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Submission For The Record of Jeffrey J. Scarpiello

Chairman Miller, Ranking Member Michaud, and distinguished members of the Committee, I appreciate the challenges facing you as you study the important role that VBA and VHA have in effectively ordering and conducting medical disability examinations (MDE) in support of benefits that America provides in law to care for our veterans.

As background, I am a service-connected disabled veteran who has underwent several compensation and pension (C&P) exams, so I understand the process and can speak from a recipient’s viewpoint.  I have also worked for Disabled American Veterans and Paralyzed Veterans of America at the busiest Regional Office (RO) in the country in St. Petersburg, FL and am familiar with the disability exam process from an advocacy perspective.  I have also worked for US Senator Bill Nelson for 8 years handling veterans and military issues and can speak directly to the impact of the backlog and veterans not being able to get timely benefits and healthcare.  In 2008, I went to work for the Department of Veterans Affairs, Veterans Health Administration (VHA) as a Legislative Health Specialist and have investigated complaints regarding the C&P exam process at several locations throughout the country and provided written responses with the findings back to members of Congress.  In 2010-2011, I was the Deputy Director of the Disability Examination Management Office (DEMO), now known as the Office of Disability and Medical Assessment (DMA) led by Dr. Gerald M. Cross who is providing testimony before you today.  Among my many responsibilities running the DEMO was to help draft, select and award the Disability Examination Management contract to vendors and implement the contract nationally.  I have also drafted all existing policies, directives and guidance currently in effect to govern the current VHA C&P exam process.  I am currently the Director of Business Development for Medical Support Los Angeles (MSLA), a Medical Company.  MSLA has an indefinite delivery, indefinite quantity contract with the VHA to conduct medical disability examinations for veterans in Region 10 (California, Nevada, Hawaii and Guam) under the Disability Examination (DEM) contract.     

I have just a few observations and recommendations to share with you, but first, want to explain several reasons why veterans are not getting timely access to health care from the Veteran Health Administration that may be a result of the disability exam process.  As a result of the system-wide delays in processing rating claims Veterans Benefits Administration implemented an initiative to eliminate the 1-year and 2-year old claims backlog by accelerating the claims rating process.  At some locations, VHA primary care providers were asked to augment /assist the C&P exams clinics.  In addition, VBA’s fully developed claim (FDC) initiative, put additional stress on the VHA health care system as veterans began making appointments with their primary care/treating providers at the urging of Veterans Service Organization’s (VSO) to have Disability Benefit Questionnaire’s (DBQ) completed in support of their disability claims.   The Office of Disability and Medical Assessment (DMA) attempted to explain that by allowing primary care providers to complete DBQ’s could be problematic.  However, the VSO’s urged the Secretary and Under Secretary of Health to do more to help veterans get their DBQs completed upon request.  DMA then instituted a “no-wrong door” policy and VHA primary care providers were informed they should do everything they can to complete DBQs when requested by the veteran.  Subsequently, DMA learned that despite the urging of the Secretary and Under Secretary of Health, many primary care providers who were not familiar with DBQs continued to refuse to complete them.

As a result of primary care providers refusing to complete DBQs, VHA DMA implemented DBQ referral clinic (walk-in) guidance instructing primary care providers who could not complete DBQs to provide a “warm-hand off” of the veteran to the C&P clinic for assistance.  Many of the larger C&P clinics are so busy with scheduled appointments that this hand-off typically results in the veteran having to have an appointment scheduled to return to the C&P clinic to have the DBQ completed. 

In 1996, when Congress gave VBA the authority to contract MDE’s at 10 locations and now with capability that VHA has developed with the DEM contract; the full utilization of these contract vehicles could free up to 7,000-10,000 C&P examiners and hundreds of administrative support staff to provide medical care/treatment services that would help to resolve the current health care scheduling, access and wait time issues plaguing VA.   

It is important to note, as I’m sure Ms. Murray & Dr. Cross will attest to in their testimony that VHA’s C&P program is a success.  In 2010/11 when I ran the Disability Examination Management Office, C&P exams were averaging over 40 days nationally and in some locations 90 days or longer.  The implementation of the DEM contract has played a critical role in exams now being completed in 22-26 days; besting the 30 day or less national requirement/standard for completion of exams.  However, there is no established national customer service survey that drives performance improvement or to help identify problems from a user/veterans perspective.  There is no centralized control of the C&P clinics within VHA, as C&P is not recognized as its own separate service line and at each location within VHA, the C&P structure varies which makes it difficult for VHA C&P clinics to get on-board nationally when new initiatives are rolled-out.  Most importantly, C&P facilities do not receive separate funding and if they utilize the DEM contract services they must pay for it the local level, unlike the centrally funded VBA contracts. 

I have identified several issues with the VBA contract that should be of concern to the Committee: 

  • VBA does not manage its contract exams as completely as the VHA DEM contract and has been reliant upon VHA to provide them with accurate C&P data.
  • VBA has no governance board and has not allowed any VHA input into the clinical aspects of the exam process.
  • The Compensation Service Director can make unilateral contract decisions that involve hundreds of millions of dollars which can give the appearance of impropriety if the same vendor continues to receive the contract award.
  • The fact that VBA only awards contracts to single vendors who can bid on the entire contract vastly diminishes the ability of other contract providers to participate in providing exam services in geographic areas where they can compete.
  • VBA allows contractors to provide their own quality assurance and has no real mechanisms in place like VHA’s quality review specialists to monitor the quality of the exams’
  • Under VBA’s existing contract, exams that are reworked can be double billed
  • No additional authorization is required for additional testing or exams.
  • Payments for exams are more expensive in some cases than VHA DEM contract, although they are listed in VBA’s contract as a flat fee. 

Suggestions and Recommendations:

  • Establish a single office that can focus on medical disability examination management.  The current oversight is fragmented as currently exists within VBA/VHA.  The new joint office should include a single SES responsible for the oversight of the program and include: contract management staff, clinicians to provide quality assurance of contract exams, administrative support, and VBA adjudicators. 
  • Establish one VA national medical disability examination contract that is broken up into multiple geographical regions including overseas exams, where multiple contract awards can be given to more than one contract vendor in each region.
  • Allowing multiple contract awards will help drive internal competition among contract vendors that will drive performance to provide quality and timely exams that will meet or exceed or contract requirements.
  • The DEM contract has a successful contract model in place where the contract is divided up into ten geographic regions and multiple vendors are awarded contracts.  This would provide fairness and equity so that smaller companies can bid in geographic areas where they are best positioned to provide services without having to bid on a single large contract.
  • The efficiencies created by using these contracts will benefit Veterans’ immeasurably by creating more options and accessibility to disability exam services and timely access to healthcare that veterans deserve and need.
  • Ensure consistent contract standards, pricing, and timeliness standards within existing contracts by VHA / VBA to eliminate confusion.
  • Fast-track any IT system solutions that have been presented that would allow   this will eliminate current barriers to why VHA facilities are not utilizing the DEM contract.

A lot of work lies before this Committee.  All of us who care about the quality of medical disability exams and the benefits we have promised veterans and their families are hopeful that your work will lay the foundation for reform and improvement of the medical disability exam process that will give truth to the commitment to those who have served this nation.

Thank you for your consideration of my observations, suggestions and recommendations for changes.  Taking care of veterans – and doing it well- is the right thing to do.