David Shulkin

White House Presser on Veterans Affairs Current Issues

delivered 31 May 2017, White House, Washington, D.C.

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Good morning, everybody.

So a few weeks ago, the President came over to my offices at VA at his 100-day mark to talk about the recognition of the progress we've had at VA.  So I thought it only fitting at my 100 days to come to his house to talk about whatís happening at VA.

And as you know, the President is so committed to fixing issues for veterans that what he has told me is, is that it is important that we be open and candid and transparent about where the problems are; that as a businessman, the only way to fix the issues in an organization is if you come out and you talk about what those problems are.  And so, as you know, I'm a doctor and I like to diagnose things, assess them and treat them.  And so what you're going to hear today is really a candid assessment of where our problems are in VA, with the focus of a businessman and the skills of a doctor to be able to actually help you with that.

And as you know, many of these challenges I'm going to talk about today have been decades in building and theyíve spanned multiple administrations.  And this is the time for us to really address these chronic problems that have affected veterans and, in many ways, have harmed veterans and their families by not dealing with these issues.  So I'm going to tackle these issues heads-on.

Just to give you a sense about what we're doing today, I'm going to talk about 13 areas of significant risk for VA.  It's going to take about 25 minutes to get through, so if you need to get up and stretch, or if you have ADD and you need to leave, I will not be offended.  But I just want to give you a sense about that.

We've had 137 different assessments and studies telling VA whatís wrong and how to fix it.  And what we've done in my first 100 days is to go through these studies -- the Commission on Care, Independent Assessment, as well as our own internal assessments -- to come up with these 13 areas of risk that I want to share.  So let me start with them.

The very first area is access.  And of course, as you know, we started with our wait time issue in 2014 -- the real crisis that began recently at VA.  So hereís my assessment on access.  We've done a significant job in improving access to care for clinically urgent veterans, so people with clinically urgent needs are now being addressed in a much more efficient way.  We've developed same-day services in every one of our 168 medical centers for primary care and mental health.  And in fact, today, over 22 percent of veterans are seen on a same-day basis.

What we've done recently is we've posted our wait times for every single one of our medical centers across the country in a public forum for everybody to see whatís good and whatís not good in terms of wait times.  There is no other health system in the country that has done anything like that, and there is no comparison to what the VA is doing in terms of transparency and wait times.  Yet veterans are waiting 60 days or more for new appointments in primary care and mental health at 30 of our locations nationwide.  So we still have more to do.

And while, as I mentioned, we've done well with meeting the urgent needs of veterans, 10 percent of the time when a provider wants a follow-up appointment in a specific time frame, we're not meeting that providerís clinically assessed time for a veteran to come back.  And that's something we have to address.

Sixteen percent of our primary care clinics are over 100-percent capacity.  When that happens we can't fully meet their needs in terms of access to care.  Ten percent of our out-patient centers do not offer same-day services today.  Now, we are committing by the end of this year that all of our out-patient centers will offer same-day services in primary care mental health.  But today 10 percent are not meeting that.

The second category is paying providers when veterans go out into the community.  And as you know, our Choice Program, our community care program, has provided increased access for millions of veterans.  And we have 500,000 community care providers -- doctors and others -- out in the community who participate in our network.  But providers are increasingly frustrated with the VAís ability to get them payments, to the point that some of them are actually leaving our network.  And that's obviously working against us.

It takes more than 30 days to process 20 percent of our clean claims at VA, and that affects about 25,000 providers across the country.  In addition, we have about $50 million in out-patient bill charges that are six months or older.  As of April this year, only 65 percent of our claims are handled electronically.  That's far below what youíd find in the private sector.  And so we need private sector help in order to find new solutions to get that number well above 65 percent, so we can have faster adjudication of payments to our community providers.

The third area is community care in general.  Though we made a lot of progress with our Choice Program -- because we've had over 70 amendments or modifications to our original contract -- we still have eight separate programs for paying community care.  That just makes it too complex and it's confusing veterans and our employees alike.

In terms of the complexity of this program -- it results in VA rejecting one out of five community care claims -- the rules are so complex, people are so confused, 20 percent of our claims are rejected.  And that's much higher that what youíd find in the private sector.  And we need Congress to help us fix those eight separate programs and put them into a single program.

In terms of our Choice Program, we still, today, only have three Department of Defense facilities that participate in the Choice network.  And we need to get the Department of Defense and VA to make all their facilities and our facilities open to veterans and to active service members.

We certainly have to work with Congress and our veteran service organizations to redesign this Choice Program.  It will expire essentially at the end of the year, and we need new legislation -- this Congress -- to make sure that veterans don't go back to waiting longer than they need to wait to get care in the community.  So we have to pass legislation this year.

The next area is quality -- quality of care in the VA.  We've shared with you our star rating systems.  We now publish that on our websites, and we also now publish quality of care comparisons between VAs and local community hospitals.  And in that, we've identified 14 of our VAs that have one-star ratings.  That means that their quality is below the standard in the community.  And so that's not acceptable to us.  We're deploying teams and implementing performance plans for each of those facilities.

Veterans shouldnít have to accept low-quality care and they deserve our very best.  I think everybody agrees with that.  And when theyíre not getting the best that they can get in the VA, and the community offers better, that's what we're going to work to do in a revised Choice Plan, is to allow them to go out into the community if theyíre not getting the very best care.

The next area is disability claims and appeals.  We have, currently, over 90,000 disability claims that are taking more than 125 days to process.  Our goal is to cut that in half over the next two years.  But 90,000-plus is too many to be acceptable.

Last week, we processed a claim for disability in three days.  That's called a due process, called a decision-ready claim.  And we're going to be introducing decision-ready claims nationwide on September 1st of 2017.  And in addition to that, we're going to be going paperless throughout all of our veterans' benefit offices by mid-2018.

So we are focused on not doing claims fast enough now, but we have plans to get much better.  In addition, it's very hard for a veteran to get information on where their claim status is, and we need to make that process more transparent.

In appeals, it takes almost three years, if you were to file an appeal today, to get a decision.  And it's going to take Congress to help us fix that system.  I'm grateful that the House passed appeals legislation last week, and we need our friends in the Senate to act on appeals legislation as soon as possible.

Information technology.  We have 20 of our facilities that have out-of-date systems for IT and inventory.  And that makes it very, very difficult for doctors and nurses to get the supplies that they need to care for veterans.  This is what we saw in the Washington, D.C. VA several weeks ago.

We've taken immediate steps to begin to start fixing these inventory systems, and we're executing on those plans.  Currently, 75 percent of our IT budget is just maintenance and sustaining our infrastructure, because our legacy systems are old and are at risk of failing.  And that would cripple our operations.  Our scheduling systems and our financial systems are outdated, and that contributes to these excess wait times. Both systems are in the process of being replaced, but it's going to take years to complete that.

We have a system called VALERI, which is the VA Loan Electronic Reporting Interface.  It's out of date.  Without funding for a new system, VA is going to have to revert to a paper-based, manual system for electronic loans -- or for loans that are going to reduce the number of veterans that we serve, from 90,000 per year to only 12,000 per year.  So we can't afford to let that happen, because veterans could be at risk of foreclosure or even homelessness, and that's a risk that we've identified.

We have to modernize all of our IT systems to make them commercially viable and cloud-based solutions to the maximum extent possible.  And I've committed to making a decision on VA's electronic medical record in the very near future -- definitely before July of this year was my commitment -- that I will talk about how we are going to move forward with the new EMR strategy.

Capital assets.  Our buildings and our facilities are increasingly fallen into disrepair.  We have a facility condition assessment report that identified $18 billion would be required to fully remediate our buildings now, including structural/seismic and electrical/mechanical improvements that need to be done.

On average, our buildings are more than 60 years old, with only half being built since 1920.  We have 449 buildings from the Revolutionary War and the Civil War; of those, about 96 are vacant.  We have another 591 buildings that were built in World War I era, which 141 are vacant.  In all, VA has 400 vacant buildings and 735 under-utilized facilities, and that costs the taxpayers $25 million a year just to maintain vacant and under-utilized facilities.

So we need to be able to act quickly.  VA currently has 27 facility leases that we're waiting for Congress to authorize.  That would provide 2.3 million square feet of needed space for 3.2 million additional clinic visits a year that today we can't do because we need authorization from Congress.

We need different types of strategic partnerships to be able to bring the type of facilities that we need to veterans, and that means working with local government, with academic affiliates, other federal agencies, and private sector partnerships.  We're going to work with Congress to develop a modernization plan for our capital infrastructure through what we call a National Realignment Strategy that's going to allow us to use our buildings in a better way, stop supporting vacant buildings and underutilized buildings, all to be a better steward of taxpayer dollars.

Construction.  Eleven of our major construction projects, totaling $1.4 billion, are on hold because the VA and the U.S. Corps of Engineers still are trying to work through very difficult processes and interpretation of the appropriation rules.  We're waiting for congressional approval on a joint proposal to move forward, which would allow these projects to go ahead.

The VA's major construction and minor construction programs have large, unobligated balances.  We carry at VA $971 million in minor construction in unobligated balances, and $2.6 billion in major construction.  VA is taking way too long to make construction awards, and these obligations are critical for us to meet facility demands in the future.

Accountability.  Under current VA law, VA has to wait at least a month to hold an employee accountable for misconduct or poor performance.  We currently have 1,500 disciplinary actions that are pending, meaning people that either need to be fired, demoted, suspended without pay, for violating our core values -- and weíre waiting for each of those actions.

Our accountability processes are clearly broken.  We have to wait more than a month to fire a psychiatrist who was caught on camera watching pornography using his iPad while seeing a veteran.  The expedited senior executive removal authority that was given to us in the Choice Program isnít working.  We werenít able to utilize that because of constitutionality issues.  Because of the way the judges review these cases, they can force us to take terrible managers back who have been fired for poor performance.  We recently saw that in one of our executives in San Juan.

Just last week, we were forced to take back an employee after they were convicted no more than three times for DUI and had served a 60-day jail sentence.  Under current law, it takes us 51 days from the date management proposes to suspend, demote, or remove an employee until the date that action takes effect.

Despite the limitations of the existing law, weíve recently removed the Washington, D.C. medical director from their position and other employees there as well due to their failure of leadership.  We removed the medical center director in Shreveport, Louisiana, and three other senior executives for misconduct or poor performance.  And the President signed an executive order that created an Office of Accountability and Whistleblower Protection that reports directly to me as Secretary.

But that isnít enough.  We need new accountability legislation and we need that now.  The House, again, has passed this and weíre looking forward to the Senate considering this.  But we need that type of action.

Staffing -- currently it takes, on average, 110 days to onboard a nurse in the VA, and 177 days to onboard a nurse practitioner.  Thatís just too long.  VA doesnít have a position management system, so itís very difficult for us to track what jobs are open.  And an organization our size needs that in order to meet the needs of our veterans and have the right resources for them.  Weíre going to establish a fully functioning management manpower office by December of this year, which is a first step in a position management system to be established.

Low salaries for many of our healthcare providers and prosthetic professionals make it difficult to recruit and retain the best professionals.  In 2016, the mean salary for a biomedical engineer in the country is $85,620.  The national average for biomedical engineers in the VA is $65,677, or 25 percent below the private sector.  For mechanical engineers, the difference between private sector and VA is $15,000 a year, or 18 percent, where VA is below the national average.  If we canít compete with private sector salaries, weíre going to be unable to retain qualified providers and support staff.

To help with these shortages, weíre pursuing legislation that would expand graduate medical education training opportunities to be able to train more health professionals to stay in the VA system.  And weíre working with the unified services university -- the medical school of the military -- to train more medical students who then would serve in the VA for 10 years after their education.

Bureaucracy.  Our central office in VA has grown too big and is too bureaucratic.  We need faster, clearer decision-making and authority thatís going to give veterans more control of their services and care.  Iíve directed the VA Central Office to remain under a hiring freeze as we consolidate program offices.  We have 140 program offices.  Iíve directed them to implement shared services so that they donít replicate common corporate services.  And that is a result that I plan to achieve of a 10 percent reduction in overhead.

In addition, weíve been reducing burdensome regulations to make VA more effective.  Effective immediately, VA will stop requiring the use of small-house design guides for future state home grants.  In other words, weíre going to stop using federal rules.  Weíre going to allow the states to use their own requirements to build veterans homes in the future in the states.  Thatís going to save taxpayer dollars while increasing access to veterans.

A few weeks ago, we announced the VA is removing the more restrictive guidelines for a mammography for women and instead adopting the American Cancer Society mammography guidelines that will allow women veterans more access to care.  Weíre restructuring our caregiver regulations to get services to veterans and make it less burdensome to get help from caregivers.

Our Vets.gov website is making it possible for veterans to get better access to our services.  At this time last year, only 10 percent of benefits applications were done online.  And because of our Vets.gov website consolidating this, we now have eight times that number online a year later.  Over 200,000 veterans have applied for health benefits using Vets.gov.

VA will be soft-launching the White House Veterans Complaint Hotline tomorrow, on June 1st.  This is something the President had talked about.  Weíre going to be testing that system, starting tomorrow, and fine-tuning it over the next several months, with the goal of it being fully operational by August 15th.  The soft launch of this, which is being worked out tomorrow, will be active -- the phone number is (855)948-2311 -- and the full launch of that, as I said, will be August 15th.

Fraud, waste, and abuse.  Detecting fraud, waste, and abuse -- it's very important we get resources to veterans and their families.  Weíve been identifying preventing fraud, waste, and abuse.  Already weíve been able to prevent $27 million in fraudulent payments and duplicate payments in fiscal year 2016.  However with centralized oversight, I know we can do much more than that.  Thatís why I stood up the Fraud, Waste, and Abuse Initiative.

I recently announced a Fraud, Waste, and Abuse Prevention and Advisory Committee and we're creating that committee -- itís actually ahead of schedule.  Weíre going to be naming co-chairs.  I can name today one of those co-chairs -- Shantanu Agrawal, who is the president and CEO of the National Quality [Forum], with a heavy background in fraud, waste, and abuse.  Weíll be naming the second co-chair very soon.

Veteran Suicides.  And this is the last of the assessments.  Though all of the risks that Iíve talked about are troubling to me and require immediate attention, nothing is more important to me than making sure that we donít lose any veterans to suicide.  As you know, 20 veterans a day are dying by suicide.  That should be unacceptable to all of us.  This is a national public health crisis, and it requires solutions that not only VA will work on but all of government and other partnerships in the private sector, nonprofit organizations.

I authorized emergency mental health services for those that were less than honorably discharged just a few months ago.  That is a population of veterans that is at very high risk for suicide.  And thatís just the beginning.  This summer, weíre going to launch a new initiative called Getting to Zero to help us end veteran suicide.  And again, thatís my top clinical priority.

So, in closing, I just wanted to reaffirm the Presidentís strong commitment to fixing VA and making VA work better for veterans.  Thatís a commitment that I share.  I wanted to come out and to talk about these 13 areas, our assessment of where the problems are.  I want to be held accountable to fix this.  Iím going to need help to fix it from Congress and from other organizations.  But this is our commitment to finally address these problems that have been plaguing VA, sometimes for decades.

The President, the Vice President, Congress, veteran services organizations all share this goal to help modernize the VA.  And thatís why Iím confident that we can turn VA into the type of organization that veterans and families deserve, and all of us want to see.  I appreciate your attention.

Thank you very much.


Question:  Mr. Secretary, you spoke of the situation in Puerto Rico, and thereís a similar situation unfolding with the VA in Phoenix as well.  Does this new legislation you talked about, does it get rid of this Merit Systems Protection Board?  And will it eliminate the possibility that somebody like DeWayne Hamlin can get their job back at least temporarily?

Secretary Shulkin:  When we talk about the situation related to Mr. Hamlin, that decision was made before I was Secretary.  I would not have supported a decision that would have allowed him back.  The Merit System Protection Board indicated that they believed that we needed to take him back.  I would have fought that through all of the appeals processes that were available to us.

The accountability bill that we are seeking, that we hope that the Senate authorizes, still maintains a due process for employees -- something I believe in.  But it shortens the time and it gives more authority to the Secretaryís decision on why these accountability actions are being taken so that the courts would be more deferential -- thatís the legal term -- to the Secretaryís opinion.  I do believe that would have changed this situation.

Question:  Will you get anything in time to prevent a similar occurrence in Phoenix?

Secretary Shulkin:  Not until we get this accountability bill through the Senate.

Question:  Is there anything you can do about that situation?

Secretary Shulkin:  Youíre talking about with the veteran benefit employees with Sharon Helman?

Question:  Yes.

Secretary Shulkin:  We are following the court cases on that.  Weíre waiting for that final decision to come out.

Question:  Mr. Secretary --

Secretary Shulkin:  Yes.

Question:  Thank you.  This is a robust agenda that you have laid out.  Do you have a specific timeline?  And how engaged has the President been in some of the discussions?

Secretary Shulkin:  The President has been extremely engaged.  His commitment to being involved in veteran issues is one of his top domestic priorities.  He has made himself fully available -- both he and the Vice President -- to anything that we need.  The White House has been extremely responsive, and they are impatient and anxious for us to get on with this.

So each of these issues that Iíve talked about, these 13 issues, have different timelines associated with them because some require legislative action and some are more administrator requirements.

The Presidentís budget this year, as you know, gave strong support to VA.  And that will allow us to accomplish a great deal of whatís on this list to modernize the system.

Question:  And as you know, the administration has been dealing with some controversies.  Has that, in any way, impacted your agenda -- your ability to carry out some of these goals?

Secretary Shulkin:  Absolutely it has not.  We are completely focused on what itís going to take to fix the VA, and there has not been any lack of responsiveness from the White House on any of these issues.

Question:  Mr. Secretary, when we look at your list -- long list of priorities, do you have a sense of sort of top to bottom of these?  Whatís the most cost-intensive and how much is it really going to take in terms of money over 10 years to get you down this road?

Secretary Shulkin:  The budget that was proposed by the President for fiscal Ď18 is a budget that will help us accomplish this task.  I have said that the problems in VA are not largely going to be solved through additional money.  These are going to be solved through management practices, focus, and some legislation changes.

But our issues are not because weíre lacking the financial resources to be able to accomplish our mission.  And so, therefore, I do believe, with the exception of one area, that we will not be coming back to Congress or the administration to ask them for additional money.  And that one exception is to modernize our IT systems.  Iíve said that I will make an announcement as soon as I can before July 1st.  That is either going to look towards outsourcing our current system to a commercial vendor or picking a system that is a commercial, off-the-shelf system, and to get VA out of the software business.  And that will require an initial capital investment that's not in fiscal year budget.

Question:  Is this the most expensive thing that you have to do?

Secretary Shulkin:  Yes.

Question:  And facilities after that?

Secretary Shulkin:  Facilities are important.  What I'm looking to do in this National Realignment Strategy is to make sure that we're using our current resources most effectively.  That's why when I'm spending money on vacant and underutilized buildings that arenít helping veterans, I want to realign that to help invest back into our facilities that need for capital repairs.

Question:  Mr. Secretary, leaders of the American Legion wrote a rather impassioned op-ed last week that suggested that a promising solution to the suicide problem could be increased medical use of cannabis.  You talked about it being a national health crisis that requires all of government.  Should the Congress reclassify marijuana from a Schedule I drug to allow for it to be better used for medical purposes?

Secretary Shulkin:  Well, right now, federal law does not prevent us at VA to look at that as an option for veterans.  I believe that everything that could help veterans should be debated by Congress and by medical experts, and we will implement that law.

So if there is compelling evidence that this is helpful, I hope that people take a look at that and come up with the right decision, and then we will implement that.

Question:  As a physician, what's your opinion?

Secretary Shulkin:  My opinion is, is that some of the states that have put in appropriate controls, there may be some evidence that this is beginning to be helpful.  And we're interested in looking at that and learning from that.  But until the time that federal law changes, we are not able to be able to prescribe medical marijuana for conditions that may be helpful.

Question:  Your department has issued multiple reports saying climate change threatens the health of veterans and your staff, and it strains the VA's abilities to carry out its mission, and raises the chance of both healthcare emergencies and vector-borne diseases.  So I guess, in the spirit of the candid assessment that you said you were doing today, do you continue to see climate change as a dire threat to your mission?  And if so, are you disappointed that the President is reportedly pulling out of the Paris climate agreement, or at least reducing U.S. climate targets?

Secretary Shulkin:  As the Secretary of Veteran Affairs, I'm focused on those environmental issues that impact veterans, and our studies are focused on usually the chemical and the environmental impacts that are used on the battlefield.  Those are the ones that I continue to be focused on.  And beyond that, it really is beyond my scope as Secretary.

Question:  You donít believe -- or you're sort of repudiating the   multiple reports that have come out of your department that say climate change in the broader sense -- things like cardiovascular disease -- is a real kind of issue for your department.  That's not something that you're even considering at this point?

Secretary Shulkin:  Look, I am focused on the health of our veterans.  And, clearly, there's a relationship between health and the environment.  What I'm not focused on is the bigger political issues about United States policy on other types of reform.  I'm focused on the health of veterans.

Question:   You said it's going to take $18 billion to repair these facilities.  Do you have plans to close any of them?

Secretary Shulkin:  What we're doing is, under the National Realignment Strategy, we're looking at the best use of our current resources, because $18 billion is not a realistic number for us to be able to get to invest and put all of our facilities up to speed.  So we're looking at using the current resources that we have, the best to help veterans.  We are making investments.  This budget this year gives us additional dollars.  That's why I'm confident that this is the right budget for us, because it allows us to invest and start making significant progress into that $18 billion.

But I donít believe -- that was our assessment of what the entire inventory, if we rebuild it up to current standards, would take.  That's not what we're seeking.

Question:  So when you walk away from this, you think that maybe some should be closed?

Secretary Shulkin:  We want to take a look at every facility to make sure it's being utilized appropriately.  I do not have specific plans for ay facility closures at this point.

Question:  Mr. Secretary, what is the holdup in filling out your nominations to the Senate?  And do you believe that the lack of nominations has impacted in any way the work that you're trying to do and described here today?

Secretary Shulkin:  Well, one of the things that I'm very fortunate, having been here in the last administration, is that we've had pretty good continuity.  And the people that are filling our acting positions are people that I've worked with, have great confidence and trust in.  So we havenít really missed a beat at VA.  We've been able to keep going.

Of course, I want all of our positions filled as quickly as possible.  The vetting process that's going on is a lengthy process -- I know having gone through it myself -- but it's also really important to get right.  And so while we want to see it done as quickly as possible, we want to see it done thoroughly and make sure that we donít make mistakes.

I do believe that you will see several other announcements in the next week or two about positions that we will be filling.

Question:  Mr. Secretary, two questions.  You said the President's budget strengthens VA.  Two specific questions about the budget.  When it comes to individual un-employability, IU is drastically cut in the President's budget, and it's likely never to be made up by compensating Social Security.  Why do you believe that that's acceptable and in line with the administration's promise to do better by veterans?

Secretary Shulkin:  Well, letís put it -- letís take a look at this overall budget.  This is a 5.5 percent increase in total budget for veterans.  And when it comes mandatory funding, which is where the IU exists, we're seeing a $7 billion increase year-to-year in mandatory benefits to veterans.  So this is a budget that is providing more care and services to veterans.

In doing so, we have a responsibility to taxpayers and to veterans to make sure that the resources of our current programs are being utilized appropriately.  So we are going back and looking at programs and saying, are those resources -- could they be reallocated in different ways not to withdraw total dollars from veterans, but could they be revised and reallocated to work better for veterans?

In the case of IU, I think that what we've proposed is not an elimination of it, but a revision to make the program and resources that are going currently to some veterans, to help additional veterans.

I understand that there is a lot of passion on this, and we will have plenty of time to work with Congress and with our veteran service organizations to make sure that we're getting this right.

Question:   I want to ask you one other question about the budget, but just to follow up on that, a lot of VSOs consider this stealing from them, to be changing so fundamentally the way IU is calculated.  Whatís your response to that?

Secretary Shulkin:  I have such great admiration and respect for VSOs, and I understand their passion and I share their commitment that it is so important that this country honor its responsibility to our veterans.  That doesn't mean that you don't go back and revisit programs that have been around for a long time and figure out different ways to use those resources, as long as they're directed to helping veterans and more veterans.

Now, I understand thereís not always going to be agreement.  This is Washington, and we're always going to get passion over important topics.  And I welcome comments from our veteran service organizations about how to do things better.  And I know that since we share the same goal of helping veterans, that weíll get to the right answer.

Question:  Let me ask you one other thing, which is about -- the budget from the President focuses on providing care and purchasing care, less so on infrastructure.  You talked a lot about infrastructure, but you know what Iím talking about in terms of the VHA and where dollars tend to go.  Are you concerned about the long-term viability and the potential preference for privatization or focus on the Choice Program that's outlined in the outlays for this Presidentís budget?

Secretary Shulkin:  What I think the wait time showed us is that VA can't do this alone.  We have to work with the private sector.  Currently right now, about one-third of all veterans are getting care outside of VA.  Iím looking to build an integrated system of the very best of VA and to strengthen VA and the best of the private sector to make one system work for veterans.  That's going to be our new Choice legislation.

This is not a privatization of VA.  This is not diluting the impact of VA.  Every day Iím in this job I am more and more convinced that veterans and America need a strong VA.  Itís essential for national security.  Itís essential to honor our commitment.  I will not allow our policies to weaken the VA; our policies will strengthen the VA.  But working with the private sector is the way to do that.

Question:  And you don't have any concerns about where these dollars are going?

Secretary Shulkin:  Whatís that?

Question:  You don't have any concerns about the long-term effects of where these dollars are going?

Secretary Shulkin:  Well, of course, I have concerns.  I look at this every day.  But I do believe the budget and our legislative proposals that we're going to work with Congress on Choice will come up with the best balance between private sector and the VA.

Question:  You said the majority of veteran suicides are people who arenít under VA care.  Why is that?  And what is being done to reach out to those vets?

Secretary Shulkin:  So of the 20 veterans a day that are taking their life through suicide, six are getting their care in the VA system and 14 arenít.  The reason why those 14 arenít getting care is really, really important and a big focus of our research and understanding.  Some of them were other than honorably discharged.  That means that, as you know, 10 to 15 percent of active service members who leave the service leave with an other-than-honorable discharge that leaves them without benefits.  That's why I made the decision to offer those veterans emergency mental health services.

Secondly, homeless veterans -- very high risk for suicide, not likely to have good access to behavioral healthcare.  We are -- this budget that the President put forth, additional $600 million for a total of $1.7 billion to help get veterans off the street, get them into homes, and get them the services that they need.

Third, the conditions themselves -- depression and traumatic stress -- tend to isolate people.  They tend to withdraw because of their condition.  And those are the ones that we worry about the most about, which is why we say suicide is everybodyís responsibility -- family members, community members.  When you see people withdrawing, that is the time to reach out and get them help.

The veterans crisis line, which we've just staffed up -- now answering 99 percent of its calls; 1 percent now only going into rollover; 95 percent answered in 20 seconds -- is there 24 hours a day if you find a veteran who is at risk.

And finally, let me just say that this issue will continue to be our top priority until we figure out all the answers how to get each of those veterans help.

Question:  Thank you.  You mentioned that you identified 14 facilities that were providing lower care -- or lower standard of care than nearby private sector hospitals.  Are those hospitals -- can you identify them?

Secretary Shulkin:  Yes, yes, they're on our website -- the 14 one-star facilities.  I think you've even published an article about this.  And so those are the 14 that we're talking about.

When you're a one-star facility, it means that you're not only the lowest in the VA compared to other VA hospitals, but you also are below community standard.  And that's why those are the important ones to focus on.

And in our Choice Program, you will see, as we go out there, we're going to be making sure that veterans have Choice in particular, where the standard of care is not being met in the private sector.

Question:  Does that mean that they've not been accredited?  If they're one-star and they're below the community standard of care, does that mean they would not be accredited?

Secretary Shulkin:  No, all of our hospitals are accredited by the same national organizations that private sectors go through.  When you talk about below standards, we're talking about averages.  And so by definition, thereís always going to be those that are below.  VA has set a bar that is above average, that essentially we want all VA hospitals, because we believe all veterans deserve the very best care possible.  So it's not a minimal standard.  All of our hospitals are accredited.

Thank you very much, everybody.

Book/CDs by Michael E. Eidenmuller, Published by McGraw-Hill (2008)

Text, Audio, Image (Screenshots) Source: WhiteHouse.gov

Audio Note: AR-XE = American Rhetoric Extreme Enhancement

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