The Peake Papers: New VA Secretary’s Written Answers to Senators’ Questions

VA Watchdog

December 13, 2007 – Dr. James Peake, the current nominee for VA Secretary, had his confirmation hearing before the Senate Committee on Veterans’ Affairs on December 5, 2007. 

From the beginning, Peake has been carefully packaged by the White House. 

Now, we have the questions the Committee submitted to Dr. Peake prior to the confirmation hearing…and Dr. Peake’s answers.

The 28 pages show a couple of interesting things.  First, Peake most certainly didn’t write these responses.  The answers are carefully-crafted public relations statements written by his “packagers.”  Second, the Committee, already knowing the questions and the answers, stuck to the script and gave Peake a “pass” at the hearing.

Basically, Peake and his “packagers” gave the Committee the answers they wanted to hear.

All the questions and answers are printed below without any edits.

Questions and answers below:

To: Committee on Veterans’ Affairs United States Senate
Attn: Kelly Fado, Chief Clerk
Subject: Response, Pre-Hearing Questions for Nominee, Dr. Peake

1. What do you believe are the most important problems and challenges currently confronting VA? In the next year, which of these problems and challenges will you focus on and how do you intend to address them?

Response: Problems & Challenges:

• Transition: The transition from active duty service member to veteran of our current generation of returning, combat experienced, men and women is an important current challenge. The challenge is broader than just those with severe injuries found unfit for service. We must be proactive for those who need support from the VA in readjustment to and reintegrating in civilian life. We must anticipate and prepare for the fact that some of these Veterans who initially did not recognize or claim a disability will have legitimate claims that require timely and accurate adjudication

• Mental Health / Traumatic Brain Injury: Understanding, appreciating, and intervening appropriately for those with mental health issues, particularly PTSD: and understanding the relation of the spectrum of Traumatic Brain Injuries and levels of associated impairment will be both a short and long term issue for this newest generation of Veterans.

• Access to Care: Insuring access to care with compassion, timeliness, quality, and without hassle whether our Veterans live metropolitan areas or in the rural areas of our country.

• Backlog of Claims: Addressing the time required to execute the claims process to provide benefits, through reproducible, thorough and accurate ratings.

Approaches to address these issues:

• Creating clear expectations within the VA as to standards, attitudes, and Veteran focus supported by an investment in training.

• Crossing the information and cultural gaps and barriers with DoD.

• Measuring the outcomes against standards and a culture of accountability.

• Process analysis and re-engineering supported by information technology I automation tools.

2. Some believe the Secretary of Veterans Affairs should he an independent advocate, for veterans, others, that the Secretary should be the executor of the Administration’s policies relating to Veterans. What is your view of the appropriate role of the Secretary of Veterans Affairs?

Response: As a member of the President’s cabinet, I appreciate that I am a part of the administration. But, I believe I am in the administration with the responsibility to not only advocate for Veterans, but to insure that our Veterans receive the best of care; that they have their benefits provided in a timely fashion, and that the many programs that serve them produce the outcomes that make a positive difference in their lives. I recognize that this means appropriately forecasting the needs and advocating for the funds to meet those needs while making sure that the funds provided arc well used.

3. What do you believe are the differences and challenges in heading a civilian department versus a military organization? As a result of any differences, do you anticipate that you will have to alter or modify your leadership style?

Response: Within the departments, there are more similarities than differences, i.e., a highly skilled work force, men and women who care deeply about the mission, many of whom have had long careers in the department. The civilian component of the DoD is larger than some might realize. In fact, 50% of the US Army Medical Command work force was made up of civilians during my tenure. The span of control with the VA is more diffuse than the military; the locations within the VA are relatively fixed compared to the deployable assets and characteristics of the military. Another difference is in the nature of our VA beneficiaries, spread throughout the land where advocacy groups have become partners in the delivery of services as well as within the department and with congress in the shaping of these services.

I do not anticipate a fundamental difference in my leadership style which I would characterize as integrity based, mission focused and recognizing that the only way to succeed is through the men and women at every level who do the real work of the organization. To accomplish this I will make focused efforts on communication to insure clarity of intent; to insure that those men and women know that I value them and count on them; and to let them get to know me. In the Army I had the advantage of having been a general officer for 8 years before I became the Surgeon General and was known. Though many in the VA do know me, it is not at the same level. I will similarly need to reach out to and communicate with the VA’s partners, the VSO’s; to this committee, and to those on the House side if I am to be an effective leader for the VA and for Veterans’ issues.

4. How have your previous experiences prepared you for heading the second largest federal department? What lessons did you learn as Army Surgeon General that you plan to apply to leading the VA?

Response: I believe that there are several areas of my experience that are relevant:

Because of the mission of the Department of Veterans Affairs – Caring for those who have borne the battle … and their widows and orphans – I do believe my 38+ years in the Army, with service in the line as an infantry officer and in medicine as a physician, 38 years of taking care of Soldiers, provides a personal background of caring, understanding and empathy that will keep my decisions true to the mission.

My management experience includes 10 years as a colonel with executive responsibility in medical teaching centers, in command of the Army medical forces in Korea, and as the Chief Consultant to the Surgeon General during Desert Shield and Storm. This was followed by 12 years as a general officer in command of progressively larger and more complex organizations with subordinate units geographically dispersed and with, particularly in my four years as Surgeon General, the important, direct interface with Congress, the joint and interagency community, and the Army staff. The lessons that I have learned in this journey, not just as the Surgeon General, are the importance of data driven decisions, measurement of outcomes and the notion that if something is measurable it can be improved: and that this approach supports a culture of accountability.

Leadership of units from a platoon in combat, to a team around an operating room table, to a department of surgical specialists many more senior than I, to the combat medical units of the XVIII Airborne Corps with active and reserve units up and down the east coast, to leading more than 50 thousand men and women of 11 major subordinate commands is valuable and relevant experience that that has emphasized the importance of listening, of valuing people, and of communicating while maintaining a clear focus on the mission. Visibility and accessibility are important as a leader. I believe my progression over the spectrum of leadership described provides a foundation to apply this experience to the much larger VA.

5. What is your management style? Are you a “hands-on manager”? Do you rely on significant delegation? Do you seek to achieve consensus with those on your management team after making a decision or do you generally gather relevant information and input, and then make a decision?

Response: The only way one can get anything accomplished in an organization much larger than even an infantry company, let alone an organization the size of the VA, is through delegation. But, with the delegation must come accountability supported by data. I do my homework on issues and ask questions to understand the issues. In that sense, I am a hands on manager. As the “intent” of policy is communicated, my expectation is that those many operational decisions made at levels below the Secretary are made consistent with that “intent”. In decision making, I welcome all input, encourage the dissenting view, and seek outside critical thinking. I am always impressed that a product can he made better. However, with that input, I will make decisions with or without consensus. As a corollary, when there is not full consensus, I recognize my increased obligation to communicate my rationale; engaging and seeing the decision to success (ownership); and in changing course if I am wrong.

If confirmed, do you expect to visit various VA facilities in order to accurately capture what is occurring in the field?

Response: I look forward to visiting the facilities, meeting with the men and women of the VA and finding the venues to meet with those we serve. My Army experience supports the importance of “visiting the troops” in the field as well as “walking around” ones own headquarters.

6. As I am sure you are aware, many veterans have raised concerns about your coming to VA from QTC, a private sector firm that has significant business relationship with the Department.

Two Questions – –

• What will you do as Secretary to ensure that you have no dealings whatsoever with QTC or with any efforts on QTC’s part to continue or expand the company’s dealing with VA or on any other matters involving QTC and VA?

Response: If confirmed, I will terminate any connection with QTC, will have no ongoing or residual financial interest in QTC, and will recuse myself in any matters related to QTC.

• What Plans do you have with respect to QTC when you leave the position of Secretary? Do you expect to return to the. firm?

Response: I have no plans to return to QTC, if confirmed; and, more specifically, I will not do so.

7. Secretary Nicholson was accused, rightly or wrongly, of being out of touch with the needs of Veterans. Are you satisfied that you are attuned to the needs of America’s veterans? If not, how do you plan to improve your understanding (of the needs of America’s veterans?

Response: My whole life has been with soldiers. My mother was an Army Nurse, my father a Medical Service Corps officer. Those who came over to our house included active duty career officers and their families and those who had worked for or with my father but who were out of the Army, sergeants, privates, officers alike. Many of those had served in WWII and in Korea. As a surgeon throughout the 70’s and 80’s I had the great privilege of taking care of many in that last “Greatest Generation” who were dual eligible for DoD and VA care. As a commander myself, I know the faces of soldiers and their families and have dealt with their needs. As a medical commander, I’ve been involved with the medical and family needs of those injured. As the Chief Medical Director of QTC, I talked with Veterans in our facilities or on the phone and dealt with their C&P examination issues.

Though I do have what I believe is a solid understanding and empathy for our Veterans, I know that I will gain an even better perspective, should I be confirmed, as I proactively engage Veterans Organizations, our own dedicated work force, and the Veterans themselves who seek the spectrum of VA services.

8. If you were able to have a one-on-one meeting with every VA employee, what would. you say? If confirmed as Secretary, how will you implement this message in terms of policies and actions?

Response: First, I would tell them how privileged I feel to be joining their team; that I believe deeply in the mission; and that I believe in them. I would want them to know of my background both in the military and in regards to my rather long association with the VA through the Special Medical Advisory Group; through working for the last year with the VBA; and even with my experience with a VA Cemetery as the commanding general at FT Sam Houston. I would talk about our opportunity to look to the future of this next generation of combat veterans returning from Iraq and Afghanistan, getting it right for them and their families while simultaneously honoring our commitment to the WWII & Korea generation and addressing the men and women of the Vietnam era, my generation, who are now finding more need for our services. I will commit to each of them, my dedication to the mission, to them, and to creating the environment for their success as, together, we serve the needs of Veterans and their families.

I will use the chain of command, all of the command information channels available and will find the personal venues to deliver this message. Policies and actions will be consistent with this message.

9. How many staff do you plan to bring with you to VA? Do you anticipate asking the White House to allow you to replace any political appointees, including any confirmed by the Senate?

Response: I am impressed with the quality of the VA senior leadership. I have no preconceived plan to replace any political appointees and have not been in a position to assess the need to bring in additional staff. 1 am aware of the potential for an Assistant Secretary for Acquisition and look forward to the support of this committee in moving forward with that position.

10. The President noted in his introduction that you are the first physician and first general to serve as Secretary. While he was certainly correct about your credentials compared with prior Secretaries, there have been other generals, including perhaps the most famous of all, Omar Bradley, who headed the VA before it became a cabinet department in 1989. It is correct, however, that you are the first physician to head either the Veterans Administration or the Department of Veterans affairs, and I think that there may be at least one compelling reason why a physician has not previously been picked for the job, namely, the potential conflict between the Secretary and the Under Secretary for Health, relating to VA’s health care mission.

By law, the Under Secretary is a health care professional responsible to the Secretary for “the operation of the Veterans Health Administration. ” The Secretary, on the other hand, is responsible for “the control, direction, and management of the Department. ” This difference suggests that the Under Secretary for Health, like the two other Under Secretaries with respect to their Administrations, is expected to exercise direct operation control of VHA and that the Secretary’s role is to supervise the Under Secretary but not to be directly involved in the operation of the VHA.

If confirmed, how do you anticipate working with Dr Kussman or whomever is the Under Secretary for Health to ensure that this division of responsibility is recognized and honored.

Response: The VA is extremely fortunate to have Dr Kussman as the Under Secretary for Health, its “Top Doc”. He has assembled a very talented team of professionals. If confirmed, I will seek to complement Dr. Kussman’s efforts and initiatives in leading his administration, not to compete. With my medical background, I anticipate being able to more quickly make the decisions that he might bring to me since I do not anticipate needing “Medicine 101”. As I execute my responsibilities as Secretary, I would anticipate that my guidance to him will be well informed because of my medical background and my military background. If anything, I anticipate a greater synergy supported by our common medical background and our long association.

I would note also that Dr Kussman, Under Secretary Cooper, and I all share the background of being flag officers. Again, common backgrounds offer synergy rather than competition for authority.

11. Please describe how you intend to work with the Deputy Secretary. Will the Deputy Secretary he VA’s Chief Operating Officer?

Response: Gordon Mansfield is one of my heroes. I am delighted that he will continue as the Deputy Secretary. He will continue as the VA’s Chief Operating Officer.

12. Please describe how you intend to work with the General Counsel. Will the General Counsel be a key member of your management team?

Response: The General Counsel will be a key member of the management team. Ethical and Legal behavior arc the hallmarks of a quality organization. The General Counsel is a major compass in this regard as well as one who will provide the detailed advice on specific policies, legislation, and initiatives. The General Counsel will have open-door access to me to ensure the communication necessary to provide that advice.

13. Please describe how you intend to work with the Inspector General. Are you comfortable with the IG’s dual responsibility, to the Secretary as the head of the Department, and to the Congress?

Response: I understand the Inspector General function from my military experience, appreciate their uniquely privileged role, and am comfortable with that role. The IG can be a very powerful force in maintaining the VA as a learning organization, identifying systemic issues that we can fix internally or acquire the support to fix externally. Their work will not sit on the shelf, but will be used to make us better.

14. Please describe how You intend to work with the three Under Secretaries and with the Assistant Secretaries.

Response: We will, on a regular basis, meet as a group; we will have dedicated one-on-one time. The Under Secretaries have unique responsibilities to exercise direct operation control of their respective administrations and the Secretary’s role is to supervise the Under Secretaries. I owe them guidance, objectives, and resourcing with the support of all of the assistant secretaries will be dedicated to their success.

15. Are you satisfied with the current alignment of Assistant Secretaries or do you anticipate proposing any changes to the number of Assistant Secretaries or to their responsibilities?

Response: The addition of a proposed Assistant Secretary for Acquisition is the only Assistant Secretarial position change of which I am currently aware. I do not have any preconceived notion of other changes that might be required.

16. How do you plan to work with the veteran service organizations? Do you anticipate meeting with VSO representatives on a regular basis?

Response: I appreciate the unique roles of the Veterans Service Organizations and the Military Service Organizations and will work collaboratively with them as we develop policy, as we seek insights from their members, as we work with them as partners in the service delivery. I look forward to meeting with them on a regular basis.

17. What are your views on the situation that was described in the media reports earlier this year about Walter Reed Army Medical Center and on earlier problems with the Medical holdover detachments at Ft Stewart and Ft Knox? In hindsight, what might you have done as Army Surgeon General to prevent or mitigate the problems that surfaced at Walter Reed, Ft Stewart, and Ft Knox?

Response: Regarding the Walter Reed issues, I do not have first hand knowledge of the details having retired in 2004. However, it is unacceptable for soldiers to be housed in inadequate barracks. What was reported as a lack of caring for those wounded warriors who moved to outpatient status was disturbing as was the failure to bring these issues through the chain of command. I know that the Army has responded with a concerted effort to reestablish appropriate chain of command and accountability for those soldiers remaining at Walter Reed in an outpatient status and keeping them focused on their individual mission of medical improvement and rehabilitation. I also believe a valuable service was done in highlighting the convoluted and complex nature of the DoD Physical disability system, the overlap of the VA disability system, and the need, as highlighted by every group who has examined this recently, for revision, simplification, and modernization to accommodate for medical and societal changes. I was gratified to read, though often as an add-on comment, the recognition of the very high quality of inpatient care, of the amazing success in bringing soldiers home from the battlefield when, in prior conflicts they would have died.

Regarding the FT Stewart issue of medical hold-over care, I was intimately engaged. The situation that the press highlighted included inadequate barracks, slow processing times, and medical resources that were not adequate to meet the demand. The majority soldiers who had reported to a mobilization site medically unfit. Others had suffered some condition in their train-up that made them non-deployable. The first group was large and a result of policy (changed as a result of this experience) that kept soldiers who reported unfit to mobilization sites on active duty for medical board disposition. I had not anticipated this category of soldiers to be large and had not expanded capacity to meet the demand.

My response: Within 24 hours of becoming aware of this issue I dispatched a general officer led team to meet individually with each of the 500 Soldiers at Ft Stewart. Questionnaires were used to collect and categorize their issues. The team also met with leaders on the installation; Division Commander, garrison commander, and other key leaders. I coordinated with the Army staff and other Army leaders to have their subject matter experts available to assist this team to resolve those issues outside of the medical arena. In addition to FT Knox, the team followed the trip to Stewart with trips to Ft Benning, and Ft Campbell, again meeting with Soldiers at each installation and their family members as well. Assessing the teams input, we immediately looked at policy issues that needing changing, new ones that should be instituted, or resource related issues of more people, equipment or facilities. Immediate changes reduced the normal TRICARE access to care standards for appointments; for MRIs and other diagnostic imaging procedures, and for surgical procedures. I pushed greater use of the community assets (purchased care) while at the same time bringing in VA, public health service staff and borrowed staff from other Army locations. I worked with Army leadership to approve mobilization of additional personnel in anticipation of increased numbers of injured/wounded Soldiers returning from both Iraq and Afghanistan and justified additional funds for contract providers, physical disability advisors and other support staff. We reduced the ratio of case managers to patients, the ratio of soldiers to disability benefit advisors, and ensured that hospitals assign primary care physicians who would directly oversee this population of patients. I approved the establishment of a unique contract that would allow quick access to healthcare professionals to include mental health specialists.

Strict reporting requirements were enacted for the medical facilities and they were held accountable to the new standards. The medical holdover population was modeled and forecasts allowed resource distribution and monitoring of our progress in resolving the needs of this population of Soldiers.

Each Soldier was mandated to have a case manager to stay with the Soldier through their hand off with the VA. I supported the development of the Community Based Healthcare Organization medical concept of operation. This initiative continues allowing Soldiers to return home and receive their care locally but under the management of the Community Based organization with National Guard leadership.

Prior to this and before the war, the issue of the disability system was on my scope. I had insisted that “The Compassionate And Efficient Disposition Of The Unfit Soldier” be placed as a key performance process on the Balanced Score Card Strategy Map for the United States Army Medical Command. In hindsight I could have recognized that the peacetime processing standards (a problem already) were inadequate to support a surge that potentially would come of wartime. I might have anticipated the impact of the flawed policy regarding the retention of soldiers unfit at the time of mobilization and fought harder to change it prospectively. I might have worked harder to create the imperative to reengineer the disability system. Though I was one of the outspoken champions of DoD/VA sharing, I could have pushed harder for advances that were more aggressive than the 50 VA caseworkers that we welcomed into Army hospitals or been more aggressive in staff sharing beyond the 4 cardiac surgeons that I detailed to the VA.

18. What difficulties confronting wounded, injured and ill service members transitioning from the military to the VA health care systems are the result of DoD policies and practices? Of VA policies and practices? Of some combination?

Response: If confirmed, I look forward to detailed briefings on the current status of policies and practices and the result of pilot programs that, I understand, are ongoing. Already addressed, as I understand from what I have read and in general discussion, are the establishment of specific standards for living quarters for wounded warriors, an expanded and aggressive case management approach; a strengthening of the chain of command for care and oversight of the wounded warrior; the beginning stages of the recovery coordinators as suggested in the Dole-Shalala report; information exchange as wounded warriors are moved into VA facilities for the next stages of their care. Each of these was an area that needed strengthening and focus. The VA has moved to expand the polytrauma capability with an additional polytrauma center planned as well as polytrauma expertise identified within each VISN. I am told that VA has pushed the limits of their authority to provide medical support to family members who are supporting their wounded warriors. The pilot program in the national capital region that began in November will provide lessons in the single physical and VA rating for Medical Evaluation Boarded service members. The incentive for the service member to move from one system to the other… or rather the incentive not to move from one system to the other is only partially addressed by these measures and is not completely within the purview of administrative change.

If confirmed, what do you believe you will be able to do to enable VA to change the current situation and to ensure that separating sevicemembers are made aware of the benefits and services that are available to them?

Response: I believe that the different demographics of separating service members require targeted approaches. The wounded warrior with recognized combat related injuries is one group. The active duty service member with an active duty unit affiliation with its full time chain of command who elects to separate from service prior to retirement is another. The retiring service member who may become dual eligible is a third group. The reserve (to include National Guard) service member, demobilizing and returning to civilian life while remaining in the reserve force, subject to call-up represents yet another group. Coordinating access for these unique groups, crafting and delivering a common message with the responsible service, appropriate counseling, the processes to deliver those services, and measuring the success of the engagement are steps that I would champion, if confirmed. I am fully supportive of web based access to assistance and would explore other methods to ease communication for Veterans / families in need of assistance.

Will your Army background be a plus or a minus in dealing with the relationships between VA and the Navy and the Air Force?

Response: I believe my background will be a plus. My joint experience at senior levels dates from my time in command of Army medical forces in Korea while serving as the Joint Surgeon with staff oversight for both armistice and wartime health care planning. As the first lead agent for Tricare, I worked closely and collaboratively with Navy and Air Force medical commanders in our region as well as with the VA leadership in Washington State and Oregon. As Surgeon General I believe my relationships with my fellow Surgeons General was positive and I have sustained those relationships with those who have moved into the senior leadership positions within the Services since my retirement.

19. Currently, the VA/DoD Senior Oversight Committee, co-chaired by Deputy Secretaries Mansfield and England, meets on a weekly basis to deal with joint VA and DoD issues. In part, the SOC has been addressing eh Dole-Shalala Commission recommendations that can be corrected administratively. If confirmed as Secretary, what would be your priorities. for the SOC?

Response: I am aware of the eight “Lines Of Action” which, I believe, address the high level key areas. If confirmed, a first priority will be to gain an in-depth understanding of the level of progress within each of these “Lines Of Action” and formulate my own assessment of progress, priorities, or potential areas for addition.

20. If implemented as set, forth in the draft legislation presented by the White House, the disability reforms recommended by the Dole-Shalala Commission would create a multi-tiered disability system.

• How would you ensure that any changes to the current disability system are fair, equitable, and uniformly administered for all veterans?

Response: With the system as it is today, I have heard concerns that there is unfairness, inequitable and non uniform decisions that occur from time to time and across different geographic areas. Working with Congress and the administration to revise the disability system offers the opportunity to simplify the process, create a way ahead for an equitable and uniformly administered system while meeting the needs of each of the tiers that might be identified.

• Do you believe that a disability system that treats veterans of different generations differently is desirable?

Response: The demographics of the Veteran population in the United States represent a spectrum. The needs at different parts of this spectrum may be quite different. The geriatric medical requirements of the World War II generation are quite different from the acute needs of the recently returned young Veteran; just as the social needs of the older Veteran who may be leaving the active work force is different from the vocational and rehabilitation needs of the your Veteran who aggressive assistance in re-entering that work force. In between is the Vietnam generation who’s medical and life circumstance may require yet a different focus. It is important that we provide the support and care needed that is appropriate to the Veteran.

• Do you believe that veterans of prior conflicts should be given a lower priority in claims processing than veterans of current conflicts?

Response: I believe that the VA should strive, through, process improvement, automation tools, training, and the expanded claims work force that the committee has supported, to do “today’s work today and to standard” for all Veterans. A quality system must have the ability to identify and deal with uniquely urgent or emergent situations by exception.

• Do you believe that claims resulting from combat versus non-combat injuries or diseases should be prioritized differently?

Response: I believe the first priority for the VA is to those who have sustained service connected disabilities whether injury or disease, physical or mental, and to those veterans in need. I understand that the term combat injury within the Dole-Shalala commission context is, according to their guidance, broadly understood to include training for combat whether in or out of a combat zone and with the opportunity for Secretarial discretion to be more inclusive if warranted.

21. I understand that VA has solicited an outside bid to carry out two technical studies that are being sought as a result of the recommendations of the Dole-Shalala Commission. Once these studies are completed, do you believe that the Secretary has the authority to implement changes to the disability compensation schedule generally? Do you believe that the Secretary has the authority to distinguish between multiple systems of compensation and how they are to be applied to different groups of veterans?

Response: The change to the disability compensation schedule requires congressional approval. I do believe that legislation is required to change the disability system itself. If confirmed, I pledge to work closely with Congress, the Department of Defense, and the Veterans Service Organizations to create and manage the change necessary to meet the needs, both short term and life-term, of this newest generation of combat veterans while insuring that we meet our enduring obligation to those of the “Greatest Generation” and of my generation who have served before.

22. The Disability Benefits Commission recently released a report on its two-and-a half year analysis of the benefits and services available to veterans, servicemembers, their survivors, and their families to compensate and provide assistance for the effects of disabilities and deaths attributable to military service. That report contains 113 recommendations. In your view, how should VA analyze, and if appropriate, implement the recommendations?

Response: Though I have not studied each of the 113 recommendations, I appreciate the work that went into developing such a detailed report. VA should analyze each of the recommendations and consider its value and validity in the scope of the larger revision and changes which are being considered in the disability system. I believe this is an area where the Senior Oversight Committee can add value, urgency and leadership and I will support their efforts at the big picture look and in ensuring appropriate improvements arc implemented in a timely manner. For those recommendations which VA has the current authority to implement, an overall implementation plan with timelines should be developed based on a prioritization of the recommendations.

23. The relationship between VA medical centers and medical schools has endured for more than 60 years and has been credited with improving quality of care for veterans. These affiliations draw the best and brightest physicians and help VA fulfill its research and educational missions. I am concerned, however, about the viability of the relationship. Please share your philosophy regarding the overall value of academic affiliations, including the role affiliates play in staffing VA facilities. What is your assessment of how Army medical interacts with Academic medicine?

Response: The academic affiliations are one of the enduring strengths of the VA. I believe that a robust teaching environment and high quality research affiliations are contributing factors to the excellence of the Veterans Health Administration. As with any relationship, it is healthy to continue to re examine the outcomes of the relationship to ensure the basis remains sound; that our Veterans benefit from the care of the affiliate, that the research is of high quality and supporting the Veterans’ needs; that our Veteran population is providing needed access to those in training, and that our changing demography of Veterans warrants the maintenance of the affiliation. The relationship of Army Medicine with academic medicine is less interdigitated. Army Graduate Medical Education programs are individually accredited but often work with civilian academic institutions for specific rotations. The Army training of ancillary medical specialties is, except for degree producing programs, done largely without affiliation with outside academic medical centers.

24. Many veterans, especially those with complicated health- issues, rely upon the specialized services of VHA. Many of these services, like spinal cord injury, blind rehabilitation, and prosthetics, are unique to VA and are unmatched by the private sector. In an era of declining budgets and decentralization of funds, please describe Your views on VA’s responsibility to maintain capacity in these programs.

Response: I fully support the continued excellence of VHA in these highly specialized areas of expertise and service.

25. Post-traumatic stress disorder is a major concern for the Committee, both in terms of compensation and health care.

• As a combat veteran, what is your experience with veterans and PTSD?

Response: In combat I had members of my platoon who handled the same level of exposure to the horrors of war quite differently; from a single soldier becoming overtly combat ineffective; to another providing effective fire in an ambush and then continuing to fire round after round even after the action was completed; to the majority of my soldiers who were able to perform their duties even in the face of the same combat stressors. Personally I experienced some of the symptoms of post traumatic stress, but at a level that would not be classified as a disorder. In fact, it is part of what I believe is a normal range of adaptation. As long as two years after I returned, I would sometimes startle at an unexpected loud noise or have an occasional dream about combat. I was fortunate that these faded with time for me and did not affect either my professional or social life.

• Do you personally know veterans who continue to suffer from PTSD or veterans who were diagnosed with PTSD, but who are now no longer suffering from the condition?

Response: I do know Veterans who continue to suffer from PTSD. On a personal basis I know Veterans who have had PTSD symptoms, who now are coping well and are not disabled. I do not know if they had been formally diagnosed with PTSD meeting the DSM IV diagnostic criteria. I believe that this spectrum of mental health issues is treatable and we will learn more as we continue to do scientific inquiry.

• Under what circumstances, if any, is it possible for a non-combat veteran to suffer from PTSD?

Response: The circumstance in which an individual experienced, witnessed, or was confronted with an event, combat or otherwise, that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and whose response involved intense fear, helplessness, or horror might cause that individual to suffer from PTSD.

• VA has significantly decreased its in-patient programs for veterans with PTSD. What do you view as the role of in-patient treatment for PI SD, in particular for veterans with co morbid substance case disorders?

Response: I am not aware of the extent of the reduction of in-patient programs or of a backlog in access to these in-patient programs. I am aware that significant advances in outpatient and community based programs for mental health treatment and support have enjoyed success and popularity, not only in the VA but nation wide. If confirmed, I will look carefully at the balance between the various treatment modalities for PTSD and the co morbid substance abuse disorders to ensure access to the right care in the right location.

• Please describe the priority that you believe VA should place on providing care to veterans with PTSD, and how would you ensure that priority is manifested in budget requests and programmatic planning?

Response: Care of our Veterans with PTSD and with related symptoms short of PTSD is rightfully a very high priority. I am aware of the recent increase in mental health workers recruited by the VA and, if confirmed, I would continue to support this initiative as well as exploring the issues of access in rural areas of the country. I will work with Congress, OMB, and the experts of the mental health community to identify new programs and emerging treatments and in programming, the resources to support them.

• What are your views on the need fur more research into the best treatments for PTSD?

Response: I believe that PTSD will be a hallmark condition of the current conflict. I am proud to know that the VA has been at the forefront of research in this area. I believe that there is still much to learn and that it is the VA’s obligation to remain at the forefront of this learning.

26. Last year VA suffered on of the biggest losses of personally identifiable information in history. Fortunately, the data was recovered and there have been no repots of any personally identifiable information being compromised. Secretary Nicholson testified last year that lie intended, for the VA to become the “gold standard” for IT security within the federal government. If confirmed, what priority will you put on efforts to ensure that veterans’ personally identifiable information is protected?

Response: The protection of personally identifiable information will be a high priority for me. Though I have not been briefed on the details, I understand that, subsequent to the noted event, many specific policies, procedures, and safeguards for information integrity have been put in place; a major information management restructuring and centralization has occurred, and investments have been made in hardware and security applications. If confirmed, I will work to ensure accountability through oversight and compliance monitoring. I understand that a specific office with this function has been established.

27. The Dole-Shalala Commission recommended that a corps of well-trained, highly skilled Recovery Coordinators be swiftly developed to ensure prompt development and execution of patient-centered Recovery Plans for every seriously insured se4rivcemember. The commission’s recommendation called for members of the Commissioned Public health Service to perform this role. On October 31, VA and Do!) announced an agreement to provide “federal recovery coordinators ” for seriously inured, ill, and wounded servicemembers and their families. Under the current concept the “federal recovery coordinator” will he VA employees and the program will apply only to those injured, ill or wounded in combat. Two questions:

• Do volt believe the care coordination role is one VA should he performing prior to a servicemember’s separation from the military?

Response: The complexity of the conditions and the complexity of the systems can he bridged by a coordinated effort from the beginning in laying out a recovery plan and monitoring it’s execution in conjunction with the patient, the patient’s family and with the agencies involved. As the care coordinator’s role evolves it must involve the VA while the service member is still on active duty.

• Do you believe that this program should he focused solely on those seriously injured, ill, or wounded in combat, or should it include others who are seriously injured or ill front service elsewhere?

Response: If confirmed, I will endeavor to insure that the broad inclusion of the “combat related” description is operative and that appropriate additional exceptions have a clear and easy process for approval.

28. VA’s vocational rehabilitation and employment program is one of the smallest, yet most important, programs within the Department. It is the linchpin for helping veterans, who incur service-connected disabilities, achieve a fulfilling and gainful future. ]am deeply committed to making sure that this program lives up to its full potential, especially when individuals who have sustained serious injuries in combat are involved. What are your thoughts on the role that vocational rehabilitation plays in terms of the total rehabilitation of an individual recovering from severe combat-related injuries?

Response: I agree with the importance of vocational rehabilitation in support of the critical objective of making our Veterans self sustaining, proud, and independent financially, socially, emotionally. I believe in finding the right incentives to get them into these programs and keeping them in these programs through the point of their transition to gainful employment. If confirmed, I will strongly support these programs for Veterans who need help in being productive citizens.

29. There has been significant discussion for at least the last decade about the need for DoD and VA to create a hi-directional/interoperable electronic health record. In 2003, the President’s Task Force to Improve Health Care Delivery for our Nation’s Veterans recommended that the VA and DoD develop and deploy such a record.

• What involvement did you have with this effort while Surgeon General?

Response: As the Surgeon General, I invited the President’s Task Force and personally briefed them on Army medicine to include being a champion for DoD/VA sharing. I was a vocal supporter of the development of a longitudinal, queriable patient record that would capture a service members care from MEPS Station to VA Cemetery.

• Based upon your experience, do you believe that, to achieve this goal, it is necessary for DoD’s and VA’s electronic health record systems to be combined or to simply have the ability to share data?

Response: I do believe this is an obtainable goal that does not necessarily require a single system. More important is the harmonizing and adoption of a common health care lexicon and standardization of processes.

• Do you believe the current problems in the area can he resolved in a timely manner so that VA doctors can have access to complete medical history, including military health records?

Response: Timely is yesterday! So my answer is that we need to move as quickly as possible with initiatives that do share digital data and records as we advance to the interoperative use of computable data as an achievable goal, while making up any short term shortfall with paper, and personal communication. We must ensure, even without perfect electronic transfer that providers have the information needed to provide outstanding care appropriate to the continuum of care.

• As a former practicing physician, what medical information do you believe VA health care providers need from DoD?

Response: I believe that VA physicians and the other health care providers within VA need the most comprehensive medical information that DoD can provide that is relevant to the patient’s current active medical conditions. It would be impossible to list here the full spectrum of the specific data elements that might be required to do this. I would point out that I do not see this information flow as a one way flow from the DoD given particularly the service to those dual eligible Veterans; the potential for a Veteran to return to active service after care in the VA; and what our rehabilitative services might achieve in returning someone who had been unfit back to duty.

30. VA currently uses the criteria of 170,000 unserved veterans within a 7.5-mile radius for purposes of establishing new national cemeteries. lit the past, the Senate has supported this standard and has authorized new cemeteries based upon VA’s recommendations. Do you believe this should continue to be the standard practice? In the absence of a VA recommendation, do you believe Congress should legislate location of new national cemeteries?

Response: I understand that the stated goal is, by 2011, to have 90 Veterans within 75 miles of a national or state veterans’ cemetery. It is my understanding that Congress has been extremely supportive of this strategic direction; Five new cemeteries are targeted to open in 2008 because of your support. If confirmed, I will continue to work closely with our National Cemetery Administration and Congress to insure the resources are available for new cemeteries and to insure the standards are maintained that mark the lasting tribute that commemorates Veterans’ service to our Nation.

31. What is your view of the correlation between combat service and homelessness?

Response: I have read that up to one in four of the single male homeless people are Veterans. It has been estimated that nearly 200,000 Veterans may be homeless on any given night. Risks include poverty, lack of family support, precarious living conditions.
I am told that, currently, there is little information to suggest that combat service, per say, has a direct link to homelessness. But, deployments with disruption of family lives, the effects of traumatic events of combat may very well contribute to homelessness and is a correlation that truly needs investigation.

• Do you believe that VA has a particular obligation to address aggressively homelessness among veterans?

Response: Yes

• Public Law 106-377 fiends the Interagency Council on Homelessness and makes the Secretary of Veterans Affairs a rotating chair of the Council. What do you see as VA’s role in working with other departments, agencies, especially HUD, to address the needs of homeless veterans and their families?

Response: I believe homelessness is a multifaceted problem that involves individual economics, skills development, mental health and social well being. If confirmed, I look forward to supporting the inter-agency / interdisciplinary approach to understanding and supporting homeless Veterans.

32. VA has a history of significant waiting times for care, a problem from which specialty care particularly suffers. What are your thoughts on the priority that should be accorded to reducing waiting times? In your view, how long should a veteran be expected to wait, for a non-emergent health care appointment?

Response: Excess waiting times result in patient dissatisfaction in any health system and so must be a priority in a patient centered and, in our case Veterans centered, care environment. In some cases excess waiting times can have an impact on the course of an illness or in extended period of patient distress. In other cases the Veteran him or herself may choose a visit time outside of specified standards for their own convenience and without compromising care. The waiting time standards should address this spectrum. I understand that the VA standard for a non-urgent specialty care appointment is within 30 days. This is consistent with the DoD Tricare standard for non urgent specialty access and is reasonable with the caveat that the referring provider can decrease that time depending on the clinical assessment.

33. The active-duty military has become increasingly more reliant on the Reserve components to accomplish its missions. What will you do, if confirmed, to ensure that governmental services, including pre-, during, and post deployment services, including transition services, are equally available to National Guard and Reserve veterans?

Response: The “pre-, during. ..” services are largely within the purview of the Department of Defense. I believe in their recently instituted annual Personal Health Assessment and reserve health readiness initiatives. Where needed and feasible the VA should be supportive of these DoD efforts. Regarding the “post deployment services, including transition services . . . “, I will, if confirmed, work to make VA an integral participant from emphasis on the Benefits Delivery at Discharge program, to educating demobilizing Guard and Reserve Veterans about their benefits, to encouraging their access to VA services in their immediate 24 months of post deployment presumptive period currently authorized, and to working with the reserve component leadership through DoD collaboration.

34. In your view, how long should a veteran have to wait to have his or her initial claim for compensation adjudicated?

Response: I am aware that the VA has as its strategic goal to provide claims decisions in an average of 125 days. I know also that this goal as been very difficult to achieve for many reasons. However, I believe VA can and must do better. VA’s compensation claims process is complex and the evidence gathering often involves obtaining information from DoD, VHA, other federal agencies, and private providers. I believe the recently introduced Disability Evaluation System pilot, a joint VA and DoD initiative, holds great potential for service members undergoing a Medical Evaluation Board Proceeding. I am committed to working with all involved parties and the Congress to streamline the disability compensation claims process for all Veterans.

35. VBA has come under fire for the lack of timeliness of its claims’ processing. While VBA has made progress in improving timeliness and accuracy of disability claims processing, further improvement is needed. VBA has turned its attention to decreasing the amount of time it takes to process a claim, but that improvement seems to he at the cost of a decrease in the quality of its decision making. Do you have any views on how a more balanced approach can he reached?

Response: The nearly 3,000 additional personnel for the Veterans Benefit Administration dedicated to claims processing will help in the short term and as they become better trained (as I understand it, a major focus of Admiral Cooper) and experienced, the accuracy will improve in addition to the timeliness.

However, I support the observation by multiple recent groups looking at this problem, that a simplified disability system with updating of the rating criteria on a go forward basis offers the best opportunity to have clear, fair, and reproducible ratings that are supportable by modem rules based information technology tools.

36. Accurate forecasting of usage of veterans benefits is essential in planning for resources to administer those benefits. What do you see as the Secretary’s role in insuring that VA forecasts the need for additional staffing resources so that Congress could appropriate those resources in ci timely manner?

Response: I believe that the Secretary must use actuarially supported data combined with real information from practice patterns and collaborate with the DOD using their best data to provide accurate forecasting and appropriately identify the resources to support those forecasted needs.

37. As one who knows first hand the value of educational benefits tinder the GI Bill, 1 am deeply committed to making sure that this important benefit is available to today’s veterans. I recognize that this benefit is not just a readjustment benefit in today’s all volunteer force. It also serves as a recruitment and retention tool.

• What are your thoughts about the delicate balance between these twin aspects of the benefit? Do you believe that one outweighs the other?

Response: From my years in the military I appreciate the value that soldiers place on their educational benefits. For many it is a way to take an economic burden of education off of their parents, for others, the GI Bill represents the only route to additional schooling post high school. It is perhaps most important as a motivator for service for those who enlist not specifically seeking a career. For the service member returning from combat, it can be a powerful readjustment benefit as described in the Bradley report of 1956. Education can produce a better adjusted Veteran and one who is better positioned to resume life as a productive citizen. I absolutely share this committee’s belief, and appreciate your history of action, in investing in those who have served this nation in uniform

• How do you see the VA working with DoD on GI Bill issues, such as the size, scope, and details of benefits under the various GI Bills and in reaching out to eligible individuals to ensure that they are aware of and use their benefits?

Response: The forum for such collaboration exists with the DoD/VA Joint Executive Council. If confirmed, I would support a focused look at this subject and would work with Congress and DoD and our Veteran Service Organizations to take the results of that work into an effective update of our GI Bill programs.

38. There has been increasing pressure in recent years for VA to contract for services in local – especially rural – communities where VA facilities care not easily accessible. Mental health is one area of particular emphasis in this regard. What do you believe is VA’s responsibility for meeting the needs? Including mental health needs, of rural veterans? If confirmed, what emphasis would you place on this issue?

Response: Rural Health is a topic that has come up on several occasions in my prehearing meetings with the committee members and so I appreciate that emphasis is needed. I believe that Veterans in rural areas may be well served locally, if care is available, but that the VA has an obligation to monitor the quality of that care. I also appreciate the challenges of making this care part of the continuum of care expected of a quality health system. If confirmed, I will ask early in my tenure for an update from the recently created Department Of Rural Health, explore the various interagency opportunities, and the potential for leveraging technologies such as Telemedicine 1 Telepsychiatry to better serve remote Veterans.

39. There are a number of issues about the current GI Bill that I find troubling.

• One aspect that especially concerns me is that there are individuals who are serving in combat, placing their own lives in harms way, who have had to make a monetary contribution in order to establish eligibility for GI Bill benefits. What are your thoughts on this issue?

Response: It is my understanding that the Montgomery GI Bill was enacted by Congress in 1984 and designed for a peacetime active duty service and supported a contribution that put skin-in-the-game. If confirmed, I will work with DoD and this committee to reexamine this premise in light of the current conflict and the sacrifices of today’s service members and Veterans.

• I am also very concerned that there are individuals who are serving with the National Guard and Reserves and who may have completed multiple deployments in combat zones but who stand to lose eligibility to valuable educational assistance benefits if they separate from their unit. What are your thoughts about these individuals and the portability of their benefits?

Response: I do not yet have a detailed understanding of the full scope of this issue. However, my sense is that once these valuable educational assistance benefits are earned, they ought to follow our service member. If confirmed, I will follow up on this issue to fully understand the issue and make appropriate corrections within my authority or recommendations for change.

40 All Federal agencies have certain responsibilities to maximize contracting opportunities for veteran-owned small business and especially service-disabled veteran-owned small businesses. In general, it appears that VA has a better record than most other federal agencies. However, some have raised concerns that to meet the goal of increased contracting with these businesses, there has been increasing reliance on partnerships between large corporations and small service-disabled veteran-owned businesses, in which the involvement of the SDVOB is really only on paper. In your view, does the VA have an obligation to ensure that contracts with. small service-disabled veteran-owned businesses truly involve and benefit these firms in the actual contracted activity?

Response: I am aware of the VA’s emphasis on Veteran-owned and, especially, service-disabled veteran owned small business as preferred contractors. Given the magnitude of some of the programs and projects it may be unrealistic to expect successful performance by any small business, veteran owned or not in the prime contractor role. I whole heartedly endorse our government providing preferential treatment to our own Veteran small business owners and particularly those service-disabled small business owners. If confirmed, I will work closely with our contracting office to insure we have clear outcome objectives that include development of these veteran owned small businesses (coaching, teaching, mentoring, investing & rewarding) and consider that such metrics may be applied to the large corporations who may be bettered positioned to function as a prime but with a specified level of subcontracting to the veteran owned concerns.

41. I have long advocated strategies for recruiting and retaining highly trained medical professionals within the VA health care system. Just a few years ago, I supported legislation to create a more competitive pay system for VA physicians and dentists, as well as other legislative initiatives targeted at nurse recruitment. Despite these efforts, VA continues to face a growing nursing shortage, as well as vacancies for specialty care physicians. In your view, what should VA do to improve personnel recruitment and retention at VA health care facilities, particularly of nurses? What more can VA realistically do to improve recruitment in areas where there are fewer specialty care physicians overall?

Response: The recruitment of all health care personnel, including physicians and nurses, remains a challenge in US health care. While I do not know all of the programs that are currently in place to support the recruitment and retention of VA physicians and nurses, I do believe that the VHA’s reputation as a high quality health care system is a strong recruitment.

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