WASHINGTON—Capacity issues, a changing patient demographic, successes and failures in information technology and the possibility of mandatory enrollment are all issues on Department of Veterans Affairs Secretary Eric Shinseki’s mind as he tries to get a grasp on the people, programs and infrastructure that make up VA. It is a task, he admitted to legislators, that he is still in the process of completing, and there are problems such as long waiting lines and the issue of priority 8 veterans that he is still researching.

Sitting before the House VA Committee last month to discuss the current state of VA, Shinseki said that whatever decisions he makes in the months to come they will be taken with the goal of “undertaking the kind of change that will restore this department to preeminence in government.”

Information Technology vs. Long Lines

Given VA’s emphasis on IT in recent years, legislators wanted to know how the department plans to use new technology to drive standardization and modernization, especially in the disability adjudication process.

“Let me give you a picture of what our adjudication process looks like. If you were to walk into one of the rooms where a group of people is [adjudicating a disability claim] you would see people sitting at desks with stacks of paper reaching almost to the ceiling,” Shinseki described. “There are thousands of people doing this daily, good people, trying to do use good judgment to [make a decision].”

Currently there are 11,100 VA adjudicators tackling over half a million pending disability claims. Last year, VA hired 4,000 new adjudicators. This year the department plans to hire 1,100 more. “If we don’t take this and create a paperless process, I’ll report a year from now that we’ve hired more people to do this,” Shinseki said. “In my opinion, this is a brute-force solution, and in my opinion we need to take this very quickly into an IT format that allows swift, consistent decision making.”

“My intent is to get to a paperless solution as soon as possible,” he said.

Transition from DoD

The backlog problem is intrinsically linked to another high-priority problem—the transition of servicemembers from Department of Defense to VA. It is an issue, Shinseki said, that must be solved from the top down.

“I’ll begin with leadership,” Shinseki said. “This is going to happen faster and at higher quality than it is happening now. This is not a technical issue in my opinion. If it’s going to be solved any faster, it’s going to take leadership.”

The week prior to the hearing Shinseki met with DoD Secretary Robert Gates to discuss chairing the agencies’ joint committee on transition. Traditionally deputies chair the committee.

“He and I agreed that we would chair the next meeting, maybe the next two meetings, to provide the leadership, establish the priorities and keep the momentum on finding solutions,” Shinseki said. “To get to the point of having a single, transferable medical record, it’s going to take leadership. Secretary Gates and I are going to have to leverage.”

Another issue the two discussed was the possibility of mandatory enrollment in VA for servicemembers leaving the military. “That alone will force the two institutions to begin to move together on what other [things] need to be handed off at that point. It would force us to do other things to achieve mandatory enrollment in VA, even for those who don’t have a disability claim at that point. Because 10 years down the road, who knows? Twenty years down the road, who knows?” Shinseki explained. “We don’t want to be doing what we’re doing now and chasing records. We want to make adjudication based on complete records.”

Priority 8 Veterans

Of VA’s plans to open up enrollment to priority 8 veterans—those lowest priority veterans without service-connected health problems who make approximately $27,000 or more—Shinseki said he is still getting a handle on how many new enrollees this would entail.

“I’m still sizing the population here. Today, at least, I don’t have a good feel for what it is,” Shinseki said. “But we are going to begin including priority 8s based on the funding and support Congress gave last year. That will begin sometime this summer.”

Shinseki estimated there would be 266,000 new priority 8 veterans entering the system, adding that, considering the current economic crisis, VA should be prepared to see some upward enrollment in all priority areas.

Rep. Mike Michaud, D-Maine, suggested that, considering how many veterans are losing their jobs and their healthcare, VA take a look at finding a way to examine a veteran’s current fiscal reality rather than their income from the year previous.

PTSD/TBI

Despite advances in polytrauma care for patients and in screening for post-traumatic stress disorder and traumatic brain injury, legislators reported hearing numerous complaints from constituents on the care they and their family members received at VA.

“VA is a bureaucracy that has a lot of good people working in it, but also has a lot of driftwood that shouldn’t be there,” declared Rep. Caro Rodriguez, D-Texas. “We [as legislators] are doing a lot of casework that the VA should be doing. VA should look at [improvements] in terms of case management.”

Shinseki said that VA had screened 235,000 new patients for PTSD and TBI to date. Of those, 45,000 were registered as potential TBI, with 12,500 of those confirmed for mild TBI. Since 2001, over 6,000 moderate and severe TBI cases have been documented in returning servicemembers.

“VA is doing similar things with PTSD. In 1999, we were providing disability payments to about 120,0000 veterans in the category of PTSD; as of this past September, that number is up to 340,000,” Shinseki said.

Rep. Bob Filner, D-Calif., committee chair, argued that the screening that VA and DoD has in place is not enough. “There has to be a mandatory evaluation for TBI and PTSD. Right now it’s a self-questionnaire. But everyone knows if they want to go home, they don’t answer questions accurately. I mean [we need] medical personnel giving an evaluation before they leave the service. You can order that to happen,” Rep. Filner said. “Even the screening when these young men and women come into the VA, a lot of it is done by self-questionnaire. The numbers are too high. The denial is too great.”

Women in VA

The number of female servicemembers returning from Iraq and Afghanistan is expected to double in the next five years—a face of modern warfare that will force VA to adapt to new care needs.

“We anticipate by 2020, 15 percent of our veterans will be women,” Shinseki told legislators. “Having come through the experience of women joining the ranks of the Army in large numbers, we played catch-up there. And we in VA are probably playing a little catch-up here. But the timing is right for us to put in place the kinds of things that will anticipate a 15 percent population. At every one of our hospitals, there is a women’s coordinator, a women’s advisory group trying to anticipate what other initiatives we should be pursuing.”

Again, Rep. Filner questioned whether VA should be doing more. “You ought to find out who these coordinators are and what they’re doing,” he said. “It might be somebody who is only doing it as a few percent of their job. [I’ve visited hospitals and found] it’s some clerk who’s collecting statistics. That’s their coordinator.”

Wrapping up the hearing, Rep. Filner told Shinseki, “[A lot of veterans] think VA means Veterans Adversary rather than Veterans Advocate. They’ve had too many problems with VA. They need to see you’re hands-on, because a lot of confidence has been lost. And I think we need to rebuild that. You have a reputation of speaking truth to power. You’ve been called a soldiers’ soldier. And now you’re a veterans’ veteran.”