[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
ACCESS TO U.S. DEPARTMENT OF VETERANS
AFFAIRS HEALTHCARE: HOW EASY IS IT FOR
VETERANS--ADDRESSING THE GAPS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
APRIL 18, 2007
__________
Serial No. 110-13
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
April 18, 2007
Page
Access to U.S. Department of Veterans Affairs Healthcare: How
Easy is it for Veterans--Addressing the Gaps................... 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 27
Hon. Shelley Berkley............................................. 8
Hon. Jerry Moran................................................. 3
Hon. John T. Salazar............................................. 4
WITNESSES
U.S. Department of Health and Human Services, Marcia Brand,
Ph.D., Associate Administrator, Rural Health Policy, Health
Resources and Services Administration.......................... 5
Prepared statement of Dr. Brand.............................. 28
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D.,
FAAFP, Acting Principal Deputy Under Secretary for Health,
Veterans Health Administration................................. 24
Prepared statement of Dr. Cross.............................. 41
______
American Legion, Shannon Middleton, Deputy Director for Health,
Veterans Affairs and Rehabilitation Commission................. 16
Prepared statement of Ms. Middleton.......................... 34
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director........................................... 19
Prepared statement of Mr. Atizado............................ 37
National Rural Health Association, Andy Behrman, Chair, Rural
Health Policy Board, and President and Chief Executive Officer,
Florida Association of Community Health Centers................ 14
Prepared statement of Mr. Behrman............................ 30
SUBMISSIONS FOR THE RECORD
Brown, Hon. Corrine, a Representative in Congress from the State
of Florida, statement.......................................... 46
Brown, Hon. Henry E., Jr., a Representative in Congress from the
State of South Carolina, statement............................. 46
Miller, Hon. Jeff, Ranking Republican Member, and a
Representative in Congress from the State of Florida, statement 46
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions for the Record:
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to
Dr. Michael Kussman, Acting Under Secretary of Health,
Veterans Health Administration, U.S. Department of Veterans
Affairs, letter dated May 2, 2007.......................... 48
Hon. Joe Donnelly to Dr. Michael Kussman, Acting Under
Secretary of Health, Veterans Health Administration, U.S.
Department of Veterans Affairs, letter dated May 2, 2007... 55
Hon. Jeff Miller, Ranking Republican Member, Subcommittee on
Health, to Dr. Michael Kussman, Acting Under Secretary of
Health, Veterans Health Administration, U.S. Department of
Veterans Affairs, letter dated April 27, 2007.............. 57
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to
Maurice Huguley, Legislative Analyst, Office of Deputy
Assistant Secretary for Legislation for Human Services,
U.S. Department of Health and Human Services, letter dated
May 2, 2007 (forwarding question from Hon. Phil Hare)...... 68
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to
Joe Violante, National Legislative Director, Disabled
American Veterans, letter dated May 2, 2007................ 73
Andy Behrman, Chair, NRHA Rural Health Policy Board, National
Rural Health Association, to Hon. Michael H. Michaud,
Chairman, and Hon. Phil Hare, Subcommittee on Health,
Committee on Veterans' Affairs, letter dated June 5, 2007.. 69
Steve Robertson, Director, National Legislative Commission,
American Legion, to Hon. Michael H. Michaud, Chairman,
Subcommittee on Health, Committee of Veterans' Affairs,
letter dated November 28, 2007............................. 72
ACCESS TO U.S. DEPARTMENT OF VETERANS
AFFAIRS HEALTHCARE: HOW EASY IS IT
FOR VETERANS--ADDRESSING THE GAPS
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WEDNESDAY, APRIL 18, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:20 p.m., in
Room 334, Cannon House Office Building, Hon. Michael H. Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Moran, Snyder, Hare, Berkley,
Salazar.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. Sorry for the delay. We got called for a vote
so we will start. I would ask unanimous consent that all
written statements be made part of the record. Without
objection, so ordered.
I also ask unanimous consent that all Members be allowed 5
legislative days to revise and extend their remarks. Without
objection, so ordered.
I apologize for a lot of the Members not being here. We
have a lot of Committee meetings that are going on and we just
broke up from a vote and Members will be drifting in and out
throughout the hearing.
The Subcommittee on Health has a lot of issues that we have
to deal with this upcoming session. The issue of providing
rural healthcare affects each of our States in a very different
way. In California, rural communities make up 92 percent of the
land mass and 8 percent of the population. In my own State of
Maine, over 40 percent of the population lives in rural areas.
It is estimated that 60 million Americans, one in five, live in
areas that have been classified as rural.
Rural populations tend to be older than urban populations
and they tend to exhibit poor health behaviors. Economic
factors also add to the challenges facing rural populations.
Rural veterans make up 41 percent of the U.S. Department of
Veterans Affairs' (VA's) patient workload. Access and resources
present serious challenges to providing high quality care for
these veterans. VA care can be second to none. Unfortunately
the quality of care is not always the same throughout the VA
system. For many veterans living in rural States like Maine,
accessing that care is a significant challenge. For certain
more complex procedures veterans in northern Maine must endure
4 days of travel to and from the VA facility in Boston to
receive care.
Addressing the distance to care and the travel burden in
rural areas is extremely important. However, given the smaller
population and frequency of certain complex procedures it does
not make sense for VA to maintain a daily in-house capacity in
every facility for something that is used on an infrequent
basis.
This problem is not unique to VA. It is a problem facing
many rural areas across the country while smaller patient
population limit the resources available to rural hospitals,
which in turn limits the services that hospitals can support
and provide. Rural areas face difficulties in providing what
has been termed ``core healthcare services'' by the Institute
of Medicine. These services include primary care in the
community, emergency medical service, hospital care, long-term
care, mental health and substance abuse services, oral
healthcare, and public health services.
For a variety of reasons, rural areas also face a greater
problem recruiting and retaining healthcare professionals.
These problems must be addressed because the demand of services
from our veterans in rural areas is only going to increase. We
have an aging population that will need long-term care. Over 40
percent of the new generation of veterans returning from
Afghanistan and Iraq are from rural areas. They have their own
unique needs including loss of limb, traumatic brain injury,
and mental health concerns.
One important approach to providing access to care is the
VA system and Community-Based Outpatient Clinics (CBOCs) which
currently number more than 650. We have five CBOCs in Maine.
The Capital Asset Realignment for Enhanced Services (CARES)
Commission recommends a sixth CBOC in the Lewiston, Auburn area
along with five part-time health access points. Only one of
these facilities is close to opening while the CBOC is not
expected to open until 2008 at the earliest.
During the CARES process, 250 CBOCs were identified by the
VA as being needed, of which 156 were designated as priority.
Since the CARES decision, VA has opened 12 of the 156, less
than 8 percent. At this pace it will take VA over 30 years to
open all the priority clinics. VA has also opened 18 clinics
not on the CARES priority list, which calls into question the
decision process and the ability of CARES to assist in
decisions in the future.
The VA has also designated facilities as Veterans Rural
Access Hospitals designed to provide inpatient service to
veterans in rural areas in which these services can be
supported. The VA has made great strides in exploring the use
of telemedicine and other technological means of providing
healthcare services. I would like to hear how these efforts are
improving care and how we can help.
One of the problems we face in the area of recruitment and
retention is the isolation that is often felt by healthcare
professionals working in rural communities. I would like to
explore how technology might be used to overcome these feelings
of isolation and thus improve recruitment and retention.
Is the VA, and our rural communities, ready to meet the
increasing and changing needs of our veterans and their
families? What is the VA in rural America going to look like in
the future? We must keep in mind that VA healthcare does not
operate in a vacuum but it is an integral part of our national
healthcare system. I would also like to know when the priority
CBOCs are going to be built or if the VA no longer intends to
follow the CARES process.
Today the Subcommittee hearing will provide us with the
opportunity to begin this exploration, to begin to examine
issues concerning access and the provision of care and the
proper expectation of veterans in rural areas regarding the
care that they can expect from the VA system.
At this point in time I would like to recognize the Acting
Ranking Member, Mr. Moran.
[The prepared statement of Chairman Michaud appears on p.
27.]
OPENING STATEMENT OF HON. JERRY MORAN
Mr. Moran. Mr. Chairman, thank you very much. I appreciate
you recognizing me. I am delighted to be here this afternoon,
although I have several meetings that are intruding. I am happy
to be here to support your efforts. And I would like for you,
Mr. Michaud, to consider me an ally. We share many similarities
in our districts despite one is in New England and one is in
the middle of the country, Midwest. I represent a district of
approximately 60,000 square miles. There is not a VA hospital
in the district. And we very much are interested in trying to
find ways to improve access for our veterans.
Your remarks about CBOC I think are right on point. I am
very interested in knowing what the plans are by the Department
of Veterans Affairs to increase the number of CBOC. We have
significant needs in that regard and are particularly troubled
to learn about the issue of not being on the priority list and
still having CBOC when those that are on the priority list are
still waiting.
I also would encourage you and the Subcommittee to take
seriously a piece of legislation that I introduced earlier this
year, the Rural Veterans Access to Care Act, giving veterans
the opportunities of utilizing their local healthcare
providers, both hospitals and physicians, clinics, in the
circumstances when a VA hospital is miles, hundreds of miles
away from where the veteran lives and where the CBOC is as
well.
And I am hopeful that this Committee will take that form of
legislation, that theory behind that legislation seriously and
work with me to see that we address the needs of our veterans
who are miles away. I spoke on the House floor recently about
this topic, veterans who are told to drive 260 miles to get
their prescriptions for their eye glasses when there's an
optometrist on Main Street three blocks away.
We need assistance when it comes to filling prescriptions
and issuing the script. The idea that our veterans must travel
hundreds of miles, particularly our World War II veterans at
ages 80 and 90, to simply have an examine so that their
prescription can be refilled in many cases it is physically not
possible.
I also am interested in hearing what Dr. Petzel has to say
in his role as Director of VISN 23 in regard to the Project
Hero. And that VISN includes six Kansas counties and I am
interested in knowing the status and findings of that pilot
program.
Last December, legislation was signed creating the VA
Office of Rural Healthcare. And I have not heard from the VA as
to the status of the implementation of that office. Whether it
is being staffed and what role it is now playing or is foreseen
to play. And finally I would raise a point that we have been
pushing for a long time, the opportunity access also includes,
particularly in rural America, the access to other providers
than a physician and chiropractic care continues to be
inadequate in many of our VISNs across the country. And, I hope
to be here to ask some questions of our Department of Veterans
Affairs witnesses.
Again, Mr. Michaud, you have been a champion in regard to
rural healthcare. I would like to be your ally, and look
forward to working with you to see that we accomplish the goal
of meeting
the needs of veterans who live across the country, regardless
of whether they are in the same community as a VA hospital.
Thank you.
Mr. Michaud. Thank you very much, Mr. Moran. I will work
very closely with you on these issues, and I agree with your
comments. We have scheduled a hearing, I don't know if the
notice has been sent to your office yet, for one of your bills
on April 26th at 10 o'clock. And we will be sending you a
notice to testify.
Mr. Salazar?
OPENING STATEMENT OF HON. JOHN T. SALAZAR
Mr. Salazar. Thank you, Mr. Chairman. And I thank you, Mr.
Moran, for your fine comments. I associate myself with both of
your comments. I think all of us share some commonalities in
that we all represent some very rural areas in our distant
communities in Kansas and in Colorado for example.
But I want to thank you, Mr. Chairman, for you calling this
important hearing. I think that a 2004 study by the Under
Secretary of Veterans Health found that veterans living in
rural areas in fact are in poor health, in poorer health than
those living in urban areas. And because of the distances, as
Mr. Moran referred to, and other difficulties associated with
obtaining care, many rural veterans put off preventative
healthcare.
I think last Congress the Office of Rural Health and the VA
was created to better focus on our veterans in rural areas. I
am looking forward to today's testimony. But in reality, over
25 percent of the veterans, I believe, live in rural areas. And
I believe it is a fair expectation that the men and women who
sacrifice for us are taken care of.
I am heartened today that we got notice from Secretary
Nicholson that, it is not really CBOC, but it is called a
Community-Based Outreach Center which is actually going to be
installed in Craig, Colorado, one of the remotest areas in
Colorado. Veterans have to travel 5 hours over the mountains to
try to get to Grand Junction for healthcare.
I want to thank the Secretary for that. We do indeed share
many, many issues when it comes to veterans' healthcare. I
think, though, that if we find that the VA is incapable of
providing that care to all of our veterans, that we can't
afford it, then I think we must look for a new direction. And I
agree with Mr. Moran on possibly looking at trying to address
the issues of allowing our veterans to obtain healthcare from
our local physicians.
But I want to thank you, Mr. Chairman, once again. And I
look forward to today's testimony. Thank you.
Mr. Michaud. Thank you, Mr. Salazar. On our first panel is
Dr. Marcia Brand who is Associate Administrator for Rural
Health Policy, Health Resources and Services Administration, of
the U.S. Department of Health and Human Services. Dr. Brand.
Dr. Brand. Thank you.
Mr. Michaud. Thanks for coming this afternoon. I look
forward to hearing your testimony.
STATEMENT OF MARCIA BRAND, PH.D., ASSOCIATE ADMINISTRATOR,
RURAL HEALTH POLICY, HEALTH RESOURCES AND SERVICES
ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Brand. Mr. Chairman, Members of the Subcommittee, thank
you for the opportunity to meet with you today on behalf of Dr.
Elizabeth Duke. She is the Administrator of the Health
Resources and Services Administration. Thank you. We welcome
this opportunity to discuss rural health access issues and what
is being done to meet the healthcare needs of the Nations rural
populations. We appreciate your interest in and support for
rural healthcare and access to healthcare for rural veterans.
The Health Resources and Services Administration, which I
will call HRSA, is the primary Federal agency for improving
access to healthcare services for people who are uninsured,
isolated, or medically vulnerable. HRSA grantees provide
healthcare to the uninsured, people living with HIV and AIDS,
and pregnant women, mothers and children. They train health
professionals and improve systems of care in rural communities.
For HRSA, the Health Center Program, the National Health
Service Corps, and rural healthcare needs are priorities. For
more than 40 years, the Health Center Program has been a major
component of the healthcare safety net for the Nation's
indigent populations. Health Center's lead the Presidential
initiative to increase healthcare access in the Nation's most
needed communities. Health Centers provide regular access to
high quality, family oriented, comprehensive primary and
preventative healthcare regardless of one's ability to pay.
President Bush's initiative to expand the Health Centers
began in 2002. The initiative will significantly effect over
1,200 communities through the support of new or expanded access
points. In 2001 HRSA funded 3,317 Health Center sites across
the Nation. We expect the number of Health Centers sites to
grow to 4,053 by the end of 2008.
Just over half of all the Health Center grantees serve
rural populations. Besides the new access points, HRSA has
distributed 385 grants to expand the medical capacity of our
existing delivery sites and another 340 grants to existing
grantees to add or expand oral health, mental health and
substance abuse services. And these are special challenges for
our rural communities.
Through these efforts, the number of patients treated
annually with Health Centers has grown from 10.3 million in
2001 to an estimated 16.3 million patients by the end of 2008.
The National Health Service Corps improves the health of the
Nation's underserved by uniting communities in need with caring
health professionals. Currently more than half the National
Health Service Corps doctors, dentists, nurses, and mental
health and behavioral health providers serve in Health Centers
around the Nation. And about 60 percent of them work in areas.
HRSA's Office of Rural Health Policy is charged with
informing and advising the Department of Health and Human
Services on matters effecting rural hospitals and healthcare.
We coordinate rural healthcare activities and maintain a
national rural health and human services information
clearinghouse. HRSA, with the Office of Rural Health Policy, is
the leading Federal proponent for better healthcare services
for the 55 million people who live in rural America.
ORHP promotes State and local empowerment to meet the
country's rural health needs in several ways. I would like to
highlight a couple of our grant programs. We manage the
Medicare Rural Hospital Flexibility Grant Program which
provides funding to State governments to work with 1,300 small
rural hospitals. We work with the State Office of Rural Health.
There are 50 State offices of Rural Health.
Additionally, we support a number of community-based grant
programs that increase access to primary care or improve rural
healthcare services. As you can see, HRSA administers a range
of programs that serve rural communities. HRSA also provides
staff support to the Department's cross-cutting rural efforts.
This includes the HHS Rural Taskforce which has representatives
from each of HHS's agencies and staff offices.
Effective, coordinated healthcare improves the health and
well-being of American's, regardless of where they live.
However, effective coordination is especially critical in rural
communities where services and providers are limited and
resources are scarce. The challenges of providing healthcare
for rural communities is compounded by higher rates of poverty,
a lack of insurance. Rural people are a little bit older and
they have higher rates of chronic disease. And there are
significant transportation barriers.
We take great pride in the work that we do to provide
better healthcare services for our rural populations. However,
we are humbled by the significant challenges that remain for
healthcare in rural areas and the underserved. We are pleased
that the Department of Veterans Affairs is establishing an
Office of Rural Health to assist the Under Secretary in issues
affecting rural veterans.
We have contacted the individuals who are creating this
Office and their charge sounds very familiar. With 20 years of
experience, we have some expertise around rural and
policymaking and research. And we look forward to collaborating
with the new Office. And we offer our assistance.
And, I would be pleased to answer any questions at this
time, sir.
[The prepared statement of Dr. Brand appears on p. 28.]
Mr. Michaud. Thank you very much, Doctor, for your
testimony. You had mentioned that the Office of Rural Health,
which is getting under way within the VA System, and the fact
that HHS has 20 years of experience in this area. What would
you tell the VA would be the number one problem that your
agency encountered in dealing with rural healthcare issues as
far as access goes?
Dr. Brand. I think that it would be difficult to say that
there is a single issue that is most challenging around access.
In rural communities we face a lot of the challenges that we
face nationwide in access--it's just that much more difficult
because it is rural. It is harder to recruit and retain
providers because infrastructure is not there and the folks who
use those services have higher healthcare needs and lower rates
of insurance.
Mr. Michaud. Okay.
Dr. Brand. It has over the past several years become
clearly a significant problem to provide mental health services
for rural communities and also to provide oral healthcare. It
is very difficult to recruit and retain providers.
Mr. Michaud. Has it been a problem trying to find qualified
staff to work in the rural healthcare arena?
Dr. Brand. There are a number of different programs that
seek to improve recruitment and retention of providers for
rural communities. A number of them focus on the fact that
folks who are from rural communities are more likely to go back
there and practice. And so a number of State programs and
several of the Federal programs try to recruit folks from rural
communities, encourage them to go to health profession schools,
and then return to practice in those areas.
Also the National Health Service Corps. Roughly 60 percent
of the folks in the National Health Service Corps practice in
rural communities. So that is another affect of Federal
program.
Mr. Michaud. You are familiar with the CARES process that
the VA went through a number of years ago?
Dr. Brand. Sir, I read the materials in preparation for
this hearing, but I wouldn't consider myself familiar with it.
Mr. Michaud. A lot of time and effort went into the CARES
process, and I commend everyone who put all the effort in
there. My concern is that that is pretty much it. We haven't
seen, at least in VISN 1, any movement or much movement in that
particular area.
My question is, when you look at rural healthcare, what you
are doing at HHS and if you look at what the CARES process
actually recommends, a lot of--there are a lot of areas that
are very similar. Do you think that that is something that your
agency could work very closely with the VA to actually speed up
the process under the CARES process?
And a good case in point is, one of the clinics under the
CARES process that was recommended in Maine, the VA actually
was working with the local hospital, was working with the
healthcare clinic in the region. And at the very last minute
they decide to go it alone.
So now we have a situation where we have a hospital that is
expanding in a rural area. You have a Federally qualified
healthcare clinic that is building a new facility in a rural
area. And then you have the VA building a new facility in the
rural area in the same town, which I think is a waste of
Federal dollars. And I think there should be some collaboration
going on.
So I hope you would actually look at the CARES process as
far as where they are recommending clinics or CBOCs and see how
you might have facilities out there where we used additional
Federal dollars in other areas to be able to help collaborate
with the VA and to move forward in a collaborative way so we
can take care of veterans in rural areas. At the same time it
will help out rural healthcare providers as well.
Dr. Brand. I think that we have a significant investment in
expanding the Health Centers and certainly there are
opportunities for collaboration with the Health Centers. There
are also 3,500 Rural Health Clinics located in those areas. And
somewhere around 1,300 small rural hospitals that we call
Critical Access Hospitals. And given the fact that resources in
rural communities are so scarce, it would be--I would be
hopeful that we would be able to find ways to collaborate more
effectively. And we are certainly willing to try to do that.
Mr. Michaud. Great. Well thank you very much, Dr. Brand.
Mr. Salazar.
Mr. Salazar. Thank you, Mr. Chairman. Dr. Brand, my
questions are similar to Mr. Michaud's questions. It just seems
to me to make a lot of sense that if you have to transport
veterans over a 250 mile range, that it would make more sense
to be able to provide them the same opportunity as normal
residents have in rural communities, for example.
What are the obstacles to VA refunding or making the
payments for a patient who is a veteran who would go to a local
hospital to get the same kind of treatment? Is there a
rulemaking process that has to take place or is it just rules
within VA or is it something that the Members of Congress could
actually do to change the----
Dr. Brand. I can speak to the Health Centers and certainly
to small rural hospitals. Our Health Centers, frankly at this
moment don't ask veterans' status. And so they do not know who
is a veteran. And similarly I think for many small rural
hospitals when someone presents either through the outpatient
departments or coming through the emergency department it is
not asked.
And, so I think that frankly opportunities to improve
collaboration are missed because Health Centers and Critical
Access Hospitals don't know who is a veteran and who might be
eligible for benefits. I think also it is important to note
that the Health Centers will see someone regardless of their
ability to pay or their veteran status. So if they present at
the Health Center, they would be seen.
Mr. Salazar. Well what about preventative healthcare? Like,
for example, just to be able to go to the local primary care
physician--do you have any mechanism for veterans in rural
areas to be able to do that?
Dr. Brand. They could certainly present at any of those
facilities. Whether or not those would be reimbursed by the
Veterans--through their veterans benefits, I think is just
depending upon a pre-existing relationship. And I am sure my
colleagues from Veterans Affairs could speak to that more
effectively than I can in terms of what those relationships
might be.
Mr. Salazar. Okay. Thank you.
Mr. Michaud. Thank you, Mr. Salazar. Ms. Berkley?
OPENING STATEMENT OF HON. SHELLEY BERKLEY
Ms. Berkley. Thank you very much, Mr. Chairman. I am very
glad that we are here to discuss access to VA healthcare, which
is obviously a very important issue to our veterans across the
country.
As you are aware I represent a very urban district and I
just want to emphasize that access to healthcare is not, for
our veterans, is not only a rural issue. With 218,000 veterans
in southern Nevada, we have no VA healthcare facilities. And of
course because of the CARES study, finally the CARES Commission
determined that with 218,000 veterans and no healthcare
facilities, that perhaps Las Vegas ought to have it's own
healthcare facility.
So many of my veterans, aside from the fact that they have
got 80-year old veterans standing in 110 degree temperature
waiting for a shuttle to take them from one temporary location
to another awaiting the building of our VA hospital, outpatient
clinic, long-term care facility. So many of my veterans that
have more specialized problems have to continue to go to Long
Beach to get their healthcare needs taken care of. And it is
just so difficult because oftentimes they are in a very low-
income bracket. Their families cannot afford to accompany them.
They go there by themselves. Many of them are Korean War
veterans and World War II vets. And this is an issue that is
bigger than our rural areas. It is pervasive across the United
States.
I have got 1,600 Nevada veterans who have just returned
from Iraq and Afghanistan. And we are estimating that there
will be at least another 2,100 coming back in the next year or
two. I can't be here for the third panel, but I think what I
would ask you as Chairman if you could please ask the third
panel how is the VA preparing to meet the needs of the growing
number of returning servicemembers who will need increased
healthcare and mental healthcare as well?
Right now in Las Vegas, we don't have facilities to handle
what we have. In 2011, which is when they are anticipating that
the facilities will be completed, is an awfully long time to
have to wait if you are a World War II vet, if you are a
disabled vet and have to keep going to Long Beach or if you are
returning from Afghanistan or Iraq and it is 2007. And you are
coming home to nothing.
So those are the questions that I would like addressed and
I am just sorry I won't be here to hear the answers. But I
thank you very much for letting me talk to you about my
extraordinary frustration and, frankly, shame that we send
young men and women to war and when they come back, we don't do
what we have promised that we are going to do, and don't
adequately fund this VA healthcare center. As I have said, the
healthcare system--as I have said before, veterans healthcare
and other benefits is the cost of war. And we ought to be
taking this into account because the men and women that are
coming back from Iraq and Afghanistan we are going to be taking
care of their healthcare needs and mental healthcare needs for
many decades to come. And we can't handle the load we have now.
So I would like to know how the VA intends to take care of
these people. Thank you, Mr. Chairman.
Mr. Michaud. Thank you very much. You have been a true
advocate for veterans. Your questions are the same that a lot
of us have as well, and you can be assured that they will be
asked. Thank you.
Mr. Hare?
Mr. Hare. Thank you, Mr. Chairman. Thank you very much for
having the hearing.
Dr. Brand, I just have a couple questions. One, you know, I
represent an area, a congressional district, with a lot of
rural areas. And you know you were talking about
transportation. And you mentioned in your testimony that there
are significant transportation barriers that affect the
coordination of services. And I am wondering if you could
elaborate on that and what HHS has done to address the issue of
providing transportation to rural patients?
Dr. Brand. Transportation is a significant challenge in
rural communities. And HHS has a process to try to improve
coordination and collaboration around transportation. And it
would be my pleasure to submit that information to you after
the hearing, sir.
[The information was provided by the U.S. Department of
Health and Human Services to Mr. Hare in the post hearing
questions for the record, which appears on p. 48.]
Mr. Hare. Thank you very much. And then you were talking
about hospital care. You said that out of the 2,000 hospitals,
I believe 1,500 have fewer than 50 beds.
Dr. Brand. Yes, sir.
Mr. Hare. And just a couple of questions. Can you describe
the type of care that is provided there and have you run into
problems finding qualified people to staff and to work at the
small hospitals?
Dr. Brand. Of the 2,000 hospitals, about 1,500 have less
than 50 beds. And those hospitals typically provide some access
to primary care through outpatient services and then standard
services such as laboratory, radiology. They have an emergency
department, they meet Medicare conditions of participation, but
most of the patients that are seen are those patients with less
complex conditions. And historically, lots of those places are
places where individuals come and are first assessed and then
it is important to have a good relationship with the next level
of hospital, the referral hospital for those conditions that
are more complex.
And so there are----
Mr. Hare. Thank you.
Dr. Brand [continuing]. Part of a system or a network of
hospitals.
Mr. Hare. And then specifically, what do you think are the
benefits and the disadvantages of running a hospital that has
fewer beds?
Dr. Brand. I beg your pardon, sir?
Mr. Hare. What are the benefits and disadvantages of
running a hospital with fewer beds from your perspective?
Dr. Brand. I think that the benefits are that you could
have contact--you can have an access point closer to where
people live. That they don't necessarily have to drive 50, 100
miles to get to a hospital. The challenges of a small rural
hospital are that with a limited, a low volume, it is always
hard to ensure that you have that financially you are in the
positive margin, because you don't have a lot of patients to
provide care for.
Mr. Hare. Okay. And I am sorry, Doctor, I think you
answered this and I was jotting a note. Have you found it
difficult to staff hospitals? To find people to staff at the
smaller hospitals?
Dr. Brand. Yes, sir.
Mr. Hare. Okay.
Dr. Brand. It is difficult to recruit and retain physicians
and nurses. It is a challenge to effectively staff your
business office and your housekeeping and your dietician
department. It is the same challenge that all small rural
hospitals face----
Mr. Hare. Sure.
Dr. Brand [continuing]. In retaining workers.
Mr. Hare. Any ideas from your end on how we can do a better
job of doing that or how we can----
Dr. Brand. A number of the States have been very innovative
in the programs that they have developed for recruiting and
retaining providers using their academic Health Centers and
their community colleges.
The National Health Service Corp is another fairly
effective tool for getting folks out into those communities. I
suspect that as long as there are remote areas, we are going to
struggle to find ways to staff up those facilities.
Mr. Hare. Okay. Thank you, Doctor. I yield back.
Mr. Michaud. Thank you, Mr. Hare. Dr. Snyder?
Mr. Snyder. Thank you, Mr. Chairman. Dr. Brand, I am
curious what is your Ph.D. in?
Dr. Brand. My Ph.D. is in higher education. My original
discipline was dental hygiene, but I couldn't sit still.
Mr. Snyder. Oh, yeah. Yeah. I see it. About half the time
people with Ph.D. either don't know what the subject field is
or simply don't understand the title of the theses. But I am
always trying to educate myself.
I have two questions. When we had our discussion in the
Armed Services Committee, one of the issues that we had
difficulty with about 2, 3, or 4 years ago with the TRICARE
system was an adequate number of obstetricians that had signed
up to provide TRICARE services to military families.
And I think a lot of it was a reimbursement problem. And I
think that has dramatically improved, at least our TRICARE
contractors are saying it has dramatically improved. And I
think it was something they learned from our Committee system.
So when they testified from our Committee hearings over the
last couple of years, so when they testified in the last month
and I asked them, where do they see their gap is now? They
testified they think their biggest gap is in mental health
services. To the point that they have just gone out and
contracted with a provider for full time, that they would
assign to different geographic areas because they just can't
find services in such an area.
And that shouldn't be--I am sure that is not a surprise to
you as somebody who works in rural health a lot. Because before
we had the war in Iraq or Afghanistan we had, I think, big gaps
in mental health services throughout the country, both urban
and rural. Would you agree with that? Yeah.
And now this niche of people, we have military veterans and
military families with these mental health things. I may have
missed it in your written statement, but I didn't really see
much of a discussion about mental health. And because it seems
to me the challenge we are talking about making it easier for
veterans but we are trying to do that in a system that has big
gaps in care for non-veterans also.
When you talk about the mental health, where do you see
that going?
Dr. Brand. Yes, sir. One of the grants----
Mr. Snyder. Would you pull that in a little closer? Maybe
it is just my old ears or something.
Dr. Brand. Is this better?
Mr. Snyder. Yeah, it is.
Dr. Brand. Sorry. One of the programs that we manage in our
Office is an Outreach Services Grant Program and it provides
resources for communities to define what their need is and then
they write to that particular program need rather than being
categorical like so many of the grants.
And if you look at the applications that the community
submits the gap that they are trying to fill, is the mental
health services gap. A significant number of them try to fill
that gap. It is--I have heard it suggested that, you know, our
jails become the waiting rooms for our mental health facilities
in rural communities because there is just not enough care to
provide folks who meet those challenges.
One of the things that HRSA is hopeful to do is improve the
whole location of primary care and mental health services. And
there has been a significant expansion of Health Centers and
mental health services. And the idea is if you can have both of
those services provided in the same facility it is much easier
for the patients and for the clients. And frankly, in the rural
communities where there is significant stigma, you can pull
your car up in front of the clinic and no one knows if you are
taking your child in for a well baby visit or if you are
accessing the mental health services.
So you are right, sir, the recruitment of providers and the
provision of mental health services is a significant challenge.
Mr. Snyder. I don't think it has helped at all by this.
What I think is just an invisible public health policy that a
lot of private insurance companies take in terms of their
reimbursement on mental health services. There is not much of
an incentive for a small rural--well a typical rural practice
of three to five physicians and maybe a nurse practitioner and
maybe a deal. There is not much incentive to put in a full-time
mental health worker with very poor reimbursement for the kinds
of services that people could benefit from.
I notice we had this occur with regard to the Iraq War was,
as Guard members and Reserve component members were being
activated, and then their families were being put on to TRICARE
as their healthcare system, they were then going to their local
doctor and finding out that the doctor just didn't accept
TRICARE. A lot of times I think it was because they just didn't
know that there were people in their area that would benefit
from that.
Is that an issue that you have dealt with at all or do you
have any kind of--I think it has gotten better as word has
gotten around to physicians. They really do need to sign up for
this program in the spirit of patriotism.
Do you have an information network that you could
disseminate information out there to providers about, here's
the, you know, consider this, sign up for this?
Dr. Brand. I believe that the Health Centers have a way of
communicating. They have sort of a list serve system. And a
number of the small rural hospitals do. In terms of whether or
not they have been encouraged to participate in TRICARE and
other programs, I don't know.
Mr. Snyder. One of the problems that we had with that was
hospitals signed up, but there were no physicians that had
signed up.
Dr. Brand. I see.
Mr. Snyder. And so there was no one to take care of them
while they were there. Thank you, Mr. Chairman.
Mr. Michaud. Thank you very much, Dr. Snyder. And just to
follow up on your last question about TRICARE, I know there is
an issue regarding reimbursement rates, particularly as they
relate to Critical Access Hospitals getting lower
reimbursements. This is a problem.
But I do want to thank you once again, Dr. Brand, for your
testimony. There will probably be additional questions----
Dr. Brand. Yes, sir.
Mr. Michaud [continuing]. For you to answer in writing and
look forward to our continuing working relationship. And on a
closing comment, as you heard from Mr. Moran and other Members
here and from those Members who aren't here, access to
healthcare in rural areas is a big concern. It is an extremely
big concern about the CARES process moving so slowly to a point
where I have heard other Members talking about authorizing
another agency to do delivery on the CARES process versus the
VA.
So I look forward to working with you and thanks again for
your testimony.
Dr. Brand. Thank you, sir.
Mr. Michaud. At this time I would like to welcome the
second panel, Andy Behrman, who is Chairman of the Rural Health
Policy Board for the National Rural Health Association; Shannon
Middleton, who is Deputy Director for Health for the American
Legion; and Adrian Atizado, who is the Assistant National
Legislative Director for the Disabled American Veterans.
I want to thank our panelist for coming today and look
forward to your remarks. And we will start off with Andy.
STATEMENTS OF ANDY BEHRMAN, CHAIR, RURAL HEALTH POLICY BOARD,
NATIONAL RURAL HEALTH ASSOCIATION, AND PRESIDENT AND CHIEF
EXECUTIVE OFFICER, FLORIDA ASSOCIATION OF COMMUNITY HEALTH
CENTERS; SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH,
VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN
LEGION; AND ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
STATEMENT OF ANDY BEHRMAN
Mr. Behrman. Mr. Chairman, distinguished Members of this
Subcommittee, I am Andy Behrman, President of the Florida
Association of Community Health Centers and the Chair of the
National Rural Health Associations Rural Health Policy Board. I
am also a veteran. And I have proudly served the United States
Navy. I want to thank you for the opportunity to speak and
testify on behalf of the National Rural Health Association and
for my fellow veterans.
NRHA is a national, non-profit and non-partisan membership
organization and our mission is to improve the health of rural
Americans and to provide leadership on rural health issues.
NRHA members have long maintained concern for the health and
mental healthcare needs of rural veterans.
Since our Nation's founding, rural Americans have always
answered the call when America has gone to war. And whether
motivated by their values, patriotism, or economic concerns the
picture has not changed much in 230 years. Simply put, rural
Americans serve at rates higher than the proportion of the
population. Though only 19 percent of the Nation lives in rural
areas, 44 percent of our recruits are from rural America and
nearly one-third of those who died in Iraq are from small towns
and communities across the Nation.
There is a national misconception that all veterans have
access to comprehensive care. This is simply not true. Access
to the most basic primary care is often difficult, sometimes
impossible, in rural America. Combat veterans returning to
their rural homes in need of specialized care due to war
injuries, both physical and mental, likely will find access to
that care extremely limited.
What this means is that because there is a disproportionate
number of rural Americans serving in the military, there is a
disproportionate need for veterans care in rural areas.
Additionally, we must all be mindful of long-term needs. And
while NRHA is pleased that both the House and the Senate for
fiscal 2008 budget calls for greater increases in VA medical
care spending than in past years, long-term healthcare planning
is critical. The wounded veteran who returns today won't need
care for just the next few fiscal years, they will need care
for the next half century.
To meet those long term needs, the NRHA respectfully makes
the following recommendations to the Committee. One: Increase
access by building on current successes. CBOCs opened the door
for many veterans to obtain primary care services within their
home community and outreach Health Centers help meet the needs
of many rural veterans.
NRHA applauds these efforts and supports the expansion of
these successful programs.
Two: Increase access by collaborating with non-VHA
facilities. Many rural veterans cannot access VHA care simply
because the facilities are too far away. Linking quality VA
services with rural civilian services can vastly improve access
to healthcare for rural veterans. As long as quality standards
of care and evidence-based medicine guide treatment for rural
veterans, the NRHA supports collaborative efforts with a number
of organizations.
First, Federally Qualified Community Health Centers.
Community Health Centers serve millions of rural Americans and
provide high quality community-based primary care and
preventative healthcare. And most importantly they are located
where most rural veterans live.
A limited number of collaborations between the VHA and
Community Health Centers already exist and have proven to be
prudent cost effective solutions to serving veterans in rural
areas. These successful models should be expanded to reach all
of rural America.
Critical Access Hospitals. These facilities provide
essential comprehensive services to rural communities. If these
facilities were linked with VA services and model the quality,
access to care would be greatly enhanced for thousands of rural
veterans.
And Rural Health Clinics. These clinics serve populations
in rural medically underserved areas. And in many rural and
frontier communities these clinics are the only source of
primary care available.
The third recommendation is to increase Traumatic Brain
Injury care. Unfortunately it appears that traumatic brain
injuries, TBI, will most likely become the signature wound of
the Afghanistan and Iraqi wars. Such wounds require highly
specialized care. The current VHA TBI Case Managers Network is
vital, but has limited access for rural veterans. We need to
expand this program.
Four: Target care and services to rural veterans. Rural
veterans have an especially strong bond with their families.
Returning veterans adjusting to disabilities and the stresses
of combat need the security and support of their families in
making their transition back into civilian life.
Vet Centers do a tremendous job in assisting veterans, but
their resources are limited. The NRHA supports increases in
funding for counseling services for veterans and their
families. And more women today serve in active duty than any
other time in our Nation's history. And unfortunately, more
women are then wounded or are war casualties then ever before
in our Nation's history.
We must target care for today's women veterans and
culturally competent care to meet the unique needs of rural
minority and female veterans.
And finally, Mr. Chairman, the NRHA calls on the Congress
and the Veterans Administration to fully implement the
functions of the newly created Office of Rural Veterans to
develop and support ongoing mechanisms for study and articulate
the needs of rural veterans and their families.
Mr. Chairman, thank you again for this opportunity. The
National Rural Health Association looks forward to working with
you and this Committee to improve rural healthcare access for
the millions of veterans who live in rural America. Thank you.
[The prepared statement of Mr. Behrman appears on p. 30.]
Mr. Michaud. Thank you very much, Mr. Behrman. Ms.
Middleton?
STATEMENT OF SHANNON MIDDLETON
Ms. Middleton. Mr. Chairman and Members of the
Subcommittee, thank you for this opportunity to present The
American Legion's views on access to quality healthcare for
veterans in rural communities.
Research conducted by the Department of Veterans Affairs
indicated that veterans residing in rural areas are in poorer
health than their urban counterparts. It was further reported
that nationwide, one in five veterans who enrolled to receive
VA healthcare lives in rural areas. Providing quality
healthcare in a rural setting has been--has proven to be very
challenging, given factors such as a limited availability of
skilled care providers and inadequate access to care.
Even more challenging would be VA's ability--excuse me--to
provide treatment and rehabilitation to rural veterans who
suffer from the signature illness of the ongoing Global War on
Terror--traumatic blast injuries and combat-related mental
health conditions.
VA's efforts need to be especially focused on these issues.
A vital element of VA's transformation in the 1990's was the
creation of CBOCs, or Community-Based Outpatient Clinics, to
move access closer to the veterans communities. A recent VA
study noted that access to care might be a key factor in why
rural veterans appear to be in poorer health.
CBOCs were designed to bring care closer to--I'm sorry. I
already said that. Over the last several years VA has
established hundreds of CBOCs throughout the system, and today
there are over 700 that provide healthcare to the Nation's
veterans.
CBOCs have been very successful, however, of concern to The
American Legion is that many of the CBOCs are at or near
capacity and many still do not provide adequate mental health
services to veterans in need.
One of the recommendations of the Capital Assets
Realignment for Enhanced Services or CARES was for more, not
less, CBOCs across the Nation. The American Legion strongly
supports this recommendation, especially those identified for
rural areas. However, limited VA discretionary funding has
limited the number of new CBOCs each fiscal year.
There is great difficulty serving veterans in rural areas.
Veterans in States such as Nebraska, Iowa, North Dakota, South
Dakota, Wyoming, and Montana face extremely long drives and a
shortage of healthcare providers and also bad weather. The
Veterans Integrated Service Networks or VISN, rely heavily upon
CBOCs to close this gap.
The provision of mental health services in CBOCs is even
more critical today with the ongoing war in Iraq and
Afghanistan. It has been estimated that nearly 30 percent of
the veterans who are returning from combat suffer from some
type of mental stress. Further, statistics show that mental
health is one of the top three reasons our returning veterans
seek VA healthcare.
The American Legion believes that VA needs to continue to
emphasize to the facilities the importance of mental health
services in CBOCs. And we urge the VA to ensure the adequate
staffing of mental health providers in the CBOC setting.
CBOCs are not the only avenue with which VA can provide
access to quality healthcare to rural veterans. Enhancing
existing partnerships with communities and other Federal
agencies such as the Indian Health Service will help to
alleviate some of the barriers that exist, such as the high
cost of contracting for care in the rural setting.
Coordinating services with Medicare or with other
healthcare systems that are based in rural areas is another way
to help provide quality care.
In the July 2006 report entitled, ``Health Status of and
Services for Operation Enduring Freedom and Operation Iraqi
Freedom (OEF/OIF) Veterans After Traumatic Brain Injury
Rehabilitation,'' the Department of Veterans Affairs Office of
Inspector General examined the Veterans Health Administration's
ability to meet the needs of OIF and OEF veterans who--sorry--
who suffered from traumatic brain injury.
Fifty-two patients from around the country were interviewed
at least 1 year after completing inpatient rehabilitation from
a Lead Center. Some of them did reside in States with rural
populations. Many of the obstacles for the TBI veterans and
their families remain, they were very similar. Forty-eight
percent of the patients indicated that there were resources in
the community--there were few resources in the community for
brain injury-related problems. Thirty-eight percent indicated
that transportation was a major obstacle. And 17 percent
indicated that they did not have money to pay for medical
rehabilitation and injury related services.
Some of the challenges noted by family members who care for
these veterans in rural settings include the necessity for
complicated special arrangements and the absence of VA
rehabilitative care in their communities. Case managers working
at Lead Centers and several secondary centers noted a limited
ability to follow patients after discharge to rural areas and
lack of adequate transportation.
These limitations placed undue hardship on the veterans
families as well. Those contributing to the report, as well as
veterans who have contacted The American Legion, have shared
many examples of the manner in which families have been
devastated by caring for TBI injured veterans. They have
sacrificed financially, they have lost jobs that provided the
sole income for family and have endured extended separations
from children.
Vet Centers are another important resource, especially for
combat veterans experiencing readjustment issues who do not
live in close proximity to a VA medical facility. Because Vet
Centers are community-based and veterans are assessed the day
they seek care, they receive timely care and are not subjected
to wait lists. Some of the services provided include individual
and group counseling, family and marital counseling, military
sexual trauma counseling, and bereavement counseling.
Realizing the value of Vet Centers to those who may
encounter obstacles when seeking mental healthcare in the VA
Medical Centers, The American Legion decided to get a glimpse
of services and needs of Vet Centers nationwide. The American
Legion's 2007 System Worth Saving report will focus on Vet
Centers as well as the polytrauma centers.
The American Legion's staff selected a sample of Vet
Centers that were located near the demobilization sites
throughout the country to ascertain the effects of the number
of returning veterans on the services provided by the Center.
The report will illustrate the types of veterans utilizing
their respective Vet Centers as well as services requested by
these veterans and outreach services offered.
The American Legion believes veterans should not be
penalized or forced to travel long distances to access quality
healthcare, because of where they choose to live. We urge VA to
improve access to quality primary and specialty healthcare
services using all available means at their disposal for
veterans living in rural and highly rural areas.
And although access is a very important issue, The American
Legion believes timeliness of access is just as critical. For
example, VA establishes it's own acceptable access standard for
primary care at 30 days. But to most Americans with private
healthcare plans, 30 days would not be acceptable.
Unfortunately, the continued disparity between demands for
services and available resources continues to cause delays in
the delivery of healthcare.
The current Global War on Terror has placed many more
demands on VA healthcare, the VA healthcare system to meet its
obligations to the men and women of the armed forces, past,
present, and future. As a grateful Nation welcomes with open
arms the newest generation of wartime veterans, veterans of
previous conflicts and the Cold War are being denied enrollment
and, therefore, access to their healthcare delivery system of
choice.
By 2003, former VA Secretary Anthony Principi decided the
enrollment of any new priority veterans--sorry--decided to
terminate the enrollment of any new priority veterans,
therefore, prohibiting access to VA medical care to hundreds of
thousands of Priority 8 veterans due primarily to limited
resources.
The American Legion disagrees with the decision to deny
access to any eligible veterans and many of these veterans are
Medicare-eligible or have other third-party health insurance
that can reimburse VA's reasonable charges for services
rendered. Yet, little has been done to improve third-party
reimbursements from private insurers and nothing has been done
to allow VA to begin receiving third-party reimbursements from
the Nation's largest healthcare insurer; the Centers for
Medicare and Medicaid Services.
The restriction of enrollment for Priority 8 veterans
creates another ``access gap'' for recently separated veterans
who did not serve in the combat setting. Some recently
separated veterans must wait until their VA disabilities claims
are approved in order to enroll. For others, unless they are
economically indigent, they are prohibited from enrolling.
Those recently separated veterans that successfully transition
may very well never be eligible for enrollment in the Nation's
best healthcare system.
None of these situations are very welcoming messages to the
men and women currently serving in the Nation's armed forces
Mr. Michaud. Could you quickly summarize? I notice your
time is running out.
Ms. Middleton. Yes, sir.
Mr. Michaud. Or ran out, I should say.
Ms. Middleton. Okay. Thank you, Mr. Chairman, for giving
The American Legion the opportunity to present views on such
important issues.
This hearing was very timely and we look forward to working
with the Subcommittee to bring an end to the disparities that
exist in access to quality care in rural areas. Thank you.
[The prepared statement of Ms. Middleton appears on p. 34.]
Mr. Michaud. Thank you very much for that excellent
testimony. Mr. Atizado?
STATEMENT OF ADRIAN M. ATIZADO
Mr. Atizado. Mr. Chairman, Members of the Subcommittee,
thank you for the opportunity to provide testimony on behalf of
the Disabled American Veterans and the Independent Budget
Veterans Service Organizations regarding the issue before us
today, access to VA medical care particularly on access to care
in rural areas.
We would like to thank Congress, the hard work of and
commitment of this Subcommittee and the Full Committee in
having provided VA additional funding in the previous two
fiscal years. But we do remain concerned about access to VA
speciality care as well as to care in rural areas.
We are especially concerned about how VA plans to address
rural veterans needs in the coming years, given that about 44
percent of all veterans returning from Operations Enduring and
Iraqi Freedom reside in rural communities. After having served
their country, these veterans should not have to be neglected
for their healthcare needs simply because they live in rural or
remote areas.
Provisions in Public Law 109-461 represents the most
significant advances to date to address the healthcare needs of
rural veterans and the needs of returning OIF/OEF veterans.
Notably, however, the final legislative language failed to
include a Rural Veterans Advisory Committee to help harness the
knowledge and expertise of representatives from outside the
Department.
We hope that Congress will reconsider this mandate and we
do urge the Secretary to use existing authority to establish
such a Committee as well as to include representatives from our
organizations as part of it's membership. And although we
acknowledge benefits of the Public Law, it also raises concerns
about unintended consequences it may have on the VA Healthcare
System regarding the use of VA purchased medical care.
We believe this tool should be used judicially so as not to
endanger VA's full range of specialized services. Putting
additional budget pressure on the specialized system of
services without making specific appropriations available for
new rural VA Healthcare Programs could only exacerbate
problems.
This new legislation also holds the VA accountable for
improving rural veterans access to care, by requiring the
development and implementation of a plan using CBOCs and other
access points. The Capital Assets Realignment for Enhanced
Services process, known as the CARES, includes a May 2004
decision by the Secretary which identifies 156 priority CBOCs
to address outpatient care. Furthermore, as part of the CARES
Initiative the VA employed Medicare's Critical Access Hospital
model as the guide to establish a new VA policy to govern many
of VA's rural and remote facilities now designated as Veterans
Rural Access Hospitals in addressing rural acute inpatient
care.
We note that VA receives no appropriations dedicated to
support the establishment of rural CBOCs or Veterans Rural
Access Hospitals. And thus VA must manage any additional
expenses from within generally available medical services
appropriations. We, therefore, urge Congress to include
specific funding in fiscal year 2008 to address at least some
of these needs in rural areas and to avoid the scavenging of
resources.
In addition to the lack of resources to meet the healthcare
needs of rural veterans, health worker shortages and
recruitment and retention of healthcare personnel remains a key
challenge to rural veterans access to care as well as quality
of that care. The 2005 IOM report titled, ``The Future of Rural
Health,'' recommended that the Federal Government renew it's
efforts to enhance the supply of healthcare professionals
working in rural areas.
To this end, we believe VA's academic affiliation as well
as health professions education programs possess special
attributes that could be brought to bear in improving the
situation in VA facilities as well as in the private sector.
Another often overlooked component of improving veterans
access to medical care is VA's beneficiary travel program. As
you are aware, sir, the mileage reimbursement rate of 11 cents
a mile has not been changed in almost 30 years, even though
Congress has delegated authority to the Secretary to make rate
changes when warranted. DAV and several other service
organizations have a long-standing resolution to reinstate the
effectiveness of the travel program. We support legislation
that has been introduced in Congress and we urge approval and
enactment of this legislation this year.
Given the cost of transportation in 2007, including record-
setting gasoline prices and reimbursement rates unchanged since
1977, pales in comparison to the actual cost of travel.
Mr. Chairman, thank you for the opportunity to provide
testimony on these very important issues which relate to access
to VA healthcare services. In the Independent Budget for fiscal
year 2008, our organizations have made a number of
recommendations in this document to Congress as well as VA that
are relevant to the issues discussed today.
We do invite you to review these recommendations. And as
always, I would be happy to answer any questions you may have.
[The prepared statement of Mr. Atizado appears on p. 37.]
Mr. Michaud. Thank you very much. And once again, I want to
thank the entire panel for your testimony. It has been very
helpful.
A quick question for the DAV. You heard from Mr. Behrman of
the National Rural Health Association. In his testimony he
talked about building upon the successes that VA has had with
approaching rural healthcare by collaboration, whether it is
with the Federally Qualified Healthcare Clinics, Critical
Access Healthcare Clinics. And I heard your testimony saying
you didn't really disagree with that, but you said it should be
used judiciously.
How do you determine judiciously? Because one of my
concerns is the fact that if you are a veteran in a rural area,
and I can state this from DAV members in Maine, where some were
pleased with what the VA did, some disapproved with what VA did
as far as the clinic in Lincoln.
How do you determine judiciously, and how far should the VA
deal with contracting for services, particularly in rural
areas?
Mr. Atizado. Mr. Chairman, as part of my written testimony,
we do outline current authority with regards to the use of
contract care as well as fee-based care. Just on the outright I
would like to clarify that we are not opposed to the judicial
use of collaboration. We are opposed--we are advocating for
judicial use of the purchased care.
As far as a current criteria that VA has to use or is
required to use for contract care, as well as fee-based care,
we think that those criteria set out specifically to protect
VA's core services. The reason why purchased care can become
dangerous is because it is considered an open access point. In
other words, if VA will agree to pay for services at a local
facility or a private facility, that is an access point that
can be challenging with regards to quality of care, and also
with making sure that the veterans come into the VA system for
tertiary or specialty care.
It is very important that when these tools are used to make
sure that not only the quality but the continuum of care that
VA is known to provide remain intact.
Mr. Michaud. Okay. I would ask Ms. Middleton to answer that
same question. And I would also ask Mr. Behrman afterward.
Ms. Middleton. Sir, your question was how do you determine
what is judicial?
Mr. Michaud. I can understand the VSOs concerns with
contracting out services because one of the concerns is that
they don't want the VA to become an insurance agency----
Ms. Middleton. Yes.
Mr. Michaud [continuing]. Which I agree with. However, at
the same time, my concern is veterans being able to access that
care. Good quality care is important, but you need to have
access to that quality care.
How does The American Legion feel about the remarks that
you heard this afternoon from the National Rural Health
Association as far as utilizing critical access, hospitals and
rural healthcare clinics? What is The American Legion's
reaction to that?
Ms. Middleton. Well, as you said, we also feel that the VA
should not be an insurance agency just, you know, handing out
money. But we definitely believe that veterans who require
care, especially if they are in rural areas, they should be
provided that care. If it is not available through the VA then,
what is near them is best.
We have been in contact with a few veterans who have
actually had very traumatic injuries and there was no care near
them and their families. As I said in my testimony, they have
gone through hardship just trying to get this care. But if it
was local then it wouldn't be such a hardship on the family.
So only when necessary. And if it is not necessary, the VA
can provide it, that is one thing. But if the veteran is going
to experience a hardship especially if he is not able to
physically take the travel, then it would be necessary and we
believe that that is the best way.
Mr. Michaud. Okay. Mr. Behrman, how do you think the VA can
move forward with the recommendations that you mentioned while
at the same time address some of the concerns that we hear from
some of the VSOs?
Mr. Behrman. Thank you, Mr. Chairman. Well, first I think
we have established that there is a hardship already. That is
part of the reason that we are having these hearings. Excuse
me.
But the reality is, first it has got to be about the
patient, what the patient's needs are, where are they going to
get their service. That would be the first thing. And I am sure
the VA looks at that as the most important criteria first.
Secondly, there needs to be a little bit more understanding
of what these organizations are about and what they do. When we
mentioned quality of care, this is a critical component of
Federally Qualified Health Centers and Critical Access
Hospitals. Most of the Community Health Centers in this country
are JCAHO accredited.
So quality of care is a important issue that has to be
reviewed. Certainly the VA would be looking at an
organizational structure that would have to have at least the
quality of care that is being provided at a VA institution.
The second thing about this, in particular, when it relates
to Rural Health Clinics and Community Health Centers, is that
primary care is what they do. This is what they are about. A
continuum of care needs to be considered where you can take
certain pieces and this may be the judiciary part that we are
talking about. Where it makes sense to provide primary care in
a medical home in a community where the veteran lives, they
will be comfortable. They know the individuals in a lot of
these small towns who are providing the services, the
healthcare services.
So there may not be the necessity to travel 150 or 200
miles to get primary basic care, comprehensive care. And
preventative care as well. A lot of the mental health issues,
alcoholism, substance abuse, all of these things come into
play. Community Health Centers have to have these services
available to them.
I agree that a judicious review of how services would be
purchased is important. Nobody wants to double pay for things.
Certainly we don't want to do that. But we also don't want to
make--we also want to make sure that there is care available,
quality care available and these access points that I would
think could be worked through some process so that the VA--I
mean these organizations could figure out who does what so we
don't duplicate services.
Mr. Michaud. Thank you very much. Mr. Salazar?
Mr. Salazar. Well, thank you, Mr. Chairman. Just a brief
question to Ms. Middleton. In your written testimony under
inpatient bed requirements you state that the, ``VA continues
to ignore the Federal mandate for inpatient care, especially in
the areas of long-term. The American Legion believes that the
VA is focused on shifting long-term care from VA to State
Veterans Homes and private nursing home industry.''
Could you expand on that, please?
Ms. Middleton. That is in reference to the number of beds
that have been established as mandatory under law. And at this
moment I don't have the number, but I know that each year the
number has been below that has been--has been available has
been below that number.
I mean it comes up in our testimony every year. But----
Mr. Salazar. Was this----
Ms. Middleton [continuing]. This side----
Mr. Salazar. Was this an issue of basically funding? Maybe
the VA can actually respond to that.
Ms. Middleton. I am not sure if it is an issue of funding,
but I do know that each year the number of beds that are
mandated by law have not been available. And by doing this that
is--by not having them available that is how the long-term care
has been shifted to the State Veterans Home, because it is not
they are not available--the number of beds are not available.
Mr. Salazar. Okay. Thank you. Mr. Atizado, is that the way
you pronounce the name, Mr. Michaud?
[Laughter.]
I have messed it up so.
Mr. Michaud. You can pronounce it any way you want to. It
is probably easier just to call him Adrian.
Mr. Salazar. Okay. Adrian, well the only question I have
for you is that you mentioned the issue of providing healthcare
for veterans and I guess there is a mechanism already in place
for remote rural areas where a veteran can go to local
hospitals or primary healthcare physicians, right?
Doesn't it make more sense to you to look at the economy or
the numbers and try to figure out the economies scale to where
maybe it will save the VA money by providing these services
where there are already local hospitals or local doctors?
Mr. Atizado. Well let me first be clear. We are not
opposing the use of VA to purchase care. What we are concerned
about is the amount that may end up being used to care for
rural veterans.
With regard to--let me give an example. With regard to
contract care, generally it is a very good program on the
outset for VA. But what we have seen is that the out years
after the first 2, 3, 4 years of the contract it becomes a much
higher dollar amount for that contract. So the out years become
very, very much out of control for VA financially. For fee-
based care, as mentioned earlier, it is much like TRICARE where
these payments are really at a reduced rate. So it becomes
disadvantageous for a physician, not only in an urban area, but
more so in a rural area where the cost of care can be that much
higher. Hence, the Critical Access Hospital model that Medicare
uses, which is a cost-based reimbursement, that actually
provides higher than normal Medicare reimbursement rates simply
because to have that kind of a facility and that kind of
medical care out in the rural community does cost more.
In other words, our concern is these tools may be used to
the point where they lose control such that core services at
the facility may be in danger. And that is what we don't want
to happen. We want to make sure that if they do use this that
it is with a thought of making sure that other services that
they provide are protected.
Thank you.
Mr. Michaud. Mr. Hare.
Mr. Hare. Mr. Chairman, in the interest of time, I know we
have votes. If it would be okay with you, Mr. Behrman, I have
three questions but if I could submit them to you and maybe
have you get them back to me regarding rural healthcare and
access to healthcare for Vets if that would be okay I would
appreciate that.
Mr. Behrman. Yes, sir.
Mr. Hare. Thank you very much. I yield back.
Mr. Michaud. Thank you, Mr. Hare. I would like to thank the
panel once again. We will follow up with additional questions.
I would like to ask the last panel to come up. Dr. Gerald
Cross who is Acting Principal Deputy Under Secretary for
Health. He is being accompanied by Dr. Robert Petzel, Dr. Adam
Darkins, and Patricia Vandenberg.
Yeah. And Dr. Cross if you could try to summarize your
remarks, we will try to move this along quickly, hopefully
before the votes.
STATEMENT OF GERALD M. CROSS, M.D., FAAFP, ACTING PRINCIPAL
DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH
ADMINISTRATION, U.S DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED
BY PATRICIA VANDENBERG, MHA, BS, ASSISTANT DEPUTY UNDER
SECRETARY FOR POLICY AND PLANNING, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ROBERT A.
PETZEL, M.D., DIRECTOR, VA MIDWEST HEALTHCARE NETWORK, VETERANS
INTEGRATED SERVICES NETWORK 23, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; AND ADAM DARKINS, M.D.,
MPH, FRCS, CHIEF CONSULTANT, OFFICE OF CARE COORDINATION,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS
Dr. Cross. Good afternoon, Mr. Chairman and Members of the
Subcommittee. And thank you for the opportunity to discuss our
ongoing efforts to provide safe, effective, efficient, and
compassionate healthcare to veterans residing in rural areas.
And I am accompanied today by Patricia Vandenberg, VHA's
Assistant Deputy Under Secretary for Policy and Planning; Dr.
Adam Darkins, VHA's Chief Consultant for Care Coordination. And
you can read into that telehealth--telemental health. And I am
especially pleased to have Dr. Robert Petzel of VHA's Network
Director for VISN 23.
And I should say that by profession as was brought up
earlier, I am a Board Certified Family Physician. Grew up in a
rural environment on a farm. Did home visits by training. And I
am a veteran as well.
My remarks will briefly review the national challenge
presented by rural healthcare and VHA's strategic direction in
the initiatives that we have underway. Among the entire
enrolled VA population almost 39 percent were classified as
rural at the end of FY 2006. And among the entire enrolled VA
population a little bit less than 2 percent, about 1.6 percent
were classified as highly rural.
Researchers have studied this population and a number of
articles have looked at the VA care in the rural environment as
well. First, studies have found that veterans living in rural
areas tend to be slightly older, have lower income, and these
same veterans will also be less likely to be employed. The
studies agree that rural veterans had slightly more physical
health problems, but fewer mental health problems as compared
to suburban and urban veterans.
VHA's strategic direction is to enhance non-institutional
care with less dependence on large institutions. Instead we are
providing more care at home and in the community. VHA now has
717 Community-Based Outpatient Clinics or CBOCs. Of this total,
320 or 45 percent of these are located in rural or highly rural
areas. But we have done much more than that. We created the
Consolidated Mail Out Patient Pharmacies, CMOPPs so that
medications are delivered to the patients home instead of
having the patient travel to the hospital.
We provide home-based primary care where the folks go to
the patients home directly. Devoting more than $175 million in
this program in FY 2008 and more than $95 million for other
home-based programs, we are using telemedicine and telemental
health to reach into the veterans homes and into community
clinics. This allows us to evaluate and follow patients without
them having to travel to large medical centers.
We are far along with our Mental Health Enhancement
Initiative that will add resources and greater mental health
expertise in primary care clinics. We are also using special
Internet sites to provide information to veterans in their home
including the ability to refill prescriptions from home. Here
is a key point as to how we are doing: At the end of FY 2006,
92.5 percent of the 5.4 million patients enrolled were within
60 minutes of VA Healthcare Facilities, and 98.5--98.5 percent
were within 90 minutes.
And among those who live outside the 60-minute range, some
veterans are in highly rural areas living in tribal areas and
so forth. A study on veterans satisfaction, and this is another
result, in 2006 compared rural versus urban veterans finding
that rural patients in the VA system were actually more
satisfied with their care than their urban counterparts.
And here is one more result: We looked at the quality of
care comparing rural versus urban clinics. We looked at 40
standard measures of quality, they were virtually identical
across the range. Rural versus urban.
To continue this strategic support for access in rural
healthcare, we have approved 24 CBOCs in 2007. Forty-three
percent of these CBOCs are in highly rural areas. And I am
pleased to share with Congressman Salazar that the Secretary
advised me today of the approval of the Colorado Outreach
Clinic.
In addition to these clinics, the VA is implementing more
care coordination home telehealth in rural areas. And since
January of 2004, we have trained over 3,500 staff to provide
this telehealthcare.
Our Vet Centers support our veterans including rural
veterans. Vet Centers provide quality readjustment counseling
and remove unnecessary barriers to the care for veterans and
their family members. And they engage in remarkable community
outreach to the veteran community and to other aspects of the
community as well. And we are continuing to expand our Vet
Centers.
By the way, the Vet Centers also maintain nontraditional
hours to accommodate veterans traveling in from greater
distances. And in accordance with Public Law 109-461, we
continue to develop our Office of Rural Health within our
Office of Policy and Planning.
VHA recognizes the importance and the challenge of service
to our rural areas. And we believe our current and planned
efforts are addressing these concerns.
Mr. Chairman, thank you.
[The prepared statement of Dr. Cross appears on p. 41.]
Mr. Michaud. Thank you very much. Mr. Salazar do you have
any questions?
[No response.]
Okay. I have several questions, Dr. Cross, but
unfortunately we have to vote and looking at all the votes we
have we will be tied up over there for probably well over an
hour or so. And I don't want to hold the panel here.
So we will submit our questions in writing and hopefully
you will be able to respond in a timely manner so we can move
forward. But I want to thank you for your time this afternoon
along with the other panels for your efforts as we move forward
on rural access to healthcare for our veterans. We have to do
better and I know the VA is intending to do better. Hopefully
with the new budget that was just passed we will be able to
improve access for our veterans.
So, once again, I would like to thank this panel. Are there
any other questions? Mr. Salazar.
Mr. Salazar. I just wanted to thank the Secretary for his
continued diligence on trying to provide access to rural
healthcare. So if you would convey that to him, I would
appreciate that.
Dr. Cross. I will certainly do that, sir. Thank you.
Mr. Salazar. Thank you. Thank you, Mr. Chairman.
Mr. Michaud. Thank you. With no further questions, this
hearing is adjourned.
[Whereupon, at 3:50 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Statement of Hon. Michael H. Michaud
Chairman, Subcommittee on Health
The Subcommittee on Health will come to order. I would like to
thank everyone for coming today.
The issue of providing rural healthcare is one that affects each of
our States and in very different ways. In California, rural communities
make up 92 percent of the landmass, and 8 percent of the population. In
my own State of Maine, over 40 percent of the population lives in rural
areas.
It is estimated that 60 million Americans, one in five, live in
areas that have been classified as rural. Rural communities tend to be
older than urban populations, and they tend to exhibit poorer health
behaviors. Economic factors also add to the challenges facing rural
populations.
Rural veterans make up 41 percent of VA's patient workload. Access
and resources present serious challenges to providing high quality
healthcare for these veterans.
VA care can be second to none. Unfortunately the quality of care is
not always the same throughout the VA system, and for many veterans
living in rural States like Maine, accessing that care is a significant
challenge.
For certain more complex procedures, veterans in northern Maine
must endure 4 days of travel to and from VA facilities in Boston to
receive care. Addressing the distance to care and the travel burden in
rural areas is extremely important.
However, given the smaller population and infrequency of certain
complex procedures, it does not make sense for VA to maintain a daily
``in-house'' capacity in every facility for something that is used on
an infrequent basis.
This problem is not unique to VA. It is a problem facing many rural
areas across the country where smaller patient populations limit the
resources available to rural hospitals which in turn limits the
services that hospitals can support and provide.
Rural areas face difficulties in providing what have been termed
``core healthcare services'' by the Institutes of Medicine. These
services include primary care in the community, emergency medical
services, hospital care, long-term care, mental health and substance
abuse services, oral healthcare, and public health services.
For a variety of reasons, rural areas also face a greater problem
recruiting and retaining healthcare professionals.
These problems must be addressed because the demand for services
from our veterans population in rural areas is only going to increase.
We have an aging population that will need long term care.
Over 40 percent of the new generation of veterans returning from
Afghanistan and Iraq are from rural areas. They have their own unique
needs, including loss of limb, traumatic brain injury and mental health
concerns.
One important approach to providing access to care is the VA's
system of Community-Based Outpatient Clinics, which currently number
more than 650.
We have five CBOCs in Maine. The CARES Commission recommended a
sixth in the Lewiston-Auburn area along with five part-time health
access points. Only one of these facilities is close to opening while
the CBOC is not expected to open until 2008 at the earliest.
During the CARES process, 250 CBOCs were identified by the VA as
being needed, of which 156 were designated as ``priority.'' Since the
CARES decision, VA has opened 12 of the 156, less than 8 percent. At
that pace it will take VA over 30 years to open all the priority
clinics.
VA has also opened 18 clinics not on the CARES priority list, which
calls into question the decision process and the ability of the CARES
to assist in decisions in the future.
The VA has also designated facilities as ``Veterans Rural Access
Hospitals,'' designed to provide inpatient services to veterans in
rural areas where these services can be supported.
The VA has taken great strides in exploring the uses of
telemedicine and other technological means of providing healthcare
services. I would like to hear how these efforts are improving care and
how we can help.
One of the problems in the area of recruitment and retention is the
separation from other healthcare professionals often felt by those
working in rural communities. I would like to explore how technology
might be used to overcome this feeling of isolation and thus improve
recruitment and retention.
The questions I would like to start to answer today are: Is the VA,
and really are our rural communities, ready to meet the increased and
changing needs of our veterans and their families? What is the VA in
rural America going to look like in the future?
And we must keep in mind that VA healthcare does not operate in a
vacuum, but is an integral part of our national health system.
I would also very much like to know when the priority CBOCs are
going to be built or if VA no longer intends to follow CARES.
Today, the Subcommittee hearing will provide us with the
opportunity to begin this exploration, to begin to examine issues
concerning access, the provision of care, and the proper expectations
of veterans in rural areas regarding the care they can expect from the
VA.
Statement of Marcia Brand, Ph.D., Associate Administrator
Rural Health Policy, Health Resources and Services Administration
U.S. Department of Health and Human Services
Mr. Chairman, Members of the Subcommittee, thank you for the
opportunity to meet with you today on behalf of Dr. Elizabeth Duke,
Administrator of the Health Resources and Services Administration
(HRSA), to discuss rural access issues as they affect the Nation and
what is being done to meet the healthcare needs of the rural
populations in this country. We appreciate your interest and support of
rural healthcare and access to care for rural veterans.
The Health Resources and Services Administration (HRSA) is the
primary Federal agency for improving access to healthcare services for
people who are uninsured, isolated or medically vulnerable. HRSA
grantees provide healthcare to uninsured people, people living with
HIV/AIDS, and pregnant women, mothers and children. They train health
professionals and improve systems of care in rural communities. For
HRSA, the Health Center Program, the National Health Service Corps and
rural healthcare needs are priorities.
The Health Center Program, a major component of America's
healthcare safety net for the Nation's indigent populations for more
than 40 years, is leading the Presidential initiative to increase
healthcare access in the Nation's most needy communities. Health
Centers provide regular access to high quality, family oriented,
comprehensive primary and preventative healthcare, regardless of
ability to pay, and improve the health status of underserved
populations living in inner cities and rural areas.
President Bush's initiative to expand the Health Centers, begun in
FY 2002, will significantly affect over 1,200 communities through the
support of new or expanded access points. In FY 2001, HRSA funded 3,317
Health Center sites across the Nation. After distributing 514 New
Access Point grants over the past few years, that count had grown to
3,831 sites by the end of 2006. We expect the number of Health Center
sites to grow to 4,053 by the end of FY 2008. Just over half of all
Health Center grantees serve rural populations.
Besides the 514 new access points, HRSA has also distributed 385
grants to expand the medical capacity of existing service delivery
sites; and another 340 grants to existing grantee organizations to add
or expand oral health, mental health and substance abuse services.
Through these efforts the number of patients treated annually at Health
Centers has grown from 10.3 million in 2001 to 14.1 million in 2005, a
37 percent increase. Of those 14.1 million patients, 5.6 million were
uninsured, 1.6 million more than were served in 2001 (a 40 percent
increase). We anticipate that Health Centers will serve an estimated
16.3 million patients by the end of 2008.
The National Health Service Corps (NHSC) is committed to improving
the health of the Nation's underserved by uniting communities in need
with caring health professionals and supporting communities' efforts to
build better systems of care. The NHSC provides comprehensive, team-
based healthcare that bridges geographic, financial, cultural, and
language barriers.
Health Centers need committed staff and the National Health Service
Corps plays an important role in the Health Center expansion. Currently
more than half of the NHSC's doctors, dentists, nurses and mental and
behavioral and other healthcare professionals serve in Health Centers
around the Nation. Some 60 percent of all NHSC clinicians--about 2,700
healthcare professionals--currently work in rural areas.
HRSA's Office of Rural Health Policy (ORHP) is charged with
informing and advising the Department of Health and Human Services on
matters affecting rural hospitals and healthcare, coordinating
activities within the Department that relate to rural healthcare, and
maintaining a national information clearinghouse. HRSA, through ORHP,
is the leading Federal proponent for better healthcare services for the
55 million people that live in rural America.
ORHP specifically promotes State and local empowerment to meet
rural health needs in several ways: by supporting State Offices of
Rural Health, by encouraging the formation of State Rural Health
Associations, and by working with a variety of State agencies to
improve rural health. Through our Medicare Rural Flexibility (Flex)
Grant Program, funding is provided to State governments to strengthen
rural health. The Small Rural Hospital Improvement Program (SHIP)
provides funding to small rural hospitals through the States to help
them pay for costs related to the implementation of the Prospective
Payment System, comply with provisions of HIPAA and reduce medical
errors and support quality improvement. The State Office of Rural
Health Grants are designed so the States can help their individual
rural communities build healthcare delivery systems by collecting and
disseminating information, providing technical assistance, helping to
coordinate rural health interests Statewide and by supporting efforts
to improve recruitment and retention of health professionals.
Additionally, the Rural Healthcare Services Outreach Grant Program
increases access to primary healthcare services for rural Americans.
The Rural Health Network Development Grant Program helps rural health
providers develop community-based, integrated systems of care. Grants
support rural providers for up to 3 years who work together in formal
networks, alliances, coalitions, or partnerships to integrate
administrative, clinical, financial, and technological functions across
their organizations. The Network Development Planning Grant Program
provides 1 year of funding to rural communities that seek to develop a
formal integrated healthcare network and that do not have a significant
history of collaboration. We also support grants to the eight States in
the Mississippi Delta for network and rural health infrastructure
development and a cooperative agreement supporting targeted activities
focusing on frontier extended stay clinics. The Small Healthcare
Provider Quality Improvement Grant Program (SHCPQI) is designed to
assist rural providers with the implementation of quality improvement
strategies, while improving patient care and chronic disease outcomes.
The Rural Access to Emergency Devices (RAED) Grant Program provides
funding to rural communities to purchase automated external
defibrillators (AEDs) and provide training in their use and
maintenance. As you can see, HRSA administers a range of programs that
serve rural communities.
HRSA also provides support staff to the Department's cross-cutting
rural efforts. The HHS Rural Task Force is made up of representatives
from each of the HHS agencies and staff offices and meets quarterly to
discuss HHS programs and policies that affect the provision of
healthcare and human services for rural Americans. Another cross-
cutting rural effort supported by HRSA is the National Advisory
Committee on Rural Health and Human Services (NAC). The NAC is a 21-
member citizens' panel of nationally recognized experts that provide
recommendations on rural health and human services issues to the
Secretary.
Effective, coordinated healthcare improves the health and well-
being of Americans, regardless of where they live. However, effective
coordination is especially critical in rural communities, where
services and providers are limited and resources are scarce. The
challenges of providing healthcare for rural communities are compounded
by higher rates of poverty and lack of insurance. Rural people are a
little older and they have higher rates of chronic disease. There are
significant transportation barriers. To provide for their needs, there
are about 2,000 hospitals, nearly 1,500 of these with less than 50
beds. There are 3,500 Rural Health Clinics. These facilities are
located in rural areas and are authorized for special Medicare and
Medicaid payments. And there are nearly 2,000 Federally Qualified
Health Centers which includes approximately 1,000 health center
grantees. Fifty-two percent of these some 1,000 centers are located in
rural areas.
HRSA takes great pride in the work we do in providing better
healthcare services for the rural population. However, we are humbled
by the significant challenges that remain for healthcare in rural areas
and to the underserved.
We are pleased that the Department of Veterans Affairs is
establishing an Office of Rural Health to assist the Under Secretary
for Health in addressing issues affecting veterans living in rural
areas. We have contacted the individuals who are creating this Office
and their charge sounds familiar. With 20 years experience, we have
some expertise regarding research and policymaking in this area. We
look forward to collaborating with the new Office and offer our
assistance.
I would be happy to answer any questions at this time.
Statement of Andy Behrman, Chair, Rural Health Policy Board
National Rural Health Association, and President and
Chief Executive Officer, Florida Association of Community Health
Centers
The NRHA is a national nonprofit, nonpartisan, membership
organization with approximately 12,000 members that provides leadership
on rural health issues. The Association's mission is to improve the
health of rural Americans and to provide leadership on rural health
issues through advocacy, communications, education and research. The
NRHA membership consists of a diverse collection of individuals and
organizations, all of whom share the common bond of an interest in
rural health.
I am Andy Behrman, President and Chief Executive Officer of the
Florida Association of Community Health Centers, and the chair of the
NRHA Rural Health Policy Board. I am also a veteran of the United
States Navy. On behalf of the Association, I appreciate the opportunity
to testify before this Committee.
The members of the National Rural Health Association have
maintained a special concern for the health and mental healthcare needs
of rural veterans for many years. The NRHA was one of the first non-
veteran service organizations to develop a policy statement on rural
veterans and this policy work is evidence of our memberships' concern
for rural veterans.
My testimony discusses current VA successes in providing quality
care for rural veterans, and suggestions for further improvements in
quality of care. NRHA respectfully requests that the Committee give
consideration to the following steps that would improve quality and
access to care for rural veterans:
1. Increase the numbers of Veteran Centers, Outreach Health
Centers, and Community-Based Outreach Centers (CBOCs) in rural areas.
2. Increase healthcare access points for rural veterans by
building upon current successes of both VA service approaches and
existing rural health approaches. Fully implement the contracting of
services from the VA to Federally Qualified Health Centers (FQHCs) in
rural areas. Develop approaches to link VA services and quality to
existing rural health providers willing to provide care to rural
veterans that follow standards of care and evidence-based medicine,
including Critical Access Hospitals (CAHs), Rural Health Clinics
(RHCs), and mental health providers.
3. Increase the number of Veterans Hospital Administration
Traumatic Brain Injury Case Managers in predominately rural States.
4. Use the high quality VA system to provide targeted and
culturally competent care to rural, minority, and female veterans and
train future rural health providers in these rural VA facilities.
5. Fully implement the functions of the newly created Office of
Rural Veterans and establish a national advisory committee on rural
veterans.
The following is additional background information and discussion
of our recommendations.
Overview
Since the founding of our country, rural Americans have always
responded when our Nation has gone to war. Whether motivated by their
values, patriotism, and/or economic concerns, the picture has not
changed much in 230 years. Rural individuals--along with American
Indians, urban African Americans and Hispanics--serve at rates higher
than their proportion of the population. Though only 19% of the Nation
lives in rural America, 44% of U.S. Military recruits come from rural
areas and nearly one-third of those who died in Iraq are from small
towns and communities across the Nation.\1\
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\1\ ``Iraq War Takes Uneven Toll at Home,'' April 3, 2004: NPR All
Things Considered.
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Where in rural America are veterans from? According to the most
recent census, rural and non-metropolitan counties reported the highest
concentration of veterans in the civilian populations aged 18 and
over.\2,\ \3\ The proportion of veterans living in rural areas in 18
States is higher than the national average of 12.7 percent. These high-
concentration States span the country, and include such geographically
varied States as Montana (16.2%), Nevada (16.1%), Wyoming (16%), Maine
(15.9%), West Virginia (14.4%), Arkansas (14.2%), South Carolina
(14.2%), and Colorado (14.1%).\4\
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\2\ ``Veterans: 2000 Census Brief,'' p. 7.
\3\ http://factfinder.census.gov/servlet/SAFFP.
\4\ ``Veterans: 2000 Census Brief,'' p. 5.
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The disproportionate number of rural Americans serving in the
military has created a disproportionate need for veteran's care in
rural areas and yet rural areas are less likely to have VA services
available to them.\5\ More than 22,000 soldiers have been wounded in
Iraq. For those wounded veterans returning to their rural homes across
the country, access to the specialized services they will need may be
limited. Often access to the most basic of primary care is more
difficult in rural America. Combat soldiers who need specialized care
to assist with their readjustment to civilian life or adaptation to
living with war injuries (both physical and mental) will likely find
access to that care extremely limited.\6\
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\5\ Veterans Health Administration, April 2000, ``A Report By The
Planning Systems Support Group, A Field Unit of the Veterans Health
Administration Office of Policy and Planning--Geographic Access to
Veterans Health Administration (VHA) Services in Fiscal Year 2000: A
National and Network Perspective.
\6\ Alvarez, L. and Lehren, A., ``3,000th Fatality in Iraq,
Countless Tears at Home.'' (New York Times, January 2, 2007) Miller,
Laura J., June 2001, ``Improving Access to Care in the VA Health
System: A Progress Report,'' Forum, A publication of the Veterans
Administration Office of Research & Development.
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It is also important to note that both differences and disparities
exist in the health status of rural and urban veterans. The Veterans
Administration's Health Services and Outreach Network has reported that
rural veterans ``have worse physical and mental health'' than their
urban counterparts and concluded that ``policymakers should anticipate
greater healthcare demand from rural populations. . . .'' \7\
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\7\ Demakis, JG., Jan. 2000, ``Rural Health-Improving Access to
Improve Outcomes,'' Management Brief Health Services Research &
Development Service, No. 13: 1-3.
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There is a national misconception that all veterans have access to
comprehensive care because they are served by the Veterans
Administration.\8\ While this may be true for many veterans, it is not
true for many small town veterans, rural veterans or those veterans who
choose to be isolated due to the complicated symptoms of Post-Traumatic
Stress Disorder.\9\ The Veterans Hospital Administration (VHA) provided
care to 4.5 million of the 7.2 million enrolled veterans in fiscal year
2003. While the quality of VHA care is equivalent to, or better than,
care in other systems,\10\ it often is not accessible to many rural and
frontier veterans.
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\8\ Weeks, WB., et al. March 2004. Differences in Health Status in
Rural and Urban Veterans. Presented to the 22nd National Meeting of
HSR&D. Washington, D.C.
\9\ Sorenson, G., ``Hinterlands are home, not a hideaway, for
Vietnam veterans,'' Vet Center Voice, Vol. VI, No. 9, October 1985, p.
1.
\10\ The Independent Budget for 2005: Medical Care. Veterans
Service Organizations. http://www.pva.org/independentbudget/index.htm.
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While the NRHA is pleased that both the House and Senate FY 2008
budgets call for greater increases in VA medical care spending than in
past years, we all must be mindful that appropriations for the last
decade have not kept up with the cost of maintaining current
services.\11\ Policymakers must not only make up for past funding
deficits, they must appropriately plan for long-term funding--because
the wounded soldiers who return today won't need care for just the next
few fiscal years, they will need care for the next half century.\12\
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\11\ The Independent Budget for 2005: Medical Care. p. 44.
\12\ The Independent Budget for 2005: Medical Care. p. 45.
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NRHA RECOMMENDATIONS
1. Increase Healthcare Access Points for Rural Veterans to Build
on Current Successes
NRHA recognizes and appreciates the successes of veteran centers
and healthcare outreach centers in meeting the needs of rural veterans.
We should seize the opportunity to build upon this success and further
improve quality of and access to care.
Community-Based Outreach Centers (CBOCs) open the door for many
veterans to obtain primary care services within their home community.
While outcomes research on CBOCs is mixed, some findings suggest that
CBOCs have been successful in improving geographic access, an important
objective of expanding community-based care to veterans.'' \13\ The VHA
has improved procedures for planning and activating CBOCs and
established consistent criteria and standard expectations for the over
450 CBOCs created since 1995.\14\ CBOCs have also been successful in
some States, such as West Virginia; however, Directive 2001-06 made
this solution less available to more rural and remote veterans and
other rural providers by raising the ceiling on the number of priority
users in a given area. Outreach Health Centers provide an appropriate
model to deal with the loss of CBOC eligibility to smaller and more
remote rural areas, and their expansion should be considered.
Furthermore, outreach efforts with rural veterans that focus on benefit
education and psycho-social education of veterans and their family
members can increase the effectiveness of services currently available
through the VA system.
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\13\ Maciejewski, M., et al. CBOC Performance Evaluation Report 2,
VA HSR&D, March 2000. http://www.hsrd.research.va.gov/publications/
internal/cbocrpt2/cboc_performance_report2.htm.
\14\ ``VHA Handbook 1006.1,'' April 11, 2003. Department of
Veterans Affairs, Veterans Health Administration. Washington, D.C.
2. Increase Healthcare Access Points for Rural Veterans to Expand
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Access
Time and distance prevent many rural veterans from getting their
healthcare benefits through a VHA facility. There are approaches
readily available in the VA system and in the rural health landscape
that could improve this situation. These approaches include Vet
Centers, Outreach Health Centers, and CBOCs, as mentioned above, as
well as Federally Qualified Health Centers (FQHCs), Rural Health
Clinics (RHCs), Critical Access Hospitals (CAHs), and mental health
providers. Policy regarding services to rural veterans needs to provide
access through a variety of existing rural health facilities and access
points because not all rural communities have access to all types of
facilities. Quality through consistent applications of standards of
care and evidence-based medicine, however, must guide all approaches to
care for rural veterans.
Federally Qualified Community Health Centers (CHCs) serve millions
of rural Americans, but most veterans cannot use their VA health
benefits to receive care at these CHCs. These centers provide community
oriented, primary and preventive healthcare and are located where rural
veterans live. Congress has passed legislation encouraging
collaborations (P.L. 106-74 and P.L. 106-117 Sec. 102(e), The Veterans
Millennium Healthcare and Benefits Act). Despite the legislative
intent, however, a national policy advocating VHA-CHC collaboration has
not emerged in an effective way.
A limited number of collaborations between the VHA and CHCs already
exist and have proven to be prudent and cost-effective solutions to
serving eligible veterans in remote areas. Successful contracts exist
in Wisconsin, Missouri, and Utah. In other States, contracts were
successful but were discontinued for reasons not related to operational
success. This model of collaboration between VHA and CHCs might do well
in other rural States and with other rural providers and systems of
care and should be implemented further.
Critical Access Hospitals provide comprehensive and essential
services to rural communities and are specific to rural States. This
model provides a great opportunity for policymakers to expand services
to rural veterans in communities where CAHs are located. For instance,
Montana has 45 Critical Access Hospitals and the highest percentage of
veterans in the Nation. Working through these existing access points of
care in many frontier communities in rural Montana by providing
linkages with VA services and models of quality could greatly enhance
care for rural veterans.
Designation as a Rural Health Clinic (RHC) provides enhanced
reimbursement for Medicare and Medicaid services for private physicians
who provide enhanced services to rural communities. RHCs are often
physician-owned or sometimes owned by small, rural hospitals, including
Critical Access Hospitals. In many rural and frontier communities, RHCs
represent the only source of primary care available.
The literature provides much evidence that linking the quality of
VA services with civilian services provides opportunities to improve
the quality of healthcare services for all citizens. Linkages can
improve the use of evidence-based medicine in chronic disease
management, in screening and diagnosis, and in treatment of many health
conditions. Linkages also provide greater opportunities for the
dissemination of VA supported research. These are additional benefits
of any collaboration between VHA and the existing rural health safety
net infrastructure.
3. Increase Traumatic Brain Injury Care
Throughout our history all citizens in our Nation have benefited
from medical research focused on the signature wounds of war.
Currently, it appears that Traumatic Brain Injury (TBI) will most
likely become the signature wound of the Afghanistan and Iraqi wars.
While the VA is gearing up for returning veterans with this condition,
the importance of the TBI Case Manager Network and other services in
the provision of quality care for these rural veterans cannot be
understated.
The Defense and Veterans Brain Injury Network of nine VA and one
civilian center provides the needed and highly specialized services
that these disabled veterans require. However, only three of these
network centers are located in two of the 18 States with high rates of
rural veterans, Virginia and Florida. Eleven western States with many
rural and frontier veterans, and the other southern States with high
numbers of rural veterans have very limited access to these centers
once discharged from inpatient care. Therefore, the VHA TBI Case
Managers Network is vital to these veterans and their families. A
review of the number and location of TBI case managers finds them very
limited in coverage in States with high numbers of rural veterans--
expansion is needed.
4. Target Care to Rural Veterans
A. Needs of the Rural Family. Rural individuals value their
families and have strong bonds and ties to their homeplace and home
communities. Our returning veterans adjusting to disabilities and the
stresses of combat need the security and support of their families in
making their transitions back into civilian life and to manage
lifestyle changes due to disabling conditions. The Vet Centers do a
tremendous job in assisting veterans with this readjustment, but the
demand for services is too great for current funding levels. The NRHA
supports increases in funding for counseling services for veterans'
families and significant others.
B. Needs of Rural Women Veterans. Additionally, the NRHA
supports better assessment of the needs of women and minority women
veterans. Currently women make up approximately 15 percent of the
active military force. Thirty-seven percent of these women are African
American. These women serve in all branches of the military, and are
eligible for assignment in most military occupational specialties
except for direct combat roles. The highest number of women in history
to serve in a war zone is currently serving in Iraq and Afghanistan.
Our Nation is also seeing the highest numbers in history of female
wounded and war casualties.\15\
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\15\ news.yahoo.com/s/afp/20070306/
lf_afpwomensusirapmilitary_070306170626-33k-March 15, 2007.
According to the Center for Women Veterans, by the year 2010, the
women veteran population is projected to be over 10 percent of the
total veteran population. The breakdown on these women by rural and
urban residence is not readily available, however, it is reasonable to
assume that a higher number of both genders from rural areas go into
military service. The VA is beginning to address changes needed to
serve an increased female veteran population, but more can be done.
Targeted and culturally competent care for today's women veterans is
needed. Additionally, the VA offers a golden opportunity to train rural
providers through rural rotations in all VA facilities and programs,
thereby exposing our future rural providers to the unique needs of
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rural, minority, and female veterans.
5. Improve Office of Rural Veterans
The NRHA calls on Congress and the Veterans Administration to fully
implement the functions of the newly created Office of Rural Veterans
to develop and support an ongoing mechanism to study and articulate the
needs of rural veterans and their families. Additionally, the NRHA
supports collaboration of this office with the Federal Office of Rural
Health Policy within HRSA to better meet the access needs of rural
veterans. Finally, the NRHA urges this office to establish a National
Advisory Committee on Rural Veterans to provide information to
policymakers on the needs of this population as it ages.
Conclusion
While NRHA recognizes the purpose of this hearing is not to discuss
specific legislation, we do recognize that H.R. 5524, the Rural
Veterans Healthcare Act of 2006, introduced in the last Congress,
includes many of the items long recommended by NRHA. H.R. 5524 calls
for expansion and improved quality of services provided by Vet Centers,
Outreach Health Centers, and CBOCs in rural areas; a heightened focus
on the needs of rural minority veterans; a focus on rural medical
education for VA residents, and new research and outreach efforts. We
hope similar legislation will again be introduced in the 110th Congress
and eventually be enacted into law.
Mr. Chairman, thank you for the opportunity to testify.
Statement of Shannon Middleton, Deputy Director for Health
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
views on access to quality healthcare for veterans in general and
veterans in rural communities in particular. Research conducted by the
Department of Veterans Affairs (VA) indicated that veterans residing in
rural areas are in poorer health than their urban counterparts. It was
further reported that nationwide, one in five veterans who enrolled to
receive VA healthcare lives in rural areas. Providing quality
healthcare in a rural setting has proven to be very challenging, given
factors such as limited availability of skilled care providers and
inadequate access to care. Even more challenging will be VA's ability
to provide treatment and rehabilitation to rural veterans who suffer
from the signature ailments of the ongoing Global War on Terror--
traumatic blast injuries and combat-related mental health conditions.
VA's efforts need to be especially focused on these issues.
Community-Based Outpatient Clinics (CBOC)
A vital element of VA's transformation in the 1990's was the
creation of CBOCs to move access closer to the veterans' community. A
recent VA study noted that access to care might be a key factor in why
rural veterans appear to be in poorer health. CBOCs were designed to
bring healthcare closer to where veterans reside. Over the last several
years, VA has opened up hundreds of CBOCs throughout the system and
today there are over 700 that provide healthcare to the Nation's
veterans. By and large, CBOCs have been pretty successful; however, of
concern to The American Legion is that many of the CBOCs are at or near
capacity and many still do not provide adequate mental health services
to veterans in need.
One of the recommendations of the Capital Assets Realignment for
Enhanced Services (CARES) was for more, not less, CBOCs across the
Nation. The American Legion strongly supports this recommendation,
especially those identified for rural areas; however, limited VA
discretionary funding has limited the number of new CBOCs each fiscal
year.
There is great difficulty serving veterans in rural areas. Veterans
in States such as Nebraska, Iowa, North Dakota, South Dakota, Wyoming,
and Montana face extremely long drives, a shortage of healthcare
providers and bad weather. The Veterans Integrated Services Networks
(VISNs) rely heavily upon CBOCs to close the gap.
The provision of mental health services in CBOCs is even more
critical today with the ongoing wars in Iraq and Afghanistan. It has
been estimated that nearly 30 percent of the veterans who are returning
from combat suffer from some type of mental stress. Further, statistics
show that mental health is one of the top three reasons a returning
veteran seeks VA healthcare. The American Legion believes that VA needs
to continue to emphasize to the facilities the importance of mental
health services in CBOCs and we urge VA to ensure the adequate staffing
of mental health providers in the CBOC setting.
CBOCs are not the only avenue with which VA can provide access to
quality healthcare to rural veterans. Enhancing existing partnerships
with communities and other Federal agencies, such as the Indian Health
Service, will help to alleviate some of the barriers that exist such as
the high cost of contracting for care in the rural setting.
Coordinating services with Medicare or with other healthcare systems
that are based in rural areas is another way to help provide quality
care.
The Presidential Task Force to Improve Healthcare Delivery for Our
Nation's Veterans made several recommendations for DoD and VA, one of
which: VA and DoD should declare that joint ventures are integral to
the standard operations of both Departments. (Recommendation 4.8) Since
this Task Force's final report in May 2003, none have materialized--yet
there are military bases in many rural communities.
Traumatic Brain Injury Patients
In a July 2006 report entitled Health Status of and Services for
Operation Enduring Freedom and Operation Iraqi Freedom Veterans after
Traumatic Brain Injury Rehabilitation, the Department of Veterans
Affairs Office of Inspector General examined the Veterans Health
Administration's ability to meet the needs of OIF/OEF veterans who
suffered from traumatic brain injury (TBI). Fifty-two patients from
around the country--including Montana, Colorado, North Dakota, and
Washington State--were interviewed at least 1 year after completing
inpatient rehabilitation from a Lead Center (Minneapolis, MN; Palo
Alto, CA; Richmond, VA; and Tampa, FL) including those who lived in
States with rural veteran populations.
Many of the obstacles for the TBI veterans and their family members
were similar. Forty-eight percent of the patients indicated that there
were few resources in the community for brain injury-related problems.
Thirty-eight percent indicated that transportation was a major
obstacle. Seventeen percent indicated that they did not have money to
pay for medical, rehabilitation, and injury-related services.
Some of the challenges noted by family members who care for these
veterans in rural settings include: the necessity for complicated
special arrangements and the absence of VA rehabilitative care in their
communities.
Case managers working at Lead Centers and several secondary centers
noted limited ability to follow patients after discharge to rural areas
and lack of adequate transportation.
These limitations place undue hardship on the veterans' families as
well. Those contributing to the report, as well as veterans who have
contacted The America Legion, have shared many examples of the manner
in which families have been devastated by caring for TBI injured
veterans. They have sacrificed financially, have lost jobs that
provided the sole income for the family, and have endured extended
separations from children. It is The American Legion's belief that VA
needs to continue to improve access to quality primary and specialty
heathcare services for veterans residing in rural and highly rural
areas.
Vet Centers
Vet Centers are another important resource, especially for combat
veterans experiencing readjustment issues who do not live in close
proximity to a VA medical facility. Because Vet Centers are community-
based and veterans are assessed the day they seek services, they
receive timely care and are not subjected to wait lists. Some of the
services provided include: individual and group counseling; family and
marital counseling; military sexual trauma counseling; and,
bereavement.
Realizing the value of Vet Centers to those who may encounter
obstacles when seeking mental healthcare in the VA medical facilities,
The American Legion decided to get a glimpse of services and needs of
Vet Centers nationwide. The American Legion's 2007 System Worth Saving
report, a compilation of information gathered from site visits
conducted by field service representatives and the System Worth Saving
Task Force members, will focus on Vet Centers, as well as polytrauma
centers. The American Legion staff selected a sample of Vet Centers
that were located near demobilization sites throughout the country to
ascertain the effects of the number of returning veterans on the
services provided by the centers. The report will illustrate the types
of veterans utilizing the respective Vet Centers, as well as services
requested by these veterans and outreach services offered.
The American Legion believes veterans should not be penalized or
forced to travel long distances to access quality healthcare because of
where they choose to live. We urge VA to improve access to quality
primary and specialty healthcare services, using all available means at
their disposal, for veterans living in rural and highly rural areas.
Although ``access'' is an important measure, The American Legion
believes ``timeliness of access'' is just as critical. For an example,
VA established its own acceptable access standard for primary care at
30 days, but to most Americans with private healthcare plans--30 days
would be unacceptable. Unfortunately, the continued disparity between
demand for services and available resources continues to cause delays
in the delivery of healthcare. The current Global War on Terror has
placed even more demands on the VA healthcare system to meet its
obligation to the men and women of the armed forces--past, present, and
future. As a grateful Nation welcomes with opened arms the newest
generation of wartime veterans, veterans of previous conflicts and the
Cold War are being denied enrollment and, therefore, access to their
healthcare delivery system of choice.
Since the decision within VA to begin transformation from an
inpatient-based healthcare delivery system to an integrated healthcare
delivery system in the early 1990s and Congress' enactment of
eligibility reform in 1996, access to VA healthcare has increased
dramatically. In 1990, the patient population of the VA medical system
was somewhere in the neighborhood of 2 million. Today, VA's patient
population is closer to 6 million with a total enrollment of
approximately 8 million veterans.
In fact, by 2003, former VA Secretary Anthony Principi decided to
terminate the enrollment of any new Priority Group 8 veterans;
therefore, prohibiting access to VA medical care to hundreds of
thousands of Priority Group 8 veterans due primarily to limited
resources. The American Legion disagrees with the decision to deny
access to any eligible veterans. Many of these veterans are Medicare-
eligible or have other third-party health insurance that could
reimburse VA reasonable charges for services rendered. Yet little has
been done to improve third-party reimbursements from private insurers
and nothing has been done to allow VA to begin receiving third-party
reimbursements from the Nation's largest healthcare insurer, the
Centers for Medicare and Medicaid Services (CMS).
Both the Department of Defense (DoD) medical system and Indian
Health Services (IHS) are authorized to bill, collect, and receive
third-party reimbursements from the Centers for Medicare and Medicaid
Services, yet VA continues to face the restriction from billing CMS.
Repeatedly, VA's average cost-per-patient remains well below Medicare's
average cost-per-patient (and the billions of dollars VA saves Medicare
is not even calculated into Medicare's final funding levels).
The restriction of enrollment for Priority 8 veterans creates
another ``access gap'' for recently separated veterans who did not
serve in a combat setting. Some recently separated veterans must wait
until their VA disability claims are approved in order to enroll. For
others, unless they are economically indigent, they are prohibited from
enrolling. Those recently separated veterans that successfully
transition may very well never be eligible to enroll in the Nation's
best healthcare delivery system. None of these situations are very
welcoming messages to the men and women currently serving in the
Nation's armed forces.
Over the years, VA has transformed itself into the Nation's best
healthcare delivery system and probably the most cost-efficient as
well. There are many reasons why the VA healthcare system has become
the best healthcare option for eligible veterans:
Quality of care,
Patient safety,
Electronic medical records,
Cost-efficient formulary,
Accessibility,
World-class specialized services,
State-of-the-arts medical and prosthetics research, and
Minimal fraud, waste, and abuse.
For these and many other intangible reasons, VA is a ``healthcare
magnet'' attracting veterans, many of which have never used the VA
healthcare delivery system before. As the veteran population continues
to age and the healthcare industry evolves, more and more veterans on
fixed incomes turn to VA as their best healthcare option--even those
with other healthcare options such as Medicare, TRICARE, or private
health insurance coverage. Many of these veterans are combat veterans
of World War II, Korea, and Vietnam. Although their transition from
active-duty to civilian life may have been ``seamless'' for many years,
they now believe their individual healthcare needs would be better met
by VA.
Returning Operation Enduring Freedom and Operation Iraqi Freedom (OEF/
OIF) Veterans
The American Legion fully supports the decision to provide recently
separated veterans from OEF/OIF to access to the VA healthcare delivery
system for 2 years after separation. However, now that they have been
presented with conditions having delayed onset, like Post-Traumatic
Stress Disorder (PTSD) and symptoms of Traumatic Brain Injury (TBI),
The American Legion supports extending those 2 years to 5 years. The
American Legion also believes that VA must ensure that it makes every
effort to outreach to eligible Reservists components, who sometimes
endure multiple deployments, to keep them aware of their eligibility
for access to the VA healthcare system and provide them with timely
access to care.
Although they were promised priority due to their combat service,
OEF/OIF veterans are encountering obstacles when trying to access the
system. We are beginning to hear stories. One veteran was told to call
back the following week for an appointment, only to be told when he
called back, that he had to wait 30 days later for an appointment.
Another OIF veteran reported having his appointment cancelled and
rescheduled 30 days later. Many conditions experienced by these
veterans may not qualify as emergencies, but are urgent enough to
require immediate care.
Inpatient Bed Requirements
VA continues to ignore the Federal mandate for inpatient care,
especially in the area of long-term care. The American Legion believes
VA is focused on shifting long-term care from VA to the State Veterans'
Homes and private nursing home industry. Access to long-term care is
often translated into being placed on a waiting list that may very well
exceed the life expectancy of the veteran placed on the list. The
Veterans' Millennium Healthcare Act clearly set the bar, but VA seems
to have ignored this Federally mandated statute.
During the CARES process, long-term care and mental health were not
included in the initial decisionmaking process. In other words, two
critical elements were included after rather than during the final
recommendations for the future infrastructure of VA. The American
Legion was extremely critical of that decision, especially when the
closing recommendations revealed medical facilities with primarily
long-term care and mental health missions. In addition, the facilities
were primarily in rural communities.
Again, thank you, Mr. Chairman, for giving The American Legion this
opportunity to present its views on such an important issue. The
hearing is very timely and we look forward to working with the
Subcommittee to bring an end to the disparities that exist in access to
quality healthcare in rural areas.
Statement of Adrian M. Atizado
Assistant National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
I am pleased to appear today at the request of the Subcommittee to
offer testimony on behalf of the Disabled American Veterans (DAV)
related to access to medical care services in the Department of
Veterans Affairs (VA) healthcare system, particularly on access to care
in rural areas. I offer this statement on behalf of The Independent
Budget (IB) for fiscal year 2008, a product of the joint efforts of
DAV, Veterans of Foreign Wars of the United States, Paralyzed Veterans
of America and AMVETS.
Congress provided VA additional funding in fiscal years 2006 and
2007, for which we are very grateful, but we continue to hear from
veterans that their access to VA specialty care is often delayed for
months. Likewise, access to VA care in rural areas of the country has
been--and continues to be--a challenge for many veterans. We are
especially concerned about how VA plans to address rural veterans'
needs in the coming years, given reports that 44 percent of all
veterans returning from Operations Enduring and Iraqi Freedom (OEF/OIF)
reside in rural communities. After serving their country, veterans'
healthcare needs should not be neglected by VA simply because they live
in rural or remote areas at a distance from major VA healthcare
facilities.
Without question, sections 212 and 213 of Public Law 109-461,
signed into law by the President on December 22, 2006, represent the
most significant advances to date to address healthcare needs of
veterans living in rural areas. Under this legislation, the VA is
mandated to establish an Office of Rural Health within the Veterans
Health Administration (VHA). This office must carry out a series of
steps intended by Congress to improve VA healthcare for veterans living
in rural and remote areas. This legislation is also aimed importantly
at better addressing the needs of returning veterans who have served in
OEF/OIF. Among its features the law requires VA to conduct an extensive
outreach program for veterans who reside in these communities. In that
connection VA is required to collaborate with employers, State
agencies, Community Health Centers, Rural Health Clinics, Critical
Access Hospitals (as designated by Medicare), and the National Guard,
to ensure that returning veterans and Guard members, once completing
their deployments, can have ready access to adequate VA healthcare. The
legislation also requires an extensive assessment of the existing VA
fee-basis system of private healthcare, and eventual development of a
VA plan to improve access and quality of care for enrolled veterans who
live in rural areas.
Rural veterans, veterans service organizations and other experts
need a seat at the table to help VA consider important program and
policy decisions such as those being discussed here that would
positively affect veterans who live in rural areas. The final
legislative language of Public Law 109-461 failed to include a Rural
Veterans Advisory Committee to help harness the knowledge and expertise
of representatives from federal agencies, academic affiliates,
veterans, and other rural experts, to recommend policies to meet the
challenges of veterans' rural healthcare. We hope that Congress will
reconsider this mandate, but the VA Secretary retains the authority to
establish such an Advisory Committee without specific statutory
authorization. The IBVSOs urge the Secretary to take this action, and
to include representatives of our organizations in the membership of
that Committee.
Although the authors of the Independent Budget acknowledge this
legislative measure will be beneficial to veterans living in rural and
remote areas, the legislation also raises potential concerns about the
unintended consequences it may have on the mainstream VA healthcare
system. In general, current law places limits on VA's ability to
contract for private healthcare services to instances which VA
facilities are incapable of providing necessary care to a veteran; when
VA facilities are geographically inaccessible to a veteran for
necessary care; when existence of a medical emergency prevents a
veteran from receiving care from a VA facility; to complete an episode
of VA care; and for certain specialty examinations to assist VA in
adjudicating disability claims. VA also has authority to contract for
the services of certain scarce medical specialists. Beyond these
limits, there is no general authority in law to support broad-based
contracting for the care of populations of veterans, whether rural or
urban. The authors of the IB believe VA contract care for eligible
veterans should be used judiciously and only in circumstances so as not
to endanger VA facilities' ability to maintain a full range of
specialized inpatient services for all enrolled veterans. We believe VA
must maintain a critical mass of capital, human, and technical
resources to promote effective, high-quality care for veterans,
especially those disabled in military service and those with highly
sophisticated health problems such as blindness, amputations, brain and
spinal cord injury, or chronic mental health problems. Putting
additional budget pressure on this specialized system of services,
without making specific appropriations available for new rural VA
healthcare programs, could only exacerbate the problems currently
encountered.
The VA has had continuing difficulty securing sufficient funding
through the Congressional discretionary budget and appropriations
process to ensure basic and adequate access for the care of sick and
disabled veterans. Congress repeatedly has been forced to provide
additional funds to maintain VA healthcare services. Also, VA receives
no Congressional appropriation dedicated to support the establishment
of rural Community-Based Outpatient Clinics or to aid facilities VA
designated as ``Veterans Rural Access Hospitals'' (VRAH), and thus VA
must manage any additional expenses from within generally available
Medical Services appropriations. VA has established and is operating
717 Community-Based Outpatient Clinics (CBOCs) as sources of primary
care. VA considers 320 of these clinics to be in rural or ``highly
rural'' areas. Given current financial circumstances within VA
healthcare, we are skeptical that VA can continue to cost-effectively
establish additional facilities in areas with even sparser veteran
populations.
Rural Hospitals
Under the federal Medicare program, a ``Critical Access Hospital''
(CAH) is a private hospital that is certified to receive cost-based
reimbursements from Medicare. The higher reimbursements that CAHs
receive under this program compared to urban facilities are intended to
improve their financial security and thereby reduce rural hospital
closures. In other words, the Centers for Medicare and Medicaid
Services (CMS) policy is to financially aid struggling rural hospitals
in hopes that the additional support can help them survive. Also the
CAH facilities are certified under Medicare ``conditions of
participation'' that are more flexible than those used for other acute
care hospitals. As of March 2006 (the latest data available), there
were 1,279 certified CAH facilities in rural and remote areas.
As a part of the VA's Capital Assets for Enhanced Services (CARES)
initiative, the VA employed Medicare's CAH model as a guide to
establish a new VA policy to govern operations of, and planning for,
many of VA's rural and remote facilities, now designated VRAH. In 2004,
however, the CARES Advisory Commission questioned whether VA's policy
was adequate and recommended VA ``. . . establish a clear definition
and clear policy on the CAH [now VRAH] designation prior to making
decisions on the use of this designation.''
Following this guidance from the CARES Commission, on October 29,
2004, VA issued a directive that is still in force setting a
significant number of parameters for VRAH designations, but that
directive seems pointed in the opposite direction from that of Medicare
for the CAH facilities in the rural private sector. Illustrative of our
concern is the basic definition of VRAH, as follows:
``A VRAH is a VHA facility providing acute inpatient care in
a rural or small urban market in which access to healthcare is
limited. The market area cannot support more than forty beds.
The facility is limited to not more than twenty-five acute
medical and/or surgical beds. Such facilities must be part of a
network of healthcare that provides an established referral
system for tertiary or other specialized care not available at
the rural facility. The facility should be part of a system of
primary healthcare (such as a network of Community-Based
Outpatient Clinics (CBOCs)). The underlying principle is that
the facility must be a critical component of providing access
to timely, appropriate, and cost-effective healthcare for the
veteran population served. The activation and operation of a
VRAH will be similar to that of any other VHA hospital. The
designation of a facility as a VRAH will not remove or diminish
that facility's responsibility in meeting appropriate VHA
requirements, directives, guidance, etc.'' (VHA Directive 2004-
061, October 29, 2004)
We believe VA must carefully monitor the scope and quality of
services performed at its smaller, rural facilities, specifically for
those procedures that are complex in nature. Further, as medical care
advances in the use of high technology and thereby elevates the
standard of care, small VA inpatient facilities may find it
increasingly difficult to effectively maintain, and actually use these
new tools, to provide healthcare at its most sophisticated levels.
However, we believe VA must maintain a safe and high quality healthcare
service within each of its facilities, and to the greatest degree
possible offer a comprehensive health benefit to veterans at each of
its facilities, whether rural, suburban or urban.
The IBVSOs remain concerned about whether VA's VRAH policy fully
considers the implications of large-scale referrals from rural VA
Medical Centers in continuing to provide high quality healthcare in
those locations, particularly when veterans are referred to other far
off medical centers within a Veterans Integrated Service Network
(VISN), or to private facilities. VA must also consider patient
satisfaction, continuity of care, family separation and travel burdens
in the criteria they use for determining which rural facilities should
retain acute care services. If acute care beds are to be retained in
one facility because of distances that veterans must travel to access
inpatient care or receive specialized services, we believe this logic
should be standardized and used systemwide to the greatest extent
possible.
Community-Based Outpatient Clinics
The new legislation discussed above holds VA accountable for
improving access for rural veterans through CBOCs and other access
points by requiring VA to develop and implement a plan for improving
veterans' access to care in rural areas. The May 2004 Secretary's CARES
decision identified 156 priority CBOCs and new sites of care
nationwide. The VA Secretary is also required to develop a plan for
meeting the long-term and mental healthcare needs of rural veterans. We
urge Congress to include specific funding in fiscal year 2008 to
address at least some of these needs in rural areas without eroding
VA's Medical Services appropriation.
Workforce
Health worker shortages and recruitment and retention of healthcare
personnel are a key challenge to rural veterans' access to VA care and
to the quality of that care. The Future of Rural Health report
(National Academy of Science, Institute of Medicine, Committee on the
Future of Rural Health Care, 2005) recommended that the federal
government initiate a renewed, vigorous, and comprehensive effort to
enhance the supply of healthcare professionals working in rural areas.
To this end, VA's deeper involvement in health professions education of
future rural clinical providers seems essential in improving these
situations in VA facilities as well as in the private sector. Through
VA's existing partnerships with 103 schools of medicine, almost 28,000
medical residents and 16,000 medical students receive some of their
training in VA facilities each year. In addition, more than 32,000
associated health science students from 1,000 schools--including future
nurses, pharmacists, dentists, audiologists, social workers,
psychologists, physical therapists, optometrists, respiratory
therapists, physician assistants and nurse practitioners, receive
training in VA facilities. These relationships of VA facilities to
health professions schools should be put to work in aiding rural VA
facilities with their personnel needs.
Beneficiary Travel Program
Another component of making sure that veterans get access to the
care they need relates to the VA beneficiary travel program. This
program is intended by Congress to assist veterans in need of VA
healthcare to gain access to that care. As you are aware, the mileage
reimbursement rate is currently fixed at 11 cents per mile, but actual
reimbursement is limited by law with a $3.00 per trip deductible capped
at $18.00 per month. The mileage reimbursement rate has not been
changed in almost 30 years, even though the VA Secretary is delegated
authority by Congress to make rate changes when warranted. The law also
requires the Secretary to make periodic assessments of the need to
authorize changes to that rate. Unfortunately, no Secretary has acted
to make those changes, despite the obvious need to update the rate of
reimbursement to reflect rises in travel and transportation costs.
In 1987, the DAV, in coordination with VA's Voluntary Service
program, began buying and donating vans to VA for the purpose of
transporting veterans for outpatient care. Since that time, the DAV
National Transportation Network has become a very significant and
successful partnership between VA and DAV. We have donated almost 1,800
vans to VA facilities at a cost exceeding $20 million. These vans and
their DAV volunteer drivers and medical center volunteer transportation
coordinators have transported nearly 520,000 veterans over 388 million
miles. We plan to continue and enhance this program, not only because
the VA beneficiary travel rate is so low, but also we have found our
transportation network serves as a truly vital link between rural
veterans and crucial VA healthcare. Its absence would equate to the
actual denial of care for eligible veterans because many of them have
no means to substitute.
DAV, along with several others, has a longstanding resolution (DAV
Resolution 212) supporting repeal of the beneficiary travel pay
deductible for service-connected veterans and to increase travel
reimbursement rates for all veterans who are eligible for
reimbursement. Additionally, we support legislation that has been
introduced in Congress to repeal the mandatory deductible and increase
the rate veterans are reimbursed for their authorized travel to and
from VA services. We believe H.R. 963 (introduced by Mr. Stupak); H.R.
1472 (introduced by Mr. Barrow, with Mr. Baca, Mr. Burton of Indiana,
Mr. Boswell, Ms. Bordallo, Mr. Boucher, Mr. Abercrombie, Mr. Boren and
Mr. Courtney); and S. 994 (introduced by Senator Tester and Senator
Salazar), all termed the ``Veterans Travel Fairness Act,'' offer a fair
and equitable resolution to this dilemma about which we have been
concerned for many years. We urge this Committee and your Senate
counterpart to approve and enact legislation this year to reform the VA
beneficiary travel program. Given the cost of transportation in 2007,
including record-setting gasoline prices, a reimbursement rate
unchanged since 1977 pales in comparison to the actual cost of travel.
Mental Healthcare
As indicated above, given that 44 percent of newly returning
veterans from OEF/OIF live in rural areas the IBVSOs believe that they
too should have access to specialized services offered at VA's
Readjustment Counseling Service's Vet Centers.
Vet Centers are located in communities outside the larger VA
medical facilities, in easily accessible, consumer-oriented facilities
highly responsive to the needs of local veterans. These centers present
the primary access points to VA programs and benefits for nearly 25
percent of veterans who receive care at the centers. This core group of
veteran users primarily receives counseling for military-related
trauma. Building on the strength of the Vet Centers program, VA should
be required to establish a pilot program for mobile Vet Centers that
could better outreach to veterans in rural and remote areas.
Homelessness
Helping homeless veterans in rural and remote locations recover,
rehabilitate, and reintegrate into society is complex and challenging.
VA has no specific programs to help community providers who focus on
rural homeless veterans. The rural homeless also deserve attention from
VA to aid in their recoveries. Likewise, Native American, Native
Hawaiian, and Native Alaskan veterans have unique healthcare needs that
VA needs to address with additional outreach and other activities.
Mr. Chairman, thank you for the opportunity to provide testimony on
these very important issues related to access to VA healthcare
services. In The Independent Budget for fiscal year 2008, our
organizations made a number of recommendations to Congress and VA that
are relevant to the issues discussed today in this testimony. We invite
you to review these recommendations, reprinted below.
Recommendations
VA must fully support the right of rural veterans to healthcare and
insist that funding for additional rural care and outreach be
specifically appropriated for this purpose, and not be the cause of
reductions in highly specialized urban and suburban VA medical programs
needed for the care of sick and disabled veterans.
VA must ensure that the distance veterans travel as well as other
hardships they face be considered in VA's policies in determining the
appropriate location and setting for providing VA healthcare services.
The VA Secretary should use existing authority to establish a Rural
Veterans Advisory Committee, to include membership by the veterans
service organizations.
VA rural outreach should include a special focus on Native
American, Native Hawaiian, and Alaska Native veterans' unmet healthcare
needs.
Through its affiliations with health professions schools, VA should
develop a policy to help supply health professions clinical personnel
to rural VA facilities and to rural areas in general.
Mobile Vet Centers should be established, at least on a pilot
basis, to provide outreach and counseling for veterans in rural and
remote areas.
VA must focus some of its homeless veteran program resources,
including contracts with, and grants to, community-based organizations,
to address the needs of homeless veterans in rural and remote areas.
Statement of Gerald M. Cross, M.D., FAAFP
Acting Principal Deputy Under Secretary for Health
Veterans Health Administration, U.S. Department of Veterans Affairs
Good Afternoon, Mr. Chairman and Members of the Subcommittee. Thank
you for the opportunity to discuss ongoing efforts in the Veterans
Health Administration (VHA) to provide safe, effective, efficient and
compassionate healthcare to veterans residing in rural areas.
In fiscal year 2006, the Department of Veterans Affairs (VA) served
about 5.4 million patients. Approximately 39 percent of these veterans
resided in rural areas and another 2 percent resided in highly rural
areas.\1\ VA is fulfilling its mission by providing the highest quality
of care to all veterans and understands that although veterans in rural
areas face many of the same health concerns as veterans in urban areas,
rural area veterans often face additional and unique challenges such as
limited finances and fewer specialists. The primary challenge in
serving veterans who reside in rural areas is to effectively address
access to quality care in areas where veteran populations are usually
widely distributed over a large geographical area.
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\1\ Definitions: Urban--areas defined by U.S. Census as urbanized
areas; Rural--all other areas excluded in U.S. Census defined urbanized
areas; Highly Rural--any rural area within a county with less than 7.0
civilians per square mile.
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The VA has undergone a profound transformation in the delivery of
healthcare over the last decade. VA has moved from a hospital driven
healthcare system to an integrated delivery system that emphasizes a
full continuum of care. New technology and treatment modalities have
changed how and where care is provided with a significant shift from
inpatient to outpatient and in-home services. Throughout that
transformation, VA has considered our veterans who live in rural areas
and how best the VA can enhance their access to the quality health
services that we strive to provide to all veterans.
VA's comprehensive approach for providing care to veterans residing
in rural areas has proven successful. We are setting the industry
standards for using advanced technology with our telehealth healthcare
delivery programs. With this advanced technology, we are providing
services directly to veterans in their homes and expanding specialized
care in our Community-Based Outpatient Clinics (CBOCs) through
telemedicine capabilities. We have been successful in creating greater
access to quality services though expansion of CBOCs. Over 92 percent
of enrollees reside within 1 hour of a VA facility, and 98.5 percent
are within 90 minutes.
Our veterans tell us that they are satisfied with the services and
high quality care we are providing to them. This is substantiated by
their high satisfaction reporting, with veterans in rural areas
reporting comparable satisfaction to their urban counterparts.
I share the Committee's concern for these veterans and would like
to take a few minutes to discuss our strategic direction and current
programs that will reveal how VA is moving toward a comprehensive plan
with initiatives to address rural veterans' issues.
RURAL HEALTH INITIATIVES
The strategic direction for providing services to veterans residing
in rural areas is to provide non-institutionalized care; to bring care
into veterans' homes. Examples of this are telehealth, mail pharmacies,
and home-based primary care. If it is not possible to provide services
in the home, veterans will come to one of the many access points that
VA has established. VA has systematically undertaken a number of
efforts aimed at addressing delivery of healthcare services to veterans
who reside in rural areas. Central to these efforts are several major
initiatives now being implemented throughout the VA system:
establishing an Office of Rural Health to focus attention on issues of
veterans who reside in rural areas; our telehealth and telemedicine
programs, which are using new technology to bring healthcare providers
to their patients, rather than patients to their healthcare providers;
establishment of CBOCs to increase access to care; and utilization of
fee-based service with private healthcare providers. I will now discuss
these efforts and others in greater detail while providing information
on key health concerns facing many of our veterans.
VHA's OFFICE OF RURAL HEALTH
VHA is focusing attention on the special needs of veterans who
reside in rural areas. In accordance with section 212 of the Public Law
109-461, VHA is establishing an Office of Rural Health. The mission of
the office is to promulgate policies, best practices and innovations to
improve services to veterans who reside in rural areas of the United
States.
TELEHEALTH--IMPACTS ON RURAL CARE
VA is an acknowledged national leader in the development of
telehealth. VA's telehealth programs have reached a size and complexity
that are unparalleled elsewhere. VA continues to implement telehealth
through further expansion of its care coordination/telehealth programs.
This approach embeds telehealth within an appropriate, effective and
cost-effective clinical environment. Consequently, access to care is
expanding and enabling convenience in how veteran patients receive
services to become a predominant consideration, one that fits with the
overarching mission for these programs of providing the right care at
the right time in the right setting.
For veteran patients with chronic disease, when it is appropriate
and their choice, the preferred setting for care is the home. Care
coordination/home telehealth programs (CCHT) are well established in
all 21 Veterans Integrated Service Networks (VISNs) and currently care
for 24,921 patients. This patient census (point prevalence figure)
already represents a 25 percent increase over fiscal year 2006 numbers
and places VA on target to meet a projected growth in the program of 50
percent by the end of fiscal year 2007. CCHT supports patients with
chronic conditions such as diabetes, chronic heart failure, chronic
obstructive pulmonary disease, post-traumatic stress disorder, and
depression to remain living independently in their own homes. The
program design is such that care can be delivered remotely from VA
Medical Centers and 25 percent of CCHT patients are in rural areas and
another 1 percent are in highly rural areas.
The next phase of expansion in CCHT programs and ongoing extension
into rural areas involves VA's implementation of a home telemental
health initiative that will support veterans with PTSD and those who
need treatment for substance abuse to be managed at home. These new
CCHT home telemental health services are intended to support the care
of an additional 2,000 veterans by the end of fiscal year 2008. VA
anticipates that such services will initially develop and thereafter
further expand in the same geographic locations as existing CCHT
programs. VA is currently working on telecommunications strategies to
facilitate the provision of CCHT services in rural areas, thus
improving access to care for veteran patients and reducing their need
to travel for services. Since January 2004, VHA has trained over 3,500
staff nationally to provide care via CCHT. This training is done via
distance learning techniques to enhance service development and ensure
their sustainability in rural and remote areas.
In fiscal year 2006, over 19,000 unique veteran patients received
care in CBOCs and outlying VA Medical Centers via telemental health.
Already, in the first quarter of fiscal year 2007, over 8,000 patients
have received care via telemental health. Current projections are that
VA will provide care in this manner to over 30,000 veterans during
fiscal year 2007.
The VA's Rocky Mountain Telehealth Training Center is focusing on
making distance learning available to the providers in rural areas who
are providing services via telehealth. Additionally, the VA
readjustment counseling program (Vet Centers) is currently working on a
strategy to expand services in rural areas by further expansion of its
telehealth capacity.
VHA has now implemented its national teleretinal imaging program to
screen veteran patients with diabetes for diabetic eye disease. This
program was instituted at a total of 159 image acquisition sites over
the past 18 months. This implementation represents a 60 percent
increase over that which was originally planned. Currently 50 percent
of these image acquisition sites are in rural areas. Overall the
program has provided services to 18,000 patients with a projected
census of 110,000 by the end of fiscal year 2007 and 200,000 by the end
of fiscal year 2008. VA's teleretinal imaging training center in Boston
has trained the necessary image acquisition and reading staff and helps
ensure that remote sites can be established and remain viable.
IMPROVING ACCESS THROUGH CBOCs
CBOCs have been the anchor for VHA's efforts to expand access to
veterans in rural areas. VHA's CBOCs are complemented by contracts in
the community for physician specialty services or referrals to local VA
Medical Centers, depending on the location of the CBOC and the
availability of specialists in the area.
VA has continued to improve access to care for veterans in rural
areas through a variety of mechanisms. VA outpatient clinics offer
rural veterans a full array of primary care services in communities
where they live and work. VA has opened 717 new CBOCs since 1995.\2\ Of
this total, 320 or 45 percent of these are located in rural or highly
rural areas. Additionally, there are a number of rural outreach clinics
that are operated by a parent CBOC to meet the needs of rural veterans.
Furthermore, there are several additional outpatient clinics that,
although located in more populated areas, are positioned to provide
care for veterans in the surrounding rural communities. The fee-basis
program, authorized under 38 U.S.C. 1703, also provides a local VAMC
director with an option in meeting the needs of veterans.
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\2\ Nomenclature clarification: In 1995, the term used for access
points was community-based or ambulatory clinic. In 2000, Community-
Based Outpatient Clinic or CBOC became the commonly used term.
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VA's current policy for the planning and activation of CBOCs
ensures that new CBOCs meet VA's goal to improve access by current
users by placing CBOCs in those areas where users travel significant
distances and/or experience excessive travel time to access care.
VA reviews and selects CBOCs through a national approval process
based upon the proposals from VA Medical Centers and the Veterans
Integrated Service Networks (VISNs). This process allows decisions
regarding needs and priorities to be made in the context of local
market circumstances and veterans' preferences.
CBOC proposals are reviewed against national planning criteria
including the needs of veterans living in rural areas. The planning
criteria include items such as access standards that address veterans
living in rural and highly rural areas, as well as additional
considerations that include the impact of new CBOCs on waiting times,
cost effectiveness, unique demographic or geographic considerations,
current workload, quality of care, and enrollment decisions. As noted
earlier, CBOC criteria do address unique demographic and geographic
concerns such as geographic barriers, low population density, medically
underserved or health manpower shortage areas which will enhance care
for rural veterans. Criteria points are added for these unique
considerations.
VA reviews and revises its policy on the planning and activation of
CBOCs annually and new planned CBOCs are centrally integrated into the
annual development of resource and budget needs. VA is currently
reviewing the CBOC criteria to emphasize those areas of the country
that have less than 70 percent of enrollees within drive time standards
to access care. (VA Drive Time standards recommend that 70 percent of
market enrollees be within 30 minutes of primary care for veterans
residing in urban and rural areas, and 60 minutes for those living in
highly rural areas). VA will then use this information to develop
infrastructure planning and budget needs.
MENTAL HEALTH SERVICES/SPECIAL NEEDS
Comprehensive and effective mental healthcare is one of the top
priorities for VA. The provision of mental healthcare in rural settings
has historically been a challenge for all health systems and providers,
including VA.
VA is making changes to address these needs. In fiscal year 2005,
VHA began an investment to improve access to mental health services
throughout the entire VA healthcare system, in both rural and urban
settings. Resources are funding services that are utilized by veterans
living in rural areas, including expansion of telemental health
programs to provide expert mental healthcare in rural areas, and
providing an innovative rural Mental Heath Intensive Case Management
program (MHICM-RANGE) where the population needing care was not large
enough to require a full team.
Some examples of VA's mental health program initiatives that will
benefit rural veterans include:
Integrating specialty mental healthcare into primary care
and other medical settings;
Continuing to expand access to specialty mental health
services at all CBOCs, either by direct staffing, local contracts, or
telehealth;
Developing and piloting a model for rural areas for
implementation of the concepts of the Mental Health Intensive Case
Management (MHICM) programs; and
Providing timely access for homeless veterans to mental
health/substance abuse assessments.
Performance Measure data indicates that as a result of our
intensive efforts to expand services for rural veterans, veterans have
access to service much nearer to home. In 1996, VA users of mental
health services lived an average of 24 miles from the nearest VA
clinic; as of 2006, they now live only 13.8 miles away (just half as
far).
These and other Performance Measures in Mental Health help to
identify success related to the mental health initiatives and to
identify areas for continued improvement. In relation to the needs of
veterans in rural areas, we are especially committed to expanding
telemental health resources, to provide the most effective opportunity
for enabling even the smallest and most rural of the CBOCs to improve
the quantity of their basic mental healthcare and also to improve
access to more specialized mental health services when clinically
appropriate.
HOMELESS PROVIDERS GRANT AND PER DIEM (GPD) PROGRAM
VA Homeless Providers Grant and Per Diem (GPD) Program provides
grants through a competitive process to community agencies providing
services to homeless veterans. The purpose of the program is to promote
the development and provision of supportive housing and/or services to
help homeless veterans achieve residential stability, increase their
skill levels and income, and independence. Efforts are made during
funding cycles to award these grants recognizing geographic dispersion.
Since GPD's inception, the program has funded more than 75 projects
that are in rural locations. It is expected that these grants will
support or create over 1,200 transitional housing beds for homeless
veterans. Most of the grants were awarded to provide operational
funding; however, grants were also awarded to assist in the renovation,
acquisition, or construction of buildings to create facilities for the
veterans who are homeless.
READJUSTMENT COUNSELING SERVICE/VET CENTERS
The Vet Center program service mission is designed to provide
quality readjustment counseling and to remove all unnecessary barriers
to care for veterans and family members. The Vet Centers are community-
based facilities located at convenient locations within the community
to promote ease of access for veterans and family members. All Vet
Centers engage in extensive community outreach activities to directly
contact and inform area veterans and to maintain active community
partnerships with local leaders and service providers to facilitate
referrals for veterans in need.
Some Vet Centers are, by plan, established and maintained in rural
areas, e.g., Grants Pass, OR; Caribou, ME; Missoula, MT; and Cheyenne,
WY, to ensure that rural veterans and families have access to
readjustment counseling services. Additionally, we have established Vet
Center outstations in rural areas such as Cedar Rapids, IA; the
Michigan's Upper Peninsula; and Keams Canyon, AZ on the Hopi
Reservation. Outstations are administratively connected to a full sized
Vet Center, utilize permanently leased space and are usually staffed by
one or two counselors who provide full time services to area veterans
on a regular weekly basis. The Vet Centers also maintain some
nontraditional hours keeping the Vet Center open after normal business
hours or on weekends to accommodate veterans traveling in from greater
distances.
Another important aspect of the Vet Center program for maintaining
care for veterans in rural areas is to actively establish and maintain
partnerships with other community providers such as State employment
services, community substance abuse programs and healthcare providers
such as Indian Health Service (IHS). The Vet Center program also
maintains a contract program with over 300 private sector providers
under contract with VA to deliver readjustment counseling to veterans
living at a distance from existing Vet Centers. Some Vet Centers in
rural areas have telehealth linkages to their support VAMC which
provides veterans in more remote areas access to VA mental health and
primary care. The Vet Centers in Santa Fe, NM; Logan, WV; and Chinle,
AZ on the Navajo reservation are examples of such sites with active
telehealth programs.
Since the onset of hostilities in Afghanistan and Iraq, the Vet
Centers have taken a lead role in providing outreach services to
returning war veterans. Since 2003 through the first quarter of fiscal
year 2007, the Vet Centers have provided services to 165,153 Operation
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans.
Following initial contact with Vet Center outreach workers at
demobilization sites, many of these veterans disperse home to rural
areas of the country. Without the initial Vet Center outreach contact,
subsequent access to VA services would be far more of a challenge for
many rural veterans.
To further enhance services to the growing numbers of the new
generation of returning warriors, VA announced, in February 2007, its
plan to expand the Vet Center program. Site selections for new Centers
were established based on evidence-based analysis of veteran
demographic distributions. In addition, site selection for some of the
new Vet Centers was based on special consideration for relatively
underserved veterans residing in rural areas at a distance from other
VA facilities. There have been 23 new Vet Centers identified to be
opened, 8 of them, or approximately 23 percent, are in rural areas.
Examples of Vet Centers planned to serve rural veteran populations in
rural locations include: Grand Junction, CO; Manhattan, KS; Escanaba,
MI; and Watertown, NY.
LTC/NURSING HOMES/DAY HEALTHCARE FACILITIES
The demand for Long-Term Care (LTC), whether in rural or urban
settings, has greatly increased due to the aging of the veteran
population. VA LTC has evolved from services delivered primarily in
geriatric clinics and inpatient nursing home settings to a well-defined
spectrum of care, including an array of home and community-based care
(HCBC) services.
VA believes that LTC services should be provided in the least
restrictive setting where services are appropriate to a veteran's
health status, functional status, and personal circumstances, and,
whenever possible, in HCBC non-institutional settings. We make every
effort to identify options that maximize the veteran's ability to stay
within the community for as long as possible. When nursing home care is
needed, especially for a veteran residing in a rural area, VA
identifies options for the patient from the broad spectrum of LTC
venues available in the veteran's community, including the local State
Veterans Home or contracted nursing home care. Contracts with rural
community nursing homes are maintained so that beds are available when
needed by veterans residing in rural areas.
Newer options of VA geriatric healthcare that provide more
opportunities for the veteran to stay close to home and family include:
(1) Integration of Care Coordination and Home Telehealth into Home-
Based Primary Care to expand coverage into rural areas; (2)
Collaboration with Administration on Aging and Indian Health Service
for Home-Based Primary Care outreach and care giver support; (3)
Promotion of Hospice-Veteran Partnerships to improve veteran access to
community hospice care in rural areas; and (4) development of Medical
Foster Home program, where veterans can receive an array of services
including Home-Based Primary Care and community hospice care in a
supportive home environment in their own community.
COLLABORATIONS
In addition to our internal efforts outlined earlier, VA continues
to look for ways to collaborate with complementary Federal efforts to
address the needs of healthcare for rural veterans. We also have
partnerships with HHS, including the Indian Health Service and Office
of Rural Health providing healthcare in rural communities. We are also
working to establish relationships with other entities, such as with
the National Rural Health Association.
CONCLUSION
Mr. Chairman, providing safe, effective, efficient and
compassionate healthcare to our veterans, regardless of where they
live, is the primary goal of the VHA. New technologies and better
planning are allowing us to provide quality care in any location. VHA
recognizes the importance and the challenge of service in rural areas,
and we believe our current and planned efforts are addressing these
concerns for our current and emerging veterans.
Mr. Chairman, this concludes my statement. At this time I would be
pleased to answer any questions that you may have.
SUBMISSIONS FOR THE RECORD
Statement of Hon. Corrine Brown, a Representative in Congress from the
State of Florida
Thank you, Mr. Chairman, for calling this hearing today.
In my home State of Florida, we have a large amount of rural land
and one of the largest populations of veterans in the country. Our
veteran population is the oldest in the country.
The wars we are currently fighting are using the National Guard and
Reserves at a higher level than any other war. Many of the veterans
coming back from OEF/OIF are not living in a traditionally military
area. There are not a lot of retirees who served at the local base
living nearby, creating a ready-made support group. These reserves go
home. There are no support services nearby.
What plans does the VA have to address these veterans 3, 4, 5 or
more years down the road?
We will hear from an expert from HHS which has been involved in
rural healthcare for decades. What can the VA learn from this
Department? Will you try to find out?
I am pleased the VA is building a CBOC in my district in
Gainesville. This will bring necessary mental health and other services
to those veterans living in that area. However, we need more for them.
I look forward to hearing the testimony from all the witnesses
today.
Statement of Hon. Henry E. Brown, Jr., a Representative in Congress
from the State of South Carolina
Chairman Michaud and Ranking Member Miller, thank you for calling
this important hearing to address a continuing concern of this
Committee: the challenges that many of our veterans face in accessing
healthcare through the VA system. While my district is home to the
Johnson VAMC in Charleston, a veteran from Myrtle Beach needing
treatment or a test has to invest the larger part of an entire day for
this visit. While treatment at our VA medical facilities is some of the
best in the world, there is something about what I just said that
doesn't make sense at all.
Last Congress, when I served as Chairman of this Subcommittee, I
was honored to travel up to Maine for a field hearing in Mr. Michaud's
district to examine some of these very same challenges. During that
hearing we discussed some of the serious challenges that rural veterans
face--not because of lack of dollars--but simply because they live in
rural areas.
One of the messages that I came away from that hearing with is the
need for Congress to continue to prod the VA forward in thinking
outside the box to deliver care in innovative ways. We know the
successful turnaround our VA hospitals have seen in the past decades.
That turnaround required a commitment not just from Congress or the
VA's political leadership, but a commitment from within the heart of
the VA's bureaucracy.
Technology certainly is a tool that can have an impact--especially
in the case of the veteran in Myrtle Beach who now has to spend their
entire day traveling to and from Charleston for a test. For veterans in
Maine and other extremely rural areas, we need to look at collaborating
further with local healthcare providers to provide care through the VA
system. Collaboration has worked at the VAMC level across the country--
we should not be afraid of it across other areas of the VA system.
Thank you again, Mr. Chairman, and I look forward to working with
my colleagues and the VA to address the access needs of our veterans.
Statement of Hon. Jeff Miller
Ranking Republican Member, Subcommittee on Health, and a Representative
in Congress from the State of Florida
Rural America has a strong tradition of military service. According
to the 2000 U.S. Census, rural and non-metropolitan counties have the
highest concentration of veterans. Both my State of Florida and the
Chairman Michaud's State of Maine are included in the top 18 States
with a greater than average proportion of rural veterans.
Not surprisingly, in the Global War on Terror, we continue to see a
high rate of combat veterans from rural settings. About 41 percent of
returning veterans from Operation Enduring Freedom and Operation Iraqi
Freedom live in small communities.
A study conducted by VA researchers, published in the Winter 2006
Journal of Rural Health, ``corroborate a concern that living at a
distance from regionalized healthcare implicitly restricts access to
and utilization of health services. Veterans may have an additional
healthcare option not available to the general public, but those
veterans who live in non-metropolitan areas, far from regionalized high
technology or specialized care, continue to experience substantial
unmet needs, greater than those of veterans in metropolitan settings.''
Central to VA's efforts to address access to healthcare in less
populated settings has been the establishment of Community-Based
Outpatient Clinic's (CBOCs). Today, VA operates about 700 CBOCs. The
May 2004 Capital Asset Realignment for Enhanced Services (CARES)
decision document provided a framework for prioritizing 156 new CBOCs
to improve veteran's access to care. More than half of these new CBOCs
were given priority because they were located in rural areas. Yet, of
these recommended new sites of care, VA has opened only 12 and expects
to activate only an additional 12 in 2007.
CBOCs are important to improving geographic access to care.
However, these primary care sites alone, cannot effectively overcome
all the barriers that exist for rural veterans to obtain high quality
care within their home community. Addressing the identified gaps in
mental health services and specialty and acute hospital care, requires
developing new approaches for delivering care. This includes the use of
emerging technologies, partnering with existing non-VA rural healthcare
providers and enhancing the training and recruitment of health
professionals in rural communities.
I thank Chairman Michaud for holding this hearing to examine how we
can best ensure all veterans have access to services when and where
they are needed. With our current combat operations and an aging
veteran population from previous wars, we can anticipate a substantial
and rapid increase in demand for VA healthcare in rural areas. VA must
step up to meet both the immediate physical and mental healthcare needs
of all veterans and their families and bear in mind the special and
unique rural healthcare delivery challenges in planning future
services.
POST-HEARING QUESTIONS FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC
May 2, 2007
Michael J. Kussman, MD, MS, MACP
Acting Under Secretary for Health
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Dr. Kussman:
In reference to our Subcommittee on Health hearing ``Access to VA
Healthcare: How Easy is it for Veterans--Addressing the Gaps'' held on
April 18, 2007, I would appreciate it if you could answer the enclosed
hearing questions by the close of business on June 5, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions from Hon. Michael H. Michaud, Chairman, Subcommittee on
Health, to Dr. Michael Kussman, Acting Under Secretary of Health,
Veterans Health Administration, U.S. Department of Veterans Affairs
``Access to VA Healthcare: How Easy is it for Veterans--
Addressing the Gaps''
Question 1: Providing Healthcare in a Rural Setting. Forty-one
percent of the 5.4 million veterans that VA treated in fiscal year 2006
were from rural or highly rural areas. That is a pretty significant
portion of the population that VA provides services to. Additionally,
over 40 percent of the returning OEF/OIF veterans are from rural areas:
Question 1(a): What do you believe is a reasonable expectation of
care for these 2.2 million veterans?
Response: The Department of Veterans Affairs (VA) believes
reasonable expectations for healthcare for veterans who reside in rural
areas fall into two broad categories; access and delivery of
appropriate services.
To ensure reasonable access, Veterans Health Administration (VHA)
uses established guidelines of drive time to access care. For rural
veterans: 70 percent of patients should be within 30 minutes to primary
care, and 65 percent of patients should be with 90 minutes to acute
care and 240 minutes to tertiary care. For highly rural areas, 70
percent of patients should be within 60 minutes to primary care, and 65
percent of patients should be within 120 minutes to acute care and
tertiary care is based on the standard for that area.
Regarding healthcare delivery, VHA is committed to providing a full
range of services as outlined in the medical benefits package. This
includes a standard health benefits plan available to all enrolled
veterans. The plan emphasizes preventive and primary care, and offers a
full range of outpatient and inpatient services within VA healthcare
system. (http://www.va.gov/healtheligibility/coveredservices/
StandardBenefits.asp)
VHA will continue to provide care consistent with our access
guidelines and review these guidelines as needs change.
Question 1(b): What level of care do you believe should be easily
accessible to these veterans, including specific services?
Response: VA believes primary care services, general medical and
preventative services including mental health, should be easily
accessible. VA supports providing high quality care balancing access
requirements within our appropriated budget.
Question 1(c): If you had to draw a line--where would you draw it--
and say, VA can't provide that care?
Response: VA will honor its obligation to provide a full range of
services to enrolled veterans within our appropriated budget. VHA will
first provide services to enrollees through its network of healthcare
facilities ranging from primary care services to tertiary care
services.
If VA is unable to provide care, care may be purchased by VA in the
community, as determined appropriate by the VA Medical Center based on
the particular clinical circumstance.
Question 2: Telehealth. Your testimony elaborates on the VA's care
coordination/home telehealth programs.
Question 2(a): What are some of the challenges that VA is facing in
procuring equipment that is standard throughout the system for these
programs?
Response: The challenges that VA faces procuring technology that is
standard for home telehealth fit into two broad categories: (1)
equipment interoperability and (2) scalability of technology. The home
telehealth industry is relatively small and emerging. When it is
appropriate to do so, VA is working with the vendor community to ensure
systems are interoperable and to extend the functionalities available
to support the care of veteran patients in their own homes.
VA has a very large installed base of home telehealth technologies
with which to support the timely care of veteran patients in their own
homes. The home telehealth network VA has created is unprecedented in
size and complexity. As this network continues to grow, VA is working
with the vendor community to ensure systems are robust, sustainable,
and compatible.
Question 2(b): Please elaborate on the telecommunications
strategies VA is currently working on to facilitate the provision of
CCHT services in rural areas to improve access and reduce travel times
for veterans?
Response: In the first phase of its national care coordination home
telehealth (CCHT) expansion--2004-2008--VA has relied upon telephone
connectivity to veteran's homes. This strategy was pursued because: (1)
telephone lines were relatively ubiquitous, (2) it was the dominant
telecommunication infrastructure chosen by the vendor community, (3)
ease of installation for patients and staff and (4) staff and patients
had the technical skills necessary to ``troubleshoot'' any problems. VA
is now considering how other telecommunications modalities could help
support the care of veteran patients when telephone lines are not
available or adequate. Ease of use by patients and staff continues to
remain of paramount concern as VA continues to explore such future
options.
Question 2(c): What is the actual number of veterans taking
advantage of the CCHT services? What percentage does that represent in
the overall veteran population that VA treats?
Response: On May 5, 2007, CCHT programs in VA were supporting
25,556 patients nationally. This number represents 0.1 percent of the
total population VHA treats. However, this CCHT figure represents 50
percent of the population of patients with chronic disease for which
the program was implemented to provide care. Given the necessary
evolution of the technology and attendant clinical and business support
processes, a possible 1.1 million (20 percent) of veterans could
benefit from such assistive devices in the home.
Question 3: CBOCs. In the last CBOC report received by this
Subcommittee, dated March 30, 2007, VA reported a growth of 8 percent
over the last 3 years in the activation of the 156 priority CBOCs that
were listed in the CARES Decision of May 2004. At that rate it will
take 30 years to open these 156. Realizing that VISNs can propose the
activation of CBOCs not in the CARES document:
Question 3(a): Do you think that a pace of 8 percent over 3 years
is going to be effective?
Response: The Capital Asset Realignment for Enhanced Services
(CARES) decision document indicated a plan to have all 156 open by 2012
(pending availability of resources and validation with the most current
data available). In fiscal year (FY) 2007, after data validation, only
CARES priority Community-Based Outpatient Clinics (CBOCs), or newly
identified CBOCs that met the CARES priority criteria were placed on
the list to open.
The newly identified CBOCs had to meet one of the following CARES
priority criteria. The CBOC must be:
Located in a market with less than 70 percent of
enrollees within access guidelines, and having more than 7,000 clinic
stops planned for the CBOC.
Located in a market with less than 70 percent of
enrollees within access guidelines, and located in a rural or highly
rural county.
Part of a Department of Defense (000) collaboration.
Needed for a CARES realignment decision.
Needed to relieve space constraints at the parent
facility and located within 20 minutes of the parent facility.
As of May 25, 2007, VA has opened or approved to open 88 CBOCs. The
following list shows where they are and when they are scheduled to open
in FY 2007 or 2008.
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VISN Clinic State Approved Status
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2 Warsaw NY Jun-04 Open
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4 Bangor PA Jun-04 Open
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4 Dover DE Mar-06 Opening in FY2007
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4 Fayette PA Jun-04 Open
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4 Gloucester NJ Jun-04 Open
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4 Monongalia County WV May-07 Opening in FY2007
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4 Venango PA Jun-04 Open
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4 Warren PA Jun-04 Open
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5 Andrews AFB MD May-07 Opening in FY2008
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5 Ft. Detrick MD May-07 Opening in FY2008
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6 CharlotteVAille May-07 Opening in FY2008
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6 Franklin NC Mar-06 Opening in FY2008
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6 Hamlet NC Mar-06 Opening in FY2008
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6 Hickory NC Mar-06 Opening in FY2008
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6 Lynchburg VA Mar-06 Opening in FY2008
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6 Norfolk VA Mar-06 Opening in FY2007
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7 Aiken SC May-07 Opening in FY2008
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7 Athens GA Mar-06 Open
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7 Bessemer AL Mar-06 Opening in FY2007
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7 ChildersbALg May-07 Opening in FY2007
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7 Goose Creek SC Sep-04 Open
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7 Spartanburg SC May-07 Opening in FY2008
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7 Stockbridge GA May-07 Opening in FY2007
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8 Camden CoGAty May-07 Opening in FY2008
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8 Jackson County FL May-07 Opening in FY2008
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8 Putnam County FL May-07 Opening in FY2008
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8 Sumter--The Villages FL Sep-04 Open
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9 Berea KY May-07 Opening in FY2007
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9 CovingtonTN Sep-04 Open
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9 Dupont KY Jun-04 Open
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9 Grayson County KY May-07 Opening in FY2008
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9 Hamblen TN Mar-06 Opening in FY2007
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9 Hawkins County TN May-07 Opening in FY2008
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9 Hazard KY Mar-06 Opening in FY2008
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9 Madison County TN May-07 Opening in FY2008
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9 Memphis--South Clinic TN Jun-04 Open
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9 Standiford KY Jun-04 Open
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9 Vine Hill TN Jun-04 Open
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9 Morehead KY Sep-04 Open
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10 CambridgeOH Mar-06 Open
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10 Florence/Boone City KY Mar-06 Open
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10 Hamilton OH May-07 Opening in FY2007
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10 Marion OH Jun-04 Open
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10 New Philadelphia OH Jun-04 Open
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10 Newark OH Mar-06 Open
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10 Parma OH May-07 Opening in FY2008
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10 Ravenna OH Jun-04 Open
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11 Alpena County MI May-07 Opening in FY2008
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11 Clare CouMIy May-07 Opening in FY2008
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11 Elkhart County IN May-07 Opening in FY2007
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15 Daviess County KY May-07 Opening in FY2007
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15 Graves County KY Sep-04 Opening in FY2009
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15 Hopkins County KY Sep-04 Open
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15 Hutchinson KS May-07 Opening in FY2008
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15 Jefferson City MO May-07 Opening in FY2008
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15 Knox County IN May-07 Opening in FY2008
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16 Branson MO May-07 Opening in FY2008
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16 Conroe TX Mar-06 Open
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16 Eglin FL Feb-06 Opening in FY2008
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16 Hammond LA Feb-06 Open
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16 La Place/St Johns LA Feb-06 Open
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16 Pine Bluff AR May-07 Opening in FY2008
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16 Slidell LA Feb-06 Open
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17 San Antonio--VA/DoD Joint TX Sep-04 Open
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18 Miami/Globe AZ Mar-06 Opening in FY2008
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18 NW Tucson AZ Mar-06 Opening in FY2007
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18 SE Tucson AZ Mar-06 Opening in FY2008
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19 Cut Bank MT May-07 Opening in FY2008
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19 Lewistown MT May-07 Opening in FY2008
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19 Western Salt Lake City VallUT May-07 Opening in FY2008
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20 Canyon CiID Mar-06 Opening in FY2007
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20 North Idaho ID May-07 Opening in FY2008
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20 Northwest WA WA May-07 Opening in FY2007
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20 Central WWAhington Feb-07 Opening in FY2007
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21 American Samoa Mar-06 Opening in FY2007
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21 Fallon NV Mar-06 Opening in FY2007
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22 Orange CA Mar-06 Opening in FY2007
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23 Bellevue NE May-07 Opening in FY2007
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23 Bemidji--Fosston MN Mar-06 Opening in FY2007
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23 Carroll IA May-07 Opening in FY2007
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23 Cedar RapIAs May-07 Opening in FY2007
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23 Holdredge NE Mar-06 Opening in FY2007
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23 Marshalltown IA May-07 Opening in FY2007
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23 Shenandoah IA May-07 Opening in FY2007
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23 Spirit Lake IA Mar-06 Opening in FY2007
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23 Wagner SD May-07 Opening in FY2007
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23 Watertown SD May-07 Opening in FY2007
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23 Western WI (Rice Lake) WI Mar-06 Opening in FY2007
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Question 3(b): What do you think the pace should be?
Response: We believe the current pace is reasonable. It is
important that VHA grow at a manageable rate as the organization
continues to make significant improvements to access.
Question 3(c): Do you believe the cumbersome planning and
activation process currently in place at VA is a stopgap for those
medical centers who serve the rural community?
Response: The difficulty in opening a CBOC in rural markets is
related to the unique challenges in providing care in remote areas.
Staff are at times difficult to hire, and partners or other contracting
entities are scarce. VA is constantly exploring and establishing
alternatives to CBOCs to provide care in these rural communities such
as outreach clinics and telemedicine capabilities.
Question 3(d): How would you streamline the process so rural
veterans are not waiting 25 years for a CBOC to be activated in their
area?
Response: As evidence of the fact that improving access in rural
areas is a high priority for VHA, of the 156 CBOCs on the priority
list, 103 are in rural areas. In some rural areas, as noted above,
outreach clinics may be more appropriate than a CBOC due to the unique
challenges in these remote areas.
Question 3(e): What good did the prioritization of the CBOCs do if
VA is not following their own plan? What is the role of the priority
list if the VA opens clinics not on the priority list?
Response: In FY 2007, only CARES priority CBOCs, or newly
identified CBOCs that met the CARES priority criteria were placed on
the list to be considered. As veteran populations and demographics are
constantly changing, some of the CARES priority CBOCs will no longer
meet the criteria, while alternative locations meet the criteria and
the needs of the patient population served. VA will continually need to
update the plans for establishing additional CBOCs in order to reflect
the changes in veteran population, as well as advances in healthcare
delivery practices.
Question 4: Access to Transportation. The issue of access to
transportation is vital to providing healthcare to veterans in rural
communities.
Question 4(a): With the veteran population aging and increasingly
rural, how can VA better connect veterans with their ongoing healthcare
needs?
Response: Technological advancements are, and will continue to be,
the primary way that VA can better connect with veterans, in their own
homes, to deliver healthcare services. VHA's Office of Care
Coordination oversees VA's CCHT program. This program uses a variety of
home-telehealth technologies to monitor the care of patients with
chronic conditions directly from their homes. The CCHT program
encourages patient self-management and a national network of care
coordinators in every Veterans Integrated Service Network (VISN)
facilitates access to appropriate care across the continuum.
VA has a variety of arrangements across the system for
transportation assistance. VA operates more than 1,300 vans donated
primarily by service organizations, which assist in bringing veterans
into VHA facilities. Once donated, VA maintains these vans, assists
with recruiting volunteer drivers, and has developed a training and
medical clearance program for all volunteers. Today, VA has almost
10,000 volunteers that have donated more than 1.8 million hours to
serve as volunteer drivers.
Further assistance in transportation is provided by the local
healthcare system and varies depending on the ability to secure donated
vans and volunteer drivers and the need of the veteran patient. Some
systems use an `out-placed van' method where they have pre-determined
pick-up stops and/or will pick up a veteran at their home to bring them
into a VA facility for appointments or services. Others operate a
shuttle service between their facilities, with some including stops at
pre-determined pick-up locations.
Question 4(b): Has the agency looked to review partnerships with
community-based public transportation systems operating in these areas?
Response: At the national level, a partnership with community-based
public transportation systems has not been addressed. However, at the
local level, VA healthcare systems work with localities to assist with
transportation. Examples of this are providing bus and/or train passes
for veterans needing transportation.
Question 5: Interventions to Improve Healthcare in Rural America.
In a study done in 2005, the Institute of Medicine found that a wide
range of interventions are available to improve health and healthcare
in rural America, such as education, community and environmental
planning. Making explicit the full range of options available to rural
communities to improve personal and population health should lead to
more optimal allocation of scarce financial.
Question 5(a): Has the VA implemented any interventions to improve
personal or population health among the rural veteran population?
Response: To address both personal and population health, VHA's
Office of Public Health and Environmental Hazards has several strategic
healthcare groups that have implemented programs and policies to
improve the health of rural veterans.
In particular, the Public Health Strategic Healthcare Group,
(PHSHCG) has addressed the needs of enrolled veterans living with human
immunodeficiency virus (HIV) residing in rural areas. For example,
employing a postage paid mail-back card allowing patients to self
report results of purified protein derivative (PPD) testing (for
exposure to mycobacterium tuberculosis), eliminates the need for rural
patients to make a return visit to the medical center. Care delivery
models which allow patients in rural areas to locally access routine
services such as blood specimen drawing through modification of CBOC
contracts and/or linkage with community-based programs located in rural
areas have been implemented.
Additionally, the Women Veterans Strategic Healthcare Group, which
is committed to providing the highest quality care to women veterans,
has continued to advocate for access for women's gender related care,
such as mammograms and obstetrical care must be provided within 1 hour
drive/50 miles, using non-VA providers when necessary (Handbook
1330.01, Proposed revisions 2007).
Through their work in national programs to improve the health of
all veterans, these strategic healthcare groups have implemented
programs and policies to improve the health of rural veterans.
The Department of Health and Human Services (HHS) and VA signed a
memorandum of understanding (MOU) in February 2003 to encourage
cooperation and resource sharing between the Indian Health Service
(IHS) and the VHA to deliver quality healthcare services and enhance
the health status of American Indian and Alaska Native (AI/AN)
veterans.
Outreach: Most networks are engaged in a variety of outreach
activities, including meetings and conferences with IHS program and
tribal representatives, VA membership in the Native American Healthcare
Network, VA participation in traditional Native American ceremonies,
transportation support to AI/AN, etc.
Clinical Programs: An example of clinical collaborations involves a
diabetes prevention program that has been developed jointly by VHA and
IHS staff in San Diego, Albuquerque, and Greater LA. The goal is to
reach Native Americans in their communities.
Education: VHA provides training programs to IHS staff and the
tribal community. In 2006, VHA delivered 145 training programs, of
which 90 were made available using satellite technology and 55 using
web-based technology. These educational programs will be continued in
2007, and VHA will also provide selected IHS staff an opportunity to
attend regional workshops.
Behavioral Health: The Behavioral Health Workgroup developed a
framework for AI/AN communities to assist returning Operations Enduring
Freedom and Iraqi Freedom (OEF/OIF) AI/AN servicemembers and veterans
reintegrate with their families and communities and readjust to
civilian life. The objective is to promote a community health model
that gives tools to Tribal communities and families to help returning
veterans address emerging adjustment reactions, traumatic stress, and
post traumatic stress disorder (PTSD), emphasizing recovery as the
goal. The Joint Committee has developed a slide presentation to be used
by outreach teams when addressing various Tribal veterans. There have
been briefings using the slide presentation in Montana, with
approximately 30 veterans now receiving services from VA.
Expanded Healthcare Services: At the local level, 10 VHA networks
are engaged in targeted initiatives aimed at providing a full continuum
of healthcare services, such as; health fairs, VA/IHS advisories, use
of health buddy, and education and/or shared services in substance
abuse, domestic violence programs, cardiac rehabilitation, dietetics,
behavioral medicine, etc.
Care Coordination: The VHA-IHS Shared Healthcare Workgroup has
drafted an Interdepartmental Coordinated Care Policy, the goal of which
is to optimize the quality, appropriateness and efficacy of the
healthcare services provided to eligible AI/AN veterans receiving care
from both VHA and IHS or Tribes; and to improve the patient's
satisfaction with the coordination of care between the two Departments.
Telemedicine: Telemedicine has proven to be extremely effective in
the treatment of PTSD in Alaskan Native villages. VA and IHS are
working to spread the use of telemedicine services by AI/AN veterans,
which will allow VA to bring physical and mental healthcare to the
tribes, especially those in remote areas of the country.
Traditional Healing: Some VHA facilities and vet centers have
incorporated traditional healing ceremonies along with modern methods
of treatment and counseling. As a national initiative, VA has sent over
500 letters to tribal leaders to ask them to provide information on
appropriate providers of traditional practices so that they may be
called upon for religious/spiritual care of AI/AN veterans.
Question 5(b): Has VA collaborated with HRSA on any of these
interventions?
Response: The Institute of Medicine (IOM) 2005 report Quality
Through Collaboration: The Future of Rural Healthcare did not
specifically recommend how rural veterans would benefit from a health
resources and services administration (HRSA), collaboration, however,
VHA has collaborated with Health and Human Services to address rural
veterans in several ways; we currently have a small number of contracts
with federally qualified health centers (FQHCs) and we have a MOU with
IHS.
In addition, rural veterans with HIV who live at a great distance
from the closest VA Medical Center were informed that they were
eligible to receive HIV/AIDS care through community-based HRSA clinics
who were recipients of Ryan White funding, if this care would be more
convenient for them.
Question 6: Hospital-at-Home. Since 1994, Johns Hopkins Hospital
has been developing a hospital-at-home model. In 2005, new research
released suggested that many of the patients could be treated just as
safely and effectively at home than in a hospital.
Question 6(a): Do you believe a program like this would work in
rural areas?
Response: The work of Johns Hopkins Hospital in this area is
commendable and adds to the weight of evidence supporting the direct
provision of care in the home to acutely ill older patients, when it is
safe and appropriate to do so. Caring for acutely ill patients via a
hospital-at-home program is an outreach program that is geographically
restricted to a defined radius (e.g. 25 miles) or set travel time (e.g.
20 minutes) from a suitably equipped acute hospital. As such, hospital-
at-home models as currently conceived are not a readily deployable
model for care in rural areas where distance, low population density
and staff recruitment issues make them difficult to implement. VA is
seeking to use telehealth to monitor such rural health patients and
enable them to self-manage their condition. This approach relies upon
early detection of patient deterioration and preemptive referral of
patients across the continuum of care. VHA's care coordination model is
conducive to this approach.
Although this may not be a model for all geographic areas, staffs
in the Office of Geriatrics and Extended Care who are charged with both
community-based care and with acute care for the elderly are interested
in promoting expansion of this model, as appropriate, within VA. Plans
are underway to initiate a hospital-at-home program at the New Orleans
VA by July 1 to partially address the shortage of VA hospital beds due
to Hurricane Katrina. Discussions have begun to explore a similar
undertaking in Honolulu, with possibly broader application throughout
the Hawaiian Island chain. Rural expansion from an urban center on
Oahu, and one based out of CBOCs as has been already discussed as a
second phase for New Orleans, will be logical next steps for assessing
the feasibility of migration of the model into more rural settings.
Question 7: Partnerships. To what extent is VA working with
existing state and federal healthcare providers, for example State
veterans homes or CMS designated Critical Access Hospitals, in rural
areas to coordinate and capitalize on limited resources available in
rural communities to maximize range of services? If this is not
occurring, is VA willing to explore coordinated efforts with these
types of government supported healthcare providers?
Response: VHA has united with existing State and Federal healthcare
providers to coordinate and capitalize on resources available in rural
communities and to maximize the range of services. Currently, VHA has a
relationship with 122 State-owned veteran's homes, 54 domiciliaries, 4
hospitals, and 2 adult daycare facilities. VA provides a per diem
payment to the facilities for veterans care. Approximately 75 of VA's
State home collaborations are in rural areas.
VHA also collaborates with FQHCs, including Community Health
Centers, at the local level based on the local needs. VA will continue
to collaborate and develop partnerships with various government and
nongovernmental organizations to meet the individual needs of veterans.
VHA will continue to partner with other agencies, including
collaboration by education and training on issues specific to providing
care to veterans. Through VHA's Office of Rural Health, we will further
explore ways to expand healthcare in rural areas.
Questions from Hon. Joe Donnelly to Dr. Michael J. Kussman
Acting Under Secretary for Health, U.S. Department of Veterans Affairs
Question 8: Elkhart County CBOC. Convenient access to local
healthcare for veterans is an important concern of both my constituents
and of this Committee. While the CARES Commission of 2004 set out
future priorities for facility management, CARES recommendations are
not always followed and are sometimes altered. Through conversations my
office and I have had with VA VISN 11 officials in Indiana, it is our
shared expectation to soon open a CBOC in Elkhart County, Indiana.
While an Elkhart County CBOC opening does not appear on the CARES
priority recommendations, according to these officials, the proposal to
open a CBOC in Elkhart County has successfully passed several
preliminary stages within the Department and is pending final approval
by the Secretary. VA officials in Indiana are optimistic that the
opening of a new CBOC could begin in early FY 2008. Further, if a new
CBOC is opened in Elkhart County, some constituents of mine are
concerned that the VA will require some veterans who live within the
county to receive care at a CBOC located in another county.
Question 8(a): Is the VA considering opening a new CBOC in Elkhart
County, Indiana? If so, at what stage in the process is this decision;
and if approved, when can the people of Elkhart County expect the
opening of the bidding process for management of the CBOC?
Response: The Elkhart County CBOC has been approved. Local VA
officials are working on the activation of the clinic. We will keep all
stakeholders informed as this proceeds.
Question 8(b): If a CBOC is opened in Elkhart County, will all
Elkhart County veterans have the opportunity to choose to receive care
at this new facility?
Response: The service area for the proposed Elkhart County CBOC
includes 100 percent of Elkhart County. All veterans within the county
may request care at the CBOC and will be accommodated based on
eligibility, clinic capacity, and the care requirements of the Veteran.
Question 9: Peru, Indiana CBOC. The Secretary's CARES Decision
included Peru, Indiana on the list of CBOC priority implementation.
Officials at VA VISN 11 hope that a new CBOC could be opened in the
Peru area during FY 2009. Is the VA considering opening a new CBOC in
Peru, Indiana? If so, at what stage in the approval process is this
decision; and if approved, when can the people of north central Indiana
expect this CBOC to open?
Response: A business plan has not been prepared by the VISN for a
CBOC in Peru, Indiana. The earliest that a CBOC for Peru could be
requested would be in FY 2009 and a business plan would be prepared at
that time.
Question 10: Fort Wayne Campus. The CARES Commission 2004 report
proposed closing the acute care and lieu services provided at the Fort
Wayne campus of the VA Northern Indiana Healthcare System, citing the
availability of tertiary care at VA facilities at Ann Arbor and
Indianapolis and initial low projections of anticipated demand for
inpatient care. However, since the report was published, projections
were updated and actually showed higher usage rates for the future. It
is my understanding that, as a result, the VA is reexamining the 2004
report's proposal regarding Fort Wayne. Many veterans in my district,
as well as many thousands more from across northern Indiana have come
to count on high-quality care and valuable patient-provider
relationships formed at the Fort Wayne inpatient facilities for meeting
their health needs. Further, directing veterans in northern Indiana to
seek care in Ann Arbor or Indianapolis would be a significant new
hurdle in receiving VA medical services. In light of the new
projections for the future use of the Fort Wayne inpatient services,
and the thousands of new Hoosier veterans who will need care connected
to their service in Operation Iraqi Freedom or Operation Enduring
Freedom, it seems to me that limiting the services provide by Fort
Wayne now would be counter-intuitive.
Question 10(a): What factors are being considered in the
reevaluation of the 2004 recommendation on Fort Wayne?
Response: Factors that are being considered in the analysis of
options for Fort Wayne include:
Access: Considers barriers whether imposed by geography,
disability, finances, or simply a lack of available services which can
compromise the quality, satisfaction, and coordination of care,
resulting in poor outcomes.
Flexibility: Measures each options ability to manage
change in demand.
Cost Effectiveness: Evaluates the total life cycle costs
for a project and then compares it against other viable project
alternatives.
Impact on Other VA Goals/Missions: Measures the impact on
other VA goals/Missions.
Risk of Implementation: Assesses risk on two dimensions,
the probability that the risk will occur and the impact of the risk.
Twenty-five individual risk factors are identified.
Question 10(b): When does the Department anticipate making a
permanent decision regarding the services provided by the Fort Wayne VA
hospital?
Response: The contractor will be submitting their final report in
August, 2007. The Secretary will make a decision after this time.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC
April 27, 2007
Michael J. Kussman, MD, MS, MACP
Acting Under Secretary for Health
U.S. Department of Veterans Affairs
Washington, DC 20420
Dear Dr. Kussman:
On Wednesday, April 18, 2007, Dr. Gerald Cross testified before the
Subcommittee on Health. As a followup to the hearing, I am requesting
the following questions be answered in written form for the record:
1. Please describe the process that VA undergoes to develop a new
Community-Based Outpatient Clinic (CBOC) and obtain all necessary
approvals. How long does each phase of that process take?
2. Have any new CBOCs been proposed since the May '04 CARES
report? Please identify where they are, and when they are scheduled to
be activated.
3. Have decisions been made not to proceed with any of the 156
CBOCs proposed in the May '04 CARES report? If so, please explain
further.
4. Does VA currently impose enrollment limits or caps on CBOCs?
If so, how does that work?
5. How would you characterize the limitations on marketing new
CBOC enrollments? How is that implemented logistically?
6. What happens if OEF/OIF veterans want to enroll in a CBOC that
has been prevented from enrolling additional new veterans?
7. Some CBOCs offer mental health services through VA staff and
others though contractor personnel. What are the criteria that
determine who provides mental health services in a given location?
8. What is the average length of time it takes for a contract
provider to be credentialed by VA? Are there any significant issues
that cause delays in provider credentialing throughout VA?
9. Mr. Behrman testified that there were a limited number of
successful collaborations between VA and Community Health Centers.
However, the contracts were discontinued. Why were these contracts
discontinued? Should this type of partnership be expanded to other
rural States?
10. Has VA established policies whereby VA will contract with
Critical Access Hospitals and other primary care providers in rural
areas to provide primary and preventive healthcare to rural veterans
who lack reasonable access to VA facilities?
11. Does VA have performance measures in place to evaluate how
effective the Vet Center program is in providing quality readjustment
counseling and removing unnecessary barriers to care for veterans and
family members?
12. VA's testimony stated: ``VA continues to look for ways to
collaborate with complementary Federal efforts to address the needs of
healthcare for rural veterans. We also have partnerships with HHS,
including the Indian Health Services and Office of Rural Health
providing care in rural communities.'' Where are the current
collaborative efforts?
13. What percent of rural healthcare is provided through contract
care?
14. What are the challenges of providing care to the aging veteran
population in rural areas? How is VA addressing these challenges?
15. How does VA differentiate between a rural veteran traveling
over an hour to a healthcare facility, and a veteran in an urban area
traveling over an hour to a healthcare clinic in rush hour?
16. Public Law 109-461 directs the Secretary to expand mental
health services in outpatient clinics. What is VA doing to expand this
capability? How many CBOCs had mental health capabilities in April 2005
and how many have mental health capabilities today?
17. What are the challenges in providing mental health services in
rural communities?
18. VA Central Office reviews waiting times. How do the waiting
times for specialty care in rural areas compare with those in urban
centers?
19. Musculoskeletal ailments (principally joint and back
disorders) are among the top health problems of veterans returning from
Iraq and Afghanistan according to a November 2006 VA study. Currently,
chiropractic care is only available at about 20% of all VA facilities
and most veterans do not have access to care, despite back issues being
the ailment that affects the most veterans. Has the VA developed plans
on how to further implement chiropractic care into the VA healthcare
system?
20. What is the status--and, if available, the initial findings--
of the VA's Project HERO demonstration project?
21. The VA's March 30th report to Congress detailing CBOCs
approved for activation only lists 6 CBOCs approved for an FY08
opening. Will more be approved? Was the proposed VISN-approved CBOC for
Hutchinson, KS turned down or is it still under consideration by the
VA?
Additionally, Dr. Petzel and Dr. Darkins accompanied Dr. Cross. I
would request that they respond to the following for the record:
1. Dr. Petzel: One may consider VISN 23 as one of the most rural
VISNs in the VA system. How has VISN 23 improved access for veterans?
Have you been working with other VISN Directors to share some of the
best practices from VISN 23 in providing access to veterans?
2. Dr. Darkins: How can telemedicine help provide access to
veterans? What are the limitations of telemedicine? Are there any
circumstances in which you would not recommend the use of telemedicine?
Respectfully,
Jeff Miller
Ranking Republican Member
__________
Questions from Hon. Jeff Miller, Ranking Republican Member
Subcommittee on Health, to Dr. Michael Kussman, Acting
Under Secretary of Health, Veterans Health Administration
U.S. Department of Veterans Affairs
Question 1(a): Please describe the process that VA undergoes to
develop a new Community-Based Outpatient Clinic (CBOC) and obtain all
necessary approvals.
Response: Planning process. CBOC planning is a partnership between
the Veterans Integrated Service Networks (VISN) and Headquarters'
strategic planning process. This allows decisions regarding CBOC need
and priorities to be made in the context of available resources, as
well as local market circumstances and veteran preferences. During the
Capital Asset Realignment for Enhanced Service (CARES) planning
process, the VISNs identified 242 CBOCs to potentially address access
and space issues. Of these 242 CBOCs, 156 were prioritized and
published in the Secretary's CARES Decision Document in April 2004
since they met the requirements of:
Located in a market with less than 70 percent of
enrollees within the access guidelines (distance a veteran is required
to travel to receive care) and having more than 7 DoD Clinic Stops
planned for the CBOC.
Located in a market with less than 70 percent of
enrollees within access guidelines, and located in a rural or highly
rural county.
Part of a VA/Department of Defense (DoD) collaboration.
Needed as a result of a CARES realignment decision.
Needed to relieve space constraints at the parent
facility and located within 20 minutes of the parent facility.
Plans for activating CBOCs are included in the VISNs' strategic
plans, and are updated with the most current data after the strategic
plan submission at the request of the Deputy Under Secretary for Health
for Operations and Management (DUSHOM) for the purposes of forecasting
activation of CBOCs for budget cycles. CBOCs are primarily funded
through existing VISN resources. As a result, planning for CBOCs is
also dependant on fiscal year (FY) budget forecasts and allocations.
VISN chief fiscal officers must certify that the facility can maintain
services given current budget scenarios at the time the CBOC business
plan is being reviewed against national planning criteria.
Review process. The review process for new CBOCs is documented in
the Veteran Health Administration (VHA) Handbook 1006.1 Planning and
Activation of CBOCs and consists of the following:
VISNs submit CBOC business plans for review against
national planning criteria. VISNs submit plans for CBOCs that were (1)
identified in CARES, (2) identified in the network strategic plan and/
or updates provided to DUSHOM on plans for CBOC activation. VISNs
certify that the CBOC can be implemented within existing funds once
approved.
National review panels (NRP) convene to review proposals
against national planning criteria as below:
Located in a market not meeting VA access guidelines
Space deficits at the parent facility
Number of users and enrollees
Market penetration
Unique considerations--such as: targeted minority veteran
populations, geographic barriers, highly rural and/or low population
density, medically underserved, DoD sharing opportunity, parking and
transit issues at parent facility
Cost effectiveness of proposed site
Impact on specialty care waiting times
The NRP submits results of review with recommendations to
DUSHOM.
Approval: Business plans for new CBOCs that are recommended for
approval by the national review panel require Under Secretary for
Health (USH) and Secretary approvals and Congressional notification.
The process is as follows:
DUSHOM obtains approvals from USH and Secretary
Office of Management and Budget (OMB) review
Congressional notification
Question 1(b): How long does each phase of that process take?
Response: Timeframes involved in the review process are estimated
below:
Develop CBOC business plans:
2-3 months
NPR review:
3 months
USH and Secretary approval:
2-3 months
Question 2: Have any new CBOCs been proposed since the May '04
CARES report? Please identify where they are, and when they are
scheduled to be activated.
Response: Since the May 2004 CARES report, VA has opened or
approved to open 88 CBOCs. The following list shows where they are and
when they are scheduled to open in FY 2007 or 2008.
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VISN Clinic State Approved Status
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2 Warsaw NY Jun-04 Open
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4 Bangor PA Jun-04 Open
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4 Dover DE Mar-06 Opening in FY2007
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4 Fayette PA Jun-04 Open
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4 Gloucester NJ Jun-04 Open
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4 Monongalia County WV May-07 Opening in FY2007
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4 Venango PA Jun-04 Open
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4 Warren PA Jun-04 Open
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5 Andrews AFB MD May-07 Opening in FY2008
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5 Ft. Detrick MD May-07 Opening in FY2008
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6 CharlotteVAille May-07 Opening in FY2008
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6 Franklin NC Mar-06 Opening in FY2008
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6 Hamlet NC Mar-06 Opening in FY2008
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6 Hickory NC Mar-06 Opening in FY2008
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6 Lynchburg VA Mar-06 Opening in FY2008
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6 Norfolk VA Mar-06 Opening in FY2007
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7 Aiken SC May-07 Opening in FY2008
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7 Athens GA Mar-06 Open
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7 Bessemer AL Mar-06 Opening in FY2007
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7 ChildersbALg May-07 Opening in FY2007
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7 Goose Creek SC Sep-04 Open
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7 Spartanburg SC May-07 Opening in FY2008
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7 Stockbridge GA May-07 Opening in FY2007
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8 Camden CoGAty May-07 Opening in FY2008
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8 Jackson County FL May-07 Opening in FY2008
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8 Putnam County FL May-07 Opening in FY2008
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8 Sumter--The Villages FL Sep-04 Open
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9 Berea KY May-07 Opening in FY2007
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9 CovingtonTN Sep-04 Open
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9 Dupont KY Jun-04 Open
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9 Grayson County KY May-07 Opening in FY2008
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9 Hamblen TN Mar-06 Opening in FY2007
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9 Hawkins County TN May-07 Opening in FY2008
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9 Hazard KY Mar-06 Opening in FY2008
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9 Madison County TN May-07 Opening in FY2008
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9 Memphis--South Clinic TN Jun-04 Open
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9 Standiford KY Jun-04 Open
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9 Vine Hill TN Jun-04 Open
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9 Morehead KY Sep-04 Open
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10 CambridgeOH Mar-06 Open
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10 Florence/Boone City KY Mar-06 Open
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10 Hamilton OH May-07 Opening in FY2007
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10 Marion OH Jun-04 Open
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10 New Philadelphia OH Jun-04 Open
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10 Newark OH Mar-06 Open
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10 Parma OH May-07 Opening in FY2008
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10 Ravenna OH Jun-04 Open
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11 Alpena County MI May-07 Opening in FY2008
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11 Clare CouMIy May-07 Opening in FY2008
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11 Elkhart County IN May-07 Opening in FY2007
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15 Daviess County KY May-07 Opening in FY2007
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15 Graves County KY Sep-04 Opening in FY2009
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15 Hopkins County KY Sep-04 Open
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15 Hutchinson KS May-07 Opening in FY2008
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15 Jefferson City MO May-07 Opening in FY2008
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15 Knox County IN May-07 Opening in FY2008
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16 Branson MO May-07 Opening in FY2008
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16 Conroe TX Mar-06 Open
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16 Eglin FL Feb-06 Opening in FY2008
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16 Hammond LA Feb-06 Open
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16 La Place/St Johns LA Feb-06 Open
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16 Pine Bluff AR May-07 Opening in FY2008
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16 Slidell LA Feb-06 Open
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17 San Antonio--VA/DoD Joint TX Sep-04 Open
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18 Miami/Globe AZ Mar-06 Opening in FY2008
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18 NW Tucson AZ Mar-06 Opening in FY2007
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18 SE Tucson AZ Mar-06 Opening in FY2008
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19 Cut Bank MT May-07 Opening in FY2008
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19 Lewistown MT May-07 Opening in FY2008
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19 Western Salt Lake City VallUT May-07 Opening in FY2008
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20 Canyon CiID Mar-06 Opening in FY2007
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20 North Idaho ID May-07 Opening in FY2008
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20 Northwest WA WA May-07 Opening in FY2007
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20 Central WWAhington Feb-07 Opening in FY2007
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21 American Samoa Mar-06 Opening in FY2007
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21 Fallon NV Mar-06 Opening in FY2007
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22 Orange CA Mar-06 Opening in FY2007
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23 Bellevue NE May-07 Opening in FY2007
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23 Bemidji--Fosston MN Mar-06 Opening in FY2007
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23 Carroll IA May-07 Opening in FY2007
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23 Cedar RapIAs May-07 Opening in FY2007
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23 Holdredge NE Mar-06 Opening in FY2007
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23 Marshalltown IA May-07 Opening in FY2007
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23 Shenandoah IA May-07 Opening in FY2007
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23 Spirit Lake IA Mar-06 Opening in FY2007
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23 Wagner SD May-07 Opening in FY2007
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23 Watertown SD May-07 Opening in FY2007
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23 Western WI (Rice Lake) WI Mar-06 Opening in FY2007
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Question 3: Have decisions been made not to proceed with any of the
156 CBOCs proposed in May '04 CARES report? If so, please explain
further.
Response: The only CARES CBOCs for which a decision has been made
not to proceed were in VISN 9. VISN 9, along with their stakeholders,
embarked on a reassessment of all proposed CBOCs analyzing current
demographics and comparing to national criteria. Based on this review,
some did not meet national criteria, and others had overlapping
coverage. The sites in VISN 9 deleted from the CARES priority list are:
Holston Medical Clinic, TN
Pennington Gap Clinic, VA
Thompson Clinic, VA
Haysi Clinic, VA
Davenport Clinic, VA
Davis Clinic, VA
West Lee County, VA
Pontotoc County, MS
Tunica, MS
Grenada, MS
Wynne-Cross County, AR
Glasgow, KY
Giles County/Pulaski, TN
London, KY
Question 4: Does VA currently impose enrollment limits or caps on
CBOCs? If so, how does that work?
Response: While there is no national guidelines on when a CBOC
would be declared ``at capacity,'' a VHA facility might infrequently
determine that they are at capacity based on the number of patients per
physician and other local factors. In these rare instances new patients
would be cared for at the nearest VA Medical Center. This would apply
to new patients only and not existing patients, and would generally be
a short term in nature lasting only until additional resources in the
form of providers and/or space can be identified.
Question 5: How would you characterize the limitations on marketing
new CBOC enrollments? How is that implemented logistically?
Response: A public announcement in the local press is made that a
CBOC has been approved. While the site is being finalized the medical
center prepares letters that are sent to existing veterans who reside
in the new service area. These veterans can elect to change their
primary care provider to the new CBOC site or remain at the parent
site.
Marketing new enrollment is not done, beyond the notification of an
opened CBOC through press releases and ground breaking. New veterans
who decide to use the VA for care complete an enrollment process. As
part of that process they have the choice of selecting the new CBOC as
their primary care site.
Question 6: What happens if OEF/OIF veterans want to enroll in a
CBOC that has been prevented from enrolling additional new veterans?
Response: Cases in which Operation Enduring Freedom/Operation Iraqi
Freedom (OEF/OIF) veterans are not able to be seen at the clinic of
their choice are very rare, but in these rare cases the veteran may
need to be seen at the nearest VA Medical Center (VAMC). A small number
of CBOCs across the country are at capacity and are referring patients
to the nearest medical center for treatment. For example, if the OEF/
OIF veteran has emergent care needs, the parent VAMC and CBOC will make
every effort to accommodate.
Question 7: Some CBOCs offer mental health services through VA
staff and others through contractor personnel. What are the criteria
that determine who provides mental health services in a given location?
Response: All CBOCs must provide mental health services either by
providing services onsite, purchasing services through a contract or
providing telepsychiatry/telemedicine. The method for providing the
care is determined locally based on the availability of services in the
community, the availability of healthcare staff in the community and
cost effectiveness.
Question 8(a): What is the average length of time it takes for a
contract provider to be credentialed by VA?
Response: There is no distinction made in the credentialing of
contract providers from other providers delivering care to veterans.
There are approximately 15 DoD licensed independent providers appointed
to the medical staff of VA facilities under contract or fee basis care
authorities out of almost 61 DoD licensed independent providers.
Contract providers can be credentialed for a full appointment,
expedited appointment, or a temporary appointment for urgent patient
care needs. Additionally, if a disaster is declared, contract providers
can be appointed under the disaster credentialing and privileging
procedures defined in facility policies.
For initial appointment to the medical staff, the average length of
time for the credentialing process to be completed is 6 to 8 weeks.
This time is reduced by half for those providers who were previously
credentialed by any VA facility through VetPro. VetPro is VHA's
electronic credentialing file that maintains the verifications of
education, training, licensure, certifications as well as reference and
personal history information. Providers who have been previously
credentialed through VetPro only need to be brought up to date from
their last VA appointment.
Temporary appointments to the medical staff for urgent patient care
needs can be done in a matter of a day or two since there only needs to
be verification of one full, current, active, unrestricted license,
confirmation of comparable clinical privileges, and one reference
obtained. Facilities have 45 workdays to complete the credentialing of
these providers which is frequently expedited. Of the almost 61 DoD
licensed independent providers, 59 have current temporary appointments
for urgent patient care needs with 47 of them being contractors, fee
basis or telemedicine providers.
Question 8(a): Are there any significant issues that cause delays
in provider credentialing throughout VA?
Response: The largest delay in provider credentialing is the
provider themselves submitting the complete application so that
verification can be initiated. The ``clock'' does not start until the
application is submitted by the provider so the 6 to 8 week period to
credential a provider does not even begin until an application is
complete.
Temporary appointments for urgent patient care needs can be done
without an application, but the provider needs to submit a complete
application upon arrival at the medical center. VA's experience is no
different than other organizations in that delays are encountered when
references do not respond in a timely manner or verification must be
obtained from overseas. VA policy does allow for documentation of a
good faith effort in these instances. Policy states that if primary
source documents are not received, after a minimum of two requests,
full written documentation of the efforts to obtain verification will
be placed in the credentialing folder in lieu of the document sought.
It is suggested that no more than 30 days elapse between each request
before the attempt is deemed unsuccessful. The practitioner should be
notified and assist in obtaining the necessary documentation through a
secondary source.
Question 9: Mr. Behrman testified that there were a limited number
of successful collaborations between VA and Community Health Centers.
However, the contracts were discontinued. Why were these contracts
discontinued? Should this type of partnership be expanded to other
rural States?
Response: We have worked with the National Rural Health Association
(NRHA), whom Mr. Behrman represents, in efforts to gain more detailed
information on the locations of the discontinued Community Health
Centers (CHC) contracts they sited. However, the NRHA was unable to
provide the needed information thus VHA can not address the specific
contracts in question.
VHA currently has a small number of contracts with the CHCs, and
other Federally Qualified Health Centers (FQHCs). We are, and continue,
to collaborate and develop partnerships with various government and
nongovernmental organizations as we explore ways to expand healthcare
in rural areas as part of our strategic initiatives in VA's Office of
Rural Health. It is not our position that collaboration solely with
FOHCs should be adopted at a national level, for they vary in scope,
types of expertise and services. Rather, collaboration is best done at
the local levels based on the needs, services and expertise available.
Question 10: Has VA established policies whereby VA will contract
with Critical Access Hospitals and other primary care providers in
rural areas to provide primary and preventive healthcare to rural
veterans who lack reasonable access to VA facilities?
Response: VHA is currently establishing an Office of Rural
Healthcare within the Office of the Assistant Deputy Under Secretary
for Health for Policy and Planning. This new office will develop
strategies for improving access to rural veterans that will be
implemented throughout the system.
Question 11: Does VA have performance measures in place to evaluate
how effective the Vet Center program is in providing quality
readjustment counseling and removing unnecessary barriers to care for
veterans and family members?
Response: Vet Center program services are monitored through several
evidence-based measures to ensure ease of access for veterans and
family members and the provision of quality readjustment counseling.
Vet Center clinical measures include the global assessment of
functioning (GAF) scale, quality of life measures, client waiting
times, veteran satisfaction and employee satisfaction. Vet Centers do
not have waiting lists and veterans who call or walk in may be seen the
same day by a counselor for an assessment and to schedule a followup
appointment. Vet Centers also maintain nontraditional hours in the
evening or on the weekends when necessary to accommodate the working
schedules of veterans and family members. Vet Centers are the gold
standard for client satisfaction in VA. Over 99 percent of all veterans
surveyed consistently report being highly satisfied with services
received and that they would refer another veteran to the Vet Center.
Based on the results of the One VA Employee Satisfaction Survey, Vet
Center employees consistently exceed other VHA employees in outcomes.
Results showed Vet Center employees have a significantly higher level
of job satisfaction.
Question 12: VA's testimony stated: ``VA continues to look for ways
to collaborate with complementary Federal efforts to address the needs
of healthcare for rural veterans. We also have partnerships with HHS,
including the Indian Health Service and Office of Rural Health
providing healthcare in rural communities.'' Where are the current
collaborative efforts?
Response: The Department of Health and Human Services (HHS) and VA
signed a memorandum of understanding (MOU) in February 2003 to
encourage cooperation and resource sharing between the Indian Health
Service (IHS) and VHA to deliver quality healthcare services and
enhance the health status of American Indian and Alaska Native (AI/AN)
veterans.
Outreach. Most networks are engaged in a variety of outreach
activities, including meetings and conferences with IHS program and
tribal representatives, VA membership in the Native American Healthcare
Network, VA participation in traditional Native American ceremonies,
transportation support to AI/AN, etc.
Clinical Programs. An example of clinical collaborations involves a
diabetes prevention program that has been developed jointly by VHA and
IHS staff in San Diego, Albuquerque, and Greater Los Angeles. The goal
is to reach Native Americans in their communities.
Education. VHA Employee Education System (EES) provides training
programs to IHS staff and the tribal community. In 2006, VHA delivered
145 training programs, of which 90 were made available using satellite
technology and 55 using web-based technology. These educational
programs will be continued in 2007, and VHA will also provide selected
IHS staff an opportunity to attend regional EES workshops.
Behavioral Health. The Behavioral Health Workgroup developed a
framework for AI/AN communities to assist returning OEF/OIF AI/AN
servicemembers and veterans reintegrate with their families and
communities and readjust to civilian life. The objective is to promote
a community health model that gives tools to Tribal communities and
families to help returning veterans address emerging adjustment
reactions, traumatic stress, and post-traumatic stress disorder (PTSD),
emphasizing recovery as the goal. The Joint Committee has developed a
slide presentation to be used by outreach teams when addressing various
Tribal veterans. There have been briefings using the slide presentation
in Montana, with approximately 30 veterans now receiving services from
VA.
Expanded Healthcare Services. At the local level, 10 VHA networks
are engaged in targeted initiatives aimed at providing a full continuum
of healthcare services, such as; health fairs, VA/IHS advisories, use
of health buddy, and education and/or shared services in substance
abuse, domestic violence programs, cardiac rehabilitation, dietetics,
behavioral medicine, etc.
Care Coordination. The VHA-IHS Shared Healthcare Workgroup has
drafted an Interdepartmental Coordinated Care Policy, the goal of which
is to optimize the quality, appropriateness and efficacy of the
healthcare services provided to eligible AI/AN veterans receiving care
from both VHA and IHS or Tribes; and to improve the patient's
satisfaction with the coordination of care between the two Departments.
Telemedicine. Telemedicine has proven to be extremely effective in
the treatment of PTSD in Alaskan Native villages. VA and IHS are
working to spread the use of telemedicine services by AI/AN veterans,
which will allow VA to bring physical and mental healthcare to the
tribes, especially those in remote areas of the country.
Traditional Healing. Some VHA facilities and Vet Centers have
incorporated traditional healing ceremonies along with modern methods
of treatment and counseling. As a national initiative, VA has sent over
500 letters to Tribal leaders to ask them to provide information on
appropriate providers of traditional practices so that they may be
called upon for religious/spiritual care of AI/AN veterans.
VHA's Office of Rural Health (ORH) has also established a working
relationship with and sought consultation from HHS's Office of Rural
Health. As the office matures, VHA's plan is to work closely with HHS
to maximize the opportunities in a range of areas including education,
training, research, and access.
Question 13: What percent of rural healthcare is provided through
contract care?
Response: The National Fee Support Office, which oversees the
processes of determining eligibility and payment of non-VA provided
healthcare, does not differentiate between urban/rural care at this
time. The Office of Rural Health will be performing an analysis of fee
basis services and will be able to provide further data at the
completion of the study.
Question 14: What are the challenges of providing care to the aging
veteran population in rural areas? How is VA addressing these
challenges?
Response: Frail, rural older veterans may be at particular risk of
illness, disability, institutional placement and death if they receive
a portion of their care from a more centralized urban VAMC. These rural
elderly veterans, in addition to their usual burden of disability
risks, have less access to VAMC-based care options. Moreover, non-VA
health and social services--besides being fragmented from the client's
perspective--are less available or nonexistent in rural areas (Dwyer,
Lee and Coward 1990). Additional challenges include: long travel
distances and lack of transportation services, frail, elderly primary
caregivers with few resources, a lower level of service awareness among
the elderly, and fewer financial resources.
VA is addressing these challenges with its shift from a hospital-
driven healthcare system to an integrated delivery system that
emphasizes a full continuum of care. The strategic direction for
providing services to veterans residing in rural areas is to provide
non-institutional care; to bring care into veterans' homes and home-
like settings. Options include:
Integration of care coordination and home telehealth into
home-based primary care to expand coverage into rural areas;
Pilot program on improvement of caregiver assistance
services;
Collaboration with Administration on Aging and IHS for
home-based primary care outreach and caregiver support;
Referral to and purchase of community nursing home, home
care, hospice and adult day healthcare services;
Promotion of hospice-veteran partnerships to improve
veteran access to community hospice care in rural areas;
Development of medical foster home program, where
veterans can receive an array of services including home-based primary
care and community hospice care in a supportive home environment in
their own community;
Establishing satellite home-based primary care programs
at remote sites such as VA CBOCs; and
Development of a model of rural longitudinal care
management.
Question 15: How does VA differentiate between a rural veteran
traveling over an hour to a healthcare facility and a veteran in an
urban area traveling over an hour to a healthcare clinic in rush hour?
Response: VHA Planning Systems and Support Group (PSSG)
differentiate travel time between rural and urban by using geographic
information software (GIS). These travel times are determined based on
road type and are adjusted using survey data from the annual urban
mobility report and civilian population densities. Seasonal and daily
adjustments (e.g. rush hour or weather), cannot be taken into account
on a national scale, thus are not reflected in the drive time analysis.
Therefore, VA cannot calculate the effect that rush hour, or other
daily fluctuations, may have on either urban or rural veterans commute
time. However, the involvement of VISNs in the planning process
provides a mechanism for this type of information to be considered.
Question 16: Public Law 109-461 directs the Secretary to expand
mental health services in outpatient clinics. What is VA doing to
expand this capability? How many CBOCs had mental health capabilities
in April 2005 and how many have mental health capabilities today?
Response: Mental health services are currently available at all VHA
outpatient clinics either from primary care staff, who are trained to
manage many common mental health problems, or from mental health
specialists, who manage the more difficult cases. To expand the
capability for specialty mental health, VHA has distributed $42.7
million to 301 CBOCs since FY 2005 for mental health professionals to
those clinics where there was a need. Eight million dollars in
telemedicine equipment has been sent to base facilities and their
corresponding CBOCs as infrastructure to provide telemental healthcare
where direct access to mental health specialists is unavailable. In
addition, VHA has allocated $37.8 million in FY 2007 to 92 VA
facilities to provide mental health specialists who will be integrated
into existing primary care clinics.
In April 2005 (end of the second quarter), 315 of 408 CBOCs (77
percent) serving more than 1,500 unique veterans provided substantive
mental health specialty services (i.e. 10% or more of the visits were
in mental health clinics). In April 2007, 429 out of 449 CBOCs (96
percent) had reached that standard.
Question 17: What are the challenges in providing mental health
services in rural communities?
Response: While CBOCs have been the anchor for VHA's efforts to
expand access to veterans in rural areas we have encountered some
challenges, such as:
Availability of qualified mental health professionals in
small rural communities is often limited.
Very small rural CBOCs may require mental health
specialists too infrequently to justify even part-time on-site mental
health staff.
VA salaries at times are not competitive in specific
locations, both rural and urban.
Transportation to and from CBOCs is problematic for many
veterans living in sparse population areas. However, telemental health
at remote clinics, where feasible, has proven to be convenient and is
generally well accepted by veterans.
VHA's CBOCs are complemented by contracts in the
community for all physician specialty services, depending on the
location of the CBOC and the availability of specialists in the area.
Some contract CBOCs prefer using their own mental health staff rather
than accepting VA providers, a situation which may present
communication barriers with veterans or with VA staffed settings.
VHA has used fee-basis care with private healthcare
providers in smaller or more remote communities for many years. Quality
control of fee basis care is difficult to achieve in part because these
providers do not have access to VA's electronic medical record system.
Question 18: VA Central Office reviews waiting times. How do the
waiting times of specialty care in rural areas compare with those in
urban areas?
Response: Appointments are made within 30 days for rural areas 96
percent of the time. For highly rural areas 92 percent of appointments
are made within 30 days. Urban CBOCs appointments are made within 30
days 94 percent of the time. These data are for specialty care using
the 47 specialty clinics out of the 50 from FY 2007 thru February 2007.
Question 19: Musculoskeletal ailments (principally joint and back
disorders) are among the top health problems of veterans returning from
Iraq and Afghanistan according to a November 2006 VA study. Currently,
chiropractic care is only available at about 20 percent of all VA
facilities and most veterans do not have access to care, despite back
issues being the ailment that affects the most veterans. Has VA
developed plans on how to further implement chiropractic care into the
VA healthcare system?
Response: Yes. In accordance with Public Law 107-135, VA is
providing chiropractic care in each of the 21 VISNs and presently has
30 chiropractors across the country. Additionally, VHA established the
Chiropractic Field Advisory Committee (FAC) to provide advice on
clinical and administrative issues relating to chiropractic care for
veterans and to serve as a communication channel between field-based
practitioners and VHA Central Office. The FAC assists with identifying
and providing data for evaluating the demographics of chiropractic
care. Chiropractic care is included in the medical benefits package,
the standard health benefits plan generally available to all enrolled
veterans. When the residence of the veteran is geographically distant
from a VHA site providing on-station chiropractic care, the outpatient
fee-basis care program is used to provide these services through
community chiropractors.
Question 20: What is the status--and, if available, the initial
findings--of the VA's Project HERO demonstration project?
Response: VA Project HERO (Healthcare Effectiveness through
Resource Optimization) is a demonstration project that is being piloted
in selected VISNs to maximize the care VA provides directly and better
manage fee care. The ultimate goal of Project HERO is to ensure that
all care delivered by VA--whether through VA providers or through
community partners--is of the same quality and consistency for
veterans.
VA issued a request for proposals (RFP) for a Project HERO
specialty care provider network on January 12, 2007 and vendor
proposals were received May 2, 2007 and are in the evaluation process.
Contract award is anticipated in July 2007. This RFP applies only to
fee care, which is care that is already being purchased and provided
outside of the VA health system.
The Project HERO Program Office and VA acquisitions team met with
vendors during due diligence sessions in March 2007. Due diligence
sessions offered potential vendors the opportunity to learn more about
VA's requirements and to ask specific questions related to their
proposed solution. Many industry leaders participated in the sessions
with representatives from the participating VISNs, the Project HERO
Program Office and other representatives from VA and VHA.
In anticipation of the demonstration, the Project HERO Program
Office is also conducting financial modeling activities to identify
areas of potential cost savings under Project HERO. Using historical
fee usage and cost data as well as projection rates from the VA
Enrollee Healthcare Projection model, the Project HERO Program Office
has been able to identify breakeven points for certain inpatient
clinical areas and geographic locations (VAMCs). The outpatient model
is currently being completed. Preliminary results from our inpatient
financial modeling efforts indicate that there are potential areas for
cost savings under Project HERO.
In addition to financial modeling efforts, the Project HERO Program
Management Office is also working with representatives from each of the
participating VISNs to identify opportunities to standardize and
improve fee business process and contract administration procedures. VA
anticipates Project HERO will contribute to current efforts to
standardize and optimize fee business processes.
A Project HERO Governing Board, which includes senior leadership
from VHA and participating VISNs, will oversee the demonstration to
ensure that veterans continue to receive high quality care, and will
review and approve any change in the terms, conditions and quantities
of Project HERO contracts. The Project HERO Governing Board will
regularly track and monitor Project HERO cost, quality, safety, vendor
performance and other data relevant to the demonstration to ensure that
Project HERO is meeting the goals and objectives outlined in Public Law
109-305. The Project HERO Program Office will prepare quarterly and
annual reports monitoring key elements of the demonstration including:
costs, the quality of care provided, veteran satisfaction, impact on
academic affiliates, clinical information sharing, and financial
analysis.
Question 21: The VA's March 30th report to Congress detailing CBOCs
approved for activation only lists 6 CBOCs approved for an FY08
opening. Will more be approved? Was the proposed VISN-approved CBOC for
Hutchinson, KS turned down or is it still under consideration by the
VA?
Response: The VA's directive on establishment of new CBOCs is
currently being revised. The Hutchinson, Kansas CBOC has been approved
and VA anticipates its opening in FY 2008.
Question 22: One may consider VISN 23 as one of the most rural
VISNs in the VA system. How has VISN 23 improved access for veterans?
Have you been working with other VISN Directors to share some of the
best practices from VISN 23 in providing access to veterans?
Response: VISN 23's primary method to improve rural access has been
to establish a network of CBOCs. Since the inception of the VISN
structure in 1995, VISN 23 has opened 36 CBOCs and/or outreach clinics.
VISN 23 provides mental health services in all of these locations by a
combination of telepsychiatry and on-site services. VISN 23 had 21
additional CBOCs approved under CARES. Three of these have opened and
three more will open this fiscal year. Several of these clinics are on
remote American Indian Reservations in western South Dakota.
The other major modality for us to reach rural veterans is telehome
healthcare. This program provides for monitoring and treatment of
patients in their homes by using remote monitoring equipment, the
Internet and multiple voice or television communication.
We also use case management and transportation networks operated by
the service organizations and counties to facilitate rural veteran
access.
The success of the CBOCs in providing better rural access has been
widely shared across all of the networks. Telehome health or care
coordination, as the program is known within VHA, has a very active
program office that has been very effective in developing and promoting
this modality.
Question 23: How can telemedicine help provide access to veterans?
What are the limitations of telemedicine? Are there circumstances in
which you would not recommend the use of telemedicine?
Response: Telemedicine enables changes to take place in the
location of care such that healthcare access is increased by removing
the travel component of a clinical encounter for either the patient, or
for the healthcare practitioner who is providing consultation/care.
Therefore, when it is an appropriate tool to use, telemedicine can make
healthcare needs better match the available resources and in doing so
take services out into remote locations.
Generally accepted limitations to telemedicine relate to the level
of encounter that can take place between patient and healthcare
practitioner with respect to clinical examination and restrictions that
lack of telecommunications bandwidth imposes in providing care in
certain areas.
Telemedicine applications that are recommended for national
deployment in VHA are ones in which the necessary clinical, technology
and business processes have been resolved to ensure they are
appropriate, safe and effective to meet the underlying patient care
need for which they have been created. The corollary of this is that
ones that are not deemed appropriate, safe and effective to meet a
defined patient need would not be recommended.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC
May 2, 2007
Maurice Huguley
Legislative Analyst
Office of the Deputy Assistant Secretary for Legislation for Human
Services
U.S. Department of Health and Human Services
Washington, DC 20201
Dear Mr. Huguley:
In reference to our Subcommittee on Health hearing ``Access to VA
Healthcare: How Easy is it for Veterans--Addressing the Gaps'' held on
April 18, 2007, I would appreciate it if you could answer the enclosed
hearing question by the close of business on June 5, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Question from Hon. Phil Hare, Subcommittee on
Health, to Maurice Huguley, Legislative Analyst, Office of
Deputy Assistant Secretary for Legislation for Human Services
U.S. Department of Health and Human Services
Question: I represent a congressional district with a lot of rural
areas. You were talking about transportation, and you mentioned in your
testimony that there are significant transportation barriers that
affect the coordination of services. I wonder if you could maybe
elaborate on that and what has HHS done to address the issue of
providing transportation to rural patients?
Response: The Department recognizes the special barriers rural
residents face in obtaining needed services and addresses
transportation issues in a variety of ways within its programs. Within
HRSA, the Bureau of Primary Healthcare (BPHC) funds the Health Centers
Program. Health centers address the transportation issue in various
ways, including: providing rides to/from the health center in center-
owned vans; providing clients with public transportation vouchers; and/
or providing clients with cab fare from a ``taxi fund.'' Health centers
are required to provide transportation services as part of the center's
``enabling services.'' Specifically, the enabling services section of
the health center authorizing legislation includes transportation
within the definition of ``required primary health services.'' HRSA
also administers the Ryan White Program. Parts A, B, and C of the Ryan
White Program provide funding for ``support services.'' The legislation
defines support services as those services ``needed for individuals
with HIV/AIDS to achieve their medical outcomes (such as respite care,
outreach services, medical transportation, and linguistic services).''
To assure collaboration and coordination across the Department's
Agencies and among other Federal Departments, HHS is part of the
workgroup working on the United We Ride project. Other Departments in
the workgroup include the Department of Transportation, Department of
Interior, Department of Labor, Department of Education, Department of
Veterans Affairs and Department of Agriculture. Within HHS, there is
participation from HRSA, Centers for Medicare and Medicaid Services,
Administration on Aging, Substance Abuse and Mental Health Services,
and the Administration for Children and Families. The link to the
website is http://www.unitedweride.gov/.
Responses to Questions from Hon. Michael H. Michaud, Chairman,
Subcommittee on Health, to Maggie Elehwany, Government Affairs and
Policy President, National Rural Health Association
National Rural Health Association
Alexandria, VA
June 5, 2007
The Honorable Michael H. Michaud, Chairman
The Honorable Phil Hare
Subcommittee on Health
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Chairman Michaud and Representative Hare:
Once again, I appreciated the opportunity to testify to the
Subcommittee during an oversight hearing on the topic of ``Access to VA
Healthcare: How Easy is it for Veterans--Addressing the Gaps'' on April
17, 2007. On behalf of the National Rural Health Association (NRHA), a
national nonprofit membership organization with approximately 15,000
members that provides leadership on rural health issues, I thank you
both for your leadership in addressing the needs of our rural veterans.
My letter today responds to the followup questions submitted to me
on May 2, 2007. The questions and answers follow.
Question 1: Increase Access Points. Difficulty obtaining reliable
transportation is a common concern. Effective, timely, inexpensive
transportation is a pervasive problem in the rural areas. There are
significant transportation barriers that affect coordination of
services and providers in the rural setting.
Question 1(a): Do you have any recommendations to address the time
and distance issues as it relates to veterans getting to a facility?
Response: Distance of travel to VA facilities is a significant
concern of the NRHA. During much of my testimony, I spoke of increasing
access points in rural communities. Two ways to increase access points
that have been successfully utilized in rural communities to a limited
extent are the use of Community-Based Outpatient Clinics and the use of
collaborative models with rural health facilities that are already in
the community, such as Federally Qualified Health Centers, Critical
Access Hospitals, and Rural Health Clinics. We believe the expansion of
services into the community in which the veterans live is the preferred
method of providing care.
The NRHA acknowledges that it may not always be possible to have
care provided in every community. A number of new innovative approaches
are currently being tried that would help limit the need for transport.
Some of these, such as telehealth and distance medicine, are the
products of new technology. Others, such as the direction of care
through a family physician and linking payment with Medicare moneys,
are simply new ways of thinking. But again, this may not provide care
for every beneficiary.
It is essential, then, that during VA outreach the issue of
transportation be raised. Through experience with other rural
populations we have found that transportation can be the biggest
barrier to care and can lead to the largest gap in patient-provider
compliance. One approach that has been successful in improving this gap
is to consider transportation from the moment the provider, in this
case the VA, contacts a patient. By asking simple questions--such as
how do you plan to get to the VA facility; do you have reliable
transportation; will someone be driving you; and are you able to afford
the transportation costs--the facility can get a much better sense of
the needs of that particular patient. In asking these questions and
considering their responses, the VA should be prepared to help pay this
transportation cost.
The VA Office of Rural Affairs will need to monitor this
transportation and access point question. While new collaborations and
telehealth approaches sound promising and the NRHA strongly supports
them, we can not be assured that these interventions are working
without sound research. This type of followup research must be a part
of any plan to overcome the lack of access points in rural communities.
Question 2: Traumatic Brain Injury Care. Given that TBI is the
``signature wound'' of OEF/OIF and that 44 percent of our returning
veterans come from rural areas:
Question 2(a): You state that the number and location of TBI case
managers is limited in coverage in States with high numbers of rural
veterans. What is the scope of ``expansion'' of the TBI case manager
network that your organization believes is needed to meet the needs of
the rural TBI patient?
Response: Simply stated, it is not clear how much expansion is
needed in the TBI case manager network to cover the needs of returning
veterans in rural America. More research is needed to better understand
TBI and the needs of those suffering from it. We strongly encourage
that this research be ongoing, throughout the duration of care given to
those returning from OEF/OIF.
We have learned from the experience of dealing with PTSD post-
Vietnam War. As the severity of PTSD began to be realized, resources
were poured into providing care. Like any new medical intervention,
some worked while others did not. Had solid quantitative evidence been
gathered from the start, perhaps less than the 15.2 percent of male
veterans and 8.5 percent of females who served in Vietnam would
currently be suffering from PTSD. Followup studies have shown more
effective ways to treat PTSD and the VA has accepted these for veterans
returning from future wars. However, when possible, research should be
ongoing, especially in the case of TBI, where waiting for followup
studies may mean leaving a generation of veterans with physical,
cognitive, behavioral, emotional and social impairments.
The evidence shows that the TBI case manager network would be more
effective in a `spoke-and-hub' model that has more than one research
and primary care center located across the Nation. By diffusing TBI
care throughout the VA, every employee will see treating TBI as part of
their core mission. Further, by using a spoke-and-hub model, more case
managers will be available to rural veterans and will still have the
support they need from larger research centers. We strongly encourage
the expansion, testing, and decentralization of the TBI case managers
to help provide rural veterans an avenue to recovery.
Question 3: Office of Rural Veterans. Your organization would like
a national advisory committee on rural veterans established to provide
information to policymakers on the needs of this population as it ages.
Question 3(a): What does your organization believe is the number
one issue that the advisory committee should take up if it is
established?
Response: There are many things that the advisory committee on
rural veterans could examine if it was established. Obviously, such a
committee would have the opportunity to set its own priorities and may
deal with issues that we have not even considered. However, we have
identified a few issues that the advisory committee could take up
immediately if established:
1. Research Agenda. Currently, there is not a specific rural
research agenda for veterans' care, and rural research is not a
priority of the general VA research projects. Since care in a rural
environment is so different than in an urban community, the NRHA is
very concerned about the lack of ongoing rural research. VA research
must include rural specific issues, and an advisory committee could
establish this priority and set the agenda.
2. Special Population Status. The VA has a long history of
monitoring ``special populations'' and using the data for providing
higher quality care. Such populations over time have included those
with spine injuries and other difficult injuries, the homeless, and
those of lower economic status. By monitoring those veterans living in
rural communities, the VA may get a better sense on how to provide care
to those furthest from VA facilities and better understand their health
status and address barriers to care.
3. Field-Based Operations. Currently, the Office of Rural Veterans
is located in one central office. For the information the Office
collects and develops to spread throughout the VA, a more diffused
network of offices may be needed. In addition, having field offices
located in VA centers across the country that serve rural veterans may
be helpful in understanding their specific needs.
Question 3(b): What would an advisory committee offer to the VA and
veterans that is not currently being provided?
Response: In a different venue, the NRHA has a long history of
working with the Federal Office of Rural Health Policy and the National
Advisory Committee on Rural Health and Human Service. We know from
experience that the National Advisory Committee is an important player
in making sure that the Office of Rural Health is meeting its goals and
identifying gaps in Federal programs. Further, the National Advisory
Committee has helped set the agenda for a priority on rural issues
within the Department of Health and Human Services.
We expect a rural advisory committee for the VA to do the same.
While the Office of Rural Veterans is a strong advocate within the
agency, an outside voice and independent review is needed.
Unfortunately, as we all know, internal agency politics can play a role
in determining the priorities of any single office. In addition,
offices can be hamstrung by set policies or internal procedures. The
advisory committee would be able to think outside of this internal
paradigm and articulate a vision of what the office and the entire VA
should be doing for rural veterans. In addition, such a committee can
help focus attention on the good things that the VA is currently doing
on behalf of rural veterans without the inherent bias that comes with
any self promotion. We expect that an independent voice on rural issues
would be helpful to the VA, and provide rural veterans with another
needed advocate for the highest possible quality of care.
Mr. Chairman and Mr. Hare, thank you for this opportunity to
respond to your questions on rural veterans' access to VA care. If you
are in need of further followup or clarification, please contact Maggie
Elehwany, NRHA Vice President for Government Affairs and Policy (703-
519-7910 or [email protected]).
Sincerely,
Andy Behrman
Chair, NRHA Rural Health Policy Board
Responses to Questions from Hon. Michael H. Michaud, Chairman,
Subcommittee on Health, to Steve Robertson, Director, National
Legislative Commission, The American Legion
American Legion
Washington, DC
November 28, 2007
The Honorable Michael H. Michaud, Chairman
Subcommittee on Health
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Chairman Michaud:
Thank you for allowing The American Legion to participate in the
Committee hearing on the President's budget request on April 18, 2007.
I am pleased to respond to your specific questions concerning that
hearing.
Question 1: Community Health Clinics. The Veterans Millennium
Healthcare and Benefits Act (P.L. 106-117) encouraged collaborations
between the Community Health Centers, that serve millions of rural
Americans, and the VA.
Question 1(a): Does your organization support these collaborative
efforts?
Response: The American Legion supports collaborative efforts
between Community Health Centers and VA to provide services to rural
veterans when VA is not capable of providing that care. In areas where
there is very limited access to VA healthcare, it is in the best
interest of veterans residing in rural areas that local care be made
available to them. Some of these veterans have physical limitations due
to age or service-connected injuries, or suffer from conditions that
make extensive travel dangerous. Many veterans have expressed concerns/
frustrations about their limited financial resources prohibiting
travel--citing the disparity caused by long travel distances, the
rising cost of gas, the limitations of the mileage reimbursement rate,
and the need to pay for overnight accommodations as huge obstacles.
Weather and geographic obstacles are also considerations.
Providing contracted care in rural communities--when VA healthcare
services are not possible--would alleviate the unwarranted hardships
that these veterans encounter when seeking access to VA healthcare.
Question 2: Level of Care. What are your organization's
expectations regarding the level of care VA should provide in the rural
community?
Response: The American Legion believes that veterans residing in
rural communities deserve the same level of healthcare and timely
access to care as veterans residing anywhere else.
Question 2(a): Do you believe the VA's presence in the rural health
community should be expanded?
Response: Yes, when doing so would improve access to care and
decrease travel time for veterans who travel hundreds of miles for
care.
If so, should the VA accomplish this by expanding
partnerships or providing its own system of care?
Response: Determining whether VA should accomplish this by
expanding partnerships or providing its own system of care should be
based on the healthcare needs of the veterans in the rural area it is
considering, services available through the rural health community, and
the number of veterans who would benefit from VA providing its own
system of care in that rural area. It would be VA's responsibility to
determine if there are any trends in needed services in particular
rural communities, especially for specialized care.
Many veterans move or return to rural areas following military
service. If the services available through community health providers
are not able to address the rehabilitative needs of those returning to
these rural communities with traumatic brain injuries, other blast
trauma injuries, or other service-related ailments, VA has a duty to
make these services available. It would be ideal if--realizing that
those requiring specialized services probably would have difficulty
traveling and coordinating care--VA would make these services as easily
accessible as possible.
Another indication that VA needs to bring its services more local
would be if a number of veterans are traveling hundreds of miles from a
specific geographic area to receive services from the VA that they
cannot receive in their communities due to lack of availability of
those services.
If needed services are available in local communities, those
traveling hundreds of miles for care would probably benefit from an
expansion of partnerships.
Question 2(b): What do you believe would be an effective approach
to providing returning veterans with the types of specialized services
they need such as TBI rehabilitation and mental health services?
Response: An effective approach to providing returning veterans
with the types of specialized services they need could be providing
more facilities, nationwide, where veterans can access these service,
and/or developing partnerships with community providers in rural
communities.
Question 3: Women Veterans and Rural Health. Women are a growing
population within the armed forces. By 2010 it is estimated that they
will exceed 10 percent of the veteran population and 15 percent of the
armed forces. Unlike their fellow female veterans from previous
conflicts, this current cohort of female veterans is routinely exposed
to combat in Operations Enduring Freedom and Iraqi Freedom.
Question 3(a): Does your organization have any recommendations as
to how to address the growing need for specialized services for women
who have experienced combat?
Response: Most importantly, we need to make sure we understand what
specialized services these veterans will need. Outreach to women
veterans is an important mechanism in identifying the specialized
services women veterans will require. They will need to know where they
can voice their needs and what services are available to them.
Also, comprehensive research on women veterans needs to be updated
to consider the health effects of combat on women veterans that address
long-term physical, as well as mental effects. Information gathered
from research would also facilitate addressing their need for
specialized services.
Question 4: Healthcare System of the 21st. The face of healthcare
is changing. VA has an Advisory Committee on Genomic Medicine. The use
of telemedicine programs is growing. Technology is advancing rapidly.
The delivery of healthcare is going to change over the next 10, 20, 30
years.
Question 4(a): What does your organization believe VA should be
focusing on in the future regarding the direction of the VA healthcare
system?
Response: The American Legion believes that the VA needs mandatory
funding to ensure that its healthcare system can adequately address the
needs of all veterans. VA should be focusing on improving access to
care and timely delivery of care.
Thank you once again for all of the courtesies provided by you and
your capable staff. The American Legion welcomes the opportunity to
work with you and your colleagues on many issues facing veterans and
their families throughout this Congress.
Sincerely,
Steve Robertson
Director, National Legislative Commission
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC
May 2, 2007
Joe Violante
National Legislative Director
Disabled American Veterans
Washington, DC 20024-2410
Dear Mr. Violante:
In reference to our Subcommittee on Health hearing ``Access to VA
Healthcare: How Easy is it for Veterans--Addressing the Gaps'' held on
April 18, 2007, I would appreciate it if you could answer the enclosed
hearing questions by the close of business on June 5, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Sincerely,
MICHAEL H. MICHAUD
Chairman
Subcommittee on Health
__________
Questions from Hon. Michael H. Michaud, Chairman, Subcommittee on
Health, to Joe Violante, National Legislative Director
Disabled American Veterans
Question: Community Health Clinics. The Veterans Millennium
Healthcare and Benefits Act (P.L. 106-117) encouraged collaboration
between Community Health Centers, that serve millions of rural
Americans, and the VA.
a. Does your organization support these collaborative efforts?
Answer: After review of P.L. 106-117, the Veterans Millennium
Healthcare and Benefits Act, we were unable to find any language
addressing the question of collaboration with Community Health Centers.
Question: Level of Care. What are your organization's expectations
regarding the level of care VA should provide in the rural community?
a. Do you believe the VA's presence in the rural health community
should be expanded? If so, should the VA accomplish this by expanding
partnerships or providing its own system of care?
Answer: We believe Congress should provide VA the additional
resources it needs to expand its presence in rural areas. As we have
often stated, veterans' healthcare is a continuing cost of war. After
serving their country, veterans should not have their healthcare needs
neglected by the VA because they choose to live in rural and remote
areas far from major VA healthcare facilities particularly when
Congress and the Administration have been aware that about 44 percent
of today's active duty military servicemembers and tomorrow's veteran
population list rural communities as their homes of record.
VA's medical benefits package is the embodiment of a continuum of
care which allows veteran patients to be clinically matched to the
appropriate level of care in order to maximize the care they receive
and the quality of life they lead. When providing medical care in rural
and remote areas, there are consequences to sick and disabled veterans,
the VA healthcare system, and the cost of such care when the
appropriate level of care is provided based on other than medical need.
As a direct provider of care, the VA has established and is
operating over 700 CBOCs, of which 100 are located in areas considered
by the VA to be rural or highly rural; however, we remain concerned
that the VA receives no Congressional appropriation dedicated to
support establishment of rural CBOCs but must manage those additional
expenses from within the available Medical Services appropriation
provided by Congress. The DAV believes that given current
circumstances, VA cannot cost-effectively justify establishing
additional remote facilities in areas with sparse veteran populations,
and therefore urges Congress to act on the report it has required VA to
provide in section 212(b) of P.L. 109-461 regarding CBOCs and
additional access points identified in the May 2004 CARES decision.
Recognizing the diversity of rural areas, the DAV does not believe
that requiring VA to provide needed medical care in rural areas should
be done solely as a direct provider or solely through expanding
partnerships. We believe the VA's ability to provide such care should
be given proper latitude, particularly as VA is establishing an Office
of Rural Health and is designating an individual at each Veterans
Integrated Service Network (VISN) to promulgate policies, best
practices, and innovations to improve healthcare services to veterans
who reside in rural areas.
Question:
b. What do you believe would be an effective approach to providing
returning veterans with the types of specialized services they need
such as TBI rehabilitation and mental health services?
Answer: The current conflicts in which our Nation is engaged are
producing a significant number of veterans suffering from polytraumatic
injuries, amputations, brain injuries, blindness, burns, spinal cord
injuries, and post-traumatic stress disorder (PTSD). The DAV believes
reforming VA's healthcare budget is of primary importance in order for
the Veterans Health Administration (VHA) to continue to provide these
severely disabled veterans with the lifetime of specialized healthcare
services they will require. To its credit, VA has taken progressive
steps to address the specialized needs of our newest disabled veterans
and is working to provide the highest quality care possible. We believe
VA should be given every opportunity to capitalize on its successes
without the fiscal uncertainties that have prevented the best
management of VA healthcare. Timely and adequate funding would make the
management of veterans' healthcare more dependable, and stable, and
with proper oversight would make VA's high quality medical care and
specialized services more cost-effective and efficient.
In an era of funding government programs through continuing
resolutions or increased funding levels provided months into the fiscal
year, VA facilities have had to restrict services provided to veterans,
delay hiring of new clinical staff, institute local and regional
freelance policies to restrict eligibility and care, and impose a
variety of questionable--and potentially hazardous--cost-cutting
measures just to make ends meet. It is clear that VA operates in a
state of management paralysis, planning chaos, and structural financial
crisis as a direct consequence of the discretionary budget process. We
do not believe this is an effective approach to providing returning
veterans with the types of specialized services they need such as TBI
rehabilitation and mental health services.
In addition to reforming the budget process, we believe the
direction taken by VA to use the effective hub-and-spoke model of it's
spinal cord injury service serves as a good first step to deliver
coordinated care for our returning servicemembers. As you are aware,
the VA established four Level I Polytrauma Rehabilitation Centers
(PRCs) at the Defense and Veterans Brain Injury Center's (DVBIC)
designated VA sites, Level II PRCs at each of the 21 regional Veterans
Integrated Service Networks, as well as a multitude of local Level III
and IV PRCs across the Nation. These new Level II centers will better
assist VA to raise awareness of TBI issues, and the Level III and IV
sites will provide increased access points for TBI veterans and allow
VA to develop a systemwide screening tool for clinicians to use to
assess TBI patients. Furthermore, clinicians and researchers are
evaluating several approaches to ensure more effective healthcare
delivery, such as standardizing patients' records from two distinct
healthcare systems and treatment plans. We believe these efforts will
provide a model of proactive care for patients with TBI and polytrauma
and enhance standards of practice within the VA and non-VA healthcare
systems.
Finally, the VA needs clear guidance from Congress on how to
proceed with new programs for the latest generation of wounded and
disabled veterans. A number of bills have been introduced dealing with
polytrauma, brain injury, and mental health; however, none have become
law at this time. We ask the Committee to consult with the veterans
service organizations as you begin to fashion these bills into law.
Question: Women Veterans and Rural Health. Women are a growing
population within the armed forces. By 2010 it is estimated that they
will exceed 10 percent of the veteran population and 15 percent of the
armed forces. Unlike their fellow female veterans from previous
conflicts, this current cohort of female veterans is routinely exposed
to combat in Operations Enduring Freedom and Iraqi Freedom.
a. Does your organization have any recommendations as to how to
address the growing need for specialized services for women who have
experienced combat?
Answer: With increasing numbers of women serving in the military,
and with more women veterans seeking VA healthcare following military
service, it is essential that the VA be responsive to the unique
demographics of this veteran population cohort. As we see growth in the
number of women veterans using VA healthcare services, we also expect
to see increased VA healthcare expenditures for women's health
programs.
At a recent VA National Conference: Evolving Paradigms--Providing
Healthcare to Transitioning Combat Veterans--one track focused on women
veterans who served in Iraq. A panel discussion by those women was very
revealing about their unique experiences in the military and the impact
of that service on their physical and mental health, as well as their
existing impressions of access to VA services post-deployment. The
women who participated in this panel, as well as other women who have
served in combat theaters, could offer the Subcommittee greater insight
on the impact of military experience on this new generation of women
veterans. We understand that VA had planned to convene a focus group of
approximately 50 women veterans of the wars in Iraq and Afghanistan to
examine gaps in service and how VA could better meet the needs of this
group. It is not clear whether VA still plans to convene such a group,
but DAV believes this could stimulate an effective policy debate within
VA and likely benefit this new generation of women veterans.
We recommend that the Subcommittee hold a hearing on women veterans
issues and invite women veterans from Operations Iraqi and Enduring
Freedom (OIF/OEF), the newly appointed Acting Chief Consultant of the
VA's Women Veterans Health Strategic Healthcare Group and a
representative from the National Center for Post-Traumatic Stress
Disorder, to discuss how the Department is currently addressing the
unique healthcare needs of women veterans who have served recently in
combat theaters.
The National Center notes that anecdotal reports from OEF/OIF
veterans suggest a number of unique concerns that have a more direct
impact on women than their male counterparts returning from combat
theaters, including lack of privacy in living, sleeping, and shower
areas; lack of gynecological healthcare; impact of women choosing to
stop their menstrual cycle; gender-specific differences in urinating
leading to health concerns for women, including dehydration and urinary
tract infection. There are also reported findings that suggest distinct
differences at homecoming including that women may be less likely to
have their military service recognized or appreciated; possible
differential access to treatment services; and possible increased
parenting and financial stress. Additionally, preliminary reports
suggest that women may be more likely to seek help for psychological
difficulties.
The National Center is looking at gender differences in mental
health, military sexual trauma (MST) in the war zone, and gender
differences in other stressors associated with OEF/OIF service and
homecoming. A number of research initiatives/projects are focused on
treatment of PTSD in women, enhancing sensitivity toward and knowledge
of women veterans and their healthcare needs among Reserve components
of the armed forces. Testimony from principal investigators in these
studies would also be of assistance to the Subcommittee in fashioning
effective policy to meet the needs of women veterans.
Finally, some women serving in the military may suffer the dual
burden of combat exposure and MST. While the DoD has established an
office to deal with the incidence of sexual trauma, the conditions of a
combat theater, quartering and lack of personal security offer special
threats to women serving. VA and DoD need to better coordinate policies
and treatment for transitioning women veterans who suffer readjustment
issues related to combat exposure and/or have suffered MST.
Question: Healthcare System of the 21st. The face of healthcare is
changing. VA has an Advisory Committee on Genomic Medicine. The use of
telemedicine programs is growing. Technology is advancing rapidly. The
delivery of healthcare is going to change over the next 10, 20, 30
years.
a. What does your organization believe the VA should be focusing
on in the future regarding the direction of the VA healthcare system?
Answer: Over the last decade, the VA has dramatically transformed
the delivery of veterans' healthcare and moved to the forefront of the
healthcare industry in areas such as patient safety, health promotion
and disease prevention, quality improvement, use of computerized
patient records, telemedicine, and biomedical and health services
research. Therefore, we believe that VA is appropriately focused to
meet the future needs of veterans and increasing demands on its
healthcare system.
As the VA continues making advances in medicine to address chronic
diseases and disabilities that are prominent in and specific to the
veteran patient population such as diabetes, cardiovascular diseases,
cancer, amputations, spinal cord injuries, polytraumatic injuries and
other similar conditions, VA must be mindful of the ever closer
association of medicine with science and technology, which presents a
dilemma where the latter broadens the former in helping the patient,
yet may undervalue the caring or ``art of medicine.'' We must ensure
the VA finds a proper balance between the promising possibilities of
modern, high-technology medicine and the actual ``high touching'' care
of patients.
Moreover, VA must remain sensitive to the limitations and
capabilities of biotechnology, genetic technology, and genomics. Rapid
technological changes occurring in the field of biotechnology coupled
with genetics, genomics, and links between the two, proffer a
tremendous shift in how healthcare will be provided in the future. The
possible effects would include a change from the current population-
based medicine to personalized medicine, such as tailormade drug
treatment for the individual patient (pharmacogenetics) as well as the
redefinition of the concept of ``disease.''
As medical care becomes more individualized, VA's Health-E-Vet
automated record offers patients an opportunity to actively participate
in their health decisions with a focus on prevention, empowerment,
wellness and satisfaction. Since the newest generation of veterans
tends to be more technologically inclined than veterans of prior wars,
but will rely on the VA for their medical care for decades to come, VA
should remain committed to this initiative.
The changes in VHA have been profound, and the benefits have been
and continue to be recognized by the veteran, medical, academic and
private sector communities. VA provides better care to our Nation's
veterans, care closer to their homes, and uses the latest technology in
delivering safe care. VA must continue to provide the right services,
at the right time, in the right place to our Nation's veterans in the
future. However, we currently face significant challenges, which we
must address to assure that our Nation maintains a comprehensive,
integrated healthcare system able to respond to the unique problems
that are associated with the military combat experience. In addition to
the most important new developments in the diagnosis and therapy of the
most common diseases, the VA must focus on how medicine in the future
can successfully combine high-tech and high-touch, and how the emphasis
can be placed more on the individual person, with his or her physical,
emotional and mental health needs--an aspect that, to the detriment of
patients, all too often is neglected in the day-to-day practice of
high-technology medicine.
A final concern is one that we have discussed previously in the
Independent Budget for fiscal year 2008: the future of VA capital
assets. The VA healthcare system operates over 1,400 centers of care,
of which a number of the more significant VA Medical Centers were
constructed in relatively brief periods following World Wars I and II,
and the Korean and Vietnam Wars. Thus, aging physical plant facilities
is a major issue for the future of VA healthcare. While it is difficult
to make firm predictions about VA's capital infrastructure needs over
the next 30 years, the existing trends of emphasis on ambulatory,
outpatient care over acute and chronic inpatient hospitalization would
seem to predict the need for smaller inpatient facilities in the
future, treating a higher acuity of case mix for shorter periods,
alongside significantly enlarged outpatient facilities, including those
promoting primary care, preventative care, ambulatory surgeries, and
other therapies that can be delivered in a same-day service setting.
This trend coupled with the underfunding of VA's construction budget
heightens our concern over the impact this may have on sick and
disabled veterans needing specialized programs such as blind
rehabilitation, spinal cord injury care, prosthetics services, and
mental health services.
The agency strategic and clinical planning, budget formulation and
Congressional appropriations processes create obstacles that cause
years, at times decades, of lag time between conception and
construction. DAV believes that Congress should provide additional
oversight to VA's construction and capital-facilities replacement
policies to improve their performance, and to help prepare for the
future of a very challenging issue. Also, we continue to question
whether VA's capital decisions are still consonant with the Capital
Asset Realignment for Enhanced Services (CARES) process that was
concluded in 2004. The CARES process was designed by VA to provide a
clear, market oriented roadmap for VA capital planning needs for the
next several decades, but in the intervening time we have been witness
to facility construction decisions that seem inconsistent with the
CARES decision memorandum of a prior VA Secretary. We ask the Committee
to provide sharper oversight of VA capital programs to ensure they are
consistent with CARES.