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Office of Public and Intergovernmental Affairs

Remarks by Deputy Secretary Sloan Gibson

National Association of State Directors of Veterans Affairs
San Antonio, Texas
August 23, 2016

Remarks by Deputy Secretary Sloan D. Gibson National Association of State Directors of Veterans Affairs San Antonio, Texas August 23, 2016

A little over two years ago, 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.

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!

We have taken ownership of our problems and are building back the trust of Veterans by making lasting progress, including in access to VA care. We are providing more care than ever before, and while we’re doing that, we’re also improving the quality of the care we’re providing. I see it every day when I review the data, and I hear from Veterans every time I visit one of our medical centers.

It was a very different story two years ago, when I was Acting Secretary.

When I went to Phoenix two years ago, I learned that we were too reliant on wait times as a measure. The standard we had set for ourselves was 14 days, but for a Veteran who needs to be seen right away, even 14 days is an utter failure.

Now, we’re focused on providing same-day access. Every month, 1 million appointments are delivered the same day. We took a cue from the private sector and started measuring success by patient satisfaction. And today nearly 90 percent tell us they are “Satisfied or Completely Satisfied” with the timeliness of their appointment. 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.

I learned two years ago that some Veterans were waiting for care because we didn’t have enough exam rooms, so we focused on opening more clinic space and taking better advantage of the space we have. Last year alone, we made 2.2 million more square feet available for clinical, mental health, long-term care, and associated support facilities to care for Veterans. We’re making better use of the space we have with night and weekend clinics.

I heard two years ago that we needed more doctors and nurses in Phoenix, and I quickly learned that was true across our healthcare system. Since April 2014, we’ve hired 25,654 more employees—an 8.7 percent increase. We’ve added over 2,100 physicians—a 9.4 percent increase—and over 6,000 nurses—an 11.6 percent increase.

I saw a workforce two years ago that didn’t feel like they could bring problems to supervisors. Culture doesn’t change overnight. We have listened. We are transforming. Secretary McDonald and I both come from the private sector. We know that the best ideas come from your employees. Much of our MyVA transformation is built around their ideas.

We’ve made many leadership changes to support the MyVA transformation. Sixteen of our top 17 executives have joined VA since my arrival—many with substantial business experience. Ten of them are Veterans.

To guide our transformation, we’ve established a MyVA Advisory Committee, chaired by Major General Joe Robles, President and CEO of USAA, who is here today. General Robles and his fellow committee members bring extensive experience in medicine, government, Veteran advocacy, customer service, and organizational change. These are innovative and respected leaders. They know business. They know customer service. They know Veterans.

With their help, we’ve identified 12 breakthrough priorities to continue improving Veteran experience. We’re not talking broad concepts here. This is real change—now—change 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 and mental health 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: Largely already in place, but full implementation by year end!
  • We’re making it easier for the 400,000 Veterans who enroll for VA healthcare each year to do it online or over the phone, with a nearly immediate response in many cases: Started last month!
  • And once these Veterans are enrolled in care, within just a couple of days, they are receiving 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. The 300,000 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 primary care and mental health 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!
  • We’re modernizing our contact centers to connect Veterans in crisis with an experienced responder through our toll-free Veterans Crisis Line, and to standardize handling of calls to VA medical centers, routing callers to scheduling, nurse triage, pharmacy, and general operator assistance. This year!
  • We’re also 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: Early FY 2017.
  • We’ve beefed up our VBA call centers with new technology and a 60 percent increase in personnel, and in the next two or three months, we’ll have the blocked call rate down to ZERO. We’ve already cut it in half.
  • How about providing Veterans information from their claims file without having to write a letter? Already in place.
  • 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? Including from their smart phone! These channels will be in place later this year, and that feedback will help us to better meet the needs of Veterans.

VA has already proven that it can accomplish major transformational tasks. A few years ago, we set our sights on three main priorities—increasing access, eliminating the claims backlog, and ending Veterans homelessness.

We’ve talked about access. What about the claims backlog?

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 or four years than VBA.

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.

Veterans homeless nationwide is down by 47 percent since 2010. We’ve cut it in half. Last year in Los Angeles, we cut Veterans homelessness by more than 30 percent—about four times the rate of decline of previous years.

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 and family members have been permanently housed, rapidly rehoused, or prevented from falling into homelessness by our programs and 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.

A lot changed since my visit to Phoenix.

VA is adopting a new model of care with VA as both a provider and payer for care. But we need Congress’s help to pass our proposal to consolidate the many programs that provide care in the community. There are over a hundred legislative proposals for Veterans in the President’s 2017 Budget—many vital to maintaining our ability to purchase non-VA care. Here are six of the most important ones:

  1. Top-to-bottom transformation and streamlining of VA’s Community Care programs, based on the roadmap we provided Congress in October.
  2. Urgent changes to VA’s purchased care authorities—provider agreements and individual authorizations—so thousands of Veterans can continue receiving care from community doctors, hospitals, nursing homes, and State Veterans Homes without interruption.
  3. 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.
  4. Flexibility on the 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. Can you imagine trying to schedule emergency-room doctors and hospitalists around two 40-hour work weeks in an 80-hour pay period?
  5. Authorization of 24 leases, many of which were originally requested almost three years ago, and nine major construction projects included in the President’s FY 2016 and 2017 budget requests.
  6. Finally, legislation to implement a modernized appeals process.

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 three to five 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.
  • And our FY 2017 budget request includes a 35 percent increase in Board staff. But I should point out that if Congress doesn’t approve our budget and passes yet another continuing resolution, we won’t be able to hire those people.

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 three to five years, but within one year.

The process we’ve proposed to Congress is the product of close collaboration between VA, the Veterans Service Organizations, and this organization. The resulting proposal reflects their work and your work. It puts the Veterans’ experience at the center of the process.

That’s how much things have changed: VA, VSOs, State Veterans Affairs Directors, and County Veterans Service Officers are working together, doing the Veterans’ business.

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 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 is 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 better than most anyone. Your voice is important, and your support for appeals modernization has been key to getting us where we are today.

With our new Memorandum of Agreement, and your help on appeals modernization, our relationship is stronger than it's ever been thanks to the outstanding leadership of David Brasuell and other past presidents, not to mention Les Beavers, who’s been on the phone with us daily, keeping us honest and on our toes.

I’d also like to thank Randy Reeves for the incredible job as your Senior VP, getting all the VSOs and other stakeholders to come together and agree on appeals modernization legislation.

Randy, we look forward to working with you and all of your fellow State Directors in the coming year—not just on appeals, but on some of our other breakthrough priorities as well.

Together, we've done great work on appeals. Now it's time for Congress to do its part.

For all you do for Veterans, thank you.