[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 VAï¿½s 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 raiseï¿½s 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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