[Senate Hearing 108-836]
[From the U.S. Government Publishing Office]
S. Hrg. 108-836
THE FINAL REPORT OF THE DEPARTMENT
OF VETERANS AFFAIRS CAPITAL ASSET
REALIGNMENT FOR ENHANCED SERVICES COMMISSION
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
__________
MARCH 2, 2004
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
.........................................................
Arlen Specter, Pennsylvania, Chairman
Ben Nighthorse Campbell, Colorado Bob Graham, Florida
Larry E. Craig, Idaho John D. Rockefeller IV, West
Kay Bailey Hutchison, Texas Virginia
Jim Bunning, Kentucky James M. Jeffords, (I), Vermont
John Ensign, Nevada Daniel K. Akaka, Hawaii
Lindsey O. Graham, South Carolina Patty Murray, Washington
Lisa Murkowski, Alaska Zell Miller, Georgia
E. Benjamin Nelson, Nebraska
William F. Tuerk, Staff Director and Chief Counsel
Bryant Hall, Minority Staff Director and Chief Counsel
C O N T E N T S
----------
MARCH 2, 2004
SENATORS
Page
Specter, Hon. Arlen, U.S. Senator from Pennsylvania.............. 1
Murray, Hon. Patty, U.S. Senator from Washington................. 2
Rockefeller IV, Hon. John D., U.S. Senator from West Virginia.... 2
Graham, Hon. Bob, U.S. Senator from Florida...................... 15
Prepared statement........................................... 15
Hutchison, Hon. Kay Bailey, U.S. Senator from Texas.............. 16
WITNESSES
Alvarez, Hon. Everett Jr., Chairman, CARES Commission,
accompanied by Hon. R. John Vogel, Vice Chairman, CARES
Commission; and Richard McCormick, CARES Commission............ 3
Prepared statement........................................... 5
Response to written questions submitted by:
Hon. Arlen Specter....................................... 13
Hon. Ben Nighthorse Campbell............................. 15
Roswell, Hon. Robert H., M.D., Under Secretary for Health, U.S.
Department of Veterans Affairs................................. 17
Prepared statement........................................... 18
Wiblemo, Cathleen C., Deputy Director of Health Care, Veterans
Affairs and Rehabilitation Commission, The American Legion..... 40
Prepared statement........................................... 41
Cullinan, Dennis M., Director, National Legislative Service,
Veterans of
Foreign Wars of the United States.............................. 46
Prepared statement........................................... 46
Ilem, Joy J., Assistant National Legislative Director, Disabled
American
Veterans....................................................... 48
Prepared statement........................................... 48
Doran, James W., National Service Director, AMVETS............... 54
Prepared statement........................................... 55
Cowell, Fred, Health Policy Analyst, Paralyzed Veterans of
America........................................................ 57
Prepared statement........................................... 57
THE FINAL REPORT OF THE DEPARTMENT OF VETERANS AFFAIRS CAPITAL ASSET
REALIGNMENT FOR ENHANCED SERVICES COMMISSION
----------
TUESDAY, MARCH 2, 2004
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 3:02 p.m., in
room
S-207, United States Capitol, Hon. Arlen Specter, Chairman of
the Committee, presiding.
Present: Senators Specter, Hutchison, Graham, Rockefeller
and Murray.
OPENING STATEMENT OF HON. ARLEN SPECTER,
U.S. SENATOR FROM PENNSYLVANIA
Chairman Specter. Good afternoon, ladies and gentlemen. The
hearing of the Senate Veterans' Affairs Committee will now
proceed. We regret the inconvenience in moving from our
scheduled hearing room in the Russell Senate Office Building.
As you know, we are in a series of votes in the Senate and
rather than postpone the hearing, it seemed preferable to
reschedule for this room where Senators can exit and vote and
come back. We are now in the middle of two of four votes this
afternoon, after having voted three times this morning. The
Senate votes take priority over just about everything else.
We are proceeding today with an examination of the CARES
Commission report, a very important report on the changes in
providing medical care to America's veterans. We are facing a
very difficult situation with veterans' care, with the current
budget proposals probably requiring a cut, at least on their
face as they have been submitted by the Administration. And
that is in the face of a recommendation by the Secretary of
Veterans' Affairs for an increase of some $1.3 billion.
We will have to sort all of that out in the budget process,
but I think there is determination in the Congress that there
not be a reduction in the quality of medical care for America's
veterans. We are facing a difficult situation internationally
with the war in Iraq and the remnants of a war in Afghanistan
and servicemen scattered around the world fighting terrorism,
and a large detachment in South Korea.
The President has proposed a 7-percent increase in the
Defense budget and about a 10-percent increase in the Homeland
Security budget. There is a direct correlation between defense
and veterans' care at a time when there is an effort made to
recruit young men and women to be put in harm's way, a very
grave problem. It is hard to recruit if the young men and women
who are being asked to enlist do not see that the veterans are
being treated well.
With respect to the CARES Commissions' proposals, this
Committee will make its facilities available to all Members of
the Senate beyond those who are on the Committee to raise
questions about proposals that might affect hospitals in their
own States. Earlier today, I talked to the Ranking Member,
Senator Graham of Florida, and his colleague, Senator Nelson,
about a field hearing that they want to have in Florida and I
have said that that would be authorized by the Committee.
The Committee will have field hearings in Pittsburgh,
Altoona and Erie. If other Senators, even those not on the
Committee, want to have field hearings, we are prepared to find
out exactly what is going on. We are determined that there will
not be a reduction in health care available to America's
veterans. If it is a substitution of different forms of CARE,
and if the substitutes are adequate or superior, then this
Committee will entertain them.
We know that the issue has to be passed upon by the
Secretary of Veterans' Affairs, and that this decision will, of
course, be subject to review by this Committee. The final word
will be up to the Congress as to what will happen.
We have a great many witnesses, but we have Senators here
who doubtless want to say something, if it could be brief.
Senator Murray, in order of arrival, would you care to make
an opening statement?
OPENING STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you Mr. Chairman. I just want to
welcome the witnesses today. Admiral Alvarez did an admirable
job, I think, putting this together, but there are very, very
deep concerns in most of our States where this is being
effected.
I have sent a letter to Secretary Principi regarding the
Walla Walla facility. I do have some questions I want to ask
you about when we get to that comment period. But, Mr.
Chairman, I was pleased to hear you mention field hearings. I
hope that Washington State can be considered for that. We are
going to have a very huge impact from this. There is a lot of
concern generated.
Chairman Specter. Senator Murray, if you want a field
hearing in Washington, you have got it.
Senator Murray. Thank you very much, Mr. Chairman.
Chairman Specter. I was a little in doubt as to whether to
go first to Senator Murray, who arrived first, or to the
longer-serving Senator who was Ranking Member and Chairman of
this Committee. I opted for Senator Murray, but now I turn to
you, Senator Rockefeller.
OPENING STATEMENT OF HON. JOHN D. ROCKEFELLER IV,
U.S. SENATOR FROM WEST VIRGINIA
Senator Rockefeller. I am going to be very, very brief.
Chairman Alvarez, we welcome you and all of your colleagues
from the CARES Commission. You should know and not be surprised
by the fact that in West Virginia, which is a land that has
about 4 percent of our land which is flat and 96 percent which
is going uphill or downhill, and that all people, all
industries, all activity has to take place in that 4 percent
virtually, the closing of the Beckley hospital is painful. Any
closing is painful. This one is very painful.
Our delegation is disappointed with the recommendations. We
strongly disagree with your conclusions, but we respect what
you have to go through and understand that tough decisions have
to be made.
I will only say, Mr. Chairman, that you have established
some key factors, principles, including how will this affect
veterans' access to health and the quality of care; what are
the views of the veterans stakeholders in the area and how do
you know their views; and what about the effect on the local
community and what are the costs to the VA; and, in addition,
are there places that they could go for health care.
So I will be discussing and questioning a couple of those
points, but I very much appreciate the Chairman's indulgence
and your presence.
Chairman Specter. Thank you very much, Senator Rockefeller.
Our first witness is the distinguished Chairman of the
CARES Commission, the Honorable Everett Alvarez, a
distinguished Naval officer and Government executive best known
as the first American aviator shot down over North Vietnam. He
was taken prisoner of war and held in North Vietnam for some
8\1/2\ years. He has a J.D. degree from George Washington
University School of Law. He has served as Deputy Director of
the Peace Corps and Deputy Administrator of the VA from 1982 to
1986.
Thank you, Chairman Alvarez, for your distinguished service
in so many capacities. We have a procedure established for a 5-
minute time period, which will give the maximum amount of time
to Senators for Q and A, and we do have a large number of
witnesses. So we look forward to your testimony. You may
proceed.
STATEMENT OF HON. EVERETT ALVAREZ, JR., CHAIRMAN, CARES
COMMISSION, ACCOMPANIED BY: HON. R. JOHN VOGEL, VICE CHAIRMAN,
CARES COMMISSION; AND
RICHARD McCORMICK, CARES COMMISSION
Mr. Alvarez. Thank you, Mr. Chairman and Members of the
Committee. Mr. Chairman, my formal testimony has been submitted
and I ask that it be accepted for the record.
Chairman Specter. Your full statement will be made a part
of the record, without objection.
Mr. Alvarez. Mr. Chairman, I am pleased to be here today on
behalf of the entire CARES Commission to present the CARES
Commission report. With me today are two other members of the
CARES Commission here, our Vice Chairman, John Vogel, on my
immediate left, and Commissioner Dr. Richard McCormick, on my
right. Also, behind me is Commissioner Charles Battaglia, who
will be available to answer any questions.
Mr. Chairman, I come before you today representing the
CARES Commission. We are 16 individuals with broad experience
in health care and veterans advocacy. I can attest that the
commissioners recognized the enormity and importance of their
task, which was to critique and modify a blueprint for
enhancing the health care of as many veterans as feasible into
the future. And let me emphasize that point, sir. The
commission views the draft National CARES Plan as a blueprint
for VA health care for the next 20 years.
Health care delivery in this country is changing. VA's
health care delivery is under change and this change needs to
be managed carefully and respectfully. The commission sees its
blueprint as a road map to the future, a tool to help manage
future change.
Within the time constraints, the commission evaluated an
enormous amount of data. We listened to many veterans,
providers of care and stakeholders. We had 81 site visits and
we held 38 public hearings across the country, and focused our
collective experience on the task.
Our report, which you have, is large and far-reaching. It
includes important discussions and recommendations on issues
that cut across the entire VA health care system. It also
includes hundreds of site-specific recommendations. If the plan
is to succeed in its goals, priorities still need to be
attended to and properly aligned. Evaluations still need to be
conducted for important components of VA health care, and
internal processes need to be overhauled.
I wish in these opening remarks to share the principles
that served as a beacon to guide us through our complex
deliberations.
First and foremost, to improve access to as many veterans
as possible to high-quality, veteran-specific health care. The
VA facilities were largely built 40 to 50 years ago. The
population demographics have shifted. The delivery of health
care has increasingly become an issue of access both for
veterans and their families, who need to partner in their care.
Cost of efficiency. When, as is the case today, the health
care needs of some veterans are unfulfilled, particularly for
the highest-priority veterans with war-related physical and
mental disabilities, then efficiency is also an issue of access
and quality of care. If we do not use resources as efficiently
as we can, some veterans in dire need of services may not
receive the care they need or deserve. Therefore, the
commission also looked at the cost/benefit of each
recommendation. We recognize that the costs that were provided
were often in need of further refinement, forcing us to
consider the likelihood, based on past experience in VHA and a
test of reasonableness, that an action would improve
efficiency.
The impact of change in the status quo on current
recipients of services, current VA employees and the
communities where our facilities have been historically located
was another key principle that guided the commission. The
commission recognizes that the shifting of resources necessary
to improve overall access will be a hardship for some. We
expect that the implementation of necessary change will take
this into account when time lines for modifications are
finalized.
The commission's recommendations are our assessment of what
is best for VA health care as we move forward. We are not
infallible. Things will change over time and there may be
factors that need to be reconsidered. However, this is our best
effort.
We look to the Secretary and to the Congress to further
refine and improve upon our assessment, keeping, we hope, in
their focus the principles that have guided our deliberations
to provide access to high-quality health care to as many
veterans as our resources permit.
Mr. Chairman and Members of the Committee, I would like to
thank you for the opportunity to address you. My fellow
commissioners and I look forward to your questions, and an
ongoing dialog, we trust, will move all of us closer to our
jointly held goal to serve those who have and are serving our
country.
Thank you, sir.
[The prepared statement of Mr. Alvarez follows:]
Prepared Statement of Hon. Everett Alvarez, Jr.,
Chairman, CARES Commission
Mr. Chairman and Members of the Committee, good afternoon. I am
pleased to be here today on behalf of the entire Commission, to present
the Capital Asset Realignment for Enhanced Services (CARES)
Commission's Report. With me today are Vice-Chairman John Vogel, and
Commissioners Mr. Charles Battaglia and Dr. Richard McCormick.
The Commission's journey began in February, 2003, when The
Honorable Anthony J. Principi, Secretary of Veterans Affairs, asked the
Commission to provide specific impartial and equitable recommendations
for realignment and allocation of capital assets to meet the demand for
veterans health care services over the next 20 years. As you know, Sir,
the goal of CARES is to enhance services, not to save money--but to
spend appropriated funds wisely. In fulfilling our obligation to
Secretary Principi, to veterans and their families, to stakeholders and
partners, and to the dedicated VA staff, Commissioners:
Visited 81 VA and Department of Defense medical facilities
and State Veterans Homes;
Held 38 public hearings across the country, with at least
one hearing in each Veterans Integrated Service Network (VISN);
Held 10 public meetings;
Analyzed more than 212,000 comments received from
veterans, their family members, and stakeholders.
At the public hearings, the Commission had the opportunity to hear
from approximately 770 invited local speakers, including VISN
leadership, veterans, veterans service organizations, State directors
of veterans affairs, local labor organizations, medical and nursing
school and other allied health professional affiliates, organizations
with collaborative relationships, and local elected officials. Seven
Governors and 135 Members of Congress participated or provided
statements for Commission hearings.
The CARES Commission Report is the compilation of information
gathered at these site visits, public hearings, and meetings as well as
information obtained from the public comments and VA. It represents the
best collective judgment of the Commissioners, who applied their
diverse expertise in making decisions related to the future of VA's
infrastructure. I would like to emphasize, Mr. Chairman, that the focal
point of the Commission's effort and report is enhancing access to
health care for America's veterans while ensuring that the integrity of
all VA missions is maintained, and any adverse impact on VA staff and
affected communities is minimized.
commission approach
Mr. Chairman, to assess the reasonableness of each proposal in the
Draft National CARES Plan, the Commission developed and applied the
following factors:
Impact of veterans' access to health care
Impact on health care quality
Veterans and stakeholder views
Economic impact on the community
Impact on VA missions and goals, and
Cost to the Government
In applying these factors, the Commission evaluated each proposal
using available data and written analysis submitted by each VISN and by
VA's Under Secretary for Health, Dr. Robert Roswell. The Commission's
recommendations are based on this evaluation and the knowledge gained
through the Commission's study of VA's infrastructure and health care
system.
national crosscutting issues
Through the public meetings, site visits, hearings and informal
meetings with individual veterans and stakeholders, the Commission
developed a deeper appreciation for the complexity of the system-wide
issues confronting VA and the significance of the changes proposed in
the Draft National CARES Plan. The Commission identified a variety of
issues that are critical to VA's success as it continues to realign and
transform its health care system. The Commission believes that
resolution of these national crosscutting issues is essential to
achieve the changes the Secretary desires and to accomplish CARES goals
for enhanced services to veterans.
The Commission identified six national crosscutting issues. These
are:
1. Facility Mission Change
2. Community-Based Outpatient Clinics
3. Mental Health Services, which includes acute inpatient and
outpatient services
4. Long-Term Care, including geriatric and seriously mentally ill
services
5. Excess VA Property
6. Contracting for Care
The Commission determined that for VA to reach a successful outcome
from the CARES process, it was essential that recommendations be
developed for these crosscutting issues. These issues and related
recommendations, while appearing at times to be discrete from one
another, are in fact interdependent, and require careful integration.
For example, facility mission changes and managing excess property
concentrate on the realignment of capital assets. The prioritization
and placement of community-based outpatient clinics and contracting for
care in local communities focus on developing equitable access to
quality health care. Similarly, the issues of mental health services
and long-term care deal with providing access to quality services.
Recommendations on the national crosscutting issues served to guide
the Commission's decisionmaking as it reviewed the VISN-specific
proposals in the Draft National CARES Plan. The Commission believes
that these crosscutting recommendations should be the basis for
developing national policy guidance.
Mr. Chairman, I would now like to discuss each of the six national
crosscutting issues.
1. facility mission changes
The intent of the CARES process is to realign resources in order to
enhance access to health care services for our nation's veterans. To
accomplish this goal, it is critical to eliminate duplicate clinical
and administrative services at VA facilities, increase efficiencies,
and allow reinvestment of financial savings.
The Draft National CARES Plan proposed consolidation of services at
40 facilities--18 with small workload volumes (``small facilities'')
and 22 within close geographic proximity of other facilities
(``proximity'') or with multiple campuses (``campus realignment''). Of
the 18 small facilities, the Draft National Cares Plan identified seven
facilities that would convert to a new type of facility modeled after
the Centers for Medicare and Medicaid Services designation of a
critical access hospital. The Commission used the term ``facility
mission changes'' to describe all recommended changes to facilities.
As mentioned earlier, the Commission applied specific factors in
its evaluation of each mission change proposal to assess the proposal's
reasonableness. In applying these factors, the Commission relied on the
broad expertise and experience of the Commission members. Further, due
to a lack of supporting data for the Draft National CARES Plan's
proposals on facilities with a potential mission change, the Commission
evaluated each facility using its own factors, taking into
consideration the unique issues in the various VISNs and issues
associated with urban and rural areas, and utilized data in a number of
areas such as past, present and projected VA workload; whether there
were alternative community resources, costs; quality of care; and
financial analyses. I should emphasize, Mr. Chairman, that the
Commission considered access and quality of care to be the primary
drivers in meeting the health care needs of veterans.
Mr. Chairman, if I may, I would like to address the Commission's
recommendations on those facilities with a potential mission change
where the Commission did not concur in whole or in part with the Draft
National Cares Plan.
Before I do, Sir, I will say that the Commission did not concur
with the Draft National CARES Plan's proposal designating seven medical
facilities as critical access hospitals primarily because VA had not
established a clear definition or clear policy on the critical access
hospital designation prior to making decisions on the use of this
designation. We understand, however, that the Under Secretary for
Health has assembled a team of experts and a draft definition has been
developed. The Commission has not evaluated this newly developed
definition.
VISN 1--Bedford, Massachusetts: The Commission did not concur with
the change in mission at Bedford. The Commission recommended a more
thorough study of the feasibility of building a single, replacement
medical center in the Boston area.
VISN 2--Canandaigua, New York: The Commission concurred with
transferring acute inpatient psychiatry beds and that Canandaigua
retain its ambulatory care programs. The Commission recommended that
Canandaigua retain long-term care, including the nursing home,
psychiatric nursing home care and the domiciliary. The Commission also
recommended that the VISN develop another strategic plan for the
challenges it faces in Canandaigua with high overhead costs, unused or
underutilized buildings, and the impact on the community and employees
and that the VISN involve stakeholders and the community to resolve
these issues.
VISN 3--Montrose, New York: The Commission recommended that the
inpatient psychiatry beds and nursing home care beds be moved from the
Montrose campus to the Castle Point campus and that the domiciliary-
based residential rehabilitation programs and the ambulatory care
services remain at the Montrose campus.
VISN 3--Castle Point, New York: The Commission concurred with the
proposal to transfer the spinal cord injury beds to the Bronx. The
Commission did not concur with designating the facility a critical
access hospital.
VISN 4--Pittsburgh, Pennsylvania--Highland Drive Division: The
Commission concurred with the proposal to consolidate services at the
Highland Drive Division of the Pittsburgh Health Care System with the
University Drive Division and the Heinz Progressive Care Center. The
Commission, however, recommended that VA conduct an improved life cycle
cost analysis.
VISN 4--Erie, Pennsylvania: The Commission concurred with the
proposal to close inpatient surgical services at the Erie VA Medical
Center and retain outpatient services (including outpatient surgery)
and long-term care programs. The Commission did not concur with the
proposal that Erie maintain the remainder of its current inpatient
services and recommended that all acute care beds be closed as soon as
reasonable. The Commission also recommended that VISN 4 continue its
referral practices to the Pittsburgh Health Care System for Erie area
veterans and that the VISN pursue available resources in the Erie
community.
VISN 4--Altoona, Pennsylvania: The Commission concurred with the
proposal that the Altoona VA Medical Center maintain its outpatient
services, as well as its long-term care programs. The Commission did
not concur with the proposal to close Altoona's acute care services by
Fiscal Year 2012 and recommended that acute care beds be closed at
Altoona as soon as reasonable. The Commission also recommended that
VISN 4 continue its referral practices to the Pittsburgh Health Care
System for Altoona area veterans and that the VISN utilize available
resources in the Altoona community.
VISN 6--Beckley, West Virginia: The Commission did not concur with
the proposal to convert the Beckley VA Medical Center into a critical
access hospital and recommended closing the acute inpatient hospital
beds and contracting for acute inpatient care in the community as soon
as reasonable. The Commission also recommended that the Beckley VA
Medical Center retain its multi-specialty outpatient services and the
nursing home.
VISN 7--Augusta, Georgia--Uptown Division: The Commission did not
concur with the proposal to study the feasibility of consolidating
selected current services at the Uptown Division to the Downtown
Division because we found the proposed realignment to be impractical.
VISN 8--Lake City, Florida: The Commission did not concur with the
proposal to move inpatient surgery services at the Lake City VA Medical
Center to the Gainesville VA Medical Center at the present time. In
light of the projected growth of enrollees and the access gap in the
North Market of VISN 8, the Commission recommended that any
consideration of transfer of inpatient services from Lake City to
Gainesville be delayed until after Fiscal Year 2012. The Commission
concurred with the proposal to maintain nursing home care and
outpatient services at the Lake City VA Medical Center.
VISN 9--Lexington and Leestown, Kentucky: The Commission did not
concur with the proposal to transfer current outpatient care and
nursing home care services from Leestown to Cooper Drive. The
Commission recommended that the Lexington-Leestown campus remain open
and continue to provide nursing home, outpatient care, and
administrative services.
VSIN 10--Cleveland, Ohio--Brecksville Campus: The Commission
concurred with the proposal to relocate current psychiatric care,
nursing home care, domiciliary, and residential services from the
Brecksville Campus to the Wade Park Campus, provided the existing level
of services can be maintained. The Commission also concurred with the
proposal to pursue enhanced use lease opportunities at Brecksville in
exchange for property adjacent to Wade Park.
VISN 11--Saginaw, Michigan: The Commission concurred with the
proposal to discontinue acute medical services at the Saginaw VA
Medical Center. The Commission also concurred with the proposal to
maintain the nursing home and outpatient care at the Saginaw VA Medical
Center.
VISN 15--Poplar Bluff, Missouri: The Commission recommended that a
target date be set for making a full cost-benefit analysis for
sustaining inpatient services at the Poplar Bluff VA Medical Center
versus contracting for such services. The Commission further
recommended that, based on the results of that assessment, a decision
be made regarding whether or not to close inpatient services at Poplar
Bluff. The Commission does not concur with designating the facility a
critical access hospital.
VISN 16--Muskogee, Oklahoma: The Commission concurred with the
proposal to close inpatient surgery and intensive care unit beds at the
Muskogee VA Medical Center and that ambulatory surgery should continue
with surgery observation beds. The Commission recommended that a more
thorough study be conducted of meeting health care needs of the
population through the Muskogee VA Medical Center versus using
community resources in the Muskogee/Tulsa area. A target date should be
set for completion of this study. In the short term, inpatient medical
services should be sustained. Expansion of inpatient psychiatry should
await the results of the study.
VISN 17--Waco, Texas: The Commission concurred with the proposal to
transfer services from the Waco campus to appropriate locations within
the VISN as follows: (1) a portion of acute care inpatient psychiatry
to Austin; (2) the balance of acute care and all the long-term
inpatient psychiatry to the Temple VA Medical Center; and (3) post-
traumatic stress disorder residential rehabilitation services to the
Temple VA Medical Center, with no decrease in capacity. The Commission
concurred with the proposal to transfer the Blind Rehabilitation Center
from Waco, but recommends that the VISN determine an appropriate
location taking into account access and the Blind Rehabilitation
Center's role as a regional rehabilitation referral center. The
Commission concurred that a new multi-specialty outpatient clinic be
established in the Waco area. The Commission did not concur with the
proposal to transfer Waco's nursing home services to the community. The
Commission recommended that time be provided for the transition to
allow an orderly transfer with minimal disruption to patients and
families and for the VISN to involve veterans, stakeholders, and the
community in a plan for the Waco campus that is most beneficial to
veterans.
VISN 17--Kerrville, Texas: The Commission concurred with the
proposal to transfer the Kerrville VA Medical Center's acute inpatient
services and recommends that the VISN contract with community health
care providers for these acute inpatient services, including urgent
care services, in lieu of or until space is available at the San
Antonio VA Medical Center. The Commission concurred with the proposal
that the nursing home and outpatient services remain at Kerrville. The
Commission did not concur with designating the facility a critical
access hospital.
VISN 18--Big Spring, Texas: The Commission concurred with the
proposal insofar as it relates to studying the possibility of no longer
providing health care services at the Big Spring VA Medical Center. The
study should take into account the input of stakeholders regarding
access to care. The Commission did not concur with designating the
facility a critical access hospital.
VISN 19--Cheyenne, Wyoming: The Commission recommended that the
Cheyenne VA Medical Center retain its current. The Commission did not
concur with designating the facility a critical access hospital.
VISN 19--Grand Junction, Colorado: The Commission recommended that
the Grand Junction VA Medical Center retain its current mission. The
Commission did not concur with designating the facility a critical
access hospital.
VISN 20--Vancouver, Washington: The Commission recommended
maintaining the current mission at the Vancouver facility, while
reducing the campus footprint. The Commission also recommended that VA
explore options to expand Vancouver's function, particularly with
regard to relocating services from the Portland VA Medical Center.
VISN 20--White City, Oregon: The Commission did not concur with the
Draft National CARES Plan's proposal to transfer the domiciliary and
Compensated Work Therapy programs from White City to other VA medical
centers in the VISN. The Commission, however, agreed with the VISN-
recommended alternative that the White City Southern Oregon
Rehabilitation Center Clinic maintain its current mission. The
Commission did concur with the Draft National CARES Plan's proposal to
maintain outpatient services at White City.
VISN 20--Walla Walla, Washington: The Commission concurred with the
proposal to close and, where appropriate, contract for acute inpatient
medicine and psychiatry care and nursing home care in the Walla Walla
geographic area. The Commission also concurred with the proposal to
maintain outpatient services and recommended that outpatient care be
moved off the Walla Walla VA Medical Center campus after inpatient
services have been relocated.
VISN 21--Livermore, California: The Commission concurred with the
proposal to transfer sub-acute beds to the Palo Alto VA Medical Center,
and that outpatient care should be shifted to CBOCs. The Commission
recommended that the nursing home beds at the Livermore VA Medical
Center be retained as a freestanding nursing home care unit.
VISN 23--Hot Springs, South Dakota: The Commission recommended that
the Hot Springs VA Medical Center retain its current mission to provide
acute inpatient medical, domiciliary and outpatient services. The
Commission did not concur with designating this facility a critical
access hospital.
VISN 23--Knoxville, Iowa: The Commission concurred with the
proposal to move all inpatient services to the Des Moines and to retain
outpatient services at the Knoxville VA Medical Center.
2. community-based outpatient clinics
Following the VISN's submissions outlining the needs for additional
CBOCs, the Under Secretary for Health developed criteria to organize
proposed CBOCs into three priority groups. The Under Secretary
indicated to the Commission that priority groups were established in
order to constrain demand on the system. The Commission believed the
Under Secretary's approach to determine priority groups has the effect
of limiting access to outpatient care, which is contrary to the goal of
CARES. It also had unintended consequences in that it inadvertently
disadvantaged veterans in rural communities by generally placing CBOCs
for rural areas in the second priority group because of the relatively
small veteran populations in these markets. Further, the same
population data used to propose a CBOC could be clustered in different
ways yielding various results in the prioritization of CBOCs.
VISNs also proposed new CBOCs to address overall workload issues
and space capacity issues at parent facilities and existing CBOCs. The
Commission learned that several facilities are currently operating at
and over capacity for outpatient care. Proposed CBOCs that address
space issues associated with increased workload are in the third
priority group. Without timely development of new sites of care,
whether designated as CBOCs or otherwise, there will be greater demand
on existing clinic space and examination rooms, leading to inefficient
workflow and a reduction in the total number of patients that can be
seen in a given day. This in turn could lead to increased wait times.
Some parent facilities also have projected growth in inpatient
workload, requiring conversion of outpatient space back to its original
inpatient purpose. Without the timely establishment of new CBOCs, many
facilities will require construction to accommodate workload increases,
a more costly solution with longer-term ramifications.
The Commission recommended that the Secretary and the Under
Secretary for Health use their authority to establish new CBOCs with
the VHA medical appropriations without regard to the three priority
groups. Also, the Commission recommended that VISNs set priorities for
new CBOCs based on VISN needs to improve access and to respond to
increases in workload. Additionally, the Commission recommended that
VISNs be able to establish new sites of care to reclaim space at the
parent facility to meet increasing demand for inpatient care. Further,
the Commission endorses the legislative requirement and VA policy to
include basic mental health services in CBOCs, whenever feasible.
Finally, the Commission recommended that VISNs collaborate with
academic affiliates to develop learning opportunities using CBOCs as
teaching sites to enhance quality of care in community-based service
settings.
3. mental health services
The care of veterans with mental disorders is a high priority
component of VA's health care mission. Nearly a half million veterans
have a service-connected mental disorder.
The National CARES Program Office recognized early in the
methodology used to project mental health services did not accurately
account for services provided by VA. As a result, the model projected
decreasing requirements for outpatient mental health services while
national projections included significant increases in outpatient
primary and specialty care needs.
The Commission is pleased to learn that the National CARES Program
Office has recently completed reworking enrollment forecasts for mental
health services. Changes to the model included ensuring that VA actual
workload and projected workload data a re comparable and account for
the needed mental health services for Vietnam Era veterans and those
who follow, such as those serving in Iraq and Afghanistan. The
Commission recommended that with the new projections, the VISNs develop
plans to address gaps in mental health services and these plans should
be integrated into the CARES process. As indicated in my earlier
discussion, the Commission reinforced Congressional intent that basic
mental health services should be provided in CBOC settings.
Additionally, the Commission recommended that acute inpatient mental
health services should be provided with other acute inpatient services
whenever feasible.
4. long-term care
The Commission learned that long-term care, including nursing home,
domiciliary and non-acute inpatient and residential mental health
services, was not included in the current CARES projections due to the
absence of an adequate model to project future need for these services.
Nevertheless, the Draft National CARES Plan includes a number of
initiatives that directly impact nursing home care, domiciliary care,
and residential and long-term mental health care.
VA's nursing home care units vary in mission and case mix. Some
operate as short-term medical rehabilitation units and some operate as
traditional long-term care units. Some provide care for seriously
mentally ill patients who also have care needs related to medical
illnesses and dementia. The Commission noted that these patients are
extremely difficult to place in community nursing homes, as most do not
admit patients with severe psychiatric illness.
The Commission heard conflicting rationale for moving current long-
term care beds. On the one hand, the Under Secretary for Health and
certain VISN officials contended that long-term care beds should be
located on the same campus as a tertiary care center to enhance overall
medical care. Some proposals in the Draft National CARES Plan are
consistent with that view. On the other hand, several proposals call
for moving long-term care beds to campuses without medical beds, or for
contracting with community nursing homes not connected to a hospital.
The Commission noted that the norm for community nursing homes is that
the nursing home facility is located away from facilities with medical
services and, VA currently has nursing homes that are not located on
the same campus as the medical center.
In addition, inconsistent views have been expressed by VISNs
concerning the extent to which community nursing homes can adequately
provide care for veterans with serious psychiatric needs. Some VISNs
expressed a willingness to contract for all nursing home beds, while
others argued strongly that a sizable portion of VA nursing home
patients could not be adequately cared for in community nursing homes.
Due to the lack of an adequate model to project future need for
long-term care services and because of the conflicting rationale for
addressing long-term care needs in the VISNs, the Commission
recommended that VA develop a strategic plan for long-term care
services, including the long-term care for the seriously mentally ill.
Additionally, the Commission recommended that long-term care facilities
located away from the medical center campus should be accepted as a
care model. Further, the Commission recommended that in developing a
strategic plan, VA should consider broader collaboration with states to
leverage VA and other public funding through the State Veterans Home
programs.
It should be noted that although there is a need for VA to complete
a strategic plan for long-term care services, the Commission observed
existing long-term care facilities, primarily nursing home units, that
have poor facility conditions or require infrastructure improvements
resolve privacy and safety issues. Recognizing this, the Commission did
not want to disadvantage current patients in VA's long-term care
facilities and recommended that renovations to existing long-term care
and chronic psychiatric care units be accomplished.
5. excess va property
Much of VA's vacant space is not contiguous, but consists of
pockets of space scattered throughout the campuses, making it useless
for other purposes. The Commission also recognized that additional
vacant space would be created through mission changes and
consolidations. Further, there is an unspecified amount of acreage that
is not currently in use and numerous properties in VA's inventory are
historically important or have historic designations.
The Draft National CARES Plan outlines demolition and divestiture,
particularly in the early years of the CARES implementation phase, as
the primary methods to reduce current vacant space as well as vacant
space that will be created through mission changes and consolidations.
The Commission recommended that VA consider all options for divesture,
including outright sale and transfer to another public entity.
The Draft National CARES Plan also places significant reliance on
the enhanced use lease process to address excess space or property. The
Commission, however, has determined that the enhanced use lease process
as currently structured is not effective.
Across the country, Commissioners consistently heard testimony on
the structural problems with the enhanced use lease process. In the
field, there often is insufficient expertise or resources to attract
potential investors or to navigate local zoning and land use
requirements. Within VA, the review and approval process is arduous and
time-consuming. The Commission, therefore, recommended that the
enhanced use lease process be reformed to ensure timely action on
proposals and that VA develop a more efficient process, perhaps
creating a separate organization to pursue disposal of excess VA
property and land.
As previously stated, there are numerous historic properties in
VA's inventory, many of which can no longer be used for medical care
services. As with other types of excess property, VA must use medical
care appropriations that could otherwise be used to provide direct
medical care to pay for the upkeep and maintenance of property that no
longer has a medical purpose. Rather than rely on medical care
appropriations, the Commission recommended that VA seek a separate
appropriation for historic preservation funds to stabilize and maintain
historic property.
6. contracting for care
VA uses contracting as one vehicle for improving access to care and
has significantly expanded access to care with CBOCs. The benefits of
contracting for care in the community are it can add capacity and
improve access faster than can be accomplished through a capital
investment; it provides flexibility to add and discontinue services as
needed; and it allows VA to provide services in areas where the small
workload may not support a VA infrastructure, such as in highly rural
areas.
The Commission concurs with the Draft National CARES Plan's
proposal to utilize contracts for care in the community to enhance
access to health care services. However, before taking action to alter
existing VA services, VA must ensure that there are viable alternatives
in the community. Additionally, the Commission recommends that the
Secretary ensure that VA has quality criteria and procedures for
contracting, and monitoring service delivery, as well as the
availability of trained staff to negotiate cost-effective contracts.
Mr. Chairman, there are six additional issues that are
distinguished from these national crosscutting issues in that they are
relevant in selected VISNs, rather than in most or all of the VISNs.
These issues are no less significant to any other issues we reviewed
and I would like to briefly address the recommendations for each of
them.
1. Infrastructure and Safety
VA has identified 63 medical centers requiring seismic correction.
Many of these medical centers are large facilities located in high
population density areas. Of this total, the Draft National CARES Plan
has prioritized 14 sites that require immediate seismic strengthening
for a total funding requiring of $560.8 million. The Commission
recommended that Secretary Principi seek necessary funding to correct
documented seismic/life safety deficiencies as soon as possible.
2. Education and Training
Although VA has transformed from a primarily inpatient delivery
model to a community-based outpatient delivery system, generally
speaking, medical schools and other clinical affiliates have not made
the transition from the traditional inpatient teaching modalities to
incorporate community-based outpatient primary and specialty care
delivery into their educational programs. The Commission, therefore,
recommended that VA and its academic affiliates develop a plan to add a
community-based outpatient component to existing and new education and
training sites.
Additionally, in light of VA's significant involvement in nursing
education and the dramatic impact the nursing shortage has on VA's
ability to provide access to quality care for veterans, the Commission
believes there is strategic value to formalizing the relationships
between VA and schools of nursing. The Commission recommended that VA
establish national policy guidance for schools of nursing comparable to
the medical school model and actively promote nursing school
affiliations, as well as affiliations with other health profession
educational institutions.
3. Special Disability Programs
The Commission found that VA uses a hub and spoke model to care for
spinal cord injury and disorder patients. Patients travel to the
``hub'' tertiary hospital for inpatient care or complex services. For
more routine services, patients receive care at regional ``spoke'' VA
medical centers. Similarly, VA's Blind Rehabilitation Centers are
structured to serve blind veterans in an inpatient environment.
The addition of two blind rehabilitation centers in VISNs 16 and 22
will assist blind veterans throughout the country. The Commission
believes inpatient settings are not the only solution, particularly
because many blind veterans do not require a residential program.
Rather, a more appropriate response to serving many blind veterans is
to provide rehabilitation and retraining in community or home settings.
As such, the Commission recommended that VA develop new opportunities
to provide blind rehabilitation in outpatient settings close to
veterans' homes.
For Spinal Cord Injury Centers, there is no strategic approach to
balancing the mix of acute and LTC beds. The Commission believes the
proposed addition of four spinal cord injury centers and additional
beds in four other locations will benefit many veterans. The
Commission, however, recommended that VA assess their acute and long-
term spinal cord injury bed needs to provide the proper balance of
these beds.
The Commission also recommended that VA coordinate among VISNs the
placement of special disability centers to optimize access to care for
veterans.
4. VA/Department of Defense (DoD) Collaboration
The Commission reviewed a wide range of VA/DoD sharing initiatives
across the country and found varying degrees of support and momentum
for their completion. At those sites with successful initiatives, the
Commission noted a clear, mutual commitment to the value of the
collaboration, dedication from the top local leadership to the making
the collaboration work, and a sustained effort to monitor and manage
the day-to-day activities. From its review, the Commission recommended
that to ensure a successful collaborative relationship between DoD and
VA, there must be clear commitment from their top leadership, both to
the initial establishment of collaboration and to its ongoing
maintenance, especially when there is a change in the local leadership.
5. Research Space
The Draft National CARES Plan includes more than 20 research
leases, new construction and enhanced use lease. The Commission notes
that VA has excelled in this core mission and, therefore, concurred
with the proposals for enhancing research space.
6. Care Delivery Innovations
VA has undertaken a number of changes in care delivery designed to
enhance access to services. Primary among them are CBOCs. However, the
use of advanced practice nurses and telemedicine are two other
illustrations of new approaches to delivering care.
Veterans reported a high satisfaction with the care provided by
advanced practice nurses and access was clearly enhanced when wait
times were reduced, services were brought closer to where veterans
live, and continuity of care was enhanced.
The Commission also observed telemedicine to be an effective tool
to enhance access to care and leverage clinician productivity
especially for veterans living primarily in rural areas and in
locations where specialty medical are not readily available.
The Commission recommended that VA use advanced practice nurses and
telemedicine to enhance access and quality of care, and urges wider
application of these resources throughout the system. Furthermore, the
Commission believes that this does not have to be limited to only
advanced practice nurses but should include other critical health care
professionals such as pharmacists, physician assistants, and other
health care team members.
closing
Mr. Chairman, I have highlighted significant recommendations from
the Commission's Report. I would like to conclude my testimony today by
saying that there were cases where the Commission came to a different
conclusion than the Draft National CARES Plan. However, the driving
force for the VISNs and the Commission was enhancing medical services
to veterans. The Commission strongly believes that it is good public
policy that VA continue to integrate the CARES process into its
planning, budget, and legislative cycles.
Mr. Chairman and Members of the Committee, I would like to thank
you for the opportunity to address you. That concludes my formal
remarks. My fellow Commissioners and I would be pleased to answer any
questions.
______
Response to Written Questions Submitted by Hon. Arlen Specter
to the Department of Veterans Affairs
Question 1. Now that you have had the opportunity to review the
CARES Commission's report and have seen how it differs from your Draft
National CARES Plan, do you feel the Commission's report adequately
meets the needs of all veterans? Do you have any reservations with
respect to the Commission's rejection or modification of some of your
recommendations?
Response. The CARES Commission undertook a monumental task in
reviewing the Draft National CARES Plan and completing their task in
the timeframe allowed them. After an intensive careful review of the
Commission's findings and recommendations, VA is confident that they
were carefully studied and are strategically sound. On May 7, 2004, the
Secretary formally accepted the CARES Commission Report. He will,
however, use the flexibility it provides to minimize the effect of any
campus or service realignment on the continuity of care to veterans
currently receiving services in those locations. The CARES Commission
Report and the Secretary's decision document comprise a blueprint for
VA's future that will effectively guide us forward. It will be VA's
reference and initial point of departure for all future planning.
Question 2. The Draft National CARES Plan applied a ``Critical
Access Hospital'' (CAH) designation to many small facilities that
furnish acute hospital care in rural or less densely populated areas.
The Commission was critical of that feature of your recommendations,
stating that you had not developed a clear definition or criteria for
the establishment of CAHs. What are your thoughts on the Commission's
disagreement with your concept of initiating a CAH model in VA? Is VHA
attempting now to clarify its conception of the CAH concept?
Response. The CAH concept is a framework used by the Centers for
Medicare and Medicaid Services for assessing the future of small
facilities. However it became apparent that we would have to customize
this framework for VA small facilities. The DNCP indicated that
``[o]ver the course of the next year, the VA will develop and implement
policies to govern the operation of acute beds in small VA facilities,
which may fit into a CAH-like model of health care delivery.'' We have
begun that process and expect to complete criteria and policy for
Veterans Rural Access Hospitals by July. The policy and criteria will
adapt the CAH concept to the VA health care system.
Question 3. As you know, many of those older veterans rely heavily
on prescription medications for daily health maintenance. The Draft
National Plan and the Commission report include plans to add more
Community Based Outpatient Clinics, but neither specifies plans to
increase the number of Consolidated Mail Out Pharmacies (CMOP) to
provide medications for these patients. Without new mail-out pharmacy
space, how will VA handle an increased patient pharmacy load? Are you
considering adding additional CMOP capacity?
Response. VA continues to increase the capacity of its existing
Consolidated Mail Outpatient Pharmacies (CMOPs) by upgrading equipment,
introducing State of-the-art technology and disseminating best
practices across the entire CMOP operation. During fiscal year 2004,
these improvements are expected to increase capacity from 83.8 million
to 93.8 million prescriptions per year (a 12 percent increase).
Additionally, VA has numerous initiatives planned that include the
implementation of a central CMOP data base that will allow more
efficient distribution of workload across VA's seven CMOPs. This will
allow for dynamic data management in support of planned specialization
of CMOP dispensing across all seven facilities, with a goal of
maximizing productivity and efficiency. In addition, this allows for
further use of direct-to-manufacturer outsourcing on difficult to
process goods such as dietary supplements, which will allow VA to
increase its prescription fulfillment capacity without additional
capital investment.
During fiscal year 2004, VA expects to increase the number of
prescriptions for chronically used medications dispensed in 90-day
supplies. This strategy of workload management has been successful in
recent years. In fiscal year 2003, VA dispensed 108 million
prescriptions, which equates to 200 million 30-day equivalent
prescriptions. This strategy allowed VA to fill an additional 92
million prescriptions than would otherwise have been the case.
VA is planning increases to CMOP capacity through replacement of
existing facilities. The CMOP-Dallas facility replacement will soon
begin. This newest generation automated dispensing system will increase
CMOP Dallas capacity by a projected 10 million Rx/year over the current
7 million Rx/year.
The approved replacements of the Bedford and West Los Angeles CMOPs
are underway. It is anticipated that these two replacements will
increase CMOP capacity by a combined additional 20 million Rx/year.
Both replacements should be operational by the end of calendar year
2005. Planning and assessment for CMOP upgrades and replacements beyond
Dallas, Bedford, and West Los Angeles are ongoing. As future needs are
identified, proposals will be made for review and consideration.
Question 4. There are concerns that the data used in the CARES
analysis ignore current military realities and do not plan for the
possibility of future wars. Do you believe the data accurately assess
the needs of tomorrow's veterans? Can such data be developed?
Response. The CARES forecasting model uses DoD-supplied forecasts
of military discharges over the 20-year forecasting period. We expect
that as 000 strategic projections of military realities change, the
forecasts of future discharges will change as well. We will incorporate
any such changes into our future strategic planning initiatives to
assess any needed modifications to the care we must provide.
As of May 19, 2004, over 21,000 veterans of Operation Iraqi Freedom
and over 4,306 veterans of Operation Enduring Freedom have received
health care from VA for a wide variety of health problems. Thus far,
their health problems have been similar to those found in other young
military populations seeking health care.
Question 5. The CARES process has not assessed VA's abilities to
provide--or veterans' needs for--long-term care and psychiatric care.
Why was this decision made? Who made it? Does VA plan to conduct a
``CARES-like'' analysis of long-term care and psychiatric care issues?
If so, when can we expect such a process to take place?
Response. The DNCP does contain forecasts of acute inpatient
psychiatry and outpatient psychiatry. The outpatient psychiatry
forecasts were problematic and as a result they were divided into
markets that showed growth and markets that showed declines in the
demand forecasts. The forecasts for growth markets were included and
the forecasts in markets that showed declines were ``flat lined'' or
held at current capacity until the forecasts could be improved. That
improvement is almost completed.
Long-term psychiatry and domiciliary bed forecasts were not
adequately addressed in the models and were held constant until the
models could be improved. The improvement of these models is almost
completed. The long-term care planning model used by VA until the CARES
process was determined to be inadequate for strategic planning in
CARES. There was no assessment of the impact of the healthier future
elderly population, female veterans, the substitution of Assisted
Living or home care. Furthermore, the model did not include the latest
survey data that reflect changes in the overall delivery of long term
care in the US health care system.
Recognizing the importance of critical renovations, 38 nursing home
projects were included in the DNCP, pending finalization of a long term
care policy and incorporation into the strategic planning model. Once
these data are finalized, VA will develop a revised long-term care
policy.
Question 6. Many of your CARES recommendations would involve the
use of VA's authority to lease out space, land, or buildings to private
companies and then use the revenue to provide care to veterans.
Inasmuch as you have yet to analyze the VA's needs for long-term care
space or psychiatric care facilities, do you believe it is wise to
begin leasing out buildings or property before that analysis is
complete?
Response. Although The CARES Commission report recommends that no
expansion or replacement of facilities occur while the plan for long-
term care is being developed, it does acknowledge that VA should
proceed with VA ``renovations. . .to improve safety and maintenance of
the facilities infrastructure and to modernize patient areas.'' We
agree with the Commission that safety and maintenance of infrastructure
is a paramount consideration, and we will take necessary action to
ensure patient safety.
We believe that using VA's enhanced use lease authority involves
similar considerations. Pending completion of our analysis for long-
term care and psychiatric care needs, we must continue to consider on a
case-by-case basis opportunities to lease out buildings and property
and take advantage of those opportunities where we believe they will
immediately benefit delivery care to our patients.
The forecasts of long-term care space needs will be completed prior
to the implementation phase of the CARES process, which will include
development of plans for leasing land and buildings. In addition, while
the enhanced use leasing process was recently streamlined by Public Law
108-170, it allows adequate time to ensure that any plans to use vacant
space reflect needed capacity for long term care.
______
Response to Written Questions Submitted by Hon. Ben Nighthorse Campbell
to The Department of Veterans Affairs
Question 1. I understand that you are working out solutions for
VISN's that did not receive favorable recommendations. Can you tell me
if this will negatively affect those VISN's who have received positive
recommendations? When do you expect the final recommendations to be
approved?
Response. The Secretary published his CARES decision on May 7,
2004. The review process took into consideration all aspects of the
Commission's recommendations to ensure that the CARES Plan approved by
the Secretary treats all VISNs equitably, in accordance with national
policy decisions.
Question 2. I notice that the CARES Commission recommends that
before any action is taken on expanding or renovating long-term care
facilities, the VA should develop a long-term care strategic plan,
including the long-term care of our mentally ill veterans. When do you
think this plan will be developed?
Response. The Long-term Care Model will be incorporated into the
next strategic plan. Updates for the 5-year capital plan will be
regularly completed. It will include a plan for the long-term
psychiatric care. The long-term care planning that will be developed
through the mental health strategic planning process will be carried
out collaboratively between VA's Mental Health and Geriatrics and
Extended Care staff to ensure that the comprehensive (psychiatric and
medical) care needs of older veterans are met.
The CARES Commission report does acknowledge that VA should proceed
with VA ``renovations. . .to improve safety and maintenance of the
facilities infrastructure and to modernize patient areas.'' However it
recommends that no expansion or replacement of these facilities occur
while the plan for long-term care (Nursing Homes, Domiciliary care, and
long-term psychiatric care) is being developed.
Chairman Specter. Thank you very much, Chairman Alvarez.
We have been joined by the distinguished Ranking Member,
Senator Graham.
STATEMENT OF HON. BOB GRAHAM,
U.S. SENATOR FROM FLORIDA
Senator Graham. Thank you very much, Mr. Chairman. I would
like to ask unanimous consent to submit for the record an
opening statement. In deference to the members of the
commission who are here and our desire to hear their evaluation
of the CARES program, I will defer presenting it.
Chairman Specter. Without objection, your statement will be
made a part of the record in full.
[The prepared statement of Senator Graham follows:]
Prepared Statement of Hon. Bob Graham, U.S. Senator from Florida
At the outset, I would like to extend my thanks to the
Commissioners and staff who have worked tirelessly to comment on plans
for the VA health care system in the future. The CARES Commission
Members have held ten public meetings and 38 public hearings, visited
an astonishing 81 facilities, and received more than 212,000 public
comments. Mr. Alvarez, you and your Commissioners truly had a difficult
job--made more difficult, in my opinion, by a flawed VA plan.
The VA's Draft National Plan--essentially vindicated by the
Commission--does hold much promise for my state, where new and improved
health care facilities are greatly needed. The Commission's report to
the Secretary includes a proposal to build a new VA hospital in
Orlando, which CARES has identified as ``having the largest workload
gap and greatest infrastructure need of any single market in the
country.''
The Plan also calls for the construction of new bed towers at the
Gainesville and Tampa VA facilities; significant renovations at Bay
Pines; a new inpatient venture with the Department of Defense in
Jacksonville; and a new satellite outpatient clinic and expanding
opportunities for hospital contracts in the Ft. Myers area. One area
which may require additional attention is the Pensacola region.
Documentation included in the Draft National Plan refers to a new
``Eastern Southern Hospital'', but nothing in the CARES recommendations
provides details. The Pensacola area obviously lacks sufficient
inpatient capability. This clearly needs our further review.
And while I am very glad that our State will get these much-needed
improvements, I remain concerned about the effects of the CARES process
on the rest of the nation. The Commission's report refines the
Administration's work--deviating from their recommendations in 12 cases
and concurring in 16 cases--for a total of 20 major mission changes,
including complete closures. This could have a significant impact on
the availability of health care to our nation's veterans.
CARES began with an amazing amount of attention paid to the
comments of stakeholders. Unfortunately, the process took a wrong turn
along the way. Halfway into the process, two dozen facilities were told
to go back to the drawing board and present new plans for closures and
reductions. The requests for these revisions came through last-minute
phone calls and internal mandates. I trust that Commissioners were
aware of this back-door manipulation and adjusted their analysis
accordingly.
The Administration's Draft National Plan also deliberately excluded
the potential for needed long-term care and outpatient mental health
treatment. Despite VA's historical role in caring for these special
populations, VA has chosen to ignore demand for these two services.
This makes no sense whatsoever. Any plan of the proposed scope of what
the Commission is looking at must address these elements. While VA has
described the draft plan as ``being neutral'' on long-term care and
mental health, it is hardly the case. Thousands of long-term care and
inpatient psychiatric beds may likely be closed--a result that cannot
be characterized as neutral. I know that Commissioners were made aware
of this flaw but did not, and could not, revamp the entire plan in
order to fix it.
Finally, if sufficient resources are not dedicated to CARES
enhancements, the entire process will ultimately be interpreted as just
one more blow to veterans. Indeed, the cost of CARES improvements will
total more than $4.6 billion. With a mere $180 million included in the
President's budget for these types of projects, we certainly have a
long way to go to deliver upon the promise of CARES--in Florida and
across the country.
Thank you.
Chairman Specter. Senator Hutchison, would you care to make
an opening statement?
OPENING STATEMENT OF HON. KAY BAILEY HUTCHISON,
U.S. SENATOR FROM TEXAS
Senator Hutchison. Thank you, Mr. Chairman. I do have an
opening statement. This is a very important topic, but since we
do have Members here and I know we are voting right now, I will
incorporate my opening statement into my questions. I do hope
we will have enough time in our question sessions to be able to
do that so that we can hear from our witnesses.
Chairman Specter. Senator Hutchison, we will see to it that
you have sufficient time.
Senator Hutchison. Thank you.
Chairman Specter. Our next witness is the Honorable Robert
Roswell. Dr. Roswell is the Under Secretary of Health for the
Department of Veterans Affairs. Prior to his nomination, Dr.
Roswell served as the head of VA's health care network for
Florida and Puerto Rico. He is a 1975 graduate of the
University of Oklahoma School of Medicine. He served on active
duty in the Army from 1978 through 1980 and is currently a
Colonel in the Army Reserve Medical Corps.
Thank you for joining us, Dr. Roswell, and we look forward
to your testimony.
STATEMENT OF HON. ROBERT H. ROSWELL, M.D., UNDER
SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Roswell. Thank you, Mr. Chairman and Senator Graham. It
is a pleasure to be here before the Committee today.
On February 12 of this year, the commission presented its
final report to the Secretary, with findings and
recommendations. VA is currently reviewing the CARES Commission
report. However, we must await the Secretary's final decision
on this comprehensive report later this month. Thus, I would be
unable to give our responses to the commission's
recommendations to you today.
Since the preparation, though, of the draft National CARES
Plan, I would like to share with you that we have continued our
planning efforts. Our initial forecast models did not fully
address the future long-term care needs of veterans. As a
result, the CARES planning model ensured that long-term care
capacity was maintained at its current level.
Since release of the draft National CARES Plan, we have
been working to develop a long-term care demand model based on
more recent and more complete information, including current
national long-term care survey criteria, disability data and
reliance factors. Also, we are viewing VHA long-term care
policy in key areas to assure that policy and capital planning
will be coordinated, and that policy supports the vision of
providing veterans with the highest-quality long-term care in
the most supportive, least restrictive environment that is
compatible with the veteran's medical condition.
With regard to mental health programs, VHA is developing a
comprehensive mental health strategic plan to transform its
mental health programs consistent with the recommendations
contained in the President's New Freedom Commission Report on
Mental Health. This plan will recommend fundamental changes in
the structure, policy and culture of our mental health care
delivery system.
As a part of the plan, VHA is creating a vision for
delivery of care to veterans with mental illness and substance
abuse within a system that places equal importance and emphasis
on mental and physical health and is an integrated, veteran-
centered program and is based on a model of recovery.
I have instructed VHA planners to assure that programs in
our domiciliary structures are focused on residential
rehabilitation and that each patient have an individual
clinical treatment plan. As each program, such as our mental
health, substance abuse and long-term services, defines its
discrete capacity for residential rehabilitation, VHA will have
a more complete picture of the total capacity requirement for
our domiciliaries.
Mr. Chairman, we are also reviewing the critical access
hospital concept that was presented in the draft National CARES
Plan and are developing a definition of what we now call
veterans rural access hospitals and how such facilities should
function in our health care delivery system. These facilities
will be important in providing access to health care in rural
markets where access to VA and/or community care is limited.
Mr. Chairman, should the Secretary approve the final CARES
plan, implementation will take place over a period of many
years. The complexity of realigning clinical services and
campuses necessitates careful planning in order to assure a
seamless transition in services. In no case will we discontinue
services without having alternative services and sites of care
available and operational.
Throughout the implementation process, we will keep you and
other Members of Congress informed and involved. And just as
important, we will keep our patients and their families
informed and involved in the process.
This concludes my opening remarks. I would be happy to try
to answer any questions you or Members of the Committee may
have.
[The prepared statement of Dr. Roswell follows:]
Prepared Statement of Hon. Robert H. Roswell, M.D., Under Secretary
for Health, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee: I am pleased to appear
before the Committee to discuss the Department's ongoing efforts with
regard to CARES.
The CARES process has involved one of the most comprehensive
evaluations of the VA health care system ever conducted. It is a data-
driven planning process designed to project future demand for health
care services in 2012 and 2022, compare them against the current
supply, and identify the capital requirements and the asset
realignments VA needs to improve access, quality, and the cost
effectiveness of the VA health care system.
Last September, Secretary Principi and I appeared before this
Committee to discuss both the CARES process and the VHA draft National
CARES Plan. At that time, the CARES Commission, under the superb
leadership of Everett Alvarez and John Vogel, was nearing the end of
its site visits and public hearings and was preparing to begin the
daunting task of writing its report. On February 12 of this year, the
Commission presented its final report to the Secretary, with findings
and recommendations.
VA is currently reviewing the CARES Commission Report. However, we
must await the Secretary's final decision on this comprehensive report
later this month. Thus, I will be unable to give you our responses to
the Commission's recommendations today.
Mr. Chairman, we know that many stakeholders have expressed
concerns about how VA intends to address the provision of long-term
care and mental health services, and the Commission raised questions
about our proposal for ``critical access hospitals.'' I would like to
say just a few words on these issues.
Our initial forecasting models did not adequately address the
future long-term care needs of veterans. As a result, the CARES
planning model ensured that current long-term care capacity was
maintained. Since release of the draft National Cares Plan we have been
working to develop a long term care demand model based on more recent
and more complete information, including current national long-term
care survey criteria, disability data and reliance factors. Also, we
are reviewing VHA long term care policy in key areas to assure that
policy and capital planning will be in synch and that policy supports
the vision of providing veterans with the highest quality long term
care in the most supportive, least restrictive environment that is
compatible with the veteran's medical condition and personal
circumstances.
In regards to Mental Health Programs, VHA is developing a
comprehensive mental health strategic plan to transform its mental
health programs consistent with the recommendations contained the
President's New Freedom Commission Report on Mental Health. This plan
will recommend fundamental changes in the structure, policy, and
culture of our mental health care delivery system. As part of the plan,
VHA is creating a vision for delivery of care to veterans with mental
illness and substance abuse within a system that places equal
importance and emphasis on mental health and physical health, is
integrated, veteran-centered, and based on recovery.
Developing a mental health demand model that accurately projects
the full range of mental health services needed by veterans has been
challenging. A revised model that is more detailed and improves on past
efforts is currently being developed. The resulting options for mental
health care will ensure that VHA maintains a robust system of
coordinated, integrated, ``state-of-the-art'' care for veterans with
mental health care needs.
We have conducted several studies of domiciliary programs over the
past year. These studies highlighted----
The need for effective coordination with non-VA programs
and services to assure that integration is achieved across a continuum
of care that is directed to meet the specific needs of individual
veterans.
That patients need to move to the least restrictive
environment consistent with their needs.
And that data based population planning is needed to bring
about some uniformity of access to this therapeutic residential care
continuum including consideration of available State Home Domiciliary
programs as well as innovative VA/community partnerships providing
Domiciliary services.
Accordingly, I have instructed planners to assure that programs in
domiciliary structures are focused on residential rehabilitation and
that each patient have a clinical treatment plan. As each program (e.g.
mental health, substance abuse, long term care) defines its discrete
capacity for residential rehabilitation, VHA will have a more complete
picture of the total capacity requirement for domiciliaries.
Mr. Chairman, we are also reviewing the ``critical access
hospital'' concept that was presented in the draft national plan and
are developing a definition of what we now call ``rural access
hospitals'' and how such facilities should function in our health care
delivery system.
We believe that these facilities may be important in providing
access to health care in certain rural markets where access to VA and/
or community care is limited. Such facilities would need to be part of
a network of health care that provides an established referral system
for tertiary or other specialized care not available at the rural
facility. The facility should also be part of a system of primary
health care (such as a network of CBOCs). Such facilities would also
need to be a critical component of providing access to timely,
appropriate and cost-effective health care for the veteran population
served.
Mr. Chairman, should the Secretary approve the final CARES Plan,
implementation will take place over a period of many years. It will be
a multifaceted process, depending upon whether implementation of
specific initiatives requires additional capital, recurring funding,
primarily policy changes, or realignments. In particular, the
complexity of realigning clinical services and campuses necessitates
careful planning in order to ensure a seamless transition in services.
In no case will we discontinue services without having alternative
sites of care available and operational. And throughout the
implementation process we will keep you and other Members of Congress
informed and involved and, just as important, we will keep our patients
and their families informed and involved.
This concludes my statement. I will now be happy to answer any
questions that you or other Members of the Committee might have.
Chairman Specter. Thank you very much, Dr. Roswell. I am
glad to hear your assurances that long-term care will be
maintained at the current level and there will be no
discontinuance of services.
Chairman Alvarez, with respect to what is proposed to
happen in Pittsburgh, there is a $100 million construction
project at Pittsburgh University Drive and Pittsburgh Heinz, to
be followed by the closing of Pittsburgh Highland Drive. Are
you in a position to assure this Committee and the veterans who
receive their care in Pittsburgh that the substitution will
result in at least equal, if not better, care for the
Pittsburgh veterans?
Mr. Alvarez. Mr. Chairman, the commission looked at that
very carefully and with regard to the $100 million, one of the
recommendations was that they take another look at the cost of
that because the numbers we had, we felt, were soft. We feel
that it may be a little more than that, but the reality is that
those numbers will be solidified.
With regard to transferring to the university level, we
stated in our recommendation that no transfer be done until the
facility at the university----
Chairman Specter. Chairman Alvarez, I don't want to
interrupt you, but we have a very limited amount of time. Let
me ask you to supplement what you have said in writing with a
specification as to what services will be lost by the closing
and what services will be gained.
Mr. Alvarez. Will do, sir.
Chairman Specter. Moving on to other facilities, there is a
concern that when you close inpatient beds that there will be
an inevitable consequence that other Pennsylvania institutions
such as Altoona, Butler and Erie--that there will be a closure
of emergency room and intensive care unit capabilities which
cannot be maintained without the inpatient beds.
Taking a look first at the ripple effect on Erie, where
there are about 800,000 applications per year for treatment in
the emergency room, the Erie VA has an intake of about 1,000 of
those individuals, and only 71 need to be referred to the local
community hospital for services not offered at the VA.
If the VA loses its inpatient beds and then the emergency
room private referrals will rise from the 71, which we have had
the experience on, to 1,000, won't that result, if my
underlying facts are correct, in a substantial increase in cost
to the Veterans Administration?
Mr. Alvarez. I think Dr. Roswell can probably address that
one better, but our concern was that they take a good look at
that as the transfer is being planned, because what we
basically specified was that we recommend that they do it
carefully, if they do it, so that there is no loss of service
there.
Chairman Specter. Well, I am glad to hear there will be no
loss of services, but would you please supplement what you have
said now? We are going to have a hearing in Erie in March 26. I
will be there, the Committee will be there, and I would like to
know the specifics as to how the services will be given and
what the cost will be to the Veterans Administration and
whether you really will be saving money.
There have been efforts all along the VA system, and I will
be detailing those as to these three facilities, to increase
efficiencies. You talk about population shifts and
efficiencies, and I agree with you that those are the
standards.
But if you take a look at Erie, in 1997 the Erie VA had 26
inpatient beds and 9 surgical beds to provide care for 11,400
veterans. Those medical and surgical bed units have been merged
into a single 26-bed unit and now serve some 18,500 veterans.
With those kinds of efficiencies, and taking into account
the population shift, Chairman Alvarez, doesn't it make sense
to keep open the inpatient beds which are now remaining and
have been consolidated at Erie?
That will be final question because I intend to observe the
time limits, as we all will, but you may answer.
Mr. Alvarez. Thank you, sir. I would answer any specifics
you would care for us to submit.
With regard to the number of visits, most of those, 94
percent of those, are outpatient, sir. And the number of
inpatient beds that we have is one that is a declining number
over the last several years. That was one of the things that we
were concerned about when we looked at the statistics.
Chairman Specter. Well, my time has expired. We will come
back. I am going to yield now to Senator Graham and when I
yield to him I am going to go to vote. Senator Murray has
already returned, and when Senator Graham finishes his
questioning, Senator Murray, we will turn to you so that we can
continue apace even though we will be moving in and out on the
votes.
Senator Graham. Mr. Chairman, we are on the second bell on
this vote. If it is acceptable, I would like to defer to
Senator Murray and I will vote and then ask my questions at a
later time.
Chairman Specter. I think that is a splendid idea. That
way, you run no risk of missing the vote.
Senator Murray.
Senator Murray. Thank you very much, Mr. Chairman. Thank
you, Senator Graham. Thank you again to the panel. I appreciate
you being here.
As you know, as I stated, I have written to Secretary
Principi several times about my concerns on this. Dr. Roswell,
I have outlined those concerns actually several times in
writing to both you and Secretary Principi since the time my
VISN director was directed to close three of the five VA
medical centers that were in Washington State.
The CARES report recommends a significant mission change at
Walla Walla VA Medical Center in my home State of Washington.
However, the current law which I have a copy of here stipulates
that no mission change shall occur at this facility. In fact,
the current law says the mission of the Veterans Administration
Medical Center at Walla Walla, Washington, shall not be changed
from that in existence on January 1, 1987. Yet, your CARES
Commission recommends that it be changed.
How do you plan on reconciling that situation?
Dr. Roswell. Senator Murray, I am no legal expert, but we
did refer that law to our general counsel for interpretation
and I believe the Department's general counsel's interpretation
was that because that law was a part of the appropriation
language--it may not have been appropriation language; I may be
mistaken with that.
As I recall, the general counsel opinion was that that law
pertained only to the mission during the term of the
authorization and/or appropriation bill. I guess it was----
Senator Murray. It was 1987.
Dr. Roswell. It was 1987. I actually recall that law at the
time of its passage, but the general counsel interpretation was
that it would only pertain to the fiscal year in which it was
enacted. Again, that is a general counsel opinion. That is not
my opinion.
Senator Murray. Well, we will continue that discussion with
you.
The recommendation for the Walla Walla center is to
maintain outpatient services by moving outpatient care off of
the Walla Walla VA Medical Center campus. Can you explain to us
what that means? Are we going to build a new facility for Walla
Walla?
Dr. Roswell. The Walla Walla campus, as you know, is a
fairly large campus. We would not be expected to maintain the
entirety of the campus to provide just outpatient care. So my
understanding would be that we would evaluate where best to
locate outpatient services. That could be on a portion of the
existing campus or it might be better situated in a new
location not on the current campus.
Senator Murray. Well, there is no money in your budget to
do that, so how does that happen?
Dr. Roswell. There is money in our budget to the extent
that major construction money is identified for CARES-related
construction needs.
Senator Murray. Well, yes. Actually, we do know that you
shift $400 million from the veterans' health care into the
construction account. I am assuming that is what you are
talking about.
Dr. Roswell. In fiscal year 2004, yes, ma'am.
Senator Murray. Well, I am deeply concerned about that
because shifting that health care to an initiative that is
going to close the very facilities that serve our veterans
today really, to me, is unconscionable. I don't see how our
veterans can feel secure when the promise to provide the health
care that they have earned is preceded by a budget request from
you that would not only under fund the health care account by
moving that $400 million, but it also robs that account to pay
for CARES projects.
I mean, how do you reconcile this? You have to understand
how our veterans out there are feeling. You are recommending
closing their facilities. You are saying something is going to
happen in the future, but there is no money in the budget to do
it, and we are reducing the health care to build some
facilities that we don't even know what they are.
Dr. Roswell. Let me back up. The expectation would be that
leaving the current campus would be if there is an enhanced use
leasing opportunity that would generate sufficient revenues to
cover the cost of relocating the facility.
Senator Murray. An enhanced lease use facility that you are
looking for somewhere else? I mean, have you ever been to
Walla, Walla? There aren't very many facilities there.
Dr. Roswell. I understand, and it is entirely possible
that--again, I don't believe that there is any foregone
conclusion, that the outpatient services would be moved off the
current campus. It is simply an option that would be explored.
Our goal would be, if this CARES recommendation were
accepted by the Secretary, to provide the highest-quality
environment of care for continued outpatient services either on
the current campus or, if it was more conducive to delivering
outpatient services, to a location off the current campus. But,
again, that would be something that would have to be
determined.
Senator Murray. Well, I remain deeply concerned because I
know your office makes a recommendation by the end of this
month. Congress has 60 days to review, whatever that means; at
this point, I am not sure. Meanwhile, we won't have identified
for those veterans where they are going to receive the care.
I just think we need from your office specific budgets and
time lines and specific places where these veterans are going
to receive their care before we end up at the end of our 60-day
time line and we are still sitting here asking you the same
questions we have been asking for the last several months.
Dr. Roswell. Let me assure you that the Department will not
take any action to close the current campus until we have fully
identified where outpatient services would be provided, how
they will be provided, and we would not close the current
facility until----
Senator Murray. But if you accept the CARES recommendation,
it states specifically that that is going to happen. So you say
on one hand the CARES Commission is accepted; that is what we
are going to do. But then you say we are not going to do that
until we have something. I am as confused as my veterans.
Dr. Roswell. If the recommendation is accepted, as I said
in my opening statement----
Senator Murray. By your office.
Dr. Roswell. By Secretary Principi.
Senator Murray. Right.
Dr. Roswell. But, yes, it would be implemented over a
period of years. In no case would we close or implement any of
the recommendations that resulted in closure of a facility
until such time ask the facilities intended to replace that are
in place.
Senator Murray. And by ``facilities'' do you mean some new
facility in Walla Walla that will be built that we haven't
budgeted for?
Dr. Roswell. We would either maintain an outpatient
facility on the current campus or create a new one somewhere in
the Walla Walla area to provide complete continuity of
outpatient services. There will not be an interruption of
outpatient care for veterans served by the Walla Walla
facility.
Senator Murray. And this is based on that we just trust
this is going to happen, because I don't see it in the budget?
Dr. Roswell. I understand your concern. Let me point out
that there is already money in the 2004 appropriation set aside
for use of CARES at the Secretary's discretion. There would be
up to $400 million that could be reprogrammed. In addition to
that, there is additional money requested in the 2005 budget
that is now being considered before this Congress. The
Secretary has made a firm commitment in addressing the CARES
Plan that there would not be an interruption of services.
Senator Murray. For outpatient. What about inpatient?
Dr. Roswell. The commitment expressed by the Secretary is
that there won't be interruption of any services.
Senator Murray. Inpatient or outpatient?
Dr. Roswell. That may mean that outpatient would shift to a
contract delivery process, but we would always have a mechanism
in place to provide that care on a contractual basis before we
closed any facilities.
Senator Murray. Again, let me just point out to you, Dr.
Roswell--and I know you are working within confines and you are
doing the best you can, but there are no other facilities in
Walla Walla to contract out to. And that is, I think, one of
the deep concerns many of us have about the CARES
recommendations.
I have taken my time. Thank you, Mr. Chairman.
Senator Graham. Thank you, Senator Murray.
Senator Hutchison. [Presiding] Mr. Chairman, I think the
gavel is mine, but did you wish to go next? I would be happy to
call on you.
Senator Graham. Thank you very much, Madam Chairman.
I would like to go back to this issue of long-term care,
because we know that it is going to be an area of increasing
demand. I think also we'll see a demand for greater
diversification in the ways in which that care is provided,
including long-term care within the communities to various
forms of institutional care.
Where is the CARES program on that issue, and what are your
recommendations as to how the VA should deal with the demand
for long-term care?
Mr. Alvarez. For the first part of that question, sir, I
think Dr. Roswell could probably answer that and I will defer
to him on the first part.
Dr. Roswell. Obviously, a long-term care projection model
wasn't included in the draft National CARES Plan submitted to
the commission because we were not comfortable with the data.
We have been working diligently with our actuaries to refine a
projection model. We believe we are very close to a model that
would project the needs for long-term care.
That will require some policy issues that the Secretary
will want to evaluate before making final determinations, but
that process would then be incorporated into a continuous
strategic planning process that will continually address and
adjust our programs to meet the long-term care needs of the
Nation's veterans.
Mr. Alvarez. Sir, Dr. McCormick can address the latter part
of your question with regard to our recommendation on that.
Mr. McCormick. Yes. In our cross-cutting issues, we were
concerned that even though the long-term care model wasn't
done, there were a number of specific items that actually
addressed long-term care at specific sites.
Two things. First of all, in our cross-cutting issues we
made a very strong statement that we believed that no action
should be taken on altering or changing current long-term care
until a strategic plan is put together, and that that plan
needed to consider the broad needs of long-term care for the
highest-priority veterans, including those with mental
disorders who will need long-term care as well.
When we then came to specific issues where there was a
recommendation about a specific nursing home, we made a
judgment but always put a caveat in that it was subject to
being consistent with the eventual model that would be run that
would say what kind of beds we need to serve what veterans in
what location.
Senator Graham. Well, I remember this Committee and the
full Congress adopted a directive to the VA relative to long-
term care, I believe, in 1999. It sounds as if the information
that you are now suggesting needs to be developed is the kind
of information which the 1999 directive precipitated.
What has happened to that 1999 legislation and to what
degree is it going to be involved in your development of the
strategic plan?
Mr. McCormick. Again, we emphasized that we felt that the
Department needed to follow the millennium bill guidelines,
which had to do with priorities again to have the right kind of
nursing homes especially for the highest-priority patients. We
also acknowledged the nursing home floor that was put into
that.
Again, our position was that the real issue wasn't even how
many beds we had overall in the system, but what kinds of beds,
where and whether, to address the needs of each specific type
of patient who would need long-term care into the future.
Senator Graham. Could you give the Committee a memorandum
of what has happened since the Millennium Health Care Act--
where that Act stands and how it is going to fit into your
planning for long-term care services and facilities?
Mr. McCormick. I guess that would be Dr. Roswell's----
Dr. Roswell. Yes, sir. That law requires that the VA
maintain its 1998 long-term care patient census of 13,391
patients. We have implemented management guidance, including a
pro-rated quota, of that national-mandated floor on inpatient
levels to each of the 21 VISN directors.
Despite those management incentives, the demand for care is
such that we are not currently at the 13,391 statutory
requirement. We are closer to about 12,000 patients right now,
despite our efforts to maintain that patient census within our
facilities.
I would note that we have significantly increased, during
this time period, the State veteran home nursing beds
available. In your own State of Florida, for example, a number
of State veterans homes have opened, creating other options for
veterans at multiple locations.
We also have significantly increased, almost tripled, the
non-institutional care programs that serve veterans in the
least restrictive setting. So we are expanding a full continuum
of services that would be reflected in the long-term care
strategic planning model that has been referenced here.
Senator Graham. Mr. Chairman, my time is up. I would like
to indicate that I am going to be asking a question relative to
the status of a new hospital that the Administration had
indicated it supported. I am speaking about a hospital in
Pensacola, Florida, which has already been named the Eastern
Southern Hospital. There doesn't appear to be any provision in
the CARES report or in the Commission's commentary relative to
that hospital, and I would like to get an understanding of why
there has not been such a provision made.
Chairman Specter. Thank you, Senator Graham.
Senator Hutchison.
Senator Hutchison. Thank you, Mr. Chairman.
Mr. Alvarez, early in this process our veterans
organizations and local community leaders worked with their
respective service network regional directors to develop plans
to optimize their facilities, but the report bears almost no
resemblance to the original recommendations made by the service
network directors in the field.
One example: the veterans integrated service network market
plan recommended establishing Waco as a regional psychiatric
resource. The plan spoke of an enhanced mission for Waco by
expanding the geographic service area and working to designate
the Waco VA hospital as a Psychiatric Center of Excellence.
When you consider that the Veterans Administration has
spent more than $80 million over the last 10 to 15 years
building state-of-the-art psychiatric care facilities in Waco
training technicians and nurses in this specialized field--and
when we visited this facility with Secretary Principi, we
learned that there are interns and residencies which could also
be enhanced from the medical school at Texas A&M, very close
by--the original recommendation to consolidate psychiatric
services in Waco seemed to be a good use of taxpayer funds.
However, the report completely reversed that and suggested that
most of the services from Waco be moved to other places.
In addition to that, your early reports estimated that it
would cost about $16 million to move these services. Now, we
have just spent $80 million over the decade renovating and
upgrading the psychiatric facilities at Waco. Now, we are
talking about $16 million to move it, and Representative
Edwards was told by someone in the VA that the moving cost was
more likely $42 million.
So could you expand on how you came to the conclusion that
moving the major parts of the psychiatric services, inpatient,
from Waco would be prudent for the taxpayers and better service
for the veterans?
Mr. Alvarez. Thank you, Senator. Let me just State that the
market plan that you referred to which called for upgrading of
the programs at Waco was not in the draft national plan that we
received. The plan that we received was the plan that
transferred inpatient acute psychiatric beds from Waco to
Temple and to the Austin area.
Ninety-four percent of the current workload at Waco is
outpatient care, and that is to remain there at Waco, whether
it is a portion of the campus or in the city itself. So the
other plans that you have mentioned really did not surface in
the draft national plan and it was not presented to us.
As far as a $15 million cost to transfer that, what caught
our attention was that we were told at the hearing by the VISN
director and staff that currently he was having to redirect
about $15 million from other facilities in his network to
support the operation at Waco because of the large overhead of
that campus. So that was one thing.
When we took a look at the cost/benefit analysis that was
proposed for Waco that was submitted at the end of October--and
we have questions about this--the life cycle cost savings over
20 years would range from $200 million to $800 million. Well,
the commission did not believe the $800 million, and probably
the $200 million is closer to it. But that was one of the
factors that we said take another look at that and see what the
more realistic numbers were. So taking everything into
consideration, our recommendation then basically went with the
plan.
We also put some caveats on this. You have some hard-to-
place inpatients in the nursing home that we said let's take a
good look at those because that kind of care is usually not
provided in the community. Dr. McCormick can probably address
that better than I can, but the key was that that large
overhead that was causing him to redirect money from other
facilities to keep that operation going was a major factor.
Senator Hutchison. You are talking about the inpatient
psychiatric?
Mr. Alvarez. No, the cost of the campus itself.
Senator Hutchison. The campus itself.
Mr. Alvarez. He would prefer to move, even if he has to
stay on that campus, to another location there if he could get
the money to build it, a multi-specialty outpatient clinic
either built or leased in the community. That would save him a
lot of money and provide up-to-date, modern care for the people
of that community.
Senator Hutchison. Well, let me just say, first of all,
that the inpatient--you were saying that 80--what percentage
did you say is outpatient care?
Mr. Alvarez. Ninety-four percent of the workload.
Senator Hutchison. Ninety-four percent. So you are saying
that only 6 percent of the workload is the inpatient
psychiatric?
Mr. Alvarez. Yes, ma'am.
Senator Hutchison. That just defies what we saw there in
the inpatient facilities. I am sure you are not not telling the
truth, but somehow we are talking apples and oranges because we
saw inpatient facilities with 60-patient capacity that were
pretty well full.
Mr. Alvarez. You have 110 beds there, inpatient.
Senator Hutchison. Yes, so it is not adding up.
Mr. Alvarez. Would you like to expand?
Mr. McCormick. To clarify, the 94-percent figure is that 94
percent of the patients who get care at Waco receive only
outpatient care, which is not unusual. There is a substantial
inpatient workload there.
Let me just say one thing, if I could, that you will find
in the report that we tried to be consistent. One of the
advantages of the proposal for Waco was to move some of the
acute beds to Austin. There is a very large, as you know, I am
sure, Senator, outpatient clinic in Austin that treats about
16,000 veterans a year, about 3,000 with mental disorders.
Right now, when one of those patients needs acute inpatient
psychiatry, which usually means he is either suicidal or
seriously mentally ill, he most often ends up having to go all
the way up to Waco. One of the principles that we used was that
in a city the size of Austin there ought to be access to acute
inpatient psychiatric care. So one of the strengths of their
proposal was to move some of the beds closer to where the
veterans lived in Austin so that their families can be engaged
in treatment.
The second strength of that proposal was to move the
remaining long-term and acute beds to Temple, which would put
them more centrally in the market, but also right on the same
campus with the medical beds. And as these patients age, there
is a clinical advantage to having acute psychiatric and acute
medical services in very close proximity.
It was really the access issue, at least from my
perspective, which caused us to approve of that plan because we
felt it was a strength and improved access and quality of care
for veterans in that central Texas market by putting the
services closer to where the bulk of them live.
Senator Hutchison. Let me just say that it seems to me that
having the specialty doctors and nurses, the trained people, is
going to be more cost-efficient if it is in fewer places. If
you are going to be inpatient, the difference between traveling
to Waco or Temple would not seem to be that big a difference,
where you have the investment already at Waco.
Let me just add that if the overhead cost of the campus is
an issue, then what I am hoping is that with the added emphasis
that the community wants to bring forward in filling the
buildings, in taking responsibility for maintaining the
campus--and further, in your report you recommended closing the
Marlin facility and building a new multi-specialty outpatient
clinic someplace in the Waco area, which would seem to be much
more economically done on a campus that the VA already owns,
upgrading facilities there and thereby filling the buildings
and lowering the cost.
So that is where I am hoping that we can add to your body
of knowledge and make the case to Secretary Principi that we
still can be efficient and keep the trained workforce in place.
Chairman Specter. Senator Hutchison, you are now at double
time, a little over 5 minutes over. I know how important the
Waco hospital is to you, so I haven't interrupted you, and the
witnesses may answer your question.
Senator Hutchison. I would love to just have them answer
this, and then there will be a second round?
Chairman Specter. That would be a third round?
Senator Hutchison. Could there be a third round, then?
Chairman Specter. Yes.
Senator Hutchison. Thank you. Well, a lot happened in
Texas, Mr. Chairman, so I am trying to focus on this.
Chairman Specter. I know how important this is to you and I
haven't interrupted you. We will come back for another round.
Senator Hutchison. OK, if they could answer this.
Chairman Specter. The witnesses may respond to your
question.
Mr. Alvarez. With regard to Marlin, Marlin is already
closed, inpatient. It is outpatient, and the draft national
plan calls for consolidating Marlin with a Waco outpatient
somewhere in the vicinity. We also said take a look at that
before you do that; because of the location where you want it,
be careful how you do that.
Mr. McCormick. I would just say one more thing about acute
inpatient psychiatry, Senator. When you are treating 3,000
patients in a large metropolitan area like Austin on an
outpatient basis, acute inpatient psychiatry is a critical part
of the care.
While 50 years ago we put our psychiatric hospitals way out
in the country, right now, of course, we have them very close
to where the patients live because the stays are shorter, the
family needs to be involved in the care. The family needs to be
able to not only visit, but really take a part, and we need to
rehabilitate the patients and put them back in the community.
The last thing I would use would be a case example. There
are very fine mental health staff at your clinic in Austin, and
they shared with me when I visited there the dilemma that we
have a one hundred-percent service-connected patient with
schizophrenia showing up in an agitated state. The ideal thing
would be to admit him to a VA bed right there.
This is not a small city, Austin. By taking him all the way
to Waco, you then separate him from his family. He may have to
wait in an agitated State for an hour for an ambulance to
arrive and then make the ambulance ride up there. With all due
respect, that is not good care, Senator.
Mr. Alvarez. Finally, Senator, if I could finish up, with
regard to the community, the community became very active and
really worked cooperatively. Our recommendation calls for more
time so that the VISN director can work with the community to
see if they can come to a solution for that campus itself, see
what else can be done there. So my understanding is that they
are working closely with them, but we will see what develops.
Chairman Specter. Chairman Alvarez, coming back to the
Altoona facility which I had mentioned earlier, in 1997 the
Altoona VA maintained 38 inpatient beds to care for 8,900
veterans. Now, it has 28 beds, a 26-percent decrease, and
provides care for more than twice as many patients, 23,000. Its
average length of stay on inpatient admissions is 5.64 days,
equal to or exceeding the standard of Medicare and the
Pennsylvania Hospital Association.
Altoona's intensive care unit was recently renovated and is
a state-of-the-art facility.
What would the justification be under these circumstances
for eliminating the inpatient beds at Altoona, Mr. Chairman?
Mr. Alvarez. Mr. Chairman, you are correct. Currently, they
have 28 operating internal medicine beds. Last year's daily
census was 19 and it has been declining, and our recommendation
is to watch that closely.
Now, when you talk about the number of veterans coming in,
the far majority of those are outpatient and specialty
programs. Again, consistent with our entire effort, we would
like to see more care for those veterans coming for ambulatory
care, special programs, et cetera.
Chairman Specter. Well, where are they going to get that
special care?
Mr. Alvarez. Well, you are not doing any surgery now at
Altoona now, but Dr. Roswell can probably be more detailed.
Chairman Specter. Excuse me. Where are they going to get
that special care if you close the Altoona inpatient beds?
Mr. Alvarez. Well, the kind of care I am talking about is
expansion of outpatient care, more CBOCs, bringing access to
care to the community, and as Dr. McCormick indicated, to
include mental health services at the CBOCs out at the
community level, that kind of an emphasis.
When our commission took a look at the Altoona situation,
recognizing the dynamics of the area, all we are really saying
is take a good, careful look at that, and when it is reasonable
it would make sense to go ahead and shut that operation down.
You have 11 community JCHA-approved providers within a 60-
minute radius of Altoona.
Chairman Specter. What will the cost of that be to the VA?
Mr. Alvarez. I don't have a figure on the cost at this
point, but that is part of our recommendation.
Chairman Specter. Well, wait a minute, wait a minute.
Mr. Alvarez. Yes, sir.
Chairman Specter. Is that important that you don't have a
cost figure? How can you close Altoona and send them elsewhere
if you don't have a cost figure for comparison? How can you do
that?
Mr. Alvarez. Our recommendation is to do the cost/benefit
analysis, and when it is reasonable at some point, go ahead and
make that move.
Chairman Specter. Now, wait a minute. If you are saying do
a cost/benefit analysis and you haven't come to a final
conclusion about the Altoona facility----
Mr.Alvarez. That is right.
Chairman Specter. You can't come to a final conclusion
about Altoona unless you do a cost/benefit analysis.
Mr. Alvarez. That is right, sir.
Chairman Specter. So you are not recommending the closing
of the inpatient beds in Altoona?
Mr. Alvarez. We are saying do that when it is reasonable at
some point.
Chairman Specter. But you have been charged, Mr. Chairman,
with making a determination as to what is reasonable. That is
your job. The people in Altoona think that you want to close
them down. Do they have the wrong impression, because that is
what your report says?
Mr. Alvarez. Our report says at that point when it is
reasonable to close inpatient services, to go ahead and do
that.
Chairman Specter. Well, if you are saying when it is
reasonable, then you are frankly not saying much at all.
Let me go on to----
Dr. Roswell. Mr. Chairman, if I may, the draft National
CARES Plan felt that that reasonable point would be
approximately 10 to 12 years from now, possibly 2012 or 2014.
Chairman Specter. Well, who knows what is going to happen
between now and 10 to 12 years from now? Are you going to come
back with another commission and Mr. Battaglia will be chairman
by that time? Is that what you are going to do?
What value does this commission report have if you are
going to come back 10 to 12 years now and if it is not going to
take effect until 10 to 12 years from now? You know, I am only
going to be in the Senate for 20 more years. I might not even
be here.
Dr. Roswell. I think the sense of the report--certainly, my
read of the commission's recommendation was if the inpatient
census declined precipitously prior to 2012 or 2014, then we
would need to reevaluate and consider closure at that time.
Chairman Specter. And if it doesn't decline precipitously,
then you would keep it open?
Dr. Roswell. In my interpretation, it would not be
feasible. The recommendation was to close those beds as soon as
feasible. If the census is maintained at the current level or
actually increases, then in my opinion, strictly in my personal
opinion, it would not be feasible.
Chairman Specter. Dr. Roswell, you don't have a personal
opinion. You are a ranking official at the VA. You speak for
the VA and I like what I have heard.
Senator Rockefeller, there is another vote on, so I am
going to excuse myself for a while.
Senator Rockefeller. Good. I can be Chairman again?
[Laughter.]
Chairman Specter. Acting Chairman.
Senator Rockefeller. Dr. Alvarez, let me go at this maybe a
little different way. What you do is you go down and you have
your principles of how it will affect access and costs and
alternatives in the community and the rest of it. You had a lot
of places to visit, or your people did. I mean, I don't know
how you did it.
There are two ways to visit a community, it seems to me.
One is that you do it the way any President does, so to speak,
Republican or Democrat; in other words, what I call rope line.
You go in, you see a cross-cut of veterans and you see the
administrators, you talk to a couple of people and you are out
of there, not because you want to be, but because you have to
be.
Then there is another way, which is what I want to talk
about, with the indulgence of the Chairman, which relates
specifically, in fact, to the VA hospital in Beckley. I
mentioned before that about 4 percent of the land is flat. In
southern West Virginia, probably it is about 2 percent. Let me
phrase it this way. If I were to ask what this means that
people would have to go to Richmond or Salem, your answer might
be yes, and then your presumption might be, well, they could do
that.
Southern West Virginia is one of the poorest places in the
country. The county right next to it, Raleigh County, is one of
the four poorest counties in the country. Every time I am in
West Virginia, I always try to meet with the families of Iraq
reserve, regular and guard. The idea is that what I am trying
to do is get a statewide organization so that they can develop
things like we have to pay for our meals even when we come home
and a lot of different factors, or just timing.
I was in Mercer County, which is actually south of
Richmond, but which is in West Virginia, and I was suggesting
to them, why don't you get together with the people in Raleigh
County and form a unit. I am trying to do this on a statewide
basis. They said to me, well, we can't go to Raleigh County; it
is much too far to drive.
Now, I am not judging them, but that was their view. I can
either say I can change their behavior by pointing out that it
is an hour-and-three-quarters up the interstate, something like
that, once you get to the interstate, or I can accept the fact
that if that is their mindset--and remember how they came; they
were the people who basically left Virginia because Virginia
didn't want us, and they were the ones who went into the
southern mountains, which is where they are with their long
rifles, and sort of said ``don't tread on me.'' They have had
that mindset ever since, and they did toward me when I came to
West Virginia from some strange State in the northern part of
this Northeast. They were very suspicious for a very long time.
They don't change their ways as fast as other people do who are
in a much more mobile psychological and economic economy. So
the fact is they probably won't go to other places.
You have a copy of the West Virginia Hospital Association.
I went and I talked with those hospital directors, including
the ones in Beckley, where they have the beds--see, it is
deceptive--but they don't have the doctors or the nurses to
staff the beds. So what appears to be a possible turns out to
be an impossible because of the nature of southern West
Virginia, where it is harder to live; it is just harder to
live, lots of things.
It turns out, in fact, that if you do go to another place,
it does cost more. And what does it save the Veterans
Administration? $3.4 million, if you stay at Beckley. So you
can say, well, that is not much of a case, Jay; we have got
billions of dollars. I would say, no, it is a case because it
is a cost/benefit thing.
So you combine the unwillingness or the inability--it is
not unwillingness; it is sort of that people don't travel; they
won't travel--with a lack of transportation to the hospital
infrastructure, in spite of the work that the DAV and VSOs and
the VA does, and they don't have that sufficiently. And you add
on the vet centers and that still doesn't do it because you are
talking about more serious work, and the 550 jobs at the
hospital.
I just put that before you that when you are looking at you
are looking at your five principles, sometimes what sticks out
at you is not the condition in which people decide whether or
not to get health care. And I know lots of people, going back
to my VISTA days in West Virginia in the early 1960's, would
rather not go to a medical facility and find out more bad news.
So they don't go, which is not your purpose.
Thank you, sir.
Chairman Specter. Thank you very much, Senator Rockefeller.
Senator Graham, you have not had a second round yet.
Senator Graham. Thank you, Mr. Chairman. I would just like
to return to the subject I broached earlier, and that is the
area of a very major and growing concentration of veterans: the
panhandle of Florida.
There seems to be Administration support for a new hospital
in Pensacola. I wonder if someone could give a status report on
that and allay my concerns that there didn't seem to be any
reference to that in either the CARES report or in the
Commission's review.
Dr. Roswell. Are you speaking to the Pensacola Naval
Hospital which would have a joint presence with the VA?
Senator Graham. Yes.
Dr. Roswell. We are working closely with the Navy and
currently have a very productive sharing agreement with the
Pensacola naval facility. The expectation is that the new
facility would have a VA sharing presence. What form that will
take--it would be premature to describe that in detail at this
point, but we will be happy to provide some follow-up
information.
Senator Graham. I am familiar with the hospital in
Albuquerque, which is a shared VA-Air Force hospital. Is that
essentially what you are----
Dr. Roswell. The concept could take the shape of the one in
Albuquerque. We have actually just completed with DoD--in fact,
I was briefed this morning following the 2002 Defense
Authorization Act which requires an evaluation by an
independent contractor of joint governance. One of the areas
looked at was the Gulf Coast area. We now have a planning model
that looks at both VA and DoD workload and how that is managed.
So it could be an integrated facility. It could be on a
contractor basis where VA would reimburse Navy for that care.
It could be a joint facility. Those types of decisions would
come with further planning which is scheduled.
Senator Graham. Would you anticipate that this issue, as
well as planning for long-term care, would be incorporated in
the final CARES report?
Dr. Roswell. I don't think it would, sir. I think that
these are decisions that would be in the implementation
planning and the continuous strategic planning process. Because
it is not specifically addressed as a proposal in the draft
National CARES plan which the commission used to formulate and
frame their recommendations to the Secretary, I would
anticipate a specific recommendation.
But I can assure you that there is active sharing at the
Pensacola facility. There is a very productive relationship and
it is something that the Joint Executive Council between VA and
DoD, as well as the Health Executive Council, is monitoring on
a continuous basis.
Senator Graham. What was the criteria to determine which
programs were officially and formally part of the CARES process
and which were not?
Dr. Roswell. The CARES process utilized a variety of
criteria, but basically there was a planning model. If there
were significantly gaps, it basically used an actuary to
project the veteran population and the demand for care in the
years 2012 to 2022. It then overlaid that demand for care with
the current infrastructure within VA and the capacity
associated with that infrastructure. If there was a gap of more
than 25 percent, either 25 percent excess capacity or 25
percent insufficient capacity, then it had to be addressed
specifically in the planning model.
In the case of Pensacola, most of that care, as you may
know, is provided through the Gulfport-Biloxi VA Medical
Center, which is responsible for the current VA Pensacola
outpatient clinic and is also the oversight or the parent
facility for the sharing situation with the Pensacola naval
hospital. I can't tell you with certainty, but my expectation
is because there was not a 25-percent gap in that parent
facility, it didn't fall out as a separate planning initiative.
Senator Graham. Just briefly, with 45 seconds left, would
the same rationale have applied to the long-term care issue?
Dr. Roswell. No, sir. The long-term care wasn't even
included in the model because, working with our actuary, we
couldn't adequately project it at that time.
Senator Graham. But do you think that it will be
incorporated in the final CARES report?
Dr. Roswell. Long-term care will not be incorporated as far
as specific recommendations, but the strategic planning process
will address that on an ongoing basis.
Senator Graham. And what is the time line of CARES and the
strategic planning model?
Dr. Roswell. The Secretary is expected to make this final
decision with the CARES plan on or about March 12, at which
point in time we would go into an implementation plan. That
would also commence a strategic planning process which should
be a continuous strategic planning process that we will
validate and update on a year-to-year basis.
Chairman Specter. Senator Graham, I would like to go back
to the time limits so we can move along. We had deviated with
Senator Hutchison, who made no opening statement and had a very
important issue. But we are going to try to stay within the
confines of the time limits.
Senator Hutchison.
Senator Hutchison. Thank you, Mr. Chairman.
I want to go back to where we left with regard to the
recommendation that there be a new multi-specialty outpatient
clinic constructed in the Waco area and ask if you did consider
renovating the existing space already owned by the VA and if
that would be an alternative that would save taxpayer dollars,
while staying in the same area for service.
Mr. Alvarez. Senator, we asked that question and the
general consensus, without any specific detail, was that it
would be far more expensive. Let's put it this way: it would be
far less expensive to go ahead and build a new, modern, up-to-
date multi-specialty outpatient clinic there either on the
campus or off the campus somewhere to serve those veterans than
to try to renovate those buildings.
That facility was built in 1932. It is 1932-era
construction. Everything is interconnected with all the
building, all the heating, electrical. It is a nightmare of a
problem, and so I don't believe they went further into it. I
guess that basically was the extent of our probing.
Senator Hutchison. Did you base it on any figures that
would be given in the cost of renovation, particularly if there
were other buildings filled that would take away some of the
operational inefficiencies?
Mr. Alvarez. No, Senator, but we do know that that is one
of the factors that the city task force was going to look into
and work with the VISN director on that.
Senator Hutchison. So in your mind, would it be an open
issue whether renovation could be done on a more cost-efficient
basis than building a new facility?
Dr. Roswell. If I may, Senator, generally speaking,
renovating 50-year-old buildings, because of the issues
Chairman Alvarez brought up, is more costly than new
construction. I think a better way to frame the question would
be that new construction would take place on the current Waco
campus or off-campus.
Senator Hutchison. Exactly. I was just going to say the
next step is, then, are you talking about buying real estate
when you are looking at the----
Dr. Roswell. Not necessarily. The Waco campus is costly to
operate because of its size. There are over 100 acres. There
are numerous buildings and that is where the excess cost of
operation comes in. If we found a sharing partner that would
want to manage the entirety of that campus, then it probably
would be more cost-efficient to move off campus with new
construction.
For example, if our regional office wanted to come in and
relocate their offices there, which is a very large office in a
Federal building in downtown Waco, then it might be more costly
to build a new outpatient clinic on the existing acreage that
VA currently owns.
Senator Hutchison. Cost-efficient, you mean?
Dr. Roswell. Cost-efficient.
Senator Hutchison. Yes. I am looking for areas where there
might be, with the community input, some way to go.
Let me just talk again about the blind rehabilitation
center. When we were there, they had just done about a $10
million renovation, a state-of-the-art facility. And now the
recommendation was to move that away, again, taking away
another service that is done that would create synergy, moving
it possibly to Dallas or Temple, or they were even talking
about Mississippi.
That didn't make sense on its face, particularly with
Temple being 30 minutes away and having the ability to have
medical students in Waco just about as easily as you have them
in Temple.
Mr. Alvarez. Can I answer that?
Senator Hutchison. Yes.
Mr. Alvarez. In keeping with the total plan to move all the
programs off that campus, the proposal with regard to the blind
center was discussed at the hearing and the VISN directors
really did not want to consider Dallas, as it was farther away
for a lot of the veterans.
His objective would be to move it closer to where the
majority of the veterans live, possibly the Austin area,
because they do serve a lot of people from the lower Rio Grande
Valley and it would be closer to them, also.
Senator Hutchison. Again, if you were going to try to
create a synergy of efficient service on that campus, keeping
that there, having your new multi-service outpatient facility,
you could work something if you were trying to do that.
Dr. Roswell. It is possible. Let me point out that the
synergy with blind rehabilitation----
Chairman Specter. Dr. Roswell, the time is expired, but you
may finish your answer.
Dr. Roswell. The synergy with blind rehabilitation has to
do with access to optometrists, to ophthalmologists, to
psychologists, a variety of specialties that may be located in
a more full-service acute care facility such as the one in
Temple.
If the University of Texas medical branch at Galveston were
to create a significant new medical school presence in the
Austin area, that would probably create an ideal site for a
blind rehabilitation center, as well as some of the acute and
long-term psychiatric facilities that Dr. McCormick spoke of.
Chairman Specter. Thank you very much. We will have a third
round.
Will one more round be sufficient for your purposes,
Senator?
Senator Graham. I waive an additional round.
Chairman Specter. Senator Hutchison, will a third round be
sufficient?
Senator Hutchison. Yes, I think so. I have so many areas to
cover, Senator.
Chairman Specter. Well, we can always submit questions for
the record, if you have them.
Senator Hutchison. Thank you.
Chairman Specter. Chairman Alvarez, coming down to Butler,
in 1997 the Butler VA facility had 28 inpatient beds to care
for 10,000 veterans. Today, it has 8 beds and it cares for
18,000 veterans. Butler does not have any unused buildings on
the campus. Some of them have been aggressively disposed of by
way of leases to the United Way-Butler County and Catholic
Charities.
Is the commission's action with respect to Butler the same
as it is with respect to Altoona, and that is a recommendation,
in effect, to see what happens over a protracted period of
time?
Mr. Alvarez. No, sir. I will let Commissioner Vogel address
that.
Mr. Vogel. Thank you, Chairman Alvarez.
Senator Specter, at Butler their average daily census right
now is between 3\1/2\ and 4 patients a day in acute medicine.
About 96 percent of the patients there receive outpatient care
only. As you know, in western Pennsylvania they are about 38
miles from Pittsburgh. They do have contractual relationships
in place now.
Chairman Specter. Have you traveled that road, Route 8,
from Butler to Pittsburgh?
Mr. Vogel. I certainly have. I am from western
Pennsylvania, sir.
Chairman Specter. You are from where?
Mr. Vogel. I am from western Pennsylvania.
Chairman Specter. Are you from Butler?
Mr. Vogel. Part of my family is in Butler, sir.
Chairman Specter. Where is your home, Commissioner Vogel?
Mr. Vogel. My home now? Charleston, South Carolina.
Chairman Specter. When did you last travel Route 8 from
Butler to Pittsburgh?
Mr. Vogel. Last summer, when we visited there.
Chairman Specter. How long did it take you?
Mr. Vogel. It took us about 55 minutes, 60 minutes.
Chairman Specter. Were you speeding?
[Laughter.]
Mr.Vogel. No. We were driven by Butler VA Medical Center
police officers, who were very assiduous to the----
Chairman Specter. I am going to fire my driver. I have
never made it in 55 minutes.
Mr. Vogel. Well, the point was that Butler Memorial
Hospital, in part, has arrangements now with VA to take care of
emergency patients and some others. Our proposal was predicated
on the opportunity to maintain the long-term care facilities
there, the domiciliary, the nursing home. They are busy
facilities. They did about 165,000 outpatient stops last year.
So no question, it is a busy facility.
Chairman Specter. Mr. Vogel, are you aware that Butler has
plans to allow the Butler Memorial Hospital to relocate at the
VA?
Mr. Vogel. Yes, sir.
Chairman Specter. Wouldn't that change your view as to what
ought to happen with the VA?
Mr. Vogel. I think the view of that would be that they have
a great opportunity for enhanced use arrangements with Butler
Memorial Hospital, and if that is achieved, they could receive
some real economies of scale by sharing and purchasing services
together--dietetic service, engineering service, lab, pharmacy.
I think we saw that as a very viable opportunity, and the CEO
of Butler Memorial Hospital met with us both on a site visit
and at the hearing.
Chairman Specter. Well, at a minimum, shouldn't the VA be
able to stay in Butler at least until they complete their
negotiations with Butler Memorial Hospital?
Mr. Vogel. Yes, Mr. Chairman. Throughout, our caveat has
been the VA ought not to do anything that would reduce access
until all things are positioned and in place through referrals
and VA contracts with community providers and other
arrangements to care for those veterans.
We really spent a great deal of effort and time on the
``E'' part of CARES, the enhanced service part of it, and
believe with the recommendations we have made we can achieve
those things.
Chairman Specter. With respect to the recommendations made
as to Erie, Chairman Alvarez, are they the same as the
recommendations made as to Altoona?
Mr. Alvarez. Yes, they are, Senator.
Chairman Specter. They are the same for Altoona, so that
you want to wait and see what happens over a prolonged period
of time, until 2012 or 2014?
Mr. Alvarez. Yes, sir. And besides that, there is something
happening in that area, also. The VA is opening new CBOCs in
that northwestern corner, and one of the factors that we
cautioned or recommended that they do is keep track of what is
happening with regard to those new CBOCs with respect to
referrals from the CBOCs to Erie. The referral pattern may
change the demand on that, in addition to the projected
workload demand. So all of that is cautionary.
But you are right; it is keep an eye on what is happening.
Of course, we basically said, you know, when feasible, when
reasonable, when you see the patient enrollment population
declining quite a bit, then go ahead and make your decision.
But beyond that, we didn't micromanage it. We said that is the
decision by the VA's management. They are fully capable and we
respect that.
Chairman Specter. So it might take as long as 2012 or 2014,
as Dr. Roswell testified to?
Mr. Alvarez. Or perhaps longer if the conditions change.
Chairman Specter. We may have another hearing, then,
sometime around that period of time.
Senator Hutchison.
Senator Hutchison. I want to go to Big Spring. You
recommended doing the feasibility study to determine what
should be done with Big Spring, but you have got a situation
here where Big Spring is 40 miles from Midland, 60 miles from
Odessa, 57 miles from San Angelo, and 100 miles from Abilene.
If you closed that facility, the closest place that those
people in west Texas would have--and all of those are fairly
large communities--would be San Antonio or Dallas.
So my question is wouldn't it make more sense to work with
the Scenic Mountain Medical Center, which is a good, solid
medical center in Big Spring, and create a public-private
partnership that would give a service to the west Texas
veterans community in a more efficient way? Just leave the
status quo on the acute care, but keep the hospital for all of
those surrounding communities--is that a feasible suggestion?
We have done a lot of studies on this already.
Mr. Alvarez or Dr. Roswell, either of you.
Dr. Roswell. Certainly, my understanding of the
commission's recommendation and our expectation is that we need
to study exactly where best to situate inpatient services for
veterans in the west Texas area.
Thanks to your office, I have become keenly aware of the
referral patterns from San Angelo and Abilene and the fact that
the Big Spring location, while not a populace area, per se, is
centrally located between the entire patient population that is
served by that medical center.
I can readily grasp some of the disadvantages of moving
such a facility to the Midland-Odessa, and I think a study
would need to look not only at the utilization of services, but
clearly the referral patterns in siting that. One of the things
that we would be very interested in is identifying in any
location, but particularly where we have a relatively low
workload, a sharing partner where we could generate
efficiencies by collaboration or sharing.
Senator Hutchison. Like the private clinic.
Dr. Roswell. Exactly, just as you have mentioned, yes, very
much so.
Mr. McCormick. I happen to have been at the hearing that
dealt with Big Spring, and I think if you read the report
hopefully it would reflect that we heard a lot of very
compelling testimony actually about the centrality of Big
Spring, very similar to what you said, both from the State
veterans director as well as some of the veterans service
organizations, and the reality that the other advantage of the
Big Spring location is that there is a relatively new, I
believe, State veterans home there that was put there,
according to the State director of veterans affairs,
specifically because of the hospital.
So while we concurred with the study, I think if you read
the report, we also tried to make it very clear that we thought
that study had to take very much into account the knowledge
base of the people on the ground that are there. Most of the
testimony we heard was in favor of the Big Spring location.
Senator Hutchison. Even the Midland-Odessa leadership, I
think, agrees on that. Well, I thank you for putting that in
the record because that is helpful.
In summary, on Waco, I think we have a lot of different
issues with regard to Waco. But if we said that the VA has a
large investment there in both facilities and real estate and
we were going to try to make the best use of it and that we
could look at the new multi-service facility, whether it is a
new building or renovating the old buildings--and I am not
convinced that we have enough data on that yet, but say it is
probably more feasible to build it on that campus rather than
buy new real estate and that you could make it more efficient
by moving other things in there, which the community is
certainly willing to work to do, as well, perhaps even medical
servicing-type facilities.
The one thing that we didn't talk about too much was adding
a nursing home-elder care facility, which I think you had
mentioned. Is that something that could be added to? And,
second, is that something that the older buildings are more
amenable to as a use than maybe some of the other inpatient-
type care needs?
Mr. McCormick. Let me just take a shot at it. First of all,
let me start off by saying we have not only an investment in
real estate in Waco, we have an investment in a community of
seriously mentally ill patients.
One of the realities is when we built places like Waco or
Chillicothe and other places, we ended up deinstitutionalizing
a lot of patients into the communities, often into foster care.
And we may have 3, 400 patients right now in Waco, for example,
and these are generally very high-priority patients.
While I still stand by what I said for acute care, because
Austin has that need, I think there are many opportunities----
Senator Hutchison. Wait. I understand your point on Austin
and not having to wait for ambulance. I understand that.
Mr. McCormick. Right. Let me go back to Waco. I think that
the reality goes to your point that given the community of
seriously mentally ill patients around there--and they will age
and they will require as they age--and the good news is they
are living longer because of the medical care and the types of
medications we use. They will need long-term care and they have
to be addressed and those needs have to be addressed.
That is one of the reasons we put the caveat in about Waco
that the issues of long-term care for the Waco population--
frankly, the patients they are treating at Waco right now in
long-term care are very needy patients, with a wonderful staff
taking care of them.
So to answer your question, I think there is clearly a need
for a very large outpatient presence, and larger than perhaps
you would usually have in that size of an area because of the
community of deinstitutionalized patients. And there is an
opportunity to look at how best to provide long-term care, and
I think both of those things do reflect on the future planning
for Waco.
Chairman Specter. Thank you very much.
Senator Hutchison. Can I just----
Chairman Specter. Do you have another question? We have
another panel, Senator.
Senator Hutchison. I am sorry. I just wanted to clarify
that last answer. I am sorry, Senator Specter. I did not know
that we were going on.
When you say large outpatient need, you are talking about
the multi-service, not just psychiatric, correct?
Mr. McCormick. Yes. I mean, you have both----
Chairman Specter. We are over time, Mr. McCormick, but you
may answer that question.
Mr. McCormick. Yes. I was saying that in addition to a size
that would fit the population for the medical needs, the
reality is that because of the special needs of the seriously
mentally ill, the outpatient services are already more
comprehensive for outpatient mental health and they need to be
sized with that in mind. So I am really saying both medical and
mental illness.
Senator Hutchison. Thank you, Mr. Chairman.
Chairman Specter. Thank you very much, Senator Hutchison.
Well, that concludes this panel. I think it has been very
informative. As I said last September, if the proposed actions
are justified by evidence of wastefulness developed through an
objective analysis of individual data relevant to the
particular VA facilities, this Committee would not object. But
we have many questions raised and I am somewhat relieved to
hear that you are not thinking about actions to Erie or Altoona
for a protracted period of time, 2012 or 2014.
I am also concerned that we not take a look at facilities
just because they are small and they are presumptively
inefficient. An article in the Journal of the American Medical
Association in its January 14 issue of this year came to the
rescue of small facilities. It concluded that small is not, per
se, inefficient.
So thank you very much, gentlemen. We will consider your
testimony very carefully.
We are going to take a very brief recess and then resume
with panel two. So we will set up panel two and we will
proceed, as I say, in a few minutes.
[Recess.]
Chairman Specter. We will proceed directly to hear from Ms.
Cathleen Wiblemo, Deputy Director of Health Care for the
American Legion. Thank you for joining us and the floor is
yours. I regret the limitation of time to 3 minutes, but I
think you are used to it. Thank you.
STATEMENT OF CATHLEEN C. WIBLEMO, DEPUTY DIRECTOR OF HEALTH
CARE, VETERANS AFFAIRS AND REHABILITATION COMMISSION, THE
AMERICAN LEGION
Ms. Wiblemo. Thank you, Mr. Chairman, for the opportunity
to express the views of the American Legion regarding the
Capital Asset Realignment for Enhanced Services Commission's
recommendations. The American Legion commends the distinguished
members of the CARES Commission for their honest effort in
analyzing the draft National CARES Plan and assembling the
recommendations contained in the report.
The CARES Commission did not shy away from stakeholder
input and actively engaged the stakeholder community. The
American Legion believes this made a significant difference in
some of the recommendations offered by the commission.
Campus realignments were introduced late into the process.
These last-minute changes led to a multitude of proposals that
were indefinite and contained contingency language that left
the status of the services in question. The proposals to shut
down facilities were not part of many of the VISN market plans.
The American Legion does not believe decisions of this
magnitude should be made absent the inclusion of long-term
care, mental health and domiciliary projections. Further, no
facilities should be closed, disposed of or downsized until the
proposed transfer of services is complete and veterans are
being treated in new locations.
Finally, the commission recommended that no services should
be altered until viable services are identified in the
community. The American Legion is in agreement with these
recommendations and hopes that stakeholder concerns will be at
the center of these initiatives. The VA must establish quality
criteria for contracting and monitoring of service delivery and
training of staff to negotiate cost-effective contracts.
The American Legion is fully committed to working with this
Committee to ensure that the recommendations resulting from the
CARES initiative do indeed result in enhanced services for all
of American's veterans and their families.
Thank you. I would be happy to take any questions.
[The prepared statement of Ms. Wiblemo follows.]
Prepared Statement of Cathleen C. Wiblemo, Deputy Director of Health
Care, Veterans Affairs and Rehabilitation Commission, The American
Legion
Mr. Chairman and Members of the Committee: Thank you for this
opportunity to express the views of the 2.8 million members of The
American Legion regarding the Capital Asset Realignment for Enhanced
Services (CARES) Commission's Report to the Department of Veterans
Affairs' (VA) Secretary. The CARES initiative is unprecedented when
considering the broad scope of VA's mission and the effects the final
recommendations will ultimately have on VA's ability to fulfill its
missions. Implementation of these recommendations will greatly impact
services provided, not only to veterans currently seeking timely access
to quality health care, but those active-duty military members, serving
in more than 130 countries worldwide, who will 1 day turn to VA for
care.
The United States military is currently preparing for the largest
troop rotation since World War II; therefore, it is imperative that the
final recommendations of the CARES report lead to substantive changes
for enhanced veterans' services rather than simply downsizing the VA
health care system. The recommendations contained in this report will
ultimately shape the future of health care delivery within VA. The
implementation and integration of those recommendations into the
strategic planning cycle over the next 20 years is crucial to ensuring
America's veterans, present and future, receive timely access to the
quality of health care they have earned through honorable military
service to this country.
the cares commission review and recommendations on the draft national
cares plan
After several months of open meetings, lengthy debates on the
overall effect of possible recommendations and nationwide VISN specific
hearings, the CARES Commission Report to the Secretary of Veterans
Affairs was finally released in February 2004.
The American Legion is concerned with contingency language
contained in the report that does not clarify certain proposed
recommendations. Those recommendations that include ``proposed
feasibility studies'' and language such as ``transfer or contract
inpatient surgery beds'' must not be open to loose interpretation. The
American Legion supports strong oversight of all the recommendations
well into the implementation stages.
The American Legion applauds the distinguished members of the CARES
Commission for their honest effort in analyzing this vast amount of
information and assembling recommendations for a report of this
magnitude.
Stakeholder Involvement--One of the biggest issues of concern
during the first phase of CARES was the obvious lack of consideration
by VA over stakeholder input. When CARES entered Phase II, it was
important to The American Legion to ensure that the voice of the
stakeholder was heard during the CARES process. The American Legion
took the following measures:
Appointed a Legionnaire in each Veterans Integrated
Services Network (VISN) to serve as its CARES representative with the
primary task of participating at the local level regarding the CARES
initiative and passing along information pertaining to CARES.
Appointed members to The American Legion's VA Facility
Advisory Committee to the Veterans Affairs and Rehabilitation
Commission of The American Legion (VAFACC). The purpose of this
Committee was to review the market plans submitted by the VISN
leadership and to monitor the progress of the CARES process.
Members of The American Legion's A System Worth Saving
Task Force visited the seven facilities targeted for closure between
November 1, 2003 and January 1, 2004. As a result of those visits, A
System Worth Saving: The American Legion Report on the Seven Facilities
Targeted for Closure in the CARES Draft National Plan was released on
January 26, 2004.
Through the hearing process and along with Internet communications,
the CARES Commission was able to solicit stakeholder concerns, and
actively sought their views. The American Legion has maintained that
stakeholder input is imperative and must be taken seriously at all
levels of the CARES process. The American Legion intends on maintaining
its participation in this process as both a partner and stakeholder in
developing the future of VA health care.
Campus Realignments and Consolidations--The Draft National CARES
Plan (DNCP) contained proposals to close seven VA Medical Center
campuses and consolidate certain services. These proposals were
introduced relatively late in the process, absent stakeholder input.
The Commission's recommendations in the report to the Secretary differ
slightly with the DNCP, and to the Commission's credit, stakeholder
input was sought out at both the local and national level to assist
them in their evaluation of the DNCP's proposals concerning the
facilities.
The American Legion cannot support the closing of any VA facility
and denying veterans access to health care simply for the sake of cost-
saving measures. No facilities should be closed, disposed of, or
downsized until the proposed transfer of services is complete and
veterans are being treated in the new locations.
canandaigua veterans affairs medical center
The American Legion disagreed with the recommendation to close the
Canandaigua VAMC as proposed in the DNCP. Current services include
long-term care, nursing home care, mental health care and alcohol/drug
rehabilitation, respite care, the post-traumatic stress disorder
clinic, the domiciliary program and the mental health intensive case
management program. This facility performs an important role in its
region and is critical in meeting the health care needs of the local
veterans' community it serves.
The American Legion is relieved to see that the Commission did not
concur with the DNCP plan to close Canandaigua VAMC. The Commission
recommends that psychiatric long-term care, nursing home care,
domiciliary and outpatient treatment remain at Canandaigua. The
American Legion opposes any change to services at Canandaigua until
accurate demand projections are accomplished. Further, we are pleased
to see the recommendation by the Commission that the VISN involve
stakeholders and the community to help resolve the challenges they are
facing.
livermore veterans affairs medical center
The American Legion could not support this proposal as presented in
the DNCP. The Menlo Park Division is 40 miles and an hours driving time
for many of the older veterans who receive their care in Livermore. The
proposal to contract out nursing home care in this area is far from
realistic considering the local community does not have the capacity to
handle these patients. The Commission recommends retaining long-term
care services (nursing home beds) at Livermore as a freestanding NHCU.
The American Legion agrees.
waco veterans affairs medical center
The American Legion disagreed with the DNCP proposal to eliminate
health care services at Waco VAMC. The Commission recommends retaining
the NHCU as a VA operated facility, transfer of inpatient psychiatry,
blind rehabilitation and PTSD residential rehabilitation to Austin and
Temple and the construction of a new multi-specialty CBOC in Waco.
Waco is a multi-VISN referral facility for chronically mentally ill
patients and a national referral facility for blind rehabilitation.
Again, the CARES model does not incorporate the mental health needs and
projections to 2012 and 2022 for veterans. Until the mental health
numbers have been included, The American Legion believes the facility
should stay open with no change to its mission considered.
va pittsburgh healthcare system, highland drive division
The proposed closing of Highland Drive and the transfer of all
services to University Drive and Aspinwall campuses would require
considerable and costly construction with estimates of more than $90
million. Due largely to the very distinct veterans' population Highland
Drive VAMC serves, any transition of services could prove detrimental
to the veterans' population relying on the services provided. Any
proposed transfer of services must be seamless with as little
disruption as possible to these veterans. If any proposed transition of
services were to take place, The American Legion insists that an
adequate amount of time be given to allow an orderly transfer with
minimal disruption to patients and families.
leestown veterans affairs medical center
The American Legion objected to the DNCP proposal to close the
Leestown Campus of the Lexington VA Medical Center. Veterans in this
area are woefully underserved in the mental health care area. The
closing of the Leestown campus would be a great disservice to veterans
in need of mental health services. Once again, The American Legion
points to the lack of accurate mental health care projections
throughout the VA system. Even if VA does include projections for
future mental health care, those figures will not be incorporated until
the next strategic planning cycle. The American Legion agrees with the
Commission recommendation to keep the Leestown VAMC open.
brecksville veterans affairs medical center
The Commission concurred with the DNCP proposal to close this
facility and transfer all services to Wade Park. This raises serious
concerns that Wade Park cannot handle the influx of new patients and
that many patients will have to forgo treatment. The American Legion is
concerned that this facility will close before proper planning and
transferring of services has taken place. The chance for disruption of
services to veterans is considerable. If the Brecksville VAMC is
closed, VA must ensure that facilities at Wade Park are sufficient and
operational before any services are discontinued.
gulfport veterans affairs medical center
The American Legion does not support the closing of the Gulfport
VAMC as proposed in the DNCP and concurred with by The Commission.
Under the plan, all services are to be transferred to Biloxi and
Keesler AFB. The American Legion believes the plan relies too heavily
upon future developments with no guarantee that they will come to
fruition. Biloxi's capacity to handle Gulfport's patient load before
2009 is questionable. Additionally, the Department of Defense (DoD) has
made no firm commitment regarding the number of beds they can or will
provide at Keesler AFB. Furthermore, gaining access to the base may be
restricted because of increased homeland security measures.
Community-Based Outpatient Clinics--The VISN market plans proposed
the establishment of 242 new Community Based Outpatient Clinics
(CBOCs). To maintain the integrity of the system, and maintain level
growth for demand of services and ensure the ability to provide quality
care, the DNCP proposed the establishment of only 48 CBOCs prioritized
into three groups.
The criteria for inclusion into the top 48 CBOCs: (1) an access
gap; (2) projected future increases in workload; and (3) more than
7,000 projected enrollees currently residing outside of access
standards per proposed CBOC.
On October 7, 2003, VA's Undersecretary of Health informed the
Commission that priority groups for CBOCs were established in order to
continue limiting any new enrollees to prevent any strain on the
inpatient infrastructure. The Commission noted that this has the effect
of limiting access to outpatient care and is contrary to the goals of
CARES to better serve veterans today and in the future.
The American Legion agrees with the Commission's recommendation
that new CBOCs be established without regard to the three priority
groups outlined in the DNCP. The American Legion believes funding for
construction of new CBOCs should come from additional discretionary
construction appropriations. Currently, VISNs and facilities struggle
to maintain timely access to quality health care for veterans,
especially when inadequate annual VA medical care appropriations are
consistently finalized well into the new fiscal year. In the fiscal
year 04 VA medical care budget, Congress will allow the transfer of
$400 million for CARES recommendations. The American Legion disagrees
with this budgetary practice. For several years, VA Construction, both
major and minor, was under funded pending the approval of CARES
recommendations. This ``robbing Peter to pay Paul'' approach is
inappropriate budgetary shenanigans. CARES' ``enhanced services''
construction funding should fall under VA Construction.
Long-Term Care, Mental Health, Domiciliary--VA provides specialized
and unique care to veterans. It has been shown that the veterans'
population cannot accurately or fairly be compared to the general
patient population. The VA patient community is an older population
that experiences a myriad of co-morbidity issues that complicate
treatment.
CARES is a data driven process. The key component is the data used
to forecast the future needs of veterans. The CARES process fails to
include information on long-term care, outpatient mental health and
domiciliary needs of veterans. VA chose to omit these important health
care needs for this assessment. The American Legion believes these
critical omissions adversely impact the effectiveness of
recommendations resulting from the CARES process. The exclusion of
these issues in the CARES process denies a complete and accurate
picture of the demand for these services.
A case in point is the disparity in demand estimates for nursing
home beds in VISN 6's Northwest Market. CARES DNCP estimates held that
the veterans' population in this Market is expected to decline from
53,000 in fiscal year 2001 to 48,000 in fiscal year 2012, and to 39,000
in fiscal year 2022. Consequently, the CARES Commission found that
``current LTC workload at Beckley WV is decreasing and does not
indicate that more nursing home care beds are needed.''
This would appear to contradict a 2002 Capital Effectiveness
Analysis (CEA) conducted by VA's own Office of Policy and Planning in
collaboration with the Geriatrics and Extended Care Strategic
Healthcare Group, the Agency for Health Care Policy and Research and
the University of Michigan. Also cited in the DNCP in a VISN Identified
Planning Initiative, the CEA study projected ``the elderly population
in West Virginia to increase from 15.3 percent in 1995 to 24.9 percent
in 2025, which will put a strain on the private sector nursing homes in
the area.'' The closest State Veterans Home is 100 miles away and
Beckley VAMC Extended Care and Rehabilitation Service Line management
is precluded from using a majority of local nursing facilities because
of patient safety and quality of care concerns. A new 120-bed nursing
home was approved for Beckley and initial phases of the project are now
underway. As a fait accompli, the Commission concurred with the
project. It is clear, however, that if only CARES data were used to
estimate NHC bed demand, current capacity would have been deemed
adequate and many aging veterans in eastern West Virginia would be
denied safe, quality nursing home care in the coming years.
The example of Beckley is illustrative of problems with the CARES
model as applied to long-term care where variables, such as aging
trends, are not part of the equations. Similar flaws exist in demand
projections for mental health services and domiciliary. The American
Legion insists that decisions on services in these areas be deferred
until accurate projections are available.
Vacant Space--According to VA's Office of Facilities Management
(OFM), VA facility assets include 5,300 buildings, 150 million square
feet of owned and leased space, 23,000 acres of land and a total
replacement value estimated at $38.3 billion. The Draft National CARES
Plan proposes to eliminate 4.9 of 8.5 million square feet of vacant
space, an ambitious 42 percent, by fiscal year 2022. The DNCP calls for
divestiture and demolition early in CARES implementation as the primary
methods to reduce vacant space. The Commission notes that much of VA's
excess property is not contiguous, but consists of pockets of space
scattered throughout campuses, making it useless for other purposes
such as Enhanced Use Leasing. Many VA buildings are considered
historic, further challenging VA's disposal of the properties. The
American Legion agrees with the Commission's findings that separate
appropriations are requested to stabilize and maintain historic
property rather than rely on medical care appropriations.
The American Legion does not agree with the Commission's finding
that VA ``. . . aggressively pursue disposal of excess VA property and
land.'' The American Legion believes a case-by-case effort should be
made to consider alternative uses of any vacant space before it is
eliminated, such as: services for homeless veterans, long-term care,
and the expansion of existing services.
Contracting Care--The DNCP proposed extensive contracting out of
care within many of the VISNs in order to meet the projected increased
demand in services through the peak years. Contracting out of care is
necessary in some circumstances and inevitable in others, given VA's
inability to pay competitive salaries to medical professionals. The
American Legion agrees with the Commission's recommendation that no
services should be altered until viable services are identified in the
community. Furthermore, VA must establish quality criteria for
contracting and monitoring service delivery and training of staff to
negotiate cost-effective contracts. Fee schedules must be reviewed and
adjusted to attract qualified practitioners; otherwise Medicare/
Medicaid style difficulties in retaining contract providers may be
experienced by VA.
Enhanced Use Lease Agreements--With Enhanced Use Lease Agreements
(EULs) VA can maximize returns from property that is not being fully
utilized. EULs allow VA to reduce or eliminate facility development and
maintenance costs. Through effective use of EULs, VA can receive cash
or ``in-kind'' consideration (such as facilities, services goods, or
equipment).
The DNCP proposed several enhanced use lease agreement projects
with the public and private sectors. Uses include homeless shelters or
housing, cultural arts center, cemeteries, inpatient beds, mental
health services and many other veterans' service enhancing ideas. The
American Legion believes that EUL agreements that result in the
development of new strip malls, commercial office buildings, or hotels
come at the expense of providing real ``enhanced services'' to
veterans.
The American Legion recognizes that the EUL process, noted by the
Commission, is fraught with delays, and a lack of demonstrated
confidence and insufficient expertise to attract potential investors or
navigate local zoning and land use requirements, is lengthy and
complex, and is subject to the ups and downs of local economic
conditions. The American Legion agrees with the Commission's finding
that the EUL process needs reform.
VA/DoD Sharing--There are many opportunities for sharing between VA
and the Department of Defense (DoD). The DNCP contains 21 high priority
collaborations/joint ventures out of the 75 proposed throughout VA.
Both VA and DoD benefit from these agreements and every effort should
be made to pursue this avenue in order to save money through cost
avoidance, in particular pharmaceuticals, supplies and maintenance
services.
Extra effort on the part of these agencies to cooperate is
essential in order for sharing to be successful. There is reluctance in
some parts of the country to ``share'' services or programs between
agencies. It is imperative that these roadblocks are overcome.
The American Legion agrees with the Commission's premise that VA/
DoD collaboration should be one of the first considerations in
addressing health care needs in a local area. However, the focus should
always be on providing quality healthcare and reasonable access to the
nation's veterans. If in the VA/DoD sharing process that cannot be
accomplished, other ways of providing the service must be evaluated and
the one that most benefits the veterans' community is the option that
should be exercised.
Medical School Affiliations--VHA conducts the largest coordinated
education and training program for health care professions in the
nation. Medical school affiliations allow VA to train new health
professionals to meet the health care needs of veterans and the nation.
Medical school affiliations are a major factor in VA's ability to
recruit and retain high quality physicians and to provide veterans
access to the most advanced medical technology and cutting edge
research. VHA's research has made countless contributions to improve
the quality of life for veterans and the general population.
VA's partnership with this country's medical schools continues to
allow VHA to enhance its ability to provide quality medical care to
America's veterans, to promote excellence in education and research,
and to provide back-up medical care to DoD in the event of war or
national emergency.
The academic medical model of integrated clinical care, education
and research is universally accepted as the best means of providing
high quality and state-of-the-art medical care. The American Legion
affirms its strong commitment and support for the mutually beneficial
affiliations between VA and the medical schools of this nation. VA
medical school affiliates should be appropriately represented as a
stakeholder on any national Task Force, Commission, or Committee
established to deliberate on veterans' health care.
The Fourth Mission--VA's fourth mission is to serve as back up to
DoD in the case of a national emergency. Any recommendations that are
implemented as a result of the CARES initiative must ensure that VA is
capable of fulfilling the fourth mission.
implementation and integration into strategic plan
CARES will not end once the Secretary renders his decision. It is
expected to continue into the future with periodic checks and balances
to ensure plans are evaluated, as needed, and changes are incorporated
to maintain balance and fairness throughout the health care system.
Service areas such as long-term care, mental health services and
domiciliary capacity, excluded from the CARES process, were to be dealt
with in strategic planning. The American Legion notes that VA's July
2003 Strategic Plan 2003-2008 contains a scant two paragraphs of
generalities on the subject of long-term care. The American Legion will
be following these issues closely in the coming months and years.
Mr. Chairman and Members of the Committee, The American Legion has
raised many concerns today. The recommendations to close VA hospitals
during a time when hundreds of thousands of soldiers are being sent to
foreign lands to fight a war and the assessment of long-term care,
mental health and domiciliary services being pushed back to the next
cycle of CARES, are serious flaws in an assessment of a system vital to
the health care needs of this nation's veterans. The American Legion
has strong reservations against the contracting of veterans' care. The
Nation is producing more and more veterans in the global fight against
terrorism, a fight that promises to be lengthy and take its toll on our
young men and women. Unfortunately, many of these new wartime veterans
will be dependent on the VA health care delivery system for the rest of
their lives due to service-connected disabilities. It is imperative
that we work together to ensure a future system of health care that
meets the needs of the veterans' community.
Mr. Chairman, this concludes my testimony. I again thank the
Committee for this opportunity to express the views of The American
Legion on the CARES Report and look forward to working with you and
your colleagues to ensure that the recommendations resulting from this
unprecedented initiative do indeed result in ``enhanced services'' for
all of America's veterans and their families.
Chairman Specter. Thank you very much for that testimony.
We turn now to Mr. Dennis Cullinan, National Legislative
Service Director for the Veterans of Foreign Wars. Thank you
for joining us, Mr. Cullinan. We look forward to your
testimony.
STATEMENT OF DENNIS M. CULLINAN, DIRECTOR, NATIONAL LEGISLATIVE
SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES
Mr. Cullinan. Thank you very much, Mr. Chairman. On behalf
of the Veterans of Foreign Wars and our Ladies Auxiliary, we
thank you for holding today's most important hearing and for
inviting our participation. I will provide a brief synopsis of
my written presentation.
The VFW recognizes that the location of mission of some VA
facilities may need to change to improve veterans' access and
to allow more resources to be devoted to medical care rather
than upkeep of inefficient buildings and to adjust to modern
methods of health care service delivery. Therefore, the VFW is
generally supportive of the CARES Commission's recommendations.
However, we have identified certain recommendations that,
if adopted, in our view, would hamper or even jeopardize
veterans' access to quality, timely health care. In addition,
as has been observed here today, CARES' methodology, statistics
and facts that it has used are far from certain. We believe
that all due caution and care have to be invested in the best
service of America's veteran patients.
That concludes my testimony, sir.
[The prepared statement of Mr. Cullinan follows:]
Prepared Statement of Dennis M. Cullinan, Director, National
Legislative Service, Veterans of Foreign Wars of the United States
On behalf of the 2.6 million members of the Veterans of Foreign
Wars of the United States (VFW) and our Ladies Auxiliary, I would like
to thank you for the opportunity to present our views regarding the
CARES Commission recommendations.
The CARES Commission was chartered to make specific recommendations
to the Secretary of Veterans Affairs on the Under Secretary for
Health's Draft National CARES Plan (DNCP) regarding the realignment and
allocation of capital assets necessary to meet the demand for veterans'
health care services over the next 20 years. The Commission was to
accept, modify or reject the recommendations of this draft plan. In
making its recommendations, the Commission was told to focus on the
accessibility and cost effectiveness of care to be provided, while at
the same time ensuring that the integrity of VA's health care and
related missions is maintained, and any adverse impact on VA staff and
affected communities is minimized.
To understand the impact of the DNCP on local markets, the
Commission conducted 38 public fact-finding hearings where testimony
was received from local Veterans Service Organizations, employee
organizations, academic affiliates, organizations with collaborative
relationships and involved elected officials. The VFW was pleased to
have local representatives participate in 30 of those hearings. While
all of the recommendations certainly deserve individual attention, I
will focus my remarks on some of the recommendations that we believe
are representative of the national plan. I would refer the Committee to
our statements before the CARES Commission for a more robust and
complete analysis of the recommendations regarding each specific
market.
We recognize that the location and mission of some VA facilities
may need to change to improve veterans' access; to allow more resources
to be devoted to medical care, rather than the upkeep of inefficient
buildings and to adjust to modem methods of health care service
delivery. Therefore, the VFW is generally supportive of the CARES
Commission's recommendations, however, we have identified
recommendations, that if adopted could jeopardize veterans' access to
quality, timely healthcare.
The VFW is concerned with recommendations to curtail VA operations
in Pennsylvania by closing a branch of the VA Pittsburgh Health System
and scaling back operations in Butler, Altoona and Erie. The
recommendations would:
1. Close the hospital on Highland Drive in East Liberty in
Pittsburgh.
2. Close acute care services in Butler, Pennsylvania.
3. Close all acute care beds in Altoona, Pennsylvania.
4. Close inpatient surgical services and all acute care beds in
Erie, Pennsylvania.
The VFW supports the first recommendation but is opposed to the
remaining recommendations. The consolidation of Highland Drive
Division's inpatient service to the University Drive campus over the
past few years resulted in vacant buildings at the Highland Drive
campus. Since considerable consolidation of services has already taken
place and the facilities are in close proximity, veterans and
stakeholders expressed support for the enhancement of service that the
proposed consolidation would bring. Further recommendations would
require a veteran residing in Altoona, Butler or Erie to travel to
Pittsburgh to receive care they once received locally. This rationing
of services is unacceptable. No veteran, who is sick and/or elderly,
not to mention their family, should have to drive over 250 miles round
trip from Erie to Pittsburgh. This approach is inequitable as it is
overly burdensome for the veteran and quite convenient for the VA.
Turning to the Northeast, the VFW agrees with the Commission's
recommendation to create and provide additional services in Boston, MA,
as well as maintain and not close the Canandaigua VA Medical Center for
veterans within that primary service area. As for Montrose, N.Y., the
VFW supports moving several services to Castle Point but would further
suggest developing a long-term strategic plan for accomplishing the
move that would ensure the seriously mentally ill patients are not lost
in the shuffle. As for the recommendation regarding Manhattan/Brooklyn,
N.Y., the VFW opposes the possible consolidation of these two
facilities noting the hardship it will cause for elderly veterans
living on fixed incomes who have no means of transportation.
Further south, the VFW generally supports the commission's
recommendations regarding Beckley, WV, facility. We agree that multi-
specialty outpatient services should remain at this small facility and
we would also support a new nursing home because long-term care is
needed in WV. The VA must ensure that contracting is feasible and that
the local community can effectively provide the necessary services.
While in Florida, the VFW supports the construction of a new bed tower
in Gainesville while retaining inpatient services at Lake City.
In the Midwest, the VFW is opposed to the closure of the VAMC in
Brecksville, OH. The recommendation would transfer functions currently
performed there to Wade Park. This will not only add to travel time of
the patients now receiving care at Brecksville, it will also exacerbate
an already intolerable parking situation at the Wade Park facility.
Finally, out West in Texas, the VFW is concerned with the closure
of the WACO VAMC. We would reiterate veterans' concerns regarding
travel and access The VA is in a much better position to go to the
veteran rather than the veteran to the VA.
It is important to point out that the VFW believes that any action
to reconfigure or expand long-term care or mental health facilities
should be developed in a strategic plan because the DNCP originally
ignored these service areas. This plan should be based on well-
articulated policies and address access to services.
Mr. Chairman, this concludes my remarks and I would be pleased to
respond to any questions you or the Members of the Committee may have.
Chairman Specter. Thank you very much, Mr. Cullinan. I
agree with what you say. They really haven't made their case,
and we appreciate your coming in to give us the view of the
veterans. We always appreciate your help.
We turn now to Ms. Joy Ilem, Assistant National Legislative
Director for Disabled American Veterans.
STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
Ms. Ilem. Thank you, Mr. Chairman. We appreciate the
opportunity to present the views of the Disabled American
Veterans regarding the recommendations of the CARES Commission
report.
Access to high-quality, timely health care services is
essential for many DAV members. Therefore, the preservation of
the integrity of the VA health care system and its specialized
programs is of the utmost importance to DAV and our members.
We concur with many of the commission's recommendations
relative to the identified cross-cutting issues, and we are
also pleased that the commission addressed many of our
concerns, specifically the need for further development of the
CARES model and projections for mental health care services,
the need for VA to develop a more cohesive long-term care
strategy, and the need for reassessment of the proposed
placement of domiciliaries and associated programs.
We will continue to rely on the expertise of our members to
make recommendations regarding the VA medical facilities they
use and rely on. Our members are intimately familiar with the
unique elements and the impact on each VISN and the medical
centers and the CBOCs within their local areas.
From a national perspective, we are opposed to facility
closure and consolidation or transfer of services at any
location for purely budgetary reasons. VA must ensure, in cases
where these decisions are determined to be the only reasonable
option, that resources and alternate access to care options are
in place prior to the realignment or transfer of services.
Under no circumstances should veterans experience a decrease in
primary or specialty care services, or denied access to
specialized programs.
Oversight by Congress, veterans and veteran service
organizations is going to be essential to the overall success
of this important initiative. Although we agree with the
commission that the final plan should be national in scope, we
hope there is sufficient consideration given to the concerns
expressed by veterans and other stakeholders as the Secretary
makes his final decision.
That concludes my statement. Thank you.
[The prepared statement of Ms. Ilem follows:]
Prepared Statement of Joy J. Ilem, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman and Members of the Committee: On behalf of the
Disabled American Veterans (DAV) and its Auxiliary, we are pleased to
express the national views of the organization on the Capital Asset
Realignment for Enhanced Services (CARES) February 2004 Report To The
Secretary Of Veterans Affairs. The CARES Commission was established by
Department of Veterans Affairs (VA) Secretary Anthony J. Principi as an
independent body to review the Draft National CARES Plan (DNCP)
regarding the realignment and allocation of capital assets necessary to
meet the demand for veterans' health care services over the next 20
years.
The Veterans Health Administration (VHA) is the largest direct
provider of health care services in the United States and offers
specialized care that is world renown to veterans with amputations,
spinal cord injury, blindness, posttraumatic stress disorder, and brain
injury. In recent years, VHA has established itself as a leader in the
delivery of quality health care and is also the nation's primary backup
to the Department of Defense (DoD) in time of war or domestic
emergency. According to VA, the goal of CARES is to enhance access to
health care services for our nation's veterans, while insuring the
integrity of its health care system. One of the most important VA
benefits for service-connected veterans is health care. Access to high
quality, timely health care services is essential for many DAV members,
especially those who have suffered severe or catastrophic disabilities
as a result of their military service. Therefore, preservation of the
integrity of the VA health care system and its specialized programs is
of the utmost importance to the DAV and our members.
DAV is looking to CARES to provide a framework for the VA health
care system that can meet the needs of sick and disabled veterans now
and into the future. From a national perspective, DAV firmly believes
that realignment of capital assets is critical to the long-term health
and viability of the entire VA health care system. We do not believe
that restructuring is inherently detrimental; however, we are dedicated
to ensuring the needs of special disability groups are addressed and
remain a priority throughout the CARES process. As CARES has
progressed, we have continually emphasized that all specialized
disability programs and services for spinal cord injury, mental health,
prosthetics, and blind rehabilitation should be maintained at current
levels as required by law.
The Commission stated in its report that CARES is the most
comprehensive assessment ever undertaken by VA to determine the capital
infrastructure needed to provide modern health care to veterans now and
in the future. DAV agrees with the Commission that the CARES process is
extremely important as it will impact the system and the delivery of
health care services to veterans for decades. Like veterans of previous
wars, many of the men and women serving today in our Armed Forces in
Iraq, Afghanistan, and other hot spots around the world, will need and
depend on the VA health care system. It is our obligation to ensure
they have access to a strong and viable health care system, dedicated
specifically to their health care needs.
Initially, we want to recognize and thank the members of the CARES
Commission for their intensive effort in analyzing the vast amount of
information associated with CARES and for the Commission's thoughtful
report. DAV believes the Commission conducted a rigorous and thorough
review of the available information provided by the National CARES
Program Office given the timeframe limitations and provided a
comprehensive assessment and analysis of the CARES data and the DNCP.
It is apparent in the Commission's final report that many of the
concerns expressed by the DAV and other veterans service organizations
(VSOs) were addressed during deliberations and included in its final
recommendations.
In our testimony, we will refrain from commenting on specific
recommendations made by the Commission relating to consolidation,
closure, transferring, or realignment of services at individual
facilities or Veterans Integrated Service Networks (VISNs). Testimony
provided by DAV members at the 38 formal hearings conducted by the
Commission will serve as the official position related to proposals
made in the DNCP for specific regions or medical facilities. Rather,
our remarks will focus on the crosscutting issues identified by the
Commission in its report, including facility mission changes,
community-based outpatient clinics (CBOCs), mental health services,
long-term care, long-term mental health care, excess VA property,
contracting for care, infrastructure and safety, research, education
and training, special disabilities programs, and VA/Department of
Defense (DoD) sharing.
facility mission changes
There were a number of instances where the DNCP proposed
consolidation or realignment of services, closure of inpatient
services, or closure of existing services, including long-term care
services. In some cases, the Commission rejected the DNCP proposals,
other times it concurred with them, made its own recommendation, or
suggested additional study prior to a final decision.
DAV will continue to rely on the expertise of its members to make
recommendations about the VA medical facilities they use and rely on.
They are familiar with the unique elements that impact each VISN, VA
Medical Center (VAMC) and CBOC in their local area taking into
consideration the local terrain, specific challenges due to urban,
rural, or highly rural areas, local weather conditions, and various
other factors.
From a national perspective DAV is opposed to facility closure,
consolidation or transfer of services at any location for purely
budgetary reasons. VA must ensure, in cases where these decisions are
determined to be the only reasonable option, that resources and
alternate access to care options are in place and available to veterans
prior to the realignment. Under no circumstances should there be a
decrease in services or denied access to needed programs and services.
Additionally, careful consideration must be given to ensure
transportation to alternate facilities is available and that services
are not interrupted for veterans who need them.
community-based outpatient clinics (cbocs)
The VISNs proposed 242 new CBOCs nationwide to address outpatient
access issues, increasing workload capacity for primary and mental
health care and space deficiencies at VA Medical Centers (VAMCs). The
DNCP divided the proposed clinics into three priority groups. The
Commission noted that the methodology used by VA generally led to CBOCs
in rural areas being placed in the second priority group and left some
markets with growing outpatient demand out of priority group one. We
agree with the Commission's findings that, ``. . . VA's rationale for
prioritizing the implementation of new CBOCs was to control new demand
for care, which disproportionately disadvantages rural veterans and is
contrary to the goal of CARES.'' We believe the CARES process should be
data driven and if VISN data supports the need, through market share
analysis, for additional outpatient clinics, CBOCs should be
established without regard to the priority group requirements outlined
in the DNCP. It should be left up to Congress to authorize sufficient
funding to meet the projected need for additional clinics.
mental health services
Of great concern to DAV is the error in calculating the gaps in
mental health services identified by VA mental health experts.
Initially, we were pleased that the CARES office convened a special
mental health workgroup which acknowledged the error represented an
underestimation of future outpatient mental health needs by
approximately 34 percent. Disappointingly, the corrections made by the
workgroup and the revised projections still have not been run or
distributed to the field. Mental health experts briefed the Commission
on several occasions and provided detailed information about the
problems this flaw in the model presents and the impact of erroneous
data for future planning of mental health services. We are pleased the
Commission acknowledged in its report this serious flaw in the model as
well as the significant variation in the current provision of mental
health services across the VISNs, including CBOCs.
We agree with the Commission's recommendations that the CARES data
for outpatient mental health services and acute psychiatric inpatient
care be corrected and forwarded to all networks as soon as possible so
that VISNs can quickly identify and revise plans to address any gaps in
service which should be integrated into the ongoing CARES process.
Additionally, VA should properly assess the need for outpatient
mental health care space requirements and ensure VHA is providing
needed mental health services in VA CBOCs. Based on VHA data, over 28
percent of users of VHA care have a mental health diagnosis and over
460,000 are service connected for mental health disorders, including
posttraumatic stress disorder and psychoses. In fiscal year 2003,
nearly 800,000 veterans used mental health services at VA facilities.
Mental health services like long-term care services make up the core of
specialized services within VHA. This particularly vulnerable
population is at higher risk for being disenfranchised during the CARES
process. Several of the sites under consideration for transfer or
consolidation of services are in areas where there are specialized
programs to treat veterans with complex mental health, substance abuse,
and violent behavioral problems. In many cases, closure of a treating
facility is devastating for these fragile patients and their families
who have come to depend on these specialized programs. Can we ensure
these veterans will be better severed and have reasonable access to
similar programs in a nearby location? In some cases, it may be more
cost effective for VA but is the veteran patient best served?
Disruption of longstanding treatment in a familiar facility can often
lead to a setback for the patient with serious mental illness.
Given veterans' reliance on and need for these highly specialized
programs, we urge the Secretary to include this critical care component
prior to his decision and finalization of the CARES plan.
long-term care and long-term mental health care
The need for long-term care services, which includes nursing home,
domiciliary, and non-acute inpatient and residential mental health
services remains a complex issue. Initially, VA identified through its
CARES model the projected need for more than 17,000 additional nursing
home beds to meet the future needs of aging veterans. Unfortunately, VA
took this issue off the table and has not made a formal policy decision
regarding the long-term care needs of veterans other than to say that
VA will focus on alternate home health care options. VA's Under
Secretary for Health has stated on several occasions that veterans do
not want to be in extended care facilities, but rather prefer to
receive care in their homes. Although this may be true, realistically,
many veterans do not have a spouse or family member that can act as
care-giver and many veterans will need the level of care provided in an
institutional setting and will not be able to remain at home.
Additionally, it appears VA is adhering to the letter of the law,
rather than the spirit of the law, related to extended care services,
providing this type of care only to veterans with service-connected
disability ratings 70 percent or higher or to veterans who need such
care for their service-connected condition. Whenever possible, VA
prefers to relegate long-term cares services to the community in either
State nursing homes, many of which are filled to capacity, or through
State Medicaid programs. Unfortunately, VA has not been as diligent in
its oversight of the quality of care provided in these alternate
settings. Transfer of patients receiving extended care services to a
nearby location can often be devastating to an elderly patient and his
or her family. Elderly spouses or family members are often frail
themselves and unable to drive long distances to see their loved ones.
VA must also take into consideration that these family members may be
unable to visit regularly and help assist their loved ones on a daily
basis. Additionally, there is the issue of extended care services for
patients with serious mental disorders.
Many VA patients with dementia and other complex mental health
issues generally do not make good candidates for transfer to community
long-term care nursing facilities. In many cases, the private sector is
unable or unwilling to accept seriously chronically mentally ill
patients, who are often difficult to manage. It seems incredible that
VA has chosen not to include this portion of care services in CARES
Phase II, given that long-term care is one of the most important and
integral components of health care today. To leave this critical piece
out of the CARES equation will only compound the problems associated
with VA's capital asset planning and restructuring in the years to
come. It is difficult to be supportive of the process when
consideration of such a key component is left hanging. Of equal concern
is that, although this issue was not fully addressed in the DNCP, there
are proposals in the plan for closures and/or transfer or consolidation
of services that directly impact on long-term care and mental health
inpatient services. The DNCP includes proposals for consolidations or
realignments with significant extended care components and construction
of new extended care facilities in some locations. We also note that
there is significant variability in the delivery and access to extended
care services throughout the networks. The Commission notes that there
seems to be inconsistency in proposals of where to locate long-term
care facilities, i.e., placement of extended care centers near medical
facilities or free standing. We agree that VHA should develop clear
criteria for the placement of extended nursing home beds/units and that
there should be uniformity and equal access to such services across the
networks with a focus on quality of care.
We concur with the Commission's findings regarding long-term care.
Specifically, that VA has not developed a consistent rationale for the
placement of long-term care units, has not adequately addressed the
needs of aging, seriously mentally ill patients, and that the proposal
for movement of domiciliary beds is inconsistent with established
programs.
The integral nature of the placement of domiciliaries and programs
for homeless veterans, substance abuse treatment, and other specialized
VA programs warrant additional study and consideration by experts in
these unique program areas.
excess va property
Dealing with identified excess VA property remains a complex issue.
VA's plan is projected to result in a 42 percent reduction in vacant
space over a 20-year period. VA identified in its evaluation process
that it had approximately 8.5 million square feet of vacant space. In
the VISN evaluations, space that was not utilized for patient care,
support patient care or other VA missions, was identified as vacant.
According to the DNCP, such space was proposed for demolition,
divestiture or lease or enhanced-use lease (EUL) authorization
agreements. The plan points out that demand for possible vacant space
at VA facilities could change in the future based on a variety of
factors, including changes in the economy or in the practice of health
care delivery. VA pointed out that in many cases unused space is not
appropriate for alternative use due to the specific location of the
building in relationship to other campus buildings, i.e., the unused
space may be located in outlying buildings or on upper floors,
therefore unsuitable for modern medical functions or attractive for
other uses. The plan also notes that the savings, profits and costs
associated with the management of vacant space is complex and difficult
to standardize. According to VA, total savings from proposals such as
closure of facilities identified in the DNCP have not been fully
evaluated.
We agree with the Commission's findings that there was heavy
reliance on EUL proposals in the DNCP and that the planning and the
process, as it currently exists, have been fraught with delays and have
led to significant lost opportunities. Although this program offers the
best way to retain resources for direct patient care, improvements need
to be made for the program to be more advantageous. We support the
Commission's recommendation to reorganize and streamline the EUL
program to best achieve VA's goals. The Commission also commented that
maintaining buildings or excess land requires VA to utilize medical
appropriations that could be used for direct patient care. We are
extremely concerned about the sale of VHA properties and the reported
requirement that such funds cannot be retained for patient care but
must be returned to the Treasury.
DAV does not want to see resources that can be used for direct
patient care used to maintain unused infrastructure or buildings that
cannot be cost-effectively reused for providing medical services.
However, we believe VA should be allowed to maintain funding from
leasing or sale of these structures for patient care. VA should
carefully consider its analysis of unused space and deal with it
appropriately, keeping in mind that some space is located in historic
structures and must be preserved and protected according to the law.
When appropriate, space should be used for enhanced use lease for
veteran-related programs.
contracting for care
The Commission found several benefits for contracting for care in
the community, including additional capacity and improved access in a
more timely manner than can be accomplished through a capital
investment; flexibility to add or discontinue services as appropriate;
and increased access in areas with smaller workloads, such as highly
rural areas.
We recognize that contracting for care is sometimes necessary to
ensure services are available. For example, when a veteran lives in a
remote geographic location, or if VA has only a limited number of
veterans that need care in a specific area, it is not always able to
recruit or attract full-time clinicians to staff a CBOC. However, under
such circumstances, VA should establish and adhere to strict guidelines
when contracting for care to ensure continuity of care and proper
patient oversight is maintained. To ensure high quality comprehensive
health care services and continuity of veteran patient care,
contracting for health care services should only occur when such
services are unavailable in VA facilities, geographically inaccessible,
or in certain emergency situations. The VA health care system was
developed to meet the complex and frequently unique health care needs
of veterans. Whenever possible, VA should be the provider of health
care to our nation's sick and disabled veterans.
infrastructure and safety
Unfortunately, VA's construction budget has decreased sharply over
the last several years with political resistance to fund any major
projects before VA developed a formal capital asset plan. Many
desperately needed construction and maintenance projects, including
seismic repairs that could potentially compromise patient safety, have
been unnecessarily delayed. DAV strongly believes that CARES should not
distract VA from its obligation to protect its physical assets whether
they are to be used for current capacity or realigned.
VHA identified 63 sites requiring seismic correction. The DNCP
prioritized 14 sites that require immediate seismic strengthening. We
agree with the Commission's recommendations that patient and employee
safety is the highest priority for VA CARES funding and that VA should
seek the funding necessary to correct the identified seismic
deficiencies as soon as possible.
Any construction needed to repair seismic deficiencies or to ensure
patient safety at VA health care facilities should be completed
immediately on buildings identified through the CARES process to remain
in the system for patient care. Careful consideration should be given
to ensure that the most cost-effective plan is chosen if there is a
need for renovation of older buildings. In many cases, it is more cost
effective to build a new facility rather than conduct major renovations
on an existing property. If space is not appropriate for its purpose,
renovation plans will be larger and more inefficient and therefore cost
more, not less.
research, education and training
Without question, VHA provides the most extensive training
environment for health care professionals and allows VA to provide top
quality cutting edge health care services to our nation's veterans.
Medical school affiliations are critical to VA's mission and they
should be treated as partners in the planning and implementation stages
of CARES. DAV, as part of The Independent Budget notes that VA has
academic affiliations with 107 medical schools, 55 dental schools, and
more than 1,200 other schools across the country. Each year, more than
81,000 health professionals are trained in VA medical centers. In
addition to their value in developing the nation's health care work
force, the affiliations bring first-rate health care providers to the
service of America's veterans. The opportunity to teach attracts the
best practitioners from academic medicine and brings state-of-the-art
medical science to VA. Veterans get excellent care, society gets
doctors and nurses, and the taxpayer pays a fraction of the market
value for the expertise the academic affiliates bring to VA.
The Commission recognized the importance of education and training
within VA but found that medical schools and other affiliates have not
made the transition from traditional inpatient teaching modalities to
community-based educational programs in VA. The Commission recommended
that VA develop a plan to address this issue by adding a community-
based component to VA's educational programs. DAV supports the
Commission's recommendation.
special disabilities programs
We are satisfied with the proposed placement of spinal cord injury/
disorder (SCI) and blind rehabilitation centers in the DNCP. We concur
with the Commission's recommendations to: (1) improve coordination
between VISNs with regard to placement of special disability centers to
optimize access to care for catastrophically disabled veterans; (2)
develop new opportunities to provide blind rehabilitation in outpatient
settings; and 3) conduct an assessment of acute and long-term bed needs
for SCI centers to provide the proper balance of beds and reduce wait
times.
va/department of defense (dod) sharing
The DNCP proposed 75 collaborative opportunities for VA/DoD
sharing. The Commission supported the recommendations of the
President's Task Force to Improve Health Care Delivery for Our Nation's
Veterans concerning this issue, and recognized VHA's vital role and
fourth mission to act as the nation's primary backup to DoD in time of
war or domestic emergency. Given the current State of world affairs,
DAV considers this a critical part of VA's overall mission. We concur
with the Commission that as the CARES process proceeds, careful
consideration must be given to this function of the VA as it relates to
VA's physical assets. As a nation, in the future, we may need VA's
support if there are additional terrorist attacks levied at the
American people. We must be prepared to deal with any given scenario
and ensure not only the safety of our nation's sick and disabled
veterans, but all our citizens. The VA health system is a natural
safety outlet in this regard if given the proper resources and support
to carry out this critical mission.
research space
As stated in The Independent Budget, VA medical and prosthetic
research is a national asset that helps attract high caliber clinicians
to practice medicine and conduct research in the VA health care system.
The resulting environment of medical excellence and ingenuity,
developed in conjunction with collaborating medical schools, benefits
every veteran receiving care at VA and ultimately all Americans. We
agree that research opportunities are an important component of VA
health care and that the proposals outlined in the DNCP for enhancing
research space should be carried out.
the future
Finally, in Appendix E of the report, the Commission discussed
problems it encountered relating to cost effectiveness analysis
submitted by the VISNs. A team was assembled by the Department to help
the Commission analyze the data but was not briefed on the methodology
utilized in realignment studies conducted by the VISNs. The Commission
noted that the team had to accept the cost estimates and workload
projections provided, without an opportunity to verify them. The
Commission noted that inconsistencies and errors in data were found in
the proposals and could mislead decisionmakers unless a more detailed
analysis is completed. The Commission stated that only a preliminary
analysis of the cost effectiveness of the proposals could be
accomplished, given the extreme limitations on time available to
complete the work.
This serves as one more example of the consequences of the
aggressive schedule that VA maintained for CARES. On several occasions,
DAV expressed concern about the compressed schedule for CARES Phase II.
We support expeditious resolution of VHA's capital asset problems;
however, we strongly urged VA to slow down and get it right the first
time. After starting CARES Phase II, VA acknowledged problems in the
model with respect to mental health, long-term care and domiciliaries.
It chose to take these issues ``off the table'' and instead of
developing solutions and extending CARES deadlines, VA chose to push
ahead, stating that it would address these critical issues after CARES
Phase II was completed, in its strategic planning process.
As this phase of the CARES process comes to a close, we watch with
some trepidation the final outcome. In reality, this is only the
beginning of CARES with future consideration of master implementation
plans at the national and local levels, uncertainty of Congressional
support and funding of the process, timeframes and priority for
individual project development. DAV strongly believes that mandatory
funding for VA health care is necessary not only to ensure that
veterans receive timely quality health care but to ensure continuation
of the CARES process and ultimately the viability of the VA health care
system.
In closing, we thank the Committee for convening this hearing today
and allowing DAV the opportunity to express our views on this important
issue. Although the Commission had a daunting task, we are thankful
that many of the concerns of veterans throughout the country have been
heard and were carefully considered as the Commission completed its
final deliberations. Although we agree with the Commission that the
final plan should be national in scope, we hope there is sufficient
consideration given to local concerns by veterans and other
stakeholders as the Secretary issues his final decision. There should
be sufficient cost-benefit analysis data to support any proposals on
consolidations or transfer of services. Ultimately, the goal of
enhanced health care services for our nation's sick and disabled
veterans and proper stewardship of the VA health care system is our
main concern on behalf of the nation's 2.6 million disabled veterans.
Finally, we agree with the Commission's recommendation to establish
an independent advisory body, with appropriate charter and authority to
monitor and advise the Secretary on the ongoing integration of CARES
into VA's strategic planning process. Oversight by Congress, veterans,
VSOs and other interested parties will be essential to success of this
important initiative.
Chairman Specter. Well, thank you very much, Ms. Ilem.
We turn now to Mr. James Doran, National Service Director
for AMVETS.
Thank you for joining us and the floor is yours.
STATEMENT OF JAMES W. DORAN, NATIONAL SERVICE DIRECTOR, AMVETS
Mr. Doran. Good afternoon, Mr. Chairman. On behalf of
AMVETS National Commander John Sisler and the nationwide
membership of AMVETS, I am pleased to offer our views of the
CARES Commission report that has been submitted to the
Secretary.
Generally, AMVETS supports the CARES process. We understand
that, under CARES, the Veterans Health Administration is going
to close some facilities and some employees will be lost. Our
primary concerns here are two-fold.
Access to health care for veterans must be maintained and
if reductions in force are required, we request that military
veterans, and especially disabled veterans employed by the VHA
be retained in all cases.
In the last century, Mr. Chairman, your father was wounded
in action during World War I, denied his benefits by our
Government and participated in the second veterans march on the
Capitol. Captain Jeffords, Colonel Graham, Sergeant Miller,
Airman Campbell, Army Engineer Akaka and 25 million other of
their comrades in arms must never be forced to suffer the same
indignation as your father. That is one of the purposes of both
this Committee and AMVETS.
There are flaws in the CARES Commission report, just as
there are flaws in the draft National CARES Plan. The
commission has addressed many of these flaws. AMVETS, on the
other hand, has not had the opportunity to fully digest the
commission report.
We do feel that any study involving excess or surplus
property should consider all methods of divestiture, which I
believe is the term they used in the commission, with the funds
being retained by the VA, not being moved back into the
Treasury for use in the general fund. We also would like to
see, prior to closing any inpatient services at any facilities,
that replacement care is in place and up and running before a
closure takes place.
In developing sharing agreements between VA and DoD, we
recommend that the agreements be signed by both the Under
Secretary for Health and the appropriate service secretary.
This would preclude military-base commanders from repudiating
the agreement at a future date. AMVETS also does not want to
see DVA-DoD joint clinics located inside the security fence at
military installations. In case of increased defense
conditions, these bases would be locked down and veterans would
be denied access to care.
We would like to also express our thanks to Chairman
Alvarez and his commission for all their hard work.
That concludes my testimony, Mr. Chairman.
[The prepared statement of Mr. Doran follows:]
Prepared Statement of James W. Doran, National Service Director, AMVETS
Good Afternoon Mr. Chairman and Ladies and Gentlemen of the
Committee. 1On behalf of AMVETS National Commander S. John Sisler and
the nationwide membership of AMVETS, I am pleased to offer our views of
the CARES Commission Report to the Secretary of Veteran Affairs.
For the record, AMVETS has not received any Federal grants or
contracts during the current fiscal year or during the previous 2 years
in relation to any of the subjects discussed today.
Mr. Chairman, AMVETS has been a leader since 1944 in helping to
preserve the freedoms secured by America's Armed Forces. Today, our
organization continues this proud tradition, providing not only support
for veterans and the military in procuring their earned entitlements,
but also an array of community services that enhance the quality of
life for this Nation's citizens. Title 38, United States Code, Section
1710 states that ``The Secretary shall furnish hospital care and
medical services which the Secretary determines to be needed to any
veteran for a service-connected disability and to any veteran who has a
service-connected disability rated at 50 percent or more.'' The Statute
delineates, in more detail, to whom the Secretary shall furnish
hospital care and medical services. The CARES Commission reports that
``Access and Quality of Care should be the primary drivers in
recommending changes to meet the health care needs of veterans.''
Generally, AMVETS supports the CARES process. However, we feel that
in some Veterans Integrated Service Networks, the needs of the veteran
may not be the primary focus of local, mid-level, management.
We understand that, under CARES, the Veterans Health Administration
is going to close some facilities. They may increase the services at
other facilities, open additional Community Based Outpatient Clinics,
or utilize contracted health care to replace closed facilities. Some
employees will undergo a Reduction in Force, others will be
transferred, and still others will be offered early retirement. Our
primary concerns here are twofold. Access to healthcare for veterans
must be maintained. If Reductions in Force are required, we request
that military veterans, and especially disabled veterans, employed by
the Veterans Health Administration, be retained in all cases.
In the last century, Mr. Chairman, your father, wounded in action
during World War One, was denied his benefits by our Government and
participated in the Second Veteran's March on the capital. Senator
Murray's father, a wounded and disabled veteran of World War Two; Navy
Captain Jim Jeffords; Air Force Lieutenant-Colonel Lindsey Graham;
Marine Sergeant Zell Miller; Airman Second Class Ben Campbell; Army
Engineer Danny Akaka; and their 25 million plus comrades-in-arms must
never be forced to suffer that same indignation. That is one of the
purposes of both this Committee and AMVETS.
There are, I'm sure, flaws in the CARES Commission Report, just as
there are flaws in the Department of Veteran Affairs Draft National
CARES Plan. The Commission has addressed many of the Draft National
CARES Plan's flaws. AMVETS, however, has not had the opportunity to
fully digest the CARES Commission Report. Yet, we do disagree with a
few of the Commissions recommendations:
1. ``. . . any study involving excess or surplus property should
consider all options for divestiture, including outright sale. . .'' An
outright sale of VA property would cause the VA to lose money. Enhanced
use of the properties enables VA to use rental revenues to bolster
their budget. Outright sale currently requires that funds realized go
to the US Treasury for deposit into the General Fund. An outright sale
of VA property would prove to be detrimental to the veteran community.
2. Prior to closing any inpatient services in Altoona, Butler, and
Erie, PA, VA must ensure that local hospitals are contracted to provide
that care. Travel time for many of the veterans served by these
facilities, and that of their loved ones, between their homes and
Pittsburgh could prove to be detrimental to their care.
3. In developing sharing agreements between VA and the Department
of Defense, we recommend that the agreements be signed by the Under
Secretary for Health and the appropriate Service Secretary. This would
preclude military base commanders from repudiating the agreement at a
future date. AMVETS also does not want to see DVA/DOD Joint Clinics
located inside of the security fence at military installations. In case
of an increased Defense Condition these bases would be ``locked down''
and access to health care denied to veterans.
The FY2004 VA appropriation gives the Secretary authority to
transfer up to $400 million to CARES construction from VA's medical
care account. AMVETS would like to see the Secretary pursue an
aggressive, accelerated construction program in order to upgrade and
improve the efficiencies of VA health care delivery as soon as
possible. A moratorium has been in place awaiting the conclusion of the
CARES process and such an acceleration would help move VA more quickly
to a system where every dollar of the budget is better used to improve
access and quality of care. We would, however, trust that the Secretary
would not proceed on an accelerated schedule until the backlog of
veterans waiting 6 months or more for their first doctor's appointment
is fully eliminated. In any event, since the Administration's fiscal
year 2005 budget request projects a carryover of approximately $800
million of medical care resources from this year's budget to next
year's, AMVETS fully expects that accelerating the CARES facilities
recommendations should not have a negative affect on the delivery of
veterans health care. Certainly with that much cushion in the
Secretary's healthcare budget, we might expect not only an accelerated
enhancement of facilities, but discontinuance of the ban on Priority 8
veterans access to the system.
Mr. Chairman, as I previously mentioned we have not been able to
fully study the CARES Commission Report. The areas I've mentioned are
just a few examples of items with which AMVETS is concerned. We are
more than willing to provide this Committee with a full, written,
comment sheet in the near future. We would like to express our thanks
to Chairman Alvarez and his Commission for all of their hard work.
AMVETS acknowledges that the Veteran Health Administration has a strong
need for capital improvements. However, we would like to remind the
Committee that although the VA provides some of the best health care in
the Nation, the quality of care is insignificant if the veteran cannot
access that care.
AMVETS National Executive Committeeman from Ohio, J.P. Brown III,
summed up our view at a CARES Commission hearing, last August, when he
said, ``[The VA does] . . . a good job with the resources available to
them. I encourage you to support this next step. It is an important
advance in addressing the physical facilities of the VA. . . . and
providing the resources that are needed to keep America's promise to
veterans.''
Mr. Chairman, that concludes my testimony.
Chairman Specter. Thank you very much, Mr. Doran.
Our final witness is Mr. Fred Cowell, Health Policy Analyst
for the Paralyzed Veterans of America. The floor is yours, Mr.
Cowell.
STATEMENT OF FRED COWELL, HEALTH POLICY ANALYST, PARALYZED
VETERANS OF AMERICA
Mr. Cowell. Mr. Chairman, Members of the Committee, PVA
appreciates this opportunity to share some of our observations
concerning the CARES Commission's final report that is designed
to realign the VA's health care system.
In the interest of the Committee's valuable time, I will be
brief and focus on those recommendations that have the most
significant implications for veterans with spinal cord injury
or disease.
PVA is pleased to see the CARES Commission recognize the
importance of expanding VA's spinal cord system of care by
calling for four new SCI centers in VISNS 2, 16, 19 and 23.
However, PVA would like to point out that the commission also
supported the establishment of a new SCI center in VISN 4, but
this recommendation did not appear as written language in the
final report. A new SCI center in VISN 4 will greatly enhance
access to VA SCI services for thousands of East Coast veterans,
especially for those who live in Pennsylvania, Delaware and
northern Maryland.
In the area of SCI long-term care, PVA supports the
commission's recommendations for adding long-term care beds in
VISN 8, 9, 10 and 22. These beds represent a significant first
step toward solving the long-term care demand crisis that is
looming for aging veterans with spinal cord dysfunction.
Regarding new SCI outpatient clinics, PVA would like to
point out the importance of VA establishing an SCI outpatient
clinic at Castle Point as the Bronx SCI consolidation takes
place, the need for a new multi-specialty outpatient clinic in
the Las Vegas area that includes spinal cord injury, and the
commission's recommendation for an SCI outpatient clinic to be
established in VISN 4 at the Philadelphia VAMC.
When considering facility closures, PVA is concerned with
the commission's recommendation to study the feasibility of
constructing a new mega-hospital in the Boston area, VISN 1. If
this new hospital were to become a reality, it would displace
thousands of veterans and result in the closure of VA's SCI
center at West Roxbury and the designated SCI long-term care
facility at Brockton. PVA feels that other commission closure
or mission change recommendations must be guided by the
principle that access and quality of VA health care will be
improved by their development.
Mr. Chairman, this concludes my remarks.
[The prepared statement of Mr. Cowell follows:]
Prepared Statement of Fred Cowell, Health Policy Analyst,
Paralyzed Veterans of America
Mr. Chairman and Members of the Committee let me begin by thanking
you for your continued advocacy on behalf of our nation's veterans.
Paralyzed Veterans of America.
(PVA) greatly appreciates the commitment of this Committee and your
staff and thank you for your willingness to hear our concerns and work
with us to find solutions.
Now that the CARES Commission has delivered its final report, I
would like to share with you a few observations we have made about the
Commission's recommendation before you make your own final decisions
concerning CARES. For the purpose of this hearing and throughout the
entire CARES process PYA has focused on those elements that have
implications for the availability and quality of care provided veterans
with spinal cord injury or dysfunction. Clearly, we are very pleased to
see that the Commission is supportive of expanding VA's Spinal Cord
System of Care by recommending new SCI Centers in four VISNs and
adding, much needed, additional long term care capacity in four others.
In the spirit of providing the very best care for those veterans
with spinal cord injury, we offer the following observations for your
consideration:
new sci centers recommendations
As stated previously, PYA is pleased to see the Commission's
recommendations for the addition of four new 3D-bed SCI Centers in
VISNs 2, 16, 19, and 23. These new Centers will greatly improve access
to VA SCI services in these areas of the nation.
However, PYA would point out that while there is no final
Commission report recommendation language to add a new SCI Center in
VISN 4, Chairman Alvarez said, at the conclusion of the CARES final
report briefing on February 13, 2004, that ``the Commission supported a
new SCI center in the southeastern portion of VISN 4.'' PYA strongly
supports this verbal Commission recommendation and believes the CARES.
projection model clearly supports the need for an additional SCI Center
in VISN 4.
PVA also supports the Commission's recommendation for additional
study concerning the appropriate location for the new SCI Center in
VISN 16. The Draft National Cares Plan (DNCP) supported the North
Little Rock facility but the Commission recognized that North Little
Rock did not provide the full range of tertiary care services required
by VA to be a proper site for an SCI Center. Additional analysis is
also needed for the proper location of a new SCI Centers in VISN 4.
During this study phase, preceding implementation, PYA has also
requested that VA review the CARES model for VISN 11 to find ways of
enhancing SCI services in this geographical area.
sci long-term care recommendations
PYA believes that the CARES Commission's recommendations for adding
SCI long term care beds in four locations in VISNs 8, 9, 11 and 22
represents a significant first step toward solving the long-term care
demand crisis that is looming for aging veterans with spinal cord
injury or disease. Currently, VA has only four dedicated SCI long-term
care facilities and three of these are on the East coast. These
facilities are located at Brockton, MA, Castle Point, NY, Hampton, VA,
and at the Hines Residential Care Facility in Chicago, IL and combined
only have a total number of 125 staffed beds. SCI veterans living west
of the Mississippi have no access to a dedicated specialized SCI long-
term care facility in their part of our country. When possible, PYA
believes that the most ideal location of a dedicated SCI long-term care
facility is adjacent to or in close proximity to an SCI Center. While
the Commission recommends further VA study for the exact location of
SCI long term care beds in VISN 8, PVA still believes that the Tampa
SCI Center is the proper location for these much needed beds. During
the construction phase of the SCI Center in Tampa the footprint for
construction included plans for the later addition of an SCI long-term
care wing. PYA recommends that VA take advantage of its advance
planning and locate these 30 long-term care beds in conjunction with
the Tampa SCI Center.
PVA supports the Commission's long-term care recommendations to add
20 SCI long term care beds in Cleveland, 20 SCI long-term care beds in
Memphis and 30 long-term care beds at Long Beach. However, PYA does not
support sacrificing acute SCI bed capacity to accommodate the 30 bed
SCI long-term care bed addition at Long Beach. From the beginning of
the CARES process, PYA supported the activation of a now vacant SCI
ward at Long Beach to meet this need.
Additionally, PYA would like to revisit a significant problem
concerning the difference between acute SCI Center care and SCI long-
term residential care, that evolved as the CARES Commission process
moved forward. As the Commission continued its fact finding work it
became clear to PYA that the Commission had blurred the distinction
between acute SCI Center care and SCI long-term residential care.
As the Commission made investigative visits throughout the VA
health care system, some members of the Commission were concerned with
their observations concerning low occupancy rates at SCI Centers. In
fact, the Special Disability Program section of the Executive Summary
of the Commission's final report quotes current occupancy rates among
VA facilities with SCI/D units as ranging from approximately 52 percent
to 98 percent. PV A feels it was this impression that led the
Commission to think of ways to fill unused SCI Center beds with SCI
long-term care need. PYA has just completed reviewing VA's SCI Center
Staffing and Bed Survey Reports of SCI centers for the twelve months of
2003 that we would like to share with you.
This analysis shows occupancy rates in 2003 at SCI Centers range
from 65 percent on the low end to 121 percent on the high end. PYA
would also like to point out that a census of SCI utilization taken on
the last day of the month, often a Friday, can result in a lower
average number. Also, the SCI census in many SCI Centers is
artificially lower than patient need due to a lack of staffing in many
facilities. We are not sure how the Commission arrived at their
occupancy rates but would be happy to discuss our methodology at your
convenience.
Upon review of the Commission's final report it is clear that the
Commission did not grasp the differences between these two modalities
of care and felt that a mixing of these services could be easily
accomplished. Once again PYA believes that the mixing of SCI acute care
beds and long-term SCI residential care beds (nursing home beds) in SCI
Centers is improper. PVA feels that re-designation of acute SCI Center
beds to long-term care is not in the best interest of SCI veterans. PYA
feels that an acute SCI hospital inpatient setting is not a home-like
environment and is the wrong location to place an aging SCI veteran.
PYA is concerned that SCI Center placement would expose these frail SCI
veterans to a number of medical risks that would further jeopardize
their health.
new sci outpatient clinics
PYA supports Castle Point to become an SCI Outpatient Clinic upon
completion of the Bronx expansion and consolidation of SCI services.
This SCI Outpatient Clinic at Castle Point was included in the DNCP and
was discussed during the Commission's final hearing but did not appear
as a recommendation in the final report. While the omission of this
recommendation may simply have been an error created during the rush to
finalize and print the final report document, PV A must draw this issue
to your attention. PYA feels Castle Point must retain SCI outpatient
services if the Bronx expansion is to be a success.
PVA's support of the Bronx consolidation was subject to VA
maintaining current SCI services at Castle Point and East Orange until
the Bronx expansion was completed. Upon completion, it was understood
by PYA that East Orange would maintain its SCI Center role and that
Castle Point would become an SCI Outpatient Clinic.
PYA supports the addition of an SCI Outpatient Clinic at
Philadelphia in VISN 4, but strongly believes that a new SCI Center in
VISN 4 is clearly needed to meet the SCI inpatient demand in this VISN.
PYA also supports the establishment of an SCI outpatient clinic in the
Las Vegas area.
facility closures
PVA must express its serious concern with the Commission's
recommendation to close Brockton, West Roxbury, Jamaica Plain, and the
Bedford VAMC in favor of building a new VA facility in the Boston area
of VISN 1. The financial commitment for this recommendation is enormous
not to mention the displacement effect this recommendation would have
on thousands of veterans. For SCI veterans it would mean not only the
closure of VISN 1's SCI Center at West Roxbury but also the closure of
a designated SCI long-term care facility at Brockton. Obviously, a
decision of this size will require years of careful planning if it is
to be implemented.
Regarding other Commission recommendations that call for facility
closures or mission changes, we hope the Secretary understands that
these actions may have an effect on certain SCI veterans. For some PYA
members, who live long distances from VA's SCI hub and spoke system of
care or in rural areas, these VA hospitals represent their only health
care option. If VA hospital closures come to pass, VA must take action
to ensure the availability of VA inpatient hospital care to meet the
health care needs of these affected veterans.
In closing, PYA would like to commend the members of the CARES
Commission and the behind-the-scene members of VA staff for their hard
work and dedication to improving access to VA health care for America's
veterans. The Commission's recommendations for expanding VA SCI
services are much appreciated.
PYA also appreciates this Committee's diligence and oversight of
the CARES process, there cannot be too much openness and oversight as
VA reorders its capital assets and charts the course for the provision
of health care for the next twenty years. I thank you for the
opportunity to present the views of PV A and we look forward to working
with you in the future.
This completes my statement and I am happy to respond to any
questions you may have.
Chairman Specter. Thank you very much, Mr. Cowell.
This Committee very much appreciates the participation of
the veterans organizations, and I regret that my colleagues
aren't here, but it is a very busy time. This was an
extraordinary day. We customarily meet, as you know, in the
Russell Senate Office Building, but when the votes came up we
moved over here.
It wasn't easy to get this room and in getting the room, I
had to make a commitment that we would be out by 5 o'clock
because this room has to be set up for a major reception at 6
o'clock. But the least I can do is invite you to come to the
reception.
[Laughter.]
Chairman Specter. That is also about the most I can do.
There are questions which we would like to propound for the
record which we will submit to you. Your full statements will
be made a part of the record and your testimony will be
reviewed and very carefully weighed. As you know, we do a lot
of work through staff and through the record, and we will be
putting the CARES Commission report under a microscope. This
Committee is not going to stand by and see veterans' care
reduced.
I was a little surprised by the testimony in that, as to
two of the Pennsylvania facilities, Altoona and Erie, they are
not even speaking as to present recommendations. It leads me to
question what the utility is if they are not going to really
activate for many years into the future. By that time,
circumstances may have changed, and we will be taking a fresh
look at what goes on.
This Committee appreciates your strenuous efforts to
protect the veterans and we are with you 100 percent. Thank you
all. That concludes our hearing.
[Whereupon, at 5:01 p.m., the hearing was adjourned.]