Office of Public and Intergovernmental Affairs
Remarks by Deputy Secretary Sloan Gibson
National Association of County Veterans Service Officers
Remarks by Deputy Secretary Sloan D. Gibson National Association of County Veterans Service Officers Beach Club Hilton, Myrtle Beach, SC May 19, 2016
Beach Club Hilton, Myrtle Beach, SC
May 19, 2016
Two years ago this month, I suddenly found myself as the Acting Secretary of Veterans Affairs, after just three months at VA. I had been consulting people who knew more about running a large healthcare system than I did, and one was Dr. Harvey Fineberg, who had just stepped down after 12 years as the president of the Institute of Medicine.
When I took over as Acting Secretary 21 months ago, one of things I did was consult with people who knew more about running a large healthcare system than I did, and one of the first people I talked to was Dr. Harvey Fineberg, who had just stepped down after 12 years as the president of the Institute of Medicine.
I told him that because of the healthcare crisis, VA could accomplish more in two-to-three years than we could otherwise have done in two-to-three decades. Dr. Fineberg immediately corrected me. “No!” he said. “VA can accomplish things now it never could have accomplished!”
Harvey was right: VA has an extraordinary opportunity and we are seizing it!
VA is the second largest agency in the Federal government with 360,000 employees—a third of them Veterans—and a $169 billion budget. Eleven million of the 22 million Veterans living today are enrolled for health care or use at least one VA benefit or service.
Among our nine lines of business—
- Last year, we provided $75.4 billion in compensation benefits to nearly 5 million Veterans and their survivors.
- We supported 100,000 disabled Veterans with $1.2 billion in vocational rehabilitation and employment benefits.
- Since 2009, we’ve paid $59 billion in Post 9/11 GI Bill education benefits to more than 1.5 million Veterans and family members.
- In 2015, we guaranteed a record number of home loans—631,000 valued at $153 billion, for a total of 2.4 million home loans on our books, with one of the lowest foreclosure rates in the industry.
- Not many realize VA is the Nation’s 11th largest insurance enterprise with nearly $1.2 trillion in coverage for 6.5 million policies for Veterans, Servicemembers, and families.
- And we operate 134 National Cemeteries, maintain 3.4 million gravesites, and perform over 130,000 interments each year.
If VA were in the private sector, we’d be a Fortune 10 company—and I’m just getting to healthcare, our ninth line of business.
We’re the largest integrated healthcare system in America, with nine million enrolled Veterans. We have 25,000 doctors and our 90,000 nurses make VA the largest employer of nurses in the country.
Last year, we completed over 56 million appointments for 6.2 million patients. Authorizations for care outside of VA generate millions of additional appointments in the community. We’re affiliated with 1,800 academic institutions. Clinicians from many of the most prestigious medical schools in the country deliver care, teach, and conduct research at VA. We train 64,000 residents and medical students, 27,000 nursing students, and 29,000 students in other health fields, annually. About 70 percent of all U.S. physicians have received at least some of their training at VA hospitals.
We spend $1.8 billion annually on research. VA researchers have —
- pioneered electronic medical records and bar-code software to safely administer medicines;
- developed the implantable cardiac pacemaker;
- proved an aspirin a day reduces risk in heart patients;
- conducted the first successful liver transplants;
- created the nicotine patch; and
- demonstrated that patients with total paralysis can use their minds to control robotic arms.
VA researchers have received three Nobel Prizes and six Lasker Awards, and in 2014 two VA researchers at the Bronx VA received the Samuel J. Heyman “Service to America” Medal for groundbreaking work on spinal cord injuries.
By any measure, VA innovation has contributed significantly to American healthcare—indeed, healthcare around the world.
A few years ago, VA set its sights on three main priorities—increasing access, eliminating the claims backlog, and ending Veterans homelessness—and we’ve made great progress on each.
We are taking ownership of our problems and building back the trust of Veterans by making lasting progress, including in access to VA care.
We expanded capacity by focusing on staffing, space, productivity, and VA Community Care. VHA staffing is up more than 24,000. Healthcare professionals are up 21,000—including 2,100 more physicians and 7,200 more nurses. We’ve activated nearly 4 million square feet of healthcare space in the past two years. We’ve increased authorizations for care in the community 46 percent. Clinical workload is up 20 percent in the past two years—as measured by the same productivity standard used by private-sector healthcare systems. This 20 percent increase in a system the size of VHA translates into over 7 million additional hours of care for Veterans.
The results: 97 percent of appointments are now completed within 30 days of the Veteran’s preferred date; 86 percent are within 7 days; 22 percent are same-day appointments. Average wait time last month?—5 days for primary care, 6 days for specialty care, and 3 days for mental health.
What do Veterans think?
We’re asking that question constantly, using automated kiosks at our facilities to let Veterans provide us immediate feedback. More than half a million have responded in recent weeks.
The question we ask: “How satisfied are you that you got today’s appointment when you wanted it?” Eighty-nine percent tell us that they are “Satisfied or Completely Satisfied.” Less than 3 percent say they are “Dissatisfied or Completely Dissatisfied.” Not sure what this would look like in the private sector, but I’ve got a hunch this would compare favorably.
But guess what? As we improve access to care, more and more Veterans are choosing VA care—for the quality, for the convenience, or for the cost-savings. Even though we’re completing millions more appointments, the number of Veterans waiting for appointments has actually gone up. So we have more work to do.
What about the Veterans Benefits Administration?
The backlog of disability claims pending more than 125 days peaked in 2013 at 611,000—It’s now down nearly 90 percent. Average days pending for all claims is now just 91 days, and we finished 2015 with the lowest claims inventory since 2008. Tell me of another major part of the federal government that has transformed more in the last three years than VBA.
I’ll have more to say about claims appeals in a moment.
What about Veterans homelessness?
We’ve built a strong, productive collaboration among the Department of Housing and Urban Development, the U.S. Interagency Council on Homelessness, Veterans Affairs, partners at state and local government, and both non-profit and for-profit organizations in the private sector.
Since 2010 we’ve seen a 36 percent decline in the estimated number of homeless Veterans.
There’s been a nearly 50 percent drop in the number of Veterans sleeping on the street.
We have a winning strategy. It’s called “Housing First”: Get Veterans into permanent housing, then meet their clinical and other needs. Since 2010, over 260,000 Veterans & family members have been permanently housed, rapidly rehoused, or prevented from falling into homelessness by our programs & HUD’s targeted housing vouchers.
For the homeless Veterans we’ve housed, emergency room visits are down 28 percent, and inpatient hospitalizations are down 30 percent. So we’re not just getting Veterans off the streets—we are healing minds and bodies and making better use of resources, so we can serve more Veterans.
That’s some of our recent progress. Here’s where we’re headed:
We have begun a major cultural and organizational transformation. It’s called MyVA, and it’s focused on five objectives:
- First, improve Veterans’ experience—a seamless, integrated, responsive customer-service experience, every time.
- Second, improve employees’ experience by eliminating barriers to excellent customer service.
- Third, improve internal support services.
- Fourth, grow a culture of continuous improvement to identify and correct problems faster and replicate solutions nationwide.
- Fifth, strengthening strategic partnerships. That is, building vital and innovative networks of collaborative relationships across federal, state, and local governments—and with both non-profit and for-profit organizations.
One way we’re doing that is by helping communities around the country form Community Veteran Engagement Boards, of CVEBs, to bring together local Veteran service providers and advocates to improve outcomes for Veterans and their families. These are community-driven networks, run not by VA but by local civic and business leaders. They give Veterans and their families a forum to address issues and promote opportunities for collaboration. And they aim to resolve issues and help all of us better meet Veterans’ needs.
Some of you may already be members of your local CVEB. We hope you are! 52 are already up and running, and we expect to have a hundred in place by the end of the year.
We’ve made the necessary leadership changes to effect the MyVA transformation. Fourteen of our top 17 executives have joined VA in the last two years—many with substantial business experience.
We’ve also identified 12 breakthrough priorities to continue improving Veteran experience. We’re not talking broad concepts here. This is real change—now—that matters to Veterans. How about some examples?
- To start, we’re on the path to provide Veterans with same-day access to clinical services in primary care when they need it—at every VA Medical Center: This year!
- We’re also enabling Veterans on the road—away from their regular VA hospital—to easily receive care or refill a prescription at any other VA medical center: Coming by year end!
- We’re making it easier for the 400,000 Veterans who enroll for VA health care each year to do it online or over the phone, with a nearly immediate response in most cases: In place this summer!
- And once these Veterans are enrolled in care, they’ll receive a phone call welcoming them to VA, offering to schedule an appointment, and telling them about other VA benefits and services: It’s called Welcome to MyVA, and it’s already happening. The 200,000 Veterans called so far this year think it’s great.
- We’re putting Veterans in control of how, when, and where they wish to be served by creating a mobile app so Veterans can schedule, reschedule, or cancel appointments on their smartphone: It’s happening this year.
- We’re creating a single phone number and a single website so Veterans have a one-stop source for information, rather than asking them to navigate our complicated internal structure: This year!
- As part of our goal to be the number one customer-service agency in government, we are standardizing training in customer service for frontline employees at every medical center, to ensure an improved, consistent, and positive Veteran experience, regardless of where a Veteran lives: By November.
- How about letting Veterans pull information from their claims file without having to write a letter? That’s now policy.
- What about giving Veterans more opportunities to provide immediate and direct feedback on the quality of the service they receive and the amount of time it took to receive that care? These channels will be in place later this year, and that feedback will help us to better meet the needs of Veterans.
- And of course, Veterans should have a claims appeal process that is fair, simpler, more transparent, and delivers a decision within a year in most cases. More on that later.
Let me touch on the budget:
The President has proposed a $182 billion budget for the Department in 2017. It’s a strong budget, with $65 billion for Veterans’ medical care—a 6.3 percent increase over 2016.
- It includes $12 billion for Care in the Community and nearly $8 billion for Mental Health.
- It supports modernizing Veteran Contact Centers and the Veterans Crisis Line, so Veterans can more easily access VA systems.
- It funds Hep C treatment for an expected 35,000 Veterans.
- It provides $8.5 billion for long-term care and $725 million for 36,000 caregivers—a nearly 20 percent increase.
- It supports increased disability exams at all Regional Offices.
- It includes a 42 percent increase in funding for the Board of Veterans Appeals and a 35 percent increase in Board staffing to work the growing inventory of pending appeals.
Funding isn’t all we need. The budget request also includes more than 100 legislative proposals to overcome obstacles we face in trying serve Veterans better. Over 40 proposals are new for this year—some absolutely critical to even maintain our current ability to purchase non-VA care. Here are six of the most important ones:
- Top-to-bottom transformation and streamlining of VA’s Care in the Community programs, based on the roadmap we provided Congress in October.
- Urgent changes to VA’s purchased care authorities—provider agreements and individual authorizations—so thousands of Veterans can continue receiving care, without interruption, from community doctors, hospitals, nursing homes, and State Veterans Homes.
- General Transfer Authority that allows us the flexibility to transfer up to 2 percent of discretionary funding to address emerging needs and overcome artificial funding restrictions on providing Veterans care and benefits.
- Flexibility on the maximum 80-hour pay period requirement for certain medical professionals. The private sector has this flexibility. We need it to improve hospital operations and attract the best hospital staff, who need more flexible schedules.
- Authorization of 18 leases and 8 major construction projects included in previous budget requests, plus 6 additional leases, 2 major construction projects, and 4 cemetery projects.
- Finally, legislation and funding to implement a modernized appeals process.
Let’s talk about appeals.
Veterans have rights: They have a right to an understandable appeals process, with clear choices about how to file and what to expect; they have a right to fairness and transparency in the appeals process; they have a right to submit new supporting evidence without restarting their effective date for benefits; they have a right to timely appeals decisions, because justice delayed is justice denied; they have a right to know why their claims and appeals have been denied; and they have a right to start afresh and file a new claim when all appeals have run their course.
The current appeals process violates those rights more and more each year—denying Veterans the outcomes they deserve. It was conceived over 80 years ago, and it’s unlike any other appeals process in the federal government. Layers of additions to the process have only made it more complicated, more opaque, more unpredictable, and less Veteran-friendly. It makes adversaries of Veterans and VA, and it’s slow as molasses. The average processing time for appeals resolved in VBA is three years. The average processing time for appeals that go before the Board is five years. Many appeals are much older. Last year, the Board was still adjudicating an appeal that originated 25 years ago—which had been decided 27 times.
That’s not right, and it will only get worse with the increasing number of claims we’re now processing. We have over 450,000 appeals pending right now—and unless Congress acts now with major reforms, instead of waiting 3-to-5 years, Veterans will be waiting 10 years or more.
VA is already doing all it can to respond to the worsening problem: We’re upgrading the technology in use; we’ve applied some lessons learned from VBA’s transformation of the claims process; we’ve adopted a standard Notice of Disagreement form to initiate appeals; we’ve added 300 VBA employees to appeals in the last year; and we’ve allocated $10 million to appeals overtime in FY 2016.
Output by the Board of Veterans Appeals has risen 33 percent since FY 2013. The Board is processing appeals at the highest rate since 1988, when Congress passed the Veterans’ Judicial Review Act. Yet despite our best efforts, appeals keep piling up, and nothing we can do now, with current law and resources, will keep the pile from getting higher and higher.
Let me be very plain about one thing: This problem has only two causes: One is the antiquated, complicated appeals system we’ve inherited. The other is a changing Veteran population, which has made it impossible for the current system to keep up.
The Veteran population is aging: Half of all Veterans are now at or beyond retirement age.
Younger Veterans are surviving the battlefield at higher rates, thanks to improvements in military medicine—but they are also returning home with higher levels of disability.
So it’s no surprise we’re seeing record numbers of claims for disability—with more causes of disability per claim—plus a dramatic increase in Veterans unable to manage their own affairs. The number of beneficiaries in our Fiduciary Program has risen 50 percent since FY 2011.
More claims means more appeals—35 percent more appeals from 2012 to 2015. Thirty-five percent in just three years.
The current system just can’t keep up. It’s failing Veterans. It’s a seriously flawed system, overwhelmed by current requirements.
The solution is fundamental reform: A new process giving Veterans clearer choices of which appeals channels to pursue, with the expectation of a decision, not in 3-to-5 years but within one year.
The process we’ve proposed to Congress is the product of close collaboration between VA and the Veteran Service Organizations, including this association. Jim Golgart and Marty Caraway have been a big help. They’ve traveled seven times to meetings to give us the benefit of their expertise, always approaching the problem from a solutions-oriented perspective.
The resulting proposal reflects their work. It puts the Veterans’ experience at the center of the process. That’s how much things have change: VA and Veterans organizations, including this one, are working together, doing the Veterans’ business. Mark Bilosz will tell you more about it tomorrow morning.
The new process won’t take away any Veteran’s rights. Just the opposite: It will ensure those rights are respected. Veterans will know what their options are and be able to follow each step in the process. They’ll get timely decisions and won’t be penalized for their choice of how to appeal. And taxpayers will benefit.
We did the math: We compared where we’d be after spending what we need to spend for the new process, with where we’d be after spending the same amount on the current process. The difference is: With the current process, we’d have three times as many pending appeals in 10 years. And with that much larger inventory of pending appeals goes much longer delays for Veterans waiting for a decision.
That isn’t right. That’s not how to do the Veterans’ business. That’s why we can’t put this reform off just to look at it a little longer. It’s been looked at for years by many different people, and the problem and the solution are both obvious.
The status quo is not an option. A modern appeals process is desperately needed. And the time to act is now—not next year with a new Congress and a new Administration. The time to act is now.
Let me close with a quick story:
Back in December, VA nurse Sharon Levenson in Battleboro, Vermont, noticed that one of her regular patients didn’t show up for a scheduled appointment. She could have done nothing and just enjoyed the lighter workload that day, but instead she called the patient, and when he didn’t answer, she called the VA Police.
Now, the VA Police doesn’t do house calls, but in this case Police Chief John Richardson tasked an Officer Guy Gardner to investigate. Officer Gardner also couldn’t reach the Veteran, so he called the patient’s emergency point of contact, and when that person reported back saying no one answered the door at the Veteran’s house, Officer Gardner called the local police and requested a welfare check.
Local police entered the home and found the Veteran unconscious, but alive. He was rushed to the hospital where he was revived and began his recovery to good health. He likely would have died, but for three VA employees who cared enough to go the extra mile.
This is who we are. It may not be what most people see and hear in the media, but it’s who we are.
We still have a lot of work to do to ensure that every Veteran has the same great experience, but we’re making progress. And with your continued advice and support, we will succeed.
You know Veterans’ needs as well as anyone. Your voice is important, and we’re very grateful for the support you’ve shown for appeals process reform.
When you meet with your representatives in Congress, remind them of things Veterans need Congress to do as soon as possible:
- Veterans need Congress to grant the President’s budget request for VA;
- Veterans need Congress to act on our legislative priorities; and especially,
- Veterans need Congress to legislate and fund a new claims & appeals process serving Veterans the way they deserve to be served.
Finally, let them know that you know there are 360,000 VA employees—just like Sharon Levenson, Police Chief John Richardson, and Officer Guy Gardner—dedicated to saving lives and changing lives every single day.
Congratulations to Ed Zachary and your other incoming leaders, and thanks to Jim Golgart for his recent leadership, including the invitation to speak tonight.
I know it’s been years since the Secretary or Deputy Secretary of VA has joined you for this event. Someone said 10 years; I think it was more like 15. That’s far too long, and you can take my presence here tonight as a sign that things have changed at VA.
We greatly value your work and your advice, and we look forward to collaborating with you in the future to improve the Veterans’ experience of VA. For all you do for Veterans, thank you.