[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
VA'S EFFORTS TO PROVIDE HIGH
QUALITY HEALTH CARE OF
VETERANS IN RURAL COMMUNITIES
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON
VETERANS' AFFAIRS
HOUSE OF REPRESENTATIVES
SUBCOMMITTEE ON HEALTH
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
_____________
JUNE 27, 2006
_____________
Printed for the use of the Committee on Veterans' Affairs
Serial No. 109-57
_____________
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COMMITTEE ON VETERANS' AFFAIRS
STEVE BUYER, Indiana, Chairman
MICHAEL BILIRAKIS, Florida LANE EVANS, Illinois, Ranking
TERRY EVERETT, Alabama BOB FILNER, California
CLIFF STEARNS, Florida LUIS V. GUTIERREZ, Illinois
DAN BURTON, Indiana CORRINE BROWN, Florida
JERRY MORAN, KANSAS VIC SNYDER, Arkansas
RICHARD H. BAKER, Louisiana MICHAEL H. MICHAUD, Maine
HENRY E. BROWN, Jr., South Carolina STEPHANIE HERSETH, South
JEFF MILLER, Florida Dakota
JOHN BOOZMAN, Arkansas TED STRICKLAND, Ohio
JEB BRADLEY, New Hampshire DARLENE HOOLEY, Oregon
GINNY BROWN-WAITE, Florida SILVESTRE REYES, Texas
MICHAEL R. TURNER, Ohio SHELLEY BERKLEY, Nevada
JOHN CAMPBELL, California TOM UDALL, New Mexico
JOHN T. SALAZAR, Colorado
JAMES M. LARIVIERE, Staff Director
SUBCOMMITTEE ON HEALTH
HENRY E. BROWN, Jr., South Carolina, Chairman MICHAEL H. MICHAUD, Maine
CLIFF STEARNS, Florida, Vice Chairman Ranking
RICHARD H. BAKER, Louisiana BOB FILNER, California
JERRY MORAN, Kansas LUIS V. GUTIERREZ, Illinois
JEFF MILLER, Florida CORRINE BROWN, Florida
MICHAEL R. TURNER, Ohio VIC SNYDER, Arkansas
JEFFREY D. WEEKLY, Subcommittee Staff Director
C O N T E N T S
June 27, 1206
Page
VA's Efforts to Provide High Quality Health Care to Veterans
in Rural Communities ..................................... 1
OPENING STATEMENTS
Chairman Henry Brown ....................................... 1
Prepared statement of Chairman Brown ....................... 32
Hon. Michael H. Michaud, Ranking Democratic Member,
Subcommittee on Health ................................... 2
Prepared statement of Mr. Michaud ......................... 39
STATEMENTS FOR THR RECORD
Wiblemo, Cathleen C., Deputy Director, Veterans Affairs and
Rehabilitation Commission, American Legion ............... 66
WITNESSES
Perlin, Hon. Jonathan B., MD, Ph.D., MSHA, FACP, Under
Secretary for Health, Veterans Health Administration, U.S.
Department of Veterans Affairs .......................... 4
Prepared statement of Dr. Perlin .......................... 41
Hartley, David, Ph.D., MHA, Director, Maine Rural Health Re-
search Center, and Professor of Health Policy and Manage-
ment, Muskie School of Public Service, University of South-
ern, Maine ............................................ 19
Prepared statement of Dr. Hartley ......................... 55
Adams, Graham L., Ph.D., Executive Director, South Carolina
Office of Rural Health, and President, National Organiza-
tion of State Offices of Rural Health .................... 21
Prepared statement of Dr. Adams ............................ 61
POST-HEARINGS QUESTIONS FOR THE RECORD
Hon. Michael Michaud ...................................... 68
VA'S EFFORTS TO PROVIDE HIGH QUALITY
HEALTH CARE TO VETERANS IN RURAL
COMMUNITIES
TUESDAY, JUNE 27, 2006
__________________
U.S. House of Representatives
Subcommittee on Health,
Committee on Veterans' Affairs
Washington, D.C.
The subcommittee met, pursuant to call, at 10:00 a.m., in Room 334,
Cannon House Office Building, Hon. Henry E. Brown, Jr. [chairman of the subcommittee] presiding.
Present: Representatives Brown of South Carolina, Michaud, Moran.
Mr. Brown of South Carolina. Good morning. The Subcommittee will come
to order. This morning, we have assembled to take a close look at how
the VA is providing for the care of our veterans who may live at a
great distance from a VA medical center, a community-based outpatient
clinic, or perhaps even a vet center.
This is not the first hearing that we have had on this subject, nor do
I expect it will be the last. Due to the large number of service men
and women we have returning from Iraq and Afghanistan and due to the
numbers of those folks who may hail from rural areas, additional
pressures are currently being placed at VA's doorsteps as more people
desire to receive their care from VA.
This is probably a good problem to have in a sense it is a testament to
the fine job that Dr. Perlin and his team are doing to provide or
purchase care for our nation's veterans, not only in urban areas, but
also in more remote areas of the country.
Having said that, we need to be able to effectively bridge the distance
gap. And one thing is clear. The gap cannot and should not in my
opinion be bridged by simply erecting new VA buildings on every street
corner across the nation. Rather, we should seek to use new, emerging technologies to export the expertise that resides inside the VA's
medical centers, CBOCs, or the vet centers.
The expanded use of telemedicine, while not a panacea, can go a
considerable way towards alleviating some of the distance-based
challenges in the area of primary care, mental health, and even long-
term or home-based care. I suspect our VA witnesses will provide
greater details on what can currently be accomplished in that area and
what we can anticipate in the future.
Equally important to the use of new technologies, we should also seek
to collaborate with local community providers wherever possible to
ensure that the level of care and quality that VA provides can be
expected of others if VA chooses to purchase those services in given
areas.
I know the Department has taken steps towards doing that by moving
forward on important initiatives like Project HERO, a multi-VISN
demonstration project that will attempt to better coordinate and
improve the purchased care that VA relies upon sometimes in very rural
areas. As many of you probably recall, we had a hearing on Project
HERO and are all anxious to see it rolled out later this year.
As I suggested, this will not be the last hearing we have on rural
healthcare at VA. But equally important, we should also recall our
last hearing on this important topic.
This Subcommittee had the distinct pleasure of traveling to Maine last
summer to examine how the State handles its uniquely rural VA
population. We had the opportunity to do that because the Ranking
Member, my friend, Mike Michaud, invited us to this beautiful district.
Mr. Michaud and I share an interest in rural health, and I am
privileged again today to examine VA's successes and challenges with my
good friend from Maine. I also look forward to working with him on our upcoming health bill and incorporating some of his rural health
provisions to that package.
With that, I would yield to the gentleman from Maine, Mr. Michaud, for
an opening statement.
[The statement of Henry Brown appears on p. ]
**********INSERT**********
Mr. Michaud. Thank you very much, Chairman Brown. I really appreciate
your cooperation and your willingness to have a hearing in the great
State of Maine, and I am hopeful we will be able to have a rural health
bill that will reflect some of the issues we heard.
I greatly appreciate also, Mr. Chairman, you holding his hearing to
explore VA's efforts to improve rural veterans' access to high-quality
VA healthcare. I also want to thank all the witnesses on both panels
for coming here today to testify.
And I am especially glad and pleased to see Dr. Hartley from Maine who
is able to be here today as well. As a member of the Committee that
wrote the 2005 ground-breaking Institute of Medicine report on the
future of rural healthcare, he has a great deal of expertise on the
challenges facing rural communities and providing high- quality,
state-of-the-art healthcare. So glad to have you here today, Doctor.
Next week, we will be celebrating our Nation's Independence Day along
with picnics and parades in recognition and respect for the courage of
farmers who took up arms to fight for freedom. The revolution that transformed colonies into a new nation happened because of rural
citizen soldiers.
Since the Revolutionary War, rural communities, certainly Maine, have continued to answer their nation's call to service. Roughly 16
percent of Mainers are veterans, one of the highest percentages in
the country. Across the nation, roughly one in five veterans enrolled
in VA healthcare are from small towns and rural communities. In time,
the percentage of rural veterans will likely increase because more than
44 percent of the recent U.S. military recruits are from rural areas.
It is important that we honor veterans with action, not just words.
Doing so is all the more important, particularly while we are at war in
Iraq and Afghanistan. Studies including the recent Institute of
Medicine report on the future of rural health have repeatedly shown
that rural communities, especially veterans, face unique challenges to
access high-quality care such as distance and the availability of
specialists.
While there are a number of efforts underway to improve access for
rural veterans to VA's high-quality care, I am concerned that we are
not adequately preparing and planning for the needs of elderly
veterans, disabled veterans, and the younger generation of veterans
returning from Iraq and Afghanistan to their home states in remote
areas.
I have introduced House Resolution 5524, the Rural Veterans Health Care
Act of 2006, which is a comprehensive approach to improving the quality
of care available to rural veterans. Following the advice of the
Institute of Medicine report, my bill aims to take a comprehensive and practical approach towards improving care for our rural veterans by
increasing facilities and outreach, encouraging recruitment and
training of healthcare professionals, focusing on research, and
developing the IT infrastructure we need to enhance services in rural
areas.
My legislation has support from veterans service organizations like the American Legion, Military Order of the Purple Heart, and Vietnam
Veterans of America. The National Rural Health Association also
supports House Resolution 5524.
So I want to thank you once again, Mr. Chairman, for holding this
important hearing, and I request that my full comments be included in
the record.
Mr. Brown of South Carolina. Without objection.
[The statement of Michael Michaud appears on p. ]
**********INSERT**********
Mr. Brown of South Carolina. Thank you, Mr. Michaud. It was a great
trip to Maine and to have a chance to visit with some of the veterans
from your region. It was my first trip to Maine and I did not
recognize how remote it really is and how far some of those people have
to travel. But I applaud you for inviting us to come and enlighten us
on some issues.
One of the things, Dr. Perlin, they said was, do not take away our VA
care because it is the best in the world. And I know you would be
interested to hear that, and that was a real compliment, I think, to
the system up in Maine and also representative across the country.
Let us now turn to our first panel. The Subcommittee welcomes Dr.
Jonathan Perlin, Under Secretary for Health, testifying on behalf of
the Department of Veterans Affairs.
Dr. Perlin is accompanied by Patricia Vandenberg, Assistant Under
Secretary for Health for Policy and Planning; and Dr. Adam Darkins,
Chief Consultant for Care Coordination; and Dr. Robert Petzel,
Network Director, VISN 23.
Welcome, Dr. Perlin.
STATEMENTS OF HON. JONATHAN B. PERLIN, M.D., Ph.D., MSHA, FACP, UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS; ACCOMPANIED BY PATRICIA VANDENBERG, ASSISTANT
DEPUTY UNDER SECRETARY FOR HEALTH FOR POLICY AND PLANNING; ADAM
DARKINS, CHIEF CONSULTANT, OFFICE OF CARE COORDINATION; ROBERT A.
PETZEL, M.D., NETWORK DIRECTOR, VISN 23
STATEMENT OF JONATHAN B. PERLIN
Dr. Perlin. Thank you, Mr. Chairman, and good morning to you and to
Ranking Member Michaud. Thank you for the opportunity to be here
before you today to talk about rural healthcare for veterans.
Thank you as well for your kind words because it really puts into
context the story of VA's transformation. In fact, ten years ago, VHA
faced a burning platform. We had to transform our care or we would
have been obsolete and failed our mission.
We were a collection of hospitals serving only as a safety net for
care, treating veterans only after they had a health catastrophe, like
a heart attack or advanced cancer. We had to change.
Instead of being a safety net, we created a model of health promotion,
disease prevention for our patients, and are now the benchmark in
preventive services in disease managements, instead preventing heart
attacks and treating illnesses like cancer and depression early.
We built a true health system out of a portfolio of hospitals,
integrating services not just between our hospitals, but across the
entire continuum of care from the patient's home to the outpatient
clinic and, of course, to the hospital.
We recognize the value of community-based outpatient clinics in
establishing that continuum of care and in meeting the primary care and
mental healthcare needs of rural veterans.
In 1995, VHA operated 102 CBOCs. Today we operate more than 700
including 234 that the CARES criteria identified as serving rural or
highly rural areas. This number does not include 156 more clinics that
are based at our medical centers for a grand total today of 876
outpatient clinics.
In fact, Secretary Nicholson announced his approval for 25 new or
enhanced CBOCs on June 23rd, and we anticipate having some of these
open by the end of this year with the remainder opening in 2007. And
fully one-third are rural.
In 2004, the CARES Commission found that VA's existing protocols for prioritizing new CBOCs disadvantaged rural veterans. As a result, we
have revised our national criteria to emphasize access to care for
rural veterans. We also created a directive on rural access hospitals
to assure quality services at those facilities.
And now according to satisfaction performance scores collected in 2005,
81 and a half percent of rural veterans rated their healthcare as very
good or excellent; in fact, slightly exceeding urban veterans' ratings.
In addition, clinical quality measures were up to 12.2 percent higher
for rural veterans compared to their urban counterparts.
And data show that rural veterans are not necessarily under-represented
in VA. As Ranking Member Michaud said, nearly one in five veterans live
in rural areas. And, in fact, 32 percent of our enrolled veterans are
rural and 34 percent of our patient population are comprised of rural veterans.
We work closely with Federal, state, and local healthcare agencies on
rural healthcare issues. A Memorandum of Understanding with the Indian
Health Service to enhance healthcare for American Indian, Alaskan
Native veterans has resulted in new activities and programs and
complements local initiatives.
And we are creating targeted partnerships with community health centers
to meet specific locally-defined healthcare needs in rural locations.
Our 207 vet centers also address rural veterans' needs. Many are
located in rural areas with staff traveling widely to reach veterans in
remote locations. Some maintain stations staffed by one or two
counselors that are connected to full-size vet centers. Many vet
centers maintain partnerships with community providers such as state employment services and local substance abuse programs.
One of VA's top priorities is providing comprehensive and effective
mental healthcare to all enrolled veterans who need it. We have
invested $300 million in new service improvements in the past two
years. And of that, nearly $17 million was used to add mental health professionals to CBOCs and another $9 million expanded our telemental
health programs.
In 1996, veterans who used our mental health services lived an average
of 24 miles from the nearest VA clinic. That average is only 13.8 miles
today.
We are increasingly relying on telehealth and telemedicine as an
effective and efficient way to provide specialty care services to rural veterans and others. Our care coordination, Home Telehealth Program
helps veteran patients manage their conditions and live independently
in their own homes. By October 1st, more than 20,000 veterans will be enrolled in this program.
A national Teleretinal Imaging Program now assesses diabetics for eye
disease. A 21-site polytrauma health network begins operations by
September 30th and more than 14,000 veterans received telemental
healthcare in the last fiscal year.
Within three years, VA expects to provide rural veteran specialty care unparalleled in any other healthcare organization in the nation. We,
however, recognize limitations in our national telecommunications infrastructure and bandwidth requirements, and appreciate your support
in improving this for rural veterans and all rural Americans.
Mr. Chairman, creation of new CBOCs, collaborations with other
healthcare organizations, new approaches to providing healthcare
services, advances in telehealth and telemedicine give me confidence
that we are continually striving to provide not only the best care
anywhere but the best care everywhere in our nation.
Thank you very much for the opportunity to testify. We would be
pleased to respond to your questions and we request that the full
statement be submitted for the record.
Mr. Brown of South Carolina. Without objection. And thank you, Dr.
Perlin, for your testimony and for your service to the veterans all
over this country.
[The statement of Jonathan Perlin appears on p. ]
**********INSERT**********
Mr. Brown of South Carolina. My first question is, what is the
department currently doing to better understand where their user
population lives and what type of strategic planning is being
undertaken in the area of rural healthcare specifically?
I know you addressed that somewhat in your testimony, but do you have
like a schematic map so you could readily see where the rural veterans
are and how it continues to change with the new veterans coming back
from the Operation Enduring Freedom and Operation Iraqi Freedom?
Dr. Perlin. Thank you very much, Mr. Chairman, for this important
question. I want to address it at two levels.
First you asked how we look at the nation and make sure we are meeting
the needs geographically, understanding that the needs are not exactly
the same in urban environments and suburban environments, somewhat
rural environments, and highly remote and rural areas.
And, in fact, on a national level, a lot of that work goes on in Ms. Vandenberg's operation in terms of the modeling of the nation's
population. I would ask her to first begin responding to how that
process is achieved.
But I would also want to introduce Dr. Randy Petzel as not only the
Director of VISN 23, the upper midwest network, but for him to respond subsequently to really describe how as network director with
operational responsibility, he looks at an environment that ranges from
the urban-ness of Minneapolis to the most remote regions of the
Dakotas, and how he would actually plan to meet services in that area.
Ms. Vandenberg.
Ms. Vandenberg. Thank you.
When we do our annual actuarial model projections for the system, we
start at the level of the veterans' population and then forecast the enrollment and then move down to unique patients.
You asked if we have a map that depicts the population. Yes, in fact, we
do. Part of my office is responsible for geo coding and so we are in a constant update of the location of our veterans. We are looking at
that from both the enrollee and the patients' perspective.
Mr. Brown of South Carolina. I know I said that because
demographically it is a real shift in this country. I know in my
region of South Carolina, which represents Myrtle Beach and along the
coast, a goodly number of those people are moving from Maine where it
is so cold and some of the other parts down to sunny Myrtle Beach.
And I just wanted to be sure that somehow or another demographically we
were taking care of that shift so that --
Ms. Vandenberg. We are monitoring that, yes.
Mr. Brown of South Carolina. -- services would be moving with them.
Thank you.
Dr. Petzel. In terms of how we might operate at the network level,
again, as Ms. Vandenberg mentioned, we annually assess the needs in our network. And one of the ways we look at our service to rural veterans
is to look at the veteran population, the proximity that they have to
care at the present time, and also overlay the studies that are done
about medically under-served communities, not just VA, but in general.
And I think that allows us to identify the most critical areas in terms
of rural-ness and in terms of a lack of healthcare.
And just as an example, during the CARES process, while there are not
an overwhelming number of veterans there, we identified Williston and Dickinson, North Dakota as being very under-served areas medically as
well as in terms of VA healthcare. And these became priorities for us
to establish a couple of outreach clinics in that area.
And, again, we go through this annually.
Mr. Brown of South Carolina. Just to follow up on that, we recently
heard that 25 new CBOCs would be established. To what extent were the
needs of rural veterans incorporated into the decision-making process?
Dr. Perlin. Well, let me answer your question, sir, in two ways.
First, they are incorporated into the decision process by their being represented. Their presence in environments that we had not previously adequately served is really the hallmark of their representation. We
identify that they are there, that they have a need for medical
services, and we bring that service to them.
Increasingly, though, network directors such as Dr. Petzel, facility
directors which have the direct purview over the community-based
outpatient clinic meet with veterans to really learn what the needs are
in the particular environment and really determine what would be most effective in terms of a specific location and try to work with serving
the identified needs in the particular community.
Mr. Brown of South Carolina. Before, Dr. Petzel, you respond, let me
add this part of the dialogue, and maybe you can even expand on that
too.
What is the department doing to explore existing rural health assets,
for instance the rural health centers established by the U.S.
Department of Health and Human Services, the State Department of Rural Community Health Centers and so forth?
While we are interested in providing for our rural veterans, we also
have to be cognizant of those facilities and resources that already
exist and not reinvent the wheel. After all, we are talking about
valuable taxpayers' dollars.
How are you all interfacing with existing other agencies?
Dr. Perlin. There are a number of existing relationships that occur
both at national levels, regional levels, and at local levels.
Nationally we have Memorandums of Agreement with the Indian Health
Service as an example for collaborating and serving our overlapping populations and increasing access for veterans.
I might in a moment ask Dr. Petzel to speak about how that occurs
specifically in his network.
At a national level, we create a framework that creates a dialogue for
the ability for us to target regionally, and locally to meet specific
needs. Community health centers are important national assets. There
are 3,600 of them. Not all of them are rural. Many are actually in
urban and under-served environments. But we have partnerships where we specifically target an opportunity to provide outreach.
Now, I should note that there is some difference in our patient
population. Our focus, of course, is veterans. Community health
centers traditionally or often is focused on maternal and children's
issues in particular. So we need to make sure that our overlap
really serves the constituencies as effectively as possible.
The second issue is that part of the ability for us to serve veterans
well is the integrity, the continuity of the health information. And
as we put clinics into the environments, we want to make sure that
they are connected to our electronic health record.
And increasingly we will have dialogues about how we can not only have
that continuity, be it whether it is within a direct sort of umbilical
cord to our system or whether it is in the future with
interoperability, with technologies that they would be introduced.
So at a very strategic and practical level, we say is there an
overlapping need, is there an overlapping population, and at a
technical level say, okay, can we carry this off and provide the right resources both to veterans and to the community health center
population.
I would ask Dr. Petzel to speak about some of the collaborations that
exist, for instance, either under the national aegis of the Indian
Health Service memorandum or some of the local initiatives that exist
with American Indians in VISN 23.
Dr. Petzel. Thank you, Mr. Chairman.
The Indian Health Service is probably the largest other Federal
healthcare provider in our part of the country. And thanks in part to
the Memorandum of Understanding that was signed several years ago, we
have had a large number of collaborations with them on the
reservations.
Just as some examples, we have contract clinics on four reservations in
South Dakota. We have compensated work therapy programs on four
reservations in South Dakota. And then in both North Dakota and South
Dakota, we have telehealth, telepsychiatry, PTSD programs where a
psychiatrist is remotely based and the facility is on the reservation,
usually in the health center that the IHS establishes.
We do have plans in the very near future to establish an additional
clinic in Wagner, South Dakota which is near the Yankton Sioux
reservation. So we have got a large number, I think, of cooperative
efforts going on with that Federal agency.
I would like to go back, though, just briefly to the previous question
when you asked about how many of the new clinics were rural clinics.
We had three outreach clinics and four community-based outpatient
clinics in that group of approvals and all of them were in highly rural
areas.
Mr. Brown of South Carolina. Are you allowing the neediest population
to use the VA clinics? I asked a question first whether you were
taking advantage of the rural health clinics and some of the other
available facilities based already there. I was just wondering if
there is any reciprocal arrangements with the VA.
Dr. Petzel. Mr. Chairman, the only reciprocal relationships we have
are in a few limited areas on reservations. We are cooperating with
the Indian Health Service and non-veteran Native Americans, American
Indians are using some of our services. But, otherwise, out in the communities, no. Our services are basically available to veterans
right now.
Dr. Perlin. I would add, sir, that, of course, our biggest partner is
the Department of Defense with the TRICARE coverage that extends and we
accept in VA.
Mr. Brown of South Carolina. Mr. Michaud, you had questions for the
panel.
Mr. Michaud. Thank you very much, Mr. Chairman.
Dr. Perlin, you mentioned that you recently announced plans to open 25
new CBOCs, some of which were never identified in the CARES process.
Can you explain in more detail how the VA has decided it can support
new CBOCs not identified in the CARES process when we still have 156
priority CBOCs that were identified and that have not been implemented
yet?
Dr. Perlin. Thank you, Mr. Michaud, for that question.
The CARES plan is a compass. It is not an absolute blueprint. I
remember when Secretary Principi testified, he said that, you know,
this was really the direction we were headed, but this would be
evaluated in the context of circumstance, need, capacity, and access
issues.
In fact, of that list of 25, depending on whether you use the CARES
definition or the Census definition, either eight or nine are rural
CBOCs. So we are really striving to make sure that we serve veterans'
needs by improving access, by reducing capacity challenges, and in some instances relieving overstresses that occur in particular areas.
Our general trajectory is, in fact, to identify and meet the needs that
are identified in the CARES report, and as I think is also understood
in the CARES document that that is a plan that extends really over the
better part of the next decade.
Mr. Michaud. I guess my concern is that when you look at 156 priority
CBOCs, they are priorities. And I know that some VISNs where there is
only one CBOC proposed, they did not even submit a business plan
because they do not have the money to do it.
So my concern is our going outside the CARES process. Out of the 25,
how much was that decision made on political reasoning in some areas?
That is a big concern that I have because there is a definite need out
there.
The next question is on the vet centers. I recently had a chance to
meet with Blake Miller who is a rural veteran from Kentucky. He was
nicknamed the "Marlboro Man" because of a picture taken after a
firefight in Felujah. He has PTSD. Both he and his wife admitted that
they need more counseling than what they are currently getting from the
VA, and they have to travel over two hours to get the services that
they need.
What are the VA�s specific plans to expand the number of vet centers
and vet centers' employees to the rural areas? Do you have a report
that you can share with us to show what the VA plans on doing to fill
that gap?
Dr. Perlin. First, let me identify a specific issue. If you are aware
of a veteran who may need additional services from us, they are not
getting it, I would be personally pleased to receive any information to
meet any need.
Second, with respect to services and increased access to mental health service, I think this is one of the areas where I want to thank you,
the Chairman for your support, exceptional.
As you know, the last two budgets have significantly increased the
mental health initiatives, 100 million in 2005, 200 million in 2006.
We put 339 in the 2007 and you saw fit to actually increase that
further. And that is really allowing us to address some of the most fundamental priorities, the Mental Health Strategic Plan, our goal of improving access.
My priorities within that have been to increase access for specialty
mental health services. And, in fact, whereas two years only 71
percent of clinics, CBOCs, had specialty mental health services, now it
is approximately 90 percent. Increasingly the remaining ten percent,
which may be very small CBOCs, very isolated outposts, in fact, have
increased telemental health services, something that is both well
received and extremely useful for remote veterans.
The third issue that you raise�s the important issue of how we are
getting to those individuals who are returning from combat who may
disperse to very rural areas. And this is indeed an important and
critical challenge, particularly since 62 percent of the veterans,
combat veterans of OIF, OEF are reserve components.
And this is really an important role for the vet centers. Vet centers
gave a lead in going out and doing transition assistance briefings to returning servicemembers at demobilization and at later training
sessions and identifying services.
At each of the vet centers or throughout the country, we have Global
War on Terrorism Outreach Counselors that are really peer counselors
both to destigmatize the issue of identifying mental health needs as
well to be able to speak on a peer-to-peer level. And that creates
great entree.
In terms of staff, Al Batres, the Director of the Readjustment
Counseling Service, provides me with needs associated with workload.
And I am very proud to say that both as Deputy Under Secretary and as
Under Secretary, every request he has brought for additional
programmatic support, including the GWOT counselors and program
expansion, including a new vet center, I have been able to support and
put forward.
And so this is an area that we are dynamically following and appreciate
any insights that might be forwarded from this Committee in terms of
needs that exist in a particular locale.
Mr. Michaud. I see my time has run out. But if you have a plan on how
you plan to expand the vet centers, you should provide the Committee
with a copy. Do you have one? Yes, no?
Dr. Perlin. I am not sure that there is necessarily a plan that is
more specific than the operational plan for meeting the needs. I would
not necessarily term it an expansion plan. It would be a needs-based, operational approach. And I am not sure that that is necessarily in a
form that is -- you know, a report that is ready to go out.
Mr. Michaud. So you do not have an official plan then?
Dr. Perlin. There is an operations process, and I would be happy to
share whatever documentation is available that associates workload with resource data.
Mr. Michaud. Thank you.
Mr. Brown of South Carolina. Thank you, Mr. Michaud.
Mr. Moran.
Mr. Moran. Mr. Chairman, thank you. Thank you and Mr. Michaud for
holding this hearing. And, Dr. Perlin, thank you for joining us.
As I have indicated previously, I represent a district of approximately
60,000 square miles and no VA hospital within the district. And so the services that we provide rural veterans are the top priority of my
service here on the Veterans' Affairs Committee.
Dr. Perlin, we will hear testimony -- let me approach this a little bit differently. First, let me compliment the VA. I think the quality of healthcare that my veterans are receiving has improved dramatically
over the last several years. Veterans are much more likely to be complimentary of the services they receive from the healthcare side of
VA than they were when I began my career in Congress.
And we conduct veteran town hall forums on a regular basis and the
compliments -- the last one we had, the headline was about the
compliments that the VA gets for the healthcare services that they are providing as compared to any negative.
So I think progress is being made, and I am very appreciative of that.
We have a tremendous relationship and I think the right kind of
attitude that comes from our VISN both in Denver and in Kansas City, as
well as the Cole Murray Hospital in Topeka and the Dole Hospital in
Wichita. And I appreciate those services very much.
As always, there is more that can be done and there are still
complaints about quality of healthcare that we need to address.
Waiting lines are getting better, but they still exist. And most
importantly, I still have an aging veteran population that have hours
to go to access VA healthcare.
In that regard, we are going to hear testimony in the second panel as
well as written testimony from the National Rural Health Association
and from the National Organization of State Offices of Rural Health in
which they again appeal for greater relationship between the VA and
critical access hospitals. Those are hospitals that are very rural in
nature and receive a different kind of reimbursement under Medicare as
well as community hospitals.
And I know that the Chairman asked you a question about that, but my
guess is that there is no community health clinic in Kansas and no
critical access hospital in Kansas that has any relationship with the
VA and that can provide services to Kansas veterans.
And so as you describe these collaborative efforts, my guess is that
there is very little evidence on the ground that a veteran can go see
their doctor or their local clinic in any place in my state. Would
that be an unfair assessment on my part?
Dr. Perlin. First, Congressman, thank you very much for your kind
appraisal of the improvements in quality. I think that is absolutely accurate. I have watched that transition in my career as well.
I looked in your part of Kansas and, in fact, today, if I count
correctly, there are nine clinics that did not exist eight years ago,
Abilene, Emporia, Junction City, Russell, Salina, Seneca, Dodge City,
Hays, and Liberal. And I am very proud of that.
I do know that it is a challenge, though, to get to the inpatient
hospital care. So our preferred goal, our desire is to make sure that
we can provide really comprehensive, integrated, safe, effective,
efficient, compassionate care for veterans. By having the health
record and providing for the continuity of care, we can achieve better outcomes.
In fact, not just our belief, but the RAND organization would find that compared to all the care in the country, VA outperforms in 294 directly comparable measures in quality and prevention and disease treatment.
That occurs with that coherence.
I would tell you that there are times where we have to purchase care at
other hospitals. What happens then? Well, sometimes I want the
veteran to go to that other hospital. Please understand if a veteran is
having crushing chest pain and they have to go a long distance to a VA,
I want them not to go to VA. I want them to go to the closest place.
On the other hand, if it is something elective, I want them to enjoy the coherence of knowing what their whole past history is based on our
electronic health record. I would also like them to do that because
over the past two years alone, our purchased hospital services went
from 600 to $975 million. That is a pretty substantial increase, many,
many times greater than the increase in the number of veterans we
served.
And so our stewardship of the resources that you entrust to us also
requires that we operate to provide not only the highest quality care,
but do that most efficiently as well.
Mr. Moran. Well, Dr. Perlin, let me make sure I understand because
what I think you are telling me is that for emergency care or traumatic injury, you would want the access to be immediate and if it is a
private provider, that is satisfactory with the VA, but if it is
routine care, your preference -- when you talk about collaboration,
the collaboration is not going to occur in a routine care kind of
setting.
You are not looking for opportunities to associate the VA with a
clinic, a private clinic, though publicly funded through community
health clinics or through Medicare for that close relationship. Is
that accurate?
Dr. Perlin. I would not draw the line quite that distinctly. For
areas where we have access to service, there is less pressing need for
the collaboration. In areas such as those that Dr. Petzel described,
for example on the reservations, the opportunity to collaborate and
partner is really exceptional.
You mentioned the community health centers. They are a terrific
resource, but the opportunity to collaborate is really not best served
where we have a veterans' community- based outpatient clinic proximate.
But where we may not have the resources to meet the veterans' needs,
that is an ideal opportunity for collaboration. I absolutely agree
with you that that is both rational and efficient.
Mr. Moran. Mr. Chairman, would you allow me any leeway to follow-up
and conclude?
Mr. Brown of South Carolina. Yes.
Mr. Moran. Thank you, Mr. Chairman.
Just a couple other points. I do appreciate the CBOCs. We work very
closely both at Wichita and Topeka. And we are hopeful that there are
two others in the works. Anxious for the 2007 report to be made public
so we can see where we are headed.
But even with those CBOCs that you describe, we still have 80-,
90-year-old veterans who are traveling two and three hours to get to
the CBOC for routine care. So it is a geographic expanse that -- as
you describe all those locations, it sounds like it is a lot and it is
going a long way in meeting our veterans' needs, but there is still a
dramatic need for services closer to home.
And it also seems that there is a trend in the VA to bring those
services, to require those veterans to travel to the Wichita or Topeka hospital. My two examples.
A resident in my local hometown, Homer Schwartz, was receiving dental
care from his hometown dentist through the VA. The VA changed the plan
this year and decided he had to drive three hours to Wichita to receive routine dental care.
Same way, Hoxie veteran, Mr. Briary, Harv Briary, needed a new pair of glasses, always done through the VA with his local optometrist. But,
again, the VA decided that under their new policy, got to come to
Wichita to access those services.
So you have someone who lives four hours from the Wichita VA having to
travel to Wichita to get a new pair of glasses. Those are the things
that I would like to see the VA address. We are working with Wichita
and Topeka on those issues, but much of what they -- their answers to
me often come from you here in Washington.
Thank you, Mr. Chairman.
Mr. Brown of South Carolina. Thank you, Mr. Moran.
We have sitting with us today, Ms. Herseth from the great State of
South Dakota. She is not a member of the panel, but with unanimous
consent from the other members, we certainly would welcome you to
entertain any questions you might have.
Ms. Herseth. Well, thank you very much, Chairman Brown. I want to
thank you and Mr. Michaud for having this important hearing and for
allowing me to participate in the Subcommittee activity today.
And I certainly am pleased that Dr. Petzel is here testifying. I
appreciate his work in VISN 23 with so many of the folks in the State
that I represent, South Dakota, which is perhaps not quite as rural,
but almost as rural as Mr. Moran's district in western Kansas.
But if I could go back and explore just a little bit the service we are providing to rural Native American veterans. And I do greatly
appreciate the efforts that the VA is taking to coordinate with IHS.
But I am concerned by the lack of healthcare providers in rural areas
in general. And, Dr. Perlin, you talked about looking at sort of
medically under-served areas, the overlay in terms of the population of veterans, and you referenced two communities in North Dakota.
Now, just on Sunday, I attended the graduation at the Oglala Lakota
College in which over a dozen individuals received their degrees in
nursing.
And so I am wondering what efforts, if any, VA is planning to work with
tribal colleges or other programs to help educate and train rural
Native American medical nursing and allied health professionals.
Dr. Perlin. Well, first, let me thank you for that question and your
support in improving rural healthcare. That is a great opportunity to
meet what is not only a rural shortage but a national shortage, that is competent, skilled nurses.
I do not have at hand the data on the particular relationship there,
but I am so interested in recruiting nurses not just in terms of VA
need but as a national need. It is something that I will take back and
be happy to provide additional information.
I do not know, Dr. Petzel, if you know anything specifically about this relationship.
Dr. Petzel. It is an interesting question, Congresswoman. First of
all, I want to thank you for your support of veterans and veterans'
issues in South Dakota. It is becoming a legend.
We have a relationship with several of the American Indian colleges in
what we call the Gathering of Healers. It is a semi-annual event that
we have where we bring healthcare providers into a remote setting, 30
of them, and they are taught about the culture of, in our cases, the
Lakota and the Dakota. And it has gone a great way towards bridging
this cultural gap.
I am going to go back and explore the possibilities that you have
mentioned in your question. We have not talked directly with them
about it, but it would be an excellent opportunity and I thank you for
it.
Ms. Herseth. I very much appreciate both of your interest, and we
would like to help you facilitate those meetings. I would commend the expertise of President Tom Shortbull of Oglala Lakota College as well
as President Lionel Bordeaux, President of the Sinte Gleska University
on the Rosebud Representative of the Sioux Tribe.
So thank you for your interest. I think it helps meet the needs in the
IHS clinics as well as promoting the collaboration that we have
undertaken to serve Native American veterans as well.
Now, I do understand that the VA is working on a special outreach
program for returning OIF and OEF veterans who are Native Americans.
And, Dr. Petzel, VISN 19 is participating. Will VISN 23 be
implementing that program as well?
Dr. Petzel. Thank you. We will be participating and we have been participating. We have not called it a special outreach, but we visit
each one of the reservations annually in conjunction with VBA and the
State Veterans Commissioners to provide for an opportunity for American
Indian veterans to avail themselves to our services.
And we will be folding into that a special attempt to try and reach out
to the returning OIF, OEF veterans. We also do have on three of the reservations actual PTSD programs, an inpatient, if you will, or
residential program on Pine Ridge, and then the PTSD telepsychiatry
programs at Rosebud and Standing Rock.
Ms. Herseth. Thank you.
Let me turn to another topic that I know, Dr. Perlin, you are well
aware of my interest in. That is the long-term care needs of veterans.
Now, most aging Americans who enter into nursing homes or long-term
care settings do so because they need assistance with daily living
activities. Now, for a rural veteran who has difficulties with daily
living activities, telemedicine may not be the solution to help them
remain independent. And, of course, we have other challenges in
reaching those veterans in offering adult day care or geriatric foster
homes.
So are we getting to the point where we have a comprehensive plan to
address the long-term needs of aging rural veterans and are there plans
either fiscal year 2006 or fiscal year 2007 for adult day care and
geriatric foster homes again targeted toward rural aging veterans?
Dr. Perlin. Congresswoman, you present a challenge that has many
layers. First, the challenge of an aging society. And we at the
Department of the Affairs certainly are at the bow wave of this aging
trend.
And I think you have heard certainly the Secretary's and all of our
passion not only on providing the best institutional care when it is
necessary but when there are other alternatives, providing the best
support of noninstitutional care to maintain spousal relationships and community relationships and so forth.
I am pleased to note that the IG recently published a report that said
that we made significant progress in really filling in some of the gaps
in the noninstitutional care programs that a year ago the GAO had
identified as opportunity for the department.
The challenge that you identify has the additional layer that in areas
that are somewhat rural, there often are providers who will make home
visits and offer the home services. In areas that are truly remote, it
is a particular challenge and not just for VA, but it really comes down
to whether you dislocate the patient from their home setting or whether
you find something that is completely nontraditional.
And I would agree with you that telehealth and telemedicine is a
wonderful adjunct up to a point, the point where the person has
limitations either mentally (with limited cognitive function to be
safe) or with the physical ability to care for themselves particularly
if there are either no- -or also aged or frail caregivers.
And that is a challenge we are grappling with. Our approach has been
to actually increase telehealth and telemedicine and extend the
relationships with those entities that do exist in the community.
I might ask Dr. Darkins, who is particularly interested in this area,
to provide additional comment as he runs the care coordination and
telehealth programs.
Dr. Darkins. Thank you very much. I would absolutely agree that
telehealth is not a panacea for everything, but it is something we
are integrating with those other services. So it is a way in which a
veteran can remain independent to self-manage their disease. And in collaboration with assistive services from long-term care, for example, medical foster home care.
We are also assessing these patients to really see exactly what the mix
of telehealth and other services is going to be in the future and based
on this data. So as we evolve these programs, in how we are take them forward.
Ms. Herseth. Mr. Chairman, if I may go over time just to add one final comment.
Mr. Brown of South Carolina. Yes.
Ms. Herseth. We have often on the Committee, a number of us have, you
know, as we try to leverage most effectively the limited resources
among different agencies, whether it is the VA, whether it is IHS, but
also as we continue to grapple with Medicare reimbursement because we
do face -- we are at a disadvantage in rural America when it comes to
home healthcare because we do not have some of the economies of scale.
We have to travel farther distances.
And so I do think that any type of collaboration, while you are looking
at and evaluating the mix of needs as some of our other healthcare
providers and rural America are doing the same, that we look at this as perhaps the prime opportunity to leverage resources locally in the
State and some of the Federal resources among different agencies to
best meet that need and overcome the disparity that I believe exists in providing a very efficient form of healthcare and home healthcare to
lower the costs in our more institution-based care.
So I thank you for your testimony.
Thank you, Mr. Chairman.
Mr. Brown of South Carolina. Thank you. We are glad to have you with
us today.
And thank you, gentlemen, for your testimony, and we will proceed with
the second panel.
Dr. Perlin. Thank you, Mr. Chairman.
Mr. Brown of South Carolina. From the great State of our Ranking
Member, we welcome Dr. David Hartley. He is Director of the Maine
Rural Health Research Center and a Professor of Health Policy and
Management at the Muskie School of Public Service at the University of Southern Maine.
Dr. Hartley has and continues to focus on research on access to mental
health and substance abuse prevention services in rural areas.
In 2003, his sustained research in rural mental health was recognized
by the National Rural Health Association with their Distinguished
Research Award.
And from my great State of South Carolina, we are pleased to welcome
Dr. Graham Adams. He serves as the Executive Director of the South
Carolina Office of Rural Health. Located in Lexington, South Carolina,
this not-for- profit entity works to improve and enhance rural health
delivery throughout South Carolina.
Dr. Adams has worked extensively in the areas of rural health, public
health infrastructure development, community mental health, and program development for under-served populations.
He has provided leadership to many public health and access improvement projects and currently serves on the advisory boards of many state,
regional, and national initiatives. Dr. Adams currently serves as the President for the National Organization of State Offices of Rural
Health.
And, gentlemen, welcome, and please proceed, Dr. Hartley, with
testimony.
SSTATEMENTS OF DAVID HARTLEY, PhD., MHA, DIRECTOR, MAINE RURAL HEALTH
RESEARCH CENTER, AND PROFESSOR OF HEALTH POLICY AND MANAGEMENT, MUSKIE
SCHOOL OF PUBLIC SERVICE, UNIVERSITY OF SOUTHERN MAINE; AND GRAHAM L.
ADAMS, Ph.D., EXECUTIVE DIRECTOR, SOUTH CAROLINA OFFICE OF RURAL
HEALTH, AND PRESIDENT, NATIONAL ORGANIZATION OF STATE OFFICES OF RURAL
HEALTH
STATEMENT OF DAVID HARTLEY
Dr. Hartley. Well, thank you, Chairman Brown and Mr. Michaud and
members of the Committee, for the opportunity to testify before this Committee.
I am speaking here today as a member of the Institute of Medicine's
Committee on the Future of Rural Health which released its report in
2005: Quality Through Collaboration; The Future of Rural Health. Key recommendations of that rural IoM report are relevant to the quality of
care that is available to rural veterans.
In Quality Through Collaboration, we brought the Institute of
Medicine's quality chasm principles to bear on rural services and rural communities, and suggested that they can improve both the quality of
personal care and the health of whole rural populations. Our report
included twelve recommendations and four key findings.
Several of those recommendations are particularly relevant to rural
veterans. With 44 percent of new recruits coming from rural places, we
can expect an increase in veterans from Iraq and Afghanistan returning
to rural America recovering from combat-related injuries both physical
and emotional.
As a member of the IoM Committee, I see much common ground between the
needs of rural veterans and the needs of rural populations more
generally.
Three of our recommendations are especially relevant to the current
issues facing rural veterans. First, an agenda to strengthen the rural workforce; second, health information technology, including a plan to
convert to electronic health records; and, third, rural mental health
and substance abuse services, a fragmented, under-funded, non-system.
I believe we can make advances in three areas that will assure quality
care to rural veterans and accelerate the agenda for providing quality
care to all rural residents.
The Department of Veterans Affairs has the best integrated health
information network in the nation with performance measures to assure
that all patients receive high quality care. That system gets good
outcomes for those who can receive and get to VA clinics.
The VA also has a residency program through affiliations with 107
medical schools. The IoM Committee struggled with the emphasis of
graduate medical education on urban teaching hospitals.
In its 2005 report, the Advisory Committee on the VHA residency program recommended that the VA should maintain this training in areas of
importance to the VA and to the nation, and that this might include
geographic redistribution.
We know that physicians who grew up in rural areas and those who are
trained in rural practices are more likely to locate in rural
communities. I suggest that the needs of rural veterans warrant
investment in rural sites in the VA residency program to assure that physicians are available to meet the needs of rural veterans.
The state-of-the-art information infrastructure that I just mentioned
will help to assure that residents trained in VA sites are
well-prepared to meet the high-quality standards set by the VA.
There are many rural areas of the United States where veterans do not
have ready access to a VA clinic, but do have community health centers,
rural health clinics, and critical access hospitals. If these types of providers partnered with the VA's information infrastructure, veterans
living in such areas could receive high-quality care and these
providers could establish 21st century information systems. Such collaborations would benefit veterans immediately and eventually other
rural residents.
In much of my career, I have documented the lack of specialty mental
health services in rural areas and explored models for delivering such services in the absence of psychiatrists and other mental health
specialists.
Lacking mental health services, rural people with psychiatric problems
have typically sought help from their primary care practitioners.
Research tell us that such care has not always been of the highest
quality.
Two conditions of veterans now returning from Afghanistan and Iraq may
not be accurately diagnosed by primary care practitioners,
posttraumatic stress disorder, PTSD, and traumatic brain injury, TBI.
When such disorders are suspected, travel from a rural area to an urban
area for VA specialty care might be the only way to get quality care.
In many of our most rural states, however, there is no VA TBI program.
And the symptoms of PTSD often affect the whole family and may lead to domestic violence, child abuse, divorce, substance abuse, and suicide.
The lack of services in rural areas poses a significant barrier to
effectively addressing these problems.
My research suggests that creative solutions are needed to address
mental health and substance abuse problems in rural areas. To meet
such needs for rural veterans, it might be necessary for the VA to
establish its own rural behavioral health research center.
The Veterans Administration has an opportunity to build on the
foundation established by the Institute of Medicine's rural report, to
improve access to quality care for rural veterans, and to bring its
unique resources for quality improvement and information management to
rural providers. This looks to me like a win-win opportunity.
That concludes my testimony. I will be happy to answer any of your
questions.
[The statement of David Hartley appears on p. ]
**********INSERT**********
Mr. Brown of South Carolina. Dr. Adams.
STATEMENT OF GRAHAM L. ADAMS
Dr. Adams. Thank you, Chairman Brown.
Good morning. I am Graham Adams, Executive Director of the South
Carolina Office of Rural Health and 2006 President of the National Organization of State Offices of Rural Health or NOSORH.
All 50 State Offices of Rural Health serve rural communities by
assisting rural providers, communities, and policy makers in improving
access to quality healthcare. I appreciate the opportunity to speak
before you to discuss this important matter this morning.
Veterans that live in rural communities face great challenges when
trying to receive care. Lack of an adequate number of CBOCs, vet
centers, or other approved sources of care make it difficult for rural veterans to receive timely, appropriate care.
According to the VA web site, my home State of South Carolina only has
nine CBOCs and three vet centers. This is especially concerning given
that South Carolina is one of the top 20 states in which veterans
reside with 14.2 percent of the state's population being veterans.
Currently more than 44 percent of military recruits come from rural communities. A 2004 NPR report claimed that 44 percent of all soldiers
killed during Operation Iraqi Freedom were from communities under
20,000 people.
Given this great commitment to service on behalf of rural communities,
we need to do more to closely examine the healthcare barriers that face
rural veterans. Developing solutions specific to rural veterans and
their unique needs is the least we owe them.
First, develop a proactive policy of the VA contracting with Federally qualified health centers, rural health clinics, critical access
hospitals, and other small, rural hospitals to provide care to rural
veterans.
Approximately 20 percent of veterans who enroll to receive healthcare
through the VA live in rural communities. While CBOCs and vet centers
provide essential points of access, there are not enough of these
facilities in rural communities.
VA providers are known for providing good, quality care to those they
serve. However, more providers are needed to serve the increasing
number of rural veterans.
One immediate and logical solution to this dilemma would be to
facilitate the VA contracting with existing rural healthcare
facilities. Contracting with Federally qualified health centers and
rural health clinics for primary care and critical access hospitals and
other small, rural hospitals for inpatient services would allow more
rural veterans to receive care in their home communities.
While Congress has adopted legislation encouraging VA collaboration in
the Veterans Millennium Healthcare and Benefits Act, few examples of
this collaboration exist in my home State of South Carolina today.
More needs to be done to facilitate these VA partnerships and engage
and adequately reimburse existing local providers in every state in
rendering care to rural veterans.
Federally qualified health centers and rural health clinics receive
cost-based reimbursement or enhanced reimbursement respectively for
Medicare and Medicaid encounters. Both have been proven models for
increasing access to under-served populations in isolated communities
for decades.
Using evidence-based medicine and uniform standards of care, the VA
needs to sharply focus on developing more access points through these partnerships with Federally qualified health centers, rural health
clinics, and critical access hospitals.
Two, bolster rural mental health and family support services for
veterans residing in small or rural communities. A lack of qualified
mental health professionals, shortage of psychiatric hospital beds, and
the negative stigma of mental illness often result in many rural
residents not getting the care they so desperately need.
In addition to the normal stressors which drive individuals to seek
mental healthcare, veterans can have the added challenges of dealing
with service-related situations or mental illnesses. Problems derived
from combat situations, readjustment to civilian life and work, and
marital and family issues related to long absences from home often
greet veterans as they return home from service.
Although vet centers provide these services, they are not consistently available at the local level. Due to the lack of rural mental health providers and a scarcity of psychiatric hospital beds, some individuals
with mental illness end up being incarcerated in lieu of receiving
proper treatment.
Our broken mental health system is not unique for veterans. However,
given their service to our country and the unique needs that they often
have, it is incumbent upon the VA and rural providers to do better.
However, in order to improve the situation, more resources must be made available in order to contract with local mental health providers, hire additional mental health providers, and contract with and adequately
reimburse critical access hospitals and other small, rural hospitals to
serve these patients.
Third, identify, fully fund, and replicate best practices in rendering healthcare, mental health, and family support services to veterans in
rural communities.
Although veterans face many challenges in seeking and receiving care in
rural communities, there are undoubtedly many communities where VA
facilities, local healthcare providers, and advocates have worked
together to develop models that work.
The VA needs to identify these models, study and analyze the data of
where and when veterans currently interact with the system, and fund
the replication of new and diverse efforts in rural communities.
This analysis of the unique needs of rural veterans, what is working
and what is not, will educate and enrich the dialogue of providing care
to those who have served our country.
The VA needs to collaborate with State Offices of Rural Health at the
State level and HRSA's Federal Office of Rural Health Policy at the
Federal level to coordinate these activities.
While many opportunities for improvement exist in providing care to
veterans in rural communities, the VA is to be commended for the
excellent service provided in many of its facilities.
Providing healthcare in rural communities requires unique solutions
whether it is to veterans and their families or to the general
population. Adopting some of these strategies referenced in this
verbal testimony will aid in addressing these rural issues.
Thank you for the opportunity to speak today.
[The statement of Graham L. Adams appears on p. ]
**********INSERT**********
Mr. Brown of South Carolina. Thank you, Dr. Adams, and thank you, Dr. Hartley, for your testimony.
We will now entertain a few questions and I will take the lead.
Dr. Hartley, in your opinion, is there a lack of contract providers who
can meet VA's high standards of care in rural areas?
Dr. Hartley. I think that your question has more to do with the high standards than whether the providers are actually there. And I cannot
say that I can answer that definitively.
What I can say is that the IoM Committee recognized that particularly
with respect to the role that information technology plays in meeting
those high standards, the answer would be no. We need to improve the availability of information technology for our rural providers.
Now, I would add that from my personal experience, community health
centers are doing a better job of getting up to speed certainly in my
State than many other rural providers.
So I would say the first opportunity to contract with the VA would
probably in many of these rural areas would be with the CHCs because
they are rapidly catching up in terms of information technology. And
once you have got that in place, I think that the sequence of events
in terms of developing high-quality standards falls into place. But information technology is the key.
Mr. Brown of South Carolina. Do you sense any problems with the
electronic transfer of the veterans' records into those community
centers? Is that a technical problem?
Dr. Hartley. A technical problem? Well, I am not familiar enough with
how VA contracts are structured to know whether that would raise any
problems or not. My sense is there would have to be some flexibility
on the part of the VA to make those contracts work. But I am not an
expert on their contracting process.
Mr. Brown of South Carolina. Let me just ask one further question.
Many studies have shown that practice makes perfect. When it comes
to medical procedures, wouldn't the low volume of patients in rural
areas be an obstacle to training physicians and nurses in maintaining
the necessary expertise required for teaching hospitals to be centers
for technically sophisticated and innovative services?
Dr. Hartley. I am sorry. I think I missed part of the question.
Mr. Brown of South Carolina. Okay. In general, even with the
consolidation of some of the services, is there enough volume to
attract in the rural areas qualified physicians and nurses and how does
that interface with the telemedicine part of it?
Dr. Hartley. Well, that is part of the answer is that there is enough
volume certainly to sustain a primary care system. When the needs go
beyond the ability of the primary care system to meet them, one of the
ways we meet those needs is through telehealth.
I was very pleased to hear the folks from the VA testifying earlier
talking about telehealth, for example, outreach to treat PTSD which I
was not aware of.
Certainly in the case of mental health, telehealth can do a great job
because it does not involve hands on in many cases. And so it is an appropriate technology and it has been well received by some patients.
I think there are many questions, though, that are remaining unanswered
in terms of what exactly we can expect to deliver at that level of
quality in areas of very, very low population density. There are
always going to be limits and certainly we cannot expect to deliver
everything out there.
Mr. Brown of South Carolina. Okay. Thank you very much.
Dr. Adams, you suggested in your written statement that VA should do
more to contract with critical access hospitals for specialty mental
health services.
Do you believe that mental health providers exist in large enough
numbers in those facilities to assist the VA?
Dr. Adams. Well, sir, I know that mental health is a problem in all
rural communities. And with the limited number of CBOCs and vet
centers available, especially in some of our more rural states, using
the critical access hospitals and other small, rural hospitals as a
source of that care through contract, I think, could be a viable
option.
There are more than a thousand critical access hospitals throughout the nation. And if you look at contracting and reimbursing adequately
critical access hospitals and Federally qualified health centers and
rural health clinics in meaningful partnerships, I believe that you can
help to increase access for rural veterans without spending undo money
and replicating some resources that might already be available in the community.
Mr. Brown of South Carolina. In South Carolina, do you have a capacity problem as you try to deal with these special hospitals? Can they
absorb the VA needs adequately?
Dr. Adams. In South Carolina, specifically in rural communities,
whether it is veterans or nonveterans, so often the mental health
system is not in place, especially after hours and on weekends. And
these folks show up at the ER of their small, local hospital. And
oftentimes if they are decompensated, they are not doing well, they end
up being carted off to jail and incarcerated because the local mental
health system cannot deal with it. I think because of the lack of
psychiatric beds, that is an additional problem that there are not even
the beds available for them to be admitted into.
Mr. Brown of South Carolina. Let me ask you a follow-up question. Do
you personally believe that marriage and family therapists should be considered a valuable resource in curbing mental health related
illnesses of veterans?
And the reason I ask is that we have provided MFT new authority to
provide care for veterans in our legislative package that should be
rolled over in the next few weeks.
Dr. Adams. I do. I think that marriage and family therapists and
other types of mental health counselors are vital, especially to the
younger veterans that are coming back from service currently. All
those issues that are involved with them being away from home, if they
have posttraumatic stress disorder, so many of those issues could
really -- the family could benefit from a marriage and family
therapist. And in some cases, those kind of resources are available
locally at a community health center.
So that is an opportunity where I believe the VA should look around,
see what resources exist, and try and contract for those services
instead of replicating the resource in the same community just because
it has the VA name on it.
Mr. Brown of South Carolina. Okay. Thank you very much.
Mr. Michaud.
Mr. Michaud. Thank you very much, Mr. Chairman. I want to thank Dr.
Adams, Dr. Hartley for your testimony this morning.
I also want to just comment briefly on Mr. Moran's question earlier to
Dr. Perlin about the collaboration with Federally qualified health
clinics or critical access hospitals, and Dr. Perlin said that they do
try to collaborate.
I am not sure that message is getting out there in the different VISNs
because I know one VISN in particular where you have a critical access hospital, you have a Federally qualified healthcare clinic and you have
the VA coming in and building a new clinic instead of working
collaboratively.
I think when you look at rural healthcare, we have to work more in a collaborative effort to make sure that our veterans get the care that
they need and deserve.
Dr. Hartley, in your testimony, you discussed a difficulty that rural
veterans may face in receiving accurate and high-quality care for PTSD
and TBI.
Is there a role that the VA can play in reaching out to these rural
care providers to assist in awareness, diagnosis, and referral and
treatment?
Dr. Hartley. I am sure there is. In my experience, this is very
similar to the problem that we have had with primary care practitioners
not recognizing depression or recognizing it and not treating it
according to protocol.
And there is quite a history of efforts to improve what we call
guideline concordant care in the primary care setting. There has been
a lot of research done on that and a lot of different things have been
tried. And much of it is outreach of different sorts.
And it seems to me that the same kinds of expertise could be
transferred to those same providers and it does seem to me that it is
the VA who has the expertise. They are the folks in their VA centers
who have the best skill in knowing how to recognize and how to deal
with these cases.
It might be something new for them to do that kind of a collaboration
with the primary care system that does not treat veterans, but I think
they definitely have something to offer.
Mr. Michaud. Could you elaborate on how the VA could build upon the
Institute of Medicine recommendation for enhancing rural healthcare?
Dr. Hartley. Well, I have mentioned two particular areas that I think
that they could have a huge impact. One of them is because they have
so many training sites. If they were to make it a priority to have
rural training sites and rural rotations, then we would have more
physicians and other healthcare practitioners having experience
practicing in rural areas which means from what we know that they would
be more likely to end up practicing there. So that is one area.
The other one that I think is even more important, of course, is
information technology. The VA, as I said, has a very good system.
Both the technical aspects of it and the quality indicators of it, the performance measures, all of that, it is why we have such good care for
our veterans.
That seems to me to be a great opportunity to transfer that technology
and that expertise by way of these collaborative contracts to many
aspects of our rural health infrastructure. It just seems to me like a
great opportunity.
Mr. Michaud. Thank you. And my last question, in rural and remote
locations where there is no VA presence, community health centers, and
rural clinics, maybe the default mental healthcare system for veterans,
and this is for either one of you or both of you. What do you
recommend VA do to reach out to these centers and clinics to help
provide care for veterans?
Dr. Hartley. Were you speaking specifically of mental health?
Mr. Michaud. Yes.
Dr. Hartley. Well, I think Graham had some specific statements on that
in his --
Dr. Adams. I might suggest developing some kind of a working group or
a committee between the National Association of Community Health
Centers, the National Association of Rural Health Clinics, the VA, and
other interested parties to really sit down and discuss the issue
because, to my knowledge, those discussions have not occurred at that
level. They may have, but I am not aware of it.
Going on the VA web site, you do not have access to the other
information about the 1,000 partnerships with community health centers
that the VA staff referenced. When you go on my State, it shows the
nine CBOCs, three vet centers, and the two VA MCs.
So I think if indeed those partnerships are out there, maybe we can do
a better job of educating and marketing the fact that they are
available to rural veterans and helping them to develop those linkages.
Dr. Hartley. There is another opportunity. There is a provider type
that we have not really mentioned at all today and that is the
community mental health centers.
Now, community mental health centers, that is not an official, specific designation the way Federally qualified health center is. There is
quite a bit of variability out there. And I would not make a blanket recommendation that we contract with all of them, but the VA does have
a system for establishing qualifications before they will contract with someone.
It does occur to me that that is one of the few entities in rural areas
that has an infrastructure for treating mental healthcare including in
many cases marriage and family therapists and including sometimes psychiatrists, often psychologists. They are out there already.
And, again, it is this issue of we cannot afford to have duplicate
systems. That is an opportunity that we should explore. And
certainly the idea of having a cooperative committee to consider these
options is a good starting place.
Dr. Adams. I might offer that the National Rural Health Association
might be the appropriate entity to facilitate that dialogue given that
they are kind of the umbrella association for all rural health needs.
Mr. Michaud. Once again, I want to thank both of you for your
testimony. Thank you.
Thank you, Mr. Chairman.
Mr. Brown of South Carolina. Thank you, Mr. Michaud.
Mr. Moran, do you have a question?
Mr. Moran. Yes, sir. Thank you, Mr. Chairman, and thank both our
panelists for taking the time to prepare and be here today.
Dr. Adams, you heard Dr. Perlin respond to my question. I wanted to
give you a chance to react. It appears to me that what Dr. Perlin was suggesting is that the opportunities for veterans to be cared for in
their local communities in the absence of a VA CBOC or vet clinic or an
actual hospital for routine services is pretty minimal, that the VA is interested in contracting with providers to meet the emergency needs,
the traumatic needs of veterans in those rural settings.
And also as I understand, as we use the word collaborative here this
morning, what I was interested in -- obviously collaboration is a
good thing. We all want to collaborate. But what I actually was most interested in is there ever an instance in which the veteran is seen by
a hometown physician, admitted to a hometown hospital, treated at a
community health clinic, treated at a mental health center, or when we
talk about collaboration, is that something just very esoteric, that
that never results in veterans being treated at home?
I am a proponent of CBOCs. I have worked hard to bring CBOCs to
veterans in Kansas, but I always have seen that as an intermediate step
for routine services ultimately being provided by the hometown
physician. Actually, the physician does not have to be hometown. The physician of the veteran's choice, the clinic, the hospital of the
veteran's choice. Again, distances to a CBOC can be two and three
hours.
And so it appears to me that a couple of explanations by the VA why
that is not at this point a good idea is technology, medical records.
We have been through this issue with the VA on filling prescriptions.
They want their own physician to write the script, not necessarily the hometown doc of the vet for purposes of quality care.
And then finally, is there any legislative authority that is lacking in
trying to get the VA to move in this direction? Your thoughts to any
and all of those things? You as well, Dr. Hartley, if you have an
opinion.
Dr. Adams. In preparation for my testimony, I spoke with two Executive Directors of Federally qualified health centers in my State, one of
which is the St. James Santee Community Health Center, which is in
Chairman Brown's area. And both of those facilities said that there is
no formal collaboration. There is no formal partnership with the VA
and their Federally qualified health center.
One Executive Director referenced that they do see TRICARE patients.
They used to not see those patients. But when the War in Iraq really
started to accelerate, they wanted to do that as service to the
enlisted and veterans in their community. They see basic TRICARE.
They do not see the upper tier of TRICARE because of the hassle
associated with referrals and such.
So while some of these community health centers do voluntarily see
veterans with TRICARE, none that I spoke to had any formal arrangements
or any formal contracts nor had been approached.
I also in preparation for the testimony spoke with the Executive
Director of our State primary healthcare association, which is the
trade association for all of the Federally qualified health centers in
South Carolina. And she also did not know of any formal arrangements,
any dialogue between the VA and her association or any of her specific clinics.
So I think that while there may be the intent to go out and develop collaborations from my research and my years in the field, I have not
seen any real tangible partnerships. I have read of certain
circumstances in Utah and Missouri and Wisconsin where the VA does
contract with community health centers and that seems to be working
well, but I do not know too much about the specifics.
I feel that there is certainly an opportunity for the VA staff to sit
down with specifically the National Association of Community Health
Centers and talk about a meaningful way that the VA could contract with community health centers at either their Federally approved rate or a
lower rate and provide some basic services.
But I would agree that it is not satisfactory to drive two, three hours
for basic, routine care. And we all know that if it is a barrier --
a lot of these folks do not have transportation -- if it is a barrier,
a lot of folks just do not seek care and then something that could have
been taken care of earlier on that could have been routine care is
going to escalate and cause that person to be hospitalized and cause
the severity of the illness to be greater.
Mr. Moran. I recognize this issue is not without its whole set of
issues in the sense that many of our veterans service organizations
fear the diversion of resources from the VA system. That is obviously
a legitimate concern.
And quality of care, the medical records that the VA has developed,
their information technology system is becoming the premier information technology system in the healthcare delivery world.
So there are issues. But it does seem to me that for the care of the
veteran that the VA has to go beyond the mindset that we are only going
to provide emergency care for veterans, that we are also going to
provide routine care, particularly in the setting when it is hours and
miles away from access to a VA physician or clinic.
And it is also important, Mr. Chairman, you know, much of my time on healthcare issues in Congress have been associated with trying to keep
access to healthcare available in rural communities. And just like a
rural community needs every student in their school system, a hospital
and a doctor needs every patient in the healthcare delivery system.
That is about revenue, about keeping doors open.
And so as we divert our healthcare dollars away from local healthcare providers, we reduce the chances that rural healthcare is going to
survive and be available to anyone in our smallest communities across
the country.
And I appreciate the testimony of our witnesses. And, again, I want to
be complimentary of the VA. This is an area, though, in which I look
forward to working with them to see that we improve access to veterans
and at the same time, strengthen our delivery system for all of rural
America as we try to provide healthcare for every American.
I thank the Chairman.
Mr. Brown of South Carolina. Thank you, Mr. Moran.
And thank you very much, Dr. Adams and Dr. Hartley, for coming and
sharing this very informative testimony and as we continue to work
towards more collaboration to do like Mr. Moran said, to try to keep as
much of a practice within the rural communities as possible.
I recognize the innovation of telemedicine and some other innovative
ways of working to meet the veterans healthcare needs. We hope that we
can find enough joint effort within our provider system to make it a
quality healthcare delivery system.
And we appreciate your testimony and appreciate your interest. And
certainly as we move forward in this collaboration, if we need local legislation in order to make it an easier accommodation, we would
certainly be willing to listen.
Thank you for coming.
Hold a minute. Members have five legislative days in order to submit an opening statement. Anyway, thank you all for coming. And without any
other business before the Committee, we stand adjourned.
[The statement of Cathleen C. Wiblemo appears on p. 66]
[Whereupon, at 11:25 a.m., the Subcommittee was adjourned.]
APPENDIX
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