0.5 million. The 2016 budget includes estimates for Civilian 

Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) 

healthcare benefits for beneficiaries up to age 26. 

• Additional budgetary resources decreased by $84.4 million (collections, reimbursements and transfers). The estimate for the Medical Care Collections Fund decreased by $26.3 million. Reimbursements decreased by $51.0 million and transfers 

to the Joint DOD/VA Medical Facility Demonstration Fund increased by $7.1 

million. 

162 

VISN and Medical Center Directors, many of whom, as you know, are acting, have 

a very challenging mission balancing funding requirements in light of new patient 

care practices, advances in medical technology, accounting for non-VA care, and supporting an aging infrastructure. We are working closely with the VISN leadership 

to ensure that each VISN has the most appropriate funding based on Veterans’ demand for health care in their region. 


94132q3VA60c.eps
163 

Question 61. Secretary McDonald, within the VA’s budget for major and minor 

construction, this account has the largest increase in terms of percentage: 46.64% 

increase in the FY 2016 request from what was enacted for FY 2015. How much 

of this money does the department intend to use to modify facilities so as to better 

accommodate and care for our female veterans 

Response. Based on the Veterans Health Administration’s (VHA) preliminary 

minor construction projects for FY 2016, VHA anticipates providing design or construction funding for projects associated with some form of privacy to accommodate 

women with total project costs totaling $341 million. These projects include new 

and/or expanded community living centers, inpatient mental health buildings, emergency departments, outpatient clinics, inpatient units, etc. 

Each of VHA’s major construction projects, submitted in the FY 2016 budget, support some aspect of women’s privacy in the project’s overall scope. In the FY 2016 

budget request, there is over $508 million of funding for construction projects that 

include some form of privacy. These projects include the construction or renovation 

of community living centers, a mental health clinic, an outpatient clinic, and rehabilitation buildings. 

The following table represents funding included in the FY 2016 budget request 

for major construction projects supporting our women Veterans: 

Location 

FY 2016 

Request 

$ for 

Women Description of Women’s Health 

Perry Point, MD ......................... $83.7M * Community Living Center: Dependent on the number of women 

residents 

West LA, CA Building 208 ........ $35M $35M Women’s Homeless Housing 

American Lake, WA ................... $11M $0 NA—Engineering Admin/Shop 

San Francisco, CA .................... $158M $0 NA—Research 

Long Beach, CA ........................ $161M * Community Living Center: Dependent on the number of women 

residents 

Alameda, CA Site Prep ............. $70M $0 NA—Site work 

Livermore, CA Stockton OPC ..... $139M $880K Women’s Specialty is part of Patient Aligned Care Teams (PACT) 

St. Louis (Jefferson Barracks), 

MO.

$90.1M * Women Veterans are seen throughout the entire facility for all of 

their treatment 

Louisville, KY ............................ $75M $0 NA—Site work 

National Cemetery Projects at 

Bayamon, PR; Portland, OR; 

Riverside, CA; and 

Pensacola, FL.

— * The FY 2016 National Cemetery Administration (NCA) major construction projects ensure eligible Veterans have access to 

burial options within a reasonable distance from their residence. These FY 2016 NCA major construction projects support all eligible Veterans and their families (to include female 

Veterans and dependents) by providing a final resting place. 

* Amount of funding is dependent on the number of women Veterans served. 

a. The FY 2015 enacted amount for construction was $1.057B and the FY 2016 

request is for $1.55B or an increase of $493M. How much of this increase is due 

to the massive cost overruns on the Denver VA Hospital? I ask this because the 

project is estimated to cost an additional $500M to $1B more than original cost estimates. 

Response. No funding in the FY 2016 budget is for the Denver hospital. 

Question 62. Dr. Clancy and Mr. Warren, I believe VA pharmacy system has some 

major shortcomings, especially in the area of information technology. For example, 

VA pharmacies are not networked and when a veteran uses multiple VAMC/CBOCs 

or moves their home to a new location, this often times is a problem. What is the 

VA doing to help modernize the VA pharmacy system? 

a. Do you have an estimate on what it would cost to network the VA pharmacies 

in a manner that would resemble how many of the large retail pharmacy (Wal-Mart) 

chains are networked? 

164 

Response. In many ways, the Department of Veterans Affairs’ (VA) pharmacies 

are already networked. They all use a single VA national drug formulary; they all 

use VA’s Consolidated Mail Outpatient Pharmacies to process and mail non-urgent 

prescriptions; they all have access to the same drug prices through the pharmaceutical prime vendor; they all use the same Veterans Health Information Systems 

and Technology Architecture (VistA) pharmacy software; and they all have visibility 

of prescriptions filled at other VA medical facilities. VA pharmacy staff is also currently able to see when a particular prescription was last filled by VA and where 

it was filled. 

VA pharmacies cannot currently refill a prescription issued at a different VA facility automatically; deduct that refill from available refills; and record the refill in the 

VistA record at the issuing facility. VA pharmacies have developed workarounds 

over the years to address the medication needs of traveling Veterans who run out 

of medications; however, these workarounds take time and are inconvenient to Veterans and staff because they generally involve generating a new prescription and 

providing a new fill. 

VA is currently working on an innovation project that will make the prescriptions, 

that VA pharmacies can now only review, actionable for refills. This will eliminate 

the need for workarounds, will make the process easier and faster and will provide 

an audit trail of these refills. This innovation is referred to as One VA Pharmacy. 

VA is also exploring the possibility of establishing a network with retail pharmacies for prescriptions filled in these pharmacies under VA programs including 

PC3, CHOICE, ChampVA, CBOCs, etc. If this is established, VA will be able to integrate non-VA pharmacy workload records into VistA in the same way a prescription 

drug hub, like Surescripts, can do. 

b. Dr. Clancy, do you believe that having a modern integrated pharmacy network 

would eventually yield cost savings in the way VA buys and dispenses medication? 

Response. As noted above, VA is also exploring the possibility of establishing a 

network with retail pharmacies for prescriptions filled in these pharmacies under 

VA programs including PC3, CHOICE, ChampVA, and CBOCs. We believe this capability is analogous to the ‘‘modern integrated pharmacy network’’ that is referred 

to in the question If thisis established, VA will be able to integrate non-VA pharmacy workload records into VistA in the same way a prescription drug hub, like 

Surescripts, can do, providing VA prescribers with greater visibility of the totality 

of prescription drug therapy for Veterans. 

VA believes such improvements can result in better convenience and the potential 

for better quality of care. Whether it would yield cost savings cannot be determined, 

as that would depend on the detailed capabilities of the system and the arrangements with retail pharmacies struck under such a network. 

c. Mr. Warren, is it correct to say that VA currently does not have an electronic 

prescription capability? Something like Surescripts? 

i. Is the VA considering investing in an electronic prescription system? 

ii. If so, would it be your intent to buy an already available commercial off 

the shelf program or would VA design their own system? Have you already explored this issue? 

Response. (i) As noted above, VA is also exploring the possibility of establishing 

a network with retail pharmacies for prescriptions filled in these pharmacies under 

VA programs including PC3, CHOICE, ChampVA, and CBOCs. We believe this capability is analogous to the ‘‘modern integrated pharmacy network’’ that is referred 

to in the question If thisis established, VA will be able to integrate non-VA pharmacy workload records into VistA in the same way a prescription drug hub, like 

Surescripts, can do, providing VA prescribers with greater visibility of the totality 

of prescription drug therapy for Veterans. We assume this capability is what is 

being referred to in the question as ‘‘an electronic prescription system.’’ 

(ii) VA would certainly consider using commercial off the shelf programs, if they 

offered sufficient compatibility, interoperability, and integration with VA’s pharmacy infrastructure. However, VA has not proceeded far enough into its considerations to come to any conclusion on this question. 

Question 63. Dr. Clancy, within VHA, there has been an effort to reduce the use 

of psychotropic and opioid medication to treat mental illness and chronic pain respectively. Many organizations and Members of Congress want to see VA take a 

more holistic approach to treating these conditions and not simply rely upon medication which has been overprescribed and abused in the past. What new and existing 

programs does VHA seek to fund to address this issue? 

Response. The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) currently supports two programs that address safe and effective use of 

psychotropic and opioid medications across the system, the Psychotropic Drug SafeVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00168 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
165 

ty Initiative (PDSI) and the Opiate Safety Initiative (OSI). The Psychotropic Drug 

Safety Initiative (PDSI) is a Nation-wide psychopharmacology quality improvement 

(QI) initiative coordinated through the Office of Mental Health Operations (OMHO) 

in collaboration with Mental Health Services (MHS) and Pharmacy Benefits Management (PBM). 

The PDSI aims to improve the safety and effectiveness of psychopharmacological 

treatment in VHA by focusing on avoiding overprescribing, addressing problems in 

clinical management, eliminating misalignment between prescribing and diagnosis, 

and decreasing missed opportunities for providing evidence-based care. The PDSI 

supports local psychopharmacology QI initiatives at facilities across the country by 

developing measures and providing data on prescribing practices, providing feedback and guidance on QI action plans, establishing a collaborative community of 

practice, and creating tools to identify Veterans who may benefit from clinical review of current psychotropic drug treatment. 

The OSI is a multicomponent national intervention which consists of: (1) tools to 

identify underutilized clinical practice guideline-recommended pain treatments and 

opioid risk mitigations strategies for local implementation at the facility level; (2) 

tools to facilitate case review of higher risk patients at the provider level; (3) innovative clinical education programs to improve pain management and opioid prescribing 

practices (e.g. via SCAN-ECHO, webinar and academic detailing based programs); 

and (4) national initiatives to implement standardized informed consent practices 

and use of overdose education and Naloxone distribution for patients receiving or 

using opioids. 

Collaboration across the PDSI and OSI are coordinated through an overarching 

steering team, which is made up of a multidisciplinary group of leaders from mental 

health, pain management, and pharmacy. VHA will monitor the effectiveness of 

these programs going forward to determine if any additional initiatives are needed 

and to identify any additional resource requirements. 

a. Are there additional programs and initiatives that you would to pursue but are 

unable to because of budget constraints? If so, what are they? 

Response. The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) has begun adding licensed acupuncturists and massage therapists to the 

list of VA occupations. VHA is also developing the qualifications standards and 

guidance that will allow local facilities to hire these types of providers as a means 

to augment existing evidence based care. 

The main barriers to adding programs is not budget, but the scarcity of data to 

support expansion of complementary and integrative practices in the management 

of conditions such as Post Traumatic Stress Disorder. The current evidence supports 

these medical care services as possible adjuncts to existing evidence based therapies. 

There is some promising information for the use of complementary and integrative 

practices as adjuncts in the management of pain. However, the strength of the data 

to support these practices as well as the lack of occupational classes for the hiring 

of complementary and integrative providers are the major barriers to the expansion 

of this type of care. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BILL CASSIDY TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 64. In testimony, it was stated that 20% of the reported number of clinic 

visits across the VA system were actually ‘‘no-shows.’’ A ‘‘no-show’’ is a missed appointment in which the patient does not show up for the appointment. Dr. Clancy 

then said two things which were contradictory. First, she said that the VA can only 

determine no-show rates for the entire system and not by institution. Then, she said 

that ‘‘no show’’ rates are higher for non-rural VA facilities. This suggests that a facility-specific analysis is possible and is being conducted. Please reconcile these differences and answer the following questions. 

a. If a facility-specific finding is not possible, how are the cumulative statistics 

established/collected? 

b. If facility specific statistics are truly not available, why are they not collected? 

This seems like a simple query—sorting attendance rates by facility to establish a 

ratio between ‘‘no shows’’ and the total number of visits scheduled. Is the VA database unable to do this? 

Response. No-shows (also called ‘‘missed opportunities’’) occur when a patient 

scheduled for an appointment does not attend. The Department of Veterans Affairs’ 

(VA) databases hold information on each individual appointment, including noshows. The statistics are collected through the Veterans Health Information System 

and Technology Architecture (VistA) scheduling system when each appointment is 

166 

processed. Therefore, VA can calculate no-shows by individual patient, clinic, facility, Veteran Integrated Service Network (VISN), etc. VHA’s highest facility no-show 

rates tend to be at large facilities in larger urban areas. 

Question 65. On August 11, 2014, FDA found safe and effective and CMS authorized for Medicare coverage for a new DNA stool based non-invasive colorectal cancer 

test. In January 2015 an application was made to the Federal Supply Service (FSS) 

program for availability in the VA health system. Based on study published in the 

New England Journal of Medicine in April 2014 the test founded 94% of Stage I and 

Stage II cancer and 69% of advanced pre-cancer. Currently VA relies on a much less 

accurate non-invasive test (FOBT/FIT) that requires a repeat of the test every year 

for five years. Peer review studies have found that adherence to the test is very disappointing. By year 4 only 14% of the more than 300,000 veterans whose records 

were examined have adhered to the test i.e. repeated it annually for four years. It 

takes one year for VA to process any new medical item for inclusion in the Federal 

Supply Schedule. The VA has been delegated the responsibility for medical items 

by the General Services Administration (GSA). Given VAs well documented problems with colorectal cancer screening, the innovative nature of the test and the poor 

adherence to the existing test, can the process be expedited on the basis of offering 

new technology to our veterans? 

Response. There is an active procurement action ongoing through the FSS multiple award schedule program, which means more than one company is awarded a 

contract for the same or similar products and/or services. While this action occurs, 

this DNA stool-based colorectal cancer screening test may be obtained by the medical centers as necessary, in compliance with prescribed acquisition regulations and 

policies. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 66. Early in FY 2014 the Montana VA experienced a backlog in inpatient 

claims. By the close of the fiscal year, a significant backlog in payments to providers 

like Kalispell Regional Health, still remained. To what extend did the VA carry a 

backlog of unfunded claims into FY15? 

Response. In June 2014, the Department of Veterans Affairs (VA) held a meeting 

with the Montana Independent Hospital Association partners. The non-VA care 

(NVC) claims processing manager collaborated directly with the independent hospitals. During this meeting, a discrepancy was discovered between VA processing 

center’s recorded claims and the independent hospital’s aged accounts receivables. 

The parties worked together to reconcile results and allowed the hospitals to clear 

aged accounts. Recurring calls, began in June 2014, and currently continue between 

the independent hospitals and the payment processing center. 

Average claim timeliness has increased slightly. In June 2014, there was an average of 32 days to process a claim. Currently, the average is 35 days. 

As of March 19, 2015, Montana had 23,969 claims on hand. 90.40% of those 

claims were under 30 days old. There were no claims over 365 days old. 

Question 67. Funding by the U.S. Treasury for FY 2014 claims in Montana appears to be sporadic and incomplete. For Kalispell Regional Health and other hospitals, these claims represent the oldest claims and present the greatest impact to 

cash-flow and bond ratings. Some of these claims have been awaiting payment for 

nearly one year, as Kalispell Regional Health’s own fiscal year closes in March 2015. 

Now that FY 2014 is closed, how are the FY 2014 claims funded in FY15? 

Response. There has been significant growth in the non-VA care in the VA Montana Health Care System resulting in temporary backlogs. Actual expenditures have 

exceeded the estimated costs for non-VA care. Additional funds were identified in 

other accounts and supplemental funding was requested and received to process fiscal year 14 obligations. 

Question 68. Is there more we can do to support the VA to facilitate fast, complete 

turn-around for full payment for these claims by the Treasury? To what extend is 

the VA taking steps to work directly with civilian providers to streamline and improve the claims process to prevent future backlogs? 

Response. The Department of Veterans Affairs (VA) has begun the process of 

streamlining and improving non-VA medical care claims processing to prevent future backlogs. VA has recently consolidated all claims processing operations VA’s 

Chief Business Office. The desired outcome is a more consistent and effective claims 

processing division. 

167 

The payment of claims begins with non-VA providers timely filing a complete bill. 

A complete bill includes accurate and complete claim information along with any 

supporting medical documentation that has been requested. The filing of a complete 

bill prevents the rejection of the claim and a subsequent request for missing documentation. Non-VA providers are also encouraged to submit their claims electronically to expedite this process. If non-VA medical care providers are receiving mailed 

paper checks from Treasury, enrolling in electronic funds transfer (EFT) payments 

will eliminate several days for payment receipts. 

VA understands that partnering with non-VA medical care providers is critical for 

successful claims processing. Therefore, VA has also taken steps to educate our partners on a range of topics through our Non-VA Medical Care Provider Web site 

(http://www.va.gov/PURCHASEDCARE/programs/providerinfo/index.asp) and email 

distribution list. Locally, Veterans Affairs Medical Centers (VAMC) provide continuous outreach to medical providers to improve the claims processing system. 

Question 69. What steps can civilian providers and the VA take to work together 

proactively to prevent payment backlogs in 2015? 

Response. The Department of Veterans Affairs (VA) believes that effective communication between non-VA medical care providers and VA is critical to prevent improper payments and backlogs. 

To further prevent payment backlogs, non-VA medical care providers should submit accurate and complete claim information along with any supporting medical 

documentation that has been requested. Ensuring accurate and complete claims are 

filed will prevent the rejection of the claim and a subsequent request for missing 

documentation. Non-VA providers are also encouraged to submit their claims electronically to expedite this process. If non-VA medical care providers are receiving 

mailed paper checks from Treasury, enrolling in electronic funds transfer (EFT) payments will eliminate several days for payment receipts. 

VA’s Chief Business Office’s (CBO) Purchased Care (PC) department maintains an 

external Web site with a designated provider page to support VA’s non-VA medical 

care partners (http://www.va.gov/PURCHASEDCARE/programs/providerinfo/index 

.asp). This page delivers the following useful information: 

• Provider guidebook that details what non-VA medical care providers should expect in terms of authorizations, referrals, claims payments, and the return of medical documentation back to the authorizing VA medical center • Instructions on how to file a claim, including using the Electronic Claims submission process • Detailed information on authorization for pre-authorized care • Detailed information on claims processing for emergency medical services • How to read a preliminary fee remittance advice report (PFRAR) • Definitions of denial codes and reasons 

VA has also launched an email distribution list so providers can stay up to date 

with the non-VA medical care program. Helpful information is provided to those on 

our community provider email distribution list about doing business with the VA 

at least once per month. 

Additionally, local VA and non-VA medical care providers can effectively communicate to address specific issues that arise. For example, if a large volume of claims 

are being denied, VA and non-VA providers can work together to assess why claims 

are being rejected and ensure the needed information is submitted. 

Question 70. Also, I understand that the VHA is considering granting Full Practice Authority to Advanced Practice Registered Nurses including Certified Registered Nurse Anesthetists and Nurse Practitioners. This is a policy I support as it 

would follow recommendations from the Institute of Medicine and align with current 

practice in the Army, Navy, Air Force, Combat Support Hospitals and the Indian 

Health Services. What is the current status is of the VHA Nursing Handbook? 

Response. The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) is developing a draft nursing handbook proposing the authorization of 

full practice authority (FPA) for advanced practice registered nurses (APRN) without regard to individual State Practice Acts, except for the dispensing, prescribing, 

and administration of controlled substances. This proposed change to nursing policy 

would standardize APRN practices throughout VA’s health care system and increase 

access to high quality care for all Veterans. Implementation of FPA would increase 

patient access by alleviating the effects of national health care provider shortages 

on VA staffing levels and enable VA to provide additional health care services in 

medically-underserved areas. VHA intends to implement this change to our policy 

through regulatory action to ensure its enforceability and allow the public the opportunity to provide comments. VHA is developing a draft regulation that would recognize FPA for APRNs, including CRNAs. The draft regulation will be published in 

168 

the Federal Register as a proposed rule for notice and comment. Following the public 

comment period, VA will review the comments received and consider whether to revise the regulation before publishing it as a final rule. VHA believes in being transparent when making health care delivery decisions and welcomes the opportunity 

to discuss policy concerns. 

Chairman ISAKSON. The second panel will come forward, please. 

[Pause.] 

I apologize to the second panel for the length and duration of the 

questioning of the Secretary, but we probably will not have a more 

important time this year or this session of Congress to deal with 

that, so I was liberal with time. That said, I am going to make sure 

everybody’s testimony gets in for the record before we have to go 

for a vote or are interrupted. I appreciate your patience, and please 

understand, the length of that was in no way meant to contrive 

what you do, but we had to see what the Secretary had to say. 

What we are going to do is go straight to your testimony, one 

after another, and we will take it all in. Then, as we have time for 

questions afterwards, we will do that. I would ask you to try to 

hold your comments within that 5-minute range, but if you go over 

just a tad, that is all right until I rap the gavel and call you to 

stop. 

First will be Carl Blake, Paralyzed Veterans of America. Next 

will be Ms. Ilem? 

Ms. ILEM. Ilem. 

Chairman ISAKSON. Ilem. It is a beautiful name for a beautiful 

lady. We are glad to have you here today. 

Mr. Kelley, we are glad to have you. 

Mr. de Planque, I saw you a lot yesterday. It is good to see you 

again. We are glad to have Ian—and it is de Planque, right? I got 

it right? 

Then, Richard Weidman of Vietnam Veterans of America, thank 

you for being here today. 

We will start with you, Mr. Blake. 

STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR FOR GOVERNMENT RELATIONS, PARALYZED VETERANS 

OF AMERICA 

Mr. BLAKE. Thank you, Mr. Chairman. Let me begin by saying 

I do not feel slighted by having the Secretary, who is the head of 

a Cabinet-level agency, being elevated above the level of the veterans service organizations for consideration, so we do not have 

any problem with that. 

I would like to thank you again for the opportunity to testify. I 

am here to represent both Paralyzed Veterans of America and the 

co-authors of the Independent Budget. We released recently our 

Independent Budget report for fiscal year 2016 and 2017. With the 

Chairman and the Committee’s permission, we would like to submit that report into the official hearing record. 

Chairman ISAKSON. Without objection. 

Mr. BLAKE. Thank you. 

[The Independent Budget report can be found in the Appendix.] 

Mr. BLAKE. I would just say that we believe that the VA’s budget 

for this year is a very good budget. We appreciate the fact that the 

administration seems, for the first time, in my view, to have taken 

169 

seriously their responsibility when it comes to reviewing advanced 

appropriations and making necessary revisions. This was the first 

year since it was enacted there has been a substantial revision to 

the advanced appropriations recommendations. The recommendations are fairly close even to what the Independent Budget has recommended. The same would be true for fiscal year 2017. 

I have a number of other comments that I was going to make, 

but I think I would rather turn my attention to some of the discussion that has been held here today on a couple of topics. 

Obviously, the hot topic has been the Choice Act. Something you 

said at the beginning about getting on board, helping make this 

program work, I can tell you, Mr. Chairman, that I believe everybody at this table with many of the other veterans service organizations were involved with the VA from the day that the bill was 

passed last August to try to get this right in the implementation. 

We had a number of meetings with the VA, talked through all 

kinds of questions. 

One of the common questions was the concept of 40 miles for 

service versus 40 miles from a facility. I will tell you that the bill 

specifically says, ‘‘An eligible veteran is a veteran who resides more 

than 40 miles from a medical facility of the Department, including 

a community-based outpatient clinic, that is closest to the residence 

of the veteran.’’ That is the specific language of the bill. 

Obviously, there is some opening for interpretation. Everybody 

would like to see it, I think, maybe in the direction of service. It 

makes sense, we believe. However, what I would say is—and 

Chairman Miller pointed this out yesterday. Congress had a hard 

time with that concept because when CBO tried to cost it, the potential cost for that concept was astronomically higher than this 

bill as passed was. So, that is a challenge, we believe, that Congress is going to have to grapple with. 

From the perspective of PVA, it is no secret that we have not 

been a big proponent of privatizing VA care or purchasing care outside the VA system. However, that being said, I am disappointed 

Mr. Moran is not still here. Kansas is a case study in the failing 

of the VA in the past in fee-based or purchased care. It has boggled 

my mind for years because I have listened to Senator Moran and 

I have listened to Mr. Huelskamp on the House Committee, rail 

over and over again about why veterans, particularly in western 

Kansas, but over a large part of Kansas, cannot get access to care 

or are being forced to drive 200, 300, and 400 miles in some cases 

to get care at a VA facility. I just cannot even fathom how that 

could happen. Even under the old rules of fee-based care, seemingly that occurrence would not happen; yet, it did. So, it would 

stand to reason that something like Choice would help alleviate 

some of those problems. 

We are interested in working with this Committee, with the 

House Committee, and with the VA to get it right. But, there are 

some steps that we believe Congress is still going to have to take 

if it really wants to go the full step. And it has to keep in mind 

that while Choice seems like a good idea for most veterans—veterans like the membership that I represent—veterans with spinal 

cord injury, do not really have a viable choice. There are facilities 

around the country that exist in the private system, but they do 

170 

not provide care like the VA’s spinal cord injury system of care. So, 

you have to consider that in any further decision about the future 

delivery of VA health care. 

The last thing I would comment on is there was a question about 

the culture of VA and changed leadership. The Secretary mentioned changed leadership. I would point out that two of the three 

Under Secretaries for Health are in an interim status currently. 

Dr. Clancy has been in this position since this basically broke last 

summer and has been charged with helping shepherd through a lot 

of monumental changes in the VA health care system that her 

predecessor was not involved in. Her predecessor had the opportunity to walk away, wipe his hands, when the damage was already done. Dr. Clancy has done a great job. PVA has already come 

out on the record saying Dr. Clancy should be made the permanent 

Under Secretary for Health, but somebody should be made the permanent Under Secretary for Health. 

I would also suggest that at a level lower than that, there is still 

an acting position for the Chief Consultant for the Spinal Cord Injury Service. That is the person charged with making sure the policy and procedure that goes on within the SCI system of care is appropriate, timely, efficient, and delivers the best service for veterans. It makes no sense that that person is not in a permanent 

status. It is time for that to be corrected. 

I think if you start putting people in place who have the best interests of change in mind, then you can make change. But, that is 

the only way you are going to get the culture to turn around in any 

meaningful way. 

With that, Mr. Chairman, I would like to thank you for the opportunity to testify, and I would be happy to answer any questions 

you have. 

[The prepared statement of Mr. Blake follows:] 

PREPARED STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR FOR

GOVERNMENT RELATIONS, PARALYZED VETERANS OF AMERICA

Chairman Isakson, Ranking Member Blumenthal, and Members of the Committee: As one of the four co-authors of The Independent Budget (IB), Paralyzed Veterans of America (PVA) is pleased to present the views of The Independent Budget 

regarding the funding requirements for the Department of Veterans Affairs (VA) for 

FY 2016 and advance appropriations for FY 2017. The IB veterans service organizations (IBVSO) recently released our report The Independent Budget for the Department of Veterans Affairs for FY 2016 and FY 2017. This report offers detailed recommendations for all of the principle line items of the VA budget. We would ask 

to make that complete report part of the official hearing record. 

The IBVSOs believe that the VA’s budget request this year is largely a very good 

budget. We appreciate the fact that VA appears to have made an honest assessment 

and revision to the medical care accounts for FY 2016. Unfortunately, we believe 

the advance appropriations amount for FY 2016 provided for by Congress in the ‘‘FY 

2015 Consolidated and Further Continuing Appropriations Act’’ approved in December 2014 is not sufficient to meet the full demand for services being placed on the 

system. For FY 2016, the IB recommends approximately $63.3 billion for total Medical Care. However, Congress recently approved only $62 billion for total Medical 

Care (based on an assumption that includes approximately $3.2 billion for medical 

care collections). The VA has now revised their FY 2016 Medical Care estimate to 

$63.2 billion. We encourage the Committee to give serious consideration to these revisions and we will be calling on the Senate Committee on Appropriations to address the shortfall that was previously approved through advance appropriations. 

Additionally, The Independent Budget recommends an advance appropriation of 

approximately $66.4 billion for total Medical Care for FY 2017. We are pleased to 

see that the Administration has requested approximately $66.6 billion (including apVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00174 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
171 

proximately $3.3 billion in medical care collections) for advance appropriations for 

FY 2017. We encourage the Committee to affirm these estimates in its Views & Estimates to the Senate Committee on Appropriations. 

The IBVSOs would also offer some concerns that we see with the Administration 

budget. The Independent Budget recommendations focus on recommendations at the 

point of service, but we believe that administrative costs across the board must continue to be reined in. We would highlight the clear differences between our recommendations for such line items as Medical Support and Compliance, General Administration and Information Technology (IT) to affirm this point. These line items 

focus a great deal of resources on administrative support, and all three of these accounts reflect significant increases in resources for FY 2016 and in the FY 2017 advance appropriations for Medical Support and Compliance. We encourage the Committee to do a thorough analysis of those accounts specifically to ensure that dollars 

appropriated for those accounts are allocated efficiently and effectively. 

FUNDING FOR FY 2016

For FY 2016, The Independent Budget recommends approximately $51.6 billion for 

Medical Services. This recommendation is a reflection of multiple components. 

These components include the following recommendations: 

Current Services Estimate .......................................... $49,468,647,000 

Increase in Patient Workload ..................................... $1,489,858,000 

Additional Medical Care Program Costs ................... $635,000,000 

Total FY 2016 Medical Services .......................... $51,593,505,000 

The current services estimate reflects the impact of projected uncontrollable inflation on the cost to provide services to veterans currently using the system. The estimate also assumes a 1.5 percent increase for pay and benefits across the board for 

all VA employees. 

Our estimate of growth in patient workload is based on a projected increase of 

approximately 148,000 new unique patients. These new unique patients include priority group 1–8 veterans and covered nonveterans as well as additional new users 

as a result of veterans being removed from the extended waiting lists and those 

whose decisions on healthcare enrollment eligibility are made. We estimate the cost 

of these new unique patients to be approximately $1.2 billion. The increase in patient workload also includes a projected increase of 71,500 new Operation Enduring 

Freedom and Operation Iraqi Freedom (OEF/OIF) enrollees, as well as Operation 

New Dawn (OND) veterans at a cost of approximately $282 million. The increase 

in utilization among OEF/OIF/OND veterans is supported by the average annual increase in new users from FY 2002 through the 4th quarter of FY 2014. 

The Independent Budget believes that there are additional projected medical program funding needs for VA. Specifically, we believe there is real funding needed to 

address the array of long-term-care issues facing VA, including the shortfall in institutional capacity; to provide additional centralized prosthetics funding (based on actual expenditures and projections from the VA’s prosthetics service); as well as funding necessary to improve the Comprehensive Family Caregiver program; and funding to address needed improvements in programs directed for women veterans. 

The Independent Budget recommends $325 million directed toward VA long-termcare programs. In order to support the continued rebalancing of VA long-term care 

in FY 2016, $125 million should be provided. Additionally, $95 million should be 

targeted at the VA’s Veteran Directed-Home and Community Based Services (VDHCBS) program. The remainder of the $325 million ($105 million) should be dedicated to increasing the VA’s long-term-care average daily census (ADC) to the level 

mandated by Public Law 106–117, the ‘‘Veterans Millennium Health Care and Benefits Act.’’ 

In order to meet the increase in demand for prosthetics, the IB recommends an 

additional $150 million. This increase in prosthetics funding reflects an increase in 

expenditures from FY 2014 to FY 2015 and the expected continued growth in expenditures for FY 2016. Our additional program costs recommendation includes investing $70 million in the Comprehensive Family Caregiver program in accordance 

with the deficiencies identified during the hearing held by the House Veterans’ Affairs Subcommittee on Health in December 2014. The Medical Services appropriation should also be supplemented with $90 million designated for women’s 

healthcare programs, in addition to those amounts already included in the FY 2016 

baseline. These funds would be used to help the Veterans Health Administration 

deal with the continuing growth in ensuring coverage for gynecological, prenatal, 

172 

and obstetric care, other gender-specific services, and for maintenance and repair of 

facilities hosting women’s care to improve privacy and safety of these facilities 

where women seek care. The new funds would also aid the VHA in making its cultural transformation to embrace women veterans and welcome them to VA 

healthcare services, and provide means for VA to improve specialized mental health 

and readjustment services for women veterans. 

For Medical Support and Compliance, The Independent Budget recommends approximately $6.0 billion for FY 2016. Our projected increase reflects an increase in 

current services based on the impact of inflation on the FY 2015 appropriated level. 

For Medical Facilities, The Independent Budget recommends approximately $5.7 billion for FY 2016, nearly $800 million more than the enacted advance appropriations 

in December 2014. Our Medical Facilities recommendation includes the addition of 

$900 million to the baseline for Non-Recurring Maintenance (NRM). The Administration’s request over the past two cycles represents a wholly inadequate request for 

NRM funding, particularly in light of the actual expenditures that are outlined in 

the budget justification. While VA has actually spent on average approximately $1.3 

billion yearly for NRM, the Administration has requested only approximately $460 

million for NRM. This decision means that VA is forced to divert funds designated 

for another purpose to meet this need. 

ADVANCE APPROPRIATIONS FOR FY 2017

The Independent Budget once again offers baseline projections for funding through 

advance appropriations for the Medical Care accounts for FY 2017. For FY 2017, 

The Independent Budget recommends approximately $54.2 billion for Medical Services. Our Medical Services recommendation includes the following recommendations: 

Current Services Estimate .......................................... $51,937,260,000 

Increase in Patient Workload ..................................... $1,576,151,000 

Additional Medical Care Program Costs ................... $670,000,000 

Total FY 2017 Medical Services .......................... $54,183,411,000 

Our growth in patient workload is based on a projected increase of approximately 

150,000 new unique patients. These new unique patients include priority group 1– 

8 veterans and covered nonveterans. We estimate the cost of these new unique patients to be approximately $1.3 billion. This recommendation also reflects an assumption that more veterans will be accessing the system as VA expands its capacity and services and we believe that reliance rates will increase as veterans examine 

their healthcare options as a part of the option for choice. The increase in patient 

workload also includes a projected increase of 74,225 new OEF/OIF, as well as OND 

veterans at a cost of approximately $301 million. 

As previously discussed, the IBVSOs believe that there are additional medical 

program funding needs for VA. The Independent Budget recommends $325 million 

directed toward VA long-term-care programs. In order to support the continued rebalancing of VA long-term care in FY 2017, $125 million should be provided. Additionally, $95 million should be targeted at the VA’s Veteran Directed-Home and 

Community Based Services (VD-HCBS) program. The remainder of the $325 million 

($105 million) should be dedicated to increasing the VA’s long-term-care average 

daily census (ADC) to the level mandated by Public Law 106–117, the ‘‘Veterans 

Millennium Health Care and Benefits Act.’’ In order to meet the increase in demand 

for prosthetics, the IB recommends an additional $165 million. Our additional program costs recommendation includes continued reinvestment of $75 million in the 

Comprehensive Family Caregiver program. Finally, we believe that VA should invest a minimum of $105 million as an advance appropriation in FY 2017 to expand 

and improve access to women veterans’ healthcare programs. 

Additionally, for FY 2017 The Independent Budget recommends approximately 

$6.2 billion for Medical Support and Compliance. The Independent Budget also recommends approximately $5.9 billion for Medical Facilities for FY 2017. As with FY 

2016, our FY 2017 recommendation includes the addition of $900 million to the 

baseline for NRM. Last year the Administration’s recommendation for NRM reflected a projection that would place the long-term viability of the healthcare system 

in serious jeopardy. 

MEDICAL AND PROSTHETIC RESEARCH

The Independent Budget co-authors have ongoing concerns about the lack of investment in Medical and Prosthetic Research. We appreciate the fact that this year 

173 

the Administration recommended a substantial increase in research funding. For FY 

2016, the Administration recommends approximately $622 million while the IB recommends approximately $619 million. 

The VA Medical and Prosthetic Research program is widely acknowledged as a 

success on many levels, and contributes directly to improved care for veterans and 

an elevated standard of care for all Americans. The research program is an important tool in VA’s recruitment and retention of healthcare professionals and clinicianscientists to serve our Nation’s veterans. By fostering a spirit of research and innovation within the VA medical care system, the VA research program ensures that 

our veterans are provided state-of-the-art medical care. 

GRANTS FOR STATE EXTENDED-CARE FACILITIES

The State Veterans Home program (State Homes) is a very successful Federalstate partnership in which VA and states share the cost of constructing and operating nursing homes and domiciliaries for America’s veterans. Today, State Homes 

provide over 30,000 nursing home and domiciliary beds for veterans, their spouses, 

and gold-star parents of veterans. Overall, State Homes provide approximately 53 

percent of VA’s long-term-care workload, for the very reasonable cost of only about 

12 percent of VA’s long-term-care budget. On average, the daily cost of care for a 

veteran at a State Home is less than 50 percent of the cost of care at a VA longterm-care facility. This basic per diem covers about 30 percent of the cost of care, 

with states responsible for the balance, utilizing both state funding and other 

sources. 

VA also provides states with construction grants to build, renovate, repair, and 

expand both nursing homes and domiciliaries, with states required to provide 35 

percent of the cost for these projects in matching funding. VA maintains a 

prioritized list of construction projects proposed by State Homes based on specific 

criteria, with life and safety threats in the highest priority group. Only those 

projects that already have state matching funds qualify are included in VA’s Priority 

List Group 1 projects, which are eligible for funding. Those who have not yet received assurances of state matching funding are put on the list among Priority 

Groups 2 through 7. 

In FY 2014, the estimated Federal share for proposed State Home Construction 

Grants submitted by states was $928 million, of which $489 million had already secured the state matching funds required to put them in the Priority Group List 1. 

In FY 2015, total estimated share of State Home Construction Grant requests rose 

to $976 million, of which $409 million already have state matching funding. The 

IBVSOs had recommended $250 million to provide funding for about half of the Priority 1 projects. The final appropriated funding for FY 2014 was only $85 million 

and only $90 million for FY 2015. For FY 2016, the IBVSOs recommend $200 million for the State Home Construction Grant program, which we estimate would provide sufficient funding for approximately half of the projects expected to be on the 

FY 2016 VA Priority Group 1 List when it is released at the end of this year. 

We encourage the Committee to scrutinize the VA’s budget with vigor. However, 

we believe than honest analysis will show that these are the resource needs of VA. 

As such, we believe that the real focus of the Committee should be on scrutinizing 

how the VA spends these critically needed resources. It is imperative that these dollars ensure that veterans receive timely, quality health care and claims decisions 

that are right the first time. 

In the end, it is easy to forget that the people who are ultimately affected by 

wrangling over the budget are the men and women who have served and sacrificed 

so much for this Nation. We hope that you will consider these men and women 

when you develop your budget views and estimates, and we ask that you join us 

in adopting the recommendations of The Independent Budget. 

This concludes our statement. I would be happy to answer any questions you may 

have. 

Chairman ISAKSON. Thank you for your testimony and for your 

support of veterans and what you do for paralyzed veterans. We 

appreciate it very much. 

Ms. Ilem. 

174 

STATEMENT OF JOY ILEM, DEPUTY NATIONAL LEGISLATIVE 

DIRECTOR, DISABLED AMERICAN VETERANS 

Ms. ILEM. Chairman Isakson, on behalf of DAV, I am pleased to 

present the fiscal year 2016 recommendations of the Independent 

Budget for the Veterans Benefits Administration. 

Without question, over the past 5 years, VBA has achieved some 

remarkable progress. The fully developed claims program, disability benefits questionnaires, and the Veterans Benefits Management System, known as VBMS, have all made significant contributions. Five years ago, no claims were processed electronically. 

Today, more than 93 percent of VBA’s roughly 500,000 pending 

claims are fully electronic. 

Likewise, VBA has made significant progress related to its target 

goal of completing disability claims within 125 days, with a 98-percent accuracy standard. From its peak in 2013, the total number 

of pending claims has been reduced by 40 percent, and the backlog 

claims pending over 125 days cut by over 60 percent. And I would 

mention at this point, as well, I think General Hickey has done an 

excellent job. She has worked tirelessly with the VSO community, 

and a lot of these changes have been really put on her, and she 

has not let up during her time. 

At the same time, according to VBA, the accuracy of decisions 

rose from 86.4 percent 2 years ago to 91 percent at the beginning 

of this year. 

Mr. Chairman, while it is unclear if VBA can achieve its goals 

by the end of 2015, in our opinion the most critical factor in VBA’s 

ability to address the backlog is sufficient staffing. Over the past 

several years, many VA regional offices have required mandatory 

overtime and diverted some of their senior employees from both 

quality review and appeals work to focus on claims processing. The 

reliance on mandatory overtime in this supplemental claims processing workforce is a clear indicator to us that VBA is insufficiently 

staffed to handle its current workload. 

In order to increase productivity now while allowing for future efficiencies from technology, we propose the VBA be provided 1,700 

additional full-time employees, half of them permanent and the 

other half under a 2-year temporary authority. At the end of the 

2-year period, VBA could make permanent the best of these temporary employees for positions that may open from attrition. 

While VBMS has generally been a success, current planning at 

VBA has delayed development of some critical IT elements, including the major modules to allow electronic transmission of medical 

examinations and service treatment records. Therefore, the 

IBVSOs have recommended a $60 million increase for IT funding 

for VBMS and other critical IT enhancements. 

While the claims backlog has been reduced, the backlog of pending appeals is now rising. Last year, the board completed a record 

over 55,000 appellate decisions, but there are still nearly now 

300,000 appeals in VBA at various stages working their way toward the board. For these reasons, we recommend an increase of 

120 new full-time employees for the board. In addition, the IBVSOs recommend that at least $15 million be 

allocated for IT modernization to aid the board’s transition to digital processing of appeals. 

175 

Mr. Chairman, to address the issue of rising appeals, the Independent Budget groups here, other VSO stakeholders, VBA, and the 

board worked together collectively to develop a new proposal called 

‘‘fully developed appeals,’’ or FDA, modeled after the fully developed claims program. The veteran would agree to assemble private 

evidence and arguments to satisfy their appeal, eliminate some 

VBA processing steps, and agree not to request a hearing. In exchange, they could save up to 2 to 3 years of processing time. The 

FDA program would be completely voluntary, and the veteran 

could withdraw from it at any time without losing any right to a 

traditional appeal. We think this option will help expedite many of 

these appeals and, therefore, urge the Committee to move legislation to create a new FDA pilot program. 

Another critical program for veterans, particularly disabled veterans, is the Vocational Rehabilitation and Employment Service. In 

2016, the IBVSOs project a nearly 10-percent increase in that participant growth; therefore, we recommend an additional 382 fulltime employees be added to the program, of which 277 would be 

dedicated as counselors and 105 dedicated to support services. 

Finally, the IB policy agenda for the 114th Congress contains a 

number of additional policy recommendations we hope the Committee will consider, including the elimination of the rounding 

down of the COLA for veterans and survivors’ benefit programs— 

or payments, and increasing Dependency and Indemnity Compensation rates for survivors, eliminating the DIC and Survivor 

Benefit Plan offsets, and allowing widows to have their benefits 

continue or restored if they remarry after age 55. 

That completes my statement. I am happy to answer any questions. 

[The prepared statement of Ms. Ilem follows:] 

PREPARED STATEMENT OF JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, 

DISABLE AMERICAN VETERANS

Chairman Isakson, Ranking Member Blumenthal and Members of the Committee: 

On behalf of the DAV and our 1.2 million members, all of whom were wounded, injured or made ill from their wartime service, I am pleased to present recommendations of The Independent Budget (IB) for the fiscal year (FY) 2016 budget related 

to veterans’ benefits and the Veterans Benefits Administration (VBA). The IB is 

jointly produced each year by DAV, AMVETS, Paralyzed Veterans of America and 

Veterans of Foreign Wars of the United States. This year’s IB Budget Report as well 

as the IB’s Policy Agenda for the 114th Congress contain numerous recommendations to improve veterans’ benefit programs and the claims processing and appeals 

system; however, in today’s testimony I will highlight just some of the most critical 

ones for this Committee to consider, particularly those requiring new resources. 

Mr. Chairman, five years ago the Veterans Benefits Administration (VBA) set out 

to transform and modernize its systems and procedures for processing veterans’ 

claims for benefits, particularly for disability compensation. Then-VA Secretary 

Shinseki announced ambitious ‘‘aspirational goals’’ for transforming the claims system, promising that by the end of 2015 VBA would decide all claims for disability 

compensation within 125 days and that they would be completed to a 98% accuracy 

standard. This aspirational goal soon became enshrined as VBA’s bedrock strategic 

target, against which all of its plans and progress would be measured. 

Today, with less than a year remaining, there are questions about whether either 

of those goals can be achieved. 

VBA HAS MADE PROGRESS IN TRANSFORMING CLAIMS PROCESSING

Mr. Chairman, unquestionably, over the past five years VBA has achieved remarkable progress, much of it visible and measurable. A new organizational model 

has been implemented, new technologies deployed and new business processes 

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adopted. The fully developed claims (FDC) program started as a pilot test, and now 

about 40 percent of all claims filed today are done through the FDC program. 

Standardized medical evidence forms known as Disability Benefits Questionnaires 

(DBQ) are now used universally, and are an essential component of creating an 

automated claims processing system. And the development and deployment of the 

Veterans Benefits Management System (VBMS) and its ‘‘e-Folder’’ have dramatically enhanced VBA’s ability to manage the volume of documents and information 

required to process over a million claims yearly. Today, VA receives more claims, 

processes more claims, has fewer claims pending in its inventory, has fewer claims 

in backlog status, takes less time to process claims, and issues decisions that are 

more accurate. 

Five years ago, no claims were processed electronically; today with VBMS fully 

deployed to all 58 regional offices, more than 93% of VBA’s roughly 500,000 pending 

claims are fully electronic. There have been more than one billion images scanned 

into VBMS or other VA systems, and both new and legacy claims documents and 

files continue to be converted into digital documents and uploaded into VBMS. Veterans’ e-Folders in VBMS can be read at all VBA offices, including the Appeals 

Management Center (AMC) and Board of Veterans’ Appeals (Board), as well as at 

148 VHA facilities and by VSOs that represent veterans. About 75 percent of the 

rating schedule, which covers more than 93 percent of all rating decisions, has been 

coded into ‘‘calculators’’ and embedded in VBMS to assist Rating Veterans Service 

Representatives (RVSRs) make rating decisions. 

Both e-Benefits and the Stakeholder Enterprise Portal (SEP) allow veterans and 

their authorized representatives to initiate, submit and track their claims online. 

These technological advancements have enabled VBA to make major improvements 

in the size of the backlog, the timeliness of claims and the accuracy of decisions; 

however, analysis of currently available data raises questions about whether the 

level and trends of progress are sufficient to meet VBA’s 2015 goals. 

According to VBA’s Monday Morning Workload Analysis reports, at its peak early 

in 2013, the total number of pending claims for disability compensation and pension 

rose to over 860,000, with the backlog (those pending over 125 days) topping 

600,000. As of last week, the total pending workload of claims was reduced by more 

than 40 percent to just under 500,000 and the number in backlog status was cut 

by over 60 percent down to about 230,000. 

Based on data from the Aspire Dashboard, the timeliness of claims has also improved; however, this performance remains far short of the 2015 goal of all claims 

being completed in less than 125 days. In January 2013, the average processing 

time and the average days pending metrics were both approximately 280 days. By 

January 2015, the average days processing was down to about 200 days and the average days pending was about 150 days. However, it is important to point out that 

both of those timeliness measures are for ‘‘average’’ times, whereas VBA’s 2015 target is based on all claims being completed with 125 days. To have all completed in 

125 days might require an ‘‘average’’ processing time of 80 or 90 days. The current 

trends raise questions about whether this target can be achieved by the end of 2015. 

Finally, the most important metric of a properly functioning claims processing 

system is the accuracy of decisions. After all, claims completed rapidly do a veteran 

little good if the decision results in a wrongful denial. In January 2013, VBA’s 

claims accuracy based on its Systematic Technical Accuracy Review (STAR) was 

86.4 percent for the 12-month average, and 86.8 percent for the three month average. Over the past two years, the accuracy rate had increased steadily reaching 91 

percent for the 12-month measure ending in January 2015, and 91.5 percent for the 

3-month measure. Among the reasons for these increases were sharpened focus on 

training, testing and quality control, including the creation of Quality Review Teams 

(QRTs), the dramatic reduction of Veterans Claims Assistance Act of 2000 (VCAA) 

‘‘duty to assist’’ notification errors due to the inclusion of this notice directly on application forms, and the elimination of errors due to automation. However, whether 

it is possible to reach 98 percent accuracy for claims remains an open question, particularly as the average number of issues per claim continues to rise. 

REALISTIC GOALS ARE KEY TO LONG-TERM SUCCESS

Overall, VBA has made significant progress toward reaching the 2015 goals; however, with less than a year remaining to reach those goals, VBA must openly and 

honestly assess whether those goals are still appropriate and achievable. Vital lessons must be learned from the VA’s scandals last year of holding onto unrealistic 

and unachievable goals. The Veterans Health Administration’s (VHA) access standard that outpatient appointments must be scheduled within 14 days of the patient’s 

desired date, was widely viewed as unrealistic considering VHA’s limited capacity 

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to provide timely care to new patients. Faced with the dilemma of an unreachable 

and unchangeable standard, some employees made the decision to manipulate data 

and cover up true waiting lists rather than be held accountable for failure to meet 

this standard. 

The critical question that VA and Congress must confront now is whether the 

goals established five years are working to drive VBA’s performance in a positive 

direction or whether it would be better for veterans and VA to review, reassess and 

if necessary, revise VBA’s target goals before they start to distort behavior in the 

chase to meet these unreachable standards. If VBA concludes they are not, VBA 

must work in a transparent and collaborative manner with Congress and its VSO 

partners to set new goals, revise its strategies and plans, and request new resources 

if needed to reach those goals. 

PERMANENTLY ENDING THE BACKLOG REQUIRES SUFFICIENT STAFFING

Recognizing that rising workload, particularly claims for disability compensation, 

could not be addressed without additional personnel, Congress provided the VBA 

with more than 3,000 full time employee equivalents (FTEE) between 2008 and 

2013, primarily in Compensation Service. However, relative to VBA’s total workload, 

including appeals, these increases have not been sufficient to keep pace with rising 

workload, including non-rating work and appeals work, as evidenced by VBA’s own 

resource allocation and personnel decisions. 

VBA’s largest increases in productivity—periods where the backlog declined most 

markedly—occurred while VBA enforced a policy of mandatory overtime for its 

workforce. During holiday periods, when mandatory overtime was curtailed, production fell off measurably. Furthermore, over the past couple of years many VA Regional Offices (VARO) have diverted some of their senior employees from both quality review and appeals work to focus on claims processing to drive down the backlog. 

Specifically, both Decision Review Officers (DRO) and Quality Review Specialists 

(QRS) have been performing claims development and rating duties during both regular and overtime working hours at many VAROs. The reliance on this supplemental claims processing workforce is a clear indicator that VBA is insufficiently 

staffed to handle its current workload. 

A blend of technology and people will be necessary to provide veterans and their 

dependents with timely accurate decisions. Although this new claims processing system has the potential to transform the delivery and accuracy of benefits, some additional time will be required before the full effect of these changes will be realized. 

Therefore, in order to increase productivity now, while allowing for future productivity increases, the IBVSOs propose that VBA be provided with 1,700 additional 

FTEE, half of them permanent and the other half under a two-year temporary authority. The temporary FTEE request is based on an approach included in the stimulus legislation that was passed several years ago that allowed the VBA to hire several thousand employees for temporary, two-year terms. At the end of those two 

years, many of these temporary employees transitioned into permanent positions 

through staff attrition. 

Allowing VBA to again hire employees for two-year temporary terms could supplement the staff and alleviate reliance on mandatory overtime, and further reduce the 

backlog of disability claims. Such an initiative would also provide an outstanding 

opportunity for VBA to develop a generous pool of trained, qualified candidates for 

succession of full-time positions vacated by employees leaving VBA. 

While this infusion of resources is necessary to supplement the current workforce, 

the IBVSOs continue to believe that a more accurate staffing and production model 

is required to determine VBA’s long-term resource needs as new technology and 

business processes evolve. 

In FY 2016, the IBVSOs recommend providing VBA’s compensation service with 

850 new permanent FTEE and 850 two-year temporary FTEE. These additions will 

require an increase in appropriations of $158.9 million. 

IT MODERNIZATION MUST BE ACCELERATED

The most critical elements of VBA’s claims processing transformation are its new 

IT systems created over the past five years: VBMS, e-Benefits and SEP. These three 

systems have led the way in moving claims processing from an outdated paperbased system to the modern digital system. Despite early challenges, the VBMS program has proven to be an effective platform for processing claims in a digital environment. The objective now is to fully integrate all elements of the claims system, 

VSOs and other VBA business lines to create a unified digital work environment. 

Current planning at VBA calls for some critical elements of the claims process, 

including major modules to allow electronic transmission to VBMS of examinations 

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and service treatment records from the Department of Defense, other government 

agencies, private businesses and other organizations, to be completed over the next 

several years. Although VBA could use these modules immediately, budget constraints have extended planning into future years. Similarly, plans to expand 

VBMS, or another compatible IT solution, to all remaining VBA business lines and 

the Board, are also being stretched out to future years due to lack of budget availability. We believe that Congress must provide sufficient resources to VBA now to 

allow these critical elements of VBMS and associated IT systems to be accelerated. 

VBA must also place greater emphasis on integrating VSOs into VBMS and resolving lingering issues in SEP, both of which are essential to maximizing the benefits that VSO service officers offer in resolving claims more quickly and accurately. 

The IBVSOs recommend increasing the amount of IT funding allocated to the 

VBMS program in FY 2016 by $60 million to support the specific IT enhancements. 

CLAIMS REFORM MUST INCLUDE APPEALS REFORM

While the claims backlog has dropped significantly as indicated above, the backlog 

of pending appeals has risen over the past couple of years. Despite the fact that the 

Board completed more than 55,000 appellate decisions in FY 2014, an increase of 

10 percent over the highest previous total, this improvement was primarily driven 

by an increase of more than 100 new FTEE. However, the number of appeals at 

various stages working their way through VBA toward the Board now tops 300,000. 

In order to address the pending workload in a reasonable timeframe, the Board will 

need to utilize a multi-pronged approach that includes increasing the size of staff, 

modernizing IT systems and innovative programs to streamline work. 

One essential element needed to permanently address the backlog of pending appeals is to complete VBA’s transformation and reform of the claims process. As the 

claims error rate goes down, and as confidence in the claims process grows, the percentage of claimants who later file appeals would be expected to fall. However, as 

VBA increases its productive capacity and the number of completed claims, an increase in the number of appeals could occur even if the accuracy rate continues to 

climb. Even accurate decisions may be appealed if they are unfavorable to claimants. 

BOARD MUST INCREASE STAFFING TO MEETING RISING WORKLOAD

After several years of reduction in workforce, the Board has significantly increased its FTEE levels over the past three years, rising from an average of 510 

FTEE in FY 2012 to an authorized level of 640 FTEE in FY 2015. Significant training and orientation are required for new Board attorneys to reach full productivity. 

The time taken away to train and mentor these attorneys reduces appeals output; 

therefore, some temporary losses in completed appeals may occur even with these 

new staff resources. 

As indicated above, over the past five years the Board has averaged approximately 90 appeals dispositions per FTEE, producing a record 55,532 decisions in FY 

2014. However, with the inventory of pending appeals now topping 360,000 in various stages at both VBA and the Board, there are simply not enough hands to do 

all the work that will be required, even with further efficiencies gained through 

technology and other reforms. 

For FY 2016, the IBVSOs recommend an increase of 120 new FTEE, a 20 percent 

increase over the FY 2015 authorized level, which will require an additional $17 million. 

THE BOARD’S IT NEEDS MUST BE ADDRESSED NOW

While VBMS for compensation claims processing has received virtually all of the 

IT attention and resources up to this point, the extension and adaptation of VBMS 

for the Board’s use has been pushed back to future years due to limited budgets. 

While the Board has access to e-Folders to review claims records, the Board is unable to process appeals within a fully electronic environment. With the inventory of 

pending appeals at both VBA and the Board growing, IT modernization at the Board 

must move forward as a high priority. 

The IBVSOs recommend that at least $15 million be allocated in FY 2016 for IT 

modernization to aid the Board. 

VBA MUST STRENGTHEN THE DECISION REVIEW OFFICER PROGRAM

Another key approach to lowering the appeals workload for the Board is to 

strengthen the DRO post-determination review process, which can often be more effective or timely than the traditional appeals process because it resolves appellateVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00182 Fmt 6633 Sfmt 6621 Z:\ACTIVE\022615.TXT PAULIN
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related disputes at the VARO level. A DRO has de novo authority, meaning he or 

she reviews the entire appeal file with no deference given to the rating board decision. DROs can overturn or uphold a previous decision, hold hearings and perform 

any activity necessary to assemble evidence, including ordering medical examinations. Even if a DRO is unable to grant the benefit sought on appeal, any additional 

development work he or she performs could potentially shorten the time required 

by the Board to produce a decision. 

For years, the IBVSOs have voiced concerns to VBA and Congress regarding the 

erosion of the DRO program. The number of DROs in the system is insufficient for 

the amount of DRO work generated in VAROs. Also the assignment of initial claims 

processing work to DROs at numerous VAROs further detracts from their intended 

work. Having DROs perform claims processing work when there is more than 

enough appeals work pending is merely shifting the weight of the backlog from one 

area to another. Over the past year VBA leadership has made some efforts to limit 

or eliminate the use of DROs in performing claims work; however, we continue to 

observe DROs at many VAROs working on claims processing activities. While we 

understand that VBA has limited resources but seemingly unending claims work, 

it is imperative that VBA ensure that DROs focus solely on appeals-related work. 

If additional personnel are required to process pending and future claims in a timely 

manner, VAROs must request additional resources, not repurpose DROs. 

FULLY DEVELOPED APPEALS PILOT PROGRAM

In order to seek new solutions that could improve the appeals process for veterans, the IBVSOs, other VSO stakeholders, VBA and the Board worked to reach 

consensus on a new proposal to create a ‘‘fully developed appeals’’ (FDA) program 

modeled after the fully developed claims (FDC) program. The premise of the FDA 

program is that the appellant would assume responsibility for gathering all private 

evidence necessary for the appeal and agree to eliminate some steps and work required by VBA and the Board. In return the veteran would receive a significantly 

quicker appeal decision by the Board with no diminution in the quality or accuracy 

of that decision. 

The FDA would become an additional option that the claimant could choose any 

time during the one-year period allowed to file an NOD. When veterans make the 

FDA election, they would be required to submit any and all additional evidence they 

want considered as part of their appeals and any arguments to support their appeals. They would also be required to certify that they have been fully informed 

about the FDA program, that they understand what they are required to do and 

not do, what VBA and the Board are required to do and not do, and that they consent to voluntarily filing their appeals in this manner. With this certification, the 

veterans’ rating decisions and complete files—supplemented by any new evidence or 

argument submitted by veterans or their representatives at time of filing their 

FDA—would be transmitted directly to the Board and placed on a new FDA docket 

for date-ordered review and decision. Unlike the traditional appellate process, no 

Statement of the Case (SOC) would be created and issued, no VA Form 9 would be 

completed, no local VARO hearings or reviews would be conducted, no Board hearings would be held, no Supplemental Statement of the Case would be created, and 

no Form 8 certification process would occur. The elimination of these steps alone 

could save two to three years of processing at the VARO compared to a traditional 

appeals process. 

Similar to the FDC program, the FDA program would require the veteran to certify that there is no additional private evidence relevant to the appeal under consideration, and if the veteran later submitted additional evidence after the date of filing, the appeal would revert from the FDA program and return to the traditional 

appeals process, without any loss of rights or options. The veteran could also withdraw his or her appeal from the FDA process at any time for any reason. The Board, 

however, would still be required to develop any Federal evidence, examinations or 

independent medical evaluations determined necessary for the Board to make its decision. The IBVSOs believe it is important that the FDA program be a time-limited, 

statutorily-authorized pilot program in order for VA to provide Congress and stakeholders the ability to oversee the program’s design, implementation and operation, 

as well as to ensure that veterans’ rights are fully protected. 

It is important to understand that the FDA proposal is not a ‘‘magic bullet’’ that 

will eliminate the backlog of pending appeals; it is designed to be another option— 

one of many for veterans seeking to overturn an incorrect or unfavorable claims decision. As discussed above, the IBVSOs continue to strongly support the DRO process, and the FDA program is neither a substitute nor replacement for it. Instead, 

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ative, if any, can consider in making decisions about the most effective and timely 

process to resolve appeals. 

RESOURCES FOR VOCATIONAL REHABILITATION AND EMPLOYMENT SERVICE

Vocational Rehabilitation and Employment Service, (VR&E), also known as the 

VetSuccess program, provides critical counseling and other adjunct services necessary to enable service-disabled veterans to overcome barriers as they prepare for, 

find, and maintain gainful employment. VetSuccess offers services through five 

tracks: reemployment, rapid access to employment, self-employment, employment 

through long-term services, and independent living. Another key program helping 

to deliver VR&E assistance at a key transition point for veterans is the VetSuccess 

on Campus (VSOC) program which is operating at 94 college campuses. Additional 

VR&E services are provided at 71 military installations for active duty servicemembers undergoing medical separations through the Department of Defense’s 

(DOD) and VA’s joint Integrated Disability Evaluation System (IDES). 

In order to meet the critical needs of veterans seeking employment, careers or 

more independent living, staffing levels throughout VR&E services must be commensurate with current and future demands. At the end of FY 2013, VR&E employed a total of 1,343 FTEE. VBA projected an increase in FY 2014 to an authorized level of 1,442 FTEE. In the FY 2015 budget request, VBA did not recommend 

increasing this staff and was again authorized 1,442 for FY 2015, despite an increasing workload. 

In order for VR&E to keep pace with demand, the IBVSOs project the total number of VR&E participants at roughly 165,000 for FY 2016, nearly 10 percent in participant growth. At present there are roughly 974 VR&E counselors managing an 

active client caseload of roughly 140,000 participants which averages a counselorto-client ratio of roughly 1 to 135. Ideally, a reasonable client-to-counselor ratio 

would consist of one VR&E counselor for every 125 veterans as has been advocated 

by the IBVSOs for the past several years. However, the average can be misleading 

as there are higher and lower actuals throughout VAROs. As an example, the Cleveland VARO’s counselor to client ratio is 206 cases for every VR&E counselor, and 

in the Fargo VARO, 64 cases for each VR&E counselor. Therefore, it is essential 

that staffing increases be properly distributed throughout all of VR&E to ensure 

that counselors’ caseloads are equitably balanced. 

For FY 2016, the IBVSOs recommend an additional 382 FTEE, of which 277 

would be dedicated as VR&E counselors and the remaining 105 employees dedicated 

to support services bringing VR&E’s total FTEE strength to 1,824. The additional 

funding required for VR&E for FY 2016 would be $41.8 million. 

OTHER PRIORITY BENEFIT PROPOSALS

Eliminate rounding down of veterans’ and survivors’ benefit payments 

In 1990, Congress, in an omnibus reconciliation act, mandated veterans’ and survivors’ benefit payments be rounded down to the next lower whole dollar. While this 

policy was initially limited to a few years, Congress has continued to extend it every 

few years. Each year’s 

COLA is calculated on the rounded-down amount of the previous year’s payments. 

While not significant in the short run, the cumulative effect over time results in a 

significant loss to beneficiaries. 

The effect of rounding down monthly COLA increases has eroded approximately 

$10 per month for every veteran or survivor. For example, a veteran totally disabled 

from service-connected disabilities would have received $1,823 per month in 1994 

and today will be paid at $2,848 per month. Had that veteran received the full 

COLA each year for the past two decades, he or she would receive about $120 extra 

this year, and cumulatively over two decades would have received almost $2,000 

more. The Independent Budget veterans service organizations note and greatly appreciate that the most recent COLAs were not rounded down and urge Congress not 

to return to a policy of rounding down veterans’ and survivors’ benefits payments. 

STRENGTHEN SUPPORT FOR SURVIVOR BENEFITS PROGRAMS

Increase DIC rates 

The current rate of compensation paid to the survivors of deceased members is 

inadequate and inequitable when measured against other Federal programs. Under 

current law, DIC is paid to an eligible surviving spouse if the military servicemember died while on active duty or the veteran’s death resulted from a servicerelated injury or disease. 

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DIC payments were intended to provide surviving spouses with the means to 

maintain some semblance of economic stability after the loss of their loved ones. All 

surviving spouses who rely solely on DIC, regardless of the status of their sponsors 

at the time of death, face the same financial hardships. 

The IBVSOs recommend that the rate of DIC should be increased from 43 percent 

to 55 percent of a 100 percent disabled veteran’s compensation for all eligible surviving spouses. 

Eliminate DIC and SBP offsets 

The current requirement that an annuity under the DOD SBP be reduced by an 

amount equal to DIC is inequitable because no duplication of benefits is involved. 

A veteran of military service is compensated for the effects of service-connected disability. When a veteran dies of service-connected causes or following a substantial 

period of total disability from service-connected causes, eligible survivors or dependents receive DIC from the VA. 

Career members of the Armed Forces earn entitlement to retired pay after 20 or 

more years of service. Survivors of military retirees have no entitlement to any portion of the veteran’s military retirement pay after his or her death, unlike many retirement plans in the private sector. Under the SBP, deductions are made from military pay to purchase a survivor’s annuity. This benefit is not gratuitous but is purchased. 

Upon a retiree’s death, the SBP annuity is paid monthly to eligible beneficiaries. 

If the veteran died from other than service-connected causes or was not totally disabled by service-connected disability for the required time preceding death, beneficiaries receive full SBP payments. However, if the veteran’s death was a result of 

military service or after the requisite period of total service-connected disability, the 

SBP annuity is reduced by an amount equal to the DIC payment. When the monthly 

DIC rate is equal to or greater than the monthly SBP annuity, beneficiaries lose 

the SBP annuity in its entirety. 

The IBVSOs recommend that Congress repeal the inequitable offset between DIC 

and Survivor Benefit Plan (SBP) because no duplication occurs between these two 

separate and distinct benefits. 

Allow remarriage after age 55 

Current law allows retention of DIC upon remarriage at age 57 or older for eligible survivors of veterans who die on active duty or of a service-connected injury or 

illness. However, remarried survivors of retirees of the Civil Service Retirement System, for example, obtain a similar benefit at age 55. Equity with beneficiaries of 

other Federal programs should govern Congressional action for this deserving group, 

therefore Congress should lower the age required for remarriage for survivors of veterans who have died on active duty or from service-connected disabilities. This 

change in eligibility would also bring DIC in line with Survivor Benefit Plan rules 

that allow retention with remarriage at the age of 55. 

Although the IBVSOs appreciate the action Congress took to allow restoration of 

this rightful benefit, the current age threshold of 57 years should be lowered to 55 

for all eligible surviving spouses, consistent with other similar programs. 

Mr. Chairman, that concludes our testimony and I will be happy to answer any 

questions from you or other members concerning these issues. 

Chairman ISAKSON. Thank you very much. 

Mr. Kelley. 

STATEMENT OF RAYMOND C. KELLEY, DIRECTOR, NATIONAL 

LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF 

THE UNITED STATES 

Mr. KELLEY. Mr. Chairman, on behalf of Veterans of Foreign 

Wars and our Auxiliaries, thank you for the opportunity to testify 

today. The VFW is responsible for the construction portion of the 

IB, so I will limit my remarks to that. 

Gaps in access, utilization, and safety in VA’s health care system’s infrastructure exacerbated the conditions that lead to VA’s 

unauthorized wait lists. VA currently sits at 119 percent capacity 

and admits they need $14 billion just to close current safety gaps. 

Every effort must be made to ensure these facilities remain safe 

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and sufficient environments to deliver care. To do this, large capital investments must be made. 

Presenting a well-articulated, completely transparent capital 

asset plan, which VA has attempted to do, is important, but not 

adequately funding that plan will prevent VA from closing those 

current gaps and only cause them to grow. 

Through Veterans Access, Choice, and Accountability Act of 2014 (VACAA), Congress provided VA $5 billion to begin closing gaps in 

non-recurring maintenance and minor construction. However, this 

is a one-time infusion of funds, and it cannot be seen as a replacement for annual appropriations but, rather, an investment to reduce the backlog of safety and access gaps. 

VA and Congress must develop a long-term funding strategy that 

addresses the four major components of capital infrastructure, 

which are non-recurring maintenance, major and minor construction, and leasing. 

Non-recurring maintenance (NRM) projects are one-time repairs, 

such as modernizing mechanical or electrical systems, replacing 

windows and equipment, and preserving roofs and floors. 

For buildings to last their life cycle, annual investments of nonrecurring maintenance must occur. Over the past several years, VA 

has requested just over $700 million annually for NRM, barely half 

of what is needed to maintain facilities for their full life cycle. 

The IB estimates VA needs to invest $1.35 billion annually in 

NRM as a baseline to ensure facilities are maintained in a safe and 

efficient manner. VA will need to invest additional funding to begin 

reducing the backlog of nearly 3,000 NRM projects. 

There are currently 45 major construction projects that are partially funded dating back to fiscal year 2009. VA has also identified 

114 major construction projects they determine will need to be completed within the next 10 years. While the IB is concerned about 

these future projects, the most pressing issue is finishing what they 

have already started. 

Included in the 45 partially funded projects are 9 major construction seismic deficiencies. It will require $4.7 billion to close these 

safety gaps. VA must make efforts to close these deficiencies in 

these properties. 

The IB recommends that Congress appropriate $1.9 billion for 

fiscal year 2016 to set VA on a course to close all currently partially funded projects and begin funding the remaining seismic deficiencies within the next 5 years. 

VA has come close to keeping up with its minor construction 

needs over the past few years. It is estimated that to close all 

minor construction gaps that have been identified, VA will need to 

invest between $7 billion and $9 billion over the next 10 years. 

Along with the funds that have been authorized for minor construction projects over the next 2 years through VACAA, the IB recommends an additional $575 million for fiscal year 2016. 

VA’s capital leasing program allows VA to improve veterans’ access to health care by entering into multiyear leases that provide 

the Department flexibility to increase and decrease the size and 

scope of care that is delivered in more than 800 communities. 

Thanks to the passage of VACAA, 27 major medical leases have 

been authorized. While funding these leases is a step in the right 

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1Department of Veterans Affairs, FY 2015 Budget Submission Construction and 10 year Capital Plan, Vol. 4 of 4, February 2014, p. 10.3–12, 9.3–11. 2Department of Veterans Affairs, FY 2015 Budget Submission Construction and 10 year Capital Plan, Vol. 4 of 4, February 2014, p. 1–4, 9.2–7. 

direction, it will be nearly 2 more years before the medical facilities 

see patients because of delays in funding and the current contract 

authorization process. 

Congress and VA must find a long-term solution to authorize 

these leases so they can be funded quickly and contracts can be 

filled without delay, so veterans do not wait years for these facilities to be completed. 

Mr. Chairman, this concludes my testimony, and I look forward 

to any questions you or the Committee may have. 

[The prepared statement of Mr. Kelley follows:] 

PREPARED STATEMENT OF RAYMOND C. KELLEY, DIRECTOR, NATIONAL LEGISLATIVE

SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES

Chairman Isakson, Ranking Member Blumenthal and Members of the Committee, 

on behalf of the nearly 1.9 million members of the Veterans of Foreign Wars of the 

United States (VFW) and our Auxiliaries, thank you for the opportunity to testify 

before you today regarding the Department of Veterans Affairs (VA) Fiscal Year 

(FY) 2016 budget recommendations. The VFW works alongside the other members 

of the Independent Budget (IB)—AMVETS, Disabled American Veterans and Paralyzed Veterans of America—to produce a set of policy and budget recommendations 

that reflect what we believe would meet the needs of America’s veterans. The VFW 

is responsible for the construction portion of the IB, so I will limit my remarks to 

that portion of the budget. 

Gaps in access, utilization and safety in VA’s heath care system’s infrastructure 

exacerbated the conditions that lead to VA’s unauthorized wait lists, causing veterans to wait too long to receive the care they need and deserve. VA currently sits 

at 119 percent capacity and admits to needing $14 billion just to close current safety 

gaps.1 Every effort must be made to ensure these facilities remain safe and sufficient environments to deliver care. A VA budget that does not adequately fund facility maintenance and construction projects will continue to reduce the timeliness and 

quality of care for veterans. 

The vastness of VA’s capital infrastructure is rarely fully visualized or understood. VA currently manages and maintains more than 6,000 buildings and almost 

34,000 acres of land with a plant replacement value (PRV) of approximately $90 billion. Although VA has decreased the number of critical infrastructure gaps, there 

remain more than 4,000 gaps that will cost between $56 and $68 billion to close, 

including $10 billion in activation costs.2

Quality, accessible health care continues to be the focus of the Independent Budget Veterans Service Organizations (IBVSOs), and to achieve and sustain that goal, 

large capital investments must be made. Presenting a well-articulated, completely 

transparent capital-asset plan, which VA has attempted to do, is important, but not 

adequately funding that plan will prevent VA from closing current access, utilization and safety gaps and only cause those gaps to grow. 

In August of last year, Congress provided VA $5 billion to begin closing access 

gaps, by including funding for non-recurring maintenance (NRM) and minor construction projects when it passed the Veterans Access, Choice, and Accountability 

Act of 2014 (VACAA). VA has identified approximately 400 minor and NRM projects 

that this funding will complete, ensuring facilities are maintained and existing facilities last for their projected life-cycle. However, this one-time infusion of funds 

cannot be seen as a replacement for annual appropriations, but rather an investment to reduce the backlog of safety and access gaps. 

VA and Congress must develop a long-term funding strategy that addresses the 

four major components of capital infrastructure: non-recurring maintenance, major 

construction, minor construction, and leasing. 

NON-RECURRING MAINTENANCE ACCOUNTS

Even though non-recurring maintenance is funded through VA’s Medical Facilities 

account and not through the construction account, it is critical to VA’s capital infrastructure. NRM embodies the many small projects that together provide for the 

184 

long-term sustainability and usability of VA facilities. NRM projects are one-time 

repairs, such as modernizing mechanical or electrical systems, replacing windows 

and equipment, and preserving roofs and floors, among other routine maintenance 

needs. Non-recurring maintenance is a necessary component of the care and stewardship of a facility. When managed responsibly, these relatively small, periodic investments ensure that the more substantial investments of major and minor construction provide real value to taxpayers and to veterans as well. 

To maintain existing infrastructure, annual investments in non-recurring maintenance must occur to ensure the building will last for its projected life-cycle. Over 

the past several years, VA has requested just more than $700 million for NRM, 

barely half of what is needed to maintain facilities for their full life-cycle. 

The IBVSOs estimate VA needs to invest $1.35 billion annually in NRM as a 

baseline to ensure facilities are maintained in safe and efficient manner. VA will 

need to invest additional funding to begin reducing the backlog of nearly 3,000 NRM 

projects. 

MAJOR CONSTRUCTION ACCOUNTS

There are currently 45 major construction projects that are partially funded dating back to FY 2009. VA has also identified 114 major construction projects they 

determine will need to be completed within the next 10 years to close gaps in veterans’ access to care. While the IBVSOs are concerned with these future projects, 

the most pressing issue is finishing what has already been started. 

Included in the 45 partially funded projects are nine major construction seismic 

deficiencies. There are also four other seismic projects that have not been funded 

at all. It will require $4.7 billion to close these safety gaps. VA must make correcting these deficiencies a priority and provide a plan to achieve these goals. 

The IBVSOs recommend that Congress appropriate $1.9 billion in FY 2016 to set 

VA on a course to close all currently partially funded projects and begin funding 

the remaining seismic deficiencies within the next five years. 

MINOR CONSTRUCTION ACCOUNTS

VA has come close to keeping up with its minor construction needs over the past 

few years. It is estimated that to close all minor construction gaps that have been 

identified, VA will need to invest between $7 billion and $9 billion. Along with the 

funds that have been authorized for VA’s minor construction projects over the next 

two years through VACAA, the IBVSOs recommend an additional $575 million for 

FY 2016 to ensure VA stays on track to close all its current and future minor construction gaps. 

CAPITAL LEASING ACCOUNTS

VA’s capital leasing program allows VA to improve veterans’ access to health care 

by entering into multiyear leases that provide the Department flexibility to increase 

and decrease the size and scope of care that is delivered in more than 800 communities. Thanks to the passage of VACAA, 27 major medical leases have been authorized. While funding these leases is a step in the right direction, it will be nearly 

two more years before these medical facilities see patients, because of delays in 

funding and the current contract authorization process. 

Congress and VA must fund a long-term solution to authorize leases so they can 

be funded quickly and contracts can be filled without delay, so veterans do not wait 

years for these facilities to be completed. 

In conclusion, the Department of Veterans Affairs has improved its capital infrastructure gap analysis through its Strategic Capital Investment Planning (SCIP) 

process, but they have continually fallen short of requesting the funds necessary to 

close these gaps and Congress continues to appropriate the amount VA requests. VA 

must present a long-term management plan than will connect the SCIP gap analysis 

with appropriate funding requests that will design, build and activate each project 

on time and on budget so access, utilization and safety gaps are closed quickly and 

veterans can receive timely, quality access to health care. 

Mr. Chairman, this concludes my testimony, and I am prepared to answer any 

questions you or the Committee members may have. 

Chairman ISAKSON. Thank you very much, Mr. Kelley. 

Mr. de Planque. 

185 

STATEMENT OF IAN DE PLANQUE, DIRECTOR, NATIONAL 

LEGISLATIVE DIVISION, THE AMERICAN LEGION 

Mr. DE PLANQUE. Good morning, Mr. Chairman. I want to extend 

special thanks to you for taking the time not only to sit down with 

our Commander after hearing our Commander’s testimony, but 

also to come out and address the members of our organization and 

give them a little bit of your vision for how this country can serve 

veterans in the 114th Congress and beyond. 

On behalf of that Commander, Commander Mike Helm, and the 

2.3 million veterans who make The American Legion the largest 

wartime veterans service organization, I appreciate the opportunity 

to testify before you today. 

I think everyone agrees our country has a responsibility to make 

good on the promises we make to those who have defended the Nation, but the country is a lot more than the budget of a single agency or the people of a single agency. Taking care of veterans requires efforts from all of us—VA, veterans, Congress, every single 

stakeholder. 

The past year brought hard truths to light. VA has struggled to 

come to terms with admitting there were problems with veterans’ 

ability to access care. We needed to bring those problems to the 

light to address them, and we have begun to address them, but it 

is going to take more time and complete transparency. 

We are happy to see that VA has chosen to address shortfalls in 

full-time workers and employees at the VBA. They are requesting 

an additional 770 workers to address claims. Regardless of whether 

the VBA eliminates the backlog this year or any other year, it is 

quite clear that additional help is needed. VBA workers have been 

working under mandatory overtime policies for over 4 years now. 

Overtime for a few weeks is indicative of a problem that needs a 

surge of assistance. Overtime for 4 years is a big indicator you just 

do not have the bodies to get the job done. 

To be fair, more studies and a clearer picture of the resource allocation would be helpful, especially for future planning to determine 

whether VA needs help long in advance of future backlogs. It is 

clear to everyone involved that VBA needs help to help veterans 

with their claims, and The American Legion strongly supports ensuring that they get the workers that they need. 

We were especially encouraged speaking with VBA officials to 

hear they anticipate boosting employees at the decision review officer level. Decision review officers have experience and skills to resolve appeals more quickly at the regional office before an appeal 

can begin a multiyear journey at the Board of Veterans Appeals. 

Sadly, for the past few years, we have seen firsthand in multiple 

offices that these decision review officers have been pushed into 

other tasks and their important work on appeals is falling by the 

wayside. Hopefully this indicates a new commitment to solving 

problems at the regional office level, fixing veterans’ claims before 

they descend into the lengthy appeals process. 

American Legion members are dedicated to making the VA a better place. Last year, over 7,000 American Legion members contributed over 900,000 hours of community volunteer service to the VA 

through the Veterans Affairs Voluntary Service (VAVS) program, 

supported by The Legion since 1946. I know all of our colleagues 

186 

here at the table and their organizations make time and contributions as well. The cost savings to the VA is immeasurable, and the 

key point here is we are all invested in this. We all have skin in 

this game. We are all working to do this. But to make sure we put 

those resources in the right place, we need to all communicate 

openly, honestly, and completely transparently with one another. 

This only works when we are all on the same page. We stress again 

the importance of a publicly open and transparent planning process 

for all stakeholders to work together to maximize what funds are 

available and to make the system work for all veterans. This only 

works when we all work together. 

I would be happy to take questions, though I first want to comment also specifically on what my colleague, Mr. Blake from Paralyzed Veterans of America, has discussed about the Choice Act and 

trying to make sure we get to those veterans within the 40-mile 

area. Just in January, I went out to Kansas myself to speak with 

American Legion members there, and I could see firsthand there 

are still a lot of problems. The numbers may have been astronomically high with the initial assessments in the budget, but we are 

seeing almost microscopically low numbers of people choosing to 

use that right now. And I think when we field calls, when we talk 

to veterans in The American Legion—and we have talked to a lot 

of them—many of them are confused and are having trouble accessing it because it is not being very well explained to them. They do 

not really understand why, if there is a facility 38 miles from them 

but they still have to go 250 miles to get the treatment that they 

need—maybe it is dialysis, maybe it is heart treatment—why they 

are not eligible for that program. 

When we spoke with Senator Blumenthal, the Ranking Member, 

in his office yesterday, one of the things he talked about was the 

intent of the program. I know the language of the bill is very specific, and I know that that was perhaps an attempt to address some 

of the concerns of the Congressional Budget Office. But, we are interested in continuing to work with Members of the Committee to 

make sure that veterans are getting access. 

The reason we came up with this was choice, and it is a choice. 

Not every veteran is going to choose to use it. Many of the veterans 

are going to choose to wait longer. But the ones who want to get 

into that care and who need the access—there are many ways VA 

has in the past used outside care, whether it is PC3 or ARCH or 

other programs. Choice is another tool that can help get those veterans into care, and we want to make sure that it is implemented 

within the intent of the Committee and the intent of the veterans 

service organizations who supported it, which is to get those veterans access to care. 

Thank you. 

[The prepared statement of Mr. de Planque follows:] 

PREPARED STATEMENT OF IAN DE PLANQUE, DIRECTOR, NATIONAL LEGISLATIVE

DIVISION, THE AMERICAN LEGION

Chairman Isakson, Ranking Member Blumenthal, and Members of the Committee: On behalf of National Commander Michael Helm and the 2.3 million wartime veterans of The American Legion, we welcome this opportunity to comment on 

the Federal budget, and specific funding programs of the Department of Veterans 

Affairs (VA). 

187 

1 http://www.stripes.com/va-workers-say-mandatory-overtime-won-t-solve-benefits-backlog1.221294 

The American Legion is a resolution based organization; we are directed and driven by the millions of active legionnaires who have dedicated their money, time, and 

resources to the continued service of veterans and their families. Our positions are 

guided by nearly 100 years of consistent advocacy and resolutions that originate at 

the grassroots level of the organization—the local American Legion posts and veterans in every congressional district of America. The Headquarters staff of the Legion works daily on behalf of veterans, military personnel and our communities 

through roughly 20 national programs, and hundreds of outreach programs led by 

our posts across the country. 

The American Legion comes before this Committee in a unique state of military 

affairs, as for the first time in over a decade, this country is not officially engaged 

in combat operations in Afghanistan or Iraq. Though combat operations in Afghanistan may have officially ceased on December 28, 2014, there is no doubt the effects 

of these wars will continue to be felt in the veterans’ communities for many decades, 

as has been the case with every previous war. The cost of war does not end when 

the guns fall silent. To paraphrase Winston Churchill this is not the beginning of 

the end, but rather the end of the beginning. 

We cannot allow focus and resources to be diverted from the VA because the limelight fades and the news cameras have gone away. The President’s proposed budget 

would offer an increase of 7.5 percent over the enacted level of Fiscal Year 2015 

funding, a healthy increase even as other agencies are forced to tighten belts under 

the effects of sequestration. However, we cannot think that just because the numbers go up that all of the money is being directed to the proper places. Here is 

where the importance of true transparency from VA becomes critical. This is where 

the importance of open and freely available planning reports, such as those proposed 

in the ‘‘Department of Veterans Affairs Budget Reform Planning Act of 2015.’’ (H.R. 

216) This legislation, recently recommended out of Committee in the House Committee on Veterans Affairs, would be helpful to the entire community of stakeholders. Many of the questions we will raise delve into matters that would be more 

clear if VA was more open and straightforward with stakeholders. 

This process only works if everyone can see all the pieces on the board. Taking 

care of veterans is the Nation’s responsibility. That includes not only the Federal 

Government, but state and county governments, veteran and military service organizations, and the citizens themselves. We have to all see how the pieces fit together 

and we have to all be on the same page if this is going to work and we’re all going 

to maximize our efforts together. 

There are areas of concern within the budget proposed by VA, but all of these 

areas can be worked out if everyone is open and above board. 

THE VETERANS BENEFITS ADMINISTRATION

This year, 2015, is to be the year the Veterans Benefits Administration finally 

‘‘breaks the back of the backlog.’’ To that end, the budget request includes requests 

to add 770 additional full time employees (FTEs) as claims processing workers and 

fiduciaries for the pension program. Adding additional workers is an important and 

needed step. VA employees have been directed to put in mandatory overtime work 

dating back to at least 2011.1 Mandatory overtime may provide a useful boost to 

push an organization through a tough patch, but four straight years of mandatory 

overtime indicates an organization that’s not going through a tough patch, it’s an 

organization that’s clearly understaffed. 

How many additional employees are appropriate? This is where it’s difficult to tell 

and where a study of VA’s resource allocation models would be helpful. At VA’s 

budget roll out, VA officials indicated some of this would be represented in making 

the Decision Review Officer (DRO) process more robust, something The American 

Legion strongly supports. DROs can often resolve appeals more rapidly than the appeal process at the Board of Veterans Appeals (BVA) and with greater accuracy and 

clarity than the average VA rater. Reports have indicated in some offices the DROs 

have been reassigned to other tasks as the pressure mounts to work on initial 

claims. It would be the hope of The American Legion that renewed interest in hiring 

and increasing the DRO force would allow DROs to return to their appeals duties, 

and help prevent a rising backlog in the appeals area. 

Whatever the case may be, better communication from VA to indicate how they 

intend to use staffing levels to effectively combat the backlog of claims is a must. 

The American Legion strongly supports additional FTEs to improve the VBA workforce. 

188 

2http://www.legion.org/sites/legion.org/files/legion/publications/war-within.pdf 

3http://www.legion.org/veteranshealthcare/222891/legion-survey-ptsdtbi-care-not-working 

4http://www.legion.org/veteranshealthcare/222891/legion-survey-ptsdtbi-care-not-working 

5http://kdvr.com/2014/12/17/va-announces-deal-to-start-work-on-aurora-hospital/ 

THE VETERANS HEALTH ADMINISTRATION

One of the key lessons learned through last year’s health care access is that VA’s 

reporting must be crystal clear to avoid the problems that occur when things are 

hidden from the stakeholders. Had VA employees not manipulated the wait time 

data a more bleak picture of the ability to serve veterans would have been painted, 

but the key stakeholders—veterans and Congress—would have known that additional resources were needed and where. Ensuring proper distribution of resources 

throughout VA depends on accurate reporting that is free from fear of reprisal for 

not meeting goals. We cannot create an environment where VA employees fear to 

report problem areas, for discerning where those problem areas are occurring is the 

critical factor in determining where resources need to go. 

To be fair, Secretary McDonald has expressed a renewed interest in openness and 

The American Legion believes VA is making a good faith effort to increase honesty, 

although we would like more clarity regarding the Secretary’s request for more flexibility in use of the funds designated for the Choice card program. VA’s budget request announces that they will be seeking more flexibility to retarget some of the 

$10 billion allotted to the Choice card program with last year’s legislation to provide 

more choice and access in care. 

Without an extremely specific accounting, which was not forthcoming in initial 

presentations of this budget, it would be difficult to support this request. The Choice 

program, which The American Legion believes is an important temporary measure 

to address shortfalls in VA’s ability to treat veterans, needs to be properly funded 

to succeed. To reprogram monies designated for this program so early into the program, barely six months into a three year pilot, seems short sighted. It would be 

the preference of The American Legion to see the program implemented as intended, 

and if funds remain at the end of the allotted time, then it would be appropriate 

to address what use those funds could best be put to. If there is money left over, 

great; that would mean VA was meeting their goal of addressing veterans’ needs 

with their in house resources, to include VA care as well as other assets in their 

arsenal such as the PC3 program or ARCH, the very successful rural health initiative. 

Regarding other important VHA funding, The American Legion notes that VA’s 

budget for medical research is relatively consistent, but positively notes the acknowledgement of the importance of additional areas of Posttraumatic Stress Disorder (PTSD) research including alternative therapies such as yoga, meditation and 

other treatments alongside cognitive processing therapy (CPT) and prolonged exposure therapy. The American Legion continues to devote extensive focus to the treatment of PTSD and Traumatic Brain Injury (TBI) through the PTSD and TBI Committee of the Veterans Affairs and Rehabilitation (VA&R) Commission. The Commission’s work included the production of ‘‘The War Within’’ and a survey conducted 

in conjunction with the Data Recognition Corporation which presented results last 

year at a June 24th symposium entitled ‘‘Advancing Care and Treatment for Veterans with TBI and PTSD.’’ 2 3 Through that survey, it was reported that nearly 60% 

of veterans undergoing treatment for PTSD and TBI reported feeling no improvement or felt worse after the traditional treatments.4 Clearly, there is still much 

room for improvement in this area. 

The American Legion supports VA becoming a robust leader in complementary and 

alternative medicine for Posttraumatic Stress Disorder and Traumatic Brain Injury. 

CONSTRUCTION AND FACILITIES

All stakeholders are aware of the much publicized struggles VA has gone through 

with major construction projects, particularly in Colorado, Florida, Louisiana and 

Nevada. VA recently came to an agreement with the contracting firm in Colorado 

and work was able to resume on the VA hospital project in Aurora. That work will 

likely cost at least $234 million, and the budget for the project has spiraled from 

approximately $600 million to over $1 billion.5 The money for these overages has 

to come out of VA’s construction budget, yet where the money to backfill that budget 

and provide for future projects will come from is still unclear. 

In February 2012, The American Legion presented the following warning about 

insufficient funding in VA’s construction budgets and capital investment plans: 

189 

6 American Legion testimony before HVAC on the VA Budget, February 15, 2012 

7 Resolution 282: Congressional Budget Office Scoring on Department of Veterans Affairs 

Leasing—AUG 2014 8http://www.legion.org/vavolunteers 

The SCIP planning process develops data for VA’s annual budget requests. These infrastructure budget requests are divided into several VA accounts: Major Construction, Minor Construction, Non-Recurring Maintenance (NRM), Enhanced-Use Leasing, Sharing, and Other Investments and 

Disposal. The Fiscal Year (FY) 2012 VA budget identified more than 5,000 

capital projects needed to close all the identified infrastructure gaps over 

the ten year period. The VA estimated costs were between $53 and $65 billion. 

The American Legion is very concerned about the lack of funding in the 

Major and Minor Construction accounts. In FY 2012 The American Legion 

recommended to Congress that the Major Construction account be funded 

at $1.2 billion and the Minor Construction account be funded at $800 million. However, Congress only appropriated $589 million and $482 million 

respectively to those accounts. Based on VA’s SCIP plan, Congress underfunded these accounts by approximately $4 billion in FY 2012. Clearly, if 

this underfunding continues VA will never fix its identified deficiencies 

within its ten-year plan. Indeed, at current rates, it will take VA almost 

sixty years to address these current deficiencies.6

Even before the setbacks in Colorado and Florida created holes in the construction 

budgets, there were already grave concerns about the ability to meet the needs that 

had been identified. Now that the struggling major projects are depleting funds at 

a greater rate than previously anticipated, the danger to future projects is even 

more severe. The American Legion urges Congress and VA to get on the same page about fixing 

these budget holes before it’s too late. We must act now. Whether this will require 

supplemental appropriations to make the troubled major construction projects whole 

again without jeopardizing the rest of VA’s construction needs, or whether this can 

be built into the budget is still a topic for discussion. What is clear is that this is 

going to present a major hurdle to ensuring VA’s facilities are able to handle the 

load. This is a problem that needs a solution. 

The hospitals are not the only area of concern in terms of facilities. Last year’s 

Veterans Access, Choice and Accountability Act (VACA) provided a respite for 27 

Community Based Outreach Centers (CBOCs). The CBOCs have been an effective 

tool in reaching veterans, particularly in rural areas where a full scale hospital 

might not be feasible. Changes in how the leases for these facilities were scored by 

the Congressional Budget Office (CBO) jeopardized the future of CBOCs within the 

VHA health care system. 

VACA provided relief for the 27 identified CBOCs, but in a sense it has only 

kicked the can a little further down the road. A long term solution to the CBOC 

lease conundrum will be required. 

The American Legion urges Congress to provide an annual or permanent exemption for the Department of Veterans Affairs leases from the Congressional Budget Office’s scoring process, so as to give VA the flexibility it needs to meet the health care 

needs of veterans.7

CONCLUSION

The past year has made it clear that VA cannot afford to be run as an entity reactive to one crisis after another. Effectiveness stems from long term planning, and 

to be truly effective that long term planning needs to include all stakeholders. The 

American Legion has been a strong and active supporter of the Department of Veterans Affairs Voluntary Service (VAVS) since 1946 and today over 7,000 volunteers 

provide 900,000 hours of volunteer service at VA medical centers, CBOCs, Vet Centers, state veterans’ homes, and nursing homes every year.8 With nearly a million 

hours of service provided, imagine the cost savings to VA in terms of additional 

FTEs they do not have to provide. 

That kind of coordination only works with open transparency. The American Legion urges VA to adopt an open and freely accessible planning process such as the 

quadrennial review proposed in H.R. 216 and endorsed by many members on both 

sides of the aisle in the House of Representatives. We would be happy to see the 

Senate take up legislation of this type to ensure VA’s planning process is robust, 

includes all stakeholders, and is transparent to allow input and analysis from all 

concerned parties. 

190 

Secretary McDonald has a daunting task ahead of him as he continues to reform 

the VA and rebuild from the failures that led to last year’s crises. There is no reason 

to go it alone. Congress has long displayed a willingness to provide VA with resources, increasing their budget nearly 75 percent since 2009 alone, and The American Legion has already gone out and conducted a dozen Veterans Crisis Centers 

and Veterans Benefits Centers in the field to help link VA and veterans up to make 

the system work. To be truly effective though, we all have to be reading from the 

same page. This is something that can and will be accomplished, and The American 

Legion looks forward to making that happen. 

Questions concerning this testimony can be directed to The American Legion Legislative Division (202) 861–2700, or ideplanque@legion.org. 

Chairman ISAKSON. Thank you very much for your testimony, 

and you are right on point regarding Choice. 

Vietnam Veterans of America. 

STATEMENT OF RICHARD WEIDMAN, EXECUTIVE DIRECTOR 

FOR POLICY AND GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA 

Mr. WEIDMAN. Mr. Chairman, thank you for the opportunity for 

VVA to present our testimony here today. Our estimate for VHA only is that $71 billion is needed for this 

coming fiscal year and 74 for the advanced appropriations. We 

have come at it from a different direction that is much more—takes 

into account that each veteran has many more presentations, or 

things wrong with them, than the civilian formula allows for. The 

formula that they use now is set up on one to three presentations. 

Why? Because it was designed for PPOs and HMOs and people who 

can afford to buy those kinds of plans. That, by and large, is not 

necessarily who we see at VA hospitals. 

In regard to the wait times, I just wanted to give some perspective here. In 2009, VVA testified before the Congress in regard to 

the budget, ‘‘We are more than a little skeptical that, as the VA 

touts, the budget will provide resources to virtually eliminate the 

patient waiting time by the end of 2009.’’ That was 5 years ago, 

and they are still struggling with it. If the formula is not working 

to tell you how many clinicians you need, then you need to get a 

new formula, as well as management improvements. 

There are a couple of things I want to mention about the Choice 

Card. VVA has always backed using fee-basis options when it is a 

service that is available in the community and it is otherwise a 

long commute for the veteran. But, the reason why—I know the 

Secretary in his motivation, which is a laudable one, to have a lot 

of flexibility in all of the fundings, but I will tell you right now, if 

the Vet Centers had not had fenced funding, they would not have 

been there when the OEF/OIF/OND veterans came home. They 

would have gone, poof, up in smoke. 

Recently, the QUERI groups around the country—those are 

groups of clinicians who come up with the best practices and come 

up with the best medicine or, excuse me, best evidence-based medicine recommendations—all of their funding got swept clean. A little 

bit of it was restored, but if you do not have QUERI groups, you 

do not have evidence-based medical practice. So, the reason for that 

is why the fences came up, because things went awry at VA over 

time. 

Another example is Hepatitis C. There are 175,000 veterans 

within the VA system who have tested positive and we finally have 

191 

a cure. We finally know who they are and can move forward. But, 

one of the reasons it has taken so long to get to that point is every 

time that Congress gave fenced-off money to the VA to address the 

problem of Hepatitis C, nobody could account for the money, and 

we think that is crazy. 

There are two things that really need to happen, and when I say 

that we want strings on the appropriations, it is: one, that they be 

able to tell you how many clinicians do they have in Dublin, GA, 

who deal with PTSD and TBI at any given time without having to 

send somebody out there to count; and, two, that you know exactly 

what is happening, that they start tracking veterans so you know 

what treatment modality is most effective. All of those kinds of accountability mechanisms are still lacking in the VA and need to get 

fixed. 

Another example of something that needs real attention. The National Vietnam Veterans Longitudinal Study, which was a replication of the original study done in the mid-1980s, the National Vietnam Veterans Readjustment Act, is finally done. It was delivered 

to the VA Central Office in September 2014 and it still has not 

reached the Congress. And, the reason is, quote-unquote, a ‘‘legal 

problem’’ the General Counsel has because they want to order the 

contractors to destroy the data of the original study back in 1985. 

Had that been done—which they wanted to do after the first one— 

there could not have been a replication. 

So, it is that kind of accountability that we need to bring in and 

have a central place for a repository of data that everybody trusts. 

We have such a thing. It was started after World War II by General DeBakey, Dr. Roger [sic] DeBakey, and its medical follow-up 

agency was part of the Institute of Medicine of the National Academies of Sciences. We recommend, one, that all things be turned 

over to them, whether ranchhand information or the National Vietnam Veterans Longitudinal Study, and, two, that VA set aside $4 

million per year for maintaining that data and cataloging it in 

modern computer language. 

Mr. Chairman, I thank you very much for the opportunity to 

present here today. 

[The prepared statement of Mr. Weidman follows:] 

PREPARED STATEMENT OF RICHARD WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY AND

GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA

Chairman Isakson, Ranking Member Blumenthal and distinguished Members of 

the Committee: On behalf of the Board of Directors, and members, I thank you for 

giving Vietnam Veterans of America (VVA) the opportunity to testify today regarding the President’s fiscal year 2016 budget and 2017 advanced appropriations request for the Department of Veterans Affairs. VVA thanks each of you on this distinguished panel, on both sides of the aisle, for your strong leadership on issues and 

concerns of vital concern to veterans and their families. 

I want to thank you for recognizing that caring for those who have donned the 

uniform in our name is part of the continuing cost of the national defense. Caring 

for veterans, the essential role of the VA and, for specific services other Federal entities such as the Department of Labor, the Small Business Administration, and the 

Department of Health and Human Services, must be a national priority. This is 

poignantly clear when we visit the combat-wounded and ill troops at military medical centers across the country. 

192 

OVERVIEW

On the whole, this budget proposal is a good start, but the overall requests for 

additional resources are just too low. With concerted work however it can be the 

most viable budget and appropriations document we have had in many years, of 

which we all can be proud. 

VVA is still concerned that there will not be enough resources to deal with the 

flood of troops that continue to separate and have recently separated from the military and may present at VA with a range of mental health as well as TBI and other 

physiological health issues. The newer veterans, and the older ‘‘new to VA’’ veterans 

from previous generations who are now using VA healthcare facilities and services 

added to a volume of needs that was already taxing VA resources. This set up the 

conditions whereby there were way too few clinicians for increasingly too many clinical needs, which put pressure all the way down the line to not have delays in seeing sick veterans. Because they did not have the organizational capacity to do this, 

then the local staff got into the business of making it appear that there were no 

wait lists. 

We do not say this in any way of excusing the lying and the falsification of data. 

There is no excuse for that. However, if the problem is to be fixed, then there simply 

needs to be a sharp increase in the number of clinicians at VA, and a priority put 

on providing enough appropriate clinical space at the earliest possible date. What 

this means is that there must be construction funds for converting what exists in 

the VA’s older hospitals to accommodate a modern clinic configuration. If they need 

to move executive and other offices to temporary buildings outside of the main hospital building (s) in order to have enough room, then let us get on with it. 

While many do not like to focus on the fact that there are way too few clinicians, 

that is the case now, as it has been for more than a decade. As one example VVA 

said in testimony in 2009: 

We are more than a little skeptical that, as the VA touts, the budget will 

provide resources ‘‘to virtually eliminate the patient waiting list by the end 

of 2009.’’ When have we heard this before? 

The ‘‘wait list’’ on the medical side, and the ‘‘backlog’’ on the Compensation and 

Pension side of VA simply have to have more resources (mostly people) if these problems are to be solved. 

To us the key is to modify the formula that is used to estimate clinical needs to 

reflect the veterans who are served. The number of disability issues to be adjudicated in each claim has risen dramatically in the last five years, even faster that 

the number of veterans seeking both medical care and adjudication of legitimate 

claims. That is mirrored in the sharp rise in the number of maladies in veterans 

seeking medical care 

Our recommendation is to change the formula to reflect reality of veteran’s health, 

and in the meantime fund VHA for at least $71 Billion this year and Advance Appropriations for at least $74 Billion, with at least $3 to 3.5 Billion in third-party 

medical care collections each year. Even this estimate is likely an understatement 

of the need. 

EVIDENCE BASED MEDICINE

VA has a well-established system of ‘‘QUERI’’ groups that have functioned reasonably well for some years to establish a baseline for evidence based medicine within 

the VA. The budgets for these groups were recently ‘‘swept away’’ by the Secretary. 

If there are efforts to reorganize and improve this vital tool, then fine. But to virtually cripple or to outright de-fund the QUERI groups signifies that VA is going 

to not have a mechanism to know the standards for evidence based medicine. 

This situation needs to be corrected immediately and certainly in the budget for 

the coming year. 

MENTAL HEALTH—NEED TO INCREASE ORGANIZATIONAL CAPACITY FOR

SUBSTANCE ABUSE TREATMENT

VVA urges that language be inserted in the Appropriations bill before Congress 

to express concern that substance abuse disorders among our Nation’s veterans are 

not being adequately addressed by the Veterans Health Administration (VHA). The 

relatively high rate of drug and alcohol abuse among our Nation’s veterans (much 

of which is self-medication to deal with untreated PTSD), especially those returned 

from service in Operations Enduring Freedom, Iraqi Freedom, and New Dawn is 

causing significant human suffering for veterans and their families. 

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These folks can and will be stronger for their experience if we only will deliver 

the effective care they need when they need it in a way they will accept. 

Further delay in moving to increase effective mental health and substance abuse 

services will lead to poorer health and more acute health care utilization in the out 

years, not to mention economic opportunity cost to the Nation and needless suffering by these veterans, and their families. 

VVA urges the Congress to direct the Secretary to provide quarterly reports beginning with a baseline report by each Veterans Integrated Service Network (VISN) 

and each VA Medical Center (VAMC) on the number and type of clinicians engaged 

in mental health, especially those engaged in treating PTSD and substance abuse. 

VVA also strongly urges the Senate to direct the Secretary of Veterans Affairs to 

update the VHA Strategic Plan for Mental Health Services, specifically to improve 

VA’s treatment of TBI, PTSD and other mental health conditions, as well as substance use disorders. These reports will provide an ongoing indication of VHA’s 

progress in the implementation of its adopted Strategic Plan as described in section 

1.2.8 of ‘‘A Comprehensive VHA Strategic Plan of Mental Health Services,’’ May 2, 

2005. In addition to baseline information, at minimum these reports should include: 

the current ranking of networks on their percentage of substance abuse treatment 

capacity along with plans developed by the lowest quartile of networks to bring their 

percentage up to the national average; and, the locations of VA facilities that provide five days or more of inpatient/residential detoxification services, either on site, 

at a nearby VA facility, or at a facility under contract to provide such care; and, 

the locations of VA health care facilities without specialized substance use disorder 

providers on staff, with a statement of intentions by each such facility director of 

plans to employ such providers or take other actions to provide such specialized 

care. 

We must continue to restore and enhance capacity to deal with mental disorders, 

particularly with Post Traumatic stress Disorder and the often attendant co-morbidity of substance abuse. In particular, substance abuse treatment needs to be expanded greatly, and be more reliant on evidence based medicine and practices that 

are shown to actually be fruitful, and be held to much higher standards of accountability, as noted above. The 21 day revolving door or the old substance abuse wards 

is not something we should return to, but rather treatment modalities that can be 

proven to work, and restore veterans of working age to the point where they can 

obtain and sustain meaningful employment at a living wage, and therefore re-establish their sense of self-esteem. 

NATIONAL CENTERS FOR PTSD

VVA also urges that additional resources explicitly be directed in the appropriation for FY 2016 to the National Centers for PTSD for them to add to their organizational capacity under the current fine leadership. The signature wounds of the recently completed wars are PTSD and Traumatic Brain Injury and a complicated 

amalgam of both conditions. VVA believes that if we provide enough resources, and 

hold VA managers accountable for how well those resources are applied, that these 

fine young veterans suffering these wounds can become well enough again to lead 

a happy and productive life. 

SEPARATE FUNDING LINE FOR THE VET CENTERS

The funds for the Vet Centers should be used to develop or augment permanent 

credentialed staff at VA Vet Centers (Readjustment Counseling Service or RCS), as 

well as coordinating with the PTSD teams and substance use disorder programs at 

VA medical centers and clinician who are skilled in treating both PTSD and substance abuse at the CBOC, which will be sought after as more troops (Including demobilized National Guard and Reserve members) return from ongoing deployments. 

VA also urges that the Secretary be required to work much more closely with the 

Secretary of Health and Human Services, and the states, to provide counseling to 

the whole family of those returning from combat deployments by means of utilizing 

the community mental health centers that dot the Nation. Promising work is now 

going on in Connecticut in and possibly elsewhere in this regard that could possibly 

be a model. In addition, VA should be augmenting its nursing home beds and community resources for long term care, particularly at the state veterans’ homes. 

BLIND AND LOW VISION VETERANS NEED MUCH GREATER RESOURCES AND ATTENTION

With the number of blind and very low vision veterans of the Nation’s latest wars 

in need of services now, VVA strongly recommends the Congress explicitly direct an 

additional $50 million for FY 2016 to increase staffing and programming at the VA’s 

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Blind and Visually Impaired Service (VIST) Centers, and to add at least one new 

center. 

Further, VVA recommends that the Congress direct the Secretary to implement 

an employment and independent living project modeled on the highly successful 

‘‘Project Amer-I-Can’’ that so successfully placed blind and visually impaired veterans into work and other situations that resulted in them becoming much more autonomous and independent. That program was a cooperative venture of the New 

York State Department of Labor, the Veterans Employment & Training Service 

(VETS), and the Blind Veterans Association twenty years ago, but can still work 

now. 

MEDICAL AND PROSTHETIC RESEARCH

For medical and prosthetic research for fiscal year 2016, VVA recommends $950 

million. This would be the largest increase ever in this part of the budget, but it 

is needed and should be ‘‘with strings’’ that the VA start doing research that will 

stand up to peer review in regard to toxins of all sorts that have affected US military members and/or their families, especially their progeny. 

VA’s research program is distinct from that of the National Institutes of Health 

because it was created to respond to the unique medical needs of veterans. In this 

regard, it should seek to fund veterans’ pressing needs for breakthroughs in addressing environmental hazard exposures, post-deployment mental health, Traumatic Brain Injury, long-term care service delivery, and prosthetics to meet the multiple needs of the latest generation of combat-wounded veterans. 

NVVLS

The National Vietnam Veterans Longitudinal Study (NVVLS) has been completed 

at long last, and languishes at the VA Central office. The General Counsel at VA 

says there is a ‘‘legal problem’’ with transmitting this report to the Congress and 

the public. The so called legal problem is that VA wants to destroy all of the data 

in the original National Vietnam Veteran Readjustment Study (NVVRS). The VA 

General Counsel first wanted to destroy that data right after that study was first 

completed in the mid-1980s. Had they done so, there could never have been this follow up study. 

VVA urges the Committee to designate the Medical Follow Up Agency (MFUA) 

as the repository of the data from NVVRS, NVVLS, and all other such studies. Dr. 

Richard De Bakey was instrumental in founding MFUA following World War II. 

Their database was used to finally be able to identify Hepatitis C in 1987. VVA 

urges that all data from all such large scale studies go to MFUA, along with funds 

to maintain and properly automate and search said data. 

VVA further urges that you ask for a specific line item of $4 million to go to 

MFUA this year and to direct VA to turn over all such data to MFUA immediately. 

Further, VVA strongly urges the Congress to mandate and fund longitudinal studies to begin virtually immediately, using the exact same methodology as the 

NVVRS, for the following cohorts: a) Gulf War of 1991; b) Operation Iraqi Freedom; 

and, c) Operation Enduring Freedom. 

Please take action now so that these young veterans are not placed into the same 

predicament Vietnam veterans find ourselves today. 

HOMELESS VETERANS

Homelessness is a significant problem in the veterans’ community and veterans 

are disproportionately represented among the homeless population. While many effective programs assist homeless veterans to become productive and self-sufficient 

members of their communities and Congress must ensure that the Department of 

Veterans Affairs has adequate funding to meet the needs of the homeless veterans 

who served this country so proudly in past wars and veterans of our modern day 

war. 

HOMELESS PROVIDER GRANT AND PER DIEM PROGRAM

The Department of Veterans Affairs Homeless Grant & Per Diem Program has 

been in existence since 1994. This program addresses the needs of homeless veterans and supports the development of transitional, community-based housing and 

the delivery of supportive services. Because financial resources available to HGPD 

are limited, the number of grants awarded and the dollars granted are restrictive 

and hence many geographic areas in need suffer a loss that HGPD could address. 

VVA recommends increasing the Homeless Grant and Per Diem (HGPD) program 

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to $250 million and increasing the Supportive Services for Veteran Families (SSVF) 

program to $375 million for FY 2016. 

HUD-VASH

The HUDVASH program was established as a partnership between the Departments of Veterans Affairs and Housing and Urban Development to combine permanent housing with supportive medical services. VVA supported passage of Public 

Law 110–161 which included $75 million for 7,500 Section 8 vouchers for homeless 

and disabled programs. Under this program, VA must provide funding for supportive services to veterans receiving rental vouchers. The FY 2016 VA budget must 

reflect a significant increase in funding these services. 

The program ‘‘housing first’’ simply does not work over a protracted length of time 

without significant and effective supportive services. Historical data that shows each 

housing voucher requires approximately six thousand dollars in supportive services—such as case management, personal development and health services, transportation, etc. Rigorous evaluation of this program indicates this approach significantly reduces the incidence of homelessness among veterans challenged by chronic 

mental and emotional conditions, substance abuse disorders and other disabilities. 

The Veterans Benefits Administration (VBA) continues to need additional resources and enhanced accountability measures. VVA recommends an additional 300 

over and above the roughly 700 new staff members that are requested in the President’s proposed budget for all of VBA. 

COMPENSATION & PENSION

VVA recommends adding at least nine hundred staff members above the level requested by the President for the Compensation & Pension Service (C&P) specifically 

to be trained as adjudicators. Further, VVA strongly recommends adding an additional $75 million dollars specifically earmarked for additional training for all of 

those who touch a veterans’ claim, institution of a competency based examination 

that is reviewed by an outside body that shall be used in a verification process for 

all of the VA personnel, veteran service organization personnel, attorneys, county 

and state employees, and any others who might presume to at any point touch a 

veterans’ claim. 

VOCATIONAL REHABILITATION

VVA recommends that you seek to add an additional two hundred specially 

trained vocational rehabilitation specialists to work with returning servicemembers 

who are disabled to ensure their placement into jobs or training that will directly 

lead to meaningful employment at a living wage. It still remains clear that the system funded through the Department of Labor simply is failing these fine young men 

and women when they need assistance most in rebuilding their lives. 

VETERANS ECONOMIC OPPORTUNITY ADMINISTRATION AT VA

VVA strongly favors moving this function to VA in a new fourth division of VA 

that deals solely with helping veterans become as independent as possible. For those 

of working age, this means helping them successfully enter the civilian workforce. 

While we will address this in greater detail next week, this is a crucial aspect of 

the budget and planning process. 

VVA has always held that the ability to obtain and sustain meaningful employment at a living wage is the absolute central event of the readjustment process. 

Adding additional resources and much greater accountability to the VA Vocational 

Rehabilitation process is essential if we as a nation are to meet our obligation to 

these Americans who have served their country so well, and have already sacrificed 

so much. 

HEPATITIS C

Vietnam Veterans of America (VVA) urges you to allocate funds for life-saving 

treatments for veterans suffering from the hepatitis C virus (HCV) consistent with 

the Department of Veterans Affairs request in the President’s proposed budget. 

The hepatitis C virus is one of the greatest health threats facing American veterans. HCV is an infectious, blood-borne disease and the leading cause of catastrophic liver damage, cirrhosis, liver cancer and liver transplants. This potentially 

fatal disease can take years or decades to present symptoms, and by the time individuals feel sick—long after many veterans have left the battlefield—the disease has 

often already taken its toll. 

196 

Veterans are at a disproportionately high risk for the hepatitis C virus due to the 

potential for blood exposure in combat or medical settings. While hepatitis C is a 

growing epidemic across the country, where more than 3.2 million Americans are 

infected with the virus, it is even more rampant among veterans. Prevalence of HCV 

among veterans who receive care through the Veterans Health Administration is 

twice the rate reported in the general population. 

Approximately 175,000 VA enrollees have been diagnosed with HCV and at least 

30,000 have cirrhosis, a number that has doubled over the last decade. In addition, 

because the infection is often asymptomatic, the VA estimates that as many as 

42,000 enrollees may be infected with the virus but are undiagnosed. 

Revolutionary new hepatitis C treatments have given veterans hope of a cure for 

this deadly disease. Early detection of the hepatitis C virus through screening and 

access to new, more effective HCV treatments significantly decreases the progression of the disease to cirrhosis, liver failure, liver cancer, and death. 

The VA has placed a high priority on ensuring that all veterans living with HCV 

have access to the treatments they need. We urge you to allocate the funds necessary to help the VA provide care to those affected and encourage the Agency to 

screen veterans to diagnose the remaining 42,000 who do not know their status. 

ACCOUNTABILITY AT THE VA

There is no excuse for the dissembling and lack of accountability in so much of 

what happens at the VA. It is certainly better than it was a year ago, but there 

is a long way to go in regard to cleaning up that corporate culture to make it the 

kind of system it should become. VA must change so that it can be trusted to get 

the ‘‘biggest bang for the taxpayer’s buck.’’ It can be cleaned up and done right the 

first time, if there is the political will to hold people accountable for doing their job 

properly. 

Thank you again, Mr. Chairman, for allowing VVA to be heard at this forum. We 

look forward to working with you and this distinguished Committee to obtain an excellent budget for the VA in this fiscal year, and to ensure the next generation of 

veterans’ well being by enacting assured funding. I will be happy to answer any 

questions you and your colleagues may have. 

Chairman ISAKSON. Well, I want to thank all of you. And as a 

testimony to the VA and its leadership, they are all sitting behind 

you, listening to your testimony. I think that is a credit to them 

and a credit to you, as well. 

Let me just say first of all, I am sorry you had to wait so long 

to testify, but I am grateful for the quality of your testimony and 

I appreciate that very much. 

Each one of you mentioned—you know, I sat here for two-anda-half hours. Nobody once questioned the quality of health care in 

the Veterans Administration, not one statement. But, the delivery 

of that health care is locked in the 19th century while the quality 

of that health care is in the 21st century. So, I think what we have 

got to do is make sure the delivery system to our veterans is improved, the access is improved, and it is a state-of-the-art system; 

that we work with the Secretary to see to it that it happens. That 

is number 1. 

Ms. Ilem, I agree with you on the fully-developed claim. One of 

the big problems, as I understand it, on the appeals now is they 

remain open many times and people file amendments to those 

claims and supplements to those claims, which protracts the decisionmaking process. I have become convinced that if we will close 

those claims and force people to get all their claims in and all their 

evidence and documentation in to have a fully-developed claim 

ready for review, we can speed up the system and improve the 

quality of claims adjudication. Would you agree with that? 

Ms. ILEM. I think we want to make sure that the VSOs work 

with VA hand-in-hand to make sure that as many as possible could 

be fully developed for the appeals, like we have with the claims, 

197 

which are now up to about 40 percent of us submitting fully-developed claims. So, we want to be able to help them make sure they 

have the appropriate evidence. But, I think we still need—we 

would still need to have the out. If the veteran needs to submit 

something else, it will revert back to a traditional appeal. 

Chairman ISAKSON. Mr. Kelley, I do not know anything about 

anything except real estate. That is how I made a living for 33 

years. You were right on target. The leasing mechanisms at the VA 

are deplorable. The construction disciplines are deplorable. And, a 

lot of it is because they simply have not modernized the process 

they go through. 

I have worked at locations of CBOCs in Georgia through leasing. 

We have amended and expanded the hospital at Clairmont Road. 

It is very important that we modernize the system of maintenance 

and operation. We are costing ourselves more money by letting deferred maintenance cause obsolescence than by having an active 

maintenance process that goes all along. So, I am going to work 

with the Secretary and the appropriate people to do exactly that. 

And, to all of you, thank you for your service. Thank you for volunteering your testimony here today. It does not go unnoticed nor 

unpublished. We will work with you to coordinate and see to it that 

next year when we come back and have the same type of hearing, 

we can report on the successes we had in accomplishing some of 

the things you recommended today, to have them implemented and 

in place next year. 

With that said, Ranking Member Blumenthal, if you have any 

questions or comments. 

Senator BLUMENTHAL. I have a couple of brief questions. First of 

all, thank you for being here, thank you for your service to our Nation in uniform and afterward, as well. And, thank you for your insights in your testimony. 

I think most of you—I believe all of you—were present when the 

panel before you testified, and you may have heard Secretary 

McDonald’s testimony about the Choice Card Program. My question to you is whether you can share with us any insights as to 

why the program has been so underutilized. Is it, in fact, the interpretation of the 40-mile rule? Is it the facilities definition that may 

ignore whether or not, in fact, care at that facility is available? Is 

it some other reason? Maybe you can give us the benefit of your 

insights on that question. 

Mr. KELLEY. I think it is a little bit of all of that. We have to 

keep in mind that we are only a few months into this program. VA 

had to implement it, begin training its personnel—and it is a complicated process, as well—to train those people to first know whether or not a veteran qualifies. How do they get hold of the person 

to schedule the appointment? How does that schedule get forwarded? So, it is a complicated process. I think the training within 

VA to get those front-line schedulers fully up to speed is critical. 

I think the idea of expanding the 40 miles or going from a geodesic distance to a driving distance, obviously, is going to change 

and the population will increase. But, I think, until we get training 

down and people are fully aware of how to implement the process, 

it is still going to be much lower than what we would want and 

what we expect. 

198 

Mr. DE PLANQUE. I am going to jump onto a couple of things that 

my colleague just said, and yes, a lot of our initial questions were 

confusion about eligibility. Am I eligible, is what we have been 

hearing. And, this is all anecdotal at this point. However, we have 

had a lot of people with concerns that, as we mentioned before, I 

am 38 miles from a facility but it does not have the service I need, 

so now I have to go 300 miles for that. So, we want to make sure 

that those veterans are going to be able to get the access to the 

care. 

As The American Legion was involved in the process, as we were 

all involved in the process of crafting this legislation last year, we 

wanted to be able to look at these metrics over the 3 years of the 

pilot program, where VA is having trouble meeting the needs, and 

be able to take that to know where to make VA more robust in the 

future; that we absolutely have seen that there are veterans who 

need to get access to their care and it is not being delivered 

through the system. It is not that veterans have problems with the 

care within VA. It is that they are having problems accessing it. 

So, to be able to use a program like the Choice Program, that we 

can get veterans into care, but also see through that, this tells us 

that this area of the country needs to have a more robust presence 

from VA and build that up for the future. This is a tool that we 

can use to supplement, whether for the pilot or other programs 

that we need to develop, to supplement what is going on with VA, 

but still with the ultimate goal of making that VA program—that 

VA Health Care System one that is there to serve veterans and is 

built in the areas that they need it. 

Because there has been some comment this morning about, you 

know, whether it is privatization or whether VA should only be a 

system for service-connected disabilities, so let us just address that 

right from the beginning. If you look at the myriad of conditions 

that can be service-connected, it affects all body systems. This is 

not—when I hear, it is only for service-connected conditions, that 

is somebody who does not understand service-connected conditions 

and does not understand what the veteran population who is using 

VA looks like. 

All of these conditions need to be within VA, and by serving a 

community of veterans who may not be service-connected for those 

issues, you are still building a community of physicians that can 

treat those service-connected veterans who have a lesser-known 

condition but that is still connected to their service. So, I think it 

needs to be a system that is robust enough to be comprehensive 

and to treat the entire veterans’ community that is out there. 

I think we absolutely need to have a lot of focus on our serviceconnected veterans and in making sure we do not make problems 

worse for them. The VA system, it is a good system. It is an unbelievably comprehensive system that delivers great medicine because it is looking at the entire veteran. It is looking at how those 

service-connected conditions affect the other body systems, and I 

think that is important, as well. 

Senator BLUMENTHAL. I appreciate both of those comments, and 

what they highlight to me is that there is a need to better implement this program. There is also a need to understand the issues 

of delivery, as Senator Isakson has correctly characterized them, as 

199 

they relate to what is happening in the private sector, as well. In 

other words, the VA is not the only one where there are delays between the time you ask for an appointment and the time you get 

one. That happens to many of us who rely on private doctors. 

What really is one of the overriding challenges here to modern 

American medical care is the shortage of primary care physicians, 

nurses, and professionals in this area. The VA is reflecting those 

shortages, much like the canary in the mine. Unfortunately, in the 

VA, there was falsification of records and cooking the books that 

led to the investigation that is ongoing in the Inspector General, 

which, as I have said before, I am going to say it again, I hope 

comes to conclusion tomorrow. That is when we need the result. 

I appreciate your making the distinctions that you do, that I 

think are very important for the future of VA health care, and, in 

effect, saying, here is where the issues are. Let us target the problems. Let us not just abandon the system. Let us make Choice 

work where it is needed. 

I could make a pretty good legal argument that under the existing statute, that 40-mile rule could be reinterpreted. I could make 

a pretty good lawyer’s argument, but there is an argument on the 

other side, too. A lot of people wish there were lawyers with only 

one hand so they would not say, ‘‘On the one hand, and on the 

other hand.’’ [Laughter.] 

I think what is necessary is clarity from the Congress to give direction that the 40-mile rule should be interpreted with common 

sense, not just the narrow technical wording of the statute. The intent of Congress was to provide as broad an access as possible, and 

that is what is perhaps lacking right now. 

Thank you so much for being here. Thanks for your patience in 

listening to all of us, and thanks for your great work for the veterans of America. 

Chairman ISAKSON. Since time is of the essence, I am not going 

to get into my opinion of lawyers, so—— 

[Laughter.] 

Senator BLUMENTHAL. I am very grateful for that, Mr. Chairman. 

Chairman ISAKSON. I have a great one to my right and to your 

left in Richard Blumenthal—— 

Senator BLUMENTHAL. Thank you. 

Chairman ISAKSON [continuing]. Who is a great Ranking Member, who I appreciate. 

I am going to introduce Senator Moran and turn the gavel over 

to Senator Moran, as well, because I have a pending appointment 

that I am about 45 minutes late for. I want to thank you for being 

here. 

The record will be held open for 7 days to amplify your comments, correct your comments, or respond to questions that were 

raised or anything else you would like to submit. Thank you for 

your attendance today and thank you for your service to the 

country. 

Senator Moran, it is all yours. 

Senator MORAN [presiding]. Mr. Chairman, what a great opportunity. I only wish this had been the case when Secretary McDonald was—oh, he is still here, which I very much appreciate. 

200 

Mr. Chairman, thank you very much for this hearing. I appreciate what I just heard the Ranking Member, Senator Blumenthal, 

say. I, too, have the opinion that the interpretation could be made 

by the Department of Veterans Affairs, but, as you know, there is 

legislation to make clear that the definition of a facility would not 

include a facility that cannot provide the services that the veteran 

needs, even though it may be within the 40 miles of where the veteran lives. 

Let me ask that question. Is there something that I am missing 

here? You were all here during my conversation with Secretary 

McDonald. I assume that it makes sense for the Department to do 

everything possible to make certain that Choice works before we 

ultimately make a determination about how valuable it is or how 

many dollars and resources are necessary to fund it. Was there 

something I should have asked the Secretary that I did not ask in 

this regard? Does anybody have suggestions for something else that 

needs to be pursued in regard to implementation of the Choice Act? 

Mr. WEIDMAN. Senator Moran, we believe that it is the devil you 

know versus the devil you do not know, and this is a new thing 

that people have not gone through this before. Those who have 

gone through trying to get the bill paid on fee-basis services in the 

past and have finally ended up paying it themselves or going bankrupt, with that in mind, they have a hard time thinking, I am 

going to go outside and I am going to be liable if the VA does not 

pay for this. 

The second thing is that, because of that same thing, some outside physicians do not want to take it, just like some do not want 

to take Medicare anymore. 

The last thing is—in the military, we used to have a saying. You 

have got to tell them, you have got to tell them again, you have 

got to tell them that you told them, and et cetera, remind them 

that you told them that you told them. It takes a while for things 

to become familiar enough that people will step outside of what 

they already know very well. 

Senator MORAN. Thank you. Anyone else? 

Mr. BLAKE. Senator Moran, one question we would like to have 

answered as it relates to the Choice Program as it eventually and 

hopefully gets implemented widespread and appropriately, is something we have heard anecdotally, also, is that veterans are choosing Choice, taking advantage of the opportunity to go out and get 

purchased care in the private sector, and some veterans are returning to VA because they are finding that the option is not there even 

in the private sector in the areas that they live in, or that the wait 

times are just as long. We have expressed this to some of the folks 

at VA who are monitoring this, too, and we would like to know 

where you are seeing that problem and how prevalent it is, because 

it speaks a little bit to—if we have a concern, it is that there seems 

to be this inherent assumption that, well, the private sector can 

help us fix this problem. I am not sure that is wholly a true answer. 

Senator MORAN. Well, it allows me to soapbox on the ARCH Program, which was designed in advance, in a sense, of the Choice Act 

to create the pilot program to figure out how to fix some of the 

problems that might arise, such as medical records, communicaVerDate Mar 15 2010 00:26 Apr 24, 2016 Jkt 000000 PO 00000 Frm 00204 Fmt 6633 Sfmt 6601 Z:\ACTIVE\022615.TXT PAULIN
201 

tions between the VA and the outside provider. It does not seem 

to me that the VA has adequately utilized ARCH as a pilot program to determine how best to now, in a sense, implement the 

Choice Act. 

There is no one here who would—that is a leading question. No 

one would disagree with me that if—— 

[Laughter.] 

Senator MORAN [continuing]. If you are a veteran that lives within 40 miles of an outpatient clinic that does not provide a 

colonoscopy, that you ought to be able to get those services at 

home, if they are provided and if that is what you want, and not 

be denied simply because there is an outpatient clinic within that 

40 miles, even though it does not provide the service that you need. 

Is that—does everyone agree with that? 

Mr. BLAKE. Senator, I explicitly remember the question being 

asked in one of our many meetings we had with VA about the 

question of, if the service is not available, how will that be handled? Clearly, VA has taken the strict interpretation of the law as 

it is written. If I looked up facility—somebody suggested, you know, 

is a facility defined as a place that cannot provide the service, well, 

it probably does not have any kind of definition relating to that if 

you looked it up in the dictionary. So, that is a challenge. This 

question has been asked before we were at November 5, the implementation date. I am not sure anybody is purely satisfied at this 

point. 

Mr. KELLEY. We also have to remember that there are other nonVA care programs that VA can use at a local level. Those need to 

be used. PC3 could very easily have been used. There needs to be 

logic to this. That is what bothers veterans, is there is a lack of 

logic across the board. They do it here, but they do not do it here. 

How about this place, and that place? We need to find that logic, 

and that is based in standardization. 

Senator MORAN. I would take what you just said and tell the Department of Veterans Affairs there are many programs—ARCH, 

PC3, now Choice Act. Ultimately, there ought to be a program in 

which they are all organized, combined, to facilitate the providing 

of service in a logical, responsible way, and those programs give 

greater opportunity, not less, for the VA to actually meet the needs 

of the veteran, and I think that is what we are all interested in. 

The example that is so bad that it makes no sense is, the veteran 

calls from Hoxie, KS, who needs his eyeglasses adjusted. Hoxie is 

31⁄2–4 hours from Wichita, 31⁄2, 4, 5 hours from Denver. But, the 

VA is insisting he goes to Wichita to get his eyeglasses adjusted. 

He is a World War II veteran. He is not going to do it. There is 

an optometrist in the town of 2,000 people that could do it. 

Ultimately, we convinced the VA to do it, but that ought not— 

I certainly welcome the calls. My staff are there to help veterans. 

There needs to be a system that addresses this. It is like the light 

bulb goes off. Well, here is the logical thing to do. We have got all 

these array of options, Mr. Kelley, that you outlined, one of which 

is the PC3. There is a way to fix this, and there ultimately was, 

but it ought to be the norm, not the exception. 

Mr. WEIDMAN. It begins with General Counsel, and we said to 

the new Secretary numerous times, we need to get beyond the 

202 

‘‘General Counsel of No.’’ When somebody does not want to do 

something in the VA, they just say, ‘‘Well, the General Counsel will 

not let us.’’ I said, really? Is that the cousin of General Elevator 

and General Confusion? Who in the General Counsel’s Office? We 

ask, all of us, very often, can we see the written opinion, and there 

is not one. 

So, what happens within VA, all the way down to the local level, 

is ‘‘no’’ becomes the default answer instead of the default answer, 

‘‘yes,’’ what is good for the vet. How do we find a way to take care 

of this vet? That is absolutely a cultural change, but it is also 

something that only stems from people who have line authority 

over people saying, we are going to do this different. Default is not 

‘‘no’’ anymore. 

Senator MORAN. Thank you. 

Mr. DE PLANQUE. I was going to say, you brought up the same 

question yesterday and our Commander, a fellow Kansan, as you 

know, he referred to it as crazy. He literally put it out there. When 

we spoke with the Ranking Member, Mr. Blumenthal, he agreed 

with that. I think it is a common sense thing that seems like it is 

going beyond crazy. If you are sitting there on one side of a lake 

and 38 miles across that lake is a facility, but you have to drive 

150 miles of roads to get around that, or in some of the very rural 

States, you know, Vermont, where you just—the roads do not go 

that way, and so we have got to look at a common sense way to 

get this interpreted and get the veterans the access to the care that 

they need. 

I think what we have seen is that there is a willingness on Capitol Hill to continue to work with the VSOs, as we get the feedback 

from veterans we are trying to get, to make sure we get this ironed 

out and interpreted in a way that we are going to get the veterans 

the care. I think all of us, the VA, I think the members up here 

of both committees in the House and Senate, I think the VSOs that 

are up here, we still have the same intent that we had at the beginning, which is how do we get the veterans the care, and we are 

trying to do that now and I think these are things that are going 

to help. 

Senator MORAN. Mr.—I can pronounce Ian. I cannot pronounce 

de Planque. 

Mr. DE PLANQUE. De Planque, just like ‘‘walk the plank.’’ 

Senator MORAN. Thank you. Mr. de Planque, The American Legion has endorsed the legislative solution, and I appreciate that, although it would be nice if, on the record, you will say that. 

Mr. DE PLANQUE. I will say that for you on the record. We have 

endorsed your legislative solution to the problem. 

Senator MORAN. Thank you very much. 

Mr. WEIDMAN. So, does Vietnam Veterans of America. 

Senator MORAN. Thank you very much. I appreciate that. 

Before I change topics, let me just say this. While we seem to 

focus on the 40 miles, and I recognize I do that, part of what someone said earlier is the expectation of whether or not veterans can— 

they have tried this before and it did not work and, therefore, they 

are reluctant to go try it again. That is why this is a broader issue 

than the 40 miles. It is, can we implement this law, the Choice Act, 

in a way that sends a message to veterans that we have finally got 

203 

a system in process—in place that processes their claims and their 

health care, and the skepticism begins to disappear. That is why 

this is so important to get it right early so that we do not dash the 

hopes of good things happening at the Department of Veterans Affairs. 

The final thing I would say, and I apologize to my colleague, Mr. 

Blumenthal, although ever since he said that the Chairman was 

his favorite Chairman—— 

[Laughter.] 

Senator MORAN [continuing]. I have lost some level of regard for 

your—— 

Senator BLUMENTHAL. No, I was referring to the Acting Chairman. 

Senator MORAN. Oh, it still is. All right. Thank you. I now understand. [Laughter.] 

Senator Blumenthal and I are—he is the Ranking Member and 

I am the Commerce Committee Chairman, but one morning in here 

he announced that Senator Isakson was his favorite Chairman, so 

I have taken offense ever since. 

I just wanted to thank the Vietnam Veterans for their efforts in 

regard to toxic substances. It is a topic that deserves more attention. Senator Blumenthal and I are cosponsors of legislation in the 

last Congress that we are getting ready to reintroduce in the new 

Congress and we want to work with all of you to make certain that 

many of our veterans who have experienced dramatic health consequences due to the presence of toxic substances during their term 

of service are cared for, but in addition to that, the concern that 

we have about having the necessary medical research to be then 

able to take care of children and grandchildren and those that follow. I think it is a hugely important topic that Senator Blumenthal 

and I care a lot about, and the Vietnam Veterans have been front 

and center with that, and I appreciate it. 

Mr. WEIDMAN. We thank you and Senator Blumenthal for your 

leadership, sir. 

Senator MORAN. I actually thought I was going to get to adjourn 

the meeting, but with the arrival of Senator Boozman, I would recognize him. 

HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN. I did that on purpose. [Laughter.] 

No, I just wanted to apologize for not being here during the entire meeting and really wanted to thank all of you. I have enjoyed 

working with you so much through the years. Time goes by. In fact, 

Jerry and I served over on the House Veterans Committee together 

and now are here, and again, I just appreciate you for your advocacy, really tireless advocacy. It is everybody working together, 

which you can be very proud, because of your efforts, hard work, 

and your memberships. You really have pushed things along and 

that is a great thing. 

One of the things that I am concerned about seeing in Arkansas 

is, the Choice Act and trying to make it easier on veterans. One 

of the concerns is that prior to that, when you had veterans with 

emergent care going and accessing a hospital or whatever, the VA 

was not paying the bill for that, or paying it very, very late. That 

204 

should not be. Now we are able to intervene and the VA on an individual basis has been good about working with us. 

A concern is that as we go forward with this other program, that 

you have situations where the hospital wants to get paid. They are 

hounding the veteran. They are hounding the VA. The VA is deciding. Next, the bill collectors are out there, I guess. Can you all comment about that? 

The other problem with that, also, is if you have that reputation, 

and we saw this with TRICARE and some other things, I can get 

people out of a sense of patriotism to participate in programs. 

Where they get in trouble is if they are hassled with unnecessary 

regulation or things that they have to do as far as extra paperwork 

or this or that. Again, everybody likes to get paid at some point, 

even if they are taking a lesser fee. 

Can you guys comment about that, because what we do not want 

to do is make it such that if we leave a bad taste in our providers, 

then it makes it more difficult than ever for them actually to participate in the first place. 

Mr. KELLEY. The good thing about the Choice Program is that 

the contractors will pay the provider and then VA will reimburse 

them. That really streamlines the process. That is a great standardization. There are some good processes in place for that. We 

need to figure out how to do that across the board, across all nonVA care delivery. 

Mr. DE PLANQUE. One of the things as we were jumping into 

working on developing the Choice Program was to be able to get 

that kind of feedback and metrics as we see how things work, and 

it is going to watch how this is working and see if it can be applied 

across to other programs, because, as you mentioned, there have 

been big problems with some of the VA contracted care programs 

in the past, getting money to doctors, and so we want to make sure 

that that was part of the thing with Choice, is that we can look 

at this as, perhaps, a model for how to make other programs work 

better. 

Mr. WEIDMAN. I would like—I am sorry, Joy. 

Ms. ILEM. I would just add, we are also very interested in the 

coordination of that care; the complete coordination of that care, 

whether it be the payment or making sure the records get back, 

you know, and making sure that the veteran then gets referred 

back to the VA when that episode of care is done, if need be, or 

that there is still that continuum of care and that connection for 

VA in the best interests of the veteran. 

Mr. WEIDMAN. It is experience. People will—vets will believe another vet who has had a successful experience, simple as that. 

Until you hit that critical mass where enough people have gone, 

you are going to have to, at each facility, walk people through the 

process, so that if they have confidence in the staff member, they 

will trust them to do it, and then they start to spread the word. 

Vets will believe another vet before they will believe the government by ten country miles. 

Senator BOOZMAN [presiding]. Right. No, in fact, one of the 

things we are seeing is the underutilization of the Choice Act, 

which I think is a reflection on the VA brand and the fact that 

205 

there is tremendous loyalty. I think the VA can be very proud of 

that. 

I see the Secretary sitting back there, and we appreciate you 

staying. I think that sends a great message, and we do appreciate 

your hard work. 

I do want to thank you all. Like I said, I figured out a way how 

to become the Chairman. [Laughter.] 

With that, we are adjourned. 

[Whereupon, at 12:19 p.m., the Committee was adjourned.] 

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