DISCOVERING A MORE EFFICIENT PROCESS: IMPROVING TIMELINESS AND ADEQUACY OF VA COMPENSATION AND PENSION EXAMINATIONS
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
APRIL 23, 2012
FIELD HEARING IN TOMS RIVER, NJ
SERIAL No. 112-58
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
For sale by the Superintendent of
Documents, U.S. Government Printing Office
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida
BOB FILNER, California, Ranking
Helen W. Tolar, Staff Director and Chief Counsel
SUBCOMMITTEE ON DISABILITY
ASSISTANCE AND MEMORIAL AFFAIRS
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
Chairman Jon Runyan
Prepared statement of Chairman Runyan
Hon. Timothy J. Walz, Democratic Member
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
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,
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.
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.
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.
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
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.
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.
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.
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.
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
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.
[Whereupon, at 12:56 p.m., the subcommittee was adjourned.]
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.
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?
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.
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.
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.
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
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
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
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.
An estimated 61,000 Veterans
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.
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.