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Hearing Transcript on Discovering a More Efficient Process: Improving Timeliness and Adequacy of VA Compensation and Pension Examinations

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Committee on Veterans' Affairs, DAMA Subcommittee,Discovering a More
Efficient Process:  Improving Timeliness and Adequacy of VA Compensation
and Pension Examinations, 4-23-12

 

 

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

 



FIELD HEARING

BEFORE  THE

SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL
AFFAIRS

OF THE

COMMITTEE ON VETERANS' AFFAIRS

U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

SECOND SESSION


APRIL 23, 2012

FIELD HEARING IN TOMS RIVER, NJ


SERIAL No. 112-58


Printed for the use of the Committee on Veterans'
Affairs

 

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COMMITTEE ON VETERANS' AFFAIRS


 

JEFF MILLER, Florida, Chairman

 

CLIFF STEARNS, Florida

DOUG LAMBORN, Colorado

GUS M. BILIRAKIS, Florida

DAVID P. ROE, Tennessee

MARLIN A. STUTZMAN, Indiana

BILL FLORES, Texas

BILL JOHNSON, Ohio

JEFF DENHAM, California

JON RUNYAN, New Jersey

DAN BENISHEK, Michigan

ANN MARIE BUERKLE, New York

TIM HUELSKAMP, Kansas

MARK E. AMODEI, Nevada

ROBERT L. TURNER, New York

BOB FILNER, California, Ranking

CORRINE BROWN, Florida

SILVESTRE REYES, Texas

MICHAEL H. MICHAUD, Maine

LINDA T. SÁNCHEZ, California

BRUCE L. BRALEY, Iowa

JERRY MCNERNEY, California

JOE DONNELLY, Indiana

TIMOTHY J. WALZ, Minnesota

JOHN BARROW, Georgia

RUSS CARNAHAN, Missouri

 

 

 

Helen W. Tolar,
Staff Director and Chief Counsel


SUBCOMMITTEE ON DISABILITY
ASSISTANCE AND MEMORIAL AFFAIRS

JON RUNYAN, New Jersey, Chairman

DOUG LAMBORN, Colorado

ANN MARIE BUERKLE, New York

MARLIN A. STUTZMAN, Indiana

ROBERT L. TURNER, New York
JERRY MCNERNEY, California,
Ranking


JOHN BARROW, Georgia

MICHAEL H. MICHAUD, Maine

TIMOTHY J. WALZ, Minnesota

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

 

       

C O N T E N T S

April 23, 2012


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

OPENING STATEMENTS

Chairman Jon Runyan

    Prepared statement of Chairman Runyan

Hon. Timothy J. Walz, Democratic Member

  


WITNESSES

Col. Mike Warner, USA (Ret.), Chair, New Jersey Governor's
Council For Military and Veterans Affairs

    Prepared statement of Col. Warner

Mr. John Dorrity, Director, Ocean County Veterans Services

    Prepared statement of Mr. Dorrity

Mr. Gene O’Grady, The American Legion, Department Vice Commander

    Prepared statement of Mr. O'Grady

Mr. Walter J. Tafe, Director, Burlington County Military and Veterans Services

    Prepared statement of Mr. Tafe

Mr.
Michael E. Moreland
, FACHE, Director, Veterans Integrated Service Network 4
Veterans Health

 Administration, U.S. Department of Veterans Affairs

    Prepared statement of Mr. Moreland

Accompanied By:

Joseph Dalpiaz, Director of the Philadelphia VA Medical Center

Robert McKenrick, Director of the Philadelphia VA Regional Office

 

 


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


Monday, April 23, 2012

U. S. House of Representatives,

Subcommittee on Disability Assistance and Memorial Affairs,

Committee on Veterans' Affairs,

Washington, DC.

The subcommittee met, pursuant to notice, at 11:19 a.m., at Ocean County College
Auditorium, 1 College Drive, Toms River, New Jersey, Hon. Jon Runyan [chairman of the subcommittee] presiding.

     Present:  Representatives Runyan and
Walz.

Dr. MCGINTY.  I’m
Dr. Jim McGinty, Executive Vice President of Ocean County College.  And on
behalf of the college president, Dr. Jon Larson, the Board of Trustees, the
faculty, staff and students, it is my pleasure to welcome you to our beautiful
and ever-expanding campus.

We are very
pleased we have been selected to act as the site for this morning’s field
hearing on Veterans Affairs.

Before I turn to
the podium, I would like to thank Congressman Jon Runyan for being here today.
As a member of the House Committee on Veterans' Affairs and Chairman of the
Subcommittee on Disability Assistance and Memorial Affairs, Congressman Runyan
is most generously donating his time and his talents to listen to and
ultimately to understand the many different issues that affect our veterans.

I hope you enjoy
the use of our facility in the Arts and Community Center and that you find
today’s field hearing both informative and productive.  Thank you.

Mr. RUNYAN. 
Thank you very much, Jim.

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

With that being
said, good morning.  Usually when we hold our DAMA Subcommittee hearings, we are
sitting in Washington.  Today I am honored and happy to be here at Ocean County College, in my home district.

While we are far
away from our national hearing room on the Hill and away from the C-SPAN
cameras, this is still an official congressional oversight hearing of the House
Veterans' Affairs Committee, and the hearing rules and hearing conduct apply in
this venue.  Therefore, I would respectfully ask that everyone be courteous to
our witnesses and remain silent until the hearing is formally adjourned.

In chairing the
Subcommittee on Disability Assistance and Memorial Affairs, I have had the
opportunity to work on the complicated issues surrounding the veterans benefit
system, including the compensation and pension process.  Through this
experience, I have had the pleasure of working alongside my good friend, the
Honorable Timothy Walz, who represents Minnesota’s 1st Congressional District. 
I am happy to introduce him to you today and welcome him to Toms River.

As many of you
know, New Jersey has the 18th largest veteran population in the U.S.  Over 60,000 veterans call the 3rd Congressional District of New Jersey home.  As many
of you know, our district is home to the largest disabled veterans population
in New Jersey, all of whom have sacrificed greatly for our nation.

We are also
fortunate to be home to the Joint Base McGuire Dix Lakehurst.  This
installation is critical and related to veterans affairs.

As we wind down
two overseas conflicts, our military population will soon begin the process of
transitioning to our veteran population.  This transition will inevitably add
additional stress to a process we are here today to discuss, examining the VA
compensation and pension exam system.  By bringing together all parties here
today, from local veterans here in New Jersey to the VA itself, our objective
is to make the process more efficient and ultimately to serve the needs of our
veterans as best as we can.

As I am sure all
of you are aware, the C&P examinations are a major cause of delay in the VA
claims adjudication process.  My office has been following a host of problems
dealing with the issues in the district and around the country.  So we are here
today to examine this problem, not from afar in Washington, D.C. but from right
here in Ocean County, where so many veterans call home and who are affected by
these delays.

Currently,
veterans in the southern counties of New Jersey receive C&P examinations
through the Wilmington, Delaware or the Philadelphia VAMCs.  All
examinations at the Wilmington VAMC are conducted by VA staff.  As best as
we have been able to discern, VA relies too much on C&P examinations. 
Often there is sufficient medical evidence in the claims file alone to
rate a disability based on VA and private treatment records.

By unburdening
the VA with all this current over-emphasis on C&P exams, the process should
become more efficient.  Also, greater access to exams could materialize.  Based
on these observations, I believe we can have these solutions moving forward.

Before jumping
ahead to what I believe are some solid solutions to these problems, I would
like to welcome our witnesses here today who will be speaking in detail on ways
to improve the system.  It is my hope that through our mutual efforts, we can
make the difference needed to increase access to C&P exams and unburden the
claims process and make our lives and our veterans’ lives easier.

Again, I am
delighted to be here with you today.  I will now yield to the distinguished
gentleman from Minnesota, my good friend, the Honorable Tim Walz.

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

Mr. WALZ.  Good
morning, everyone.  Thank you, and thank you, Chairman Runyan, for the
invitation to this beautiful district and this beautiful facility.  Thank you
to our host here for putting this on.  A special thank you to the majority and
minority staffs for continuing to work to serve our veterans in a most
professional manner.  And a special thank you to all of you who took time out
of a busy day, other things you could be doing.  You chose to be here for one
simple reason:  you understand that this country’s promise to our veterans is
sacred, and to make sure that it is followed through with is not only our moral
responsibility, it is our national security responsibility to prove to coming
generations that if you choose to serve this nation, this nation will serve you
and will do right by you.

I have to tell
you that serving on this committee is one of the greatest honors that I have
ever been given.  I spent 24 years in the military myself, and I always tell a
little story that is true.  I went down to Walter Reed and was visiting a
Marine, and they said this is Congressman Walz, he is a retired Command
Sergeant Major.  And a Marine said, oh, I’m really sorry about that.  I thought
he was talking to the Army guy.  He said, no, I’m sorry you took the demotion to
Congress there.

[Laughter.]

Mr. WALZ.  The
fact of the matter is, though, that the service provided by this committee --
and I will have to tell you, seeing a new congressman come in, and your
congressman, Jon Runyan, he chose and asked to be on the VA Committee, and to
be quite honest with you, not a lot of people do because it is a lot of hard
work, and Jon is trying to get it right.  He chose to be there, and since day
one has decided that first and foremost the care of our veterans trumps
everything else.

So it is an honor
for me to be here with him.  It is an honor, and I think if you would see this,
the Chairman mentioned there are no C-SPAN cameras.  I wish they were on in the
VA Committee more often.  I think what you would see is the America that you
think it could be, the idea of working together for a common goal of
understanding that we have precious resources and it is right to deliver them
in the most targeted, effective manner.

I always say this
to our friends from the VA.  I am your staunchest supporter, but I will be your
harshest critic, because if one veteran falls through the crack, it is one too
many.

This is a
zero-sum proposition, and having these hearings, I cannot tell you, this is
where the work is done.  When you have someone, Chairman Runyan, and all the
members of that committee, they are not there for the cameras.  They sit there
through the long hearings and learn the issues.

And to the
witnesses coming here, I come from a little different area.  My district is Southern Minnesota.  It is the whole northern tier of Iowa.  My district starts right
outside Sioux Falls, South Dakota and runs over to the Mississippi River in Wisconsin.  It holds some of the most fertile farming land.  We are the second-leading
producer of hogs, corn, soybeans and turkeys, and we are also home to SAM,
which I know you are so proud of, as we are.  We are also home to the Mayo
Clinic.

With that being
said, the diversity that is out there and the differences when I come to New Jersey, yes, you can see geographic differences, but I can tell you there are no
cultural differences.  We have some of the most patriotic people, just like you
do, and young people willing to serve their nation, and we understand that the
challenges of getting them care -- and Mr. Runyan has been fabulous about
talking about this.

I said today, the
teacher and the sergeant major in me, I hate to be late for anything, but you
actually have stop lights out here, and we can turn left in Minnesota, by the
way, to get to places, which is something a little different.  But there is
absolutely no difference culturally in the care of our veterans.  So when these
problems arise, I think you would see a sense of pride in what can be done, of
working together, of trying to listen to the issues and come up with working
solutions.

And I will tell
the witnesses before we get started that we are here to hear from you.  That is
the important part.  We did one of these out in Minnesota back in 2007, and
literally in the shadow of the Mayo Clinic, and we provided evidence, and at
that time then sitting Chairman Filner received evidence, scientific evidence
on the correlation between exposure to Agent Orange and Parkinson’s disease. 
We had a cluster of six individuals out there who came together with no
commonality in their lives, middle-aged men about 55 to 60 years old, all of
them developing Parkinson’s.  Their commonality was their service to their
country in Vietnam.

And through that
field hearing, and through that start as it moved up in a bipartisan manner, we
added Parkinson’s as a presumptive disorder of exposure to Agent Orange, along
with ischemic heart disease and some others.  That is the way it should be
done.

So thank you for having me here today.  Thank you for each of you
working to do better by our veterans and by our country, and I am proud to be
here with my friend, who has done a great job of leading our subcommittee on
this and is moving things forward, Mr. Runyan.

So with that, I
yield back.

Mr. RUNYAN.  Thank you, Mr. Walz.

And with that, I
wanted to -- we will do an introduction and official titles of the witness
panel and begin with their testimony.

So first we are
going to be joined by Colonel Mike Warner, who is the Chair for the New Jersey
Governor’s Council for Military and Veterans Affairs.

Then we will hear
from Mr. John Dorrity, the Director of Ocean County Veterans Services.

We will also hear
from Mr. Gene O’Grady, Department Vice Commander for the American Legion.

And finally, we
will hear from Mr. Walter Tafe, the Director of the Burlington County Military
and Veterans Services.

Each of you will
have 5 minutes to summarize your testimony.  Your full written statement will
be made part of the hearing record.

With that being
said, Colonel Warner, we will begin with you, with your oral testimony.

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

STATEMENT OF MIKE WARNER

Colonel WARNER. 
Thank you, Congressman Runyan and Congressman Walz.  Thank you for the
opportunity to testify on important issues pertaining to our country’s
veterans.  My name is Michael Warner.  I am a retired Army officer and
service-connected disabled veteran.  My last assignment was commander at Fort Dix, New Jersey.  Upon my retirement, I was appointed by Governor Whitman to the
position of Deputy Commissioner for Veterans Affairs for the State of New Jersey.  In that capacity I had the privilege to serve the veterans of New Jersey and manage the state’s veterans programs.  Those programs included the
management of the largest state veterans cemetery in the United States, operations at three nursing homes, and oversight of New Jersey’s veterans benefits
programs, assisting veterans in the filing of their disability claims.

I would like to
comment on a couple of areas that are of direct concern to the subcommittee. 
First, while it may not be particular to this particular hearing, I would like
to comment in the area of the state veterans cemetery.

I strongly
encourage the Congress to authorize an increase in burial allowance for
veterans in order to offset the increasing costs associated with the burial of
veterans and the operations of the state veterans cemetery program.

Similarly, I
believe that it is important to authorize a burial allowance for the spouses of
veterans interred at the state veterans cemetery.  The U.S. Department of
Veterans Affairs cemeteries and Arlington Cemetery inter spouses at no cost to
the veteran.  New Jersey provides for the burial of spouses at no cost to the
veteran.  However, the state veteran’s family members interred at the state
veteran cemeteries should receive the same consideration as the veteran family
members interred at our national cemeteries.

I would also
testify that spouses of veterans are as much veterans of the military service
as their service member.  The family members serve by ensuring that the veteran
can do his or her duty with the confidence that their family is being held
together by the strong and capable hands of their spouses, many times on
multiple separations for long periods of time.

The other area I
would like to comment on is the claims process, and specifically the
accessibility of the C&P examination to the examiners.  I believe that the
process of conducting the C&P examination needs to be reevaluated. 
Currently, veterans are required to travel to their VA medical center to meet
with the VA medical personnel and their C&P examination.  For this area in
South Jersey, that requires the veteran to travel to Philadelphia, Newark, New Jersey, or Wilmington, Delaware for their examination.  This poses a hardship
on many of our veterans, particularly our older veterans and their care
providers.

I believe that
many of these examinations and interviews could be conducted at the
community-based outreach clinics via teleconference or other methods, or by
having the C&P examiners come to the CBOC.  While the requirement to travel
to the medical center may not be entirely eliminated, this approach would
reduce the number of visits to the medical center that the veteran would be
required to undertake.  Bringing the C&P examiners and other professionals
to the CBOC would be in keeping with the concept of bringing the VA to the
veterans as much as possible, as opposed to requiring the veterans to travel to
the medical centers for all services.  It is not any more difficult to schedule
a veteran for a visit to the CBOC than it is to schedule a veteran to a medical
center for a visit.  Frankly, it would also be good for the C&P personnel
to get out of the VA medical centers and see veterans in their community.

The process of
claims also seems to be a never-ending problem no matter how hard we work to
fix it.  I have been dealing with this since I was the deputy commissioner in
1992.  The process of claims has been an issue to veterans even before I was
responsible for the state’s program to assist veterans in filing their claims. 
In fact, there is a great article on the backlog of claims, almost 600,000, in
the Friday edition of the National Journal.  According to that edition, as I
said, the backlog of claims is in excess of 600,000.

I believe that
one of the ways to reduce the time it takes to process veterans claims is to
sort claims by difficulty and the number of primary conditions the veterans
claim.  For example, if claims with one primary condition were developed and
submitted, the process of review would be very simple.  The claims officer
would only be required to review the 214, review the veteran’s doctors’
information, and then determine if the veteran’s condition met one of the 15
presumptive conditions.  If so, then approve the claim and determine the level
of compensation.

For example, if
the veteran served in Vietnam and his physician has documented prostate cancer,
he should be rewarded compensation without a full C&P review.  Every
veteran who served their country is presumed to have been exposed to Agent
Orange.  If the veteran later develops prostate cancer, it is presumed that the
cancer is a result of the service in theater.  There should be no need to drag
out the process any longer unless there are other secondary conditions that
have been claimed at some point.  We need to trust the veteran and their
physicians to not have to reexamine everything.

In summary, the
claims process would be significantly reduced for claims that had one primary
condition and that condition is one of the 15 presumptive conditions.  If these
claims were assigned to one office and not mixed in with more difficult claims,
they would be adjudicated quickly.  There is no reason for these claims to
dwell in the system for months or years, or many years.  This approach would
allow the C&P examiners to focus more of their time on more difficult
claims that had to be reviewed.

Thank you for the
opportunity to discuss these important issues with you, and I will take any
questions you may have for me.

[The statement of
Mike Warner appears in the Appendix.]

Mr. RUNYAN.  Thank you, Colonel Warner.

Mr. Dorrity, you
are now recognized for your testimony.

STATEMENT OF JOHN DORRITY

Mr. DORRITY.  Thank
you, Congressman Runyan, and thank you, Congressman Walz.  This is a very
important discussion we are having this morning.

I am just a vet. 
I would like to bring your attention to my executive summary as it pertains to
Colonel Warner and testimony that I and others will be giving relative to
presumptive conditions and timeframes.  Under B1, I have cited two subsections
of 38 CFR that relate to this issue.  Under B2, I have also cited a subsection
of 38 CFR that relates to inadequate examinations.  If I might, I would like to
read my testimony into the record.  Thank you, Congressmen.

I have broken it
down because I need chronology myself to follow myself some days.

A1.  When a
veteran’s request for disability entitlements is submitted to the Veterans
Benefits Administration, or VBA, a process is enjoined that requires various
steps in development of the claim in order to arrive at a decision.

After acceptance
of VBA and entry of the claim into the system, a rating specialist is assigned
to the claim based usually on the veteran’s last two digits of the claimant’s
claim number or through other factors of consideration relative to the policy
and procedure of the particular VA regional office, or RO.

Number 2.  As
development of the claim proceeds, an integral part of the process of
adjudication is required and requested by that VBA employee who the claim is
assigned to.  That part of development is the employee’s request of VHA, or the
Veterans Health Administration, to arrange for a comp and pension, or a C&P
examination, and either a contract provider but more usually at the VA medical
center or VAMC in which the veteran resides.  These evaluations are supposed to
be objective and comprehensive.  I will address the positives and negatives of
this aspect of the process.

B1.  On average,
between the time that VBA receives the claim and the C&P is ordered, at
least 6 to 16 weeks have transpired.  From the point of the last C&P
issued, approximately 180 days passes before a decision is issued by VBA.  If
the claims issues are relatively uncomplicated, this timeframe may be less. 
This brings the adjudicative process to approximately 1 year, give or take.

I base this
observation on my over 30 years of prosecuting veterans claims through the VA
central office, or the CO, and the ROs might disagree with my assertion here.

In terms of
presumptive service-connected issues such as Agent Orange, POW, Persian Gulf, et cetera, this is purely inconsistent with filing decisions from VBA, the
C&P process.  With presumptive disabilities and supportive public or
private medical evidence, the need for a C&P eludes me.  C&Ps cost
money, gentlemen.  At a time when our nation is feeling the noose tighten
economically, it makes more sense, as long as all evidentiary requirements are
met, to decide the claim without an unnecessary step of a costly C&P for
presumptive service-connected conditions.

Number 2.  In an
effort to streamline the backlogged claims process, the Secretary of the VA has
initiated information technology, or IT procedures.  This is a laudable effort,
with much thought and preparation on the part of the Secretary and his CO staff
that I hope works.

One of the
efforts enacted by the CO of the VA is the Disability Benefits Questionnaire,
or the DBQ.  As a matter of fact, many of the VHA C&P clinicians, in
conducting VA exams, or VAX’s, as they are referred to, are struggling to
complete these relatively simple forms and somewhat hampered by the process as
it does not provide the examiner the ability to utilize their intellect and
expertise in arriving at an objective finding.

A case in point
is my own C&P.  It was conducted on 4/13/2012, at which my examiner, one of
my examiners, both of my examiners, but one in particular struggled for
approximately 20 minutes just to enact the DBQ program relative to my claim and
my service-connected injuries.  When I received and read my own results, I felt
as though the examiners had someone else in the examination room as the VAX did
not reflect any of the conversations between the examiners and myself.  There
is information that was not indicated on the results, the DBQs, that I know
transpired in conversation between the examiners and myself.

DBQs do not
always provide for the objectivity required to arrive at a just decision for
the veteran.  Many times, because of this limited IT improvement, there is a
lack of prudent, objective medical observation and testing that goes by the
wayside as a matter of procedure in an effort just to complete the DBQ, as
required by the CO’s mandate.

In older
service-connected injuries, an x-ray, other than showing a fracture, is
entirely inconclusive.  In this regard, I feel that many inadequate C&Ps
are conducted which leads to an incorrect decision on the part of VBA and
prolongs the claims process for the veteran on orthopedic issues.

Number 3.  Another
issue that we veterans contend with at C&P is the attitude of the
examiner.  As previously indicated, C&Ps are to be objective, as the entire
claims process is purported to be.  More often than not, I have seen upon
review of the C&P subjectivity, not objective opinion, on the part of the
VHA examiner.  Although the C&P notification suggests that the veteran bring
any other medical evidence relative to the issue, rarely, rarely do the
examiners utilize this evidence in formulating their final report.

Another case in
point is audiology C&Ps.  When an older veteran files a claim for, say,
bilateral hearing loss and tinnitus, on more than half of the occasions I have
had the examiner opine that the reason for the conditions is old age.  This is
not only discriminatory, but it’s downright despicable.  If the evaluator truly
understands the nature of the process outside of their own little world of
supposed expertise, then they would contend with the issue of the etiology of
the acoustic trauma as indicated within the veteran’s military exposure or
military occupation and specialty, as MOS, or her MOS.  A veteran who served in
artillery, aviation, armor, or other units where the acoustic trauma is
apparent are not afforded this objective review and conclusion.

Many C&P
examiners indicate that they have reviewed the veteran’s record.  Without the
shipment of the file, voluminous or not, to the examiner’s desk, this is an
outright fabrication.  Many VHA examiners do not have a clue in terms of the
overall claims process due to lack of military service themselves.  Therefore,
they have no understanding or compassion in terms of the source of the
veteran’s initial exposure to loud noises.  A combat veteran invariably is
exposed to acoustic trauma on a daily basis.  This is a given amongst any of us
who have defended this nation, our nation.

Number 4.  On
more than one occasion I have seen proof of the veteran’s third party being
billed for a C&P.  I have some proof with me today.  The problem with this
erroneous aspect of C&P is that a third party payee, a private insurance
carrier, et cetera, reduces the lifetime cap coverage afforded the individual
through no fault of their own.  If I am not mistaken, not only is a C&P a
requirement of the adjudication process and not monetarily chargeable to
anyone, but the veteran is afforded travel pay by VHA.

This portion of
the C&P process needs review as some diligent veterans who wait at the
travel station receive their travel pay immediately.  But those who send their
travel pay reimbursement forms in are not quite so lucky.  I have clients who
have been made to wait more than 90 days for a reimbursement and others who
submit the necessary forms and are never, never reimbursed.  Clearly,
irrespective of the fiefdom culture that emerges in large bureaucracies, a
national standard of this component of the process is long overdue for review.

C1.  As a direct
representative of veterans, I wish to suggest that all is not doom and gloom
within the system.  There are many good people within VBA and VHA.  This issue
and other problematic elements are endemic in any large agency.  If we do not
stay ahead of the curve on the problems of agency, then any initiative
undertaken by any secretary of the VA is unlikely to bear fruit.  I am in favor
of the Secretary’s present initiative and supported through my many
interactions with my peers on the local, state, and national level.  I speak to
many that we need to embrace the technology and utilize it to our constituents’
benefit.

I would point out
that in a Federal agency that employs nearly 300,000 employees, the Secretary
would be well served to ensure that the culture, the culture of his agency is
in sync with his mandates.

Number 2.  In the
past I have CC’ed the House Veterans Affairs Committee any and all written
complaints that I have received from individual veterans with respect to the
problems of C&P, and will continue to do the same as long as I draw breath.

Again, I thank
you for this opportunity.

[The statement of
John Dorrity appears in the Appendix.]

Mr. RUNYAN.  Thank you, Mr. Dorrity.

Mr. O’Grady, you
are now recognized.

STATEMENT OF GENE O’GRADY

Mr. O'GRADY. 
Good morning to Chairman Runyan, and also to Congressman Walz.  I would like to
say thank you for selecting me, as I am a past student here at Ocean County College prior to my Army service, and being a member of the 3rd Congressional
District.

I am here to
represent the American Legion on behalf of Atlantic, Burlington, Cape May and Ocean Counties.  As a Vice Commander of the American Legion for this area, I understand how
greatly affected our veterans are by the VA current compensation and pension
claims processing.

The examination
process for claimants filing compensation or pension claims can be improved to
allow for better timeliness in the adjudication process.  This would require a
liberalization of the Title 38 United States Code to allow for the examination
to be conducted by a non-VA physician or by a VA physician furnishing
outpatient care.

When a claim is
filed for service-connected compensation of conditions alleged to be related to
military service, an examination in many cases is conducted to establish a
nexus and to determine the extent to which the condition is disabling.  A claim
for non-service-connected pension requires an examination only when the
claimant is below 65 years of age.

While it may
prove difficult to establish the relationship of the specific medical condition
to military service in the instance where an original claim is being filed
after an individual has separated from active duty for more than a year, the VA
should explore the complex issue with a view towards accepting private medical
evidence in lieu of conducting a compensation examination.

In cases where
service connection has already been established and the veteran is filing for
an increased rating based upon a worsening of the condition, then some provision
should be made to recognize medical evidence either from a private physician or
from a VA physician in the instance where the veteran receives outpatient care
at a VA facility.

Requiring this
specific examination for a service-connected condition is in many cases
redundant and only serves to slow the claims process unnecessarily.  The
development of an alternative method for assessing and adjudicating medical
conditions that a claim can be related to the military service and/or
establishing the necessary degree of disability for non-service-connected
pension should expedite the claims process significantly.

It is not
suggested that the adequacy of determining the relationship of a medical
condition to military service or the existing degree of disability should be
compromised, but it is believed that alternatives to a specific compensation or
pension exam exists, and that their feasibility for using claims should be
assessed in order to improve the timeliness of the adjudication process.

This may require
the development of new forms that may be furnished, to be completed and
returned by physicians who have been treating the veteran for the conditions
claimed.  It could also take the form of utilizing VA outpatient records in
those cases where a veteran received medical care at a VA facility.  VA
physicians can be trained to include specific notes or references to the
veteran’s treatment record that will assist in adjudicating a claim.

There are likely
to be claims that will require compensation or pension examinations, but with
the proper development I believe that those situations can be reduced
significantly, with the result that timeliness can be greatly improved.

I would like to
thank you for allowing me to testify here today before your subcommittee.

[The statement of Gene O’Grady appears in the Appendix.]

Mr. RUNYAN. 
Thank you, Mr. O’Grady.

Mr. Tafe, you are
now recognized.

STATEMENT OF WALTER J. TAFE

Mr. TAFE.  Good
afternoon, Congressman Runyan, Congressman Walz.  Thank you for inviting me to
speak on this important subject.  My name is Walter Tafe, and I’m the Director
of Burlington County Department of Military and Veterans Affairs.  Our office
serves over 35,000 veterans.  With our close proximity to Joint Base McGuire
Dix Lakehurst, approximately 20 percent of our clients are returnees from the
global war on terrorism.  I am here today to share my observations regarding
the Veterans Affairs requirements for compensation and pension examinations.  I
don’t come here to throw stones at the VA.  I understand the backlog issues and
hope to make meaningful testimony that will help all involved gain a better
perspective of the veteran’s point of view.

Although I am
sure this program was intended to speed the process by providing verification
of a veteran’s condition, in many cases it has the exact opposite effect.  The
reality is that the veterans face a wait of several months before seeing a
doctor for a visit that is often no more than 10 minutes in conversation, with
a doctor taking a cursory look at the medical records, and that’s assuming that
the regional office has sent the medical records to the regional hospital.

Veterans leave
this examination extremely frustrated.  Many tell me they feel they’ve wasted
several months waiting for an appointment that wasn’t even a real medical
examination.

I would like to
discuss several recommendations that I believe could have a dramatic impact on
the process, reducing both the waiting time for C&P examinations and the
backlog that is presently crippling the claims process.

My
recommendations are based on my conclusion that many, at least 50 percent of
the C&P examinations conducted by the VA health care system, are
unnecessary.

Many of my
clients are receiving their health care exclusively from the Veterans
Administration health care system.  This means the VA already has their
complete medical history in their possession.  When these veterans file a new
claim or a claim for increase, they must first receive a C&P examination to
verify the condition.  The veteran waits several months to receive a C&P
examination so that the VA doctor can verify the condition that was already
diagnosed by a VA doctor.  This makes absolutely no sense.  It seems like the
VA does not trust their own doctors to make a competent assessment and recommendation. 
Often these veterans interpret this as a means of delaying the process, and as
a result it builds great animosity between veterans and the very department
that is supposed to protect them.

As I initially
stated, approximately 20 percent of my current clients are only just returning
to civilian life after serving on active duty.  They are National Guard Reserve
personnel being released from activation, or active duty military members
separating or retiring.  In these cases, the entire service medical records are
available to the VA.  These members normally file a claim within the first
three months of separation.  Many are combat wounded or have conditions
diagnosed while on active duty and verified during their separation physical
examinations.

Even with a
definitive medical exam at the close of their service, they must still wait
months for a C&P exam appointment, and the only point is to verify the
medical condition that is already a matter of record.  These examinations could
be completely eliminated if the VA and the DoD simply communicate with each
other and share their information.  I recommend that the military member’s
separation examination consist of the same verification procedure used by the
VA, thereby reducing the redundancy of the claim.

Another concern I
share with others in my field is the requirement for full verification for
every condition when the veteran is cared for by a private physician.  I
understand that in some cases verification by the VA of a condition is needed
to be fully justified.  However, for documented cases of Stage 4 cancer, severe
diabetes with insulin dependence, coronary artery disease and similar terminal
conditions, a C&P seems unnecessary.

Add the
additional step of filing a claim and submitting a VA form allowing his or her
doctor to release the information and records to the VA, the resulting delay
can seem to be cruel.

A case and
example, former Marine Ron Guernon.  He is presently temporarily service-related
100 percent for kidney cancer.  Over a year ago, his condition worsened and his
prognosis was determined to be terminal.  At that time I filed a request for
upgrade to permanent and total status.  I also requested aide and attendance. 
He now resides in Spring Hill, Florida, where his wife, a registered nurse,
provides his care.  He also receives hospice care.  His life expectancy is
listed month to month.

Despite the
ongoing documentation of Mr. Guernon’s deteriorating condition and the fact that
all medical records have been given to the VA, the Tampa regional office
requested he come for a C&P examination to determine whether his condition
has worsened.  This veteran is literally unable to travel due to his
condition.  This proud Marine absolutely is convinced that the VA is, and I
quote, “waiting for me to die so they don’t have to bother.”

While I’m sure
this is not the case, Mr. Guernon is the perfect example of the crippling
bureaucracy that is so significant in complicating our VA claims process.  The
VA is making some strides, and I applaud the new disability benefits
questionnaire forms that have been produced for veterans to bring to their
health care providers.  These questionnaires were developed so the veteran
could give it to his or her doctor to complete, providing all the medical
information required to make a rating decision based on certain conditions. 
These questionnaires have been developed for almost all conditions a veteran
can receive compensation for.  If used correctly, they should begin the C&P
process in most cases.

In closing, I’d
like to say it is my strong belief that the present C&P examination system
is severely hindering rather than helping the veterans claim process.  In most
cases, examinations are not thorough and they leave veterans questioning why
they waited several months for a 5-minute exam.  The perception that C&P
exams are a method of delaying and denying claims is rampant in the veterans
community, and it is all the more potent when veterans like Mr. Juran share
their stories.

It is my sincere
hope that these hearings will result in a thorough self-examination by VA
personnel to evaluate the relevance of this requirement and eliminate
unnecessary examinations.  I thank you for your time and consideration of my
testimony.

[The statement of
Walter Tafe appears in the Appendix.]

Mr. RUNYAN.  Thank you, Mr. Tafe.

With that being
said, we are going to open it up for a round of questions to everyone and be a
little lenient with the time seeing as how there are only two members here and
we usually have a panel up here.

I really want to
start with, obviously, the story Mr. Tafe just pointed out, and I know Mr. Dorrity
just had his experience.  I know, Colonel Warner, you just had your own C&P
exam not too long ago, and I know you communicated with my staff a little bit
about that.  But could you talk about your experience with that and how a CBOC
would improve access and improve the process also?

Colonel WARNER. 
Yes, sir.  First of all, the C&P process requires multiple trips to
Philadelphia to see the doctors, re-see the doctors, audio tests for hearing
two or three times, then fitting for hearing aids, and on and on.  Some of
those are not going to be eliminated.  You can’t eliminate things like that. 
But I do believe that we could use the CBOC to conduct more and take advantage of
technology.  A lot of these things would be -- these visits would be eliminated
by the veteran being able to either interface directly with the examiner or to
use telecommunications where the veteran can sit and take advantage of state-of-the-art
technology to have the interview conducted by telecommunication.  I believe
that that would eliminate it.

My real concern
is that too many times the veteran perceives that the interview process is
adversarial, that the veteran is out to get over on the system and get
something, and particularly for elderly veterans.  I will give you an example
of my father-in-law.  My father-in-law is a veteran, was a veteran of World War
II, Korea and Vietnam, and his entire dealing with his disability claim was not
to get anything more for himself, was to establish a basis of understanding for
his spouse, for my mother-in-law, because he was going to die of cancer.  The
entire process was so that she would be able to receive the compensation that
she was due because of his disabilities.

And so it wasn’t
that he wanted to get over.  It was that he wanted to make sure that his wife
was taken care of.  Unfortunately, I think too many times it is seen as a
get-over by the veteran.

Mr. RUNYAN.  Thank
you.

My next question
is for Mr. Dorrity.  Just dealing with the impact of delays of scheduling exams
and the impact that that actually has on the family, Colonel Warner kind of
touched on it as future, but as current, what could be done to actually help
the DBQ process also?

Mr. DORRITY.  In
order to help the DBQ process, I have seen the C&P examiners utilize them,
and I have seen them experience difficulty.  One of my doctors -- and I have to
allude to something that Walter said, five minutes in and out.  Twenty minutes
to get on the screen, and five minutes worth of discussion really provides for
an inadequate VAX.

I think that many
of the forms, particularly in the area of the presumptives, really don’t
require a DBQ, the ischemic heart for one, the ALS, every condition that is
listed.  Why isn’t a private board-certified diplomat in that specificity, why
isn’t their word good?  They don’t work for the VA.  That’s why?  That’s not
good enough, that’s not good enough.

I have prosecuted
over 100,000 claims, give or take, in 30 years.  I have had the distinct
tragedy of watching probably close to 100 people die, die, while this lengthy
process takes place.  I think that we can do better.  I know that we can do
better.

I know that we
have mandates.  I have been around since the first secretary was initiated, and
that was -- I am sorry.  It was a Polish name.  Sorry about that.  But I have
been around for a long time, and I have seen different secretaries take
different initiatives which haven’t come to fruition.

Now listen, being
someone who is a direct representative of veterans, I can tell you that there
are a number of variables that fit into the equation of the backlog.  One of
the primary ones was in the late ‘90s.  The Court of Veterans Appeals made one
of the stupidest decisions going:  No claim is well grounded.  Do any of you
remember that?  Okay.  So every legitimate claim that I sent in with proofs was
bounced back as a denial.

What I feel the
DBQs are going to do, Congressman Runyan, is I think that on the front end --
and I dispute the 600,000 figure.  I do.  And I get my figures from the VA.  I
feel that on the front end it will probably lower the numbers some, but on the
back end, the holds, the appeals, they are going to go through the roof.  And I
own -- I, my office, owns probably 40 to 60 percent of the appeals in this
region.  So here we have added on three-and-a-half more years in national time,
in average national time to have an appeal heard before we get to sit in front
of a judge, and they have heard everything that went before them.  So the
timeframe kind of, sort of gets to five years.

And for older
folks, like Colonel Warner’s father-in-law, and like my 100 or so clients, they
will be dead.  They will be dead, like Walter’s dad.  What more do you need? 
What more do you need?  What can I do to give you so that you adjudicate this
claim properly, correctly?

I would suggest
that many of the C&Ps are totally inadequate.  I know that they use archaic
methods.  One of the problems I have had in C&Ps that I have had and that I
have seen -- because I get my clients to release the C&P to me so I can
read it -- no diagnosis is issued.  Now, what the hell am I there for, you
know?  If you can’t confirm the diagnosis with some archaic x-ray, as opposed
to an MRI, you have provided no service.  You spent my tax dollars doing
nothing, and this person is not going to -- especially with orthopedics.  They
are degenerative in nature.

So it is a
problem that I don’t have all the answers for.  It is not a challenge, Mr.
Secretary.  A challenge is you and I trying to climb Mt. Everest.  These are
problems that have been around for a long time.  You probably would make it.  I
wouldn’t.

They are problems
that are endemic in a large system, and one of the secretaries -- and I will
invoke his name, Jesse Brown -- he had a unique way of dealing with problems
out in the field.  He went out there, non-descript.  I try to do that, and
people know exactly who I am.  But he was able to find areas, he was able to
actually change the culture.

And listen, don’t
think, as Walter indicated, that I am slamming the VA, VBA or VHA.  I just want
the process to work better.  Thank you.

Mr. RUNYAN.  I
think we all do.

Mr. DORRITY. 
Yes.

Mr. RUNYAN.  One
more question.

Mr. DORRITY.  Shoot.

Mr. RUNYAN.  And
quickly, because I personally know you.  I have known you a little longer than
anybody.

[Laughter.]

Mr. RUNYAN.  We
talked about this before, but how common are the payment errors to third-party
private insurance?

Mr. DORRITY. 
Listen, they are happening every day.  Medical care cost recovery is out of
control.  It has been out of control since the day it started.  It is my
understanding, unless I am wrong -- and if I am wrong, I will eat my words --
that if you are 50 percent, you are not paying the co-pays.  I am seeing
insurance companies send ELPs back to veterans, and the veteran will come in
with the ELP and say -- and I say, well, they didn’t charge you.  But what you
need to do is call MCCR, and you need to correct this.

One of the proofs
I brought in to you today is one of my guys who I sent for a C&P, and he
was denied.  Okay.  But now they are reducing his Social Security benefits to recover
the MCCR costs that were charged for his comp and pension evaluation.  Comp and
pension is free.  As a matter of fact, you get travel pay for comp and pension.

I don’t
understand how it got to this point.  One of the problems that we have locally
with MCCR is people aren’t always able to get in touch.  That is part of the
culture that we may be able to bring into line so that these occurrences don’t
happen.

I am sorry to be
so long-winded.  I notified an insurance company many years ago about these
overages and charges that they shouldn’t be paying.  But like everybody, they
get a letter from a Federal agency saying you owe X amount of dollars, the
first thing they do is they send a check, because who wants the IRS looking at
them, or who wants a red flag up?

I notified them. 
I got forwarded to an investigator.  He said are you saying fraud?  I said,
listen, I don’t think it is fraud.  I think it is just a misunderstanding on
the part of MCCR as to what is chargeable and what isn’t.  You know, that is
why we have laws, 32,000 pages of them, but that is why we have them.

So I believe that
a review of MCCR and their billing process is appropriate, too.  How often? 
That is a long way around the bush.  Every day, every day, every stinking day.

Mr. RUNYAN. 
Thank you for putting some light on that.

Mr. DORRITY. 
Thank you.

Mr. RUNYAN.  I
have a question for Mr. O’Grady, too.  I know I am well over my time, but these
are important discussions.  Dealing with a private medical opinion and the
C&P exam, to your experience, is there a difference?  Is the private
medical opinion usually right on with the C&P exam?

Mr. O'GRADY. 
With my own experience with going through a compensation assessment -- I guess
that is what they call it -- for worker’s comp, you have so many individual
doctors that are in the process, and I think there are too many doctors that
are involved.  We should be able to take that outside doctor and use his
opinion.  If he can be treated properly and he is going to do the same exact
evaluation, our veterans shouldn’t have to start back at square one.

It is the same
process.  These doctors are trained.  They know how to do their evaluations. 
If we are using the same standard, that is it.  If the VA has some super
standard that they have to have, then we need to have our doctors on the
outside find out about that, and hopefully that is going to speed up our
process.

But I think it is
a similar process that they go through.  It is just that the VA system seems to
be redundant.

Mr. RUNYAN. 
Thank you.  And just one, maybe two, for Mr. Tafe.  In your statement, you say
about 50 percent of the exams are unnecessary.  Can you elaborate on why you
think that number is so high?

Mr. TAFE.  Sure. 
I think it is so high because there are so many instances when the VA is
spending time verifying their own decisions that could be totally eliminated.

I am in a very
large retirement community, as you well know, and many of those veterans are
already 50 to 100 percent rated.  So their exclusive health care comes from the
VA, and I just don’t understand why the VA would diagnose someone, even with a
terminal illness, and then require a C&P examination to verify their own
decision.  I don’t understand that at all.  I think it is extremely redundant.

I also believe
that those coming off of active duty, their records are so readily available,
and some of them are diagnosed as combat wounded.  I don’t understand the
reason for them to wait four to five months to go for a C&P examination,
which is just five minutes in the door and out the door.  In many cases, it is
an adversarial meeting that takes place.  I have people who receive C&P examinations
for post-traumatic stress disorder who come back to me and say “I’m never going
back there again.  I don’t care if I get any money, I’m not going back.  I will
not do it.”

So I think many
of those cases, or almost all of those cases for post-traumatic stress disorder,
have been verified and diagnosed by a VA doctor because that is the requirement
now, either an outside provider or a diagnosis from a VA doctor.  So I cannot
understand the redundancy, at least in the environment that I am in, for
continuously bringing them back to check the same thing that they have already
checked.

In my case in
particular, I visited the Fort Dix clinic for a service-connected illness that
I had a rating for.  The VA doctor told me to go for a C&P examination.  I
had no intention of asking for an increase at all.  The VA doctor said you have
to go put in for an increase, and then I had to go wait four months for the
appointment to take place, go to Philadelphia and spend five minutes with the
doctor to verify, and I was seeing a specialist at Fort Dix and saw a
physician’s assistant at the VA hospital.  I don’t understand that reasoning.

Just one other
thing that was mentioned earlier, and I just want to hit on it, if I had an
oncologist who diagnosed Stage 4 lung cancer, why would I have to go to the VA
facility and have that verified by a physician’s assistant who has no
experience in the field?  I think that those type of redundancies could be
eliminated, and I do think it would have a dramatic impact on the number of
cases that are backlogged.

Mr. RUNYAN.  I
would agree with you because, obviously, in the case that you had in your
testimony with Mr. Guernon, the Marine, he has been diagnosed with terminal
kidney cancer, and yet they want an exam.  I mean, common sense says why would
I need an exam to --

Mr. TAFE.  And
there is a feeling out there, because he is 100 percent temporary, well, 100
percent is 100 percent.  Permanent and total status for veterans in New Jersey is critical because his widow, unless he is determined to be permanent and total
at the time of his death, his widow is not eligible for the tax exemption for
her property tax.  So it is a very critical thing that I don’t even think is
being understood on the other end of the C&P table because they have no
idea what the individual state laws are.  If his case isn’t settled, it will be
a dramatic impact on his wife for the rest of her life.

So I think it is
very important that they understand the ramifications of delay.  This gentleman
has been delayed for a year with a terminal illness.

Mr. RUNYAN.  Thank you, Mr. Tafe.

With that, I will yield to the gentleman from Minnesota, Mr. WALZ.

Mr. WALZ.  Thank
you, Chairman.

Thank you, each
of you.  I am very appreciative.

It probably
wouldn’t surprise any of you, if we held this panel in Minnesota, we would hear
very similar things.

Mr. Dorrity, I
hope every congressional district has somebody like you to be that conscience.  Speak
as long as you want on things.

This is not a
destination.  It is a journey.  And those of us who have been involved in this
issue, we have been fighting it for decades.  It is very frustrating, and I
know the Chairman has expressed frustration, as he should, as we take these
things on and we try and improve and we try and move forward, and it seems like
we beat our head against the wall.

It is our goal to
try and get there, to do a more perfect union, if you will, and I think the
things we need to keep in mind is -- I think you all made that very clear, that
the VA is there to serve our veterans.  Everybody here has the same goal, care
of our veterans that they have earned in the best possible way, and guarding
the taxpayer dollars, as sacred as they are.

With that being
said, we have the best health care in the world.  I say this.  The VA medical
centers are the best health care in the world.  I represent the Mayo Clinic, so
I do a lot on medicine, do a lot on that.  The Mayo Clinic will tell you, if
they have somebody with heart disease, they will send them to the VA medical
center in Minneapolis for some of those things.

And you know
what?  That is exactly what our veterans should deserve.  When people tell me,
why do they have that big, beautiful building, and the lawns are all mowed or
whatever, and I say, what, do you want to send our veterans into a double-wide
and tell them to get secondary care?  Of course not.

But with that
being said, in a time of economic uncertainty, we have to be very pointed in
how we are doing this.  So I think this issue hit on several things, and I
would come back to this table here, Chairman Runyan, his staff.  I have talked
about this until I am blue in the face.  People are sick of it.

But the systemic
issue here for me is this seamless transition out of DoD into the VA, of
combining resources and not allowing that Grand Canyon gap of dropping off and
pulling them back.  In this day and age of IT technology we have, it is
absolutely ludicrous that we don’t have that seamless.  We are getting there.

Now, the private
sector doesn’t necessarily have that electronic medical record either, but that
is going to go a long way.  But that is the implementation side.  Each of you
hit on something, and you are after my heart on this.  I am a cultural studies
teacher, the culture that is out there.  And the VA, I know this hurts them
when they hear this.  I know it hurts people serving in the VA because many are
veterans themselves and they care about their mission.

When they hear
that they believe the C&P exams are meant to delay the process or whatever,
the thing I would tell the VA is if you think that is just what they think, their
perceived reality, perceived reality is reality for our veterans.  They believe
it is happening, it gets out there, and you have to break that.  You have to
break where exactly that is.

I am very, very
frustrated as I see, as you said, the redundancy of this.  Chairman Filner,
former Chairman Filner, the Congressman from California, he always brought up a
great point.  He usually brought it up this time of year.  Last year millions
of Americans, or last week millions of Americans filed their tax returns.  The
IRS accepted that you were telling the truth, and then they went back and
audited them.  The VA assumes you are lying and then verifies them afterwards,
and that is an attitude that is cultural that is in there.

Now, we as
taxpayers, these are all the false choices we always set up -- and this is why
I love this committee -- it is not about a false choice.  We want to get
efficiencies.  You are going to ask us to don’t allow fraud, waste and abuse to
happen.  I think at times what happens, and I think C&P exams are an
example of this, they are done with the intention of insuring that taxpayers
are protected, but a perverse thing happens where it ends up not only causing
problems but costing us more.

I think we need
to come to some type of agreement or some type of new way, and I am really glad
the Chairman is hitting on this, that I think we are going to find a
commonality on this.  I think these examples you bring up -- who in their right
mind can defend what happened to Mr. Guernon?  Who can defend that?  No one is
going to ask you to be able to defend that, but I can tell you it is not being
done with maliciousness.  It is being done with an intent on it is the letter
of the law, not the spirit of the law.  And somehow we, in a country of laws,
have to get at that.

So I wanted to
ask just a couple of questions.

Colonel Warner,
this is an issue I struggle with.  It is that choice between centralized
control and uniformity versus decentralized efficiency amongst that.  We are
going to hear from VISN 4 folks.  I represent VISN 23, which sets out in the
Dakotas and the Upper Midwest.  If you go and look at this, veterans know
this.  They know where to go to get a C&P exam to get a better rating and
quicker service and things like that.

My question to
you, have you witnessed this amongst the states that there is a difference here
that is either hindering -- because my argument on this is if that young
warrior comes back from Afghanistan and settles right down the road here in Mr.
Runyan’s district, or decides to go out into Southern Minnesota, they should
get the equal care.  They should get the same level of care.  Do you think it
is happening that we have these differences?

Colonel WARNER. 
I have not perceived this.  I am not going to say that there is.  I think that
there is inherent in the system that there will be differences between rating
officers and how they look at things, but I am not sure that there is a
systemic issue between offices and that one office is an easier office than
another office to go to.

When I was the
commissioner for veterans affairs, speaking to my counterparts, I am not sure
that I experienced that.  I think that the concern -- and I will tell you, I
think one of the concerns the VA has in the C&P process, by keeping it
centralized at the VA medical center, is the fact that they do want to control
it.  Again, if they want to give a uniformity, then there is an underlying
thing, is that is it, in fact, that the veteran truly has that claim.

The only way,
though, to address this and to increase the timeliness of adjudication is to
decentralize the interview process.  If you are a C&P officer and you are
doing it in Philadelphia or Newark or Wilmington, and you are doing it there, causing
the veteran to come to you, or doing it at the CBOC in Fort Dix but you are
still interviewing and you can do it more timely, even going over
telecommunications --

Mr. WALZ. 
Colonel Warner, or let me ask this to all of you, are you concerned about fraud
in the system if we allow C&P exams to be done on the outside?  Do you
think there is that ability there, or are there redundancies in the system to
be able to check against that?

If the argument
is we have to have the C&P exam done to make sure it is all kosher, it is
all going through right, do you fear that having, whether it be the private
sector -- and this is all of us in this room, and the veterans know this.  This
is ongoing tension, that we have to do this right.

The real fix
isn’t to have government do it all or the private sector do it all.  It is that
mix.  There is a time and a place for fee-for-service.  I see this in rural
areas, where it makes sense to do fee-for-service.  But many veterans groups
get nervous when they say “but the core mission of the VA medical center must
remain intact.”

Do you feel like
in this instance, giving either private sector or CBOC, for goodness sake,
makes sense to me because it is in their -- I mean, Mr. Tafe made that
argument.  You can’t argue with that.  What about the private sector?  Are you
afraid that we will see that?

Mr. DORRITY.  No,
I don’t feel that we would see fraud.  There is a statement that I used to know
in Latin, and it said something to the effect that we don’t judge a system by
its possible abuse.

Congressman, there
is fraud all over the place.  I like the CBOC idea.  I realize that there are
limitations to that with the teleconferencing.

But fraud?  No. 
When I detect fraud, I guess after my long years I can smell when stuff ain’t
right.

Mr. WALZ.  That
goes back to Mr. Filner’s thing, that we will punish the entire veterans
community for the perceived potential from a few, and that is the exact
opposite of the IRS.

Mr. DORRITY.  You
made a great illustration there.

Mr. WALZ.  So you
are not fearful of that?  You think that --

Mr. DORRITY.  I
am not fearful of fraud.

Mr. WALZ.  Certainly
not in the CBOCs, right?

Mr. DORRITY.  Not
in the CBOCs certainly, and if we have a board-certified diplomat in a specific
form of medicine, their license and everything else is on the line.

Mr. WALZ.  Do you
agree with that, too?

Mr. DORRITY.  One
more thing.  I have seen fraud in the VA.  We have a contract out with some
company in London, Kentucky, and the decisions I am getting, you would laugh,
because I sit there and say, oh, gee --

Mr. WALZ.  I want
you to come back to that hearing, too, the contract thing.  That is an entire
other -- that is a big giant can of worms.

Mr. DORRITY. 
Rather than listing -- let me just get this out.  Rather than listing all of
the disabilities, this company says “miscellaneous disabilities.”  Do you know
what you did?  You just pulled the due-process rug out from under the veteran,
by law.  But I will get off that.

I don’t see fraud
as a greater hazard.

Mr. O'GRADY.  I am
not afraid of fraud.  I think it will be the same as in every other segment of
our population.  You can provide the oversight and correct it when it happens.

Mr. TAFE.  I
agree, Congressman, but I wouldn’t say that there are times when there should
be some verification, on secondary illness, secondary to an illness, where they
very well may have to verify that through the CBOC or through the VA --

Mr. WALZ.  You
know, we made some changes.  One of the things we have done in having these
hearings over past congresses is that these initial claims, especially the
catastrophic claims, approve them on spot and get them paid, get them going,
and then come back, and the ones that take the rest of the time that are a
smaller portion of it and aren’t going to impact the families’ livelihood,
aren’t going to impact some of those, get after them later.

I think, to tell
you the truth, I think the real fix here is let’s get that seamless nature done
so it is easy and so you are out processing physical counts at your C&P and
you are done and you move forward.  In lack of that, let’s use the CBOCs and
approve those for the folks that are there, and to get further down, let’s get
to the good folks that are getting those.

I think that the
Chairman is right on this.  I think the time for the C&P exam as being that
detrimental to veterans has passed.  I think there are other things that we can
do in there, and I think technology gives us that ability.  So I appreciate
those insights.

I yield back, Mr.
Chairman.

Mr. RUNYAN.  I want
to thank the gentleman, and I want to be conscious of everyone’s time.  We
could probably have this conversation for the next month and still have plenty
to talk about.  But with that, I want to thank each and every one of you for
your testimony and your time today.  I appreciate it.  You are now all
excused.  I want to welcome the second panel to the table.

Colonel WARNER. 
Thank you.

Mr. RUNYAN. 
Thank you.

The second panel
consists of Mr. Michael Moreland, the Director of Veterans Integrated Service Network 4 for the Veterans Health Administration.  He is accompanied by Joseph Dalpiaz, the Director of the Philadelphia VA Medical Center, and Robert
McKenrick, the Director of the Philadelphia VA Regional Office.

Each of you will
have 5 minutes to summarize your testimony, and your full written statement
will be made a part of the hearing record.

Mr. Moreland, you
can begin.

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

STATEMENT OF MICHAEL E. MORELAND

Mr. MORELAND.  Chairman Runyan and Ranking Member Walz, it is my pleasure to be here today to discuss
how we provide high-quality care to veterans in Southern and Central New Jersey.  I am accompanied by Mr. Joe Dalpiaz, Director of the VA Medical Center in Philadelphia, and Mr. Robert McKenrick, the Director of the Philadelphia VA Regional Office.

Today I will
discuss the collaboration between VHA and VBA on compensation and pension
examinations, and then review VHA services provided to New Jersey veterans.

VHA and VBA work
collaboratively to deliver compensation and pension examinations for veterans. 
VISN 4 ensures access through dedicated staff that provide coordination between
VA medical centers and VBA regional offices, and also manages the Integrated Disability
Evaluation System called IDES, or I-D-E-S.

In New Jersey’s 3rd Congressional District, most veterans receive C&P examinations at the
Philadelphia VA Medical Center, with a small number at the Delaware, Wilmington
VA Medical Center, or in community-based outpatient clinics.  Philadelphia also
coordinates with a contract provider, QTC, for a small number of exams.

At the Philadelphia VA, the average wait time between the date the appointment is scheduled and
the date of the examination is between 13 and 16 days.  Philadelphia has made
tremendous progress in reducing the no-show rate for C&P exams, from 15
percent in 2009 to about 7.5 percent in 2012.  Philadelphia’s examination
volume has increased by more than 20 percent during the last year or so.

The Philadelphia
VA Medical Center has also increased staff capacity in 2011, and schedules
C&P clinics on weekends and holidays for the convenience of veterans.  A
new sharing program has a physician traveling to the VA regional office to
provide one-day medical-opinion-only turnarounds on some priority cases.  Philadelphia also shaved 15 days off of the completion time for traumatic brain injury
exams by providing follow-up neuropsychology exams on the same day as the
initial screening for the veteran.

At the Wilmington VA, the average wait time for the C&P examination is 10 to 14 days.  Wilmington conducts all C&P exams on-site and is exploring options to use TeleHealth
for certain examinations in community-based outpatient clinics.  Wilmington has seen a 33 percent increase in C&P examination volumes between ’09 and
’11, and has a current no-show rate of about 10.8 percent.  Wilmington has
improved its processes by adding staff at the C&P clinics and scheduling
appointments on evenings and weekends.  Wilmington is looking at opportunities
to support the Dover Air Force Base and the Philadelphia VA Regional Office as
part of the IDES process, and is exploring ways to increase TeleHealth usage to
conduct behavioral health C&P examinations at their CBOCs.

VA has a
nationally established benchmark of 30 days for cumulative average processing
time for C&P examinations, and in each month in FY 2012, both Philadelphia and Wilmington performed better than that benchmark, 25 days in Philadelphia and 20 days in Wilmington.

The vast majority
of examinations also surpassed the quality standards that VA has.

Eighty-six
percent of urban South New Jersey enrollees live within a 60-minute drive of
the Philadelphia or Wilmington facility for inpatient care, while 100 percent
of rural Southern New Jersey enrollees live within 90 minutes of inpatient care
in the VA.  VISN 4, therefore, is better than the current guidelines that 65
percent or more are to have that level of access.  Outpatient care is provided
by Philadelphia at the CBOCs in Gloucester County, Camden County, and Fort Dix in Burlington County.  Wilmington serves New Jersey veterans at CBOCs in Northfield, Vineland, and Cape May, New Jersey.

VISN 3 also
operates facilities in New Jersey.  Counseling and outreach services are also
provided in the area at vet centers in Philadelphia, Pennsylvania and in Ewing,
Lakewood, and Ventner, New Jersey.

Specific to New Jersey’s 3rd Congressional District, VA provides care to veterans in Burlington and Camden Counties through services at the Philadelphia and Wilmington Medical Centers, as well as the CBOCs at Fort Dix and the Camden County Annex.  In Ocean County, veterans receive care from VISN 3 facilities.

VA access
standards indicate that 70 percent of veterans should be within 30 minutes of
primary care.  VISN 4 surpasses that requirement in Burlington County with 94 percent of enrollees living within 30 minutes, and in Camden County where 100 percent of veterans meet the level of access.  In VISN 3, 90 percent of Ocean County veterans have access to primary care within 30 minutes.

In conclusion,
VHA and VBA are a strong team providing a full range of benefits in health care
to Central and Southern New Jersey veterans.  VBA and the Philadelphia Regional
Office, together with VHA and VISN 4, furnish veterans with timely and accurate
pension and compensation evaluations.

Mr. Chairman,
this concludes my testimony.  My colleagues and I look forward to questions.  I
am the only one really giving a prepared statement.

[The statement of Michael E. Moreland appears in the Appendix.]

Mr. RUNYAN. 
Well, I thank you for your testimony, Mr. Moreland, and I will begin the
questioning.

I think Congressman
Walz and I actually had this discussion on the floor of the House the other
day.  You said in your statement 100 percent of veterans in South Jersey are
within 90 minutes’ drive of the closest VISN 4 facility.  Is it up and down the
Garden State Parkway on a Friday afternoon?  Is it the drive time, or is it
calculated by the mileage?  Because I know when we get over into the western
part of the state, into Burlington County, I can’t get anywhere in a
half-an-hour in Burlington County at 5 o’clock any day of the week.  So what is
the determining factor of that?

Mr. MORELAND.  We
use drive time, sir.  But I think it is the average drive times.  We don’t
focus in on the rush-hour drive times which, as you know, would be
substantially larger.  And just for clarity, that is access to inpatient care. 
We have much closer CBOCs in outpatient care.  So we are really talking about
90 minutes to an inpatient facility with high-level specialty care.

Mr. RUNYAN.  And
how about providing the transportation to disabled veterans?  I know we have an
issue in the county where a lot of times there is a legal issue where the
county won’t even pick them up because there is a liability issue.

Mr. MORELAND.  It
is interesting.  Across the VISN, we have a lot of different situations
depending on the county and, frankly, the state.  Some counties are very
supportive and provide payment to drivers.  They provide vans.  They provide a
pretty extensive infrastructure to get veterans to the clinics; in other
counties, not so much.  And so we rely heavily on volunteers.  The DVA,
American Legion, VFW, they do a phenomenal job of supporting veterans getting
to the facilities.

We also run VA
transportation to select areas.  As you know, we have a bus coming out of deep
southern New Jersey that we have used quite a bit, and that has worked really
well, and we have, in fact, expanded that bus and expanded the services for
that.

But I don’t deny
that it is a challenge for people, on occasion, to get there.  So we are
working with the counties, the veterans’ auxiliary organizations, and everyone
else to make sure veterans get the service access they need.

Mr. RUNYAN.  And
dealing with QTC and the process of the audiology and the mental health
exams in the area, and that they have to travel to multiple locations, do you
see that having to run around becomes a factor in the delay of the
processing of the claims?

Mr. MORELAND. 
QTC is one of the contract vendors that we use, and there is a --

Mr. RUNYAN. 
Well, not being centralized, though, and having to go from one office to the
other office to get the claim so it is presentable.

Mr. MORELAND. 
Yes, that is one of the challenges always, is making sure that the exam meets
the standards so that when I send it to VBA, it answers the question of the
documentation, has all the clinical information.  So, one of the reasons that
we really like having VA staff do that is because they are trained and
knowledgeable and able to do that.

We are working
with several different contractors.  QTC is the one that is being used in Philadelphia, but we have three nationally, and the Pittsburgh VA is using a different
vendor.  To be honest with you, sir, I am encouraging us to use some of the
contractors because I want to see how do they work, is it more convenient, do
they give me a good quality product.  I am using different vendors because I want
to see if there is a difference between the contractors.

So I think the
decision is still out on how effective and how their service will be, and we
are evaluating that data.  You can take a look at it.

Mr. RUNYAN. 
Okay.  And in your statement you also stated the number of compensation and
pension exams processed had increased in both Philly and Wilmington. 
Obviously, it is probably a rhetorical question.  Can you explain the reasons
for that?

Mr. MORELAND. 
Well, we have seen that not just in Philly and Wilmington.  Across VISN 4 we
have seen a large increase in exams, and I don’t think I am overstepping my
bounds to say that has been nationally, and there have been several reasons for
that.

Of course, we
have the returning Iraq and Afghanistan vets, and so we have their service that
needs to be provided.  We are also in the midst of many people filing reclaims
and additional claims.  So there has just been a big influx, and we have
increased our staff, increased our services, expanded our hours to do exams,
and we are bringing in contractors to help with some of that variation in
demand to make sure that we are able to meet needs.

Mr. RUNYAN.  And
dealing with providing, obviously, a more efficient and veteran-friendly exams
process, you may have stepped out several weeks ago when I was at the CBOC on
the joint base, but I had asked the question in there, and you may not have the
answer to it, but I want to make everyone aware of it and get it into the
hearing record also, I asked a question about TeleHealth, and obviously
Secretary Shinseki had asked the question also.  Do we know the
limitations of it and what we are capable of doing and what we are not capable
of doing?

But obviously,
the conflicts that we are coming out of now, the mental health issues -- and
Secretary Shinseki was also very interested in the Parkinson’s aspect of it,
and he asked that question.  I asked one about brain injuries and PTSD
and all that kind of thing and the ability of a clinician to actually make a
diagnosis over a teleconference, over a video teleconference, with the
distraction of the technology in front of the veteran.  I raised that question,
and it wasn’t truly addressed.

Have you had that
discussion or are you aware of it in looking at that?  Because, obviously, this
conflict we have been in the last 10 years, we are going to have a vast number
of mental and behavioral health issues that I am afraid -- and I have expressed
this to Congressman Walz also -- that we are not prepared for, because when we
look at what we are dealing with, a lot of the stuff that we have is still
dealing with the Vietnam era.

Mr. MORELAND. 
Several things.  I think that there are opportunities to look at TeleHealth,
and in some areas I think it is absolutely appropriate.  It absolutely will
work.  I will mention in a second some of my personal experience with that.  I
think in other areas, we will have to wait and see.  So we need to back up that
effort with on-site physical review.  So I don’t think TeleHealth answers all
of our concerns.

But I have talked
to the mental health leads at Philadelphia and Pittsburgh, our two largest
mental health areas, and there are psychiatrists and psychologists there, and
talked to them about their personal experience of exams via teleconference.  Ten
years ago, when I saw my first example of a psychiatry visit by TeleHealth, I
frankly was uncomfortable with it, but in talking to the veteran, he was quite
good with it.  In talking to the psychiatrist, he was a little uncomfortable
with it, but that was 10 years ago.  People who have had the experience are
getting very comfortable with this venue.

And so I think
that TeleHealth will continue to expand.  It is a viable and very good option
for certain conditions -- not all, but for certain.  So I am seeing us starting
to expand that.  We are doing quite a bit on mental health not only C&P,
but we are doing a lot of treatment actually by video conference, and I have
been surprised to find out that veterans sometimes can be more forthcoming with
that little bit of separation by the video conference, but then they develop
that good relationship with the provider.  So I think it will work, sir.

Mr. RUNYAN.  I
see that aspect of it, but I just worry about the clinical analysis of it
sometimes, because whether that clinician in and of themselves has been trained
in how to do that because it is a different way of delivering medical care.  It
is something that, as we move there and we try different aspects of our
veterans’ care, we have to be very conscious of that because it is a different
delivery method and there are most likely different procedures and protocols
around that to make sure no one falls through those cracks.

That being said, I will yield to Mr. WALZ.

Mr. WALZ.  Thank
you, Chairman.

Thank you each for
being here.  More importantly, thank you for choosing to serve our veterans. 
Each of you possesses skills you could take to the private sector and probably
make more money and have less of these questions.  But you have chosen not to
be, and for that I am thankful.  It is important work you do.  It is complex,
and the thing that I am noticing, and this is what is so great about this
nation, the diversity that we have.

When I hear rural
New Jersey, I look out here and I don’t see rural.  Rural is my town where I
had 25 kids in my graduating class and 12 were cousins.  That is rural.  That
is the truth.  I say it is like Lake Woebegone.

But listening to
the Chairman talk about this, it is an important issue, this issue of travel
for our veterans, this issue of getting there.  So we are looking at a very
narrow issue today but an important one for veterans, because I think it does
set up the cultural expectations.  I think it sets up their experience.

Older veterans,
we all lived through this where you wouldn’t go to a VA hospital because you
were afraid of the care you would get.  Now you are fighting to get in that
thing, and that is a testament to the work you have done.  But again, it is
zero sum.  We have to continue to force this.

I would say you
are also seeing more people because we made it clear that this nation is going
to serve those veterans.  Five years ago we had to hold a hearing that
clarified for the VA that they could advertise for services.  Some of you
remember that.  And I said I wanted to see -- we need a few good men in the
Marines.  We need those few good men and women when they come back to go to the
VA if they need the care, and it isn’t because they were victims, or it isn’t
because they want something for nothing.  It is because these are our best and
brightest who put themselves in a situation where the reaction to it is
absolutely normal, to experience PTSD, to experience some of these issues.

So I am really
glad that you are incorporating this traumatic brain injury piece.  It was a
piece of a bill that I did last year incorporated into that.  I am glad to see
you are streamlining that.

Do you believe
that is being implemented?  And again, I don’t want to pit one VISN against
another.  I am trying to get a broader picture here with the Chairman.  This is
a great opportunity for me.  Are they implementing those things, Director, do
you think, on a broader basis?

Mr. DALPIAZ.. 
Yes, yes.

Mr. WALZ.  Are
they sharing best practices amongst each other?

Mr. DALPIAZ... 
Yes, sir.

Mr. WALZ.  Are we
getting this right in this complexity of standardized rules issue?  I mean, it
does go back again to how far is 90 minutes, and I will confess today it was
longer than 90 minutes from Philadelphia this morning, for me, just as a
veteran traveling the other way.

But just with
that being said, do we put you in a complexity of a box that doesn’t allow you
to adapt to your veterans, adapt to changing local areas?  This is a case where
many times we ask government to function more like a business and be more
adaptable at times.  Large businesses tend to not be as adaptable as smaller
ones.  We should take a hybrid of that.

Do you have that
ability to be able to adapt, or are the centralized rules kind of there for
everybody?

Mr. DALPIAZ..  I
think we have the ability to incorporate the private sector evaluation and
build our treatment plan or build our analysis or build our evaluation or our
decision around that.  I believe we have the flexibility to do that.

Mr. WALZ.  This
is a real conundrum.  They have their facilities.  Their goal is providing that
specialized care, and out of their budget comes the fee-for-service to reach
down.  And there is this belief for some of us out there, Minneapolis doesn’t
cordon their money, send it down to Laverne and Pipestone and those places or
whatever, but it is not quite so simple.

My point to each
of you is focusing back on this issue of C&P exams.  Are you fearful of
fraud if we allow some of your contractors who have proven to be able to do
this?  Because my CBOCs are a combination of VA-run CBOCs, and Sterling Medical
is the contractor that runs the others.  They do a great job.  I call them and
provide the oversight, just like I do to you to them, and I trust those guys
could do it.

So I am asking. 
I know it is a tough question.

Mr. MORELAND. 
No, I think it is a good question.  My concern is not with fraud.  My concern
is to assure good quality.  So, for example, we have 44 community-based
outreach clinics across VISN 4.  About 15 or so of them are contract.  I am an advocate
of having a little bit of both because I think it provides some incentive and
motivation for both of them.

But I am not
concerned about fraud.  It is about quality.  So if I can get a QTC, for
example, to give me good quality exams, I am not worried about fraud.  It is
quality, because if I send a bad exam to VBA, it just delays the process, and I
don’t want to delay the process.  So that is my goal.

Mr. WALZ.  And
speaking of the process, and I am a believer in this, and I think it is a
complex issue.  There are 310 million people in this country, 20 million
veterans, a million new veterans a year.  It is complex on this.  But I am
always frustrated by the idea that if I sent you in a copy of my packet, I
could trace it from when it left Minnesota via UPS, every place it was on there
on my computer, and I know we are getting to that point.

Can we get to
where a veteran at least knows where their claim is at, knows where it is going
to be, at least has some idea?  These guys sitting behind you will tell you, I
think it is that uncertainty of knowing that it is going to be rejected and
then say, yeah, they always reject it.

I think a fix on
this -- and I throw this out.  I maybe should have asked the Colonel when he
was up here from the state perspective a little more.  I am a big fan of these
county veteran service officers having more power to help push these claims and
giving them access.  Does that make sense?  Do you think that is the way to go?

Mr. MORELAND.  I
will tell you that I view the whole thing as a team together.  The veteran
service officers from the different service groups are critically important in
this process.  The county veterans’ officers are a critical piece to this.

You know, when
they -- as a couple of the gentlemen mentioned, I am prosecuting and fighting
for these cases.  That is what I want because if I don’t have the advocate for
the veteran, then I can’t assure that I am always looking to get better.

You mentioned
that we have the best health care anywhere.  I am convinced we do.  But if you
are not trying to get better every day, you starting to fall back, and it is
the same thing with the C&P.

Mr. WALZ.  Yes,
and especially from your perspective.  This perception that you know is real,
that you guys are just trying to delay these until they die, or you are told to
kick them back and not approve them, that causes so much tension in this,
especially assuming I see it from your side, I hear many of the claims adjusters
say, “For God sakes, man, I’m a combat veteran.  These are my brothers and
sisters in arms.  I want to do what’s right, but I can’t because of this, and
it needs to be there.”

So I am trying to
figure out how do we strike that proper balance, to go back to maybe some of
the art, not just the science, of processing a claim.  And I know I am biased
on this.  The benefit of the doubt always goes to the veteran.  That is where I
approach it from.

But how do we do
that?

Mr. MORELAND. 
And I am glad you mentioned about our staff.  We have fabulous staff who are
dedicated.  You know, both these gentlemen and me, I went to work in the VA as
a clinical social worker, sir, and my goal was to go to help veterans, and I
have been in the VA for 32 years.  So anyone that asks me why are you trying to
hold up a claim, are you joking?  I am not.  But I don’t disagree with you that
there are people that may have that perception.  So we have got to get there
and find those.

I wrote down some
names as they were talking today, and I always remind the veteran officers and
the county people, if you have a name, if you have somebody who you think has a
case, send an email, call me, go to Mr. Dalpiaz, got to the VBA and ask, and we
will track them down.  The gentleman in Florida, I am already going to track
him down and find out what is going on with that case.

So that is the
only way I know to deal with the perception, is to find the real one and go fix
it.

Mr. WALZ.  What
tool can we give you?  Was I being overly optimistic in saying if we can get
this seamless transition, that there is no darn reason you shouldn’t help press
that in your service and be ready to go?  Is that the fix?

Mr. MORELAND.  I
think that is a big piece of the fix.  The IDES is a wonderful growing-up
system.  So I now have staff in VHA, and in my office even, that are calling
the military treatment facilities and saying, “What’s that guy’s name?  What’s
that lady’s name?  They need to have an exam.”

And we are seeing
it now in our medical centers, from the active duty as they are out-processing,
and that has just got to continue to grow and make that more seamless, as you
said.

Mr. WALZ.  Okay. 
Well, again, I appreciate this.  I think that is what we have to figure out,
what is the direction.  I do think -- what is the best way to put this? 
Everybody in this room is here to serve the veterans.  Large organizations can
be cumbersome.  We can have people believing they are doing the right thing,
but in the long run I have seen places where we made sure we didn’t have fraud,
waste, and abuse, and in doing so we have caused lots of grief and created more
waste.  And I think it is being targeted, laser focused on that while moving
the things we can.

So again, thank
you for the care of the veterans.

I yield back to
you, Mr. Chairman.

Mr. RUNYAN.  I
thank the gentleman.

Just your
personal experience -- and I am pretty sure that Congressman Walz, he probably
doesn’t have any more questions.  I just have one thing, and I think
Congressman Walz -- I think Mr. Moreland brought it up, and it is government
acting more like private business in adapting to their clientele.  I brought it
up to Secretary Shinseki back in a budget hearing.

We talk about
metrics and we talk about all the things that we are doing well.  I think a lot
of the time we miss the goal of customer service, which should be the primary
metric.  We can talk about how many claims we have filed, how many we have had
to re-adjudicate and all that kind of stuff, but have you seen a movement at
all, much like the private hospital system has kind of branched out and become
more community-based and decentralized than the hospital, have you seen that?

Mr. MORELAND. 
One of the metrics that I look at every month is the patient satisfaction
scores of both my VA facilities and their sister private-sector hospitals
across the street.  And so I am looking at their private-sector patient
satisfaction results and mine, and in about five of the VA hospitals in VISN 4,
we actually do better than the community hospital across the street, which I
think is something that most people don’t know.

When I look at
the other five, three of them are doing essentially the same, and two of them
are a little bit lower.

So on one level I
will say to you, Mr. Chairman, I think we are doing in many cases as well or
better than the private sector.  But I never wanted to compare myself to other
people.  I wanted to compare myself to what can I do best.

So what we are
really focused on is not only doing better, but getting to the best.  So what
we are doing is, through the Secretary’s real big push with ICARE, his values,
we are very much focused on having every veteran understand that we are here to
serve you.  So that is why we are running a public service announcement
campaign right now across VISN 4 about quality indicators and how well we are
doing.  It is why we have a new one that is coming out very soon about Iraq and Afghanistan vets.

Fifty-two to 55
percent of the returning vets have already enrolled in VISN 4, and I am really
happy about that, but I am not happy because it is not 100 percent.  So we are
really working hard because I want 100 percent to come to us so that they can
see us and find out that our public service is very good.

Mr. RUNYAN.  Mr.
Walz, do you have anything further?

Mr. WALZ.  No. 
Just again, I want to thank the staff, and I think that is exactly right, and I
think it is important for us to keep in mind that that 100 percent, in the long
run, serves this nation so much better if we get them what they need, get them
back to work, get them contributing.  They are our leaders and our future.

I want to thank
you, Mr. Chairman, for the work you have done, for the committee staff, both
the majority and the minority staff.

If you leave with
anything, leave with the faith that although messy and ugly and, as Churchill
said, the worst form of government ever, as democracy is, but better than every
other one.  It is messy and it is terrible, but there are good folks.  There
are good, dedicated servants.  There are people who have served this nation.

We can get this
right.  And again, it is going to take us a long time, but we have to ask these
hard questions.

So I want to
thank you all.  You could have been elsewhere, but you were here, and for that
I am grateful.

I yield back, Mr.
Chairman.

Mr. RUNYAN.  I
thank the gentleman.

I thank each of
you for your time today and for taking our questions and your testimony.

This completes
our oversight hearing.  In closing, I want to say stay tuned, New Jersey
veterans, that the House Committee on Veterans' Affairs and my subcommittee will
continue to listen to your needs and work to fix the several issues we
discussed here today.

Mr. Walz, thank
you for being here in New Jersey’s 3rd Congressional District and helping make
this important hearing possible.  It has been my pleasure having you serve as
Ranking Member throughout this hearing.  I know our veterans and the
subcommittee benefit greatly from your dedication to military service,
Congressman Walz, and again, thank you for your service to this great country.

Do you have any
other closing remarks?

Mr. WALZ.  Nope,
I am good.

Mr. RUNYAN.  I
ask unanimous consent that the members have 5 legislative days in which to
revise and extend their remarks.

Hearing no
objection, so ordered.

Once again, it is
my pleasure to have you all with us here today, and I thank all of our esteemed
witnesses for their testimony, and my good friend, Mr. Walz, for making a pit
stop on his way back to Washington from Minnesota to be present here today.

With that being
said, this hearing is adjourned.

Mr. WALZ.  Thank
you, Chairman.

Thank you all.

[Applause.]

[Whereupon, at 12:56
p.m., the subcommittee was adjourned.]


APPENDIX


PREPARED STATEMENT OF HON. JON RUNYAN

Good morning. Usually when we hold our DAMA Subcommittee hearings, we are
sitting in Washington.  Today, I am honored and happy to be here with all of you
at Ocean County College in my home District. 

While we are far away from our normal hearing room on the Hill and the CSPAN
cameras, this is still an official Congressional oversight hearing of the House
Veterans Affairs Committee, and hearing rules of hearing conduct apply.
Therefore, I would respectfully ask that everyone be courteous to our witnesses and
remain silent until the hearing is formally adjourned.

In Chairing the Subcommittee on Disability Assistance and Memorial Affairs, I
have had the opportunity to work on the complicated issues surrounding the
Veterans Benefits system, including the Compensation and Pension process.

Through this experience, I have had the pleasure of working alongside my good
friend, the Honorable Timothy Walz, who represents Minnesota’s First
Congressional District.  I am happy to introduce him to you today and welcome
him to Toms River.

New Jersey has the 18th largest veteran population in the U.S and over 60,000
veterans call the Third District of New Jersey home.  As many of you know, our
District is home to the largest disabled veterans’ population in New Jersey –all
of whom have sacrificed greatly for our country. 

We are also fortunate to be home to the Joint Base McGuire-Dix-Lakehurst.
This installation is critical and related to veterans’ affairs.

As we wind down two overseas conflicts, our military population will soon
begin the process of transition to our veteran population.

This transition will inevitably add additional stress to a process we are
here today to discuss: examining the VA compensation and pension exam system.

By bringing together all parties here today, from local veterans here in New
Jersey to the VA itself, our objective is to make the process more efficient
and, ultimately, to serve the needs of our veterans as best we can.

As I’m sure all of you are aware, C&P examinations are a major cause of delay
in the VA claims adjudication process. My office has been tracking a host of
problems dealing with this issue in this district and around the country.

So we are here today to examine this problem, not from afar in Washington DC,
but right here in Ocean County where so many vets call home and who are affected
by these delays.

Currently, veterans in the southern counties in NJ receive C&P examinations
through the Wilmington, Delaware or Philadelphia VAMCs.  All examinations at the
Wilmington VAMC are conducted by VA staff.

As best as we have been able to discern, VA relies too much on C&P
examinations. Often times there is sufficient medical evidence in the claims
file alone to rate a disability based on VA and private treatment records.

By unburdening VA with its current over emphasis on C&P exams, the process
could become more efficient.  Also greater access to exams could materialize.
Based on these observations, I believe we can create solutions moving forward. 

Before jumping ahead to what I believe are some solid solutions to these
problems, I’d like to welcome our witnesses here today who will be speaking in
detail on ways to improve the system.

It is my hope that through our mutual efforts, we can make the difference
needed to increase access to C&P exams, unburden the claims process, and make
your lives easier. 

Again, I am delighted to be with you today and I will now yield to the
gentleman from Minnesota, and my good friend, the Honorable Tim Walz.

PREPARED STATEMENT OF COLONEL MIKE WARNER

THANK YOU FOR
THE OPPORTUNITY TO TESTIFY ON IMPORTANT ISSUES PERTAINING TO OUR COUNTRY’S
VETERANS.

MY NAME IS
MICHAEL WARNER.  I AM A RETIRED ARMY
OFFICER AND SERVICE CONNECTED DISABLED VETERAN. 

MY LAST
ASSIGNMENT WAS COMMANDER OF FORT DIX, NEW JERSEY. 

UPON MY
RETIREMENT, I WAS APPOINTED BY GOVERNOR WHITMAN TO THE POSITION OF DEPUTY
COMMISSIONER FOR VETERANS’ AFFAIRS FOR THE STATE OF NEW JERSEY.  IN THE CAPACITY, I HAD THE PRIVILEGE TO SERVE
THE VETERANS OF THE NEW JERSEY AND MANAGE THE STATE’S VETERANS’ PROGRAMS. THOSE
PROGRAMS INCLUDED MANAGEMENT OF THE LARGEST STATE VETERANS’ CEMETARY IN THE
UNITED STATES, OPERATIONS OF 3 VETERANS’ NURSING HOMES, AND OVERSIGHT OF NEW
JERSEY’S VETERANS’ BENEFITS PROGRAMS – ASSISTING VETERANS IN THE FILING OF
THEIR DISABILITY CLAIMS.

I WOULD LIKE
TO COMMENT ON TWO AREAS THAT ARE THE DIRECT CONCERN OF THIS SUB COMMITTEE.

FIRST, IN THE
AREA OF STATE VETERANS’ CEMETARIES, I STRONGLY ENCOURAGE THE CONGRESS TO
AUTHORIZE AN INCREASE IN THE BURIAL ALLOWANCE FOR VETERANS IN ORDER TO OFFSET
THE INCREASING COSTS ASSOCIATED WITH THE BURIAL OF VETERANS AND OPERATIONS OF
THE STATE CEMETARY PROGRAM.   SIMILIARY I
BELIEVE THAT IT IS IMPORTANT TO AUTHORIZE A BURIAL ALLOWANCE FOR THE SPOUSES OF
VETERANS INTERRED IN STATE VETERANS’ CEMETARIES.  U. S. DEPARTMENT OF VETERANS’ AFFAIRS
CEMETARIES AND ARLINGTON CEMETARY INTER SPOUSES AT NO COST TO THE VETERAN.  NEW JERSEY PROVIDES FOR THE BURIAL OF SPOUSES
AT NO COST TO THE VETERAN. HOWEVER, STATE VETERANS’ FAMILY MEMBERS INTERRED IN
STATE VETERANS’ CEMETARIES SHOULD RECEIVE THE SAME CONSIDERATION AS VETERANS’
FAMILY MEMBERS INTERRED IN OUR NATIONAL CEMETARIES.  I WOULD ALSO TESTIFY THAT SPOUSES OF VETERANS
ARE AS MUCH VETERANS OF MILITARY SERVICE AS THEIR SERVICE MEMBER.  THE FAMILY MEMBERS SERVE BY ENSURING THAT THE
VETERAN CAN DO HIS OR HER DUTY WITH THE CONFIDENCE THAT THEIR FAMILY IS BEING
HELD TOGETHER BY THE STRONG AND CAPABLE HANDS OF THEIR SPOUSES – MANY TIMES ON
MUTILPLE SEPERATIONS FOR LONG PERIODS OF TIME. 

THE OTHER
AREA I WOULD LIKE TO COMMENT ON IS THE CLAIMS PROCESS, AND, SPECIFICALLY, THE
ACCESSABILITY OF THE C&P EXAMINERS.

I BELIEVE
THAT THE PROCESS FOR CONDUCTING THE C&P EXAMINATION NEEDS TO BE
RE-EVALUATED.  CURRENTLY, VETERANS ARE
REQUIRED TO TRAVEL TO THE VA MEDICAL CENTER TO MEET WITH THE VA MEDICAL
PERSONNEL FOR THEIR C&P EXAMINATION. 
FOR THIS AREA AND SOUTH JERSEY, THAT REQUIRES THE VETERAN TO TRAVEL TO
PHILADELPHIA, NEWARK OR WILLMINGTON FOR THEIR EXAMINATION.  THIS POSES A HARDSHIP FOR MANY OF OUR
VETERANS, PARTICULARLY, OUR OLDER VETERANS AND THEIR CARE PROVIDERS.

I BELIEVE
THAT MANY OF THESE EXAMINATIONS AND INTERVIEWS COULD BE CONDUCTED AT THE CBOC
LOCATIONS.  WHILE THE REQUIREMENT TO
TRAVEL TO THE MEDICAL CENTERS MAY NOT BE ENTIRELY ELIMINATED, THIS APPROACH
WOULD REDUCE THE NUMBER OF VISITS TO THE MEDICAL CENTER THE VETERAN WOULD BE
REQUIRED TO UNDERTAKE. 

BRINGING THE
C&P EXAMINERS AND OTHER PROFESSIONIALS TO THE CBOC WOULD BE IN KEEPING WITH
THE CONCEPT OF BRINGING THE VA TO THE VETERANS AS MUCH AS POSSIBLE, AS OPPOSSED
TO REQUIRING THE VETERAN TO TRAVEL TO THE MEDICAL CENTER FOR ALL SERVICES.  IT IS NOT ANY MORE DIFFICULT TO SCHEDULE A
VETERAN FOR A VISIT TO A CBOC THAN IT IS TO SCHEDULE THE VETERAN TO A MEDICAL
CENTER FOR A VISIT.  FRANKY, IT WOULD
ALSO BE GOOD FOR THE C&P PERSONNEL TO GET OUT OF THE VA MEDICAL CENTER AND
SEE VETERANS IN THE COMMUNITY.

THE
PROCESSING OF CLAIMS ALSO SEEMS TO BE A NEVER ENDING PROBLEM NO MATTER HOW HARD
WE WORK TO “FIX” IT.  THE PROCESSING OF
CLAIMS HAS BEEN AN ISSUE TO VETERANS EVEN BEFORE I WAS RESPONSIBLE FOR THE
STATE’S PROGRAM TO ASSIST VETERANS IN FILING THEIR CLAIMS. IN FACT, THERE IS A
GREAT ARTICLE ON THE BACKLOG OF CLAIMS IN THE FRIDAY EDITION OF THE “NATIONAL
JOURNAL.”  ACCORDING TO THE ARTICLE, THE
BACKLOG OF CLAIMS EXCEEDS 600,000. 

I BELIEVE
THAT ONE OF THE WAYS TO REDUCE THE TIME IT TAKES TO PROCESS VETERANS’ CLAIMS IS
TO SORT CLAIMS BY DIFFICULITY AND THE NUMBER OF PRIMARY CONDITIONS ON THE
VETERAN’S CLAIM.  FOR EXAMPLE, IF CLAIMS
WITH ONE PRIMARY CONDITION WAS DEVELOPED AND SUBMITTED, THE REVIEW PROCESS
WOULD BE VERY SIMPLE.  THE CLAIMS OFFICER
WOULD ONLY BE REQUIRED TO REVIEW THE DD 214, REVIEW THE DOCTOR’S INFORMATION
AND THEN DETERMINE IF THE VETERAN’S CONDITION MET ONE OF THE 15 PRESUMPTIVE
CONDITIONS.  IF SO, THEN APPROVE THE
CLAIM AND DETERMINE THE LEVEL OF COMPENSATION. 
FOR EXAMPLE, IF A VETERAN SERVED IN VIETNAM, AND HIS PHYSICIAN HAS
DOCUMENTED PROSTATE CANCER, HE SHOULD BE AWARDED COMPENSATION WITHOUT A FULL C
AND P REVIEW.  EVERY VIETNAM VETERAN WHO
SERVED IN COUNTRY IS PRESUMED TO HAVE BEEN EXPOSED TO AGENT ORANGE, AND IF THE
VETERAN LATER DEVELOPS PROSTATE CANCER, IT IS PRESUMED THAT THE CANCER IS A
RESULT OF HIS SERVICE IN THE THEATER. 
THERE SHOULD BE NO NEED TO DRAG OUT THE PROCESS ANY LONGER UNLESS THERE
ARE OTHER SECONDARY CONDITIONS THAT HAVE BEEN CLAIMED.  AT SOME POINT, WE NEED TO TRUST THE VETERAN
AND THEIR PHYSICIAN.

IN SUMMARY,
THE CLAIMS PROCESS CAN BE SIGNIFICANTLY REDUCED FOR CLAIMS THAT HAVE ONE
PRIMARY CONDITION, AND THAT CONDITION IS ONE OF THE 15 PRESUMPTIVE
CONDITIONS.  IF THESE CLAIMS WERE
ASSIGNED TO ONE OFFICE AND NOT MIXED IN WITH THE MORE DIFFICULT CLAIMS, THEY
COULD BE ADJUDICATED QUICKLY.  THERE IS
NO REASON FOR THESE CLAIMS TO DWELL IN THE SYSTEM FOR MONTHS.  THIS APPROACH WOULD ALLOW THE C&P
EXAMINERS TO FOCUS MORE OF THEIR TIME ON THE MORE DIFFICULT CLAIMS.

THANK YOU FOR
THE OPPORTUNITY TO DISCUSS THESE IMPORTANT ISSUES WITH YOU.

DO YOU HAVE
ANY QUESTIONS?

PREPARED STATEMENT OF JOHN
DORRITY

A-1) When a Veteran’s request
for disability entitlements is submitted to the Veterans Benefits
Administration (VBA), a process is enjoined that requires various steps and
development of the claim in order to arrive at a decision. After acceptance at
VBA, and entry of the claim into the system, a rating specialist is assigned to
the claim based usually on the Veteran’s last 2 digits of the claimant or
through other factors of consideration relative to the policy & procedure
of the particular VA Regional Office (RO).

      2) As development of the
claim proceeds, an integral part of the process         of adjudication is
required and requested by that VBA employee whom the claim is assigned to. That
part of development is the employee’s request of VHA to arrange for a C&P
examination at either a contract provider or usually the VA Medical Center
(VAMC), in which the Veteran resides. These evaluations are supposed to be
objective and comprehensive. I will address the positives and negatives of this
aspect of the process. 

B- 1) On average, between the time that VBA receives the
claim and the C&P is ordered, at least 6-16 weeks has transpired. From the
point of the last C&P issued, approximately 180 days passes before a
decision is issued by BVA. If the claims issues are relatively uncomplicated,
this time frame may be less. This brings the adjudicative process to
approximately 1 year, give or take. I base this observation on my over 30 years
of prosecuting Veteran’s claims although VA Central Office (CO) and the ROs
might disagree. In terms of presumptive service connected issues (AGENT ORANGE,
POW, PERSIAN GULF, etc.), this is purely inconsistent with timely decisions
from BVA. With presumptive disabilities and supportive public or private
medical evidence, the need for a C&P eludes me. C&Ps cost MONEY. At a
time when our Nation is feeling the noose tighten economically, it makes more
sense, as long as all evidentiary requirements are met, to decide the claim
without an unnecessary step of a costly C&P.

2) In an effort to streamline
the BACKLOGGED claims process, the Secretary of the VA has initiated
information technology (IT) procedures. This is a laudable effort with much
thought and preparation on the part of the Secretary and his CO staff, that I
hope works. One of the efforts enacted by the CO of the VA is the Disability
Benefits Questionnaire (DBQ). As a matter of fact, many of the VHA C&P
clinicians conducting VA Exams (VAX), are struggling to complete these
relatively simple forms and are somewhat hampered by the process as it does NOT
provide the examiner the ability to utilize their intellect and expertise in
arriving at an objective finding. A case in point is my own C&P conducted
on 4/13/2012, at which my examiner struggled for approximately 20 minutes just
to enact the DBQ program relative to my claim and service connected injuries.
When I received and read my own results, I felt as though the examiners had
someone else in the examination room as the VAXs did NOT reflect any of the
conversations between the examiners and myself. There was information that was
NOT indicated on the results, DBQs, that I know transpired in conversation
between the examiners and myself. DBQs do not always provide for the
objectivity required to arrive at a JUST decision for the Veteran. Many times,
because of this limited IT “improvement”, through the lack of prudent,
objective medical observation and testing goes by the wayside as a matter of
procedure and in an effort just to complete the DBQ, as required by the CO’s
mandate. An ORTHOPEDIC injury, claimed by the Veteran, through the VHA examiner
will dictate that an X-ray be taken, as part of the C&P. In older service
connected injuries, an X-ray, other than showing a fracture is entirely
inconclusive. In this regard, I feel as though many INADEQUATE C&Ps are
conducted which leads to an incorrect decision on the part of VBA and prolongs
the claims process for the Veteran. 

3) Another issue that we
Veterans contend with at C&P is the ATTITUDE of the examiner. As previously
indicated, C&Ps are to be objective (as the entire claims process is
purported to be. More often than not, I have seen, upon review of the C&P,
subjectivity NOT objective opinion on the part of the VHA examiner. Although
the C&P notification suggests that the Veteran bring any other medical
evidence relative to the issue, rarely do the examiners utilize this EVIDENCE
in formulating their final report. Another case in point is AUDIOLOGY C&Ps.
When an older Veteran files a claim for say BILATERAL HEARING LOSS and
TINNITUS, on more than half of the occasion, I have had that examiner opine
that the reason for the conditions is OLD AGE. This is not only discriminitory
but downright despicable. If the evaluator truly understands the nature of the
process outside of their own little world and supposed expertise, than they
should contend with the issue of the etiology of the ACOUSTIC TRAUMA, as
indicated within the Veteran’s military exposure or MILITARY & OCCUPATIONAL
SPECIALTY (MOS). A Veteran who served in the ARTILLERY, AVIATION, ARMOR or
other units where the acoustic trauma is apparent are NOT afforded this
objective review and conclusion. Many C&P examiners indicate that they have
“reviewed“ the Veteran’s record. Without the shipment of a file, voluminous or
not, to the examiner’s desk this is an outright fabrication. Many VHA examiners
do not have a clue in terms of the overall claims process due to a lack of
military service themselves therefore, they have NO understanding or compassion
in terms of the source of the Veteran’s initial exposure to loud noises. A
COMBAT Veteran invariably is exposed to acoustic trauma on a daily basis, this
is a given amongst any of us who have defended our Nation.

4) On more then 1 occasion, I
have seen proof of the Veteran’s 3rd party being billed for C&P.
The problem with this erroneous aspect of C&P is that a 3rd
party payee (private insurance carriers, etc.) reduce the lifetime coverage
afforded the individual through no fault of their own. If I am not mistaken,
not only is the C&P a requirement of the adjudication process and NOT 
monetarily chargeable to anyone but, the Veteran is afforded TRAVEL PAY by VHA.
This portion of the C&P process needs review as some diligent who Veterans
wait at the travel station receive their travel pay immediately but, those who
send their travel pay reimbursement forms in are not quite so lucky. I have
clients who have been made to wait more than 90 days for reimbursement and
others who submit the necessary forms and are NEVER reimbursed. Clearly,
irrespective of the fiefdom culture that emerges in large bureaucracies, a
national standard of this component of the process is overdue for review.

C.- 1) As a DIRECT
representative of the Veteran, I wish to suggest that all is not doom and gloom
within the system. There are many good people within VBA & VHA. This issue
and other problematic elements are endemic in any large agency. If we do not
stay ahead of the curve on the problems of agency, then any initiative
undertaken by any Secretary of the VA is unlikely to bear fruit. I am in favor
of the Secretary’s present initiative and support it through my many
interactions with my peers on the local, state and national level. I speak to
many that we need to embrace the technology and utilize it to our constituent’s
benefit. I would point out that in a Federal agency that employs nearly 300,000
employees, the Secretary would be well served to insure that the “culture” of
his agency is in sync with his mandates.

2) In the past, I have cc’d ththe HVAC any and all written
complaints that I have received from individual Veterans with respect to the
problems of C&P and will continue to do the same as long as I draw breath.

PREPARED STATEMENT OF GENE
O'GRADY

Good Afternoon and Thank you Chairman Runyan and Members of
the Subcommittee for the opportunity to speak on behalf of our nations heroes
on such an important issue. As Vice Commander of the American Legion for this
area I understand how greatly affected our veterans are by the VA’s current
compensation and pension claims processing.

 The examination process
for claimants filing compensation or pension claims can be improved to allow
for better timeliness in the adjudication process. This would require a
liberalization of Title 38 United States Code to allow for the examination to
be conducted by a non-VA physician or by a VA physician furnishing outpatient
care.

When a claim is filed for service-connected compensation (a
condition(s) alleged to be related to military service) an examination, in many
cases, is conducted to establish a nexus and to determine the extent to which
the condition(s) is disabling. A claim for non-service connected pension
requires an examination only when the claimant is below 65 years of age.

While it may prove difficult to establish the relationship of
a specific medical condition to military service in the instance where an
original claim is being filed after an individual is separated from active duty
for more than a year, the VA should explore this complex issue with a view
toward accepting private medical evidence in lieu of conducting a compensation
examination.

In cases where service connection has already been established
and the veteran is filing for an increased rating based upon a worsening of the
condition then some provision should be made to recognize medical evidence
either from a private physician or from a VA physician in the instance where a
veteran receives outpatient care at a VA facility.

Requiring a specific examination for a service connected
condition in many cases is redundant and only serves to slow the claims process
unnecessarily. The development of an alternative method for assessing and
adjudicating medical conditions that are claimed to be related to military
service or for establishing the necessary degree of disability for non-service
connected pension would expedite the claims process significantly.

It is not suggested that the adequacy of determining the
relationship of a medical condition to military service or the existing degree
of disability should be compromised but it is believed that alternatives to a
specific compensation or pension exam exist and that their feasibility for use
in claims should be assessed in order to improve the timeliness of the
adjudication process.

This may require the development of new forms that may be
furnished to and completed and returned by physicians who are and have been
treating the veteran for the condition(s) claimed. It could also take the form
of utilizing VA Outpatient records in those cases where a veteran receives
medical care at a VA facility. VA physicians can be trained to include specific
notes or references to the veteran’s treatment record that will assist a rater
in adjudicating a claim.

There are likely to be claims that will require a
compensation or pension examination but with proper development it is believed
that those situations can be reduced significantly with the result that
timeliness will be greatly improved.

PREPARED STATEMENT OF WALTER J.
TAFE

Good afternoon. Thank you for inviting me to speak on this
important subject. My name is Walter Tafe and I am the Director of Burlington
County Department of Military and Veterans Affairs. Our office serves a
community of over 35,000 veterans. With our close proximity to Joint Base
McGuire-Dix-Lakehurst approximately 20 percent of our clients are recent
returnees from the Global War on Terrorism.

I am here today to share my observations regarding the
Veteran Affairs (VA) requirements for Compensation and Pension (C&P)
examinations. I don’t come here today to throw stones at the VA. I understand
the backlog issues and hope to make meaningful testimony that can help all
involved gain a better prospective of the veteran’s point of view. Although I’m
sure this program was intended to speed the process by providing verification
of a veteran’s condition, in many cases it has the opposite effect. The reality
is that veterans face a wait of several months before seeing a doctor, a visit
that’s often no  more than a five to 10
minute conversation with a doctor who takes just a cursory look at the medical
records—and that’s assuming the regional office has sent the records at all.
Veterans leave this examination extremely frustrated; many tell me they feel
they’ve wasted several months waiting for an appointment that wasn’t even a
real medical exam. 

I would like to discuss several recommendations that, I
believe, could have a dramatic impact on the process, reducing both the wait
time for C&P examinations and the backlog that is presently crippling the
claims process. My recommendations are based on my conclusion that many—at
least 50 percent—of the C&P examinations conducted by the VA are
unnecessary.

Many of my clients are receiving their health care
exclusively from the Veterans Administration health care system. This means
that the VA already has their complete medical history in its possession. When
these veterans file a new claim or a claim for increase, they must first
receive a C&P exam to verify the condition. The veteran waits several
months to receive a C&P examination so a VA doctor can verify a condition
that was already diagnosed by another VA doctor. This makes absolutely no
sense.  It seems like the VA does not
trust its own doctors to make a competent assessment and recommendation. Often,
the veterans interpret this as a means of delaying the process; as a result, it
builds great animosity between veterans the very department that is supposed to
protect them. 

As I initially stated, approximately 20 percent of my
current clients are only just returning to civilian life after serving on
active duty. They are National Guard and Reserve personnel being released after
activation, or active duty military members separating or retiring. In these
cases the entire military service medical records are available to the VA.
These members normally file a claim within the first three months of
separation. Many are combat wounded, or have conditions diagnosed during active
duty and verified during separation physical examinations. Even with a
definitive medical exam at the close of their service, they must wait months to
receive a C&P exam appointment—and the only point is to verify a medical
condition that’s already a matter of record. These examinations could be
completely eliminated if the VA and DoD would simply communicate with each
other and share information. I recommend that a military member’s separation
examination should consist of the same verification procedure used by the VA,
thereby reducing the redundancy and expediting the claim.

Another concern I share with others in my field is the
requirement of a full verification process for every condition when a veteran is cared for by a private physician.
I understand that in some cases verification by the VA of a condition is needed
and fully justified. However, in documented cases of stage four cancers, severe
diabetes with insulin dependence, coronary artery disease or similar terminal
conditions a C&P exam seems unnecessary. Add the additional step of filing
a claim and submitting a VA Form allowing his or her doctor to release all
records to the VA, and the resulting delay can begin to seem cruel.

A case in example: 
Former Marine Ronald Guernon. He is presently temporarily rated at 100
percent for service-connected colon and kidney cancer. Over a year ago his
condition worsened and his prognosis was determined to be terminal. At that
time I filed a request to upgrade his condition to permanent and total. I also requested
Aid and Attendance. He now resides in Spring Hill Florida where his wife, a
registered nurse provides care. He also receives hospice care. His life
expectancy is listed as month-to-month. Despite the ongoing documentation of
Mr. Guernon’s deteriorating condition and the fact that all medical records
have been given to the VA, the Tampa Regional Office requested he come for a
C&P examination to determine whether his condition has worsened. This
veteran is, literally, unable to travel to Tampa due to his condition. This
proud Marine is absolutely convinced the VA is “just waiting for me to die so
they don’t have to bother.” While I’m sure this is not the case, Mr. Guernon is
the perfect example of the crippling bureaucracy that is so significantly complicating
the VA claims process.

The VA is making some strides and I applaud the new
“Disability Benefits Questionnaires” forms that have been provided for veterans
to bring to their health care providers. These questionnaires were developed so
a veteran can give it to his or her doctor to complete
providing all the medical information required to make a rating decision on
certain conditions. These questionnaires have been developed for almost all
conditions a veteran can receive compensation for. If used correctly, they
should negate the C&P process in most cases.  

In closing I would like to say it is my strong belief that
the present C&P exam process is severely hindering, rather than helping,
the VA claim process. In most cases the examinations are not thorough and leave
veterans questioning why they waited several months for a five-minute exam. The
perception that C&P exams are a method of delaying and denying claims is
rampant in the veteran’s community; and it’s all the more potent when veterans
like Mr. Guernon share their stories. It is my hope that these hearings will
result in a thorough self-examination by VA personnel to evaluate the relevance
of this requirement and eliminate unnecessary examinations. Thank you for your
time and consideration of my testimony.  

PREPARED STATEMENT OF MICHAEL E. MORELAND

Chairman Runyan and Members of the Subcommittee,
it is my pleasure to be here today to discuss VA’s efforts to provide the best
care possible to Veterans residing in Central and Southern New Jersey.  Joining me today are Joseph Dalpiaz, Director
of the Philadelphia VA Medical Center (VAMC) and Robert McKenrick, Director of
the Philadelphia VA Regional Office (VARO). 

I will begin my testimony by furnishing
an update on how VHA and the Veterans Benefits Administration (VBA) collaborate
on compensation and pension examinations, to include the scheduling of those
exams.  I will also review VHA services provided
to New Jersey Veterans. 

Compensation and Pension Examinations

VHA and VBA work together to deliver
compensation and pension (C&P) examinations for Veterans.  VISN 4 monitors and ensures access to these
exams through dedicated staff that coordinate between VA medical centers and
VBA regional offices.  VISN staff also
coordinate efforts related to the Integrated Disability Evaluation System
(IDES) and provide additional resources when needed to VA medical centers.  In the Third Congressional District of New
Jersey, the vast majority of Veterans receive their C&P examinations at the
Philadelphia VAMC, while a small number visit the Wilmington VAMC or a VA
community-based outpatient clinic.  In
addition, VHA also coordinates some examinations through contract provider, QTC.  This contract has allowed the Philadelphia
VAMC to conduct additional clinical examinations.  QTC has performed 38 audiology C&P
examinations since November 2011.  QTC
conducts its examinations at sites closer to where Veterans live, including
several locations in New Jersey.

At the Philadelphia VAMC, the current
average wait time between when an appointment is scheduled and the date of the
C&P examination is between 13 and 16 days.  In February 2012, the national average was 25
days.  The Philadelphia VAMC has made
tremendous progress over the last 3 years in reducing the rate of patient
no-shows for these exams, cutting the figure in half from 15 percent in FY 2009
to 7.5 percent in FY 2012.  This is
particularly noteworthy as the total volume of examinations conducted at the
Philadelphia VAMC has increased over the same time period by more than 20
percent (18,718 examinations in FY 2009 and 23,132 examinations in FY
2011). 

The Philadelphia
VAMC implemented several process changes and increased staff capacity and
proficiency in FY 2011.  The facility has
restructured all C&P clinical appointment profiles to better manage the
increasing complexity of examinations requested and is scheduling C&P clinics
on weekends and holidays to enhance capacity and convenience for Veterans.  A new physician sharing program has one
physician travel from the Philadelphia VAMC to the Philadelphia VARO to provide
one-day turnaround service on priority cases that do not require an on-site
examination.  Leadership at the
Philadelphia VAMC reviews C&P performance measures on a weekly basis and
develops strategies as appropriate to implement corrective action when
necessary. 

One final
innovation particularly helpful to Veterans of Operation Enduring
Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) involves a
revision to examinations conducted for traumatic brain injuries (TBI) to
expedite the examination, thereby reducing the need for multiple reviews and
simplifying the process for Veterans.  Philadelphia determined that 70-80 percent of the Veterans
presenting for TBI were not scoring well enough on their initial screen to
avoid a second appointment with neuropsychology.  Previously, this would require
these Veterans to schedule a second appointment and return to the medical
center at a later date.  Philadelphia staff considered this a hardship for
the Veterans, as a large number of the patients have a significant disability.

To address the issue, Philadelphia changed their
process for providing the TBI exam.   They worked with neurology
service to hold appointments available for the days that Veterans were
scheduled for their initial TBI exam.  If the Veterans scored low and
required the second appointment, they would be scheduled later that same day to
complete the neuropsychology exam, without the need for a return visit.  This process has shaved approximately 5-15
days off the exam completion time and eliminated the need for return visits. 

At the Wilmington VAMC, the average wait
time for a C&P examination is between 10 and 14 days.  The Wilmington VAMC conducts all C&P
examinations on-site, and is exploring options that would use telehealth to
conduct certain types of examinations at community-based outpatient clinics in
New Jersey and Delaware.  The Wilmington
VAMC has seen an even greater increase in the number of C&P examinations
conducted between FY 2009 and FY 2011 than the Philadelphia VAMC, growing by
more than 33 percent (4,902 examinations in FY 2009 and 6,553 examinations in
FY 2011).  The Wilmington VAMC no-show
rate has remained fairly constant and is currently at 10.8 percent for FY
2012. 

The Wilmington VAMC has also improved its
processes.  It has added staff in C&P
clinics to allow greater flexibility in patient scheduling, including evening
and weekend hours.  The facility has
identified a new C&P physician leader who works with the Philadelphia VARO
on pending issues and to support collaborative problem solving.  Wilmington VAMC is also looking at
opportunities to support the Dover Air Force Base and the Philadelphia VARO as
part of the IDES process.  Finally, the
Wilmington VAMC is exploring ways to increase the use of telehealth to conduct
behavioral health C&P examinations at any of five community-based
outpatient clinic locations this fiscal year.

Both the Philadelphia and Wilmington
VAMCs use a proactive, patient-centered approach to scheduling appointments by
contacting patients and establishing appointment times that are as convenient
as possible for Veterans.  These facilities
also make reminder calls to Veterans prior to their scheduled appointments to
reduce the no-show rate.  VA has
established a national benchmark of 30 days for a cumulative average processing
time for these examinations, and in each month of FY 2012, both the
Philadelphia and Wilmington VAMCs exceeded the national benchmark (25-day
average at Philadelphia and 20-day average at Wilmington).  This represents a significant improvement for
the Philadelphia VAMC, which had an average processing time of almost 35 days
in FY 2010.  The vast majority of
examinations conducted also pass all quality indicators for sufficiency and
consistency between the available medical evidence and the examination report.  Since FY 2009, the insufficiency rate at both
Philadelphia and Wilmington was at or below 0.5 percent.  VA’s national benchmark for this figure is 1
percent, with a smaller figure being better.

VISN 4 Overview:  Central
and Southern New Jersey

Veterans Integrated Service Network
(VISN) 4 consists of 10 VA medical centers and 43 community-based outpatient
clinics (CBOCs), 17 Vet Centers and one rural mobile clinic, which serve 104
counties throughout Pennsylvania, West Virginia, Delaware, New Jersey, New York,
and Ohio.  Almost 455,000 Veterans are
enrolled in VA’s health care system in VISN 4, and more than 318,000 unique
Veterans received health care in VISN 4 during fiscal year (FY) 2011.  Between FY 2010 and FY 2011, we saw modest
growth in the number of Veterans using VISN 4 for health care, despite a slight
decline in the total number of Veterans enrolled.  VISN 4 employs 13,144 people and has a total
operating budget of $2.44 billion. 

In close proximity to the Southern New
Jersey Veteran population, VA and VISN 4
operate medical centers in Philadelphia, PA and Wilmington, DE.  As evidence of the accessibility of our
inpatient services, 86 percent of urban Southern New Jersey enrollees live
within a 60-minute drive of these facilities, while 100 percent of rural
Southern New Jersey enrollees live within 90 minutes or less of these
facilities.  Approximately 82 percent of
Veteran enrollees in Southern New Jersey live in urban areas, with the
remaining 18 percent considered rural. 
The VA standard is that 65 percent of Veterans meet that level of
access, which indicates that VISN 4 exceeds the current guidelines.  To provide convenient outpatient care in
Southern New Jersey, Philadelphia VAMC operates CBOCs in Gloucester County and
Ft. Dix in Burlington
County, as well as an annex clinic in Camden County.  Wilmington VAMC serves New Jersey area
Veterans at CBOCs in Northfield in Atlantic County, Vineland in Cumberland
County, and Cape May in Cape May County. 
VISN 3 operates other VA facilities in New Jersey as well.  Counseling, outreach and referral services
are also provided to Veterans in the Southern New Jersey area in Vet Center
locations in Philadelphia (two sites), Ewing, Lakewood, and Ventnor.

Specific to the Third
Congressional District of New Jersey, VA provides care to Veterans in
Burlington and Camden Counties through services available at the
previously-mentioned VAMCs in Philadelphia, PA, and Wilmington, DE, as well as
the CBOC at Ft. Dix in Burlington County,
and the annex clinic to the Philadelphia VAMC in Camden County.  According to data published by the Joint
Commission, a national hospital accreditation organization, these two
facilities perform as well or better than their local private sector
counterparts in all metrics for which there is sufficient data for comparison.[1]  In Ocean County, the majority of Veterans receive
care from facilities located in VISN 3.

An estimated 61,000 Veterans
reside in Burlington and Camden counties.  In FY 2011, 19,455 Veterans from Burlington
and Camden Counties were enrolled in VA’s health care system.  For that same time period, the medical
centers in Philadelphia and Wilmington
treated 5,586 unique patients from Burlington
County and 5,721 from Camden County. 

VA has established a
standard that 70 percent of Veterans have access to primary care within a 30
minute drive of their residence.  VISN 4
surpasses this requirement in Burlington County, where 94 percent of total
enrollees live within 30 minutes of primary care, and in Camden County, where
100 percent of Veterans have this ready access. 
In VISN 3, approximately 90 percent of Ocean County Veterans have access
to primary care within 30 minutes.

The Philadelphia VAMC is an
acute care, teaching hospital, providing comprehensive patient care services,
including primary care, tertiary care, and long-term
care in areas of medicine, surgery, psychiatry, rehabilitation, neurology,
oncology, dentistry, and geriatrics.  A
wide range of specialty care services are offered to Veterans at Philadelphia,
such as substance use disorder treatment; mental health care, including
evidence-based treatment for post-traumatic stress disorder (PTSD);
hemodialysis for Veterans with kidney disorders; skilled nursing home care;
respite care; Home-Based Primary Care; laser surgery; and other intensive care
programs.  High-tech diagnostic services
such as computerized tomography (CT) and magnetic resonance imaging (MRI)
complement the treatment modalities.  In
May 2012, the medical center will open an outpatient dialysis center for
Veterans, and already operates a Women's Health Clinic providing primary and
gender-specific specialty care to female Veterans.  The facility’s 240-bed Community Living
Center serves the metropolitan Philadelphia area and provides extended care,
rehabilitation, psycho-geriatric care, palliative care, and general nursing
home care to area Veterans.

Philadelphia also operates several
Centers of Excellence, including:

·       
The
Mental Illness Research, Education and Clinical Center (MIRECC), which focuses
on improving the identification of substance abuse and other mental health
problems in Veterans;

·       
The
Center for Health Equity Research and Promotion (CHERP), which works to reduce
disparities and promote equity in health care among vulnerable groups of
Veterans; and

·       
A
Parkinson’s Disease Research, Education and Clinical Center (PADRECC), one of
six such facilities that strive to improve care for Veterans suffering from
Parkinson’s disease and other related movement disorders.

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

Conclusion

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



[1]
See The Joint Commission, Quality
Measure Set Comparison between Wilmington VA Medical Center and Christiana Care
Hospital, July 2010-June 2011.  Available
online:  http://www.qualitycheck.org//Consumer/SearchQCR.aspx.  See
The Joint Commission, Quality Measure Set Comparison between Philadelphia VA
Medical Center and Pennsylvania Hospital, July 2010-June 2011.  Available online:  
http://www.qualitycheck.org//Consumer/SearchQCR.aspx