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Hearing Transcript on Servicemembers’ Seamless Transition into Civilian Life–The Heroes Return.













MARCH 8, 2007

Printed for the use of the Committee on Veterans' Affairs

SERIAL No. 110-7





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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

HARRY E. MITCHELL, Arizona, Chairman

TIMOTHY J. WALZ, Minnesota
GINNY BROWN-WAITE, Florida, Ranking
BRIAN P. BILBRAY, California

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.



March 8, 2007

Servicemembers' Seamless Transition into Civilian Life—The Heroes Return


Chairman Harry E. Mitchell
  Prepared  Statement of Chairman Mitchell
Hon. Ginny Brown-Waite, Ranking Republican Member
  Prepared Statement of Congresswoman Brown-Waite


Hon. Cliff Stearns, a Representative in Congress from the State of Florida, statement


U.S. Department of Veterans Affairs:
    Michael J. Kussman, MD, MS, MACP, Acting Under Secretary for Health, Veterans Health Administration
        Prepared Statement of Dr. Kussman
    Shane McNamee, MD, Director, Hunter Holmes McGuire Richmond Veterans
    Affairs Medical Center, Richmond, VA
        Prepared Statement of Dr. McNamee
   Steven G. Scott, MD, Medical Director, Tampa Polytrauma Rehabilitation Center,
   James A. Haley Veterans' Hospital, Tampa, FL
        Prepared Statement of Dr. Scott
    William F. Feeley, MSW, FACHE, Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration
        Prepared Statement of Mr. Feeley
    Edward C. Huycke, MD, Chief Department of Defense Coordination Officer, Veterans Health Administration
        Prepared Statement of Dr. Huycke
    Ira R. Katz, MD, PhD, Deputy Chief Patient Care Services Officer for Mental Health, Veterans Health Administration
        Prepared Statement of Dr. Katz

U.S. Government Accountability Office, Cynthia A. Bascetta, Director, Health Care
    Prepared Statement of Ms. Bascetta

Lain, Kimberly, Millersville, MD
Pearce, Kathy, Mesa, AZ
Sullivan, Paul, Cedar Park, TX
Walter Reed Medical Center/Bethesda Naval Hospital:
    Kathy Dinegar, Social Worker Liaison for Seamless Transition
    Sherry Edmonds-Clemons, Social Worker Liaison for Seamless Transition


Letter dated March 7, 2007, from U.S. Department of Veterans Affairs Secretary Nicholson to Congresswoman Ginny Brown-Waite, regarding the ability of DoD and VA to provide world-class health care to servicemembers and veterans

U.S. Government Accountability Office Letter dated June 30, 2007, from Cynthia A. Bascetta, Director, Health Care, to Congressman Michael Bilirakis, regarding Transition of Care for OEF and OIF Servicemembers (GAO-06-79R)

U.S. Government Accountability Office Report entitled, "Vocational Rehabilitation—More VA and DoD Collaboration Needed to Expedite Services for Seriously Injured Servicemembers," dated January 2005 (GAO-05-167)


Response to Questions for the Record from Paul Sullivan, Cedar Park, TX, and former Project Manager for the U.S. Department of Veterans Affairs, dated March 27, 2007 [The exhibits submitted by Mr. Sullivan are being retained in the Committee files]


Thursday, March 8, 2007
U. S. House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 3:43 p.m., in Room 334, Cannon House Office Building, Hon. Harry E. Mitchell [Chairman of the Subcommittee] presiding.

Present:  Representatives Mitchell, Space, Walz, Rodriguez, and Brown-Waite.

Also Present:  Representatives Filner, Hare, Buyer, Bilirakis, and Lamborn.


Mr. MITCHELL.  Welcome to the Oversight and Investigations Subcommittee of the Committee on Veterans' Affairs March 8, 2007, hearing entitled, Servicemembers' Seamless Transition into Civilian Life—The Heroes Return.  I want to thank everyone for being here today.  Two weeks ago, the American people learned that some of the most seriously wounded warriors were recovering in dilapidated conditions at the Walter Reed Medical Center, supposedly the Army's premier medical facility. 

These conditions are absolutely unacceptable and the American people are rightly outraged.  Sadly, it appears the buildings are just the tip of the iceberg.  Reports have been filtering in about a labyrinth of bureaucratic red tape our returning soldiers are having to navigate to get the basic health care benefits they need and deserve.  These problems have a direct impact on these men and women as they transition from the military's health care system to the VA.  We have a responsibility to investigate how issues at the Department of Defense affect soldiers as they become veterans.  We have a responsibility to make sure that the Department of Veterans Affairs is doing its job to make the transition as easy as possible. 

I am not convinced the that U.S. Department of Veterans Affairs (VA) is doing its part.  Last night, ABC News reported that a proposal to keep seriously wounded vets from falling through the cracks of the bureaucracy was shelved in 2005 when Jim Nicholson took over as VA Secretary.  I am deeply troubled when wounded soldiers say in news reports that the VA has made them feel horrible.  That is unacceptable and embarrassing and the American people deserve answers.  Today, we hope to get to some of them.  In today's hearing, we will hear from witnesses who have seen and experienced firsthand the difficulties veterans face when they transition from the DoD health care system to the VA.  Their stories are compelling, and I am eager to learn how the VA is responding to their concerns as well as the health care needs of their fellow veterans who have taken time to come to observe our hearings. 

In particular, I would like to recognize Specialist Greg Williams, Corporal Noel Santos, Sergeant Frank Valentine, Staff Sergeant Danny Vega.  We are honored to welcome these young heroes here today.  At this time, I ask unanimous consent that Mr. Filner, Mr. Buyer, Mr. Hare, Mr. Lamborn, and Mr. Bilirakis be invited to sit at the dais for the Subcommittee hearing today.  Hearing no objections, so ordered.

[The statement of Chairman Mitchell appears in the Appendix.] 

Mr. MITCHELL.  Before I recognize the ranking Republican member for her remarks, I would like to swear in all of our witnesses.  And at this time, if you would please stand, we will swear you in.

[Witnesses sworn.]

Mr. MITCHELL.  Thank you.  Now I would like to recognize Ms. Brown-Waite for her opening remarks. 


Ms. BROWN-WAITE.  I thank the Chairman.  And I apologize both to the Chairman and to the members for my tardiness.  It was an issue relating to a sexual predator in my district who was found guilty yesterday, and I was speaking to the family and to some members of the press about it.  And I thank the gentleman for yielding.  The Committee on Veterans' Affairs has been conducting oversight reviews of the seamless transition issue for our Nation's servicemembers for the past several Congresses. 

In the last Congress alone, the Committee and its Subcommittee held 10 hearings on the transition of our servicemembers.  I believe that I speak for all of us when I say that this is a top priority issue, that despite our best efforts has not always been entirely resolved.  Congress codified the concept of DoD/VA sharing, now known as seamless transition, in 1982, with the passage of the Veterans Administration and the Department of Defense Health Resources Sharing an Emergency Operation Act.  This Act created the VA Care Committee to supervise and manage opportunities to share medical resources.  Now, 25 years later, we are still discussing this issue.  Some progress has been made in the area of transitioning servicemembers back to the workforce.

Last Congress, Public Law 109-461 was enacted which included various transition assistance initiatives ranging from health care needs to education and employment needs.  During the last Congress, members and staff from the Committee conducted numerous field and site visits at the VA and military treatment facilities and military bases to review efforts on the seamless transition, and held oversight hearings in May and September of 2005.  The transition and integration back into civilian life should be transparent and effortless for our servicemembers. 

However, this apparently does not always seem to be the case.  More often than not, the handoffs have been fumbles.  In a GAO report prepared for this Subcommittee on June 30, 2006, it was found that the VA has taken many aggressive actions to provide timely information to OEF and OIF servicemembers and their families, especially in their critical time of need.  The report also noted the positive steps taken to increase the awareness training and sensitivity of staff and medical providers on the needs of OIF and OEF servicemembers and veterans.  The report also found the VA continues to have problems assessing real-time medical information from DoD treatment facilities.  Mr. Chairman, I ask unanimous consent that a copy of this report be inserted in the official hearing record, and I will be happy to hand that to you. 

Mr. MITCHELL.  So ordered.

[The referenced GAO Report entitled, "Vocational Rehabilitation—More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured Servicemembers," (GAO-06-79R), appears in the Appendix.]

Ms. BROWN-WAITE.  I appreciate that. 

We know that we have witnesses from Walter Reed Army Medical Center, and I want to make it clear that today's hearing is not about the conditions at Walter Reed, but about the transition of our servicemembers and how they are making it from DoD to VA care, how the process works, are there any gaps in care, and is VA getting the information that it needs from DoD in a timely manner to ensure the continuity of care for these new veterans, so that waiting periods for care do not extend for months after separation from active duty.  And why to this day is information on DoD personnel being cared for at the VA's polytrauma centers still not being electronically transmitted?  Is there a difference between DoD electrons and VA electrons?  Again, Mr. Chairman, I thank you and I yield back the balance of my time. 

[The statement of Congresswoman Brown-Waite appears in the Appendix.]

Mr. MITCHELL.  Thank you.  At this time, I am asking members to submit their opening statements.  We have 13 people on three panels that we are going to hear today.  So it will take quite a while.  If you could submit them for the record, I would appreciate that. 

We will now proceed to panel one, we are pleased to welcome Dr. Michael Kussman, the acting Under Secretary of Health for VA.  Dr. Kussman has had a long and distinguished military career beginning with his service in the 7th Infantry Division in Korea.  He has held leading medical positions at multiple facilities while on active duty, such as serving as commander of the Walter Reed health care system. 

As the Director of Health care at the GAO, Ms. Cynthia Bascetta provides our Subcommittee with a major service not only in her ability to provide independent assessment of VA program performance, but also to place the performance of VA's seamless transition programs in a historical context.  As many of you are aware, last night, Mr. Paul Sullivan appeared on ABC News to discuss a data tracking system, which would have made the seamless transition of new veterans much more efficient.  We are pleased to welcome him here today to answer questions and share his knowledge and experience on this issue. 

Finally, Private First Class Kimberly Lain who has recently gone through the transition process to the VA from the Walter Reed Medical Center is here to share her experiences with us.


Mr. MITCHELL.  Dr. Kussman, if you would please.  If everyone could please, in front of you is a little clock with a green light, a yellow light and a red.  And if we could keep that, keep it in line with that, I would appreciate it.  Dr. Kussman?


Dr. KUSSMAN.  Good afternoon Mr. Chairman and members of the Subcommittee.  I would like to submit the written record for the record if that is okay, Mr. Chairman.  Thank you for this opportunity to comment on VHA's seamless transition efforts.  Before I begin, however, let me address an issue with which was discussed in the news media last night.  In 2003, VA developed a contingency tracking system to meet the Veterans Benefits Administration, not the VHA's immediate need to track their benefits, assistance activities in support of seriously injured servicemembers as they transition from MTFs to our health care facilities. 

The VA employees who worked on the system hoped that it would evolve to meet the VHA.  Unfortunately, it could not meet VHA's needs or even all of VBA's needs without additional development costs, and in February 2005, our Department decided to consider other ways to accomplish this task. 

Because VHA's case management needs were not met by the system, we developed our own tracking system which is known as the MTFs to VA.  Last summer, we were briefed on DoD's joint patient tracking application, or JPTA system, which provides a great deal of information on the progress of seriously injured veterans through DoD's health care system. 

Together, DoD and VA realized that enhancing DoD system was our best option, providing both departments with a much better tool to track case management issues.  DoD provided us with the capability to look at their records towards the end of last year, and earlier this month, we developed the ability to enhance the system to enable VA case managers to add their own notes and information about phone calls they have made to patients. 

Our vision is to create a continuous clinical record of transfers and case management activities for all seriously injured patients as they progress through both DoD and VA systems of care.  VHA will continue to use the MTF to VA system until JPTA can create such a record for seriously injured patients. 

One other thing, before I leave this subject, contrary to what was erroneously reported last evening, the decision to use one system which was felt better met our needs over another one was made appropriately at the administrative level.  This was a programmatic decision and not one made by the Secretary.  VHA's efforts to create a seamless transition for men and women as they leave the service and take up the honored title of veteran begins early on.  Our outreach network ensures that returning servicemembers receive full information about VA benefits and services. 

In each of our medical centers and benefits offices now has a point of contact designed to work with veterans returning from service in Operation Enduring Freedom and Operation Iraqi Freedom.  VHA has coordinated the transfer of other 6,800 injured or ill active duty servicemembers and veterans from the Department of Defense to the VA. 

Our highest priority is to ensure that those returning from the global war on terror who transition directly from DoD military treatment facilities or MTFs to VA medical centers continue to receive the best possible care available anywhere.  This month, we are attempting to call each of these severely injured servicemembers and veterans to see if they need additional support.  And we are directing facilities to provide OIF/OEF care coordinators at each facility. 

VA social workers benefits counselors and outreach coordinators advise and explain the full array of VA services and benefits to servicemembers while they are still being cared for by DoD.  These employees assist active duty servicemembers as they transfer to VA medical facilities from MTFs. 

In addition, our social workers help newly wounded soldiers, sailors, airmen, and marines and their families plan a future course of treatment for their injuries after they return home.  Currently, VA social work and benefits counselors are located at 10 military treatment facilities.  One important aspect of coordination between DoD and VA to a patient's transfer to VA's access to clinical information.  The Bi-Directional Health Information and Exchange, BHIE, allows VA and DoD clinicians to share text space clinical data in a number of sites, including Walter Reed and National Naval Medical Center and the two military treatment facilities that refer them, they are the two military treatment facilities that refer the majority of polytrauma patients to the VA. 

Mr. Chairman, case management for our patients begins at the time of transition from the military treatment facility and continues as their medical and psychological needs dictate.  Patients suffering severe injuries or those with complex needs receive ongoing case management at the VA facility where they receive most of their care.  VHA has recently determined that every medical center will have a full-time case manager for OIF/OEF veterans needs and we are in the process of hiring a hundred new OIF/OEF veterans to serve as ombudsmen to support severely wounded veterans and their families. 

Each VA NC also has a designated point of contact to coordinate activities locally for OIF/OEF veterans and to ensure the health care and benefits needs of the returning servicemember and veterans are fully met.  VA has distributed specific guidance to field staff to ensure that the roles and functions of the points of the contact and case manager are fully understood and that proper coordination of benefits and services occur at the local level.  To ensure that all eligible veterans are aware of the services they are entitled to, VA's developed a vigorous outreach education and awareness program for our returning veterans and their families. 

To allow us to provide coordinated transition services and benefits for National Guard and Reservists, a memorandum of agreement was signed with the National Guard in May 2005.  Similar memorandums are under development with the United States Reserve and the United States Marine Corps.  These new partnerships will increase awareness of and access to VA services and benefits during the demobilization process as former servicemembers return to their local communities. 

VA is also reaching out to returning veterans whose wounds may be less apparent.  VA's a participant in the DoD's post-deployment health risks and assessment program.  We provide information about VA care and benefits, enroll interested Reservists and Guardsmen in the VA health care system and arrange appointments for referred servicemembers. 

As of December 2006, an estimated 68,800 servicemembers were screened under the provisions of this program resulting in more than 17,000 referrals to the VA.  Finally, VA provides outreach to our newest veterans through our readjustment counseling service, commonly known to veterans as the Vet Centers Program.  Vet centers were created by Congress as the outreach element in VA's health administration.  The approximate number of OIF/OEF combat veterans served by vet centers today is 180,000.  Vet centers have provided bereavement services to the families of over 900 fallen warriors.  VA plans to expand the Vet Center Program.  We will open 15 new vet centers and eight new vet center outstations at locations throughout the Nation by the end of 2008.  At that time vet centers will total 232. 

We also expect to add staff to 61 existing facilities to augment the services they provide.  Seven of the 23 new centers will be opened during calendar year 2007.  Mr. Chairman, this concludes my presentation.  At this time I would be pleased to answer any questions that you may have.  Thank you. 

Mr. MITCHELL.  Thank you, Dr. Kussman, for your presentation.

[The statement of Dr. Kussman appears in the Appendix.] 

Mr. MITCHELL.  The others are here just for questions.  We will not have an opening statement.  But I do have some questions I would like to ask of you to start with.  I am going to ask about the complaint system that is in place that the VA has.  When a patient approaches the VA with a complaint about treatment they have received, how is that complaint handled? 

Dr. KUSSMAN.  Sir, there would be multiple ways.  We have patient advocates at every facility.  There are signs up that tell the patients that if they are unsatisfied with what they have they can go to the patient advocate.  They could call the IG, they could call our Office of Medical Inspection.  They could go directly to the hospital director or they could send an e-mail directly to me, which people do, as well as the Secretary. 

Mr. MITCHELL.  And is there someone who follows up with this after they have made a complaint? 

Dr. KUSSMAN.  Yes, sir.  Personally, if it is to me. 

Mr. MITCHELL.  And to follow up with this, the follow-up, who follows up with the facility to make sure that they correct whatever is wrong?  Does anybody follow up?  Because it seemed to me, you know, when we hear about Building 18 and some other buildings out there—I am sorry, that was Walter Reed, not under your control.  But let's say that there was a facility that someone complained about, is there anybody who follows up with the facility? 

Dr. KUSSMAN.  Yes, sir.  Our assistant, I mean, our Deputy Under Secretary for Operations and Maintenance, Mr. Bill Feeley, is responsible for the upkeep and the services at all the facilities and through him and the hospital directors we would be sure that things were corrected.  We also have a lot of inspection teams that come and visit us.  If there was an issue like that, not only the joint commission, but we have what we call our own supports, there are a mini joint commission that we do on ourselves.  The IG comes and reviews us with their CAP reports.  We have other outside agencies that review, CARF which reviews rehabilitation centers.  So there is a lot of review and follow up if there is identified a deficiency in any of our facilities. 

Mr. MITCHELL.  What kind of records do you keep on patients' complaints? 

Dr. KUSSMAN.  Again, I think that would be at the facility level.  But we also have very elaborate patient satisfaction surveys that are done when patients come in, they fill out a form, and those are reviewed and kept that, I believe at the facility.  They are tracked at the facility as part of the performance measures for the leaders of the facilities to be sure, but we also have the University of Michigan do a consumer satisfaction review service every year, and thank goodness every year that we have done very well on that is a customer satisfaction, and have actually been 10 points higher than civilian facilities.

Mr. MITCHELL.  What is the process you use for taking valid complaints and taking corrective action? 

Dr. KUSSMAN.  Well, as I said, sir, hopefully that would be handled at the facility level, that if somebody raised a complaint about something, that through the patient advocate or anybody else who took the complaint, the facility director and associate directors would act on that.  If the patient doesn't get satisfaction, it could be raised through the division level or to the central office through an 800 hotline call to the Secretary, the IG, or the Office of Medical Inspection.

Mr. MITCHELL.  How often do you review these surveys or these complaints?  Are they done every day?  Once a month?  Every three months?  How often do you review these complaints or these satisfaction surveys?  Once a year? 

Dr. KUSSMAN.  The survey, the large survey, as I mentioned from the University of Michigan, is done once a year, but other surveys are done on a rotating basis.  The IG does—rotates through our facilities.

Mr. MITCHELL.  Besides surveys about satisfaction, what about complaints about service or the care they are getting?  How often are those reviewed and are there records of those? 

Dr. KUSSMAN.  Well, as I said, I think it depends on whether the complaint got up to the central office or not, but the complaints are generally handled at the local level if they can be handled.  If the individual doesn't get satisfaction, it would bubble up, but that is an ongoing thing.  They review those complaints and see if there is any pattern. 

Mr. MITCHELL.  If a patient doesn't feel they have gotten satisfactory compliance or haven't had their complaint satisfactorily answered, what happens then? 

Dr. KUSSMAN.  Well, I would encourage them and they would be encouraged to take it to the higher level.  They can come to the division or they can come to the central offices if they don't get satisfaction.  That is our job, to take care of veterans and if they are not satisfied with what they want, we would encourage them to call us.

Mr. MITCHELL.  Do you have any idea about how many complaints you might get a month? 

Dr. KUSSMAN.  No, sir, but I can go back and ask and get it to you. 

Mr. MITCHELL.  All right.  Thank you.  I yield my time. 

Mr. BUYER.  Mr. Chairman, I ask for a parliamentary inquiry. 


Mr. BUYER.  My inquiry is that the witnesses sitting with the Acting Under Secretary, the individuals sitting there, are they witnesses or are they sitting there in an individual capacity? 

Mr. MITCHELL.  Mr. Buyer, they were sworn in.  So they are here to answer questions as we try to further this. 

Mr. BUYER.  Further parliamentary inquiry.  Is it the intention of the Chairman to follow rule XI of the House Rules when it comes to the rules and procedures of the Committee? 

Secondly, Mr. Chairman, in the 15 years I have been here in Congress, I have never seen a committee or a subcommittee ever treat an official of the Administration without respect and dignity of their position and station.  And I have been here through Republican and Democratic administrations.  This is a very curious manner in which you are treating the Under Secretary of Health for the VA.  So I, again, ask you, is it the intention of the Chairman to follow the rules and protocols of the House under rule XI? 

Mr. MITCHELL.  We will take a five-minute recess on that.


Mr. MITCHELL.  We will reconvene.  Mr. Buyer recommends that having Mr. Sullivan and Ms. Lain appear with Dr. Kussman on the panel does not show proper respect.  So, we will ask Ms. Lain and Mr. Sullivan if they would step down and join the second panel.  If you would do that, please. 

Mr. SULLIVAN.  Yes, Mr. Chairman. 

Mr. MITCHELL.  That's the only way I guess we can get proper respect.  Thank you. 

Mr. BUYER.  I thank the Chairman. 

Mr. MITCHELL.  Ms. Brown-Waite? 

Ms. BROWN-WAITE.  I would address this to Dr. Kussman.  Today I received a letter from Secretary Nicholson addressing what the VA has done and what they are doing, and what they're going to do in the future to ensure that the wounded veterans receive everything that they need as a transition from DoD medical facilities to the VA.  If you would please talk about that, I'm sure that you were involved in that letter.  Is that correct?  

Okay.  If you would just please discuss that, and I think that every member here does plan, you know, holding the Secretary's feet to the fire to make sure that those promises made in the letter, and I think everyone received one, I think the Chairman received a letter today, that that really does take place.  I think regardless of the party affiliation, every member here wants to make sure that our veterans are well taken care of, and in response to the Chairman's question about what happens when the number of complaints pile up, I can just tell the Chairman that I'm aware of at least one hospital administrator who was removed from that post in my district, and I am sure that the freshman members here will learn and that we will be also contacted when the VA is not responsive. 

The families and/or the veterans and military people won't hesitate to also let us know.  So if you would just elaborate a little bit on that letter, I would appreciate that very much. 

Dr. KUSSMAN.  Congresswoman, I don't have the letter right in front of me, so I didn't have it memorized, but obviously I am aware of the content of the letter.  We believe very strongly in our responsibility to veterans and their families for care, and I believe that we have done that, as mentioned with the satisfaction surveys that we have.  But I believe this was just another way of energizing and reminding our people and our facilities of our obligation to do the things that we need to do.  We are hoping we will accept responsibility when things don't go well, and we pledge to fix them when they're not, and so we want to be sure that we've assessed everything that we are doing, and be sure that we can raise the bar as appropriate. 

Ms. BROWN-WAITE.  You know, when I first ran for office, I thought it was a really good idea to virtually have the veterans be able to go to non-VA hospitals.  I really thought that was a good idea until I really got to know the veterans population both in my district and the organizations that are represented up here.  And I learned what a very high satisfaction level that the clear majority of veterans have and also the very good survey results that the virtual—the customer satisfaction survey that takes place.  I know I don't have a VA hospital in my district. 

I have three great ones around me, and we're going to hear later from the head of the polytrauma unit there.  But I get great results and the veterans who aren't happy also contact us, you know, I would be interested in the number of complaints.  I think maybe we should—every member should have that information available, and how many of them were resolved.  You know, so that we can also assure the veterans that if they do have a question, or a complaint, that their complaint is taken seriously, and is resolved. 

Dr. KUSSMAN.  Yes, ma'am.

Ms. BROWN-WAITE.  Mr. Chairman, I would also request that Secretary Nicholson's March 7 letter addressed to me and to you regarding the VA's efforts to ensure the seamless transition into the VA system from DoD, that that can be also submitted for the record. 

Mr. MITCHELL.  Without objection, so ordered.

[The March 7, 2007, letter from Secretary Nicholson appears in the Appendix.] 

Ms. BROWN-WAITE.  I appreciate that.  In the letter it also said that every VA medical center now has specialty PTSD treatment capability.  Would you elaborate a little bit on that?  And how recent is it that the PTSD treatment availability has been available? 

Dr. KUSSMAN.  Thank you for the question.  The VA, as you know, has been the leader in the treatment evaluation and research of PTSD ever since the diagnosis was first used in 1980, and we have a national center in White River Junction and other research sites that are seen as international resources for the treatment research and evaluation of PTSD.  We, in 2004, developed a very thorough and elaborate mental health strategic plan to look at where we were at the time and what are the things that we could do better.  And one of those things we realized that we could do better was to be sure there was PTSD treatment teams at all our facilities and there are over 200 of them and that is more than just our facilities, because as you know, we have about 155 hospitals.  We've also put PTSD treatment teams in large clinics as well to meet the needs of people who have PTSD or are being looked at for PTSD.  And so this is really part of our mental health strategic plan to enhance the services available.

Ms. BROWN-WAITE.  I thank the Doctor, and I yield back the balance of my time. 

Mr. MITCHELL.  Thank you, and just one follow-up question real quick.  What is the waiting time for a person to receive treatment in these centers? 

Dr. KUSSMAN.  Sir, obviously our goal, first of all, if anybody has urgent or emergent care, they get in right away.  Our goal is that if it is not urgent or emergent the person should be seen within 30 days of the request. 

Mr. MITCHELL.  How long? 

Dr. KUSSMAN.  30 days. 

Mr. MITCHELL.  Thank you.  Mr. Space? 

Mr. SPACE.  Thank you, Mr. Chairman.  I understand that Ms. Bascetta is available for questioning? 

Mr. MITCHELL.  Right. 

Mr. SPACE.  I hope I have pronounced your name correctly. 

Ms. BASCETTA.  Bascetta.

Mr. SPACE.  Thank you.  And I apologize. 

Ms. BASCETTA.  That's okay.

Mr. SPACE.  Ms. Bascetta, you, in your work for the GAO, obviously have invested many hours in researching, in documenting matters concerning seamless transition.  My question is to what extent—I am assuming you have made recommendations.  And I am curious to what extent those recommendations have been followed, and if there have been matters that you have recommended, issues that you have suggested that have been ignored.


Ms. BASCETTA.  I wouldn't say that the VA has ignored any of our recommendations in this regard.  I can't say, however, that the two departments working together have followed our recommendations so far to the extent that we'd want them to.  And the one that I'm most concerned about is that VA and DoD do a better job collaborating on rehabilitation so that veterans or servicemembers, for that matter, who need services get them as early as possible.  Our work has shown that if there is a delay in getting rehabilitation, there can oftentimes be deficits that can't be made up.  And one of our most significant concerns is that, of course, all veterans start in the DoD system.  And if they don't work together early, meaning that DoD at times would have to let VA in early, it could happen that when VA has a veteran arrive for care in their system, you know, there could be deficits that VA can't make up. 

I'd also say that with regard to the seamless transition, it remains a work in progress rather than a fully implemented reality, but I think that because of the complexity of the process, there will always be room for continuous improvement.  When we reported on it in 2006 to this Committee, we did not make recommendations because in the course of our work when we found problems to VA's credit, they corrected them while we were completing our work.  Most of those were problems with regard to individual patients.  So we would have to do more work at this time to look systematically to reassess how well it is working.

[The statement of Ms. Bascetta appears in the Appendix.] 

Mr. SPACE.  Thank you.  Have you made specific recommendations concerning the fashion in which these delays can be eliminated, specifically with respect to rehabilitation?  And if so, can you provide us with a copy of those specific recommendations? 

Ms. BASCETTA.  I can submit our report for the record.  The recommendation was a conceptual one that the two departments collaborate to come up with a plan and an agreement as to when it would be appropriate for VA to have data about servicemembers.  And that through the course of them working out the details early intervention could become a reality.

[The GAO report (GAO-05-167) reference by Ms. Bascetta appears in the Appendix.]

Mr. SPACE.  Thank you.  I yield back the balance of my time. 

Mr. MITCHELL.  Thank you.  Mr. Buyer? 

Mr. BUYER.  Mr. Chairman, I will follow the protocols of the Committee and I will go at the end of the sitting members of the Committee for questions.  Thank you. 

Mr. MITCHELL.  Thank you.  Mr. Walz.

Mr. WALZ.  Thank you, Mr. Chairman.  And thank you, Dr. Kussman, for being here.  Ms. Bascetta, I appreciate the opportunity to speak with you, and I want to thank you for the work you've done for our veterans.  I said I do think that is critically important that we keep that in mind, and having spent a lot of time in our polytrauma center in Minneapolis, I know the quality of care and the professionalism there is something that I am very proud of. 

My constituents demand that we get this right and we're here today to question and to look ahead and I think that is a healthy exercise, I think it is one we need to do and we can get this right.  We must get it right.  I would associate myself with the ranking member Ms. Brown-Waite when she said, that this is a priority.  This is one that we have to get right.  I feel it is a moral imperative to take care of our wounded warriors when they return home, but I also think that it is a national security issue. 

We need to make sure this is part of what we're doing so soldiers know they're being taken care of.  Results matter in this, and it is one of these situations that I think we have to shoot for.  You're right, it is always going to be a continuing process.  But this is a zero sum proposition.  One mistake is too many in this.  One soldier left untreated is too many. 

And I think all of us agree with that, and the goal is to try to get it to zero.  If we ever get there, we must continue to try.  So just a couple of questions, Mr. Kussman.  How long have you been with the VA—I'm not sure if I got that—have you been working in your current position, sir? 

Dr. KUSSMAN.  In my current position?  Since 12 August 2006.

Mr. WALZ.  How long have you been with the VA in general, Dr. Kussman.

Dr. KUSSMAN.  I first came to the VA on 24 September 2000.

Mr. WALZ.  Very good.  My first question on this is do you believe there were substantial changes made or substantial preparations made starting in about March of 2003 when this current conflict in Iraq got started?  Were there preparations made for the influx of wounded veterans that we would see? 

Dr. KUSSMAN.  We always, sir, are ready to take whatever we need.  I think that the thing that surprised everybody was the type of injuries that we were seeing, not necessarily the volume, although no one could predict how long the war was going to go on, and that is a different issue.  But what we have seen is that there are certain signature injuries of this war.  One is PTSD, particularly for the National Guard and Reserves because I am not trying to minimize the active component, but they do have a cocoon around them, and in my previous life I appreciated that.  But what do you do with the people who then, when they get discharged, don't have that same type of cocoon? 

The other thing is because of the body armor and the far-forward surgical care, servicemembers are surviving with much more complicated wounds.  So that was one of the things that drove us very quickly to build on our four TBI centers that we have in Palo Alto, Minneapolis, Tampa and Richmond.  And we have two of the directors here that will be on a follow-up panel.  We put in place there, the full multidisciplinary approach for things, not just TBI.  But TBI is another signature injury that is occurring, partly because I think when we went into the war, we thought that we would see the more traditional types of casualties, gunshot wounds, shrapnel, the usual thing. 

The enemy is taking a different tact in using IEDs and car bombs that create blast injuries, and one of the blast injuries among others is the traumatic brain injury which is—not to minimize it, it is head rattle that occurs inside the helmet, the brain floats and things in the brain, it is not locked in.  So there is a whole spectrum of mild to moderate traumatic brain injuries to severe traumatic brain injuries. 

Mr. WALZ.  And just using the last bit of my time, do you feel like we're prepared for the large number that are going to be diagnosed as we start to check everyone now the traumatic brain injury?  Sometimes it's not so visible, vision, different things like that, and PTSD.  Do you feel like we're prepared?  And you are absolutely right, in my former life, it was 24 years in the National Guard.  And I know when they go out to rural Minnesota, it is a lot different than when we're on an active military base.  Are we prepared for these soldiers today, tomorrow and 5 years and 50 years down the road? 

Dr. KUSSMAN.  Sir, as you know, I can't read a crystal ball, but I think right now we put in place the procedures and processes that we can take care of this group of patients.  As you know, of the 613,000 servicemembers that have transitioned out of the active component since the OIF/OEF started, some are active component people who have left, others are transitioned back to the National Guard or Reserve or just get out of that as well.  We've seen 205,000 of those people with a myriad of differing complaints.  We see—we project that number—that was out at the end of FY 06.  We project that number in FY 08 to be 263,000. 

We project that we will see 5.8 million veterans.  So it is a relatively small number of our total force, but they have certain needs, and we believe with our four polytrauma centers, our 17 additional level two centers and teams and all our facilities, we are ideally poised to be able to take care of the patients as they transition out. 

Mr. WALZ.  Thank you.  And I yield back, Mr. Chairman. 

Mr. MITCHELL.  Mr. Rodriguez? 

Ms. BASCETTA.  Mr. Chairman, may I add something?  I'm sorry. 

Mr. MITCHELL.  Go ahead, ma'am.

Ms. BASCETTA.  I would just like to elaborate a little bit on what Dr. Kussman said.  And that is, we did some budget work for this Committee last year and reported in September 2006 that one of the factors that caused one of the problems in VA's budget estimation was underestimating the cost of serving veterans returning from Iraq and Afghanistan.  And part of that was due to the fact that their data largely predated the conflict.  But the other part was—and I can't make this point too strongly—that they have had trouble getting data from DoD that they need for planning purposes.  So it is another example of the need for these two agencies to work together. 

Mr. MITCHELL.  Thank you.  Mr. Rodriguez? 

Mr. RODRIGUEZ.  Thank you very much.  I wanted to follow up with the GAO.  And you answered one of my questions because I recall some time back, we pushed an effort in terms of trying to get both the active-duty soldier and the VA working together more and it seems based on the GAO report that there are still some serious problems in communication and, in fact, some even questioning the part of the DoD about the fact that they have concerns that they might even provide services to them while they're still in the military.  And I was wondering, why would they be concerned about that? 

Ms. BASCETTA.  They told us—and this was about a year and a half ago now—that they were concerned about their retention goals.

Mr. RODRIGUEZ.  They were concerned about their retention goals? 


Mr. RODRIGUEZ.  And not necessarily concerned about their health, I gather.

Ms. BASCETTA.  They didn't say that.

Mr. RODRIGUEZ.  They didn't say that.

Ms. BASCETTA.  They were worried about VA coming in too early and giving servicemembers the idea that they might want to leave the military.  And our concern was that these servicemembers needed rehabilitation from VA, from DoD, from the private—

Mr. RODRIGUEZ.  Whoever can provide it, I agree.

Ms. BASCETTA.  So they could fully recover both medically and vocationally and have the option to, you know, work to their fullest potential, either in the military or in the private sector, in the civilian sector and many of them, I think, might have opted to stay in the military and many are because it is their career, and they're dedicated to it.  Others have told us that they don't want to leave the military because their families need health care, health insurance.

Mr. RODRIGUEZ.  And I know that doesn't have anything to do with VA, but you also, in the GAO report, talk about our military soldiers having difficulty paying, or when creditors go after them, when they're unable to get their loans, unable to buy a car, and mainly, because they're being harassed by credit agencies and going after them for fees?

Ms. BASCETTA.  Yes, sir.  There are long-standing problems with the military pay system that have not been fixed.  And it aggravates an already antiquated system.  If I might add too, there are other problems that we noted in the course of the seamless transition work.  It was done for the VA Committee.  So we didn't report these findings in the report, and we didn't make recommendations to DoD because they weren't within the scope of our reporting.  But some of them had to do with other bureaucratic problems that the family members and the servicemembers get caught up in. 

For example, in one case, a disabled servicemember was to be discharged from a PRC to a VA nursing home.  And DoD refused to pay to have the wheelchair transported.  It didn't fit in the ambulance, and they refused to have it transported separately until a cost analysis could be done.  They told the VA social worker that would take several weeks.  The VA social worker, to her credit, found donated post funds, not appropriated funds, and used them to have the wheelchair shipped to the nursing home so the servicemember would not be confined to his bed. 

Mr. RODRIGUEZ.  My God.  You know, and I know that, you know, I had left for 2 years from Congress, but I remember prior to leaving, we were working hard at trying to establish a system where the soldier automatically leaves the military and can be picked up as quickly as possible.  Now you also mention that the VA is still having difficulty getting the prognosis and diagnosis, and the medical history, because it isn't electronically done? 

Ms. BASCETTA.  That's correct.

Mr. RODRIGUEZ.  What can we do from the VA perspective in terms of trying—because that is part of—you know, and the other part, and I know you have only been there a short time and I know the responsibility falls with all of us.  I don't like the idea of coming down—this I am referring to the administration—firing the commander at Walter Reed who has only been there for 6 months when in all honesty, that responsibility falls with all of us in ensuring that they have the resources that are needed, and I know that we haven't provided that, and I know that with a large number, some 23,000 soldiers that are coming back seriously injured, we need to beef up on funding.  I was pleased to see on the CR, that $3.6 million, and I want to get your feedback on it, and we're hoping to add some additional supplemental funding, but not only to the VA, but also to the active soldier. 

And in saying that, we had talked about seeing how we can, you know—and maybe you can guide us from the VA perspective.  What do we need to do to make sure that we accomplish that goal that when that soldier leaves the military and the VA picks him up, how can we make sure we don't have to reduplicate everything and retest everything in terms of the soldier? 

Dr. KUSSMAN.  Sir, is that a question to me? 

Mr. RODRIGUEZ.  Yes, sir.

Dr. KUSSMAN.  We are working very closely with DoD, particularly with the more seriously injured people.  And let me just add to what Ms. Bascetta said.  The two health care systems, by their nature, have been complementary, that the VA does some things and DoD does others.  I mean, we don't do pediatrics and things of that sort.  She is exactly right, that when people have multidisciplinary problems, you need to get at them all quickly because you can then lose some momentum with one thing if you are only focused on one.  So we have moved to put a blind rehabilitation specialist into Walter Reed, a spinal cord specialist coming out of the Washington VA, because those are the two things that—

Mr. RODRIGUEZ.  If I can, what else do we need to do to try to correct some of those things that were mentioned by the GAO from the VA perspective? 

Dr. KUSSMAN.  Well, I think that we have done a lot of the things that the GAO mentioned, and Ms. Bascetta said that.  What we did is we realized that we have those four wonderful centers that we have, and I think they're state of the art and multidisciplinary, but people leave those centers.  They don't live near there, so we put 17 additional—there are really 21 level II sites, one for each of our divisions.  But the 17 are additional.  The four that we already have in VISNs, we didn't see any reason to duplicate on top of the level I.  So there is a total 17 new, but a total of 21 centers as well as putting resources at our facilities to try to provide the full depth and breadth of services close as we could.

Mr. RODRIGUEZ.  Did I hear you saying that we don't need to do anything else, that you have established the things that are there in order for us to—for the service person to be able to be picked up?  Is that what I am hearing? 

Dr. KUSSMAN.  We can always do better.  We appreciate your assistance.

Mr. RODRIGUEZ.  The question is how can we do better?  What do we need to do to help to you do better?  Because apparently we're not doing—

Mr. MITCHELL.  Mr. Rodriguez, your time has expired.

Mr. RODRIGUEZ.  Thank you.

Mr. MITCHELL.  Thank you.  Mr. Buyer? 

Mr. BUYER.  Thank you very much.  Ms. Bascetta, I was sitting here trying to think how many years we have been on this issue.  I can't even remember.  It has to go back 12 or 13 years.  It is not nice to talk about age with a lady, but it has been a long time.  I can't even begin to count the number of GAO studies you've done and supervised over the years.  You know, this is 20-plus years in the making, trying to get DoD and VA to coordinate and cooperate. 

And Dr. Kussman, I've got history with you too, even back when I was on the Armed Services Committee and you were a commander at Walter Reed, which a lot of people may not even realize, back in the 90s.  And you know what—pardon? 

Mr. FILNER.  Now we know who is responsible. 

Mr. BUYER.  Well, if you want to know who is responsible, let's go back and do a little history.  I remember—let's do this, Dr. Kussman, because you were a senior officer then in the medical corps.  In the 1990's, we would come out of two rounds of base closures, back then the defense budgets were about $270 billion, and we were doing everything we could to try to downsize everything from wings and ships and divisions, and were trying to make it work, and then that is when I had the supervision over the military to help the delivery system. 

So what was the response?  The response was that if we had less dollars, we'd create centers of excellence.  Remember?  So we created Brooke, Bethesda, and Walter Reed as centers of excellence because there weren't enough dollars to go around out of those budget years to fund all of those hospitals at all the ports or all of the bases and forts.  So we create the three centers of excellence.  And we had this belief coming out of the first Gulf War that, gee, we weren't going to have as many wounded, we wouldn't be in a continuous war for a long period of time.  It was challenging for me when Walter Reed came out on the BRAC.  I was pretty surprised by that.  I knew it was an aging facility.  But at a time of war, for us to put one of our centers of excellence on the BRAC was bothersome to me. 

Now I no longer had served on the Armed Services Committee, so I have a void in my background in intellect here as to exactly what happened and transpired over the last 5 years.  But even to say we're going to transition it all over to Bethesda is a pretty heavy burden.  So as we had a surge of wounded and other than hospitals were not able to accept those capacities, we had a problem. 

And I also, then, add to this Congress, GAO, and Inspectors General have put a lot of pressure on commanders of bases that have been BRAC'ed about what monies you are going to spend on facilities that are about to be closed.  And so, what an untenable and difficult position we put a commander in at Walter Reed by squeezing him from both ends.  We're going to maintain the standard and quality of care, and at the same time, by golly, you'd better be careful what dollar you spend, and the worst, horrible things that happened is, I can almost see an individual thought they would make a well-intentioned decision by saying, let's keep these unmar