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MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2016 

TUESDAY, MARCH 10, 2015 

U.S. SENATE, 

SUBCOMMITTEE OF THE COMMITTEE ON APPROPRIATIONS, 

Washington, DC. 

The subcommittee met at 2:34 p.m., in room SD–124, Dirksen 

Senate Office Building, Hon. Mark Kirk (chairman) presiding. 

Present: Senators Kirk, Murkowski, Hoeven, Boozman, Capito, 

Cassidy, Tester, Udall, Schatz, Baldwin, and Murphy. 

DEPARTMENT OF VETERANS AFFAIRS 

VETERANS HEALTH ADMINISTRATION

STATEMENT OF DR. CAROLYN M. CLANCY, M.D., INTERIM UNDER SECRETARY FOR HEALTH 

ACCOMPANIED BY JAMES TUCHSCHMIDT, M.D., ACTING PRINCIPAL 

DEPUTY UNDER SECRETARY FOR HEALTH 

OPENING STATEMENT OF SENATOR MARK KIRK

Senator KIRK. Let me just start with a brief opener here and say 

that back in 1984, I came to my first House Appropriations Committee meeting. I would say that, for some of the staff in this room, 

you may be in this chair one day 30 years from now. And it is a 

great honor for me to be chairing this subcommittee, to take care 

of my fellow veterans, and to make sure the Active Duty forces are 

properly housed and taken care of. 

And I am very excited to have testimony from Dr. Clancy and Dr. 

Tuchschmidt. 

And I will turn it over to my august ranking member, Senator 

Tester. 

STATEMENT OF SENATOR JON TESTER

Senator TESTER. Well, thank you, Chairman Kirk. I look forward 

to working with you, too, and congratulations on assuming the 

chairmanship of this subcommittee. The issues that will come before this subcommittee are very important. 

Secretary Clancy, Dr. Tuchschmidt, thank you for appearing before the subcommittee and thank you for your service to our Nation’s veterans. You are facing enormous challenges in restoring 

the credibility of the Veterans Health Administration (VHA) and 
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ensuring top-notch healthcare for our veterans. And I assure you 

that I will do all that I can to assist you in your job and your mission. 

The scandals that rocked the VHA over the past year have revealed severe problems in management of the agency’s healthcare 

system. As you noted in your prepared testimony, Secretary 

Clancy, to say that the VHA had a crisis on its hands in 2014 

would be an understatement. 

Congress acted swiftly and aggressively in response to that crisis 

with passage of the Veterans Choice Act. And it is now up to the 

Department of Veterans Affairs (VA) to use the authorities and resources that Congress has provided to take the necessary steps toward correcting our course. 

In doing so, the VA must ensure both transparency and accountability in implementing the act and allocating those resources. VA 

must also recognize the Choice Act as a temporary program, a 

bridge to give the VA time and the resources to align its healthcare 

programs, providers, and facilities to meet the needs of today’s and 

tomorrow’s veterans. 

I am most interested in how the VA will address these urgent 

issues while also building its capacity to serve veterans in the 

years to come, as that capacity will need to be increased. 

In Montana, much of the conversation begins and ends with the 

VA’s ability to address medical workforce shortages. It has reached 

a crisis level in our State. It is impacting the VA’s ability to deliver 

care, and it is undermining the credibility of the VA. It needs to 

be addressed, and it needs to be addressed soon. 

I look forward to your thoughts on how the VHA plans to undertake this mission. 

With that, Mr. Chairman, once again congratulations, and I look 

forward to working with you. 

Senator KIRK. Any other members seek recognition? 

Mr. Schatz. 

Senator SCHATZ. Mr. Chairman, I would be happy to move forward with the testimony, thank you. 

Senator KIRK. Thank you. 

Proceed, guys. 

SUMMARY STATEMENT OF DR. CAROLYN M. CLANCY, M.D. 

Dr. CLANCY. Good afternoon, Chairman Kirk, Ranking Member 

Tester, and members of the subcommittee. Thank you for the opportunity to appear before you to discuss the Department of Veterans Affairs’ Veterans Health Administration fiscal year 2016 and 

2017 medical care advance appropriations budget request. 

I am accompanied today by Dr. James Tuchschmidt, Acting Principle Deputy Under Secretary for Health. 

As Senator Tester just said, the year 2014 will likely be recognized as one of the most memorable in VHA’s history, and to say 

that we had a crisis on our hands would be an understatement. We 

realize the significant work that lies ahead. 

The good news is that moving forward along with Congress, we 

have an incredible, amazing opportunity to reshape the future and 

make long-lasting valuable changes. The Department of VA as a 

whole is working to rebuild trust with veterans and the American 
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people, improve service delivery, and set the course for long-term 

VA excellence in reform while delivering better access to care and 

benefits. 

This includes 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. 

As we enter 2015, all of us in the VA healthcare system will be 

focused on the MyVA initiative, as well as VHA’s own Blueprint for 

Excellence. This blueprint is aligned with the Department’s strategic plan and supports the MyVA initiative. The blueprint lays out 

the themes and supporting strategies for transformation to improve 

the performance of VA healthcare now, making it not only more 

veteran-centered, but also veteran-driven by putting our customers 

in control of their VA experience. 

The Blueprint for Excellence will serve as a guide in all of the 

programs I mentioned in my written statement. I am confident 

that the deep sense of mission we share will carry us through the 

next year and any challenges we might face in the future. 

I also just want to note that Secretary McDonald and I and all 

the senior leaders in VA envision that the future of VA healthcare 

is both that we are a provider, a top-notch provider, and also a 

health plan taking advantage of getting veterans care in the community when it is needed. 

VHA’s fiscal year 2016 budget request will support VA’s goals to 

expand access to timely, high-quality care, end homelessness 

among veterans, and continue to transform the Department 

through its MyVA initiative. 

Through the fiscal year 2016 budget, we will continue to develop 

and expand our mental health system, as well as our innovative 

and cutting-edge medical research. We are committed to increasing 

access to care for veterans, and have placed special emphasis on 

telehealth services for those in rural and remote locations. 

To address the growing number of women veterans, VA is strategically enhancing services and access for female veterans. 

Another high priority is ensuring that all enrolled veterans who 

require treatment for the hepatitis C virus have access to the necessary therapies. 

VA is also dedicated to promoting the health and wellbeing of 

caregivers. The cost of fulfilling this care and other obligations to 

our veterans grows, and we expect it will continue to grow for the 

foreseeable future. 

We know that services and benefits for veterans do not peak 

until roughly 4 decades after a conflict ends. Therefore, more resources will be required to ensure that VA can provide timely, 

high-quality care into the future. 

The fiscal year 2016 budget requests additional resources, which 

are critical toward providing veterans the care that they have 

earned through their service and sacrifice. 

In conclusion, VA is committed to providing the highest quality 

care, which our veterans have earned and deserve. I appreciate the 

hard work and dedication of VA employees, our partners from veterans service organizations (VSOs), very important advocates for 

veterans, our community stakeholders, and our dedicated VA vol-
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unteers. I respect the important role that Congress has in ensuring 

veterans receive quality healthcare and benefits that they rightly 

deserve. 

I look forward to continuing our strong collaboration and partnership with this subcommittee, our other subcommittees of jurisdiction, and all of your colleagues as we work together to continue 

to enhance the delivery of healthcare services to our Nation’s veterans. 

Mr. Chairman, members of the subcommittee, this concludes my 

remarks. Thank you again for the opportunity to testify, and my 

colleague and I will be happy to respond to any questions from you 

or members of the subcommittee. 

[The statement follows:] 

PREPARED STATEMENT OF DR. CAROLYN M. CLANCY, M.D. 

Good morning Chairman Kirk, Ranking Member Tester, and members of the subcommittee. Thank you for the opportunity to appear before you to discuss the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) fiscal 

year 2016 and 2017 medical care advance appropriations budget request. I am accompanied today by Dr. James Tuchschmidt, Acting Principal Deputy Under Secretary for Health. 

The year 2014 will likely be recognized as one of the most memorable in VHA’s 

history. To say that we had a crisis on our hands would be an understatement. We 

realize the significant work that remains ahead. The good news is that moving forward, along with Congress, we have an opportunity to reshape the future and make 

long-lasting valuable changes. 

The Department of Veterans Affairs as a whole is working to rebuild trust with 

veterans and the American people, improve service delivery, and set the course for 

long-term VA excellence and reform, while delivering better access to care and benefits. This includes 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. As we enter 2015, all of us in the 

VA healthcare system will be focused on the ‘‘MyVA’’ initiative, as well as VHA’s 

Blueprint for Excellence. The Blueprint is aligned with the Department’s Strategic 

Plan and supports the ‘‘MyVA’’ initiative. The Blueprint lays out themes and supporting strategies for transformation to improve the performance of VA healthcare 

now—making it not only more veteran-centric but also veteran-driven by putting 

our customers in control of their VA experience. The Blueprint for Excellence will 

serve as a guide in all of the programs I mention throughout my testimony. I am 

confident that the deep sense of mission we share will carry us through the next 

year and any challenges we might face in the future. 

VHA’s fiscal year 2016 budget request will support VA’s goals to expand access 

to timely, high quality healthcare; end homelessness among veterans; and continue 

to transform the Department through its ‘‘MyVA’’ initiative, which reorients VA 

around veteran needs and empowers employees, to assist them in delivering excellent customer service to improve the veteran experience. 

The cost of fulfilling this care and other obligations to our veterans grows, and 

we expect it will continue to grow for the foreseeable future. We know that services 

and benefits for veterans do not peak until roughly four decades after a conflict 

ends. Therefore, more resources will be required to ensure that VA can provide 

timely, high-quality healthcare into the future. The fiscal year 2016 budget requests 

additional resources which are critical toward providing veterans the care that they 

have earned through their service and sacrifice. 

IMPROVED ACCESS TO CARE

VA is taking multiple steps to expand capacity at our facilities. The fiscal year 

2016 budget request provides $60.0 billion for VA medical care, a 7.4 percent increase above the 2015 enacted level. In addition, the 2016 budget request supports 

implementation of the Veteran Access, Choice, and Accountability Act of 2014 (‘‘Veterans Choice Act’’) with the goal of providing timely, high-quality healthcare for our 

Nation’s veterans. The Veterans Choice Act provided $5 billion in mandatory funding to increase veterans’ access to healthcare by hiring more physicians and clinical 

staff and improving VA’s physical infrastructure. 
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As a result of the Veterans Choice Act, VA is recruiting to hire more than 10,000 

additional medical professionals and support staff with funding provided in the act, 

and expanding our clinical trainee programs. The VHA National Recruitment Program (NRP) provides an in-house team of skilled professional recruiters employing 

private sector best practices to fill the agency’s most critical positions. The NRP has 

increased its targeted recruitment efforts for mission-critical clinical vacancies that, 

once filled, will improve access to care. 

In addition, the Choice Act increased the maximum award amount of the Education Debt Reduction Program to improve recruiting and retention of medical professionals. The Veterans Choice Act also provided $10 billion in mandatory funding 

through 2017 to establish a temporary program (the ‘‘Veterans Choice Program’’) to 

increase veterans’ access to healthcare by allowing certain veterans to elect to receive non-VA care from eligible providers if the veterans qualify based on their place 

of residence or when VA is unable to schedule an appointment within the VHA’s 

wait time goals. In order to ensure VA’s ability to deliver high-quality healthcare 

to veterans, the Veterans Choice Act also authorized VA to procure 27 new Major 

Facility Leases nationwide. VA’s leasing program provides flexibility to meet shifts 

in demographics, and the changing service needs of our veterans. 

The Veterans Choice Program may provide a measure of short-term relief from 

the pressure of escalating healthcare needs as current patients in the VA system 

elect to receive their care through this program. These investments, together with 

the fiscal year 2016 budget request, will provide the authorities, funding, and other 

tools to enhance services to veterans in the short-term while strengthening the underlying VA system to better serve veterans in the future. 

VA is committed to increasing access to care for veterans, and has placed special 

emphasis on those in rural and remote locations. Telehealth services are missioncritical to the future direction of VA care to veterans. Telehealth utilizes information 

and telecommunication technologies to provide healthcare services when the patient 

and practitioner are separated by geographical distance. The fiscal year 2016 budget 

requests $1.224 billion, an increase of $126 million (11.5 percent) for telemedicine. 

The number of veterans receiving care via VHA’s telehealth services grew approximately 18 percent in fiscal year 2014, and is anticipated to grow by approximately 

28 percent in fiscal year 2015. VHA provided care to more than 717,000 patients 

via the three telehealth modalities: Clinical Video Telehealth, Home Telehealth and 

Store and Forward Telehealth. This amounted to more than 2,123,000 telehealth 

episodes of care; 45 percent of these veterans lived in rural areas and may otherwise 

have had limited access to VA healthcare. 

We are appreciative of the Veterans Choice Act’s support to improve access as we 

build capacity within the VA system to better serve those who rely on us for 

healthcare. My testimony will now discuss key initiatives highlighted in the President’s budget request. 

MENTAL HEALTHCARE

Long deployments and intense combat conditions require comprehensive support 

for the emotional and mental health needs of veterans and their families. Accordingly, VA continues to develop and expand its mental health system. VA has integrated mental health services into primary care in the new Patient Aligned Care 

Team (PACT) model. Providing mental healthcare within the primary care clinic 

minimizes barriers that may discourage veterans from seeking mental healthcare. 

VA has many entry points for mental healthcare, including 150 medical centers, 

830 Community Based Outpatient Clinics, 300 Vet Centers providing readjustment 

counseling, 80 Mobile Vet Centers, a national Veterans Crisis Line, VA staff on college and university campuses, and a variety of other outreach efforts. Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Transition and Care 

Management Teams are located at every VA Medical Center to welcome returning 

veterans, and to provide specialized care management services as they transition 

from Department of Defense to VA. 

VA implementation of integrated mental health services in the PACT program 

has resulted in substantial increases in the number of VHA patients each year who 

receive Primary Care—Mental Health Integration encounters, rising from 131,589 

in fiscal year 2008 to 699,454 in fiscal year 2014. Between 2005 and 2014, the number of veterans who received mental healthcare from VA grew by 71 percent. This 

rate of increase is more than 3 times that seen in the overall number of VA users. 

The increase in the number of mental health encounters or treatment visits, from 

10.5 million in 2005 to 19.6 million in 2014, has been even more dramatic—an 87 

percent increase. As a consequence of these trends, the proportion of veterans 

served by VA who receive mental health services has shifted substantially. In 2005, 
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19 percent of VA users received mental health services, and in 2013, the figure was 

27 percent. We anticipate VA’s requirement for providing mental healthcare will 

continue to grow. The fiscal year 2016 budget requests $7.455 billion, an increase of $349 million 

(4.9 percent) to ensure the availability of a range of mental health services, from 

treatment of common mental health conditions in primary care to more intensive 

interventions in specialty mental health programs for more severe and persisting 

mental health conditions. We will continue to focus on expanding and transforming 

mental health services for veterans to ensure accessible and patient-centered care, 

including treatment for post-traumatic stress disorder (PTSD), ensuring timely access to mental healthcare, and treatment for military sexual trauma. 

We are committed to ensuring the safety of our veterans, especially when they 

are in crisis. Our suicide prevention program is based on enhancing veterans’ access 

to high-quality mental healthcare and programs specifically designed to help prevent veteran suicide. Losing one veteran to suicide shatters an entire world. Veterans who reach out for help must receive that help when and where they need it 

in terms that they value. 

HEPATITIS C VIRUS

VA places a high priority on ensuring that all enrolled veterans who require treatment for the Hepatitis C virus (HCV) have access to the necessary therapies. Chronic infection with HCV is the most common blood-borne infection in the world and 

is a major public health problem facing not only VHA but the United States in general. VA has approximately 174,000 veterans in care with HCV, making VHA the 

largest single HCV provider in the United States. The fiscal year 2016 budget requests $690 million to capitalize on the availability of new therapies to improve access to and quality of HCV care. The new drugs will save veterans’ lives. 

SPECIALIZED CARE FOR WOMEN VETERANS

The number of women veterans enrolling in VA healthcare is increasing, placing 

new demands on a VA healthcare system that historically treated mostly men. In 

fiscal year 2014, there were more than 2 million women veterans in the United 

States, accounting for more than 400,000 users of VA healthcare services. To address the growing number of women veterans who are eligible for healthcare, VA 

is strategically enhancing services and access for women veterans. The fiscal year 

2016 budget requests $4.659 billion in total for women veterans healthcare, an increase of $502 million (12.1 percent). 

VA strives to be a national leader in the provision of healthcare for women, thereby raising the standard of care for all women. VHA works to ensure that timely, 

equitable, high-quality, comprehensive healthcare services for women veterans are 

provided in a sensitive and safe environment at VA facilities nationwide. 

Reproductive mental health is also an area of increasing focus. This area of specialty addresses the fact that reproductive health transitions (for example before, 

during, or after pregnancy or menopause) can increase susceptibility to or exacerbate current mental health conditions. One of VA’s goals is to transform reproductive mental healthcare delivery across the VA for women veterans by enhancing collaborations between mental health, primary care, pharmacy and women’s health. 

VA is stepping up to meet the needs of a growing women veteran population and 

enhancing primary care to meet their needs. We will continue addressing gaps and 

working to provide the compassionate care and welcoming environment our women 

veterans deserve. 

CAREGIVER SUPPORT PROGRAM

VHA recognizes the crucial role that family caregivers play. They are partners in 

helping veterans as they recover from injury and illness, in supporting veterans in 

their daily lives in their communities, and in helping veterans remain at home. The 

Caregivers and Veterans Omnibus Health Services Act of 2010, also referred to as 

the Caregiver Law, has allowed VA to provide unprecedented support and services 

to family caregivers of eligible veterans. After the law was enacted, VA established 

a comprehensive National Caregiver Support Program, with a prevention and 

wellness focus, which includes the use of evidence-based training and support services for family caregivers. 

The fiscal year 2016 budget requests $555 million for total obligations, an increase 

of $73 million (15.1 percent) from 2015, of which $469 million is for the monthly 

stipends paid to designated primary family caregivers under VA’s Program of Comprehensive Assistance for Family Caregivers, an increase of $58 million (14.1 percent). The increases to the stipend obligations are due to the increases in the under-
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lying hourly wages used to calculate the monthly stipend rates combined with the 

designation of additional primary family caregivers. 

In addition to the Program of Comprehensive Assistance for Family Caregivers, 

VA offers a variety of services and resources through the General Caregiver Support 

Services including: local Caregiver Support Coordinators, the National Caregiver 

Support Line staffed by licensed social workers, the VA Web site dedicated to family 

caregivers, as well as the Peer Support Mentoring Program. Additionally, VA offers 

a menu of training and provides many educational opportunities for veteran caregivers. VA is dedicated to promoting the health and well-being of caregivers who 

care for our Nation’s veterans, through education, resources, support, and services. 

ENDING VETERANS HOMELESSNESS

The administration has made the elimination of veteran homelessness a national 

priority. Between 2010 and 2014, overall veteran homelessness dropped by 33 percent, and we have achieved a 42 percent decrease in unsheltered veteran homelessness. Through unprecedented partnerships with Federal and local partners, we have 

greatly increased access to permanent housing, a full range of healthcare including 

primary care, specialty care, and mental healthcare; employment; and benefits for 

homeless and at risk for homeless veterans and their families. As a result of these 

investments, in fiscal year 2014 alone, VA provided specialized homeless services to 

nearly 260,000 homeless or at-risk veterans. Nearly 72,000 veterans and their family members were placed in permanent housing or were prevented from becoming 

homeless. 

In fiscal year 2016, VA will continue to focus on prevention and treatment services. The fiscal year 2016 budget request of $1.4 billion provides for VA homelessrelated programs, including case management support for the Department of Housing and Urban Development (HUD)-VA Supportive Housing program (HUD-VASH), 

the Grant and Per Diem Program, VA justice programs, and the Supportive Services 

for Veteran Families program. Ending homelessness among veterans remains a top 

priority for VA. We are committed to achieving the goal of ending homelessness and 

we will not rest until every homeless veteran has a place to call home. 

ADVANCES IN MEDICAL AND PROSTHETIC RESEARCH

The 2016 budget includes $622 million for development of innovative and cuttingedge medical research for veterans, their families, and the Nation. One example includes continuing the Million Veteran Program (MVP), a groundbreaking genomic 

medicine program, in which VA seeks to collect genetic samples and general health 

information from one million veterans in the next 5 years. MVP will help provide 

answers to many pressing medical questions and lead to improvements in care and 

prevention to veterans and the Nation. MVP complements the Administration’s Precision Medicine Initiative, which seeks to improve treatment of disease by improving 

our understanding of gene-environment interactions and their influence on the development, progression and treatment of disease. 

VA supports a range of studies on post-deployment mental health concerns such 

as PTSD, depression, anxiety, substance abuse, and suicide. Research aims to: 

—Describe the incidence and prevalence of mental health disorders; 

—Identify their risk factors; 

—Quantify their effect on health outcomes; 

—Understand the basic mechanisms of individual disorders; 

—Identify effective treatments; and 

—Develop models of care that will deliver effective treatments more quickly, widely, and reliably to veterans in need. 

The fiscal year 2016 budget request also includes funding for a new strategic initiative toward building a learning healthcare system that is responsive to new information, adapts to implement more effective clinical practices, and is committed to 

an ongoing mission of excellence, supported by a culture of self-reflection and continuing education. In addition to the direct appropriation, medical research will be 

supported through an additional $1.2 billion from VA’s medical care program and 

other grants, contracts and cooperative agreements. 

As part of one of the largest integrated health systems in the United States, VA’s 

research program benefits from clinical care and research occurring together, allowing research to be directly coordinated with veterans’ care. Indeed, VA research is 

often the only source of Federal effort addressing important sequelae of combat and 

military occupational exposures; VA leads the national effort in areas ranging from 

neuroprosthetics to social reintegration of injured veterans. 
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CONCLUSION

In conclusion, VA is committed to providing the highest quality care, which our 

veterans have earned and deserve. I appreciate the hard work and dedication of VA 

employees, our partners from Veterans Service Organizations—important advocates 

for veterans—our community stakeholders, and our dedicated VA volunteers. I respect the important role that Congress has in ensuring veterans receive quality 

healthcare and benefits that they rightfully deserve. I look forward to continuing 

our strong collaboration and partnership with this subcommittee, our other committees of jurisdiction and the entire Congress as we work together to continue to enhance the delivery of healthcare services to our Nation’s veterans. 

Mr. Chairman, members of the subcommittee, this concludes my remarks. Thank 

you again for the opportunity to testify. My colleague and I will be happy to respond 

to any questions from you or other members of the subcommittee. 

FRONTLINES TO LIFELINES LEGISLATION

Senator KIRK. Let me start out with the first question. The first 

question is, have you been able to review our legislation called 

Frontlines to Lifelines? 

Dr. CLANCY. I have had a chance to review that, and I have also 

been—— 

Senator KIRK. Let me just interrupt you there. This is legislation 

that would take the corpsmen and trained first responders in the 

medical side of the Active Duty force, to bring them quicker into 

VA. 

Go ahead. 

Dr. CLANCY. Thank you. I have had a chance to review that and 

also to speak at some length with one of our colleagues from the 

Lovell facility in North Chicago, which is a facility that we share 

with the Department of Defense, and they share our excitement 

about this as well. 

We have had a similar pilot program going on in VHA for the 

past 2 to 3 years. About 15 of our facilities participated in this, and 

those facilities that participated were very enthusiastic about the 

program. 

I think most imagined that these corps-men and -women would 

be the best fit with emergency department care, and, in fact, many 

were. But about a third of those people actually ended up doing 

other things that no one had envisioned, for example, working with 

patients who have indwelling IV lines for chemotherapy or antibiotics who are getting care at home. 

I actually think the potential for this kind of role in the future 

is bigger than we can even imagine right now. So right now, we 

are actually working with the Office of Personnel Management to 

get these positions classified. 

For some of these individuals, this will be a very important entry 

point to the VA, and then getting educational benefits to go on to 

other kinds of career opportunities. So several of the people who 

enrolled in our program or participated went on to become physician assistants. One went to medical school. Others will, I think, 

actually be able to develop a full career within the Veterans Health 

Administration or, frankly, in other healthcare systems. 

HINES VAMC WHISTLEBLOWER

Senator KIRK. Let me follow up with a question about whistleblowers. I want to ask you about Germaine Clarno, who is working 

in the Hines VA. She is a very prominent whistleblower who told 
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us about waiting lists and everything. She has had a lot of retribution against her by VA leadership. 

I want to ask you, is there a way that we can address the protection of this specific whistleblower? 

Dr. CLANCY. So the Secretary, Deputy Secretary, and I, and, 

again, all of our senior leaders, have made it very, very clear that 

retaliation or poor treatment in any fashion of whistleblowers, 

whether those are official whistleblowers who register with the Office of Special Counsel or people who step forward and make their 

concerns heard, is completely unacceptable. 

I will say I just spoke with the network director for that network 

the other day, and she told me they had just had their labor-management forum. She thought their relationship with Germaine was 

quite good. 

You know, whistleblowers play a very, very valuable role in our 

system, in any system, bringing forth complaints. Sometimes we 

don’t like hearing that news, but it is almost always valuable. And 

we take that opportunity for what it is worth. 

Senator KIRK. I would say, in my experience with Hines VA, it 

is an utterly corrupt culture there. And we are looking at you being 

a change agent there. Thank you. 

So let me go for any questions to Shelley Moore Capito, a new 

member of the subcommittee. 

Senator CAPITO. Thank you, Mr. Chairman. Thank you for letting me go to the front of the line. We have another committee 

meeting that I am going to be chairing here in about 10 minutes, 

so I appreciate it. I want to thank the ranking member, too. I don’t 

know if you are a party to this, but I will thank you for it. 

Thank you, Dr. Clancy, for coming and visiting me in my office 

yesterday. It is very, very helpful to have great communication, 

and I appreciate your efforts there. 

VA CHOICE CARD AND RURAL AREA ACCESS TO CARE

We talked about the VA Choice Card when you were in my office, 

and we talked about some of the problems that I have heard 

anecdotally, and you acknowledged that it hasn’t rolled out and 

hasn’t been as used in such great numbers as the hope was in the 

beginning. For a rural area, though, it is extremely important. 

But what is the VA doing to make sure that patients seeking assistance through this hotline are not falling through the cracks? 

Somebody calls and wants to use the VA Choice Card, how do you 

follow up with that veteran? 

Dr. CLANCY. A really great question. I am going to start and then 

turn to Jim, because he’s been doing a very deep dive on this. 

I want to make it clear that we had to stand up, essentially, a 

new insurance program in about 90 days and, in fact, the feedback 

we got from many large, well-established insurance companies in 

the private sector was that they expected that it would take about 

12 to 18 months to stand up a program. However, we got this implemented on time. 

Each one of our facilities has a Choice Champion to help veterans if the entire process doesn’t go quite as seamlessly as it does. 

We have tried a variety of communication venues to get the word 

out because, after all, every single veteran enrolled in our system 
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got a Choice Card in the mail. We finished all those mailings by 

the end of January, starting first with those who lived more than 

40 miles from any of our facilities. And there is information online. 

We are working with the VSOs to get good information out, trying 

a variety of venues. 

And, in fact, we also have a public service ad, if you will, which 

I think has been sent to all of your offices. So any of you who can 

put that on your homepage, we would be most appreciative. So it 

is just another way for veterans to know about this. 

Do you want to add to that, Jim? 

Dr. TUCHSCHMIDT. Sure. So any veteran who is in the 40-mile 

group, they don’t need to go through the VA at all. They can automatically call the 866 number for the third-party administrator 

(TPA) and will automatically be directed to the right TPA for their 

geographic area. And they have a standing authorization to get the 

care that they need. 

For those patients who are in the 30-days group, actually, when 

we first launched this program, there were about 120,000 of those 

people. We have reached out by telephone to call every one of them 

to coordinate their care with the TPA. So we have tried to contact 

them. And if we can’t, we try three times, and we leave voicemail. 

And if we get the person on the phone and they say they want to 

have care through the Choice program, we do a warm handoff right 

then and there to the TPA to help them get their care coordinated. 

Patients who have subsequently ended up on the list are instructed to call the TPA, and they will work with them, if they 

choose to use the Choice program. We find a lot of veterans when 

they tell us at the time that they are making an appointment—oftentimes a follow-up appointment, that is the vast majority of 

them—if we can’t get them an appointment, we book them an appointment in the VA. So there is always a fallback, even if it is not 

within 30 days, and then tell the veteran how they can contact 

TPA, provide either TriWest or Health Net and authorization, and 

the veteran can call them. 

If the veteran accepts an outside appointment, the third-party 

administrator calls us so that we can cancel that appointment 

within the VA. We are in the process—— 

40-MILE RULE

Senator CAPITO. I am going to stop you there very quickly because I only have a minute left. 

On the 40-mile limit, we had this discussion yesterday, living in 

West Virginia, 40 miles can take you 40 minutes or 3.5 hours, depending. That is an exaggeration, but it can take quite a bit of 

time. So we were asking for some adjustments there in terms of 

driving time, or driving miles instead of just how the crow flies. 

OPIOD PRESCRIPTION

The last thing, since I am running out of time, we did talk about 

this but the opioid prescription issue within the VA. Many people 

are reliant on it. I recounted a Stan White from my district, who 

lost his son, who makes a very compelling case that there were 

some conflicting prescriptions with some outside use of other 
11 

things, something I think that you all are monitoring very closely 

here. 

And I know it may hurt some people on the other side who have 

good, repeated use of pain killers and need that, but I would still 

encourage you to continue to look, because there is a high incidence 

of overdose within the VA population, to make sure that those conflicts are resolved. 

With that, I thank both of you, and I thank the chair and ranking member. Thank you. 

Senator KIRK. Mr. Tester. 

Senator TESTER. Yes, thank you, Mr. Chairman. I will start with 

a thank you to Dr. Clancy for getting the VA Montana permanent 

director position filled. It allows me to have somebody that I can 

hold accountable, as well as you. So we thank you for that. 

CHOICE ACT STAFFING ASSESSMENT

The Choice Card required a staffing assessment of each VA medical facility. When will we see that assessment? 

Dr. TUCHSCHMIDT. The Secretary signed off on it. And my understanding is it was being couriered over today. 

Senator TESTER. Oh, we will get it today. That is good. 

It is my understanding that assessment calls for a detailed analysis of the VA succession planning for leadership positions at medical facilities, much like we had in Montana. The VA’s proposed 

budget also requests a legislative change to the appointment and 

compensation system for VA medical center directors and network 

providers. I assume that is all in that report? 

Dr. TUCHSCHMIDT. Yes. All of the required sections are there. 

Senator TESTER. Okay. You have seen the report? 

Dr. TUCHSCHMIDT. I have seen the report. 

Senator TESTER. Do you think it will expedite our ability to get 

medical directors in quicker? 

Dr. TUCHSCHMIDT. Well, I am not sure the report in and of itself 

will do that, but there, certainly, is a lot of information that we 

have gleaned out of putting the data together. And I think that we 

have clearly significant recruitment challenges recruiting hospital 

directors. And I think Montana has probably been a good example. 

Senator TESTER. We will get into that in a minute. 

Do you think you will need any legislative changes to be able to 

do what you think is necessary to fill positions as quickly as possible? 

Dr. TUCHSCHMIDT. I can’t comment on that right now. We are 

looking at legislative changes that are in the queue right now. 

Senator TESTER. Okay. It would be great. 

I don’t know when the markup is going to be on this bill, Mr. 

Chairman. 

It would be great if you could get those legislative changes to us 

with some time to be able to visit about them. 

In recent years, Congress provided significant resources and additional tools to be able to address workplace shortages across-theboard. Unless Montana is an exception, I would say, we are losing 

ground. 
12 

When do you think the VA will start making progress to address 

the staffing issues that are out there, whether it is doctors, nurses, 

administrative personnel, whatever it might be? 

Dr. CLANCY. So part of the reason I know that Secretary McDonald and I are coming out to visit with you in Montana is precisely 

to try to figure out what other opportunities there might be to recruit people there. 

I think at some of our facilities, they can do a better job, and we 

are committed to helping them do a better job to do local market 

surveys, so they know when they need to up the salaries, for example, of nurses, depending on what local competition is paying. 

One of the issues that surfaced in Phoenix was that, in addition 

to the other challenges they had, they had trouble recruiting schedulers. There was a huge turnover because they were getting better 

jobs with other Federal departments in the same area. 

So it is that kind of thing. I don’t think that we need legislative 

change, but I think we need better business processes that are 

more rapid in responding to that kind of market force. 

Senator TESTER. Okay. I got that. 

Well, it will come from your end down, to be able to make sure 

that is implemented. 

CREDENTIALING

Mental health counselors and marriage and family therapists 

make up about 40 percent of the overall health independent practice workforce in the private sector. However, they make up less 

than 1 percent of the VA mental health workforce. Can you tell me 

why that is? 

Dr. CLANCY. One of the issues has been our requirements. 

Credentialing is a very important function of most healthcare systems, and we have wanted to hire people who have the best skills 

to meet veterans’ needs. And so we have wanted to hire graduates 

of programs that are accredited. 

In some States, California being one example, they graduate a lot 

of master’s level people where the university is accredited but not 

the program. The good news is that a lot of those programs are 

starting to get accredited now, so I think that will open up a pipeline for us. 

Senator TESTER. Okay, let me ask you this. When you are looking at hiring folks, are there policies that say that they aren’t to 

be hired right out of college, that they need to have worked in the 

system, in mental health, in particular? 

Dr. CLANCY. It depends on the job description. So if you are going 

to be mental health counselor, yes, then you do need probably postbachelor training. Depending on other jobs, whether you are going 

to be a clerk or administrative assistant, it all depends on the job. 

Healthcare being—— 

Senator KIRK. Doctor, if I could interrupt you, I would just say, 

I want to jump in here on credentialing and say that is the number 

one way that I found that whistleblowers are silenced. The VA 

leadership will say to a doctor, ‘‘If you don’t shut up, we are going 

to tell everybody on the credentialing board that you are not qualified, so you won’t be able to be a cardiologist anywhere.’’ This is 

a way to get someone who is highly qualified to be quiet. 
13 

Dr. CLANCY. I have not had specific examples of that brought to 

me, but if you know of specific examples, or Germaine or other people do, please, I would want to address them. It falls into the same 

category as general whistleblower issues that we discussed. 

Senator TESTER. I would follow up and just point out, and this 

is very parochial, but I am aware of a person who went to VA, they 

had an opening in Montana. VA didn’t hire them. They went to 

work in the private sector, contracted back to VA. That very same 

person, who was working for a private sector group, they could 

have hired cheaper. I just want to point that out. 

I have another round of questions. Thank you, Mr. Chairman. 

Senator KIRK. Mr. Schatz. 

Senator SCHATZ. Thank you, Chairman Kirk. I appreciate the accommodation. I have another subcommittee hearing with Senator 

Capito. 

MENTAL HEALTH PROFESSIONALS IN RURAL AREAS

Following up on Senator Tester’s question related to mental 

health services, access to mental health services remain a tremendous challenge, particularly in rural areas. And I understand you 

are continuing to suffer from a mental health professional shortfall. 

But I am wondering, of the 9,600 new hires that the VA plans 

to make, what percentage of them are going to be mental health 

clinicians? And how many of them are intended to provide services 

in the rural context? 

Dr. TUCHSCHMIDT. I don’t have those exact numbers, but I can 

get them for you. 

Dr. CLANCY. I will say just generally, Senator, that the two areas 

where we are going to have the most trouble recruiting are mental 

health and primary care. A lot of that I think is going to reflect 

our need as a department, with all of our resources and, frankly, 

any other partners we can work with, to try to get to students and 

professionals very early in the pipeline. 

I think the help that you have given us through the Choice Act 

with the debt-reduction programs, particularly now that we can 

pay the lenders directly, it turns out to be a huge thing that is in 

the Choice Act. It will be very, very helpful. The Clay Hunt Act 

helps some more. 

But in general, if people aren’t looking to get into that path at 

a critical juncture in their careers, which is generally going to be 

the last couple of years of medical school for doctors, we are going 

to have a problem. 

And you have probably seen recent reports from the Association 

of Medical Colleges about what shortages of doctors were, so we are 

going to be in tough competition with the private sector for both 

groups of professionals. 

CREDENTIALING

Senator SCHATZ. I would just add, in following up on Senators 

Kirk and Tester’s line of questioning, in this space, that part of the 

problem is credentialing. And I understand you want psychiatrists 

and you want qualified mental health professionals, but you also 

want case management. You also want peer counseling. And you 

have lower thresholds for credentialing and you have the oppor-
14 

tunity, at a lower price, to provide real mental health services. And 

so there is a tendency in any bureaucracy, not just yours, but there 

is a tendency in any bureaucracy to kind of push the work up, and 

for people of good faith to focus on credentialing and Q.M. where 

you are really comparing no service at all from getting somebody 

some help and back in the pipeline. 

Dr. CLANCY. No, and we rely a lot on the two groups of individuals that you just mentioned, especially case managers. It is huge, 

because a growing proportion of the veterans we serve have multiple chronic illnesses, so they have mental health disorders as well 

as other medical problems. And coordinating that is a big, big challenge. 

Dr. TUCHSCHMIDT. I would just like to add that we also have an 

array of mobile vet centers. So not only do we have our stationary 

vet centers around providing, I think, many of the kinds of services 

you are discussing, but we also have the mobile vet centers. 

One of the things that we are doing right now through the 

Choice legislation is looking at those to say what telehealth capacities do they need, what is the productivity of those, and the schedule for those vans. 

So we are doing a lot of work right now to look at how we can 

use that resource, particularly in rural areas, to reach out to veterans. 

STIGMATIZATION OF MENTAL HEALTH CHALLENGES

Senator SCHATZ. I will just add, finally on this issue, you have 

the general trepidation that a lot of veterans have in terms of 

availing themselves of services at VA, but you also have the special 

challenges of the stigmatizations of mental health challenges. And 

some of this is changing generationally, depending on what war or 

conflict your veterans are coming from. But some of this has to go 

all the way down to the line level so that people are greeted to a 

welcoming environment when they enter VA and not made to feel 

like they have done something wrong or displayed some sort of 

weakness, in terms of wanting to avail themselves of mental health 

services. 

Dr. CLANCY. Yes, so two points I would just make there, Senator. 

One is that many people find the vet centers, which are separate 

from, but a very vital asset for us, but they are separate from the 

main medical facilities, to be a much easier place to go in and 

share their problems. 

Many recent veterans, in particular, who don’t like government 

and actually don’t want to have much to do with government, find 

these centers a whole lot easier to deal with. 

The other place where I think we are making great inroads is integrating mental health professionals into primary care. As a primary care internist, I can’t tell you how many times I have had 

that sensitive conversation with a patient and everyone agrees, we 

both agree, that the next step is going to be seeing some kind of 

mental health professional, except it doesn’t happen. 

When that person is down the hall, and you can literally walk 

the veteran down and introduce them, that is what we sort of mean 

by a warm handoff. It makes a huge difference. 
15 

So we think that voltage drop, if you will, will go down quite a 

bit. 

Senator SCHATZ. Thank you. 

Senator KIRK. Dr. Cassidy, a new member of the subcommittee. 

Senator CASSIDY. Dr. Tuchschmidt, you were one of my resident 

fellows at L.A. County Hospital. May I point out, I have grayed far 

worse than you. And you are a very good instructor, so good to see 

you again, Jim. 

Dr. Clancy, thank you for the phone call yesterday. Very helpful. 

And thank you for the material you gave. 

MENTAL HEALTH VISITS NO-SHOW RATES

Now let me ask, we have both spoken yesterday and at the previous hearing regarding missed opportunities, folks who are noshow. And you were nice enough to give me this data from the Louisiana facilities. And you already have fiscal year 2015, so I assume 

that is fiscal year-to-date. 

So, actually, my gosh, Shreveport is getting worse with mental 

health for females going 23 percent missed to 26 percent missed, 

to 29 percent no-show rates, going in the wrong direction. 

Now the conversation we had on the phone was very helpful, and 

you used a term that I have told you I have already used again, 

that seeing something like that is diagnostic of a problem. You 

don’t know the problem, but you know there is a problem. 

So that said, it is getting worse. What is the VA doing with this 

real-time data? This is going south, you know what I’m saying? 

Dr. CLANCY. So the first thing that we do is we review data from 

across our system on an almost daily basis with our Deputy Secretary, both about how we are doing in terms of access and wait 

times, as well as what we see as inputs to problems with the access 

and wait times, and the missed opportunities rates is something 

there. 

The other thing that we are doing, in the case of your State, is 

trying to get a terrific network director in there, the last one having stepped down at the end of calendar year 2014. We have an 

acting person in there now. 

Senator CASSIDY. The network director would be over the entire 

system. But I suspect there is something particular about that hospital and particular about that mental health unit. 

Dr. CLANCY. One of the things that I, in gathering this data for 

you, have become very interested in, is looking at—the table I gave 

him, by the way, for his facilities has all veterans on one side and 

female veterans on the other. 

In some areas for some conditions, one of the issues for female 

patients, in general, is sometimes childcare. Some of our facilities 

have a way of dealing with that, others actually don’t. But I think 

it is very important to know why it is that people aren’t showing 

up. 

And I think, frankly, we have to do a better job in getting the 

word out and reminding people. Across our system, we do see that 

the missed opportunity or no-show rate for patients coming in for 

mental health visits tends to be higher than for other visits. 

Senator CASSIDY. And increasing. I would just point that out. 
16 

And knowing that you have only been on the job for a short period of time, this is just going in the wrong direction. 

Dr. CLANCY. Yes. 

Senator CASSIDY. And I encourage my colleagues, because Dr. 

Clancy was nice enough, I asked her for the granular data and she 

got it for the clinics in my State, showing the no-show rate. In private practice, that should just not happen. People are getting follow-up phone calls. And the fact that it is growing is not best practice. It is not standard practice. 

Secondly, we spoke yesterday. In my medical practice, I knew 

there were many that would come to see me and then subsequently 

go see the VA. I knew they had coverage, because I wasn’t seeing 

them in the public hospital where I worked, but in my private practice. 

THIRD PARTY INSURANCE BILLING

So the next question is, knowing that there are those who have 

dual coverage, and that the VA is allowed to bill third-party insurance companies in some cases, I am told that there is potentially 

$6 billion billed last year but only $2 billion collected. 

Knowing the generalized problems the VA has, it is easy to imagine that it was a failure of systems, but it could be just the normal 

sort of contract disputes between an insurance company and a provider. 

Any comments on that? We’re leaving $4 billion on the table. 

Can we get some of that money to the taxpayer? 

Dr. TUCHSCHMIDT. I am not sure about the amount we billed. We 

collected about, I want to say it is around $3.2 billion, is my recollection. 

The biggest reason that we don’t collect, I think, is that a lot of 

the third-party insurance that our veterans have is essentially 

Medigap insurance. And without an explanation of benefits (EOB), 

that Medigap provider doesn’t pay that claim, right, because there 

was no Medicare service. 

So we find that a lot of those claims go unpaid in our system. 

NONRECURRING MAINTENANCE

Senator CASSIDY. Let me ask one more thing quickly. You have 

a supplemental appropriations, a second bite, if you will, which is 

$1.3 billion. And you know, that is a substantial amount of money. 

And it includes $247 million for nonrecurring maintenance (NRM). 

First question, why was this not included in the regular budget 

request for fiscal year 2016? Secondly, knowing that you received 

$5 billion in section 801 last year, some of which could be spent on 

nonrecurring facility management, how much of that was spent? 

Again, a lot of money, second bite, some of it seems it should be 

included in the regular budget, and there is also supplemental 

money last year. Any elaboration on that? 

Dr. TUCHSCHMIDT. Yes, so of the $5 billion, roughly half of that 

is being spent on NRM and construction on space requirements. 

The other half is being spent on people. The space requirement is 

really frontloaded to this year, and people kind of more backloaded 

to the next year, because of the time it takes to recruit. 
17 

And the amount of NRM requested in the budget, it is really a 

re-estimation of what we need to really meet our needs, particularly to have enough exam rooms per provider. 

Senator CASSIDY. I yield back. I am over time. Thank you. 

Senator KIRK. The Senator for Connecticut. 

Senator MURPHY. Thank you very much, Mr. Chairman and Senator Tester. It is an honor to be on this subcommittee with both 

of your leadership. Great to see both of you. 

CHOICE ACT SECTION 802

Dr. Clancy, you have about $10 billion through 2017 in mandatory money with which to implement the Veterans Choice programs. Is that right? 

Dr. CLANCY. Yes. 

Senator MURPHY. And this is in part to follow up to your question and answer with Senator Capito. You have seen maybe a slower than expected take-up thus far, but you are doing everything 

within your power right now. You are taking all of the necessary 

steps to make sure that the take-up is accelerated and that everyone that is eligible for this program is going to be able to take advantage of it. You are confident that you are taking those steps? 

Dr. CLANCY. Yes. 

Senator MURPHY. And so, let’s just imagine for a moment a point 

at which having taken all of those steps, having done everything 

that you believe and collectively that we believe is necessary to 

have that program reach as many people as possible, you aren’t 

then on track to expend the totality of that money. We have talked 

about just in the last half an hour a number of other needs within 

the VA, whether it be mental health needs, whether it be coordination services. Every single one of us probably has a list of capital 

projects that we would like to see undertaken. 

If perhaps the estimate that we put into the law doesn’t actually 

turn out to be the case, how do we make sure that some of these 

other needs are taken care of or that you have the ability to take 

care of some of these other needs? 

Dr. CLANCY. So I started this off in response to the chairman by 

saying that we felt it was important for us to present a budget that 

reflected our honest need for requirements, what it took to serve 

veterans. We have also requested flexibility in terms of this $10 billion of mandatory dollars. 

It becomes particularly acute, and we had a brief chance to chat 

about this previously, because we have two big buckets or opportunities to help veterans get care in the community. One is what we 

call non-VA care and does include Project ARCH and things like 

that, which comes out of our budget. 

That is discretionary, and then there is this mandatory pile. 

At one point, we thought many of the veterans for whom we are 

now buying care in the community with non-VA care, we would be 

doing that with Choice. That is not our experience to date. 

We have some continued process improvements to make, and I 

would also expect, just looking at the experience with the rollout 

of managed care in the private sector, that we will start to see a 

more enthusiastic uptake. I just don’t know how steep that curve 

is for Choice. We know that many people who have long-estab-
18 

lished relationships with providers are not the first people to jump 

on-board a new option, so they are going to be a little slower to try 

something new. 

If we don’t see that, that is why we are requesting flexibility, 

both to make sure that we can have a seamless experience for veterans, whether it is in our facilities through telehealth or by getting care in the community or addressing other underlying needs, 

like you just said. 

So it is a bit of juggling act. And unfortunately, our budget puts 

us in a funky position, because we have so many different lines to 

manage. 

You know, the example Secretary McDonald used was to imagine 

if you had a checking account for gas and one for food, and the food 

one is getting empty, and the price of gas drops, and you are hungry, right? I mean, that is actually the way we are trying to manage our budget right now, and that is what gets clunky. That was 

the request for flexibility. 

Senator MURPHY. Well, I appreciate those comments. I think, as 

I mentioned, that our responsibility first is to make sure that we 

are building out this Choice program in a way that is true to the 

law, but I hope we would work with you to make sure that we don’t 

leave this funding on the table, should we realize that we have the 

ability to reprogram it to the other needs that we probably can all 

pretty quickly agree on. 

Mr. Chairman, that is my only question. Thank you very much. 

Senator KIRK. The Senator for all of Alaska. 

ALASKA AND THE CHOICE PROGRAM

Senator MURKOWSKI. Thank you, Mr. Chairman. Welcome to the 

subcommittee, and I’m pleased to have you back at the helm here, 

Mr. Chairman. 

I want to speak just a minute about the situation in Alaska. 

Sometimes I feel a bit like a broken record in trying to describe 

why it is so different, why it is so unique, the highest veteran population per capita amongst the States; second lowest population; facilities, very, very limited facilities, very disperse. We don’t host a 

full service VA hospital, but we do have opportunities that we have 

created because of other Federal systems, whether it is working 

within the Indian Health Service (IHS). 

We have more patients than providers. We just simply don’t have 

doctors that are taking Medicare-eligible individuals. 

So as we built out this legislation last year, quite honestly, it was 

going to be a very, very hard fit for Alaska. Initially, it was going 

to be that folks were paid on the Medicare rate, which, of course, 

in Alaska is lower than anything else. It would have chased everybody away. We have that adjusted. 

But still, we are limited to participation in the Choice Card program to a Medicare provider. And again, we just don’t have the 

providers to go around. I am told that central office has reduced 

Alaska’s VA budget for partnerships and purchased care about $78 

million now. And because what we have done, what we built out 

over the years are all of these alternatives so our veterans can find 

some level of services, this is a problem for us. 
19 

We just simply do not have facilities in these places where our 

veterans live. For so many years, the veteran was put on a plane 

to Seattle, to fill the gaps. We had some long battles in this subcommittee and others. Secretary Shinseki really stepped up and 

helped address how we could, again, fill in these gaps for services 

for our providers. 

And we work in partnership with our native health system. And 

by all accounts, this is working for us. 

The Choice Card, on the other hand, is untested. The provider 

needs to be willing to accept the card. Again, we have more patients than providers. 

I am concerned about where we are. The question, this is perhaps a little broader than what you have had from others, is, does 

the VA have enough flexibility to ensure that Alaska’s veterans 

don’t lose the gains that we have fought so hard to put into place? 

We are moving to the Choice Card, but are we going to see, almost 

by default, an erosion of the level of access that we have been able 

to build up over the years, utilizing other Federal partners? 

Dr. CLANCY. I see absolutely no reason why we would see an erosion. You are right that it is early days for the Choice program, 

and we are committed to working with you. 

First, we are committed to finding any flexibility that we can, 

vis-a`-vis the 40-mile rule. There is one—— 

Senator MURKOWSKI. We are already—— 

Dr. CLANCY. Yes. 

Senator MURKOWSKI. All veterans in Alaska are enrolled. 

Dr. CLANCY. Not relevant to Alaska, for sure. 

When you say that there has been a cut in the budget for purchased care, I think that what you are seeing is that, as a result 

of the Choice Act, we have consolidated a lot of the funding for purchased care to our central business office. But that doesn’t necessarily mean that we are buying less purchased care. 

Thus far, our experience would suggest that that is not the case. 

And in fact, in the middle of our access crisis, when things felt particularly acute, what I learned was that some of the facilities in 

Alaska are very, very good at the coordination that goes on there, 

because they have had to be, and that is terrific. We also have spent to date about $10 million on partnerships 

with the Indian Health and Tribal Services. And I couldn’t close 

this without acknowledging that Alaska has long been a source of 

inspiration for us, because of the Nuka clinic, which has won so 

many awards and really has inspired many of our efforts in primary care. 

Senator MURKOWSKI. Well, I appreciate that, and I encourage 

you all to remember that we’ve had to think outside the box. We’ve 

had to be creative. And we have done it to relative success. So 

again, we would hate to see any erosion. 

RECRUITMENT AND RETENTION IN ALASKA

Very quickly in my remaining time, and this goes to Senator 

Tester’s issue about recruitment, in many cases, the issue for us 

with VA care in Alaska has not been the wait to see a VA provider, 

but it has been this extraordinarily heavy caseload that our providers have, particularly in our community based outpatient clinics 
20 

(CBOCs). And you have all heard the example of the CBOC there 

in Wasilla. You had a physician begging for help, begging for help, 

and they couldn’t provide anybody to her. She eventually leaves. 

VA continues to make the excuse that we just can’t get providers 

to Wasilla. This is the second largest community in the State now. 

It is on the road system. IHS seems to be able to recruit for places 

like Barrow, Kotzebue, Nome, all off the road systems. 

I can’t figure out what the problem is here, and I would like to 

know, Dr. Clancy, that you are looking at this here, you are evaluating it, you are trying to figure out what it is that we are doing, 

because just an interim fix isn’t addressing the needs of our veterans out there. 

Dr. CLANCY. No, I hear you. And, I would say that recruiting and 

retention is probably our biggest number one challenge, particularly for some areas that are not well-served. 

I did speak with your colleague Senator Tester yesterday, wondering if we might actually figure out working with the University 

of Washington, since it reaches out to those four States, including 

Alaska and Montana, to try to figure out if we can get more students into rotations that would have a focus on VA. So that is on 

my list of opportunities to explore. 

But I hear you, that we have to get more people up there. 

Senator MURKOWSKI. We will keep pushing on that. 

Thank you, Mr. Chairman. 

Senator KIRK. The Senator for the land between Kenosha and 

Rhinelander. 

TOMAH VAMC INVESTIGATIONS

Senator BALDWIN. And a few other places. Thank you, Chairman 

Kirk, and thank you, Ranking Member Tester. 

I would like to focus on two problems within the Veterans Health 

Administration, both nationwide and in Wisconsin, and ask what 

the VHA is doing to put solutions in place. 

It is apparent to me that the VHA lacks clear and appropriate 

system-wide policies and protocols, as well as suffers from inadequate oversight of individual facilities. By way of example, at the 

Tomah VA Medical Center in Wisconsin, current and former employees and patients have brought to my attention allegations of inappropriate opioid and benzodiazepine prescribing practices, and 

abusive administrative authority, including retaliation against 

whistleblowers. 

While the Tomah VA is currently the subject of a VA investigation led by you, Dr. Clancy, it is my hope that we can answer a 

few fundamental questions here today. 

In the case of your current investigation into the over-prescription of opioids and retaliation at the Tomah VA Medical Center in 

Wisconsin, my office did bring a number of these concerns to the 

attention of the VA’s central office in June of last year, and asked 

for an investigation at that time. 

However, the VA central office forwarded the letter to the regional VA office, VISN 12, to respond instead of looking into the 

matter on its own. Six months later, you have launched an investigation, full investigation. 
21 

So why didn’t the VA launch an investigation when my office 

first contacted the central office in June of last year? 

Dr. CLANCY. So there were a number of investigations ongoing 

led by the network, and in retrospect and as we have discussed, the 

then-network director retired—or, he didn’t retire; he’s way too 

young for that—left at the end of October for a job in the private 

sector. 

What has surfaced for me is that there is less than a complete 

understanding about which issues at a network level are shared 

with central office, and that is a set of issues that we are working 

on very hard right now. 

I think the good news, and looking back at the timeline and 

going over all of this detail by detail for the past several years with 

the current acting network director, I think a lot of what they did 

was quite appropriate. There was an unfortunate 

miscommunication, or actually it was a communication, I will say 

that, and we have now clarified that for all of our facilities. 

When the director of the facility was told you may not share this 

inspector general’s report with anyone, we have now clarified for 

all of our facility and network directors that those reports can be 

shared and should be shared, not only beyond the facility with the 

network but with the central office. 

Senator BALDWIN. So that I can cover a little more territory, and 

I will stay around for a second round of questions, but to be clear, 

this wasn’t a letter to the inspector general. This was a letter to 

the VA central office in June of last year. 

So what happened with that letter is rather than the central office responding, VISN 12, the network, responded on June 27, and 

ticked off a list of actions already taken to improve Tomah’s prescribing practices, making it seem like everything was under control at Tomah, and ended by suggesting that I contact the chief of 

staff at Tomah directly if I had any further questions. 

It ends, ‘‘Thank you for your inquiry and the opportunity to address the concerns raised by your constituent. If you have any additional questions, please contact David Houlihan, M.D., chief of 

staff,’’ and lists the phone number. 

However, the Tomah chief of staff is at the center of a series of 

allegations regarding inappropriate prescribing practices and creating a culture of fear and intimidation at the facility. 

Do you believe that this was an appropriate response and a correct assessment of the situation to give a United States Senator? 

Dr. CLANCY. With the perfect clarity that comes with hindsight, 

I would say no. 

Senator BALDWIN. All right. 

Dr. CLANCY. I did not see that letter. And as you said, it was referred to the network. I would very much hope that we would have 

a different set of actions right now. 

It has uncovered for me, in addition to the very specific circumstances at Tomah, some of the unique challenges of making 

sure that we have fair practices at some of our smaller facilities. 

At a larger facility, for example, Milwaukee, the chief of staff sees 

patients and has their practices reviewed. It is very easy to blind 

that just because it is a larger place. And by the way, he’s an internist. 
22 

At Tomah, this person is a psychiatrist. It is very, very difficult 

to actually blind their practices for the purposes of peer review. 

And, as you know, there are currently a number of investigations 

going on now, and we are not waiting, per our announcement yesterday and the fact that our Deputy Secretary is in Tomah today, 

yesterday and today. So that is where we are. 

Senator BALDWIN. Will there be an opportunity for a second 

round of questions? 

Senator KIRK. I think we will go in the regular order. 

How are we doing here? 

We can give you additional time, if you like. 

Senator BALDWIN. I appreciate it, then. 

At least three veterans—Thomas Patrick Baer, Jason 

Simcakoski, and Jacob Ward—who were treated at the Tomah VA 

have tragically lost their lives. Jason Simcakoski died at the facility. 

And I know there was a broad review involving the joint commission, but you are leading an investigation of the Tomah VA right 

now, which includes evaluating the treatment of patients. So I am 

asking, does your current investigation include an evaluation into 

the care that Jason Simcakoski received at the Tomah VA? 

Dr. CLANCY. The network had led an evaluation and review of 

that, which included both people from the network—that is to say, 

outside the facility—and also involved in external review from our 

partner that we work with a lot, the quality improvement organization in California, Livanta. And that was prior to the investigation 

that was launched in January. 

And at this point, the inspector general is also reviewing that 

death. Their final report has not been done. I have had an informal 

conversation with them, but we are staying on top of that. 

Senator BALDWIN. Jacob Ward also passed away of a drug overdose after he left the Tomah facility. However, he reportedly was 

treated with opioids when he was a patient at Tomah. 

I’d ask, does your current investigation include an evaluation of 

the care that Jacob Ward received while at Tomah? 

Dr. CLANCY. His care and his ultimate death are being reviewed 

right now. 

Senator BALDWIN. Okay. And then Thomas Patrick Baer passed 

away at the Gundersen Lutheran hospital in La Crosse, Wisconsin, 

after being transported from the facility at the Tomah VA. He initially sought care at the Tomah facility for a stroke, yet reports indicate that Tomah did not have a working C.T. scanner and failed 

to give him anticoagulants and didn’t have an operational helicopter available to transport him quickly to another facility that 

could care for him. 

Does your current investigation include an evaluation of the care 

of Thomas Patrick Baer? 

Dr. CLANCY. We have conducted a review of his care and his 

death. And his death and experiences are also currently under review by the Office of the Inspector General as well. In addition to 

that, as a result of our own review, we have identified deficiencies 

in care that we are addressing right now. 

It is a bit separate from the opioid safety issue, but there were 

clearly missed opportunities to identify the fact that he was prob-
23 

ably having some of those symptoms while sitting in the waiting 

room, and in addition to the fact that he should have been sent to 

the other facility in Tomah. Their CAT scan was down for preventive maintenance, which happens, but he should have been sent to 

the other facility. 

Right now, we are actively exploring how it is that we might exploit our capabilities, both at Tomah and across the system, to 

make sure that veterans presenting with possible stroke could get 

their care by telehealth, if there is not a stroke team on-site, because today, if you have a stroke in Tomah, regardless of whether 

you are a veteran or not, it is not a great place to do it. It’s much 

better to be in Madison, because they have all the capabilities 

there. But we have the capability to actually link those two. 

So that will be coming. But right now, it is under review by the 

inspector general. 

Senator BALDWIN. Mr. Chairman, I have two more questions, if 

you’ll indulge me. Otherwise, I can wait for a second round. 

Senator KIRK. I know this is a really important issue. I would 

like to give a chance to Mr. Boozman to eventually ask his questions. 

HOMELESS VETERANS REINTEGRATION PROGRAM

Senator BOOZMAN. Thank you, Mr. Chairman. 

Dr. Clancy, in your opening statement, you addressed veterans 

homelessness, which is, certainly, an issue that all of us on the 

committee care about and glad that you singled that out. 

I noticed in your testimony that you mention that HUD Veterans 

Affairs Supplemental Housing (HUD–VASH) programs that provide permanent housing to many veterans. Senator Tester and I 

have introduced a bill to reauthorize the Homeless Veterans Reintegration Program (HVRP). 

Are you supportive of reauthorizing HVRP? 

Dr. CLANCY. We are supportive of anything that will help us with 

homeless veterans, for sure. 

What I can say is the one thing we have learned in terms of addressing this important problem, which is one of our top three priority goals for the Department, is that you have to get people in 

housing first, then you can address all other problems. So just as 

we have managed to work with partners in the Los Angeles community to dissolve a longstanding lawsuit and are trying to take 

advantage of the land there, there is almost no option that we 

wouldn’t look at across the system to help people get into housing, 

and then address their other needs for healthcare, for employment, 

and so forth. 

Senator BOOZMAN. Good, Dr. Clancy. And that brings up what 

we are trying. Part of this bill, what we are trying to do is that, 

in HUD–VASH, as the law stands now, if a veteran receives housing through an assistance program, they then become ineligible for 

HVRP because, technically, they are not homeless anymore. 

That seems crazy. That is only perpetuating the cycle of homelessness with many of these veterans. 

In our bill, we make a clarification of the law and allow veterans 

who are receiving housing through HUD–VASH to participate in a 

HVRP. And again, I would ask you if you would support that kind 
24 

of change, which is a very commonsense change that Senator Tester and I are trying to get done. 

Dr. CLANCY. We would be happy to work with you on that. 

What we know is we have made big improvements, in terms of 

homeless veterans, so that is great. But we have a long way to go. 

Senator BOOZMAN. Good. 

Dr. CLANCY. We have reduced the number by about a third, and 

some cities have been able to announce that for the moment they 

have solved the problem—New Orleans, Phoenix, and so forth. But 

we have to make that happen everywhere. 

Senator BOOZMAN. I know it is an issue that everyone is working 

really hard on. Again, it doesn’t seem to make sense to provide 

housing and then say, ‘‘Well, they are not homeless anymore,’’ and 

then eliminate benefits that could break the cycle, which we are all 

trying to do. 

HEPATITUS C DRUG TREATMENT

Let me ask you about hepatitis C. There are the new drugs on 

the market now that have up to a 97-percent cure rate. They truly 

are miracle drugs. That said, they come with a steep price tag. And 

I know that you are able to negotiate and a pill that normally costs 

$1,000, you are paying $540. That is a very, very good thing. 

One thing, though, that I am a little bit concerned about in the 

budget, you requested $7 million less for fiscal year 2016, $690 million as compared to fiscal year 2015, $697 million then. The projected advanced appropriation for fiscal year 2017 is $660 million. 

So you can see it is going down, which is a $30 million reduction. 

I guess the question is, why are we decreasing funding for hepatitis C, in the sense that we have this cure, which is very expensive, and in making that cure now, certainly, long term, are going 

to save the VA a tremendous amount of money as opposed to all 

the problems that we get with hepatitis, in the sense of liver failure and the very expensive things that come up in the future? 

Dr. CLANCY. Sure. Just to take a quick moment to brag on things 

I had nothing personally to do with, but all of the science about 

screening for and treating people with hepatitis C really comes 

from VA, which is a really good thing. 

Some part of the change in budget may, in fact, be due to the 

fact that they are now shorter courses, these newer drugs. I can’t 

overstate how important that is. The older drugs, some of which 

made you feel like you had the flu for a year, had very high dropout rates. So it didn’t matter if the drug worked, because people 

stopped taking them. They felt awful. 

Now we have newer treatments that were employed enough to 

emerge on the market, sort of off-budget cycle, which is why we 

need to make a big investment. 

And very recently, we were able to arrange a negotiation with a 

company. I think it used to be part of Abbot AbbVie—am I saying 

that correctly?—which comes out of North Chicago, for a greatly reduced price per course of treatment, so we are giving you our best 

estimate. 

Some of this has to be an estimate, because it depends on the 

genotype of the virus, and so forth. 
25 

But I think we are in good shape to cure this for many of the 

veterans who are affected. There is a little bit of estimation that 

goes on, as well, about screening newer veterans, in terms of how 

many cases—— 

Senator KIRK. Dr. Clancy, if I can interrupt you a little bit. I understand the economics of this treatment. It’s about $83 grand for 

a full course of treatment. That obviates the need for a liver transplant, which otherwise could cost the VA $300 grand. 

That is my understanding. Is that your understanding of the economics of the situation? 

Dr. CLANCY. That would be one way to look at it, yes. 

Senator BOOZMAN. Actually, with you getting the reduced prices, 

it is probably better than that, isn’t it? I think that is the conventional, if you are a regular patient. 

Dr. CLANCY. The newer treatment is somewhere between 20 and 

30 for a course of treatment, yes. It is just unclear how many veterans that will be the best fit for. 

Senator BOOZMAN. I would just ask you to look at that. Again, 

we are dealing with a case that we truly do have a miracle drug. 

It’s lots of money. As you mentioned, the side effects and the cure 

rate is just, like I said, it truly is a miracle drug. 

So thank you, Mr. Chairman. 

Dr. CLANCY. The other point I would just make is, it is much 

easier to administer in our system. The older drugs mostly had to 

be done by specialists. Now primary care clinicians can do this. It 

is much, much easier to give out. 

Senator KIRK. Let me recognize the Senator for the greater Albuquerque metroplex. 

Senator UDALL. Thank you, Chairman Kirk. 

And congratulations, Senator Tester, for your assumption of 

power in this subcommittee. 

I want to echo what Chairman Kirk said here. He pointed about 

the Frontlines to Lifelines Act. I am an original cosponsor, and I 

think this legislation is tremendously important for vets and 

transitioning vets. We have seen that in New Mexico. So I thank 

you for your hard work on that. 

Dr. Clancy, thank you for taking the time to be here with us on 

the VA budget. This budget, as you know, is of utmost importance 

to our Nation’s veterans and to veterans in New Mexico, for sure. 

Last year, I submitted concerns from employees at the VA to the 

VA Office of Inspector General, and these concerns centered around 

issues of scheduling and timeliness of VA care. But ultimately they 

were about a loss of trust between the VA and many of our veterans, a trust that I think the VA is still trying to recover. 

In New Mexico, the controversy has led to the appointment of a 

new director of our VA hospital. And New Mexico veterans and I 

really appreciate this new director and his efforts. He’s traveling 

the State. He’s meeting directly with veterans, holding a series of 

town halls, really trying to put himself in a position of turning 

around what happened there at the VA. 

And most veterans I have spoken to believe that the care that 

they receive at the VA is second to none, if they can get in the door 

and get the care. 
26 

And this budget, I appreciate very much, helps support that. 

This budget, however, also helps to ensure that the VA’s care remains second to none in the future, and that improvements are 

made where care is lacking. 

For example, in your document, you talk about, and I am quoting 

here, ‘‘VA researchers are pursuing,’’ and this is an area I think 

you are very familiar with because you headed up the research 

part of the establishment for 10 years, ‘‘VA researchers are pursuing a way to address Iraq and Afghanistan veterans’ most pressing mental and physical health issues.’’ And they include, PTSD, 

traumatic brain injury (TBI), traumatic limb loss, sensory dysfunction and loss, pain, and polytrauma. 

And the work the VA researchers do in these areas also benefits 

veterans of all ages, just like you were pointing out with the hepatitis C research. And we really appreciate your efforts in that area. 

OPEN-AIR BURN PITS REGISTRY

My question focuses on open-air burn pits, and veterans coming 

in contact with burn pits and then getting serious illnesses, respiratory illnesses and others. And it seems to me, in looking at all 

these lists and looking at the VA research justification, in the justification, the VA mentions mental health, homelessness, pain 

management, TBI, and a number of other areas, except exposure 

to open-air burn pits. In fact, the only mention of the open-air burn 

pits that I could find in the justification was that the registry has 

been created. 

Dr. Clancy, I am asking you if the VA is not making open-air 

burn pits research a priority in this budget on par with other signature ailments of Iraq and Afghanistan, then just what is the VA 

planning on doing with the registry and how does the VA intend 

to research ailments caused by exposure to these open-air burn 

pits? 

Dr. CLANCY. So thank you for the question. It is a topic that I 

am particularly interested in, in part because I have some close colleagues who have taken a great interest in this outside of VA. 

There has been a little bit of research done in the VA, some of 

it coming out of Northport, New York, but we have a lot more to 

learn. So I am personally quite thrilled by the brisk, enthusiastic 

response to opening this registry. It took us a little bit longer to 

get launched than we had hoped, but I want to say that we have 

tens of thousands of people enrolled right now. 

I think the first step that will offer us is generating hypotheses, 

what seems to be the most promising. The prior research I cited 

was a very small, well-done study, but actually to look at much 

larger numbers of individuals to see what their experiences have 

been. 

I might yield to my colleague here, who is a pulmonologist, if you 

had more to say about the burn pits. Okay. 

Senator UDALL. She’s covered it all, yes? She’s not even an expert in pulmonology. 

Dr. CLANCY. So I think that will be a first step, and I think that 

we are likely to learn a lot that we didn’t know about this. And 

some of that I think is going to come from figuring out what was 

the exposure, really. That is a huge area of investigation for us, 
27 

writ large, whether you are talking about agent orange, or the C– 

123 planes, or other types of exposures. 

We just got a report today from the Institute of Medicine on getting some clarifying guidance for people who were exposed to toxins 

at Camp Lejeune. I think we are going to see more and more of 

this in the future, and I think the airborne issues will be a big part 

of that. 

Senator UDALL. Thank you, Dr. Clancy, for your work there. And 

do you think you need additional authorities to work with both 

public and private research institutions to share information in the 

registry and allow that research to take place between veterans’ research and out in the private sector, universities and places like 

that? 

Dr. CLANCY. I don’t think we do right now. But if I should perceive any barriers, I will be on your doorstep to let you know. 

Senator UDALL. Okay. Thank you very much. 

Sorry for running over a little, Chairman Kirk. 

CHOICE ACT

Senator KIRK. Let me start the second round here and ask you 

about the Choice Act. I understand the Department is using some 

pretty low utilization expectation numbers from veterans. I would 

ask you, do you have good third-party validation on those numbers? 

If we get it all wrong, the committee may under-appropriate and 

you may not have enough money to take care of people as we promised in the act. 

Dr. CLANCY. So just about every aspect of VA healthcare will be 

assessed by independent organizations. That was written into the 

law. And frankly, we welcome that. I think it is an incredible gift. 

And, in fact, I spoke to the Blue Ribbon Panel, along with Dr. 

Tuchschmidt, a few weeks ago, just to thank them in advance for 

all the hard work they are going to do. 

I am not surprised by the low utilization at this point in time. 

I think the bigger question is what happens over the next 3 to 6 

months to a year. And that we are just going to have to watch very 

closely. 

But I will tell you that we are consulting with private industry, 

who knows a lot more about the insurance business than we do, 

both with an eye toward getting help with problem-solving right 

now, as well as trying to figure out what capabilities we need to 

bring in-house. 

Senator KIRK. Thank you. 

Senator Tester. 

Senator TESTER. Yes. Thank you, Mr. Chairman. 

NOMINEES FOR UNDER SECRETARY FOR HEALTH

Dr. Clancy and Dr. Tuchschmidt, one has an ‘‘interim,’’ the other 

has an ‘‘acting’’ before their name. At the VA hearing we had last 

week or 2 weeks ago, I asked the Secretary, and he said he was 

going to put some names forward. That hasn’t been done yet. 

Has he indicated to you when he’s going to put names forth, for 

you guys? 

Dr. CLANCY. I heard what you heard. That is all I can say right 

now. 
28 

RECRUITMENT OF PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS

Senator TESTER. Okay. We will follow up with him. I think it 

does speak to the problem, quite frankly. 

Can you tell me to what extent does VHA grant full practice authority to physician assistants and nurse practitioners? 

Dr. CLANCY. Right now, our policy is that, as you know, there is 

great variation among the States, so as a Federal system, all of our 

professionals have to be licensed in a State. And if you are a nurse 

practitioner, for example, that comes from a State that gives a lot 

more latitude to nurse practitioners, then you have the opportunity 

to use that, depending on which facility you are in and so forth. 

Senator TESTER. Are you actively recruiting nurse practitioners 

and physician assistants in those States in which they have that 

authority? 

Dr. CLANCY. They can work anywhere, as long as they are licensed in a State. What we are looking at now is whether we 

should have a system—— 

Senator TESTER. So let me get to recruitment. Are you actively 

recruiting those folks? 

Dr. CLANCY. Yes. 

Senator TESTER. Okay, good. 

Dr. CLANCY. Without question. 

REIMBURSABLE PAYMENTS TO NON-VA PROVIDERS

Senator TESTER. I am going to give an example. You tell me how 

pronounced this is in the VA. 

Kalispell Regional Medical Center in Kalispell, Montana, is owed 

more than $500,000—these are their numbers, not yours—in 2014. 

That is the bad news. The good news is, 2015 payments are coming 

in just fine. 

Number one, is this an outlier? And number two, if it isn’t an 

outlier, how are we taking care of this? And quite frankly, from a 

parochial standpoint, how are you dealing with Kalispell Regional 

Medical Center right now? Go ahead. 

Dr. TUCHSCHMIDT. So we centralized under the Choice Act. We 

centralized the funds. So we track our timeliness of payments. 

Senator TESTER. Yes. 

Dr. TUCHSCHMIDT. They did deteriorate. And right now, we have 

a corrective action plan to get back on track by the end of April. 

I don’t know about Kalispell, per se, but I wrote it down. I will go 

follow up on that. 

Senator TESTER. Okay. 

Dr. TUCHSCHMIDT. We do have some places where we—— 

Senator TESTER. How many Kalispells do you have out there? 

Dr. TUCHSCHMIDT. That I don’t know, but I can tell you that we 

had about 2,400 people, places, bills, that we owed beyond a year, 

and we are trying to catch up with those. 

Actually, most of them are disputes about whether the care that 

was rendered was authorized by us. 

Senator TESTER. Yes. 

Dr. TUCHSCHMIDT. But we are working to resolve all of those by 

the end of—— 
29 

Senator TESTER. I don’t need to tell you the trouble there. I 

mean, if we are talking about building partnerships, and they are 

not getting paid, it’s tough to build a partnership, okay? 

Dr. TUCHSCHMIDT. You are preaching to the choir. 

Senator TESTER. Okay, all right. 

GRANTS FOR STATE EXTENDED CARE BUDGET REQUEST

The priority list for building projects, your priority list, 2015 fis- cal year, $409 million for projects, yet your request is $80 million— 

$80 million for a program that needs $400 million. Can you give me thoughts on why you requested $80 million, and 

whether we are doing anything more than just treading water 

when it comes to facilities? And if these numbers are wrong, tell 

me, because I am getting it from these guys, you know? 

Dr. TUCHSCHMIDT. So I think we have our 27 leases that we are 

pursuing. Some of those are funded in prior fiscal years, so that we 

are now bringing online. So we have a significant need, for sure, 

for construction. In fact, I would think it is probably—— 

Senator TESTER. This is for extended care facilities, by the way, 

not the whole baby, just the extended care facilities, to be clear. I’m 

sorry. 

Dr. TUCHSCHMIDT. Yes. Your $80 million number threw me off. 

I wasn’t sure. 

Senator TESTER. Sorry. I should have prefaced that. Keep going. 

Dr. TUCHSCHMIDT. Yes. So I don’t have the specifics on the extended care facilities, but I am happy to get that information to 

you, so that you have that. 

Senator TESTER. Okay. We want the budget to match the need. 

I think that is going to be the challenge for this subcommittee. I 

am giving you flexibility in making sure that you have enough 

money to meet the needs of the veterans out there. 

And when it comes to extended care facilities, in particular, the $409 million vs. $80 million, that is less than one-fifth, less than 

20 percent. So it is a big issue. 

Thank you, Mr. Chairman. 

Senator KIRK. The Senator for King Cove, Alaska. 

Senator MURKOWSKI. Thank you, happy to be the Senator for 

King Cove, Alaska, Mr. Chairman. 

PATIENT-CENTERED PRIMARY CARE CONTRACT IN ALASKA

Let me ask about the patient-centered primary care contract for 

the State. I will tell you, I was a little bit surprised to learn after 

the contract was issued that the PC3 contract provides and that 

the contractor may set the reimbursement rates for the care that 

is referred outside of the VA system. But as you know, we don’t 

have managed care within the State. We have more patients than 

providers, as I mentioned, and providers reject managed care. 

TRICARE does not allow its contractor to set rates in the State. 

So when we learned that TRICARE was charged under its contract 

with negotiating rates in Alaska, again, it really gets your attention. It really surprised you there. 

So we were told that when the PC3 contract was entered into, 

my staff checked with your folks at the VA to ensure that the contractor was aware of the need to pay market rates there in the 
30 

State. We were assured at the time that the contractor knew about 

that. 

But what we are beginning to get now are complaints, and I will 

acknowledge that they’re sporadic complaints, but complaints that 

the providers are not getting market rates. 

We heard just recently from an anesthesia group that was very 

frustrated in working with the PC3 contract and is considering no 

longer serving our VA patients, which, of course, is exactly the opposite direction of where we want to take this. 

Is this something that the VA is monitoring? 

Dr. TUCHSCHMIDT. So I don’t know about the PC3 contract in 

Alaska provisions, per se. I wasn’t really involved at the time the 

PC3 contract was constructed, but I will go look at that. 

I will tell you that I think you are raising probably one of the 

most significant issues we face, and it is not just for Alaska right 

now. I think that one of the things that we are doing really 

prompted by the Choice legislation is to ask kind of ourselves what 

is the future of purchased care in VA? What does that look like? 

What does a VA health plan look like? We have employed Deloitte 

to help us do an assessment of our current purchased care processes. 

And I think we have a whole smorgasbord, quite frankly, of options from local contracts to the spot market to sharing agreements, to PC3, to Choice, to Project ARCH. 

Senator MURKOWSKI. And they can be different all over the country. 

Dr. TUCHSCHMIDT. And they are different all over the country. 

And I think one of the things that we are going to be doing over 

the next few months is sitting down and saying, ‘‘How do we reconcile all of this?’’ And quite frankly, TriWest tells me almost on 

a daily basis what an awful position we have put them in, because 

they are going out to the same providers that we are contracting 

with, saying, ‘‘Would you like a PC3 contract? And by the way, we 

have a Choice contract over here.’’ And it is mind boggling. 

So we definitely have to resolve this. I think you’ve hit the nail 

on the head. 

Dr. CLANCY. If I could just make one point? 

Senator MURKOWSKI. I would ask you to look not only at Alaska 

but look across the system, because it just doesn’t seem to be 

trending right here for us. 

Dr. CLANCY. We would not want one-size-fits-all, right, because 

the markets are very different. 

Senator MURKOWSKI. Right. 

Dr. CLANCY. Alaska is going to be very different than Wisconsin, 

for example, or New Mexico. They are just very different constellations, ecosystems, if you will, of medical services. But at the same 

time, we have a lot of work to do to try to rationalize this because 

if it is illogical for us, it is going to be much, much harder to give 

veterans a seamless, terrific experience every time. 

Senator MURKOWSKI. Yes, I appreciate that. 

VA AND DOD MENTAL HEALTH DRUG FORMULARY

One last question, and, Dr. Clancy, we were trying to connect 

yesterday as I was traveling cross-country, and we weren’t able to 
31 

do it, but I think you were alerted. I had read the op-ed piece in 

the Washington Post this weekend by the former Vice Chief of Staff 

of the Army, General Chiarelli, suggesting that the VA’s mental 

health drug formulary is just too narrow to ensure that the medications that the Department of Defense provides, when that individual separates and then moves over to the VA side, that they can 

be maintained after he leaves service. 

Now, it is my understanding that you have attempted to address 

this through regulations. General Chiarelli suggests in his op-ed— 

in fact, is pretty emphatic—that the regulations aren’t sufficient, 

that they leave broad loopholes. 

Can you tell me where we are with this? Does he have valid concerns here? 

Dr. CLANCY. So first, given his work and interest in mental 

health, traumatic brain injury, and so forth, I mean, I have huge 

respect for his contributions and building awareness of these 

issues. What I can tell you is we are working very closely with the 

Department of Defense to ensure as seamless a transition as we 

possibly can for servicemembers who are leaving the military and 

coming to VA. 

As a result, in particular, of the executive action issued by the 

President in August, focused on improving mental healthcare, a 

whole series of actions, we actually have directed all of our facilities and clinicians that servicemembers can continue their medications at least until they can have time to be evaluated by a clinician in VA. 

Some drugs that are good for short-term treatment may not be 

the ideal choice for longer term treatment, and it is often very common with the chronic use of drugs to treat different mental health 

disorders that you are going to need to make changes. You know, 

one antidepressant works for a while, but then it doesn’t work so 

well and so forth. 

And we do that for other medications as well. We would be 

happy to come and give you a full brief on that. 

I think a little bit of what happened was that the commission 

that General Chiarelli was working on, which has just delivered its 

report to the Department of Defense, the military compensation 

and retirements—I can never remember the entire acronym—was 

working independently, as they very much wanted to, at the time 

when this executive action and other activities were in process. 

Senator MURKOWSKI. I would be curious to know and understand 

a little bit more, because I thought, at least the way that the General had outlined it, it appeared that we were not syncing the systems. And when the systems don’t line up, then it is the veteran 

and the veteran’s care that suffers. 

So I don’t know whether he’s correct in that. We do still have 

loopholes that need to be addressed. But if you can provide me with 

a little more information on that? 

Has the Department been in contact with the General about his 

recommendations, do you know? 

Dr. CLANCY. I have been trying but have not managed to connect 

with him. 

Senator MURKOWSKI. Okay. All right. 
32 

Dr. CLANCY. He is actually part of the Blue Ribbon Panel that 

is reviewing all of these independent assessments, but cell phone 

land didn’t make it possible. 

Senator MURKOWSKI. All right. I appreciate it. 

Thank you, Mr. Chairman. 

Senator KIRK. The Senator from Wisconsin. 

Senator BALDWIN. Thank you. 

TOMAH VA INVESTIGATION ON WHISTLEBLOWERS

We have already had an opportunity to converse, Dr. Clancy, 

about concerns raised by some of the whistleblowers in the Tomah 

investigation who want to speak up but feel that they can’t because 

of confusing guidance they have received by managers and supervisors at the Tomah VA regarding Health Insurance Portability 

and Accountability Act (HIPAA) privacy concerns, privacy regulations, and the so-called section 7332 data, which I understand to 

be related privacy issues. 

So I would ask you to give me an update right now as to whether 

there will be updated guidance that your team of investigators can 

share. And will you ensure that once there is clarified and updated 

guidance, that everyone who wants to speak up and meet with and 

discuss and talk with your investigators are able to do so, because 

we are getting mixed messages even as of earlier today as to 

whether that updated HIPAA guidance has been put together? 

Dr. CLANCY. I appreciate you sharing what you are hearing from 

many people. The Drug Enforcement Administration (DEA) went 

into Tomah to do an investigation. They had been there in the past, 

and apparently, I don’t think that was productive or didn’t lead to 

any definitive conclusions. 

But very recently they went in and there was a little bit of confusion, some of which was that our regional counsel was advising us 

that they didn’t have the right paperwork to be looking at information that was sensitive at the patient level. 

I have been informed by the acting network director that they 

have resolved those issues. But since you are hearing this even 

today, we will loopback. I know that Sloan Gibson, as I said, is on 

the ground today, reinforcing for people that we want to hear from 

everyone who has concerns about this or other issues. 

Senator BALDWIN. Right. And it was in a conversation with him 

earlier today that it sounds like they may not have definitively resolved those concerns, and so I am very eager to have that done. 

When do you expect to complete your investigation? And will you 

make the full report public at that time? 

Dr. CLANCY. So we will be making at least summaries of it public. As you know, the investigations on the clinical side are protected by peer review privilege, in the same way they would be at 

any other hospital. But we will be releasing a summary of the results from the first phase of clinical investigation. 

The second phase, when it is done, we will have some kind of 

summary as well, although it too will be a protected peer review, 

mostly so that we can get at all the facts. And as our announcement yesterday indicated, in our work for the past few weeks, in 

terms of rolling out this new tool to make it easier, much, much 

easier for primary care clinicians to do the right thing, we are not 
33 

waiting until all the investigations are done to make improvements 

that we can see right now. So that is nursing care and the urgent 

care part of Tomah, with respect to the care that Mr. Baer got and 

other issues there. 

It is also about safe prescribing of opiates. And the tool that we 

announced yesterday, as I think you know, was all about making 

it quite visible to clinicians in a very easy way which of their patients are on opiates, what kind of dose have they had, the urine 

drug testing, are they on benzodiazepines, and other things where 

there might be an adverse reaction, and so forth. 

It also allows them to see whether patients getting those narcotics from other points of care in our system. 

Senator BALDWIN. I would just state for the record that absolute 

transparency is so critical here. There have been numerous concerns raised about unpublished reports, about lack of transparency 

in the oversight of the Tomah facility. And I will want to press further on that when it comes to the final report of this investigation. 

OPIOIDS PRESCRIPTION

Lastly, you have talked already a little bit about the VHA’s review of how opioids are prescribed system-wide. Since this is an appropriations subcommittee hearing, I would ask, are those efforts 

prioritized in your budget request? 

Dr. CLANCY. I think that that is on-going work that is built into 

our medical care budget, but I have to get back to you on that, in 

terms of how that has happened. 

This initiative was fully rolled out in February 2014, and we 

have seen system-wide decreases in the use of opioids, so that is 

good. 

But we are also seeing, when we actually have this new tool and 

look at our dashboards, that, frankly, we need to up our game at 

Tomah and across the system. And again, this new tool will help 

people do that. 

I don’t know how much it is specifically identified. It is no different than we don’t have a separate line item for, say, high blood 

pressure or diabetes. But we can, certainly, give you an accounting 

of what all this is costing, if that would help. 

Senator BALDWIN. That, and as you do system-wide overhauls, as 

you try, and as non-VA medical systems try to roll significant protocol changes, those are big undertakings. 

Dr. CLANCY. Yes. 

Senator BALDWIN. And in many systems, it fails because adequate attention and emphasis isn’t put on it. 

Dr. CLANCY. Yes. 

Senator BALDWIN. We want to make sure that you are in a capacity to get everyone’s attention system-wide, so as we work on 

the appropriations subcommittee marks, I want to be in communication on that. Thank you. 

Dr. CLANCY. Thank you. 

I will just say, for the record, one of the things that I found actually quite thrilling was, as a result of being part of many, many 

phone calls across our system, so I reach more than 2,000 primary 

care docs and facility directors, network directors, and really over 

the past few weeks to say this is really important, we are making 
34 

progress, and it is not easy, because 50 to 60 percent of the veterans that we serve have some kind of chronic pain issue, as compared to about 30 percent of Americans. I actually got a lot of fan 

emails saying thank you. 

And some part of that, I believe, Senator, is about these patients 

have other issues too, and we want to pay a lot of attention to 

opioid safety and making sure we are helping and deploying every 

tool in our toolbox in terms of pain management to help these veterans. But we don’t want to miss dealing with their other medical 

issues, as well. And I am starting to hear that from some of our 

primary care docs. So I think this tool will be helpful. 

Senator KIRK. Let me just add my concerns to the Senator from 

Wisconsin’s. 

I have been warned through my family and patients that I have 

seen, including an ex-staffer of mine, there is a growing method in 

medicine just to give the patient happy pills, which emphasize 

opioids, and get them pretty heavily addicted. We are very worried 

about that. The Tomah facility was called in the press the candy 

store. 

GAO REPORTS VHA A HIGH-RISK PROGRAM

Let me close with one last question. The Government Accountability Office (GAO) has said that VHA is a high-risk government 

program. Do you agree with that assessment by the GAO? Could 

you comment on that? 

Dr. CLANCY. You know, I think by every criterion, given our experience in 2014, it would be hard to make a strong argument that 

we shouldn’t be on their high-risk list. The one question I had for 

them, they did come and give us a heads-up, and I wanted to know 

what were the criteria for getting off the list. There are some highrisk lists in government programs that can be hard to get off of, 

for a variety of reasons. And they actually assured me that with 

improvements—I think they were blown away when we said we 

welcome your reports and we are paying far more attention to 

them in a systematic fashion than we have in the past. In fact, I 

was glad they were sitting down. I thought one of them was going 

to hit the floor when we said that. 

I think they have perceived in the past that we weren’t necessarily attentive to their findings. And to that I would say, with 

new leadership, it’s a new day. 

Senator KIRK. I will note our clerk told me about some Navy 

leaders who one time said, ‘‘Don’t give me another budget increase 

because it encourages my leadership to not make choices.’’ As long 

as you are receiving steady increases, you are in a culture that will 

not make any tough choices. That may be the lesson here. 

Dr. CLANCY. Well, what I would say is the budget that we have 

presented for fiscal year 2016—— 

Senator KIRK. He corrects me that that was Admiral Mullen, the 

Chairman of the Joint Chiefs of Staff, who said that. 

Dr. CLANCY. I would never disrespect any individual publicly. I 

will simply say the budget that we submitted represents our very 

best effort to reflect to you a true requirement, as best we see it, 

to meet veterans’ needs. 
35 

And I will also say that Secretary McDonald is strongly committed to finding all possible efficiencies. But you can’t really get 

there until you kind of address the backlog of need. 

Senator KIRK. Thank you. I think we have kind of beat this to 

death. 

Senator Hoeven. 

Senator HOEVEN. Thank you, Mr. Chairman. 

Senator KIRK. You get the patience award now. 

Senator HOEVEN. Thank you. 

Senator KIRK. Go ahead. 

Senator HOEVEN. I would like to thank both of you for coming 

today to testify. And, Dr. Clancy, to pick up on some things that 

you and I talked about earlier, thanks so much for the earlier conversation. 

REIMBURSEMENT FOR NON-VA NURSING HOME CARE

The first one I want to pick up is provider or VA reimbursement 

to nursing homes. Right now, as you are aware, when a veteran 

stays in a nursing home, if the reimbursement comes through 

Medicare, the Centers for Medicare and Medicaid Services (CMS), 

then that nursing home is not required to comply with the small 

business contracting requirements. But if the reimbursement 

comes through the VA, then they are, which means that in many 

cases, a nursing home won’t take VA reimbursement for taking 

care of a veteran, which denies veterans opportunity for care closer 

to home. 

So I believe that that is something we need to remedy. I talked 

to both Secretary McDonald and yourself, but I would like to know 

what you believe we can do to ensure that nursing homes aren’t 

subject to that small business contracting requirement, so that they 

will accept VA reimbursement. 

Dr. CLANCY. I will first acknowledge that I have not been burdened by a legal education and say that what I understand from 

our legal team is that we need a much stronger basis for provider 

agreements that we have used in the past than we have right now. 

And we would look forward to working with you on that. 

Senator HOEVEN. Well, what we need to get to is, what authority 

did you have to provide reimbursement and not subject the nursing 

homes to that requirement? And does it require a statutory fix, in 

which case, I am more than happy, in fact—— 

Dr. CLANCY. Yes, it does require a statutory fix, and we will follow up with you with specific language and needs. 

Right now, our only alternative, it appears, is to use contracts, 

which, as you acknowledge, can be very, very difficult for some of 

the providers who can provide great care to veterans to comply 

with. 

PROVIDER AGREEMENT LEGISLATION

Senator HOEVEN. I have legislations to do that. I have talked to 

Senator Isakson, who is the chairman of the Veterans’ Affairs Committee. He’s supportive. So I would like to go work with you on the 

wording and have your support and see if we can’t pass that this 

year. 

Dr. CLANCY. Terrific. I will come visit with my general counsel. 
36 

Senator HOEVEN. Thank you. 

CHOICE ACT’S 40-MILE RULE

The other is, on the Veterans Choice legislation, which I very 

much support and cosponsored, the challenge that I talked to you 

about earlier, and that is under the 40-mile rule, we have situations where we have individuals who are within 40 miles of a 

CBOC, community-based outpatient clinic, but a long way away 

from a VA healthcare facility where they can get full services. 

So in cases where they have proximity of 40 miles or less to that 

CBOC, they can face long-distance travel to get to medical services 

that the CBOC doesn’t provide, which can be a real problem, 

versus being able to get those services from a local provider, if they 

are more than 40 miles away. 

So somebody is actually disadvantaged by being within 40 miles. 

They can be forced, like in our case, in our State, to travel in excess 

of 300 miles one way to get the health services they need rather 

than getting them locally when a CBOC doesn’t provide them. 

So that is a real challenge for us, in terms of the Veterans Choice 

Act, that we need to address and would like your input on what 

you think is the best way we can accomplish that. 

Dr. CLANCY. So we are working through an array of options right 

now. Full credit to Dr. Tuchschmidt, who is leading this. There are 

one or two minor tweaks that we could make that I think will help 

some veterans, but that is actually kind of at the margin. 

I think more than that, we are probably going to definitely need 

your assistance, because we are going to need some legislative 

change or amendments to make that possible. 

And I did come back after our conversation and explain to Jim 

about the great map in your office with all the pins and that you 

were illustrating the distances travelled. I get that. 

One of the challenges we have right now, and again this gets 

back to our request for flexibility, for some of the specific examples 

you gave me, the gentleman who travelled 300 miles to get a shot, 

for example, not technically eligible for Choice right now, as the 

law is written, we actually could arrange something through our 

non-VA care program. Again, that comes out of our budget choices 

and mandatory separate allocation. That is why we are looking for 

a little bit of flexibility. But we are looking for relief on the 40 

miles, because it has been a big problem for many, many veterans. 

I can’t say we have heard from all of them, but we have heard from 

many. 

Senator HOEVEN. And I think if there is statutory help or flexibility that we can give you there, that is what we want to do. Like 

I say, I am already working with Senator Moran of Kansas on legislation to do that. But it can actually be a cost savings for the VA 

because there may be cases, or I think in many cases, getting that 

procedure close to home may actually save the VA money, versus 

that veteran travelling to a healthcare center, getting it there, having to travel back, and then all the time and cost to travel and 

lodging, and/or him or her missing their work and that kind of 

thing. 

So there may be some work we have to do with CBO, but I think 

this is a fix that, one, serves veterans, two, can be cost-effective. 
37 

And we need to nail down what authorities you have, so where can 

we do this administratively? And we need, you didn’t call him an 

ombudsman, but a person at each of the VA health facilities that 

can actually provide these decisions for when individuals can get 

the services at a local healthcare provider, versus traveling to the 

VA facility. 

Dr. CLANCY. Yes. I am not sure ombudsman is quite the right 

word. But effectively, we have a champion for the Choice program 

at each facility, so that is a good thing. And we have other people 

who deal with non-VA care. 

Ultimately, I think, we need to have a more logical way for veterans not to have to worry about this and to figure out that they 

are on the wrong end of the facility. ‘‘I went to the wrong department. Now I need to go over here to get what I need.’’ We need 

to be integrating that in a way that is logical and completely easy 

for veterans. That is where we need to get to. 

Senator HOEVEN. And that is what we need to understand is, do 

your Choice Champions have enough flexibility to provide the authority to get this healthcare locally when it makes sense, or is 

there something else that is needed so that you can actually deliver 

on this? 

Dr. CLANCY. That is a process that we are doing a deep dive on 

right now, to figure out how we can do this and where do we need 

legislative help, and that includes the 40 miles. So we will be back 

to you in the very, very near future. 

Senator HOEVEN. Thank you. 

ADDITIONAL COMMITTEE QUESTIONS

Senator KIRK. Thank you. 

All right, let’s wrap her up. Let me thank our witnesses for coming and tell you that the record will remain open until the close 

of business on Friday. 

[The following questions were not asked at the hearing, but were 

submitted to the Department for response subsequent to the hearing:] 

QUESTIONS SUBMITTED TO THE OFFICE OF INSPECTOR GENERAL

DEPARTMENT OF VETERANS AFFAIRS

QUESTIONS SUBMITTED BY SENATOR TAMMY BALDWIN

Question. The Veterans Affairs Office of Inspector General (OIG) completed a report in March 2014 regarding the Tomah VA Medical Center in Tomah, Wisconsin. 

The VA OIG has conveyed that it shared the report with Tomah VA Medical Center 

leadership. My office contacted the Tomah VAMC on April 7, 2014, on behalf of a 

constituent and requested a full review and investigation of various concerns, including concerns about opioid and benzodiazepine prescribing practices at the facility. In his response, Mario DeSanctis, Tomah VA Medical Center Director, did not 

mention the existence of the March 2014 VA OIG Report. 

At the March 10, 2015, hearing, Dr. Clancy stated that the director of the facility 

was told not to share the report with anyone. However, Dr. Clancy further stated 

that those reports can and should be shared. 

Who told Tomah VA Medical Center leadership not to share the March 2014 VA 

OIG report? 

Answer. There is some confusion about the difference between administrative closures and OIG final reports. In March 2014, the OIG administratively closed our 

inspection of the Tomah VAMC. The OIG did not tell the Tomah VAMC leadership 

not to share the March 2014 administrative closure report with anyone, including 

the VA Central Office. In advance of a July 3, 2014, briefing with the Tomah VA 
38 

Medical Center Director, Tomah VAMC Organizational Improvement Analyst, and 

Veterans Integrated Service Network (VISN 12)—VA Great Lakes Health Care System Quality Management Officer, an OIG physician sent the Tomah VAMC Director 

the report of administrative closure. He advised the Tomah VAMC Director that because the report was an internal document, copies should not be distributed to others. A similar advisement was given to the VISN 12 Network Director prior to a 

briefing on July 16, 2014. This advisement in no way was intended to mean that 

the contents could not be discussed with or shared with senior Veterans Health Administration (VHA) officials. The intention was to protect the contents from external 

disclosure because, as an administrative closure, it had not been reviewed for potential redactions by the OIG Release of Information Office for public release under the 

Freedom of Information Act (FOIA). This is consistent with the OIG’s advisement 

to Senator Baldwin’s staff at a July 22, 2014, briefing to submit a FOIA request 

to obtain the administrative closure. The version provided to Senator Baldwin on 

August 29, 2014, and subsequently posted on the OIG Web site on February 6, 2015, 

contained redactions by the OIG Release of Information Office pursuant to the Freedom of Information Act. 

We also note that advisements against external distribution of draft reports are 

routine. For example, OIG draft reports issued to VA officials for comment bear the 

following warning: 

‘‘This is not a final OIG report and is subject to revision. Recipients of this draft 

report must not, under any circumstances, show or release its contents for purposes other than official review and comment. It must be safe guarded to prevent publication or other improper disclosure of the information it contains. 

This draft and all copies of it remain the property of the OIG.’’ 

While the administrative closure report was not initially sent to VHA Central Office officials when it was sent to the Tomah VAMC and VISN 12 Network Directors, 

VHA Central Office staff were well aware of the allegations since April 13, 2011. 

The OIG Hotline sent an information copy of the allegations to staff in the office 

of the Deputy Under Secretary for Health for Operations and Management at VHA 

Central Office on April 13, 2011, when the OIG Hotline sent a case referral to the 

VISN 12 Network Director for review, fact-finding, and potential corrective action. 

The issues under review at Tomah were the frequent subject of discussion at regular OIG-VHA monthly meetings between the Assistant Inspector General for 

Healthcare Inspections and senior VHA Central Office staff, to include the VHA 

Chief of Staff and VHA Management Review Service (MRS) Director. In addition, 

on March 11, 2014, the Assistant Inspector General for Healthcare Inspections provided VHA Central Office senior staff with a list of open complaints that the OIG 

was working (including Tomah) and the major topic of concern (medication management, pain management, quality of care) to further their ability to take whatever 

action they deemed appropriate. The Tomah administrative closure was signed a 

few days later on March 14, 2014. 

Question. Please describe the VHA’s current policy for the sharing of OIG reports 

that are distributed to local VA facilities. In addition, please include answers to the 

following questions: 

Answer. The liaison office between VHA and the OIG is VHA’s MRS, which is located in VHA Central Office. The OIG sends MRS copies of all draft OIG reports 

that deal with VHA including reports by the OIG’s Office of Healthcare Inspections 

on individual facilities. We request that any comments to OIG draft reports from 

the facility or the VISN be routed through MRS so as to ensure that VHA Central 

Office is aware of the report. VHA will provide more detailed information on their 

internal practices directly under separate correspondence. 

Question. Are local VA facilities currently directed to make OIG reports available 

to the public? 

Answer. OIG draft reports are considered pre-decisional and as such include the 

following warning when the report is with VA officials for comment: 

‘‘This is not a final OIG report and is subject to revision. Recipients of this draft 

report must not, under any circumstances, show or release its contents for purposes other than official review and comment. It must be safe guarded to prevent publication or other improper disclosure of the information it contains. 

This draft and all copies of it remain the property of the OIG.’’ 

With regard to a final OIG report, the standard distribution list includes the Veterans Health Administration in VHA Central Office for all reports whether they are 

national reports or a report on a single facility. If it is a single facility report, the 
39 

Director of that facility and the VISN Director who has management oversight of 

that facility are included in the distribution. Also included in the standard distribution list for all OIG reports are all OIG oversight committees and the Members of 

Congress who represent the facility or who may have constituents who use the facility. The OIG electronically distributes the final report to all addresses at the same 

time. This is how reports are routinely published. We also post all final reports on 

our public Web site the same day as they are issued to VA. Members of the public 

who subscribe to the OIG’s email distribution program or to our Really Simple Syndication (RSS) feed, which automatically downloads new content when posted to our 

Web site, also receive reports at the same time the reports are issued. 

The Tomah Administrative Closure was not processed this way because it was not 

a final report. As stated above, the closure was provided to facility and VISN management prior to a conference call and a meeting with OIG staff. When Senator 

Baldwin’s office contacted the OIG about a similar issue, we communicated to her 

office that the OIG had performed an inspection, held a teleconference briefing, and 

subsequently provided a copy of the report to that office as allowable under the 

Freedom of Information Act and the Privacy Act. 

The OIG has changed its policy regarding administrative closures in March 2015. 

As a result of a review of OIG decisionmaking practices on closing reviews administratively, the then-Deputy Inspector General instituted a new policy requiring coordination of administrative closures within the Immediate Office of the Inspector 

General, the Office of the Counselor to the Inspector General, and the Release of 

Information Office. This process will ensure consistency in decisionmaking regarding 

when and how public release of related documents is handled. 

Question. Are local VA facilities currently directed to share OIG reports with 

Members of Congress? 

Answer. For final OIG reports, the OIG shares the report according to a standard 

distribution list that includes the OIG’s oversight committees and Members of Congress who represent or have constituents who may use the facility or facilities that 

are the topic of the report. 

Question. Are local VA facilities currently directed to share OIG reports with congressional committees with jurisdiction over the VA? 

Answer. For final OIG reports, the OIG shares the report according to a standard 

distribution list that includes the OIG’s oversight committees and Members of Congress who represent or have constituents who may use the facility or facilities that 

are the topic of the report. 

SUBCOMMITTEE RECESS

Senator KIRK. We will also have our next hearing on Tuesday, 

March 17. 

I close this hearing. Thanks, everybody. 

[Whereupon, at 4:12 p.m., Tuesday, March 10, the subcommittee 

was recessed, to reconvene Tuesday, March 17, at a time subject 

to the call of the Chair.]