DOD-VA HEALTH CARE AND RELATED ISSUES

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1 STATEMENT OF JOHN L. MAKI DAV ASSISTANT NATIONAL SERVICE DIRECTOR BEFORE THE MILITARY COMPENSATION AND RETIREMENT MODERNIZATION COMMISSION WASHINGTON, D.C. NOVEMBER 4, 2013 DOD-VA HEALTH CARE AND RELATED ISSUES DAV appreciates the opportunity to comment on topics of the Commission s interest as indicated in your letter of invitation to this hearing, specifically as related to the DOD and VA health care systems, and how well they work together. Over the years, DAV has testified before Congress and other commissions on a number of these common-ground issues, including outreach and education of service members about VA benefits and health care services as they transition to veteran status; dual eligibility for access to both DOD and VA health systems; health resource sharing between the Departments, including jointly operated health facilities; the establishment of a fully interoperable DOD/VA electronic medical record; and, seamless transition of wounded service members from both the health care and benefits perspectives. As a foundation for our positions, DAV urges joint collaboration between the Departments to ensure that service members transitioning from military service are afforded VA benefits briefings prior to discharge to ensure they are aware of their earned benefits. DAV has been involved in, and committed to, general transition assistance for decades. Also, specially trained DAV Transition Service Officers (TSOs) assigned at nearly 100 domestic military installations provide counseling and assistance to ill, injured or wounded service members, and represent them in filing their claims for VA benefits. By filing compensation claims at separation centers where service medical records and examination facilities are readily available, we are able to provide prompt service to these future veterans. Last year, our TSOs conducted 2,760 formal presentations to 63,215 transitioning service personnel. During that same period, they filed 18,214 claims for VA benefits on behalf of these veterans. Counsel and representation of active duty personnel during their transitions was provided in conjunction with the military s disability evaluation system. DAV devoted almost $2 million to this program in DAV believes this program is very beneficial to service members and an essential part of the outreach and education process. Introduction to veteran service organizations (VSOs) such as DAV is also an important transition element. Our services are provided without charge and help millions of veterans each year gain access to their earned disability compensation, vocational rehabilitation, specialized or general health care, education, life insurance and other VA benefits. DAV has experienced challenges in the past in gaining access to on-base transition briefings; the decision to allow veterans service organizations (VSO) into various military installations is left

2 to individual base commanders to authorize, and some have expressed reluctance, provided only partial access, or simply refused to allow us on site. While we have since addressed this challenge with the Secretary of Defense, DAV urges the Commission to support the role of VSOs participating on base during the transition process. DAV also supports VA s continued collaboration with DOD in post deployment briefings for Guard and Reserve unit personnel (including voluntary enrollments into the VA health care system during these briefings) and the sharing of names and addresses of recently discharged veterans so that VA can communicate early and directly with them to inform them of their VA benefits, and direct them to appropriate VA medical facilities. This type of outreach in recent years has been very effective with service members returning from combat deployments as evidenced by high rates of enrollment and VA use among our newest veterans. This outreach has been especially noticeable among Iraq and Afghanistan women veterans with over a 50% health care enrollment penetration rate. A person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable is eligible to apply for VA health care benefits. Reservists and National Guard members may also be eligible for VA health care if they were called to active duty (other than for training) by a federal order and completed the full period for which they were called or ordered to active duty. Minimum service period requirements apply by law for eligibility of veterans who enlisted after Sept. 7, 1980, or who entered active duty after Oct. 16, These veterans must have served 24 continuous months, or complete the full period for which they were called to duty, in order to be eligible for VA services. VA operates the nation's largest integrated health care system with more than 1,500 sites of care, including 151 medical centers and systems of care, nearly 900 community-based clinics, 134 community living centers (AKA skilled nursing facilities) for long term services and supports, and 300 readjustment counseling centers. Once discharged from military service veterans can enroll in the VA health care system online or in person by submitting applications for enrollment (VA Form 1010EZ). Once enrolled, veterans may receive health care at VA health care facilities anywhere across the nationwide system of care. The following four categories of Veterans are not required to enroll in VA health care in order to access VA s services: 1. Veterans with a service-connected disability of 50 percent or more. 2. Veterans seeking care for a disability the military determined was incurred or aggravated in the line of duty, but which VA has not yet rated, within 12 months of discharge. 3. Veterans seeking care for a service-connected disability only. 4. Veterans seeking registry examinations because of exposure to ionizing radiation, Agent Orange, depleted uranium, or are Persian Gulf, Iraq and Afghanistan veterans. During the enrollment process, each veteran is assigned to a VA priority group. Because funding levels for the VA health care system are discretionary and are determined and authorized by Congress on an annual basis, VA uses priority groups to balance demand for VA health care enrollment with available resources. Changes in resource availability from year to year may 2

3 reduce the number of priority groups VA can maintain in care. The eight priority groups (with several priority sub-groups) and their categories of veterans are complicated but generally divided by whether a veteran is service-connected and to what degree; if a veteran was awarded certain military decorations; if a veteran was exposed to an environmental or man-made toxin; if a veteran served in a particular period of war or conflict; and, if a veteran is poor as defined by law or regulation. Longevity-retired military service members and those who are medically retired from active duty are veterans for purposes of Title 38, United States Code and, thus generally possess dual eligibility for care in both the DOD and VA health care systems, depending on priority group assignment. For example, if service connection for an illness or disability stemming from military service is adjudicated by VA, the retiree is eligible and may choose to receive partial care in a military treatment facility but specialized services (amputation care; prosthetics; mental health care, etc.) from VA. Annually, VA treats hundreds of thousands of military retirees, including many members of DAV. DAV strongly supports veterans maintaining access to both the DOD and VA health care systems for those eligible, and we urge the Commission to support the continuation of that important veterans right. AFTER A DECADE OF WAR, SEAMLESS TRANSITION STILL ELUDES Congress, DOD and VA have long recognized the value and importance of overseeing a seamless transition of military service personnel to civilian life as veterans. However, several chronic barriers continue to obstruct seamless transition for the war wounded, injured and ill subset of this population. These obstructions are exquisitely illustrated when ill and injured service members, their families, and personal caregivers struggle through the process first hand. Numerous Congressional hearings and reports by the Government Accountability Office, mandated committees and commissions decry the waste of limited resources from both duplication and fragmentation of efforts between and within DOD and VA to provide health care, various benefits and case management and coordination of services for recovering service members and veterans. Despite the work of both departments to develop better policies and procedures through a collaborative, interagency strategy, such dilemmas persist. As a prime example, both DOD and VA are seemingly unable to integrate and align the numerous care coordination and case management programs that have been created to assist wounded, ill, and injured service members and veterans during their transitions from DOD s to VA s health care system. In 2008, the DOD and VA jointly developed the Federal Recovery Coordination Program (FRCP) in response to the Dole-Shalala Commission s recommendation for an integrated approach to care management to improve seamless transition across the recovery continuum. Designated federal recovery coordinators (FRCs) are advance practice nurses, clinical social workers and others specially trained in the myriad benefits, programs, and services provided by VA, the DOD, the Department of Labor, the Social Security Administration, other federal 3

4 agencies, and private and community organizations. By serving as the single point of contact among all of the case managers, these FRCs work with service members, veterans, their families, and medical providers to create a Federal Individual Recovery Plan for both the clinical and nonclinical services needed by these enrollees. Separately developed from the FRCP, the Recovery Coordination Program is a DOD-specific program established by the National Defense Authorization Act (NDAA) for FY 2008, a program designed to improve the care, management, and transition of service members. DOD sets program requirements that each military service must meet. Depending on how a military service s wounded warrior program is structured, a service member may receive either case management or care-coordination services, or both. As a result of duplication, many recovering service members and veterans are enrolled in more than one care-coordination or case management program, and sometimes several simultaneously. As a result, they may be assigned multiple care coordinators and case managers, duplicating agencies efforts and reducing the effectiveness and efficiency of the assistance they provide. Furthermore, service members and veterans who have specialty needs may be given case managers affiliated with particular programs or services, such as for polytrauma, amputation or spinal cord injury, outside of but theoretically in coordination with DOD s wounded warrior program. Moreover, DOD and VA maintain differing definitions of the operational purposes and goals of the FRCP by DOD and VA despite the FRCP s supposedly being a jointly operated program. Furthermore, conflicting policies govern the referral of injured service members to the FRCP despite current law directing the DOD and VA to establish a comprehensive (and thus, collaborative) policy to improve the care, case management and overall transition of wounded, injured and ill service members toward recovery. The unfortunate result of these conflicts, duplication and the discord they create is that VA and DOD programs are not well serving their intended beneficiaries. Eligible ill and injured service personnel have been seen to be unable to access these programs without conflict or confusion, and the competing programs are often seen to be duplicating or contradicting others, providing inadequate or incomplete information, and adding to the frustration and confusion of severely injured service members, veterans, their caregivers, and their families, all of whom are trying to concentrate on rehabilitation, recovery and reintegration. Another huge barrier impeding seamless transition is the scant progress of DOD and VA toward developing an integrated electronic health record (EHR) that is fully computable, interoperable, and promotes two-way, real-time electronic exchange of health information, treatments, and other vital data. Existence of an interactive records system of this nature would promote an effective sharing and meaningful use of information and data that could increase health resource sharing between agencies and providers, laboratories, pharmacies, and patients; help these newest, and in fact all DOD and VA beneficiaries, to transition between health-care settings; reduce duplicative and unnecessary testing; improve patient safety through reduced medical errors; and increase general understanding of the clinical, safety, quality, financial, and organizational value of health information technology. 4

5 The development of an integrated DOD-VA EHR has been beset with problems for years. VA operates the time-tested and award-winning Veterans Health Information Systems and Technology Architecture (VistA) that supports its computerized patient record system (CPRS). The VistA CPRS promotes use in a broad array of health provider settings and establishes extensive clinical and administrative capabilities from its clinical, financial, administrative, and infrastructure functions. DOD s Armed Forces Health Longitudinal Technology Application (AHLTA) system, primarily designed as an outpatient care EHR, has consistently experienced performance problems and has not delivered the full operational capabilities originally intended. The VistA CPRS system is unacceptable to DOD, and the DOD s AHLTA system is unacceptable to VA. In February, 2013, the Secretaries of Defense and VA announced their decision to halt further development of a joint EHR, and instead to pursue separate IT solutions, including a plan to eventually join these two next-generation systems through a commercial software interface. Subsequently, DOD and VA efforts to create a joint DOD/VA EHR were halted. Resetting the effort to the state that existed prior to this most recent initiative resulted in wasted effort and the wasteful spending of hundreds of millions of dollars in both departments. DOD and VA health care providers generally expect to gain access to some kind of electronic health record information between the departments for transitioning veterans, yet these health care providers are not able to electronically share complete health records of recovering service members when they move from DOD to VA. Therefore, to provide clinical transition, providers resort to less efficient and burdensome methods of records transfer (including the use of paper records). Notwithstanding these egregious examples of failures on the part of both agencies, DAV acknowledges that some progress has been made over the past decade of war. DAV urges that the Commission recommend that Congress ensure the joint policies, governance, business and administrative operations that were created to allow for a smoother, but still not seamless, transition remain a living investment within and between DOD and VA, especially after this period of war has subsided. Continuing and perfecting these practices and reinforcing what should be common ground between the departments would help ensure that future generations of combat wounded, ill and injured service personnel and veterans can reap the benefits of institutional knowledge in moving them toward recovery and reintegration. If DOD and VA suspend their joint efforts and separate once the period of war ends, any such future capability would need to be recreated at a great human and financial cost. Mr. Chairman and members of the Commission, on behalf of DAV, thank you for this opportunity to appear before you at this important hearing. I would be pleased to respond to your questions or those of other members of the Commission. 5