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[Senate Hearing 114-233]
[From the U.S. Government Publishing Office]

                                                        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
       
       
       
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Richard Blumenthal, Connecticut, 
John Boozman, Arkansas                   Ranking Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Jon Tester, Montana
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                 John Kruse, Democratic Staff Director
                 
                 
                 
                            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
Weidman, Richard, Executive Director for Policy and Government 
  Affairs, Vietnam Veterans of America...........................   190
    Prepared statement...........................................   191

                                APPENDIX

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

           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 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 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 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 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.
    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.
    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 
veteran-centric 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 prosthetics 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:]
    Prepared Statement of Hon. Robert A. McDonald, Secretary, U.S. 
                     Department of Veterans Affairs
                     
                     
                     
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
 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.
    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 requesting 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.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.

 
------------------------------------------------------------------------
                                                       2016
                                        --------------------------------
              Description                 Advance    Revised   Increase/
                                          Approp.    Request    Decrease
------------------------------------------------------------------------
Physicians.............................      611        651         40
Dentists...............................       15         10         (5)
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.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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 short-term 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        3,897,215
 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)..............
Funds Transferred from Line items:
  Facility Security........................................    8,401,000
  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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    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 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)
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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 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.

 
----------------------------------------------------------------------------------------------------------------
                                                                                Average               Issues Per
                          FY                            Completed    Issues      Issues     Direct       Direct
                                                         Claims     Completed   Claimed     C&P FTE       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.
    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 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 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 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 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 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.
    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 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 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 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 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, 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.
    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?

                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.
    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?
    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, 
Post-
9/11 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 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.
    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. 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.
    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.
    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 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 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.
    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 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 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?
    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 service-connected 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 helpful 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.
    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?
    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 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 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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.

     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: ``Medicare-equivalent 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.

     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 industry-mandated 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 increasing 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 co-
located 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 pharmaceuticals 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-over-year 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
     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.

    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. 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.
    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 nationally-funded 
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 appropriations. 
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.
    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.
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    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?
    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 land-use 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 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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.
    The table below reflects the anticipated use of the APDF in fiscal 
year (FY) 2016:

 
------------------------------------------------------------------------
                                                               Planned
                Location/Project Description                   Amounts
                                                                ($000)
------------------------------------------------------------------------
American Lake, WA--Buildings 81, 81AC and 18 Seismic             6,000
 Corrections...............................................
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        5,000
 and Replace Building 1....................................
San Francisco, CA--Seismic Retrofit Buildings 1,6 and 8/           200
 Replace Building 12.......................................
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           5,000
 Projects..................................................
Historic Preservation, Environmental, Value Management, and     10,000
 Cost Estimating Services (Various Projects)...............
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
------------------------------------------------------------------------
                                                               Number of
                           Project                               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 medical 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 non-rating 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 mandatory 
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 non-rating 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):

 
------------------------------------------------------------------------
                                         Non-Rating Claim
                                                and          Non-Rating
                                 FTE      Administrative     Production
                                         Actions Completed     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.

    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' 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 record-breaking 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     Appeals
                                               Completed    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
     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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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:

 
------------------------------------------------------------------------
                                                       2015       2016
       Received Claims           2013       2014     Estimate   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     642,573    731,274    807,070    830,759
 Products...................
Compensation Other End          584,742    666,898    710,454    731,767
 Products...................
                             -------------------------------------------
    Total Compensation        2,609,446  2,930,063  3,285,789  3,445,474
     Workload...............
------------------------------------------------------------------------

 
------------------------------------------------------------------------
                                                       2015       2016
      Completed Claims           2013       2014     Estimate   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     572,620    727,443    656,180    666,804
 Products...................
Compensation Other End          554,974    633,614    713,225    729,944
 Products...................
                             -------------------------------------------
    Total Compensation        2,555,882  3,035,159  3,276,230  3,335,679
     Workload Actions.......
------------------------------------------------------------------------

    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 accuracy. 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 management 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.

    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. Sec. 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 already-existing 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.
    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\ $16,0  \2\ $31,9
                                                           78         46
------------------------------------------------------------------------
\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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Question 35.  VA has requested $1.828 billion to maintain the 
current IT infrastructure. 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.

 
------------------------------------------------------------------------
                                                   Planned     Contracts
                Large Contracts                     Total      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
------------------------------------------------------------------------

 
------------------------------------------------------------------------
                                                   Planned     Contracts
               Other IT Support                     Total      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 customer 
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       VA delivers IT capabilities
 engaging with stakeholders          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   VA ensures all IT Project
 knowledge and skills                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     VA's Chief Information
 executives supporting the           Officer (CIO) and all Deputy Chief
 programs                            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       The business sponsor/
 involved in the development of      customer creates and approves a
 requirements                        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       Business sponsors and end
 testing of system functionality     users participate in reviews of
 prior to end user acceptance        code prior to also participating in
 testing                             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
------------------------------------------------------------------------
(6) Government and contractor        VA has re-structured the
 staff being stable and consistent   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       VA's IT delivery framework
 requirements                        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 re-
                                     prioritization (as necessary) of
                                     requirements
------------------------------------------------------------------------
(8) Program officials maintaining    IPTs are the organizational
 regular communication with the      entity for ensuring program
 prime contractor                    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    No project can start or
 funding                             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, well-defined 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 bi-weekly 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 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 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 long-standing 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 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. 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
------------------------------------------------------------------------
                                            Number of Male
                                              and Female
                                               Veterans
                   Year                      Receiving VA    Obligations
                                             MST-Related
                                                 Care
------------------------------------------------------------------------
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 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.
    Response. Please see the attached VBA Workforce Analysis submitted 
to Congress on March 2, 2015.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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 case-tracking 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
----------------------------------------------------------------------------------------------------------------
                                                             VSO                      Claim Agents
                    Calendar Year                      Representatives    Attorneys                     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 accreditation 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 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 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:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    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.
                         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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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) Comparing 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 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 non-institutional 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 Development-VA 
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 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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.

    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:

 
----------------------------------------------------------------------------------------------------------------
                                              FY 2016     $ for
                  Location                    Request     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;         --         *   The FY 2016 National Cemetery Administration
 Portland, OR; Riverside, CA; and                                  (NCA) major construction projects ensure
 Pensacola, FL.                                                    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?
    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 Safety 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 no-shows. The statistics are 
collected through the Veterans Health Information System and Technology 
Architecture (VistA) scheduling system when each appointment is 
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.
    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 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 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 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 approximately $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-term-care 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 (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 $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, 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 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 clinician-
scientists 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 
Federal-state 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 long-term-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.

 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.
    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 full-time 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 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 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 paper-based 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 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 appellate-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, it 
will provide another option that each individual veteran and his or her 
representative, 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 counselor-to-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 service-related injury or 
disease.
    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 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 non-recurring 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 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.
---------------------------------------------------------------------------
    \1\ Department 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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \2\ Department 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.
---------------------------------------------------------------------------
    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 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.

  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 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).
    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.
---------------------------------------------------------------------------
    \1\  http://www.stripes.com/va-workers-say-mandatory-overtime-won-
t-solve-benefits-backlog-1.221294
---------------------------------------------------------------------------
    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.
                   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.
---------------------------------------------------------------------------
    \2\ http://www.legion.org/sites/legion.org/files/legion/
publications/war-within.pdf
    \3\ http://www.legion.org/veteranshealthcare/222891/legion-survey-
ptsdtbi-care-not-working
    \4\ http://www.legion.org/veteranshealthcare/222891/legion-survey-
ptsdtbi-care-not-working
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    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.
---------------------------------------------------------------------------
    \5\ http://kdvr.com/2014/12/17/va-announces-deal-to-start-work-on-
aurora-hospital/
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    In February 2012, The American Legion presented the following 
warning about insufficient funding in VA's construction budgets and 
capital investment plans:

          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\
---------------------------------------------------------------------------
    \6\ American Legion testimony before HVAC on the VA Budget, 
February 15, 2012

    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\
---------------------------------------------------------------------------
    \7\ Resolution 282: Congressional Budget Office Scoring on 
Department of Veterans Affairs Leasing--AUG 2014
---------------------------------------------------------------------------
                               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.
---------------------------------------------------------------------------
    \8\ http://www.legion.org/vavolunteers
---------------------------------------------------------------------------
    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.
    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 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.
                                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.
    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 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 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.
    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-
and-a-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, 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.
    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 
service-connected 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 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.
    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, 
communications 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 
non-VA 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 3\1/2\-4 hours from Wichita, 3\1/2\, 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 
``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 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 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 non-VA 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 
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.]

                            A P P E N D I X

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