[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 1448, H.R. 1853,
H.R. 1925, H.R. 2005, H.R. 2172, H.R. 2173,
H.R. 2192, H.R. 2219, H.R. 2378, and H.R. 2623
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
JUNE 14, 2007
__________
Serial No. 110-27
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
37-465 WASHINGTON : 2008
----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
Washington, DC 20402-0001
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
__________
June 14, 2007
Page
Legislative Hearing on H.R. 1448, H.R. 1853, H.R. 1925, H.R.
2005, H.R. 2172, H.R. 2173, H.R. 2192, H.R. 2219, H.R. 2378,
and H.R. 2623.................................................. 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 53
Hon. Jeff Miller, Ranking Republican Member, prepared statement
of............................................................. 53
WITNESSES
U.S. Department of Veterans Affairs, Hon. Michael J. Kussman,
M.D., MS, MACP, Under Secretary for Health, Veterans Health
Administration................................................. 38
Prepared statement of Hon. Kussman........................... 80
______
American Legion, Shannon Middleton, Deputy Director for Health,
Veterans Affairs and Rehabilitation Commission................. 23
Prepared statement of Ms. Middleton.......................... 62
American Veterans (AMVETS), Kimo S. Hollingsworth, National
Legislative Director........................................... 25
Prepared statement of Mr. Hollingsworth...................... 65
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director........................................... 26
Prepared statement of Mr. Atizado............................ 68
Herseth Sandlin, Hon. Stephanie, a Representative in Congress
from the State of South Dakota................................. 6
Prepared statement of Congresswoman Herseth Sandlin.......... 53
Hodes, Hon. Paul W., a Representative in Congress from the State
of New Hampshire............................................... 14
Prepared statement of Congressman Hodes...................... 60
Lowey, Hon. Nita M., a Representative in Congress from the State
of New York.................................................... 17
Prepared statement of Congresswoman Lowey.................... 61
Miller, Hon. Jeff, a Representative in Congress from the State of
Florida........................................................ 18
Prepared statement of Congressman Miller..................... 58
Moran, Hon. James P., a Representative in Congress from the State
of Virginia.................................................... 3
Prepared statement of Congressman Moran...................... 55
Paralyzed Veterans of America, Carl Blake, National Legislative
Director....................................................... 28
Prepared statement of Mr. Blake.............................. 72
Rodriguez, Hon. Ciro D., a Representative in Congress from the
State of Texas................................................. 2
Prepared statement of Congressman Rodriguez.................. 54
Salazar, Hon. John T., a Representative in Congress from the
State of Colorado.............................................. 16
Prepared statement of Congressman Salazar.................... 56
Veterans of Foreign Wars of the United States, Dennis M.
Cullinan, Director, National Legislative Service............... 30
Prepared statement of Mr. Cullinan........................... 76
Vietnam Veterans of America, Barry Hagge, National Secretary..... 31
Prepared statement of Mr. Hagge.............................. 77
Watson, Hon. Diane E., a Representative in Congress from the
State of California............................................ 5
Prepared statement of Congresswoman Watson................... 56
______
SUBMISSIONS FOR THE RECORD
National Rural Health Association, Andy Behrman, Chair, Rural
Health Policy Board, statement................................. 85
Reyes, Hon. Silvestre, a Representative in Congress from the
State of Texas, statement...................................... 87
United States Ombudsman Association, Ruth Cooperrider, President,
and Deputy Ombudsman, State of Iowa--Office of Citizens' Aide/
Ombudsman, letter.............................................. 89
MATERIAL SUBMITTED FOR THE RECORD
Hon. R. James Nicholson, Secretary, U.S. Department of Veterans
Affairs, to Hon. Bob Filner, Chairman, Committee on Veterans'
Affairs, letter dated August 19, 2007, views on H.R. 2623 and
H.R. 2699...................................................... 91
U.S. Department of Veterans Affairs, Veterans Health
Administration, report entitled: ``Plan to Increase Access to
Quality Long-Term Care and Mental Health Care for Enrolled
Veterans Residing in Rural Areas,'' January 10, 2008........... 96
Job Description for Program Analysis Officer, Office of the
Assistant Deputy Under Secretary for Health for Policy and
Planning, Veterans Health Administration, U.S. Department of
Verterans Affairs.............................................. 103
LEGISLATIVE HEARING ON H.R. 1448, H.R. 1853, H.R. 1925, H.R. 2005, H.R.
2172, H.R. 2173, H.R. 2192, H.R. 2219, H.R. 2378 AND H.R. 2623
----------
THURSDAY, JUNE 14, 2007
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:00 a.m., in
Room 340, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Brown of Florida, Snyder,
Hare, Miller, Brown of South Carolina.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. This hearing will now come to order. I'd like
to thank everyone for coming today. I 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
five legislative days to revise and extend their remarks.
Without objection, so ordered.
Today's legislative hearing will provide members of
Congress, Veterans, the U.S. Department of Veterans Affairs (VA
and other interested parties the opportunity to discuss
legislation within this subcommittee's jurisdiction in a clear
and orderly process. While not necessarily in agreement or
disagreement with the bills before us today, I do believe that
this is an important process that will encourage frank
discussion and new ideas.
We have ten bills before us that seek to improve healthcare
for the Nation's veterans and I look forward to hearing the
views of our witnesses. I also look forward to working with
everyone here to continue to improve the quality of care
available for our veterans.
There are two draft discussions that are not before us
today. There is a discussion draft on homelessness, and a
discussion draft on mental health services. Congressman Patrick
Murphy of Pennsylvania has also introduced H.R. 2699. I'd ask
that the members of the third panel, the veterans service
organizations (VSOs), and the fourth panel, VA, provide
comments and views on these three items for the record once
they are made available. We'd like to have the written comments
submitted to the Committee by June 21st of this year.
We may as well begin, starting off with Mr. Rodriguez.
[The prepared statement of Chairman Michaud appears on p.
53.]
STATEMENTS OF HON. CIRO D. RODRIGUEZ, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS; HON. JAMES P. MORAN, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF VIRGINIA; HON.
DIANE E. WATSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
CALIFORNIA; AND HON. STEPHANIE HERSETH SANDLIN, A
REPRESENTATIVE IN CONGRESS FROM THE STATE SOUTH DAKOTA
STATEMENT OF HON. CIRO D. RODRIGUEZ
Mr. Rodriguez. Mr. Chairman, thank you very much. And
members of the Committee thank you for this opportunity to be
here before you. I have my bill, H.R. 2173, a bill introduced
by myself and my colleague Congresswomen Grace Napolitano,
provides for increase in the capacity for mental health
services through contracts with qualified community health
centers.
This is an opportunity for veterans in rural communities,
especially to be able to get access to services, not to mention
in those areas where we don't have access to mental health
services within our VA system. It's also a great opportunity to
follow up on individuals that need the services.
Recent surveys show that one in eight returning Iraqi war
veterans report symptoms of post traumatic stress disorder
(PTSD). The same studies also report high incidents of major
depression and anxiety disorders among returning members of the
Army and Marine combat unit. As a member of this Committee, we
have long identified mental health services as a major issue
facing returning soldiers as well as the Department of Veterans
Affairs.
Experts note that the manifestation of clinical symptoms of
post traumatic stress disorder and other mental health
disorders often occurs over several years. With the increase of
active duty, guardsman and reservists returning from combat,
the necessary capacity to provide mental health services is
relatively unknown. It is difficult to know if our large number
of returning veterans will need mental health services beyond
what the VA is capable of providing.
My bill, H.R. 2173, authorizes the VA to contract with
community mental health centers to increase the capability. In
my opinion the need has out paced the capacity of the VA to
provide mental health services in out patient clinics.
Contracting out to the community mental health centers is
already been done successfully in some States, and could serve
as a model for the VA-wide implementation.
Mr. Chairman, in my previous career, I worked as a mental
health field social worker. I am fully aware of the great
services provided by the community health centers. And if there
is any doubt of the quality of the care they can provide, I can
tell you of the hundreds of families who's lives have been
changed by the treatment received during my professional career
in the field, but you don't have to take my word.
Each year community health centers have nearly six million
children, adults, families and communities across this country
the chance to recover and lead productive lives. Our returning
soldiers deserve nothing less and we hope that we can provide
them with that opportunity.
As I mentioned before, it is clear that our soldiers
returning with an increased need for mental health services,
but after this long war, it is unclear what the VA capacity to
fulfill this need will be. It is my hope that H.R. 2173 can
provide the VA with the tools to continue to provide top notch
mental health services to our veterans in their own
communities.
Mr. Chairman, once again I would like to thank you for
allowing me this opportunity, and I urge your support, and just
indicate that this piece of legislation, I think, will help
enhance the quality of care for our veterans especially in
rural communities and in those areas, urban areas, where
there's a large number of our veterans.
Thank you.
[The prepared statement of Chairman Rodriguez appears on p.
54.]
Mr. Michaud. Thank you very much. As you know I am very
concerned about access to healthcare benefits for veterans
particularly in rural areas that need that access.
Mr. Moran?
STATEMENT OF HON. JAMES P. MORAN
Mr. Moran. Thank you Mr. Chairman, and Mr. Miller, Mr.
Salazar, Mr. Brown. I want to thank you for holding this
important hearing today and commend the Subcommittee for the
work that it has already undertaken on behalf of our Nation's
veterans.
The problem of suicide among our veterans is one of the
most serious issues that we have to address as we care for our
older veterans and prepare for a new generation of returning
soldiers.
The Centers for Disease Control recently released very
troubling statistics. Each year approximately 115,000 veterans
attempt suicide. This accounts for nearly 20 percent of all
suicide attempts, and yet the veteran population only accounts
for 11 percent of the entire population. So in other words,
veterans are much more likely to attempt suicide as other
groups of our society.
This disproportionate prevalence of suicide among veterans
suggest that in addition to our overall national strategy on
suicide prevention, particular attention should be paid to
preventing suicide among this special population.
Unfortunately, I expect this trend to continue as more of our
brave men and women return from multiple deployments with the
symptoms of post traumatic stress disorder.
As we have learned, the staggering 20 percent of soldiers
returning from Iraq are experiencing depression, sleep
depravation, anxiety, and other symptoms of PTSD. I am proud
that this Congress has already acknowledged the growing problem
of PTSD and dedicated substantial resources to it. Still, I
believe as scientific evidence suggests, that as our returning
soldiers are increasingly susceptible to PTSD, they are at an
elevated risk for suicide attempts.
My bill, the ``Veterans Suicide Prevention Hotline Act of
2007,'' would create a 24-hour National toll-free hotline to
assist our Nation's veterans in crisis. It would be staffed
predominately by veterans trained to appropriately and
responsibly answer calls from other veterans. The hotline would
follow the models of the national suicide, sexual assault, and
domestic violence hotlines who have volunteers trained in
active listening and crisis de-escalation respond to a variety
of crisis calls.
I believe that this cultural competency, the ability to
connect to another veteran who understands what the caller may
be experiencing can make a real difference in crisis
counseling. It is difficult to connect on this level with
anyone else, even trained doctors or other professionals.
So to build this capacity nationwide, my bill calls for a
3-year competitively awarded grant for two and a half million
dollars in the next three fiscal years. The funding will be
made available to a qualified non-profit crisis center to
establish, publicize, and operate the hotline including
developing curricula to train and certify volunteers.
We have reached out to the Department of Veterans Affairs
and are encouraged that the Veterans Health Administration
(VHA) is undertaking new efforts to establish a suicide hotline
and address mental health needs. Their plan is to divert
callers from the national suicide prevention hotline to a VA
facility staffed by doctors, psychologists, and other certified
counseling professionals. On the surface, the VHA's effort may
appear duplicative of what I am proposing, but there are some
very important differences that I feel need to be highlighted.
First, my legislation requires that the people answering
the phones, those dealing directly with the veterans are
veterans themselves. There are times when speaking with someone
who has the cultural competence and the empathy to really
understand the experiences of veterans in crisis can help make
the difference between successful integration to mental health
treatment and failure to reach a veteran in dire need of
services.
Second, the VHA has many responsibilities for providing the
highest quality of healthcare for our veterans. However, they
have experienced stressed budgets and staffing shortages in
recent years. Because the demands placed on any veterans
hotline may be much greater as our Nation redeploys from Iraq
in the future, I have concern that the VHA may not have the
capability and commitment to the hotline that a non-profit
organization dedicated to suicide prevention as its sole
purpose might be able to provide.
Third, there are times when a person in crisis doesn't want
to talk to a doctor. They want to talk to a volunteer. Mentally
ill individuals all face societal stigmas associated with
seeking care. Research from the Air Force's suicide prevention
effort suggest that this is perceived to be even more profound
in the military and veteran communities. Fear of the system, of
an un-friendly mental health establishment or of potential job-
related consequences keep many from seeking care. One of the
motivations behind the National Suicide Hotline and this bill
is to give people in crisis another option, an anonymous
hotline that can respond to their immediate crisis.
To conclude, our vets deserve as much support when they
return from combat as they receive while in battle. Too many of
our veterans are struggling to make the difficult adjustment
back to society and need someone they can talk to, someone who
has walked a mile in their shoes. This legislation will offer a
caring voice at the end of the line when it feels that there is
no where else to turn.
Thank you, Mr. Chairman.
[The prepared statement of Congressman Moran appears on p. 5
5.]
Mr. Michaud. Thank you very much. Ms. Watson?
STATEMENT OF HON. DIANE E. WATSON
Ms. Watson. Thank you so much, Mr. Chairman, for holding
today's hearing and letting me speak on the bill H.R. 1853, the
``Jose Medina Veterans Affairs Police Training Act of 2007.''
I believe this legislation is vital to protect our heroes
and who have sacrificed their minds and bodies to protect our
freedoms. And I feel the two previous bills presented will be
complimented by this legislation.
Mr. Chairman, too many veterans are suffering from mental
health problems after returning from combat, and they are not
receiving the proper treatment they deserve. Congress has a
responsibility to provide quality healthcare for our veterans.
We must analyze every aspect of services associated with the
treatment of post traumatic stress disorder or PTSD for our
vets.
So I have introduced H.R. 1853, the ``Jose Medina Veterans
Affairs Police Training Act of 2007,'' a bill that will force
the Department of Veterans Affairs to better prepare it's
police force to interact with patients and visitors at the VA
medical facilities who suffer from mental illnesses.
Jose Medina is a constituent of mine. He is a Vietnam vet
who suffers from PTSD. In January of 2006, Mr. Medina was
assaulted by two west Los Angeles VA police officers who kicked
him and forced him to the ground after he isolated himself and
fell asleep in a hallway at a VA medical center in Los Angeles.
After a physical altercation ensued, this 56-year-old
veteran was forced to lay first face down on the hospital
floor. The officers injured Mr. Medina, and after the
altercation they did not allow him to use the hospital's
emergency room. Instead, the officers handcuffed him and
detained him for an hour before sending him home and gave him a
loitering ticket.
This is not the way we should be treating veterans who have
served and protected this country. What bothers me the most is
that when we see someone sitting on a hospital floor, one would
think law enforcement would have hospital staff come and
question the individual to see if that individual was all right
or in need of assistance. Instead, in this case, Mr. Medina was
without medical treatment and was mistreated at the same time.
This is happening to too many of our brave veterans out of
sheer ignorance. As we look to the future, thousands of
veterans will be entering the VA healthcare system. We must
ensure that the VA has the ability to administer quality
healthcare services to veterans that suffer from mental
illnesses. With over 20 percent of the one and a half million
veterans that served in Iraq or Afghanistan showing signs of
PTSD, we do not want any of them to endure what Mr. Medina went
through. They simply deserve better.
So, Mr. Chairman, the Department of Veterans Affairs
believes this legislation is unnecessary, but the story of Jose
Medina and other veterans from around the country who have
contacted my office with similar problems have confirmed that
this training is indeed necessary.
As Congress debates funding strategies and time lines for
our military missions, we must not overlook the fact that they
not only--that we not only need for our vets to have the
resources for results from the battlefield, but they must also
be treated with dignity and respect once they resume their
lives after combat. We must ensure that this occurs.
So, Mr. Chairman, I thank you for this opportunity to
explain what this bill would do, and I urge the members to
support H.R. 1853. Thank you.
[The prepared statement of Congresswoman Watson appears on
p. 56.]
Mr. Michaud. Thank you very much. Appreciate your
testimony. Ms. Herseth Sandlin?
STATEMENT OF HON. STEPHANIE HERSETH SANDLIN
Ms. Herseth Sandlin. Thank you, Chairman Michaud and
Ranking Member Miller. I appreciate the opportunity to discuss
here today the Services to Prevent Homelessness Act, a bill
which I introduced May 17, 2007, to provide supportive services
to very low income veterans.
The U.S. Census Bureau estimates that 1.5 million of our
Nation's veterans live in poverty, including 702,000 veterans
with disabilities and 404,000 veterans in households with
children. Six hundred and thirty-four thousand of the 1.5
million poor veterans live in extreme poverty. These poor
veterans face residential insecurity due to their low income
levels or their past episodes of homelessness. They also face
health and vocational challenges and access barriers to
supportive services, which limit their ability to sustain
housing and maintain independence for more costly public
institutional care and support.
These poor veterans may benefit from flexible and
individualized support services provided at home based
settings. The services to prevent Veterans Homelessness Act
would authorize the Secretary of Veterans Affairs to provide
financial assistance to non-profit organizations and consumer
cooperatives to provide and coordinate the provision of
supportive services that addresses the needs of very low-income
veterans occupying permanent housing.
The financial assistance shall consistent of per diem
payments for each household provided supportive services.
Supportive services that may be offered include physical and
mental health, case management, daily living, personal
financial planning, transportation, vocational counseling,
employment and training, education, assistance in obtaining
veterans benefits and public benefits, child care, and housing
counseling.
Veterans sub-populations expected to benefit from the
program include veterans transitioning from homelessness to
permanent housing, poor disabled and older veterans requiring
supportive services in home-based settings, and poor veterans
in rural areas with distance barriers to centrally located
services.
While Federal programs exist to help create veterans home
ownership, there is no national housing assistance program
targeted to low-income veterans. Permanent housing
opportunities for veterans ready for independent living are
limited.
In addition, the VA currently is not permitted to provide
grants to create affordable permanent housing and the resources
that are available for providers are inadequate and highly
sought by competing housing projects.
Thank you again for the opportunity to be here today. I
look forward to continuing to work with the Chairman and the
Ranking Member to support efforts to meet the housing
assistance needs of our Nation's low income veterans through
the establishment of a permanent housing assistance program for
this population.
I am happy to take any questions that you may have.
[The statement of Congresswoman Herseth Sandlin appears on
p. 53.]
Mr. Michaud. Thank you very much. I have a couple of
questions on some of the bills. The first one is to Ms. Watson.
You so eloquently explained the problem you had with one of
your constituents at the VA facility. Is this typical? Is this
the first case or is it really ongoing out there? Have you
heard from the different VSOs?
And my second question, what type of training do you think
additional training they need?
Ms. Watson. Yes. To address your first concern, it is one
of our top calls that comes in to my office and I had my
staffers in here who could supply the actual numbers. But in
Los Angeles, our homeless population on any given night is
somewhere between 80,000 and 90,000. Those people who are
homeless, 33 percent of them, are vets in need of mental health
services.
So it is a pervasive problem that we must address. And I
hope in Markup to put a provision in this bill that would say
that the training must come from highly trained professionals.
And the kind of training that it will supplement what is
already called for in prior legislation is the handling and the
respect for dealing with mentally ill patients.
And so we get in to the actual behavior of law enforcement
and other personnel that deal with the mentally ill.
Mr. Michaud. Great. Thank you. My next question is for Mr.
Moran. You had mentioned setting up this separate hotline. Do
you know if there is currently a national hotline for suicide
prevention? How many calls go in to that hotline that actually
deal with veterans? Do you have any idea of that?
Mr. Moran. I don't have the numbers, Mr. Chairman. The way
I came up with this idea was that I was talking with some
people that are involved with a group called Crisis Link that
provides suicide prevention throughout the Washington
Metropolitan area. And one gentleman I was asking what is going
on and he said, ``Well when veterans found out that we had a
veteran volunteer that they could talk to, that veteran become
overwhelmed with calls.'' He is spending overtime. It is taking
up much of his life, because the word spreads. And there is a
clear indication that most veterans would like to talk to
another veteran that can empathize with them. That is what is
distinct.
And I think that the numbers don't necessarily reflect
that, but the fastest increasing number of calls with this
group was because of the presence of that veteran on the other
end of the line, but I don't have any specific numbers as you
have asked.
Mr. Michaud. Great. Thank you. My last question actually
goes back to Ms. Watson. Is the police force at VA facilities,
is that a contracted service or are they regular VA employees?
Ms. Watson. They are employees that have come in under a
contract and I don't know whether they are paid from the
contract or from the VA. Would you know that information? They
are Federal officers.
Mr. Michaud. Okay. Great. And hopefully the VA officials
here will be able to let us know of all facilities whether they
are VA Federal officers or contracted positions.
Mr. Miller?
Mr. Miller. Thank you, Mr. Chairman. Mr. Moran, I think we
agree that the end result of what you are trying to have done
is what we are trying accomplish, though I do have a question.
We passed H.R. 327, the Joshua Omvig Veterans Suicide
Prevention Act, earlier this year that required an in-house 24-
hour hotline. Can you expand a little bit on why we would need
this hotline. H.R. 327's hotline is veterans, these are members
of the VA Office, and they are specially trained, why we would
need to go outside and do this independently?
Mr. Moran. That is a very good question. I think the
difference, and I address this in my testimony, is that the VHA
line is designed to get people into the VA system, it's doctors
and psychologists who are not necessarily veterans that are on
the other end of the line.
What this is, what I am suggesting is a volunteer
organization. These organizations exist in many of our
districts. People who are not necessarily professionals, but
get specific training. And many people have found that they can
relate better to the veteran. They are not trying to get them
in to necessarily a mental health establishment immediately and
there is some stigma to calling the VA. And while the VA does
wonderful work, and the professionals associated with the VA do
a great job, the veteran that may be attempting suicide is not
necessarily wanting to get in to what they consider to be the
establishment to talk to necessarily a professional who has an
objective. We find that in other situations.
And what we are going to try to do if this is established,
if it is not then groups will try to do it on their own, is to
find a great many veterans who are willing to volunteer to get
the training to be there for other veterans on a volunteer
basis. So it is a different kind of thing.
One is professional. It is an official arm of the
Department of Veterans Affairs. It is designed to get people in
to the VA system. Another is volunteer hotline for people that
can perhaps empathize to a greater extent with who will be
there for them if they are having difficulty coping.
And so it is different personnel. It is a differently run
organization. The ultimate purpose, of course, is the same; to
save people's lives and to be there for people in crisis.
Mr. Miller. Thank you, I had some other questions, but all
of you did such a good job. Ms. Watson?
Ms. Watson. Yes. If I can extend the response. I mention
that we have 33 percent homeless vets on the streets, and so
this service nationally will allow them an opportunity. They
are not necessarily in-house, but wherever they are and I was
just thinking as Representative Moran was speaking, that we
might want to locate these services in homeless shelters, on
skid rows, and places that will be assessable.
What we find in Los Angeles is that many of our people who
are homeless are committing suicide through overdoses of drugs.
And they really need someone to talk to. They don't know how to
access that. So I think the idea of having them locate it where
homeless people or homeless vets would go on the streets is
something that we need to fill in our chain of services.
Mr. Miller. I think, if I am correct, Mr. Moran's proposed
legislation is a single provider, a single hotline. That is why
I was asking the questions in regards to the single hotline
that is already provided or will be provided under the Omvig
bill that we passed earlier this year.
There may be a desire to expand it, but then you are
talking about other mental health providers. Now we are really
beginning to go far beyond what I think the original intent and
scope, which is to provide a single call that that veteran can
make to somebody when he or she is at their very darkest,
lowest moment.
That was what my question was. Again, I think we are all
trying to get to the same place, and I salute everybody here.
My other questions you have already answered in your opening
statements. Thank you.
Mr. Michaud. Mr. Salazar?
Mr. Salazar. Thank you, Mr. Chairman. I just have a
question for, let's see, Ms. Watson, Mr. Moran, and Mr.
Rodriguez. Most of your issues deal with mental health issues
of veterans. Is there a way to be able to coordinate your three
bills into one bill, which might be a little more effective way
of addressing the issue of veterans and mental health issues?
Mr. Rodriguez. Let me just indicate that the need for us to
provide especially in mental health settings to provide
training for those officers to treat people and to recognize
them is essential. And that has got to happen. That has to
occur. Those people that are law enforcement, first responders,
need to be aware of that whether they are public sector or
private sector.
Secondly, the area of mental health we just have one too
many veterans that are committing suicide. So we need to
provide that access. And you yourselves and your offices I have
had veterans come in to my offices that threaten our office and
they are mentally ill. And they need services. And that is why
we really need to push forward, and because we are just having
one too many of them committing suicide.
The contracting out to the community mental health centers
throughout this country, those are the ones that provide the
most access to mental health than anyone else in this country.
Those were created in the sixties. It is a great opportunity to
provide that access. Major metropolitan areas have crisis
intervention centers that have 1-800 numbers.
But one of the ways to look at it is maybe in some of the
rural communities, there is one thing to provide the access,
but the other thing is the referral that are needed and the
follow up that is required in order to respond to those needs.
And some how we have to fill those gaps.
And I think a comprehensive program that allows that to
occur, and especially in rural America where you don't have as
much and some of those mental health services are available
where you don't have VA services. So I think a comprehensive
program is needed and the sooner we can do that the better.
Mr. Salazar. Mr. Moran?
Mr. Moran. Mr. Salazar, everything that we have recommended
is complimentary and deliberately complimentary of everything
that the Department of Veterans Affairs is doing. Mine is
pretty limited in scope. It is simply to have one single
national hotline number that is available any time that
veterans can memorize and call and find another veteran at the
other end of the phone to expand it to include these, which is
fine. The dollar amount that is being recommended over a 3 year
period would have to be substantially greater to do it right.
That is why the amount of resources that I suggested is pretty
limited.
So they are all fine things, it is just that as you expand
them you would have to contribute provide more money to make
them work properly.
Ms. Watson. And in response, we gave a name to our bill
because we want to send a message out there. So we are naming
the Jose Medina. And if it would fit in to other pieces of
legislation that is to be considered as well. But we wanted to
tag this with his name to send the word out there like the
Miranda Act, and so, it comes out of an event. And we want to
let the veterans know that these incidents are very important.
We are sensitive to them so we put his name on it.
And so I guess we could integrate this in to another piece
of legislation and we can talk about that.
Mr. Salazar. Thank you. Ms. Herseth Sandlin, your bill
talks about housing and the transition from homelessness toward
someone who can actually live in a home. Does your bill address
the issue of those who are almost at the transition point of
becoming homeless? They have a home, but because of their
income they are almost there or are in danger of becoming
homeless?
Ms. Herseth Sandlin. I think the bill is more focused on
the transition of the veterans subpopulation that has had
episodes of homelessness, has transitioned to temporary housing
programs of which we may be familiar with in our districts, but
then addresses really that next hurdle of moving to more
permanent housing.
So your question is a good one. I think that we could
certainly as the Secretary would have the authority in
establishing the criteria for the non-profit organizations or
cooperatives, consumer cooperatives, that would be utilized to
extend the service that certainly it could address those that
might be at danger of homelessness, although I think we are
catching them already to a degree, at least a significant
percentage of them in the subpopulation that has previously had
episodes of homelessness.
So I appreciate the question and it is something that we
could pursue I think more if we were to get this enacted with
the Secretaries. We work with them to establish a formula and
the criteria as it relates to contracting with the non-profits.
Mr. Salazar. Thank you. I yield back, Mr. Chairman.
Mr. Michaud. Mr. Brown?
Mr. Brown of South Carolina. Thank you, Mr. Chairman and I
thank the witnesses for coming and bringing testimony to solve
a problem that we have been trying in this Committee for a long
time to connect to the homeless veteran. We recognize that
there are many homeless veterans that do have a mental
condition.
We have tried to provide resources, and I believe they are
adequate resources out there if we could just match the
homeless veteran to the resource. I appreciate the effort that
you are trying to do that.
Ms. Watson. If I might respond, Mr. Chairman? One unique
feature of our bill is that we address police brutality. We
have received complaints from not only the West Los Angeles
Medical Center, which is just right next to my district it is
coterminous, but from Michigan, San Antonio, Texas and so on
and it is all referring to the police brutality. So we address
that issue uniquely in our bill.
Mr. Brown of South Carolina. I know, Mr. Moran, in your
bill and I appreciate that for the trying to reach out to those
veterans that need particularly care. And I know in our region
we have like the 2-1-1 number where they can call and talk to
some counselor that is online all the time.
Is part of your bill to require that there be some voice at
the end of that line all the time?
Mr. Moran. Thank you, Mr. Brown, for asking that question.
The answer is yes. Many of these suicide prevention hotlines
are very good and they have very fine people, but I notice that
the volunteers tend to be young, single people who have the
time to provide. They don't necessarily tend to be veterans.
And what this would do is to put a special emphasis upon
getting trained veterans on the other end of the line.
Now, they are not veterans who have the career choice or
interest, ability, whatever, to become doctors or psychologists
or specific mental health counselors. They are trained simply
to be there to listen and to try to get help, get somebody to
get through a crisis. So we would be going out to veterans
organizations just trying to get recruits to volunteer to help
them to be there and have one single line nationally that would
be toll free that people could call.
That is why it is fairly limited in scope, but it is
particularly designed to get a veteran on the other end of the
phone.
Mr. Brown of South Carolina. Thank you. Thank you, Mr.
Chairman.
Mr. Michaud. Mr. Hare?
Mr. Hare. Thank you, Mr. Chairman. Thank you for holding
this hearing this morning, it is very important. Let me thank
my four colleagues for being here today and for proposing
various legislation. You know we have seen a lot and heard a
lot about all wounds that people have aren't necessarily wounds
that people can see. So I am really delighted that you have
come together on this and I want to commend you all for that.
I have a question, if I could, for Mr. Rodriguez as soon as
I find it. Sir, like you, I have a lot of rural area in my
district. I know your district is extremely large, probably one
of the largest in the country. And I wonder if you could tell
me a little more about how the bill that you have would address
the problems that your constituents face accessing mental
healthcare particularly in a geographic area that is so
incredibly large?
Mr. Rodriguez. First of all, the one of the few
organizations that is responsible for that and that provides
some degree of access to healthcare to in mental health
throughout this country is the community mental health centers.
And so to provide services, and this is one of the few
areas that where we can provide that access and the follow up.
The purposes of the community mental health centers were
basically were to try to get the mentally ill out of the
institutions in the sixties. So they were created to reach out
to the community throughout America and meet those needs.
And so these centers are trained to do that. And I really
believe that we have some figures that we have seen of three
million veterans committing suicide every year directly are
tied in to the VA and there is a larger number that are not
tied to them. And so we really need to you know, provide those
services as quickly as possible. And I really believe I would
of preferred it under the VA System, but I really believe that
they don't have the capability at the present time to meet the
massive need that is needed out there.
And so I really believe that this is one of the few ways of
meeting that need and that is reaching out through the
community mental health centers that exist throughout the
country, even in rural communities. And they can reach out and
get some kind of professional treatment that is required. There
are some areas where we don't. I got one psychiatrist in one
community and I think it was a contract that was out there in
the private sector, but the community health center there is
actually a little better equipped to handle that.
Now the urban areas have the crisis centers and have the
for the homeless and others, but in those other areas you know
we have got to do more to those individuals that are out there,
especially the ones who have hit the bottom of the totem pole
which is the homeless veterans that find themselves without
anything and find themselves without access. And you have got
to have those outreach workers that do that.
And I think that that is one of the better ways. Now we
still have a problem in that in rural America in terms of how
do we, you know, in those areas where you have to provide that.
I have that problem in terms of trying to provide offices. I
have five offices right now and I don't have the manpower to
provide the staffing throughout my office. And so there is
still a need to provide some mobile units to go out in to rural
America.
Mr. Hare. Thank you. And I just have a question for my
colleague Ms. Herseth Sandlin. And I apologize for coming in
just a bit late, I was on the floor. But you know we see the
stand downs that we have throughout the country every year to
help homeless veterans. The problem is that is a weekend,
excuse me, that is a weekend opportunity. And I was amazed in
my district that when Congressman Evans was hosting these and
working on them, that the number of veterans that would use,
you know, the stand down and be able to come in.
I am wondering could you just expand a little bit on what
your bill would do to establish assistance program so that we
can move homeless veterans into, to give them some decent
housing that they clearly, ``A,'' need; and ``B,'' deserve?
Ms. Herseth Sandlin. Well thank you for the question. And
you are right. With the weekend stand downs one of the
wonderful things about that is that you have generally this a
centralized location that offers a whole host of other services
that are either important to veterans who are interested in
what they can access to avoid homelessness, if they are very
low income veterans, but certainly those that have had episodes
of homelessness that have perhaps been in transitional housing
but the eligibility is 24 months of transitional housing and
then what more may be needed in terms of financial counseling,
access to other benefits to which they are eligible to have a
more holistic approach, comprehensive approach to what the
needs of the veterans are on a more consistent basis than the
weekend stand downs where they look forward to that opportunity
and word gets around the veteran population of a particular
community or particular region of a district or a State.
And so what the bill does is I think it addresses a gap
that currently exists in what the VA can provide in setting up
a grant program, establishing a formula and the criteria for
non-profit organizations and consumer cooperatives to access
the grant and provide these services, particularly targeted
toward veterans and their families who are very low income who
are in that transition period.
But as Mr. Salazar asked earlier, I think that the
availability of support services for very low income veterans
and their families that may already be in housing but at great
risk for homelessness can also be provided within the terms of
this bill.
So I think it addresses a significant gap that exists and I
think especially at this time in our country's history when we
have many veterans returning who have very young children, who
are very young themselves, this is an important grant program
that needs to be established.
Mr. Hare. Thank you very much. And once again, Mr. Moran
and Ms. Watson, thank you very much for your legislation. I
think they are wonderful pieces of legislation. I yield back.
Mr. Michaud. Dr. Snyder, you have any questions?
Once again, I would like to thank our first group of
panelists for your testimony today and look forward to working
with you as we look at this legislation later on. Thank you.
Mr. Moran. Thank you.
Mr. Rodriguez. Thank you.
Mr. Michaud. I would now like to welcome our second panel.
The first individual I will ask to give his statement is
Mr. Hodes. I want to thank you, Mr. Hodes, for your interest in
veterans issues. I know you have been a strong advocate for
veterans issues, we have dealt with your legislation earlier in
the year as well. So thank you very much for coming here today.
Mr. Hodes?
STATEMENTS OF HON. PAUL W. HODES, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF NEW HAMPSHIRE; HON. JOHN T. SALAZAR, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO; HON.
NITA M. LOWEY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
NEW YORK; AND HON. JEFF MILLER, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF FLORIDA
STATEMENT OF HON. PAUL W. HODES
Mr. Hodes. Thank you, Chairman Michaud, and Ranking Member
Miller for holding this important hearing today. I appreciate
the opportunity to come before this Subcommittee to testify
about H.R. 2192, the bipartisan bill I introduced establishing
an Office of the Ombudsman in the Department of Veterans
Affairs. I also want to thank Chairman Filner, who is not here,
for his support of the bill.
This bill grew out of the visits I made to Walter Reed Army
Medical Center and the hearings held by the Oversight and
Government Reform Committee on which I sit. I talked with
numerous soldiers about the problems they experienced
transitioning out of active duty and into the VA. I also talked
with numbers of veterans organizations within my own State, New
Hampshire, and numbers of veterans.
Veterans in my district have repeatedly told me their
compelling stories of the great difficulties and challenges
they have faced in understanding and receiving all the benefits
and services to which they are entitled. The ombudsman's
office, which as proposed in this bill, should serve as the
outreach master office. A coordinating and coordinated center
for benefits and health information services available both
within and outside of the VA.
I am not interested in creating another meaningless layer
of bureaucracy. Instead, I would like the Ombudsman Office to
become a one stop shop for veterans. A CENTCOM for veterans
benefits information. I applaud the VA for their hard work in
providing information that veterans need. The VA has numerous
hotlines and support services available to veterans. I have
counted ten different 1-800 numbers on the VA's website to help
with different types of benefits. One for disability pension,
another for healthcare benefits, another for life insurance,
etc.
And while the VA provides veterans benefits and services
information, the veterans may not know where they put their
informational pamphlets 6 months or one year down the road when
they have a question or a problem. Our veterans are falling
through the cracks and do not know where to turn.
It was very interesting to me, recently a number of both
active duty wounded soldiers and veterans came to the floor of
the House to talk with a number of Members of Congress. There
were seven or eight members of Congress there and we heard
compelling stories there on the floor from veterans who
described what they--described as their ordeal working through
the bureaucratic maze and the red tape in the Veterans
Administration. And this office is designed to provide that one
stop shop that would help them cut through the red tape.
It would provide a focal point of information within the
VA. The office should head up the advocacy and information
campaigns that the VA already has in place and consolidate the
information services with an 800 number to address all the
veterans needs and complaints. For a veteran who has just
returned from active duty an Operation Iraqi Freedom (OIF) or
Operation Enduring Freedom (OEF) with traumatic brain injury,
it would be a whole lot simpler and easier to have only one
office to call to receive the information he or she needs.
The VA has a patient advocacy program for healthcare but a
lot of brave men and women need help with loans for their homes
and schooling too. They shouldn't have to run around asking the
same ten questions to ten different offices. The Ombudsman's
Office can help the veteran figure out all the services in the
benefit system not just the healthcare and not just about
disability.
I have reviewed the testimony of the esteemed panelists,
the VA and VSOs who have presented written testimony before
this Subcommittee. And just in the six testimonies that
specifically discuss the Ombudsman's Office, the panelists
referred to 14 different programs both within and outside of
the VA that veterans could turn to for help with benefits
coordination. That is good news and the bad news.
The good news is the services are available. The bad news
is there are so many of them which can be confusing. These 14
programs are extremely important to our veterans in providing
specialized services. But as a healthy member of Congress and
not a PTSD patient or an ailing elderly veteran, I am even
confused to some degree about which programs to use and under
which circumstances.
So, Mr. Chairman, I am not trying to make redundant
services. The VA provides advocacy and resources and many VSOs
provide advocacy and resources. I look forward to working with
the Honorable Members of the Committee to mold the Office of
the Ombudsman in to a viable helpful resource for veterans. I
believe that this consolidation of various information sources
in to a coordinated center of information will help make sure
the veterans receive the care they need and cut through the
seemingly endless amounts of bureaucratic red tape.
I would like to point out to the Subcommittee that
especially with respect to the duties section as it is
currently set forth in the draft bill, I believe that through
markup and working with the expertise of the Committee, that
section probably didn't come back as complete to me from
legislative counsel as it ought to be and should be expanded so
that the duties include coordination of services and benefits
both within the VA and also that may be available through VSOs
and or the communities in which the veterans are so that it is
a comprehensive coordination effort.
Thank you again for giving me the opportunity to testify
before this Subcommittee and I look forward to working with the
Committee to help veterans understand and access the benefits
they deserve.
[The prepared statement of Congressman Hodes appears on p. 6
0.]
Mr. Michaud. Thank you very much, Mr. Hodes. Mr. Salazar?
STATEMENT OF HON. JOHN T. SALAZAR
Mr. Salazar. Thank you Chairman Michaud and Ranking Member
Miller and Members of the Subcommittee. I want to first of all
thank you for your interest in rural veterans healthcare and I
know that you have both been major leaders in this fight.
Mr. Chairman, today I am happy to bring H.R. 2005 to the
Subcommittee. I am looking forward to discussion of this
important legislation. This bill called the Rural Veterans
healthcare Improvement Act seeks to improve healthcare services
to veterans in rural areas.
As many of you have heard over the last several years in
this Committee that a study of more than 767,000 veterans by
researchers working for the Department of Veterans Affairs
shows vets in rural areas are in poorer health than vets living
in the cities.
The VA found that the health of rural veterans still
persist even after researchers adjusted for social economic
factors such as race, education, and employment status. It was
identified in this study that access is a care--to care is a
key factor. The study suggested that in addition to
establishing more clinics in rural areas VA should consider
coordinating services of Medicare and other healthcare services
based in rural areas similar to what Mr. Rodriguez was talking
about earlier in the earlier panel.
As a way to begin addressing some of these issues, the
Veterans Benefits Health Care and Information Technology Act of
2006, which passed at the end of the 109th Congress created the
office of Rural Health within the VA. Dr. Kussman's testimony
will tell you that the VA is opposed to this legislation
because the Office of Rural Health is charged with these tasks.
I would like to make the point that even though Congress
directed VA to establish this office it has not yet been
implemented. This new office, when the VA decides to set it up,
needs support, direction, and resources in order to fulfill its
mission of coordinating care in this vital constituency. The
Rural Veterans Health Care Improvement Act of 2007 would task
the director and the Office of Rural Health with developing
demonstration projects, centers of excellence, and a
transportation grant program. And the bill would also more
fairly reimburse veterans in rural areas for traveling expenses
they incur when driving long distances to VA medical clinics.
Mr. Chairman, with both an ailing veteran population to
care for and a new generation of veterans returning from
service in Iraq and Afghanistan, we immediately need to address
access to care issues in rural areas. It is estimated that
nearly 45 percent of all new recruits are coming from rural
America and with a large percentage of this war burdened on our
national Guard, the number is only going to increase.
Many vets must travel hundreds of miles to access medical
care that we promised and they do so almost entirely at their
very own expense. Currently we reimburse veterans at the rate
of 11 cents a mile. The rate has not been increased since 1978.
In 1978 the average price of a gallon of gasoline was 63 cents
a gallon. Today in rural America, in rural Colorado, the
average is right around $3.39 a gallon.
This legislation would increase the reimbursement rate to
48 cents a mile the same rate paid by--to Federal employees.
This legislation also establishes a transportation grant
program called Vet's Ride. Vet's Ride encourages veteran
service organizations to develop innovative transportation
options to vets in rural areas. With a grant up to $50,000, the
VSO can purchase a van or find other ways to assist veterans to
travel to VA medical centers.
This bill also establishes centers for excellence to
research waste, to improve care for rural veterans. These
centers would be based at VA medical centers with strong
academic connections. The outcome of these centers would be the
development of specific models to be used by VA in providing
health services to vets in rural areas.
The Rural Veterans Health Care Improvement Act of 2007 also
tasks the office of Rural Health with following their studies
own advice. It develops demonstration projects that would
examine the feasibility of expanding care to rural areas
through partnerships. Partnerships between the VA centers for
Medicare and Medicaid services, the Department of Health and
Human Services through critical access hospitals and community
based centers.
Demonstration projects would also be carried out in
partnership with Indian Health Services to improve healthcare
for Native American veterans. In 2003, the VA entered into a
memorandum of understanding with the departments to encourage
partnerships like these. However, 4 years have passed without
accomplishments and our vets have suffered.
Mr. Chairman, we must explore every option to ensure that
healthcare services we promised to our veterans were delivered.
The Rural Veterans Health Care Improvement Act of 2007 aims to
improve one of the greatest problems that plagues the VA
system. I am proud of this bipartisan work. We have--we
currently have over we are close to 40 co-sponsors. Very
bipartisan legislation.
And I want to thank the Chairman and the Ranking Member and
members of this Subcommittee for allowing us to testify in
front of this Committee.
[The prepared statement of Congressman Salazar appears on p.
57.]
Mr. Michaud. Thank you very much, Mr. Salazar. Ms. Lowey?
STATEMENT OF HON. NITA M. LOWEY
Ms. Lowey. Thank you very much, Mr. Chairman. Mr. Ranking
Member, members of the Subcommittee. I really do appreciate,
number one, your holding this hearing and for considering the
VA Hospital Quality Report Card Act of 2007.
I introduced this legislation in an effort to provide
increased disclosure and accountability in the VA hospital
system, and ultimately increase the quality of care for the men
and women who have served in the armed forces.
The treatment provided to our veterans is not a partisan, a
political issue, and I am pleased that this legislation is
cosponsored by some of my republican colleagues as well. I do
believe that we can all agree that quality care initiatives and
public disclosure should not end when an individual leaves
active military service. In fact the quality of care for those
who have bravely served our Nation should be of the highest
standard possible.
To achieve that goal, we must have a clear picture of the
quality of care provided by the Department of Veterans Affairs,
and this information must be continually assessed and updated.
As we learned, unfortunately, with Walter Reed Army Medical
Center, a facility that once defined excellence may not do so
the next time without constant internal assessments. My
legislation would require the Department of Veterans Affairs to
establish a formal Hospital Report Card Initiative and publish
reports on individual hospitals level, and quality of care.
The resulting report cards would provide clear outcomes
data to be used for peer review and quality improvement,
galvanize hospitals to make changes by creating public
accountability, and provide our veterans with the information
they need to make sound healthcare decisions. Several States,
including Pennsylvania, New York, California, Florida, and
Illinois have already implemented Hospital Report Card
Initiatives.
March 2007 Veterans Administrative report exposed major
deficiency in the physical condition in many veteran's
facilities. In this report, the VA Hudson Valley Health Care
System, which serves over 25,000 veterans throughout my
district and the surrounding areas, was cited for ceiling
molds, suicide hazards in the psychiatric ward, and cosmetic
deficiencies.
I am going to repeat one part of that because I think it
underscores the level of neglect seen throughout the VA
healthcare system. Suicide hazards in a psychiatric ward in
area in hospitals that most certainly should limit the ability
of an individual to harm him or herself.
Dr. Michael Kussman, Under Secretary for Health at the VA
previously stated, ``VA hospitals are inspected more frequently
than any other healthcare facilities in the Nation.'' If this
is true, then the Department should have no problem complying
with the requirements of this legislation.
If we are serious about ensuring a seamless transition
between the U.S. Department of Defense (DoD) provided
healthcare and VA provided healthcare, we must have an accurate
assessment of the VA system and the VA Hospital Quality Report
Card Act of 2007 would provide just that.
So, I thank you very much. Thank you for your work. And I
would be delighted, as I know my colleagues are, to respond to
any questions.
[The prepared statement of Congresswoman Lowey appears on p.
61.]
Mr. Michaud. Okay. The last member of the panel is also the
Ranking Member of this Subcommittee, Mr. Miller?
STATEMENT OF HON. JEFF MILLER
Mr. Miller. Thank you very much, Mr. Chairman. I have two
bills for the hearing today. The first one I would like to
discuss is H.R. 2623. This bill is designed to prohibit the
collection of copayments for all hospice care furnished by the
Department of Veterans Affairs.
Currently VA offers a compliment of hospice and palliative
care options as part of the comprehensive healthcare benefit
provided to all enrolled veterans. Hospice and palliative care
are a continuum of comfort oriented supportive services
provided across settings including a hospital, extended care
facilities, outpatient clinics, and private residences.
Under current law a veteran receiving hospice care in a
nursing home is exempt from any applicable copayments. However,
if hospice care is provided in any other setting such as an
acute care hospital or even in the veteran's home, the veteran
may be subject to an inpatient or outpatient primary care
copayment. Essentially, VA's current policy penalizes a veteran
who chooses to remain at home for their hospice care or out of
medical necessity receives that hospice care in an acute care
setting.
Mr. Chairman, this legislation would correct this inequity
by exempting all hospice care provided through VA from
copayment requirements. This bill is important to ensuring that
every veteran preference for end of life care is provided for
in an equitable and compassionate manner.
I thank you for the opportunity to present this bill and I
would be available to answer questions.
If I could move to H.R. 1925, a bill to direct the
Secretary of Veterans Affairs to establish a separate Veterans
Integrated Service Network (VISN) for the Gulf Coast region of
the United States. I have a couple of charts. We will go--we
will flip back and forth. This will give you an idea of the
work loads at the different VISNs. I apologize for the people
in the audience not having an available one for you to see as
well.
[Chart.]
Mr. Miller. Twelve years ago most of you know that the VA
instituted the VISN. The plan was put in motion as a way for
the large VA network that healthcare that VA provides would be
more attuned to the needs of its patients.
You can see where it basically is today and graphically
it's there are 22 VISN's although there is a number 23 on there
some time ago, there were two VISN's that were combined into a
single VISN, but that gives you the idea. The gray is the
enrollees, the red is the actual patient load.
The VISN's were implemented as a way to maintain the high
quality of care while allowing more regional management so that
the central office in DC was not unnecessarily micro managing
the day-to-day aspects of the delivery of the healthcare. The
network has enjoyed its successes in providing better access
and more patient centered care. However, as always, there is
room for improvement and I think that the Gulf Coast region of
this Nation is an area where such improvement is needed.
Having already seen, as I said earlier, the consolidation
of two VISN's since it's creation, it is clear that flexibility
within the healthcare system is necessary. This bill creates a
VISN specifically targeted to improving the delivery of
healthcare to a large and ever increasing number of veterans
living in the Gulf Coast. In other words, a Gulf Coast VISN.
It would create a better healthcare network that can better
respond to veterans and the unique needs and problems facing
veterans in the area. The area involved would, if you would
flip it over, give you an idea. Everything the gray shaded
areas are not part of VISN 16, but the teal and the purple and
the peach color that is VISN. There is also a little green down
at the very bottom, that is VISN 16. So basically it goes from
the center of the Florida panhandle all the way to the Oklahoma
panhandle geographically. It is the largest geographic VISN,
but that is not necessarily the point. The point is the
workload that is in there now.
Obviously, my district, district one is on the southeast
corner of the panhandle, so that gives you an idea of how large
the VISN is. If you would, there are some and I don't know if
staff going to handout, smaller charts for you to look at. VISN
16 is actually the second largest in patient enrollment and
patients as well.
This creates again, as I said, the ability for VA to
deliver to the unique needs and problems facing veterans in the
area. It does stretch all the way from the Florida panhandle
over to the State of Louisiana and up into Alabama. The Capital
Asset Realignment for Enhanced Services (CARES) Program did
identify this area as under served, and its unique geographical
location is no doubt part of the reason that it was so
designated. Most of the region would be in VISN 8. It would be
where VISN 16 meets VISN 8. By the way, VISN 8 as Ms. Brown
knows is also the number one VISN in the country. It happens to
be the peninsula part of the State of Florida.
You can see that the veteran population continues to grow
in those regions. Looking back and looking at the map you can
see how diverse and how largely rural. As we have talked about
with other testimony today, regions can be over looked because
of major metropolitan areas that are being served. We don't
think, and I am sure that most people would agree that the
300,000 veterans that are currently being served in that region
there are many, many more veterans, but these are enrolled
veterans. They certainly don't want their healthcare overlooked
either.
Several reasons why I see this bill as important and
successful. Again, a new Gulf Coast VISN director could take
great advantage of the sharing opportunities that are there
between DoD and VA. The Gulf Coast is home to multiple defense
installations and while a few DoD/VA facilities exist now,
there is tremendous opportunity for expanding this relationship
to deliver a wider range of healthcare service.
I would say that all of our veterans across the Nation
deserve more timely access to VA healthcare. The intent of my
bill, albeit there could be other geographic areas that are as
under served as ours, is to get a first step toward creating
that access. Again going all the way back to it's original
creation, obviously the demographics have shifted and time for
a re-look is upon us.
Mr. Chairman, thank you for letting me testify on this
bill, and I can and am ready to answer questions on this or the
other bill as well.
[The prepared statement of Congressman Miller, and the
charts attached to Congressman Miller's statement, which he
referred to, appears on p. 58.]
Mr. Michaud. Thank you very much, Mr. Miller. A few
questions: The first one for Mr. Hodes. If I understand
correctly, what you want to do is look at all of these programs
and work toward having one access point for veterans to be able
to access these programs.
Have you given any thought about also trying to streamline
the process? And for those who can use a computer, to ask just
a few basic questions on a computer-based system that will tell
them where to go?
The reason why I mention that is when we had a couple of
mills shut down and healthcare was a big issue, drug companies
offered programs for individuals. There are 329 different
programs that drug companies offered with applications for each
one of those programs. And if you are laid off trying to find a
job and healthcare, you are not going to do it.
However, what they did was take all of these programs,
narrowed it down to four basic questions, established an 800
number and that will show an individual applying for one of
these programs where to go.
Is that something that you would envision under your
legislation as well?
Mr. Hodes. That would certainly be part of a good way for
the Ombudsman Office to accomplish it's work, because I guess
if I had to use a word I see the Ombudsman Office as providing
the hub to which people go. And it--the Ombudsman Office would
then help route people through the system. They could then
return to the Ombudsman Office as they are working their way
through the system for other questions.
So your suggestion would certainly be a good part of
implementing the Office of the Ombudsman. Thank you, Mr.
Chairman.
Mr. Michaud. Ms. Lowey, I have read the testimony from the
Department and they talk about the Joint Commission previously
known as the Joint Commission Accreditation of Health Care
Organizations (JCAHO). They have a website that provides a lot
of the data that you were talking about. Have you looked at
that website and is it inclusive of what you are including in
your legislation?
Ms. Lowey. Well, I thank you for bringing up that question,
because the Joint Commission does reviews. We have been told it
is about every two, 3 years and it is not as--it is not as
comprehensive as the kind of review we propose.
And again the basic idea here is to do it frequently at
least twice a year, provide up-to-date information,
transparency so that VA's veteran's can access this information
and actually make some decisions based upon the information
provided.
Mr. Michaud. Great. And my last question actually deals
with one of Mr. Miller's bills, the hospice bill. If I read and
heard your testimony correctly, veterans will not have to pay
the copayment if they go through VA for services. Now does that
include contract services? I am just thinking of someone in a
rural area that needs hospice care, how do you envision that?
Mr. Miller. It would cover them. Absolutely.
Mr. Michaud. It would cover them. Okay. Good. Thank you.
Mr. Miller do you have any questions?
Mr. Miller. Ms. Lowey, I am interested in and we all can
appreciate the desire to set some type of standard. Do you
envision measuring VA hospitals against private facilities in
some way where or is this just within the VA healthcare system
where you are saying this one is an ``A,'' ``B,'' ``C.'' Are we
going to measure them against other facilities?
Ms. Lowey. That is an important question. And it has been
suggested to me and I certainly would be flexible about it,
that we might call it VA Medical Center because it would
encompass a more extensive group of hospitals that would be
included in this review.
I was thinking about the VA system, but I would certainly
be open if the Committee would suggest it to making it more
expansive.
Mr. Miller. The reason I ask the question is the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO)
standards that you know all hospitals go through accreditation,
how would this be more in depth? How would it compare to those
standards, and if you are not sure right now you can report
back.
Ms. Lowey. I am not sure about the JCAHO standards.
Mr. Miller. No, I would like to know in regards to
standards that are out there that VA currently has to abide by
how far we are looking at going forward.
Ms. Lowey. You know I am very interested in the idea of
providing facilities that specialize, for example, in traumatic
brain injury (TBI) to veterans making them inclusive and
expanding opportunities for veterans getting these services.
So, although I was talking about the VA system, I am hoping
that we can bring in hospitals such as the Helen Hays Hospital
in part of my district in Rockland County which has expertise
in traumatic brain injuries.
So it is another issue that I know some people are thinking
about, because the numbers of people that are coming out of the
hospital. Just recently I was talking to a group called the
``Wounded Warrior Project.'' And they are providing the role of
the intermediary. I was interested in what my colleague was
talking about in the ombudsman position, because many of these
veterans come out so lost and need additional guidance and
additional help.
So with this bill, I was talking about an assessment of the
VA hospital system to provide the transparency and to provide
the information to the veterans. But I certainly would be happy
to work with you, Mr. Miller, to see if you believe that it
should be more expansive and more inclusive.
Mr. Miller. Thank you very much. The other question, Mr.
Salazar is in regards to the mileage reimbursement, would you
envision it paying for service and non-service connected visits
or just service connected visits?
Mr. Salazar. Basically just service-connected visits and it
would just be similar to what we get. I mean, as members of
Congress we get 40 or we are allowed to get 48 cents a mile.
The current reimbursement rate of course is only 11 cents.
And I get the story, I represent a district that is larger
than half of the State of Colorado. And many of my veterans
have to drive 5 hours to one center or another and some even
have to go to Albuquerque. And many of them will tell me that
their wives cannot go with them because gas is so expensive
they can't afford the hotel to stay in over night. So for that
reason I think it is only fair that we look at this. You know
gas was only 63 cents a gallon in 1978 and that is when the
last raise was or the last, I guess, increase was made. So
thank you.
Mr. Michaud. Mr. Hare?
Mr. Hare. I don't have any questions, Mr. Chairman.
Mr. Michaud. Dr. Snyder?
Mr. Snyder. Thank you. I wanted to ask our Ranking Member,
Mr. Miller, just a couple questions. I notice that the bill
regarding the hospice co-pay is not on the list that Dr.
Kussman discusses. Was that a late add on or do you know what
the VA position is on that bill?
Mr. Miller. VA supports it.
Mr. Snyder. Supports it. Okay. And then the second with
regard to the VISN lines. Were all the VISN boundaries have
they been set by statute in the past or were those set
administratively?
Mr. Miller. I believe they have been set administratively.
Mr. Snyder. Administratively. Thank you.
Mr. Michaud. Ms. Brown.
Ms. Brown of Florida. I don't have any questions at this
time.
Mr. Michaud. Thank you. Once again, I would like to thank
the panelists for your testimony this morning. I look forward
to working with you as we move forward with these pieces of
legislation. Thank you very much.
Mr. Hodes. Thank you very much.
Ms. Lowey. Thank you.
Mr. Michaud. I would like to ask the third panel to come
up. We have Shannon Middleton, American Legion; Kimo
Hollingsworth, AMVETS; Adrian Atizado, Disabled American
Veterans; Carl Blake, Paralyzed Veterans of America; Dennis
Cullinan, Veterans of Foreign War; and Barry Hagge, Vietnam
Veterans of American.
I would like to welcome all the panelists here today and I
look forward to hearing your testimony.
We will start with Ms. Middleton and just work down the
table.
STATEMENTS OF SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH,
AMERICAN LEGION; KIMO S. HOLLINGSWORTH, NATIONAL LEGISLATIVE
DIRECTOR, AMERICAN VETERANS (AMVETS); ADRIAN M. ATIZADO,
ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN
VETERANS; CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, PARALYZED
VETERANS OF AMERICA; DENNIS M. CULLINAN, DIRECTOR, NATIONAL
LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED
STATES; AND BARRY HAGGE, NATIONAL SECRETARY, VIETNAM VETERANS
OF AMERICA
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 the several pieces of legislation
being considered by the Subcommittee today.
The American Legion commends the Subcommittee for holding
the hearing to discuss these very important issues. And I will
limit my comments to just a few of the bills being considered.
Mr. Michaud. Could you pull the microphone up a little bit
closer please?
Ms. Middleton. This better?
Mr. Michaud. Much better.
Ms. Middleton. Much better. H.R. 2005, the ``Rural Veterans
Health Care Improvement Act of 2007,'' addresses many issues
affecting veterans who reside in rural areas. It seeks to
increase the beneficiary travel rate to make it equivalent to
the rate provided to Federal employees; establish centers for
rural healthcare--rural health research, education, and
clinical activities; offer transportation grants for service
organizations to assist rural veterans; and explore
alternatives to improve transportation to medical facilities
for rural veterans. The American Legion fully supports this the
provisions in this bill.
Beneficiary travel pay has not been increased from its
current rate since 1978. The price of gasoline has steadily
increased since the 11 cent per mile rate was established,
creating a financial hardship for veterans who have to travel
long distances for care, or those who have limited financial
resources.
Since service-connected veterans and other veterans
authorized beneficiary travel only receive 11 cent per mile and
are subjected to a six dollar per trip deductible, this amount
does very little to defer the cost of travel.
There are no provisions in law that VA must increase the
per mile travel authorization on a regular basis. The
beneficiary travel program is discretionary and the Secretary
of Veterans Affairs has determined that it is necessary to
maintain the current reimbursement rate in order to allow the
VA healthcare system to accommodate the increasing patient
workload.
The lack of a consistent and reliable mechanism to
periodically adjust the rate authorized for beneficiary travel
creates an injustice and an unfair economic burden for many
veterans. The American Legion believes that mandatory funding
for VA healthcare would allow the Secretary to provide adequate
healthcare without inversely affecting programs designed to
mitigate the cost of accessing that care.
Establishing centers for rural health research, education,
and clinical activities would afford VA the opportunity to
build strategies to improve it's system of care for rural
veterans, as well as educate and train healthcare professionals
on health issues prevalent in specific rural veteran
populations.
And offering transportation grants for organizations that
can assist rural veterans and exploring alternatives to improve
transportation to medical facilities for rural veterans would
make accessing care easier for those who are not financially
able to travel to facilities, especially those who, due to
their financial--sorry--their physical condition are not able
to make extremely long trips in 1 day. If more transportation
options became available it may also improve coordination of
care for those who have to travel distances for special
services, especially in the unavailability of a family care
giver.
H.R. 2173 seeks to amend title 38, U.S. Code, to authorize
additional funding for the Department of Veterans Affairs to
increase capacity for provision of mental health services
through contracts with community mental health centers, and for
other purposes.
The American Legion believes that VA should contract with
community providers only when it is unable to provide needed
services to the veteran, if travel for the veteran would be a
danger to his or her health, or the veteran resides in a rural
area. As long as VA healthcare remains discretionary, VA will
always struggle to maintain sufficient funding to provide
access to quality care for eligible veterans seeking care in VA
facilities. Mandated funding would provide a method to provide
dependable stability, stable and sustained funding for veterans
healthcare.
H.R. 2378, Services to Prevent Veterans Homelessness Act.
This bill aims to establish a financial assistance program to
facilitate supportive services for very low income veteran
families to assist them in ending their chronic homelessness
state and to prevent chronic homelessness.
Enactment of this legislation will enable funding to
provide much needed supportive services to veterans and their
dependants. It takes into account that the VA Grant and Per
Diem Program can only provide services to veterans and fill a
much needed gap of caring for their dependents.
Veterans require a coordinated effort that provides secure
housing and nutritious meals; essential physical healthcare,
substance abuse aftercare, mental health counseling; as well as
personal development and empowerment. They also need job
assessment training and placement assistance.
The American Legion fully supports this bill in it's
efforts to assist homeless veterans. And we applaud that the
bill recognizes that families also suffer alongside the
veterans struggling with homelessness.
Again, thank you Mr. Chairman for giving the American
Legion this opportunity to present it's views on such important
issues and we look forward to working with the Subcommittee to
address these and other issues affecting veterans.
[The prepared statement of Ms. Middleton appears on p. 62.]
STATEMENT OF KIMO S. HOLLINGSWORTH
Mr. Hollingsworth. Mr. Chairman, members of the
Subcommittee, I am pleased to offer testimony on behalf of
AMVETS regarding the health legislation for this Subcommittee.
Regarding the Hospital Quality Report Card Initiative,
AMVETS would like to note that the Government Performance and
Results Act requires that agencies develop measurable
performance goals and report these results against these goals.
In addition, the Department has tracked and monitored the
quality of care at VA facilities since the early seventies
through comprehensive quality management programs. In addition,
there are some Federal laws that require VA Office of Inspector
General to oversee VA Quality Management (QM) Programs at every
level. And a large part of the VA Inspector General's Office
performs the Combined Assessment Program (CAP). These reports
review focus on quality safety and timeliness of VA healthcare.
Overall AMVETS supports efforts to improve VA healthcare
and supports the intent of H.R. 1448. However, we believe the
bill would mandate a duplicative effort as many of the items to
be reported in the report card are already reviewed and
reported through either the VA QM and CAP programs.
Regarding the training of police officers to interact with
visitors and patients at medical facilities who are suffering
from mental illnesses, AMVETS supports this bill.
Regarding the creation of a new VISN, AMVETS has testified
previously that CARES was supposed to be system-wide process to
prepare the VA for meeting the current and future healthcare
needs of veterans. Overall, AMVETS supported the CARES process,
and we believe that Congress should consider the CARES
recommendations in deliberations about VA infrastructure to
include deliberations about the current VISN model.
I would like to note that there has been some considerable
time has elapsed since implementation of the VISN model, and
there clearly have been some demographic changes within the
general population that would most likely include changes to
the veteran population as a whole.
Regarding the Rural Health Care bill, AMVETS continues to
support an increase to the mileage reimbursement rate.
Regarding the overall Centers of Excellence, AMVETS would like
to note that Congress did set up the Office of Rural Health
Care and we urge Congress to fully fund and require the VA to
conduct that assessment.
With regards to the establishment of the Ombudsman within
the Department of Veterans Affairs, AMVETS supports this bill.
H.R. 2219 would direct the Secretary to award a grant to a
private non-profit entity to establish and publicize a toll
free suicide prevention.
Overall, Mr. Chairman, AMVETS would oppose efforts by
Congress to mandate the Secretary enter in to contracts with a
private entity for these services. And we believe that the
Secretary must continue to have the flexibility in how he
implements these services.
Lastly, H.R. 2378 regarding a financial assistance program
to facilitate the provision of supported services for very low
income veteran families in permanent housings. We support the
intent. A large part of this bills, many of these services are
already available to veterans. However, we do have concerns
with the provision that specifically targets payments to
veterans. And we would urge Congress instead to consider
priority assistance at one of the other agencies that deals
with housing.
This concludes my testimony. I would be happy to answer any
questions.
[The prepared statement of Mr. Hollingsworth appears on p.
65.]
STATEMENT OF ADRIAN M. ATIZADO
Mr. Atizado. Mr. Chairman, Ranking Member Miller, members
of the Subcommittee, thank you for inviting the DAV to testify
at this important legislative hearing. For the sake of brevity,
I will cover a number of bills or provisions relevant to the
DAV and would request the Subcommittee refer to my written
testimony for more details regarding all the measures under
consideration with exception to the two draft bills that we
were unable to provide comments due to time constraints.
While we support sections two and four of H.R. 2005, the
``Rural Veterans Health Care Improvement Act of 2007,'' we
consider these provisions a good first step to ensure sick and
disabled veterans are able to access the medical care they
need.
As funding for both provisions will most likely come from
VA's medical services account, we urge first and foremost that
Congress and VA correct inequity in the VA beneficiary travel
program. This program unlike the Transportation Grant Proposal
affects access for all veterans residing in rural, urban, and
medically under served areas.
Second, for good stewardship of taxpayer dollars and for
the most effective use of such precious medical care funds, we
urge that this Transportation Grant Program not be duplicative
of current services, particularly those provided by the DAV
Transportation Network or other transportation networks in
existence.
Further, the implementation of this proposed program should
be coordinated through the Office of Rural Health to assure
that unmet needs of rural veterans are addressed. As you may be
aware, the DAV knows first hand the benefits of a
Transportation Program. The DAV, in coordination with VA's
Voluntary Service Program, began buying and donating vans to
the VA facilities. To date, we have donated nearly 2,000 vans
at a cost exceeding $39 million.
Since inception, these vans, the dedicated VA volunteer
drivers and volunteer transportation coordinators have
transported more than 10 million veterans over 397 million
miles to and from VA medical appointments.
Having said that, we must not forget one of the reasons our
transportation program began in 1987. Regulations amended by
the VA, effective April 13, 1987, severely curtailed and
restricted the eligibility and method by which beneficiary
travel was paid. Many veterans in need of VA medical care found
themselves effectively precluded from receiving such care.
In addition to our transportation program, DAV has a
longstanding resolution to repeal the beneficiary travel pay
deductible to create a line item budget for this program and to
increase travel reimbursement rate, which remains unchanged
since 1977 at 11 cents a mile.
We urge this Subcommittee to approve and enact legislation
this year to reform the VA beneficiary travel program.
H.R. 2173 would allow the VA to provide mental health
services through contracts with community mental health
centers. The DAV believes that VA-purchased care is an
essential tool in providing timely access to quality medical
care.
However, as VA's contract workloads have grown
significantly at a cost of about $3 billion this year, we are
concerned that this bill does not provide any consideration for
the judicious use of purchased care. Nor does it address our
concerns regarding the lack of a systematic process to improve
VA contract care services.
H.R. 2219, the ``Veterans Suicide Prevention Hotline Act of
2007,'' would require the VA to award a grant to a private,
nonprofit entity to establish and operate a national toll-free
suicide prevention hotline.
The DAV notes that there is already in existence a
Federally funded 24-hour, toll-free suicide prevention service
comprised of over 120 individual crisis centers across the
country. From the toll-free number, a caller is seamlessly
routed to a certified provider of mental health and suicide
prevention services nearest to the call of origination.
If applied to service veterans, a veteran could be
transferred similarly, but to a VA mental health provider if
the individual wants the services and support of the VHA.
We would like to thank Ranking Member Miller for
introducing H.R. 2623 and Chairman Michaud for including it in
today's hearing. This bill seeks to prohibit the collection of
copayments for all hospice care furnished by the VA.
The DAV has previously testified before this Subcommittee
on this important issue, and we support the intent of this
measure. We would just like to ensure that its scope is broad
enough to include exemption of veterans from copayments for
hospice care provided in any treatment setting.
This concludes my testimony. I'd be happy to answer any
questions you may have.
[The prepared statement of Mr. Atizado appears on p. 68.]
STATEMENT OF CARL BLAKE
Mr. Blake. Mr. Chairman, Ranking Member Miller, and members
of the Subcommittee, on behalf of Paralyzed Veterans of
America, I would like to thank you for the opportunity to
testify today.
Given the broad spectrum of bills on the agenda, I will
limit my comments to only a few items.
Although PVA has no objection to the requirements for a
Hospital Quality Report Card Initiative, as outlined in H.R.
1448, we remain concerned that this wealth of information will
go unused.
Collecting this information and assessing it without acting
on any findings from that information, would serve no real
purpose. We would hope that the congressional Committees will
use this information published in these reports each year to
affect positive change within the VA.
PVA generally supports H.R. 2005, the ``Rural Veterans
Health Veterans Health Care Improvement Act.'' However, we have
concerns about the demonstration projects that will establish
partnerships between the VA and the Centers for Medicare and
Medicaid Services to seek care in critical access hospitals or
community health centers.
Principally we believe that this legislation is ``jumping
the gun'' by getting ahead of the Office of Rural Health, which
is responsible for determining if solutions, such as this
proposed demonstration project, are feasible.
We think that this new office in the VA should be given
time to do its job before Congress begins legislating solutions
to the problems that rural veterans face. However, this
certainly does not say that Congress should not pressure the VA
into implementing this office expeditiously as we believe they
have not done so.
PVA has serious concerns about the provisions of H.R. 2172.
PVA strongly opposes the provisions of H.R. 2172. PVA strongly
opposes the provision of section 2 of the bill that would allow
the VA to contract for service and repair of prosthetic
devices.
We interpret this legislation to mean that the VA can
contract with a single entity to provide these services and
repairs. This is absolutely a bad idea. By using a single
entity, the pool of devices and services available will be
severely limited.
A one-size-fits-all approach to prosthetics cannot be
applied. As an example, prosthetics departments that serve PVA
members needing wheelchairs often, if not always, contract with
multiple different vendors to provide those wheelchairs.
Because every PVA member, and every disabled veteran for
that matter, is different, the equipment they need varies.
Although an Invacare power chair may be suitable for one spinal
cord injured veteran, another spinal cord injured veteran might
be better served by a Jazzy wheelchair.
Two uniquely different veterans cannot be expected to use
the same equipment simply because it might streamline processes
for the VA.
PVA has no objection to the provision of the legislation
that would require certification of VA orthotic-prosthetic
laboratories with the ABC in Orthotics and Prosthetics or the
Board of Orthotics and Prosthetic Certification.
However, we believe that the VA already meets these
requirements, but if this provision will reinforce that action,
then we have no problem with it.
The incidence of suicide among veterans, particularly OEF
and OIF veterans, is a serious concern that needs to be
addressed. PVA principally supports H.R. 2219. Any measure that
will reduce the incidence of suicide among veterans is
certainly a good thing.
However, we must emphasize a couple of important points.
First and foremost, there need to be absolute standards
established that ensure that the individuals staffing this
hotline are adequately trained to handle the complex issues
associated with individuals contemplating suicide.
We certainly support the idea that this service should be
staffed by veterans, but they must have the proper training to
deal with these cases. Simply having the shared experience of
military service is not enough.
Secondly, clear steps for referral into VA mental health
clinics and other VA facilities with related services must be
outlined. The private entities responsible for the operation of
the suicide prevention hotline must understand how to refer
veterans dealing with these problems into programs that will
provide the services that they actually need.
These services are essential to helping the veteran
overcome the suicidal feelings he or she may be dealing with.
Mr. Chairman, Mr. Miller, and members of the Subcommittee,
we look forward to working with this Subcommittee to develop
workable solutions that will allow all veterans to get the best
quality care available.
I would like to thank you again for allowing us to testify,
and I would be happy to answer any questions that you might
have.
[The prepared statement of Mr. Blake appears on p. 72.]
STATEMENT OF DENNIS M. CULLINAN
Mr. Cullinan. Mr. Chairman, distinguished members of the
Subcommittee, On behalf of the men and women of the Veterans of
Foreign Wars, I want to thank you for inviting us to
participate in today's most important legislative hearing.
The VFW is pleased to support H.R. 1488, the ``VA Hospital
Quality Report Card Act.'' Resulting data would allow veterans
to compare quality of services the VA provides, letting them
make more important judgments about their healthcare.
It would allow VA to identify areas of improvement, and it
would provide essential data for Congress to better use its
essential oversight.
We only urge that this action not conflict with the
reporting requirements that VA is already undergoing and
attempting to implement.
The VFW supports H.R. 1853, the ``Jose Medina Veterans
Affairs Police Training Act.'' Given the large numbers of
returning veterans who are suffering from mental illnesses of
various degrees, extra training for VA employees on how to deal
with these patients is entirely appropriate. This is especially
true for those patients who are vulnerable and suffering the
most. The extra training will ensure that wounded warriors are
treated with dignity and respect.
The VFW has no objection to H.R. 1925, legislation that
would establish a new VISN in the Gulf Coast Region.
The VFW is pleased to support H.R. 2005, the ``Rural
Veterans Health Care Improvement Act.'' The legislation is
aimed to solve one of the greatest problems facing the large
number of veterans who live in remote areas: access to care. It
aims to improve services including transportation for disabled
vets, research and partnerships with small communities.
We are strongly supportive of section 2, which would
increase the mileage reimbursement rate veterans receive for
their travel expenses related to VA healthcare to the rate
provided to all Federal employees.
The VFW is supportive of H.R. 2172. However, the VFW is not
sure if changing the rules of VA's prosthetic programs is
needed, and we have concerns that the certification
requirements that would affect all service and repair programs
for prosthetics and orthotics is necessary.
We are also concerned that some efforts to create a
certification process could lead toward excessive
standardization that aims for one-size-fits-all solution.
The VFW supports H.R. 2173 that would allow the Secretary
to enter into contracts with service for community mental
healthcare.
With the number of returning servicemembers who are
suffering from mental health conditions, it is clear that VA
can and must do more.
However, an over reliance on contract care, especially the
mental health area, could lead to some extensive continuity of
care problems.
Among other things, VA would have to determine some way to
ensure that no veteran falls through the cracks when going from
the department to a local provider.
Further, it would be absolutely critical that patient
records be transferable among all providers so that all
information is provided to all involved healthcare givers. With
respect to H.R. 2192, ``Providing for VA Ombudsman,'' the VFW
is supportive of the intent of this act. We only question
whether it's feasible for a single office or entity to gather
together and properly coordinate so much information.
Be that as it may, there is definite need for additional
assistance for veterans in this complex system.
The VFW supports H.R. 2219, the ``Veterans Suicide
Prevention Hotline Act.'' We understand, however, that the VA
is in the process of establishing a similar hotline. So it may
be necessary to determine how much overlap there is between the
programs. It is clear, however, that the program would be
beneficial.
The VFW supports H.R. 2378, which would establish a program
of financial assistance to help veterans and their families
from slipping back into homelessness.
The VFW offers our strong support for H.R. 2623 that would
exempt patients seeking hospice care from paying copayments.
This is a compassionate idea that relieves a burden on the
veteran and their loved ones at a most critical time.
Thank you, Mr. Chairman, for my testimony.
[The prepared statement of Mr. Cullinan appears on p. 76.]
STATEMENT OF BARRY HAGGE
Mr. Hagge. Good morning Mr. Chairman, Ranking Member
Miller, and Members of this Subcommittee. Thank you for giving
Vietnam Veterans of America the opportunity to offer our
comments on several veterans' health-related bills that are up
for discussion here today.
All of these bills, with the possible exception of H.R.
1853, are extremely important. And with a few reservations,
they are worthy of your consideration and certainly our
support.
I note that while we have not adopted an official position
on H.R. 1925, we do not object to it.
The topic of accessibility to VA medical services for
veterans who live in rural areas has been percolating of late.
We believe that H.R. 2005 offers pragmatic solutions to address
the problems of access to healthcare experienced by too many
rural veterans.
The bill would increase travel reimbursement for veterans
who travel to VHA facilities to the rates paid to Federal
employees.
The current reimbursement rate was established decades ago
and does not adequately compensate for the costs of gasoline,
``wear and tear'' on the vehicle and increased insurance that
may be necessary in order to travel to distant medical centers.
In the same vein, the grant program for rural veterans'
service organizations to develop transportation programs could
be an innovative way to strengthen community resources that may
already assist with veterans' travel needs.
The establishment of centers of excellence for rural health
research, education, and clinical activities, another component
of this bill, should fill a gap in VA healthcare and should
lead to innovation in long-distance medical and telehealthcare.
These centers have brought the synergies of clinical,
educational, and research experts to bear in one site. Such
centers have allowed VA to make significant contributions to
the field of geriatric medicine and mental illnesses.
It would require demonstrations of rural treatment models.
Demonstrations on treating rural veterans' populations would be
extremely useful in assessing effective ways to offer
healthcare to individuals who are generally poorer, more likely
to be chronically ill, and almost, by definition, more likely
to have challenges in access to regular healthcare.
And establishing partnerships with the Indian Health
Service and with the Department of Health and Human Services
should also add to greater cooperation and collaboration in
meeting the needs of rural veterans.
We would caution, however, that we would not like to see
these demonstration projects exploring more opportunities to do
widespread contracting out of veterans health services.
Demonstration models should be assessed according to a number
of outcomes such as quality of care, cost, and patient
satisfaction and the results reported back to Congress.
H.R. 1448, the ``VA Hospital Quality Report Card Act of
2007,'' is a quality control measure that would help with
accountability and issues regarding follow-up care and timely
visits.
It would require the VA to provide grades for its medical
centers on measures such as effectiveness, safety, timeliness,
efficiency, patient``centeredness,'' and equity. Health-care
quality researchers have long thrived trying to objectively
define some of these measures.
As members of this Subcommittee are aware, the VA has a
number of performance measures it regularly assesses in order
to reward its medical centers and network directors among
others. Some of these outcomes, such as immunizations for flu,
foot care and eye care for diabetics, set the benchmark for
care in the community.
In addition to these internal performance measures, VHA
voluntarily submits to Joint Commission on Accreditation of
Healthcare Organization, Commission on Accreditation of
Rehabilitation Facilities, and managed care quality review
standards.
VVA understands the importance of quality measurement.
There is an expression with which we agree, and it's called
``What's measured, matters.''
We also agree that VA officials should be held to the
highest degree of accountability, and whatever measures are
available to allow this to better occur, we wholeheartedly
endorse.
However, before enacting this clearly well-intended
legislation, we could require significant retooling of quality
measurement systems in the VA. The Committee should hold a
hearing to identify the gaps and deficiencies in current
performance and quality measurement systems.
It would also be useful to understand how report cards
would be used and reported to improve VHA processes and
performance rewards. Would poor grades be dealt with by changes
in management? By withholding bonuses to senior executives?
With more funding? How would good grades be rewarded?
Such questions should be addressed before requiring a
significant new quality measurement program to be installed.
Again, VVA appreciates the opportunity to testify before
this Subcommittee, and we thank the Chairman for the
opportunity.
[The prepared statement of Mr. Hagge appears on p. 77.]
Mr. Michaud. I would like to thank all the panelists once
again for your testimony, and we appreciate all the work that
you are doing and have done as it relates to fighting for
healthcare services for our veterans. We really appreciate it.
You represent your organizations very well.
I only have a couple of questions. The first one to Mr.
Blake. You were talking about Mr. Salazar's bill. You mentioned
that we ought to wait and see what happens with the Office of
Rural Health, which was enacted in the 109th Congress. How long
should we wait for that office to get up before we start, you
know, taking steps?
A lot of bills that we have heard today, a lot of bills
that we heard earlier, dealt with access issues. If the VA
would move forward, whether it is the Office of Rural Health,
whether it is the CARES process, we would not see a lot of
these bills if they were doing the job that they should be
doing.
And quite frankly I have a problem with this Congress,
because of the funding issues, but hopefully we will be
addressing that later on today. Mr. Blake?
Mr. Blake. Mr. Chairman, I would say that I guess on some
level you kind of answered the question for me. I would say
that they--it should have been done in January. When the bill
was enacted in December, they should have gotten it up and
going right away, and we haven't seen any sign. I mean, maybe
they have, but we haven't seen any real sign that they have
done anything with that office yet. And maybe the VA will be
able to testify to the--what the office is doing now when they
have the opportunity.
Short of that, I mean, I couldn't give you a timeframe to
say, well, let us give them six more months and act. I
understand all of the members frustration, and given that you
created an office that doesn't seem to be doing anything, I
don't necessarily blame you for taking action.
But we don't want to jump over that hurdle without giving
an office that is directed with this responsibility the chance
to come up with something.
Mr. Michaud. Thank you very much.
My next question goes to Mr. Atizado, and it relates to,
once again, Mr. Salazar's bill dealing with the increase in
mileage reimbursement.
I know the DAV has vans that help veterans with getting to
VA services and facilities. My question is where are you on
your vans? Is there a need for more vans? Do you think that
this might be a way to help hold down costs by getting more
veterans to utilize the vans?
Mr. Atizado. Well, thank you for the question, Chairman
Michaud. The DAV transportation network obviously cannot
provide its services to all veterans who need it. Every year we
have requests from our local chapters requesting additional
vans for the network, and the way that it is structured, it is
actually structured for services in--basically in concentric
circles outside the facility. And when we map that out across
the Nation, there are some gaps out there.
What we would like to see is that, as I had mentioned in my
testimony, the moneys, the funds that are going to go into this
program, are going to come from the medical care services
account, which as we have noted earlier, has experienced some
shortages, and we have always advocated for additional funding
in those accounts.
In fact, our resolution speaks to that about the
beneficiary travel pay. That is these funds are to be used out
of that--out of that account for which--for either one of these
programs, that it be done efficiently, effectively, and without
duplication of services.
Mr. Michaud. Could you provide for the Subcommittee what
these are as it relates to the gaps that you have talked about
as far as getting vans?
Mr. Atizado. Sure. We would most certainly love to work
with the Subcommittee on that. We will give you that answer for
the record.
Mr. Michaud. Great. Thank you very much. Mr. Salazar?
Mr. Salazar. Thank you, Mr. Chairman.
I believe that most of you understand that what we are
trying to do here is to create a quality--some kind of
semblance of the fact that 40-some percent of most veterans are
coming from rural communities, and we need to address the needs
and the shortfalls.
You know, the study that I related to, it talked about how
healthcare or basically veterans health was in poor shape in
rural communities, and that is basically what our intent is
with this legislation.
In reference to the reimbursement rate, this is only
relative to those traveling 100-mile radius, over 100-mile
radius. In my district, many veterans have traveled 250 to 300
miles to get access to healthcare.
So I understand the situation, but I also hope that you can
understand that we have to continue fighting for rural
veterans, because I think they are the ones that lack access.
Thank you, Mr. Chairman.
Mr. Michaud. Mr. Hare?
Mr. Hare. Thank you, Mr. Chairman. Just a comment to you,
Mr. Blake, and then a couple of questions.
I do share with you this concern of the contract out of the
one-size-fits-all for folks, and I would like to say I want to
get--I want us to be very careful that we do not hurt our
veterans while we are trying to help. So I share with you that
concern, and I think that is something that we need to be
taking a look at.
I would like to ask you, Mr. Hollingsworth, with regard to
H.R. 2378. In your testimony you urged Congress to provide
priority assistance to the Department of Health and Human
Services, as opposed to creating a new program.
Now, I was wondering why you think that would address the
problem better?
Mr. Hollingsworth. Well, I think it is a good--it is a fair
question. We struggled with this bill internally, and I think
our overall concerns are clearly we want to help those at risk.
Clearly we want to help homeless veterans not become homeless.
But I think we are dealing with the reality of limited
financial resources for a lot of things. We want to maintain
true to the mission of VA with regards to providing priority
service healthcare to those injured in the line of duty and
service.
And I think our overall fear, quite frankly, is what we
didn't want to see happen is to create a voucher program within
the Department of Veterans Affairs for low-income veterans.
Mr. Hare. Thank you. I appreciate that. Just one other
question for--that I have.
Mr. Atizado, regarding H.R. 2173, to increase the funding
for the VA, can you tell me a little bit more about the
concerns that you have for the bill and how you think it would
affect the VA and the current VA system?
Mr. Atizado. I'm sorry, Congressman.
Mr. Hare. That is okay.
Mr. Atizado. If you could repeat the question.
Mr. Hare. Sure.
Mr. Atizado. Because I had to look up what the bill was.
Mr. Hare. I was just wondering if you could tell me on H.R.
2173, the bill to increase the funding for the VA for mental
health services, could you tell me a little bit more about the
concerns that you had with the bill and how it would affect the
current VA system?
Mr. Atizado. I thank you for that question it actually
deals with the issue--it is a two-prong issue. Right now VA has
the authority to contract services.
Our concern isn't what the quality of care providing
community mental health clinics. Our concern is how this
legislation implements services to be provides through
community mental health clinics.
The two-prong issue is how it requires VA to contract these
services, as opposed to using its current statutory authority
to make discriminate use of limited resources to contract care.
The second concern we have is how VA actually provides
contract care. There are some issues such as care--coordination
of care, getting veterans out to seek care in the private
sector and then back into the healthcare--the VA healthcare
system, to ensure that VA's holistic care of a disabled veteran
is, in fact, intact.
When a Veteran leaves the VA healthcare system to seek care
outside, it is subject to issues that VA has addressed and is
considered high quality such as patient satisfaction, medical
and medication errors, patient safety issues.
So we would like to make sure that these veterans who
receive care outside the VA healthcare system, come back in to
enjoy what has been called the best healthcare system at least
in the Nation.
Mr. Hare. I just want to conclude, Mr. Chairman, by saying
that--to all the panelists, I have only been here for going on
6 months now that the great thing is to see that the pieces of
legislation, the numbers of this legislation coming out for
veterans, I think that is a wonderful thing.
And I appreciate all of you and what you do. And I look
forward to working with you, because I certainly have no quorum
of wisdom on all these bills. And it is good to hear from the
people that you represent with what you think is right about
these bills, what you think is wrong about them. I think it
helps us to put together a better bill.
And I just want to compliment all of you for--and thank you
for taking the time, but also compliment you on what you do
to--for representing the people that you do each and every day.
So I was look very much forward to working with you on
that. Not just these bills, but other bills, the assured
funding and some other things as we go down the path.
So with that, Mr. Chairman, I give it back.
Mr. Michaud. Dr. Snyder?
Mr. Snyder. I don't have any questions. Thank you all for
being here.
Mr. Michaud. Ms. Brown?
Ms. Brown of Florida. Yes. I just have a couple of
questions, Mr. Chairman, thank you.
Mr. Hollingsworth, can you expound a little bit more about
the report card? You say a lot of the information is available,
but it seems to be scattered, and difficult to use. Can you
expound upon that a little bit more?
Mr. Hollingsworth. As I indicated in my testimony, the VA
does track and report on quite a few statistics and quality of
care initiatives.
I can speak very specifically to the combined assessment
program, because I have actually had some personal dealings in
that area. And it is a very thorough review. The assessment
team will go into the facility. It is generally supposed to be,
to the best of my knowledge, unannounced, and they do kind of
the top-to-bottom review. And it looks at everything from
patient care to patient safety issues.
And they issue a report, and generally within that report,
not only are there discrepancies listed, but they recommend
courses of action to fix those discrepancies. And they provide
a period of time for the VA to come back and fix those.
So I guess the only thing I am saying is that we would
encourage--you know, there are numerous programs in place, and
we would encourage Congress to continue to hold VA accountable
for those programs in those reports.
You know, last but not least, and I forget the exact
numbers and the statistics, but I would encourage this
Committee to possibly take a look at formally.
There are a lot of reports the VA puts together. Okay? And
it costs a lot of time, money, and resources, and many of these
reports their time may have come and gone.
So we are leery about mandating the fact that you are going
to formally institute something for VA to do something when
they are going to take manpower, resources to put together
these things and provide it to Congress when, in fact, it just
may become another program that is there.
Ms. Brown of Florida. Thank you.. Mr. Blake, you mentioned
the hotline. You had some concerns about that. Could you
expound on that a little bit?
Mr. Blake. Well, after listening to some of the discussion
this morning about what the VA is doing with their own internal
hotline versus this outside entity, I thought the discussion
was interesting in that Mr. Moran suggested that these are
different types of people providing, you know, an outside
service.
And the VA, as I understand it, is going to staff their
hotline, and maybe I am incorrect, with clinical professionals
and individuals who work in the mental health field. And not to
suggest that those aren't the right people, but this secondary
hotline maybe provides a different perspective.
Now, I have to reiterate our point that we made that you
can't just stick anyone behind--on the other end of the
receiver and have them answering phone calls, particularly for
this population of veterans.
But the shared perspective of a veteran, I think, is
important. Understanding that they have to have some kind of--I
don't want to say expertise maybe, but some kind of formal
training in understanding how to handle these types of
individuals.
I mean, most of the hotlines for special needs like that
are volunteers that don't necessary--aren't necessarily
clinical professionals as well. And it provides some
perspective that might provide balance to what the VA is doing
internally.
Ms. Brown of Florida. My last question concerns not the
reimbursement, the cost, but about moving forward and
permitting another program.
I am thinking that we need to be considering how we can
pool resources and other ways to get people to the different
facilities, as opposed to what is wrong here. Everybody wants
to drive their own car. I understand that, but that is part of
our problem.
With gasoline being $3.00-plus a gallon, we have got to
come up with some alternative ways to move people. And it seems
to me it could be scheduling, working together, and more vans,
more car pools. What are your ideas?
Mr. Hollingsworth. Well, from AMVETS perspective, we have
testified in the past and will continue--rural healthcare and
in under served areas, it is a real issue. And it is a problem.
I think all of the veteran organizations know that.
You know, the Secretary of Veterans Affairs does have the
authority in some cases to contract out. You know, we walk a
fine line, because, you know, from an AMVETS perspective, we
want to maintain the integrity of the Veterans' Affair system.
But at the same time, we want to provide rural veterans in
underserved areas healthcare.
So we would encourage the Secretary to continue to contract
out. However, we, obviously, hope he uses that authority
judiciously where applicable.
Ms. Brown of Florida. Mr. Chairman, I have a couple more. I
want to see if he can answer my question.
Mr. Blake. I just wanted to kind of reiterate our point
about the travel reimbursement rate. I think most of the
organizations here, if not all of them, principally believe
that if you had a reasonable travel reimbursement rate, you
might do away with some of the complaining that veterans have
about access in rural areas. That is not to say it solves the
problem entirely. That certainly doesn't.
But a lot of the problem that veterans have that live in
rural areas is they have to foot a large part of the bill out
of their own pocket just to get the care from a VA facility.
Yes, some veterans have to drive 250 miles. Well, that is
expensive, because it is a tank of gas.
But in a lot of cases they foot the bill for a hotel,
because they probably have to stay somewhere overnight if they
have to travel that far, eating, and all those types of things.
And 11 cents to the mile just doesn't get it done when
addressing that concern.
So we think that some of those concerns would be offset if
they knew that they weren't going to have to foot the bill out
of their own pocket. Now again, some rural access issues are
broader than that. Some of them are just--but an area that are
clearly under served as a whole.
That is not just the VA. I mean, there are a lot of areas
across the country that are under served for healthcare in
general. So--and I think that is another issue that falls in
line with that as well.
Ms. Brown of Florida. Thank you, Mr. Chairman.
Mr. Michaud. Maybe we could get railroad access to some.
Ms. Brown of Florida. We will work it out.
Mr. Michaud. The Chairwoman chairs the Railroad
Subcommittee on Transportation. Mr. Miller?
Mr. Miller. No questions.
Mr. Michaud. Once again, I thank the panel for your
testimony this morning, and we look forward to continue to work
with you as we deal with veteran issues. Thank you.
And the last panel that we have this afternoon is Dr.
Michael Kussman who is the Under Secretary for Veterans Health
Administration, who is accompanied by Walter Hall who is the
Assistant General Counsel for the Department of Veterans
Affairs.
I want to thank both of the gentlemen for coming today, and
I turn it over to you, Dr. Kussman. I want to congratulate you
for no longer acting as the Under Secretary of Health, and now
that you are no longer acting, hopefully we will see good,
strong results, particularly as it relates to the Rural
Healthcare Office.
STATEMENT OF HON. MICHAEL J. KUSSMAN, M.D., MS, MACP, UNDER
SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A. HALL,
ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Kussman. Thank you Mr. Chairman and Mr. Ranking Member,
and other Members of the Subcommittee.
When you were talking about no longer being acting, I want
to assure you that I am now going to pretend to be the Under
Secretary of Health.
Thank you for inviting me here today to present the
Administration's views on the nine bills affecting the
Department of Veterans Affairs health programs.
As you mentioned, sir, with me today is Walter A. Hall,
Assistant General Counsel.
As you already did, Mr. Chairman, I don't have to request
that the written statement be submitted for the record, because
you all did that.
Mr. Chairman, I am going to focus on my remarks on five of
the bills, but I would like to state from the beginning, VA
does not oppose the intent of any of the bills under
consideration.
In some cases, the VA's current efforts meet or exceed the
requirements of the bill and in others, some additional work is
needed to allow the Congress and the VA to best serve our
Nation's veterans.
And our request would be that we could continue to partner
with you and the staff to get the best bills possible.
Mr. Chairman, H.R. 1925 would require the Secretary to
establish a separate ``Veterans Integrated Services Network''
for the Gulf Coast region.
While VA certainly desires to serve all our veterans, we
find at this point, on the basis of information that we have,
no justification for establishing a separate VISN for a service
area driven by the workload needed to make such a significant
organizational change cost-effective.
Current facilities and referral patterns provide the best
access for the veterans on the Coast using the combined efforts
of VISNs 7, 8 and 16 who--which are--work very well together to
provide the care for veterans living in the area.
H.R. 2005 is intended to improve the VA's ability to meet
the healthcare needs of rural veterans. The VA recently
established the Office of Rural Health, which is charged with
determining how we can best continue to expand access to care.
And the Office of Rural Health is developing a strategic
plan for operations that there is consideration for a proposal
to create new research centers.
We would request that the Congress wait until these
assessments are complete before requiring further action
Moreover, while we recognize the significant increase in fuel
prices, beneficiary travel payments are paid to a limited
category of eligible veterans out of funds appropriated for
healthcare for all the veterans.
Our initial estimates project that the bill would cost
potentially and approximately up to $7 billion over the next
ten years. At present, that cost would have to come out of
medical care services.
H.R. 2173 would amend VA's authority readjustment
counseling while permitting the Secretary to enter into
contracts with community mental health centers for the
provision of mental health services.
I have to admit that I have been a little bit confused by
the discussion, because the bill talks about veterans health
centers, not the VA in general contracting for care. The Vet
Centers currently have authority to contract with community
mental health agencies for the provision of readjustment
counseling services.
For veterans with more complex mental health needs, the
veterans--Vet Centers routinely refer them to the VA medical
facilities.
This provision, if it really was intended for the Vet
Centers to contract out for the full services of mental health,
would blur the distinction between the VA's readjustment
counseling and more sophisticated mental health services.
Readjustment counseling is a special, more than medical
community based counseling service that creates--that treats
veterans and family members under the bereavement counseling to
help them make a successful readjustment from combat to
civilian life.
VA mental health is a medical care service provided by VA
mental--medical centers for enrolled veterans. We already have
the authority to outsource and contract if for care, and it is
very clear that my guidance is that there are only two ways
that you can do this. Let me make it three, but one is
unacceptable.
One is that you--we have an obligation to provide whatever
services are necessary for the veterans consistent with out
benefit package. That we can either do it in-house, and if we
can't have the resources, you don't have the infrastructure,
then we are obligated to buy it. In other words, contract with
it.
The third thing is not to do it, and that is totally
unacceptable.
H.R. 2219 would require the Secretary to establish a
national toll-free hotline for suicide prevention, staffed by
peer-to-peer counselors.
Mr. Chairman, as you already know and has been mentioned
already, VA's already developing a comprehensive program for
suicide prevention, including a national 24-hour toll-free
hotline.
The VA plans to staff the hotline with VA mental health
professionals who may access the electronic health record of
the callers and can work with local facility suicide prevention
coordinators to provide immediate and provide more
comprehensive care.
H.R. 2378 intends to prevent low-income veterans in
permanent housing from falling back into their former homeless
condition.
The VA generally supports H.R. 2378, but we strongly
recommend the bill be modified to allow VA to establish
additional criteria to ensure that this program reaches veteran
families requiring additional support to end their
homelessness.
There was one bill, the 2623, the ``Hospice Care Bill''
that I don't know exactly what happened in the process. I did
not provide comments on that either in written or verbal, but I
would be happy to answer any questions about it. But we didn't
develop a formal response to that bill.
[Comments for H.R. 2378 and H.R. 2623 were provided by the
U.S. Department of Veterans Affairs on August 19, 2007, and
appear on p. 91.]
I am pleased to answer any questions you or any of the
other members may have, Mr. Chair.
[The prepared statement of Hon. Kussman appears on p. 80.]
Mr. Michaud. I have a few questions. What have you provided
to the Subcommittee dealing with Ms. Watson's bill as far as
training. Looking at PVA's testimony, they had mentioned that
they had talked to one of the VA chiefs and were told that the
officers received training primarily on how to handle veterans
aged 60 to 70 years old. I want to know if you could provide to
the Subcommittee what other requirements for the officers as
far as training goes.
[The FY 2007 Basic Police Officer Training Course Syllabus
and Training Schedule from the U.S. Department of Veterans
Affairs Law Enforcement Training Center, North Little Rock,
Arkansas, is being retained in the Committee files.]
Mr. Michaud. Another issue talked about--a report on the
reports. I think it is important that we have reports. But, I
am concerned about the redundancy and how we can streamline
that process.
Regarding testimony the VA does a good job on a lot of its
programs, but I can see the frustration that people might have
in trying to access the system.
It is my hope that the VA will look at how it can improve
access to programs, such as through a computer and telephone
system. Did you want to comment on that?
Dr. Kussman. Yes, sir. I would be happy if I could, if I
could remember all the questions you had.
But first and foremost, as was mentioned, all our VA police
are VA employees by statute. They are not contracted. There may
be some confusion. I think that there is some contracting for
guards, but not for the police themselves.
If I may just take a minute. Clearly, the description of
what happened to Jose Medina is unacceptable, and all I can say
as the leader of the VHA, that is unacceptable. And we
apologize for whatever happened or anything veteran who is
inappropriately treated by any employee in our system, much
less the police.
Now, we--in the hiring our VA police, there is an extensive
training program done even before they get to the ability to
work. There is an 80-hour basic injury level of training course
at whatever medical center they are going to be employed on.
And then a 200-hour residential basic police office training
course at our law enforcement training center, I think, that is
in Little Rock, Arkansas. And we have been lauded by much of
this training.
Title 38, U.S. Code, section 902, requires VA to create
regulations with respect to training department police
officers, with particular emphasis on situations involving
patients.
The specific question that you had, it was alluded to that
the training was only for people over 60. I have to go back and
look at that, but clearly our job is to take care of the full
depth and breadth of veterans, with specific emphasis on
adjustment reactions in mental health and people who may or may
not be acting in a way that is not normal the way they act
because they are ill. And that is something that all medical
employees have to do.
Whether it is a policeman or anybody else is that people
don't necessarily act the way they might in the department
store versus--or a bank versus when they come into mental--for
medical services, because that is the problem. They are coming
for medical services.
Much of the training, there is a 17.5 hour block of
training in behavioral science, which includes training on
mental illness----
Mr. Michaud. Instead of going through that whole thing----
Dr. Kussman. Okay.
Mr. Michaud [continuing]. Could you provide that for the
Subcommittee?
[The following was subsequently received:]
By statute, the Secretary is required to provide VA Police Officers
with training that emphasizes effective management of situations
involving patients. To carry out that mandate, VA provides specialized
training to VA Police Officers in dealing with disruptive and other
unusual behaviors, key portions of which are taught by VA
psychologists. VA officers must successfully complete:
An 80-hour basic entry level training course at their
Medical Center;
A 200-hour residential basic police officer training
course at the VA Law Enforcement Training Center in Little Rock,
Arkansas;
A 17.5-hour block during their residential basic officer
training in Behavioral Science (including topics such as mental
illness, communications/conflict management, verbal judo, crisis
intervention/conflict resolution, and the dynamics of the suicidal
individual); and
A biannual refresher training program.
Dr. Kussman. Sure.
Mr. Michaud. I know my time is up.
Dr. Kussman. Okay. I am sorry. Just--okay.
Mr. Michaud. But the other issue you could look at that we
are dealing with today is the budget. It is a very robust
budget for the VA system, and our problem, when you look at the
bills that you mentioned earlier, a lot of these issues could
have been dealt with if the VA had the budget and moved
forward, whether it is the CARES program or other access
issues.
I am also looking at how we can help save costs. A good
example, is the dental area.
For example when you go to the VA for dentures or you need
amalgam fillings, it depends on whether the VA gets it. If you
go to the dentist, the dentures tend to cost twice as much, as
much as $600.00 or more if you went--than if you went to a
denturist. Likewise, if you go to a dentist and they decide to
fill a filling with a white filling versus an amalgam filling.
The white tends to be a lot more expensive and it doesn't last
as long.
So hopefully the VA is looking at ways where they might be
able to save money, and it might make the system more
effective. I will ask other members to ask that question, and
we will go a second round if we have time.
Mr. Miller?
Dr. Kussman. So you--there was one--on the last part of
your question about the ombudsman?
Mr. Michaud. Yes
Dr. Kussman. Yes.
Mr. Michaud. Excuse me.
Dr. Kussman. And, obviously, in intent, that is a great
idea, and it really depends on what type of veteran you are
talking about. Whether it is the more routine veteran that is
getting out, using the Benefits Delivery at Discharge (BDD)
process, the Transition Assistance Program (TAP) process, and
all those things. That is where a lot of that counseling goes.
But we realize that people who are injured in service,
particularly with TBI and more severe injuries, needed a lot
more care. And as you know, we have had our benefits counselors
and case managers get deeply involved with these VA facility.
They wrap themselves around, try to communicate with them, make
sure everybody knows that their benefits are. Military people
who are in our four Polytrauma Centers to help on the reverse
way of making sure that people get help if they are worried
about the Medical Evacuation Proponency Directorate (MEPD)
process.
We also, as you know, just put in place a program of
transition patient advocates that are going to glom themselves
on, on a one-on-one basis with people who are in the Walter
Reeds of Bethesda and Brooks, and help them longitudinally as
they go through the process but not give up on them. They are
going to have cell phone contact. They are going to picked by
where the patient would generally want to go and will keep in
contact with them over a period of years.
Mr. Michaud. Thank you. Mr. Miller?
Mr. Miller. Thank you very much, Mr. Chairman. Doctor, good
to see you.
Dr. Kussman. Nice to see you, sir. Thank you.
Mr. Miller. I look forward to working with you. I did put
the chart back up so you could refer to the VISN in the Gulf
Coast Region.
You stated in your testimony that there was not sufficient
workload to make an organization change, create a new Gulf
Coast VISN. Could you give me some type of idea of what you
consider as sufficient workload?
Dr. Kussman. The information that I have, and, sir, I would
have to go back and validate it and discuss with you further,
but the information that I have is that in 2005, there were
88,000 enrollees in the area that you are describing, with
281,000 veterans of which 88,000 were enrolled with us.
Mr. Miller. So you are saying--my question is not----
Mr. Snyder. I was not sure of his answer. Is the number he
is giving in the new area that he wanted----
Mr. Miller. You can't--I mean, you--I mean----
Dr. Kussman. Okay.
Mr. Snyder. Yeah, that is what I figured.
Mr. Miller. My first question is what do you consider an
adequate workload, a sufficient workload? Looking at this
chart, it is very clear that there are two VISNs that are
absolutely covered up. One is 16; one is eight.
Obviously, a lot has changed since the inception of the
VISN, and I think the Gulf Region is the concept works, and,
obviously, because we took two and we fold them into one, there
is flexibility in doing what needs to be done.
Clearly, you can look and see that VISN 16 has three times
the number of Gulf veterans as VISN two, five, or 19. My
question is at what time would the enrollment be too high that
you would look at splitting? Splitting, not combining, but
splitting this?
Dr. Kussman. That actually is a very good question, and I
don't think we have a criteria for that. And we certainly
should look at it.
[The following was subsequently received:]
Question: For the record, ``the opportunity for VA to look closer
at the numbers'' of VISN 16, particularly how many veterans it has
relative to other VISNs and whether that should be reconfigured.
Response: Currently, we have no data to support an additional VISN
in the Gulf Coast Region. The size of the area proposed for a VISN does
not have the workload needed to be cost effective, nor to require that
level of management. This area has only 88,583 enrollees and 281,476
veteran population in 2005, with the 2025 projections at 94,779
enrollees (a 7% increase) and 223,598 veteran population (a 21%
decrease). The smallest VISN currently has at least 200,000 enrollees
and over 500,000 veteran population.
This area has one hospital, the Gulf Coast Veterans Healthcare
System in Biloxi, Mississippi, and no tertiary care facility. The Gulf
Coast area has four operational Community Based Outpatient Clinics
(CBOCs) in Panama City, Pensacola, Dothan, and Mobile, and one approved
to open in the next year in Jackson County, Florida. In addition, there
are sharing agreements in place at three major military installations
in Pensacola, Ft. Walton, and Panama City for inpatient and other
healthcare services as needed.
Each of the other 22 VISNs has at least four hospitals, with at
least one providing tertiary care, and at least 15 CBOCs to manage the
services and healthcare for veterans. With only one facility in the
Gulf Coast, there is no need for Network Management. In addition,
balancing the budget, opening new programs, and making large capital
investments, among others, will be difficult at best. The Gulf Coast
area does not have a tertiary care facility and as is the current
practice, patients would still be referred to the closest tertiary care
facility--Birmingham, Alabama; Jackson, Mississippi; or Gainesville,
Florida.
The current facilities and referral practices in this area provide
access for veterans. VISNs were originally created around referral
patterns and geographic boundaries. In addition, VISNs work together
along their borders to ensure access to healthcare for veterans in
those areas. The Gulf Coasts region is one area where VISNs seven,
eight, and 16 have worked together to manage care for veterans in the
area. VA has no plans at this time to add an additional Network for
this region.
Mr. Miller. What catches me by surprise with a visual such
as this, that is it is very, very clear that there are some
areas I would say are underserved or under worked.
Now, they won't say that, and I would never impute that or
imply that, because they are all overworked. However, if the
folks in VISN two, five, and 19 are overworked, then eight and
16 are really overworked.
I would like for the record the opportunity for VA to look
closer at the numbers, and if it is time to realign the whole
network, fine. I am looking obviously at the veterans in the
Gulf Coast Region, but it may be other regions as well.
Another thing, on a personal note if I may, Public Law 109-
461 required a report not later than 180 days after enactment
on the option of construction of a VA medical center in
Okaloosa County. We are upon that date. In fact, it may even be
next week. My question is are we going to meet that deadline,
and when can we see a copy of the report?
Dr. Kussman. Sir, we working on it, and let me get back to
you exactly when we will get that report to you.
[The ``Report to Congress on Options for the Construction
of Department of Veterans Affairs Medical Center in Okaloosa
County, Florida,'' dated June 26, 2007, is being retained in
the Committee files.]
Mr. Miller. Okay. Thank you.
Mr. Michaud. Mr. Salazar?
Mr. Salazar. Thank you, Mr. Chairman. And, Dr. Kussman,
thank you for being here, and I understand the issues that you
face with VA funding. And I can assure you that this Congress
is trying to do everything they can to provide these funds that
are badly needed for veterans.
Can you tell me what model you use to estimate the $7
billion that you talked about that it would cost VA for mileage
reimbursement?
Dr. Kussman. I would have to go back to policy and planning
and resource managers, and I will get you an answer. I don't
have it at the tip of my tongue about how they develop the
estimation.
[The following was subsequently received:]
Question: What was the methodology used to determine the $7 billion
cost for beneficiary travel in Section 2 of HR 2005, the Rural Veterans
Health Care Improvement Act of 2007?
Response: (16, 10A5, 17) Beneficiary travel is a discretionary
program with funding coming directly from the annual VA healthcare
appropriation. Funds expended for beneficiary travel decreases those
available for direct medical care. The Secretary is required to
undertake a yearly evaluation of the program in order to determine
whether VA has sufficient funds to continue to provide veteran
transportation benefits and whether any rate changes should occur.
Given the unprecedented rise in veteran patient workload and the
associated demand for limited VA medical care resources, the current
reimbursement rates of .11 mile for travel relating to medical care and
.17 mile when a veteran is recalled to redo a portion of a C&P
examination that were established in 1979 have been maintained. Note:
Under current law, when the beneficiary travel rate is adjusted, the
deductible is adjusted proportionately to the adjustment.
The proposed legislation requires VA to reimburse veteran mileage
at the same rate as that of federal employees. It would also pay a
subsistence amount (e.g. meals, lodging) at the same rate as a federal
employee for that locality. Cost determination data is presented below.
Cost Analysis: H.R. 2005, Section 2, changes the method of
determining the mileage reimbursement rate of the VA Beneficiary Travel
Program by equating it to that received by Federal employees as well as
provides for a subsistence rate equal to that of a federal employee.
The following provides a 5-year and 10-year estimate of the cost that
would result from enactment of the proposed bill.
----------------------------------------------------------------------------------------------------------------
Estimated Reimburseable Increased Cost
Fiscal Year Mileage* Payment Rate** (Millions)
----------------------------------------------------------------------------------------------------------------
2008 675,363,636 .375 $253
----------------------------------------------------------------------------------------------------------------
2009 776,668,181 .40 $311
----------------------------------------------------------------------------------------------------------------
2010 893,168,408 .425 $380
----------------------------------------------------------------------------------------------------------------
2011 1,027,143,669 .45 $462
----------------------------------------------------------------------------------------------------------------
2012 1,181,215,219 .475 $561
----------------------------------------------------------------------------------------------------------------
5-Year Total $1,967
----------------------------------------------------------------------------------------------------------------
2013 1,358,397,502 .50 $679
----------------------------------------------------------------------------------------------------------------
2014 1,562,157,127 .525 $820
----------------------------------------------------------------------------------------------------------------
2015 1,796,480,696 .55 $988
----------------------------------------------------------------------------------------------------------------
2016 2,065,952,800 .575 $1,188
----------------------------------------------------------------------------------------------------------------
2017 2,375,845,720 .60 $1,426
----------------------------------------------------------------------------------------------------------------
10-Year Total $7,068
----------------------------------------------------------------------------------------------------------------
May not add up due to rounding
*Estimated 15% increase in mileage per year
**Federal Rate minus current .11 mileage rate
Methodology: Number of miles for FY 2008 is based upon projected
expenditures for Budget Object Code (BOC) 2120, ``Beneficiary Travel-
Mileage'' from the first half of FY 2007. Note: While VA does pay 17
cents per mile for recalls due to the need to redo a portion of a C&P
exam this is considered to be relatively rare, therefore the 11 cents
per mile rate is used to determine base miles).
Projected expenditures for FY 2007 are a 15% increase over FY 2006,
and based upon continued increase in the number of veterans accessing
VA healthcare it is estimated that this mileage rate increase will
continue. Base Federal employee rate of 48.5 cents per mile is current
rate. For the past 10 years there has been an annual average 2.5 cents
per mile increase to the Federal employee rate, thus the rate changes
noted.
A subsistence rate adjustment has not been included since meals and
lodging is estimated to have minimal impact due to current operations
of only paying when hotel or other VA lodging is not available and the
trip requires an overnight stay. VA usually pays actual charges in this
event for lodging and meals.
Mr. Salazar. I would appreciate that very, very much. And
as far as the office that was established in January, the
Office of Rural Health Care, could you also provide to this
Committee an assessment as to what you have done to date in the
last 6 months?
Dr. Kussman. Yes, sir. Thank you for the question. As you
know, we owe you a response in September of 2007, a written
response about what progress has been made in the Office of
Rural Health.
Right now it has been stood up under the auspices of the
Office of Policy and Planning under the direction of the
Assistant Deputy Under Secretary for Health, Pat Vandenberg.
This is a good place for this office, because it is involved
with the office that does projections on workload, access,
CARES, and the Milliman Model.
Right now, Peter Sellick is in charge of that office, and
they are looking at some strategic recommendations. At the same
time, they are in the process of hiring a full-time director
and establishing the necessary staff. So we will have a report
for you.
Mr. Salazar. So we still do not have a director, and we
still are not fully staffed?
Dr. Kussman. Right. That is correct.
[The U.S. Department of Veterans Affairs, Veterans Health
Administration, submitted the following report on January 10,
2008,``Plan to Increase Access to Quality Long-Term Care and
Mental Health Care for Enrolled Veterans Residing in Rural
Areas,'' which appears on p. 96.]
Mr. Salazar. One other question, Doctor. You talked a
little bit about the Centers of Excellent and your objection to
us directing you to establish the Centers of Excellence; is
that correct?
Dr. Kussman. I----
Mr. Salazar. Could you tell us what your objection is to
this?
Dr. Kussman. Yes, sir. I will try. By the way, I was
accused last year when I was here as being ``Dr. No.'' I
don't--I would like to be ``Dr. Yes.''
But to answer your specific question, we are not--I am
not--I don't think anybody is against the Centers. The question
is is there five, or four, or three that would be needed, and I
think that is what we would hope that the Office of Rural
Health, approaching the appropriate experts and everything,
would recommend of how many or whatever that we need of these
centers, because I think they are valuable centers.
Mr. Salazar. But would you also agree that it is really up
to members of Congress to request from you that these offices
wouldn't just be established on one coast or the other and
forget about middle America?
And, you know, I think that is one of our reasons for
trying to move this legislation forward so that we can
basically make these Centers of Excellence, you know, located
in--so that they address the needs of middle America as well,
like Colorado, or Montana, or South Dakota.
Dr. Kussman. Yes, sir. I wouldn't take exception. I don't
recall that the legislation prescribed where they would be, but
I don't disagree with you. It ought to be in areas that have
the most need for the research and development of things
related to rural health.
Mr. Salazar. Thank you. I yield back.
Mr. Michaud. Mr. Hare?
Mr. Hare. Thank you, Mr. Chairman. Thank you for coming
today, Dr. Kussman. Just three questions, I guess. One on H.R.
2623, the--which prohibits the collection of copayments for the
hospice care.
I was wondering if the VA has a position on that or----
Dr. Kussman. Well, as I mentioned earlier, I apologize. For
some reason we didn't get that bill to put together an official
policy. But in the past, and as we have done already with
certain segments, we understand the need for that.
And I don't want to prejudice the ability to look at the
legislation, but it is clearly something that we need to look
at.
Mr. Hare. Thank you. The other one is on H.R. 2219, the
``Veterans Suicide Prevention Hotline.'' I was wondering if you
could just maybe update me on the status of the--of this
project that you have.
Specifically, when you expect it to be up and running, the
qualifications of the people who are staffing the hotline, and
does the VA plan on advertising this resource, so that the
veterans have an understanding that it is there or their
families have an understanding that it is there to be used? And
if so, how are you going to do that?
Dr. Kussman. Well, yes, sir. Obviously, any suicide is one
too many, and our goal is to be as aggressive as we can. And we
put together a very aggressive suicide prevention program,
including having suicide coordinators at every facility, and
this is another aspect of that, training all our people to know
about how to look for and treat, even non-mental health people.
The intent here, this will be established fully by the end
of September of this year, and that we believe, after much
discussions and everything--and by the way, the Joshua Omvig
bill actually drove saying--we were doing this before that, but
it was consistent with the bill, that said that they would be
mental health professionals.
And so our intent is to have the most sophisticated
responses available to people when they call in, especially
that they have access to the medical records if they weren't a
veteran that we had never seen, so that they would be able to
know about the veteran and assess the patient, because they
would have the information. And then be able to coordinate
directly with the suicide coordinators and the clinical people
who are actually taking care of this person.
Mr. Moran's point is well taken, and I think that it is
something that we want to look at in balancing this, because
there are veterans who don't like to use the system. That is
what the Vet Centers, the readjustment counseling centers, are
so valuable for.
So I think that this is just another thing that we need to
work together to decide what was the best way to do this. But
having two hotlines, I am not sure how productive that would
be.
Mr. Hare. How do you plan on advertising this so the
veterans can call in? The other question I had was for those
who are staffing the hotline, what qualifications they had to
have in order to be there?
Dr. Kussman. With all our communication efforts with our
newspapers and information papers at the facilities, we will do
everything we can to make sure that people and their families
know.
Clearly when people transition out of the military, they
will know as well as all the other veterans. Our intent is to
have fully trained psychiatrists or psychologists available to
provide that service.
Mr. Hare. Do you have--just one last question. Is there a
guesstimate, if you will, on how many veterans or families who
would utilize this hotline during the course of the year? I am
thinking several thousand.
Dr. Kussman. Well, I am sorry. I don't know. We can look at
per capita things that have happened in other hotlines, and
presume that that would be----
Mr. Hare. Would you--would you expect the numbers would be
significant or your thought maybe even?
Dr. Kussman. I don't know if they would be higher than we
thought, but I think that we need to do it even if it is small
numbers.
Mr. Hare. I agree. All right. Thank you. I yield back, Mr.
Chairman.
Mr. Michaud. Dr. Snyder?
Mr. Snyder. Thank you, Mr. Chairman. Dr. Kussman, I--is it
Kussman or Kussman?
Dr. Kussman. I think my father who is deceased would say it
was Kussman, but everybody says Kussman. So I have been called
worse.
Mr. Snyder. There was a San Diego Padre ballplayer named
Kussman. I don't know if you----
Dr. Kussman. It is K-O-O-S.
Mr. Snyder. If I call you Koosman, I will harass you for
your batting average.
Dr. Kussman. I don't see well enough.
Mr. Snyder. Regarding--Mr. Miller had to leave, but in
regard to this VISN issue, you know, part of VISN 16 includes
Arkansas. And I have not heard much. You try to reach out a
little bit on Mr. Miller's bill, and I have heard many
complaints either way about how the lines have been drawn.
I do have some concerns though that if we were to start
drawing these lines by statute, and regarding seeing some
benefit to doing that, and we changed the lines. And so I would
hope that you would take into consideration Mr. Miller's
concerns about those areas and waiting on the veterans. And I
think it has been growing. And I hope we take a very formal
look at this.
And it may well be that in Arkansas we should also be
concerned. Maybe there is an additional benefit to our veterans
to have a smaller number of them under that administrative
umbrella. I don't know what is magic, but I don't think Moses
had golden tablets that said, what the most efficient number of
enrollment is, this number versus a smaller number.
It doesn't follow beyond that because you have a larger
number. You can be more efficient. I would assume that the
staffing would reflect the numbers of veterans, and those kinds
of issues.
But I hope you will formally look at that, and get that
evaluation back to us, because----
Dr. Kussman. Yes, sir.
Mr. Snyder [continuing]. It has been a while since we took
a look at it administratively.
The second question I want to ask, but I share your
concerns about the dental hotlines. So many years ago was that
before I ever got into medicine and practiced medicine,
staffing hotlines, you really do get a lot of kinds of calls
that come into the different hotlines.
But there are--every once in a while, there is one that
really is a major problem and how that call is handled can make
a huge difference in that person's life for better or worse.
And I share your concern about who we would have on the
hotline, and then like the real hotline. I think there could be
some real confusion.
I think, ultimately what everyone wants is that there be a
place that people can go when they really are having a problem.
If everything else is broken down, hopefully they are calling
their health professionals or before they reach the hotline,
but I share your concern.
The issue of contracting out service in rural areas, about
half my district is--would be considered rural, if not a little
bit more. A great expanse of Arkansas are considered rural. We
are very pleased with our VA system, the healthcare system in
Arkansas.
One of the things I like about it is if something goes
wrong, I can pick up the phone or my staff can pick up the
phone and go straight to a VA employee and say, ``Fix this.''
When things are contracted out, that is not so easy to do. You
have people who have contractual responsibilities, which is
different than having responsibilities to a member of Congress.
I remember my office sent you a letter. We faxed it yesterday
afternoon. If you haven't seen it, we have an issue going on
now with regard to the seat back business in my district. I
know we are hearing about veterans.
But my specific question is, if they can provide the best
care, more power to them. The problem is, I also noticed
reports--especially reports out of Eureka, California, that
they were rejected for a contract out there. We have had some
indication that one of the VA's out there said they were real
concerned about the company. That they decided to reject that
contractor.
But now we have got them in another VISN. That people may
have a different set of information. How much information is
shared when you have these kinds of--when you use this kind of
contractor? How much information is shared amongst the
decisionmakers, so that we are sure that the experience is good
or bad and the contractors in one area that they reach out to
other areas? How is that information shared so we know that
they work on the same basis, and don't have to rediscover?
Dr. Kussman. Thank you for the question. I have not seen
the facts, so I apologize. But I think that the point is very
well taken. Obviously is what do we learn from one place to
another.
You know, the old adage, you have seen one VA, you have
seen one VA, is not what I believe. We have to have standards
and consistency in the deliver.
I have no idea why that Eureka, California, contractor was
rejected. There could be a lot of reasons. If it was truly the
quality of care, then we certainly should be able to track
that, because what brought in all the other sea box that they
may be contracted around the country.
So I think we certainly have to look at that, and see if
how we transmit information related to good contracts or bad
contracts.
Mr. Snyder. The number of contracts contracted is certainly
going down. Thank you, Mr. Chairman.
Mr. Michaud. Thank you. Ms. Brown.
Ms. Brown of Florida. Thank you. Mr. Chairman, I don't have
all of the details right before me, but in the last couple of
days there was a news report. It indicated that veterans, over
the last, I think it said 10 years, were twice as likely to
commit suicide than people who were non-veterans.
And I guess in response to that and other issues, the
Department has indicated that they are going to hire 153
prevention counselors at all of the veteran centers.
My question lies--and I am not one for contracting out, but
perhaps in a situation like this, it would be better, because I
don't know what the cost is to hire 153. But how would those
people who can't be available 24 hours help all the veterans.
This would be the opportunity to work with some organizations
and other groups to have people available and training in
coordination.
I just don't know how it is going to work. Can you expound
upon that?
Dr. Kussman. Yes, ma'am. We are constantly looking at our
mental health processes, suicide, PTSD, whatever it is.
Ms. Brown of Florida. Are you familiar with the study that
I am talking about?
Dr. Kussman. I am aware of it. I haven't read the study
specifically. The subject matter experts are looking at that to
determine, because a lot of times the small numbers, and it is
hard to know for sure what was in the report. I am not
debunking the report at all.
I mean, I--but the ones--the counselors we were talking
about are suicide coordinators to make sure that the facilities
have all the programs and processes in place. That the staff is
educated in things of that sort.
I have put in place a new policy related to mental health.
That when somebody surfaces, that they need to be evaluated
within 24 hours of what it is. Now, obviously, if a suicide,
you can't even wait 24 hours, but we have people on call 24
hours a day. And we will make that the standard in our
facilities.
So if somebody calls, again, and they call the hotline,
that hotline has the way of getting to wherever the geography
if the person will tell us. Sometimes they call and won't tell
you where they are, and you have got to look at the call--
caller ID and see the area code.
But if somebody comes to the emergency room or somebody
knows about it, we have people on call 24/7 to come in and
assess that person, because you have to take every person who
says, ``I think I am going to do something bad to myself,''
seriously.
Thank God most of them don't do it. But there are enough
that do that we have an obligation to try to intervene to the
maximum extend possible.
Ms. Brown of Florida. One follow up. You indicated in your
written testimony you generally support most of the bills, but
under the area of permanent housing for the homeless vets, why
would clinical indicators be a reason to deny permanent
housing?
I felt that if we are looking at veterans, there is going
to be a big increase in funds to deny a program to staffing
issues is kind of--is very unacceptable to me. And I would like
for you to be ``Dr. Yes.''
Dr. Kussman. Or ``Maybe Could Be.'' I don't know. But in
truth, I don't think we are against the permanent housing. I
think what we were saying is that we support the bill. It would
be a better bill for us if we could add some of these clinical
services that are there.
For instance, we would want to know what--if there was a
history of mental illness, whether there was a history of
substance abuse, demonstrated significant impediments to
holding a job, whether there was social dysfunction in the
family. All those things would make it better for us to be able
to provide services.
Ms. Brown of Florida. Well, would you work with us as we
move forward----
Dr. Kussman. Yes.
Ms. Brown of Florida [continuing]. With the bill and my
staff to make sure that we include those areas that you think
would make it better?
Dr. Kussman. Yes, sir. And I think as the Chairman knows, I
would like to do that in all the different bills, because I
think we agree in principle as I said. We just want to
maximally affect what we can do, and not, perhaps, get
someplace where we are duplicating what we are doing.
But our effort is to take care of veterans.
Ms. Brown of Florida. I know you know that there is a lot
of frustration----
Dr. Kussman. Right.
Ms. Brown of Florida [continuing]. With us, because we all
care about the veterans, and it is just--it seemed to be not
working for them.
Dr. Kussman. Right. It----
Ms. Brown of Florida. And they are very frustrated, and
they get on us. And then we have to get on you.
Dr. Kussman. Yes, ma'am, I understand that. I have been
sworn in since the 30th of May.
Ms. Brown of Florida. All right, ``Dr. Yes.''
Mr. Michaud. Just a follow up. I think it was Mr. Hare's
question and others about hospice. I believe that was actually
requested from the VA back in the 2006 budget.
Just one last question, and we'll take questions in
writing. It gets to questions asked earlier about the Office of
Rural Health. You had mentioned you had not hired a director or
anyone in that office.
Dr. Kussman. I have to go ask Matt about that. I think that
they have, but I don't want to give you the wrong information.
Let me get back to you on that, whether they have actually
hired any specific--they have a lot of detailed work out to
hire the people. I don't know if anybody has actually been
brought on.
As you know, there some challenges sometimes when we want
to go hire somebody. It has got to go through all the process
that can take months.
Mr. Michaud. Again, it would be interesting to know, and
particularly for the director of Rural Health, who that
individual might be and what you are looking for in that
individual. I would hate to have someone from Boston or Los
Angeles or Chicago. But I would like to have somebody who
really understands and has a mindset of problems that people
are facing in rural areas.
Dr. Kussman. Yes, sir. And there is a job description that
is established. I would be happy to try to get it to you.
[The job description for the Program Analysis Officer,
Office of the Assistant Deputy Under Secretary for Policy and
Planning, Veterans Health Administration, U.S. Department of
Veterans Affairs, appears on p. 103.]
Mr. Michaud. Great. Once again, I want to thank the panel
for your testimony today and we look forward to continue
working with the VA as we move forward in this upcoming
Congress. Thank you very much.
Dr. Kussman. Thank you, Mr. Chairman.
The hearing is adjourned.
[Whereupon, at 12:41 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of the Honorable Michael H. Michaud,
Chairman, Subcommittee on Health
Today's legislative hearing will provide Members of Congress,
veterans, the VA and other interested parties with the opportunity to
discuss legislation within the Subcommittee's jurisdiction in a clear
and orderly process.
While I may not necessarily agree or disagree with the bills before
us today, I do believe that this is an important process that will
encourage frank discussions and new ideas.
We have ten bills before us that seek to improve healthcare for the
nation's veterans, and I look forward to hearing the views of our
witnesses.
I also look forward to working with everyone here to continue to
improve the quality of care available to our veterans.
There are two draft discussions that are not before us today. There
is a discussion draft on homelessness, and a discussion draft on mental
health services. Congressman Patrick Murphy of Pennsylvania has also
introduced H.R. 2699. I ask that the members of the third panel, the
VSOs, and the fourth panel, VA, provide comments and views on these
three items for the record once they are made available. We would like
your written comments submitted to the Committee by June 21st, 2007.
Prepared Statement of the Honorable Jeff Miller, Ranking Republican
Member, Subcommittee on Health
Thank you, Mr. Chairman.
I appreciate your holding this legislative hearing and welcome the
opportunity to discuss the ten different legislative proposals before
us today. I would like to offer brief introductory remarks, and note
that I have introduced two of the bills and will expand on these bills,
H.R. 1925 and H.R. 2623, at the appropriate time.
As we evaluate this legislation, it is important to consider that
the demand for veterans' healthcare is increasing and will continue to
grow. While there may be some areas that will see a decrease in the
veteran population, other areas, including my own Florida district, are
experiencing a large increase in the veteran population. In fact, in
the past 10 years, the number of veterans living in FL CD 1 has grown
more than 30% and is among the top 10 districts in the United States
for growth of veterans since 2000.
I'd like to thank my colleagues, Dr. Kussman and all of the veteran
service organization representatives for their commitment to join us
today to discuss these very pertinent issues affecting our Nation's
veterans.
Thank you, Mr. Chairman, I yield back.
Prepared Statement of the Honorable Stephanie Herseth Sandlin,
a Representative in Congress from the State of South Dakota
Chairman Michaud and Ranking Member Miller, thank you for allowing
me to be here to discuss the Services to Prevent Homelessness Act, a
bill which I introduced on May 17, 2007, to provide supportive services
for very low-income veterans.
The U.S. Census Bureau estimates that 1.5 million of our nation's
veterans live in poverty, including 702,000 veterans with disabilities
and 404,000 veterans in-households with children. 634,000 of the 1.5
million poor veterans live in extreme poverty. These poor veterans face
residential insecurity due to their low-income levels or their past
episodes of homelessness. They also face health and vocational
challenges and access barriers to supportive services, which limit
their ability to sustain housing and maintain independence from more-
costly public institutional care and support. These poor veterans may
benefit from flexible and individualized support services provided in
home-based settings.
The Services to Prevent Veterans Homelessness Act would authorize
the Secretary of Veterans Affairs to provide financial assistance to
nonprofit organizations and consumer cooperatives to provide and
coordinate the provision of supportive services that addresses the
needs of very low-income veterans occupying permanent housing. The
financial assistance shall consist of per diem payments for each
household provided supportive services.
Supportive services that may be offered include physical and mental
health, case management, daily living, personal financial planning,
transportation, vocational counseling, employment and training,
education, assistance in obtaining veterans benefits and public
benefits, child care, and housing counseling.
Veteran subpopulations expected to benefit from the program include
veterans transitioning from homelessness to permanent housing, poor
disabled and older veterans requesting supportive services in home-
based settings, and poor veterans in rural areas with distance barriers
to centrally located services.
While federal programs exist to help create veterans homeownership,
there is no national housing assistance program targeted to low-income
veterans. Permanent housing opportunities for veterans ready for
independent living are limited. In addition, the VA currently is not
permitted to provide grants to create affordable permanent housing, and
the resources that are available for providers are inadequate and
highly sought after by competing housing projects.
Thank you again for allowing me to be here. I look forward to
continuing to work with the Chairman and Ranking Member to support
efforts to meet the housing assistance needs of our Nation's low-income
veterans through the establishment of a permanent housing assistance
program for low income veterans.
I would be happy to answer any questions you may have.
Statement of the Honorable Ciro D. Rodriguez, a Representative in
Congress from the State of Texas
Chairman Michaud, Ranking Member Miller, and distinguished Members
of the Subcommittee. Thank you for the opportunity to speak before you
in support for an issue near and dear to my heart. H.R. 2173, a bill I
introduced with my friend and colleague Congresswoman Napolitano,
provides for the increase in capacity for mental health services
through contracts with qualified community mental health centers.
Recent surveys show that one in eight returning Iraqi war veterans
report symptoms of post traumatic stress disorder (PTSD). The same
studies also report high incidence of major depression and anxiety
disorders among returning members of Army and Marine combat units. As a
Member of this Committee, we have long identified mental health
services as a major issue facing returning soldiers as well as at the
Veterans Administration (VA).
Experts note that the manifestation of clinical symptoms of PTSD
and other mental health disorders often occurs over several years. With
the increase of active duty, guardsmen and reservists returning from
combat, the necessary capacity to provide mental health services is
relatively unknown. It is difficult to know if our large number of
returning veterans will need mental health services beyond what the VA
is capable of providing.
My bill, H.R. 2173, authorizes the VA to contract with community
mental health centers to increase their capacity. In my opinion the
need has outpaced the capacity for the VA to provide mental health
services in outpatient clinics. Contracting out to community mental
health centers is already been done successfully in some states and
could serve as a model for VA-wide implementation.
Mr. Chairman, in my previous career, I worked in the mental health
field as a social worker. I am fully aware of the great service
provided by community mental health centers. If there is any doubt of
the quality of care they provide, I can tell you of the hundreds of
families whose lives have been changes by the treatments received
during my professional career in the field. But don't take my word for
it. Each year, community health centers give nearly 6 million children,
adults, and families in communities across the country the chance to
recover and lead productive lives. Our returning soldiers deserve the
same opportunity.
As I mentioned before, it is clear that our soldiers are returning
with an increased need for mental health services, but after this long
war, it is unclear what the VA's capacity to fulfill this need will be.
It is my hope that H.R. 2173 can provide the VA with the tools to
continue to provide top notch mental health services to veterans in
their own communities.
Mr. Chairman, I would like to again thank you and the Members of
this Subcommittee for the opportunity to speak on this bill. I urge the
Members to support this important legislation. Thank you and I would
gladly answer any questions you may have.
Statement of the Honorable James P. Moran,
a Representative in Congress from the State of Virginia
Mr. Chairman, members of this Subcommittee, I want to thank you for
holding this important hearing today and commend the Subcommittee for
the work that it has already undertaken on behalf of our Nation's
veterans.
The problem of suicide among our veterans is one of the most
serious issues that we have to address as we care for our older
veterans and prepare for a new generation of returning soldiers.
The Centers for Disease Control recently released a troubling
statistic: Each year, approximately 115,000 veterans attempt suicide.
This accounts for nearly 20% of all suicide attempts, yet, the veteran
population only accounts for 11% of the entire population.
The disproportionate prevalence of suicide among veterans suggests
that, in addition to our overall national strategy on suicide
prevention, particular attention must be paid to preventing suicide
among this special population.
Unfortunately, I expect this trend to continue as more of our brave
men and women return from multiple deployments with the symptoms of
post-traumatic stress disorder, or PTSD. As we have learned, a
staggering 20% of soldiers returning from Iraq are experiencing
depression, sleep deprivation, anxiety and other symptoms of PTSD.
I am proud that this Congress has already acknowledged the growing
problem of PTSD and dedicated substantial resources to it. Still, I
believe, as scientific evidence suggests, that as our returning
soldiers are increasingly susceptible to PTSD, they are at an elevated
risk for suicide attempts.
My bill, the ``Veterans Suicide Prevention Hotline Act of 2007'',
would create a 24-hour national toll-free hotline to assist our
Nation's veterans in crisis. It would be staffed predominantly by
veterans, trained to appropriately and responsibly answer calls from
other veterans. This hotline would follow the models of the National
Suicide, Sexual Assault and Domestic Violence hotlines, where
volunteers trained in active listening and crisis de-escalation respond
to a variety of crisis calls.
I believe that this cultural competency--the ability to connect to
another veteran who understands best what the caller may be
experiencing--can make a real difference in crisis counseling. It is
difficult to connect on this level with anyone else, even trained
doctors or other professionals.
To build this capacity nationwide, my bill calls for a 3-year,
competitively awarded grant for $2.5 million in the next three fiscal
years. The funding will be made available to a qualified non-profit
crisis center to establish, publicize, and operate the hotline,
including developing curricula to train and certify volunteers.
We have reached out the Department of Veterans' Affairs and are
encouraged that the VHA is undertaking new efforts to establish a
suicide hotline and address mental health needs. Their plan is to
divert callers from the National Suicide Prevention Hotline to a VA
facility, staffed by doctors, psychologists and other certified
counseling professionals.
On the surface the VHA's effort may appear duplicative of my
proposal, but there are some very important differences that I feel
need to be highlighted.
First, my legislation requires that the people answering the
phones, those dealing directly with the veterans, are veterans
themselves. There are times when speaking with someone who has the
cultural competence and empathy to really understand the experiences of
veterans in crisis can help make the difference between successful
integration into mental health treatment and failure to reach a veteran
in dire need of services.
Second, The VHA has many responsibilities for providing the highest
quality of healthcare for our veterans. However, they have experienced
stretched budgets and staffing shortages in recent years. Because the
demands placed on any veterans' hotline may be great as our Nation
redeploys from Iraq in the future, I have concern that the VHA may not
have the capability and commitment to the hotline that a non-profit
organization dedicated to suicide prevention as its sole purpose might
be able to provide.
Third, there are times when a person in crisis doesn't want to talk
to a doctor--they want to talk to a volunteer. Mentally ill individuals
all face societal stigma associated with seeking care. Research from
the Air Force's suicide prevention efforts suggests that this is
perceived to be even more profound in the military and veteran
communities. Fear of ``the system'', of an unfriendly mental health
establishment, and of potential job-related consequences keep many from
seeking care.
One of the motivations behind the National Suicide hotline and this
bill is to give people in crisis another option--an anonymous hotline
that can respond to their immediate crisis.
To conclude, our vets deserve as much support when they return from
combat as they receive while in battle. Too many of our veterans are
struggling to make the difficult adjustment back to society and need
someone they can talk to, someone who's walked a mile in their shoes.
This legislation will offer a caring voice at the end of the line
when it feels like there's no where else to turn.
Statement of the Honorable Diane E. Watson,
a Representative in Congress from the State of California
Thank you Mr. Chairman for holding today's hearing, and letting me
speak about my bill, H.R. 1853--The Jose Medina Veterans Affairs Police
Training Act. I believe this legislation is vital to protect our heroes
who have sacrificed their minds and bodies to protect our freedoms.
Mr. Chairman, too many veterans are suffering from mental health
problems after returning from combat, and they are not receiving the
proper treatment they deserve. Congress has a responsibility to provide
quality healthcare for our veterans. We must analyze every aspect of
services associated with the treatment of Post Traumatic Stress
Disorder, or PTSD, for our vets.
I have introduced H.R. 1853--The Jose Medina Veterans Affairs
Police Training Act, a bill that would force the Department of Veterans
Affairs to better prepare its police force to interact with patients
and visitors at VA medical facilities who suffer from mental illnesses.
Jose Medina is a constituent of mine. He is a Vietnam veteran who
suffers from PTSD. In January 2006, Mr. Medina was assaulted by two
West Los Angeles VA police officers who kicked him and forced him to
the ground after he isolated himself and fell asleep in a hallway at a
VA Medical Center in Los Angeles.
After a physical altercation ensued, this fifty-six year old
veteran was forced to lay face down on a hospital floor. The officers
injured Mr. Medina, and after the altercation they did not allow him to
use the hospital's emergency room. Instead, the officers handcuffed him
and detained him for an hour, before sending him home with a loitering
ticket. This is not the way we should be treating veterans who have
served and protected this country.
What bothers me the most is that when you see someone sitting on a
hospital floor, one would think law enforcement and hospital staff
would ask the individual if they were all right, or in need of
assistance. Instead, in this case, Mr. Medina was mistreated. This is
happening to too many of our brave veterans.
As we look to the future, thousands of veterans will be entering
the VA healthcare system. We must ensure that the VA has the ability to
administer quality healthcare services to veterans that suffer from
mental illnesses. With over 20% of the one and a half million veterans
that served in Iraq or Afghanistan showing signs of PTSD, we do not
want any of them to endure what Mr. Medina had to endure.
Mr. Chairman, the Veterans Administration believes this legislation
is unnecessary, but the story of Jose Medina and other veterans from
around the country who have contacted my office with similar problems
has proven to me that this training is indeed necessary. As Congress
debates funding strategies and timelines for our military missions, we
must not forget that not only do we need our vets to have the resources
for the battlefield; they must also be treated with dignity and respect
once they resume their lives after combat. We must ensure that this
happens!
Mr. Chairman, I thank you for the opportunity to address your
committee, and I urge the members of the committee to support H.R.
1853.
Statement of the Honorable John T. Salazar,
a Representative in Congress from the State of Colorado
Thank you Mr. Chairman.
Mr. Chairman, I'm pleased to bring H.R. 2005 to the Subcommittee
this morning, and I look forward to the discussion on this important
legislation.
The Rural Veterans Healthcare Improvement Act seeks to improve
healthcare services to veterans living in rural areas.
A study of more than 767,000 veterans by researchers working for
the Department of Veterans Affairs shows vets in rural areas are in
poorer health than vets living closer to cities.
The VA found that the health of rural veterans still persisted,
even after researchers adjusted for socioeconomic factors such as race,
education or employment status.
It was identified in the study, that access to care is a key
factor.
The study suggested, that in addition to establishing more clinics
in rural areas, VA should consider coordinating services with Medicare
or other healthcare services based in rural areas.
As a way to begin addressing some of these issues, the Veterans
Benefits, Health Care, and Information Technology Act of 2006, which
passed at the end of the 109th Congress, created the Office of Rural
Health within the VA.
Dr. Kussman's testimony will tell you that the VA is opposed to
this legislation because the Office of Rural Health is charged with
these tasks. . . .
I would like to make the point that even though Congress directed
VA to establish this office, it has yet to be implemented.
This new office, when the VA does decide to set it up, needs
support, direction, and resources in order to fulfill its mission of
coordinating care to this vital constituency.
The Rural Veterans Healthcare Improvement Act of 2007 would task
the Director of the Office of Rural Health with developing:
demonstration projects
centers of excellence
a transportation grant program
and the bill would also more fairly reimburse veterans in rural
areas for the traveling expenses they incur when driving long distances
to VA medical facilities.
Mr. Chairman . . . with both an ailing veteran population to care
for, and a new generation of veterans returning from service in Iraq
and Afghanistan, we immediately need to address access to care issues
for our rural vets.
It is estimated, that nearly 45% of all new recruits are coming
from Rural America, and with a large percentage of this war burdened by
our national Guard, that number is only going to increase.
Many vets must travel hundreds of miles to access the medical care
we've promised and they do so almost entirely at their own expense.
Currently, we reimburse veterans at a rate of $0.11 cents per mile,
a rate that has not increased since 1978.
In 1978 . . . the average price of gasoline was $0.63 cents. I
don't have to remind the Committee of the price of gasoline today.
This legislation would increase the reimbursement rate to $0.48
cents per mile, the same rate paid to federal employees.
This legislation also establishes a transportation grant program
called VetsRide.
VetsRide encourages Veterans Service Organizations to develop
innovative transportation options to vets in rural areas.
With a grant up to $50,000, a VSO could purchase a van, or find
other ways to assists veterans with travel to VA medical centers.
This bill also establishes Centers of Excellence to research ways
to improve care for rural veterans. These centers would be based at VA
Medical Centers with strong academic connections.
The outcome of these Centers would be the development of specific
models to be used by VA in providing health services to vets in rural
areas.
The Rural Veterans Healthcare Improvement Act also tasks the Office
of Rural Health with following their studies own advice.
It develops demonstration projects that would examine the
feasibility of expanding care in rural areas through partnerships.
Partnerships between the VA; Centers for Medicare and Medicaid
Services; and the Department of Health and Human Services through
critical access hospitals and community health centers.
Demonstration projects would also be carried out in partnership
with the Indian Health Service to improve healthcare for Native
American veterans.
In 2003, the VA entered into a Memorandum of Understanding with
these departments to encourage partnerships just like these, however 4
years have passed without accomplishment and our vets have suffered.
Mr. Chairman . . . We must explore every option, to ensure that the
healthcare services we promised to our veterans are delivered.
The Rural Veterans Healthcare Improvement Act of 2007 aims to
improve one of the greatest problems that plague the VA system.
I am proud of the bipartisan work that has gone into this bill and
the forty cosponsors that share these goals.
Thank you Mr. Chairman. I'm happy to answer any questions the
Committee might have.
Statement of the Honorable Jeff Miller,
a Representative in Congress from the State of Florida
Mr. Chairman, thank you for considering H.R. 2623. This bill would
prohibit the collection of co-payments for all hospice care furnished
by the Department of Veterans Affairs (VA).
VA offers a complement of hospice and palliative care options as
part of the comprehensive heath care benefit provided to all enrolled
veterans. Hospice and palliative care is a continuum of comfort-
oriented and supportive services provided across settings, including
hospital, extended care facility, outpatient clinic and private
residence.
Under current law, a veteran receiving hospice care in a nursing
home is exempt from any applicable copayments. However, if the hospice
care is provided in any another setting, such as in an acute-care
hospital or at home, the veteran may be subject to an inpatient or
outpatient primary care copayment.
Essentially, VA's current policy penalizes a veteran who chooses to
remain at home for their hospice care or out of medical necessity
receives hospice care in an acute care setting.
Mr. Chairman, this legislation would correct this inequity by
exempting all hospice care provided through VA from copayment
requirements.
This bill is important to ensuring that every veteran's preference
for end-of-life care is provided in an equitable and compassionate
manner.
I appreciate the opportunity to testify on H.R. 2623, and will be
happy to answer any questions on the bill.
H.R. 1925
Thank you, Mr. Chairman.
Nearly 12 year ago, the VA's Veterans Integrated Service Network,
or ``VISN,'' plan was set in motion as a way to make the large VA
healthcare network more attuned to the needs of its patients. For
certain, VA provides some of the best care in this nation. The VISNs
were implemented as a way to maintain the high quality of care while
allowing more regional management so that the central office in
Washington did not unnecessarily micromanage the day-to-day aspects of
healthcare delivery.
The VISN network has enjoyed its successes in providing better
access and more patient-centered care. However, there is room for
improvement, and the Gulf Coast region of our nation is an area where
such improvement is needed. Having already seen a consolidation of two
VISNs since their creation, it is clear that flexibility within the VA
healthcare system is necessary. My bill, H.R. 1925, would create a VISN
specifically targeted to improving the delivery of healthcare to the
large and ever-increasing population of veterans living in the Gulf
Coast--a ``Gulf Coast VISN.''
A new Gulf Coast VISN would create a healthcare network that could
better respond to the unique needs and problems facing veterans in the
area. The area involved covers the coastal counties just west of
Tallahassee, Florida over to the Louisiana state line, an area home to
few VA clinics and lacking hospitals providing inpatient care. It is an
area identified by the CARES report as underserved, and its unique
geographical location is no doubt part of that reason. Most of the area
that would make up the Gulf Coast VISA is in the region where VISN
eight meets VISN 16. VISN eight encompasses the rest of the state of
Florida. VISN 16, the largest single VISN in the country, reaches all
the way west past Houston, Texas, and all the way up through Oklahoma.
Looking at the map, you can see how this largely rural region can
get overlooked in such a huge VISN with major metropolitan areas. The
more than 300,000 veterans that would be directly served within this
VISN do not want their access to care overlooked--and that has happened
for far too long. With even basic outpatient care being difficult for
many to obtain, it is time to ensure that the Gulf Coast's veterans are
provided the full range of services they have earned.
There are several reasons why I see this bill as being successful.
With an increased focus on the unique, shared needs for veterans in the
area, the Gulf Coast VISN director could take great advantage of the
sharing opportunities with the Department of Defense (DoD) that are
available in that region. The Gulf Coast is home to multiple DoD
installations, and while a few joint VA/DoD facilities exist now, there
is a tremendous opportunity for expanding this relationships to deliver
a wider range of healthcare services.
The VISN system was founded on good principles to improve access
and quality of care by eliminating the inefficiencies of a centralized
bureaucracy and promoting a local, patient-focused system of healthcare
delivery. However, it is not perfect, and with the findings of the
CARES Commission as well as the simple fact that veterans in the Gulf
Coast area have to drive upward of three hours in many instances to
receive inpatient care, it is abundantly clear that improvements are
still needed. I feel the creation of a Gulf Coast VISN can do just
that. Its implementation would be neither costly nor particularly
difficult. In addition, the bill would give VA the authority to decide
on the location of the VISN headquarters.
The GulfCoast's veteran population clearly deserves more timely
access to VA healthcare. Creating a Gulf Coast VISN would be a
significant step toward providing that access.
Thank you, Mr. Chairman, for considering this important legislation
and I am pleased to answer any questions on the bill.
[GRAPHIC] [TIFF OMITTED] 37465A.001
[GRAPHIC] [TIFF OMITTED] 37465A.002
Statement of the Honorable Paul W. Hodes,
a Representative in Congress from the State of New Hampshire
Thank you Chairman Michaud and Ranking Member Miller for holding
this important hearing today. I appreciate the opportunity to testify
today about H.R. 2192, the bipartisan bill I introduced establishing an
Office of the Ombudsman in the Department of Veterans' Affairs. I would
also like to thank Chairman Filner for his support of the bill.
I recently visited Walter Reed Army Medical Center with the
Oversight and Government Reform Committee. I talked with soldier after
soldier about the problems they experienced transitioning out of active
duty and into the VA. Veterans in my district have repeatedly told me
their compelling stories of the great difficulties and challenges they
have faced in understanding and receiving all the benefits and services
to which they are entitled.
The Ombudsman's Office should serve as the outreach master office--
a coordinating and coordinated center for benefits and health
information services available both within and outside of the VA.
I am not interested in creating another meaningless layer of
bureaucracy. Instead, I would like the Ombudsman's Office to become a
one stop shop for veterans, a CENTCOM for veterans' benefits
information.
I applaud the VA for their hard work in providing information that
veterans need. The VA has numerous hotlines and support services
available to veterans. I've counted 10 different 1-800 numbers on the
VA's website to help with different types of benefits--one for
disability pension, another for healthcare benefits, another for life
insurance, etc.
While the VA provides veterans benefits and service information,
the veterans may not know where they put their informational pamphlets
6 months or 1 year down the road when they have a question or a
problem.
Veterans are falling through the cracks and do not know where to
turn.
The Office of the Ombudsman would provide a focal point of
information within the VA. The Ombudsman's Office should be a one stop
shop of information and resources. The Office should head up the
advocacy and information campaigns that the VA already has in place,
and consolidate the information services with one 1-800 number to
address all the veterans' needs and complaints.
For a veteran who has just returned from active duty in OIF
(Operation Iraqi Freedom) or OEF (Operation for Enduring Freedom) with
Traumatic Brain Injury, it would be a whole lot simpler and easier to
have only one office to call to receive the information he or she
needs. The VA has a patient advocacy program for healthcare, but a lot
brave men and women need help with loans for their homes and schooling
too. They should not have to run around asking the same ten questions
to ten different offices. The Ombudsman's Office can help the veteran
figure out the all the services in the benefits system, not just
healthcare, and not just disability ratings.
I have reviewed the testimony of the esteemed panelists, the VA and
VSOs. Just in the six testimonies that specifically discussed the
Ombudsman's Office, the panelists referred to fourteen different
programs both within and outside of the VA that veterans could turn to
for help with benefits coordination. These fourteen programs are
extremely important to our veterans and providing specialized services.
But, as a healthy Member of Congress and not a PTSD patient or an
ailing elderly veteran, I am even confused about which programs to use
and under which circumstances.
Mr. Chairman, I am not trying to make redundant services. The
Veterans Administration provides advocacy and resources, VSOs provide
advocacy and resources.
I would, however, like to work with the Honorable Members of the
Committee to mold the Office of the Ombudsman into a viable, helpful
resource for veterans. I believe that this consolidation of various
information sources into a coordinated center of information will help
make sure the veterans receive the care they need and cut through the
seemingly endless amounts of bureaucratic red tape.
Thank you again for giving me the opportunity to testify before the
Subcommittee on Health today. I look forward to working with the
Committee to help veterans understand and access the benefits they
deserve.
Statement of the Honorable Nita M. Lowey,
a Representative in Congress from the State of New York
I want to thank the Committee for holding this hearing today and
for considering the VA Hospital Quality Report Card Act of 2007. I
introduced this legislation in an effort to provide increased
disclosure and accountability in the VA hospital system, and ultimately
increase the quality of care for the men and women who have served in
the Armed Forces.
The treatment provided to our veterans is not a partisan or
political issue, and I am pleased that this legislation is cosponsored
by some of my Republican colleagues.
I believe we can all agree that quality care initiatives and public
disclosure should not end when an individual leaves active military
service. In fact, the quality of care for those who have bravely served
our Nation should be of the highest standard possible.
To achieve that goal we must have a clear picture of the quality of
care provided by the Veterans Administration, and this information must
be continually assessed and updated. As we learned with Walter Reed
Army Medical Center, a facility that once defined excellence may not do
so in the future without constant internal assessments.
My legislation would require the Department of Veterans Affairs to
establish a formal Hospital Report Card Initiative and publish reports
on individual hospitals' level and quality of care. The resulting
report cards would: provide clear outcomes data to be used for peer
review and quality improvement; galvanize hospitals to make changes by
creating public accountability; and provide our veterans with the
information they need to make sound healthcare decisions. Several
states, including Pennsylvania, New York, California, Florida and
Illinois, have already implemented Hospital Report Card Initiatives.
A March 2007 Veterans Administration report exposed major
deficiencies in the physical conditions in many veterans' facilities.
In this report, the VA Hudson Valley Health Care System, which
serves over 25,000 veterans throughout my district and the surrounding
areas, was cited for ceiling mold, suicide hazards in the psychiatric
ward and cosmetic deficiencies. I'm going to repeat one part of that
because I think it underscores the level of neglect seen throughout the
VA healthcare system--suicide hazards in a psychiatric ward, an area in
hospitals that most certainly should limit the ability of an individual
to harm him or her self.
Dr. Michael Kussman, Under Secretary for Health at the VA,
previously stated, ``VA facilities are inspected more frequently than
any other healthcare facilities in the nation.'' If this is true, the
Department should have no problem complying with the requirements of
this legislation.
If we are serious about ensuring a seamless transition between DOD-
provided healthcare and VA-provided healthcare, we must have an
accurate assessment of the VA system, and the VA Hospital Quality
Report Card Act of 2007 would provide just that.
I thank the Members of the Subcommittee once again for this hearing
and I look forward to working with each of you to provide our veterans
with the level of healthcare worthy of their service and dedication to
our country.
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
view on the several pieces of legislation being considered by the
Subcommittee today. The American Legion commends the Subcommittee for
holding a hearing to discuss these very important and timely issues.
H.R. 1448, VA Hospital Quality Report Card Act of 2007, seeks to
establish the Hospital Quality Report Card to ensure quality measures
data on the Department of Veterans Affairs (VA) hospitals are readily
available and accessible.
The state of VA healthcare/medical facilities are an important
issue for The American Legion. Each year the organization is mandated
by resolution to conduct a series of site visits to various VA medical
facilities and submit a report to the President, Congress and VA.
The bill is similar in scope to our report--A System Worth Saving.
Periodic assessments would enable VA to get a clearer picture of its
system-wide needs and assist lawmakers in determining adequate funding
for the VA healthcare system.
H.R. 1853, Jose Medina Veterans Affairs Police Training Act of
2007, seeks to ensure that VA police officers receive training on
interacting with visitors and patients suffering from mental illness at
VA medical facilities. The American Legion has no official position on
this issue, but hopes that VA is training all of its employees to
interact with veterans and their families in the dignified, respectable
manner in which they deserve.
H.R. 1925, A Bill to Direct the Secretary of Veterans Affairs to
Establish a Seprate Veterans Intergrated Service Network (VISN) for the
Gulf Coast Region of the United States, would mandate that the
Secretary create a VISN that would encompass several counties in the
states of Florida, Alabama and Mississippi. The American Legion has no
position on this issue.
H.R. 2005, Rural Veterans Health Care Improvement Act of 2007,
addresses many issues affecting veterans who reside in rural areas. It
seeks to increase the beneficiary travel rate to make it equivalent to
the rate provided to federal employees; establish centers for rural
health research, education, and clinical activities; offer
transportation grants for service organizations that assist rural
veterans; and explore alternatives to improve transportation to medical
facilities for rural veterans. The American Legion fully supports the
provisions in this bill.
Beneficiary travel pay has not been increased from its current rate
since 1978. The price of gasoline has steadily increased since the
$0.11 per mile rate was established, creating a financial hardship for
veterans who have to travel long distances for care, or those who have
limited financial resources.
Since service-connected veterans and other veterans authorized
beneficiary travel only receive $0.11 per mile are subjected to a $6
per trip deductible not to exceed $18 per month--this amount does very
little to defray the cost of travel. Eligible veterans are not
reimbursed at a reasonable level for costs incurred to visit a VA
medical facility for service-connected or other authorized care and
treatment.
There are no provisions in law that VA must increase the per mile
travel authorization on a regular basis. The beneficiary travel program
is discretionary and the Secretary of Veterans Affairs is required to
review the program annually to determine the Department's ability to
maintain the program and its ability to increase the reimbursement rate
for eligible veterans. The Secretary has determined that it is
necessary to maintain the current reimbursement rate in order to allow
the VA healthcare system to accommodate the increasing patient
workload.
The lack of a consistent and reliable mechanism to periodically
adjust the rate authorized for beneficiary travel creates an injustice
and an unfair economic burden for many veterans. The American Legion
believes that mandatory funding for VA healthcare would allow the
Secretary to provide adequate healthcare without inversely affecting
programs designed to mitigate the cost of accessing that care.
Establishing centers for rural health research, education, and
clinical activities would afford VA the opportunity to build strategies
to improve its system of care for rural veterans, as well as educate
and train healthcare professionals on health issues prevalent in
specific rural veteran populations.
Offering transportation grants for veterans' service organizations
that assist rural veterans and exploring alternatives to improve
transportation to medical facilities for rural veterans would make
accessing care easier for those who are not financially able to travel
to facilities, especially those who, due to their physical condition,
are not able to make extremely long trips in 1 day. If more
transportation options became available, it may also improve
coordination of care for those who have to travel distances for special
services, especially in the unavailability of a family care giver.
H.R. 2172, Amputee Veteran Assistance Act, would require that VA's
orthotic-prosthetic laboratories, clinics, and prosthetists are
certified by either the American Board for Certification in Orthotics
and Prosthetics or the Board of Orthotics and Prosthetic Certification.
It is The American Legion's understanding that VA's ortho-prosthetic
labs/clinics are accredited and each has at least one orthotist that
has certification which is how the labs were able to gain
accreditation. The orthotists and prosthetists are being trained on
latest prosthesis at Walter Reed, so they can be knowledgeable about
the prosthetics being given to returning soldiers. They also
participate in focus groups with veterans' service organizations, and
OIF veterans. Furthermore, VA already contracts with non-Department
entities when the medical facility is not capable of providing the
service or the veteran lives too far away and patients are given
information about their prosthetic choices.
H.R. 2173, Seeks to Amend Title 38, United States Code, to
Authorize Additional Funding for the Department of Veterans Affairs to
Increase Capacity for Provision of Mental Health Services Through
Contracts with Community Mental Health Centers, and for Other purposes.
The American Legion believes that VA should contract with community
providers only when it is unable to provide needed services to the
veteran, if travel for the veteran would be a danger to his or her
health, or if the veteran resides in a rural area. As long as VA
healthcare remains discretionary, VA will always struggle to obtain
sufficient funding to provide access to quality care for eligible
veterans seeking care in VA facilities. Assured (mandated) funding
would provide a method to provide dependable, stable and sustained
funding for veterans' healthcare. The American Legion believes that
Congress should designate assured funding for VA medical care; continue
to provide discretionary funding, as required, to fully operate other
programs within the Veterans Health Administration's budgetary
jurisdiction; and provide, if necessary, supplemental appropriations
for budgetary shortfalls in VHA's mandated and discretionary
appropriations to meet the healthcare needs of America's veterans.
H.R. 2192, A Bill to amend Title 38 USC, to establish an Ombudsman
within the Department of Veterans Affairs, would designate an Ombudsman
to serve as a liaison for veterans and their families to guarantee the
receipt of VA healthcare and benefits. The American Legion supports the
provisions of this bill. Establishing a point of contact to work with
families to ensure that veterans receive all benefits, to which he or
she is entitled, based on his or her unique situation, would reduce the
stress and frustration associated with navigating the complex VA
healthcare and benefits system.
H.R. 2219, Veterans Suicide Prevention Hotline Act of 2007. The
American Legion has no position on this issue.
H.R. 2378, Services to Prevent Veterans Homelessness Act. This bill
aims to establish a financial assistance program to facilitate
supportive services for very-low income veteran families to assist them
in ending their chronic homeless state and to prevent chronic
homelessness.
Enactment of this legislation will enable funding to provide much
needed supportive services to veterans and their dependents. It takes
into account that the VA Grant and Per Diem (GPD) program can only
provide services to veterans and fills a much-needed gap of caring for
their dependents..
The American Legion fully supports this bill in its effort to
assist homeless veterans. We applaud that the bill recognizes that
families also suffer alongside the veteran struggling with
homelessness.
The American Legion supports the efforts of public and private
sector agencies and organizations with the resources necessary to aid
homeless veterans and their families. The American Legion supports
proposals that will provide medical, rehabilitative and employment
assistance to homeless veterans and their families.
Currently, the VA has no authority to provide grant funding to
create affordable permanent housing units for low-income veterans and
those who have completed their transition programs. Veteran service
providers must compete with other housing projects for limited HUD
funding, and constantly search for additional funding sources to
provide this housing option.
This legislation will be in addition to the VA Grant and Per Diem
program, but will enable the mechanism of funding supportive services
to become more streamlined.
Homeless veteran programs should be granted full appropriations to
provide supportive services such as, but not limited to outreach,
healthcare, habilitation and rehabilitation, case management, daily
living, personal financial planning, transportation, vocational
counseling, employment and training, and education.
Veterans need a coordinated effort that provides secure housing and
nutritious meals; essential physical healthcare, substance abuse
aftercare and mental health counseling; as well as personal development
and empowerment.
Veterans also need job assessment, training and placement
assistance. The American Legion believes all programs to assist
homeless veterans must focus on helping veterans reach their highest
level of self-management.
The most effective programs for homeless and at-risk veterans are
community-based, nonprofit, veteran-staffed groups. It is critical that
community groups continue to reach out and help to provide the support,
resources and opportunities most Americans take for granted.
Homelessness impacts every community in the nation. Approximately
200 community-based veterans' service organizations across the country
have successfully reached homeless veterans through specialized
programs. Veterans who participate in these programs have a higher
chance of becoming productive citizens again.
A full continuum of care--housing, employment training and
placement, healthcare, substance abuse treatment, legal aid, and
follow-up case management--depends on many organizations working
together to provide services and adequate funding. The availability of
homeless veteran services, and continued community and government
support for them, depends on vigilant advocacy and public education
efforts on the local, state and federal levels.
The FY 2006 Department of Veterans Affairs Community Homelessness
Assessment, Local Education and Networking Groups (CHALENG) report
estimates that nearly 200,000 veterans are homeless at any point in
time. Prior reports state that one out of every three homeless men
sleeping in a doorway, alley or box in our cities and rural communities
has put on a uniform and served this country. According to the February
2007 Homeless Assessment Report to Congress (U.S. Department of Housing
and Urban Development 2007) veterans account for 19% of all homeless
people in America.
For FY 2006, The VA Health Care for Homeless Veterans (HCHV)
reports that 101,182 homeless veterans are enrolled in their programs.
Community-based organizations are attempting to assist the overwhelming
remainder of veterans who are homeless.
In addition to the complex set of factors affecting all
homelessness (the extreme shortage of affordable housing, livable
income, and access to healthcare), a large number of displaced and at-
risk veterans live with lingering effects of Post Traumatic Stress
Disorder (PTSD), substance abuse, and a lack of family and social
support networks. Many times these veterans have mental health
disorders related to their honorable service to their country, are
unable to compensate for their condition. They unfortunately
deteriorate to unrecognizable individuals compared to their pre-
military experience.
Operation Iraq Freedom and Operation Enduring Freedom (OIF/OEF)
veterans are at high risk of becoming homeless. Combat veterans of OIF/
OEF and the Global War on Terror who need help--from mental health
programs to housing, employment training and job placement assistance--
are beginning to trickle into the nation's community-based homeless
veterans' service organizations. Already stressed by an increasing need
for assistance by post-Vietnam Era veterans and strained budgets,
homeless services providers are deeply concerned about the inevitable
rising tide of combat veterans who will soon be requesting their
support.
Since 9/11, nearly 800,000 American men and women have served or
are serving in a war zone. Rotations of troops returning home from Iraq
are now a common occurrence. Military analysts and government sources
say the deployments and repatriation of combat veterans is unlike
anything the nation has experienced since the end of the Vietnam War.
The signs of an impending crisis are clearly seen in VA's own
numbers. Under considerable pressure to stretch dollars, VA estimates
it can provide assistance to about 100,000 homeless veterans each year,
only 20% of the more than 500,000 who will need supportive services.
Hundreds of community-based organizations nationwide struggle to
provide assistance to as many of the other 80% as possible, but the
need far exceeds available resources.
VA's HCHV reports 1,049 OIF/OEF era homeless veterans with an
average age of 33 years young. HCHV further reports that nearly 65% of
these homeless veterans experienced combat. Now receiving combat
veterans from Iraq and Afghanistan daily, the VA is reporting that a
high percentage of those casualties need treatment for mental health
problems. That is consistent with studies conducted by VA and other
agencies that conclude anywhere from 15 to more than 35% of combat
veterans will experience some clinical degree of PTSD, depression or
other psychosocial problems.
Homeless veteran service providers' clients have historically been
almost exclusively male. That is changing as more women veterans and
women veterans with young children have sought help. Additionally, the
approximately 200,000 female Iraq veterans are isolated during and
after deployment making it difficult to find gender-specific peer-based
support. Access to gender-appropriate care for these veterans is
essential.
More women are engaging in combat roles in Iraq where there are no
traditional frontlines. In the past 10 years, the number of homeless
women veteran has tripled. In 2002,the VA began a study of women and
PTSD. The study includes subjects whose PTSD resulted from stressors
that were both military and non-military in nature. Preliminary
research shows that women currently serving have much higher exposure
to traumatic experiences, rape and assault prior to joining the
military. Other reports show extremely high rates of sexual trauma
while women are in the service (20-40%). Repeated exposure to traumatic
stressors increases the likelihood of PTSD. Researchers also suspect
that many women join the military, at least in part, to get away from
abusive environments. Like the young veterans, these women may have no
safe supportive environment to return to, adding yet more risk of
homeless outcomes.
``Homeless providers continue to report increases in the number of
homeless veterans with families (i.e., dependent children) being served
at their programs. Ninety-four sites (68 percent of all sites) reported
a total of 989 homeless veteran families seen with Los Angeles seeing
the most families (156). This was a 10-percent increase over the
previous year of 896 reported families. Homeless veterans with
dependents present a challenge to VA homeless programs. Many VA housing
programs are veteran-specific. VA homeless workers must often find
other community housing resources to place the entire family--or the
dependent children separately. Separating family members can create
hardship.'' (FY 2006 VA CHALENG report)
Homeless veteran service providers recognize that they will have to
accommodate the needs of the changing homeless veteran population,
including increasing numbers of women and veterans with dependents. In
conclusion, The American Legion supports the provisions in H.R. 2378
which will be helpful in addressing the issues of homeless veterans.
H.R. 2623, Seeks to amend title 38, United States Code, to prohibit
the collection of copayments for all hospice care furnished by the
Department of Veterans Affairs. The American Legion is continuing to
study the bill and will provide an addendum to this testimony to the
Committee.
Again, thank you Mr. Chairman for giving The American Legion this
opportunity to present its views on such important issues. We look
forward to working with the Subcommittee to address these and other
issues affecting veterans.
Statement of Kimo S. Hollingsworth,
National Legislative Director, American Veterans (AMVETS)
Mr. Chairman and Members of the Subcommittee:
I am pleased to offer testimony on behalf of American Veterans
(AMVETS) regarding pending health legislation before this Subcommittee.
AMVETS appreciates the Subcommittee's work to ensure the Department of
Veterans Affairs can fulfill its obligation to provide healthcare and
other health related services to veterans.
Mr. Chairman, some of the issues relevant to today's hearing are
extremely important to returning veterans from Operations Iraqi Freedom
and Enduring Freedom. Specifically, suicide prevention, mental health
funding, and access to healthcare in rural or underserved areas. These
issues were identified and highlighted at the AMVETS sponsored
``National Symposium for the Needs of Young Veterans'' in Chicago,
Illinois last year. More than 500 veterans, active duty and National
Guard and reserve personnel, family members and others who care for
veterans examined the growing needs of our returning veterans. With
regards to today's legislative agenda, AMVETS would like to offer the
following observations.
H.R. 1448 would establish a Hospital Quality Report Card Initiative
in order to report on healthcare quality in the Department of Veterans
Affairs Hospitals. The Government Performance and Results Act, Public
Law 103-62, requires that agencies develop measurable performance goals
and report results against these goals. In the President's Fiscal Year
2008 budget request, VA focuses on the Secretary of Veterans Affairs
priority of providing timely and accessible healthcare that sets a
national standard of excellence for the healthcare industry. VA
generally tracks the timeliness of care in two broad areas--primary and
specialty clinic appointments. Over the next year, the percent of
appointments scheduled within 30 days of the desired date is expected
to reach 96% for primary care appointments and 95% for specialty care
appointments.
In July 2005, the VA Office of Inspector General (OIG) reported
that VHA's scheduling procedures needed to be improved and issued eight
recommendations. As of September 2006, five of the eight
recommendations for improvement remained open and AMVETS encourages the
Department to implement the remaining recommendations. The Department
has tracked and monitored the quality of care at VA facilities since
the early seventies through comprehensive quality management (QM)
programs. Furthermore, Public Laws 99-166 and 100-322 require the VA
OIG to oversee VA QM programs at every level and a large part of the VA
Office of Inspector General Combined Assessment Program (CAP) reviews
focus on quality, safety and timeliness of VA healthcare. Mr. Chairman,
AMVETS supports efforts to improve VA healthcare and supports the
intent of H.R. 1448. However, we believe this legislation would mandate
a duplicative effort as many of the items to be reported in a report
card are already reviewed and reported through the VA QM and CAP
programs.
H.R. 1853 would direct the Secretary to ensure the Department of
Veterans Affairs police officers receive training to interact with
visitors and patients at medical facilities who are suffering from
mental illness. VA police officers already receive some degree of
training in interacting with individuals with potential mental
illnesses and mandating this training will codify an existing practice.
AMVETS supports the intent of the bill.
H.R. 1925 would direct the Secretary of Veterans Affairs to
establish a separate Veterans Integrated Service Network (VISN) for the
Gulf Coast Region of the United States. Mr. Chairman, Public Law 104-
204 directed VA to implement a more equitable resource allocation
system that was to reflect, to the maximum extent possible, the
Veterans Integrated Services Network developed by the Department to
account for forecasts in expected workload and to ensure fairness to
facilities that provide cost-efficient healthcare; and . . . ways to
improve the allocation of resources so as to promote efficient use of
resources and provisions of quality healthcare . . . Obviously the
Veterans Equitable Resource Allocation (VERA) model is designed to
bring consistency, fairness and stability to the VA funding process.
This in turn is dependent upon the VISN model.
The Capital Asset Realignment for Enhanced Services (CARES) was
supposed to be a system-wide process to prepare the VA for meeting the
current and future healthcare needs of veterans. CARES addressed the
appropriate clinical role of small facilities, vacant space, the
potential for enhanced use leases and the consolidation of services and
campuses. To date, it is the most comprehensive analysis of VA's
healthcare infrastructure conducted. The CARES made some very specific
recommendations with regards to healthcare infrastructure, to include
areas of the Florida Panhandle and the Gulf Coast.
Overall, AMVETS supported the CARES process and we believe Congress
should consider the CARES recommendations in deliberations about VA
infrastructure to include deliberations about the current VISN model.
AMVETS would like to note that VA adopted the VISN model in 1995.
Considerable time has elapsed since implementation of the VISN model
and there clearly have been demographic changes within the general
population that would most likely include changes to the veteran
population.
H.R. 2005 would seek to improve healthcare for veterans living in
rural areas, to include providing an increase in the travel
reimbursement and establishing centers of excellence for rural health
research, education and clinical activities. AMVETS continues to
support an increase to the travel reimbursement rate for our veterans.
The VA beneficiary travel program was intended by Congress to assist
veterans when trying to access VA healthcare. The mileage reimbursement
rate is currently fixed at 11 cents per mile; however, current law
limits the actual reimbursement with a $3.00 per trip deductible capped
at $18.00 per month. The Secretary of Veterans Affairs has the
authority to make rate changes to these rates, but changes have not
been adopted in more than 30 years. Obviously the price of owning and
operating a vehicle has risen dramatically during this time period.
AMVETS believes it is now time for Congress to act by mandating a
realistic reimbursement rate for the VA beneficiary travel program.
Regarding the delivery of rural healthcare, an important issue
brought forth at the ``National Symposium for the Needs of Young
Veterans'', Sections 212 and 213 of Public Law 109-461 are specifically
targeted at advancing the healthcare needs of veterans in rural areas.
VA is mandated to establish an Office of Rural Health within the
Veterans Health Administration (VHA). The office is charged with
improving VA healthcare for veterans living in rural and remote areas.
Among other provisions, the law 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. AMVETS would encourage
Congress to fully fund the Office of Rural Health and allow VA to
conduct the mandated assessment.
H.R. 2172 would require VA orthotic-prosthetic laboratories,
clinics and prosthesists to be certified by either the American Board
for Certification in Orthotics and Prosthetics or the Board of
Orthotics and Prosthetic Certification. Mr. Chairman, the VA already
receives certification from these agencies and we support the
certification process. AMVETS does have concern with the section of the
bill that would require the VA to enter into contracts for service and
repair of prosthetic devices with non-department entities. This
provision would create a ``sole-source'' contract, and AMVETS would
oppose this provision.
H.R. 2173 would authorize additional funding to allow VA to enter
into contracts with local or community health centers. Mr. Chairman, as
we are all aware, there is a large number of National Guard and reserve
units that have deployed or will be deployed into a theater of combat
operations. Many of these units and personnel are from areas of the
country that do not have VA healthcare or VA healthcare services
readily available. AMVETS continues to support the Secretary of
Veterans Affairs in his authority to contract out for medical and
healthcare services when/where applicable and also supports additional
funding for these services.
H.R. 2192 would establish an Ombudsman within the Department of
Veterans Affairs to act as a liaison for veterans and their families
with respect to the receipt of healthcare and benefits administration.
The VA has a long history of special efforts to bring information on VA
benefits and services to active duty military personnel. These efforts
include counseling about VA benefits through the Transition Assistance
Program (TAP), a nationally coordinated federal effort to assist
military men and women to ease the transition to civilian life through
employment and job training assistance. A second component of the
program, the Disabled Transition Assistance Program (DTAP), helps
separating servicemembers with disabilities.
VA also has launched special efforts to provide a ``seamless
transition'' for those returning from service in Operations Iraqi
Freedom and Enduring Freedom. Internal coordination was improved and
efforts currently focus on reducing red tape and streamlining access to
all VA benefits. Each VA medical facility and benefits regional office
has identified a point of contact to coordinate activities locally to
help meet the needs of these returning combat servicemembers and
veterans. In addition, VA increased the staffing of benefits counselors
at key military hospitals where severely wounded servicemembers from
Iraq and Afghanistan are frequently sent. AMVETS does not oppose
legislation to establish an Ombudsman within the VA.
H.R. 2219 would direct the Secretary to award a grant to a private,
nonprofit entity to establish, publicize and operate a national toll-
free suicide prevention telephone hotline targeted to and staffed by
veterans of the Armed Forces. Mr. Chairman, the Department of Veterans
Affairs Office of Inspector General recently reported that veterans
returning from Iraq and Afghanistan are at increased risk of suicide
because Veterans Administration health clinics do not have 24-hour
mental healthcare available. Many facilities lack 24-hour staff,
adequate screening for mental problems, or personnel who were properly
trained.
The report also concluded that VA clinics and military hospitals
must improve their sharing of health information, particularly for
patients who might return to active-duty status and that VA should
loosen criteria for inpatient PTSD care. Currently only veterans with
``sustained sobriety'' get treatment. It is AVMETS' understanding that
the VA Undersecretary for Health, concurs with findings and
recommendations, and that VA has recently installed suicide prevention
coordinators in each medical center to better develop prevention
strategies. AMVETS supports the Undersecretary in this endeavor;
however, AMVETS would oppose efforts by Congress to mandate the
Secretary of VA to enter into contracts with a private entity for these
services and believes that the Secretary must continue to have
flexibility in how he implements these services.
H.R. 2378 would establish a financial assistance program to
facilitate the provision of supportive services for very low-income
veteran families in permanent housing. We continue to urge Congress to
provide resources and oversight on homeless veterans programs and
veterans who may be at risk. With regards to the establishment of a
financial assistance program for very low-income veterans, AVMETS would
urge Congress to provide veterans priority assistance through the
Department of Health and Human Services as opposed to creating a new
program within the Department of Veterans Affairs.
Mr. Chairman, this concludes my testimony.
Statement of Adrian M. Atizado,
Assistant National Legislative Director, Disabled American Veterans
Mr. Chairman, Ranking Member Miller and other Members of the
Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this important legislative hearing of the Subcommittee on
Health of the Committee on Veterans' Affairs. DAV is an organization of
1.4 million service-disabled veterans, and along with its auxiliary,
devotes its energies to rebuilding the lives of disabled veterans and
their families.
You have requested testimony today on ten bills primarily focused
on healthcare services for veterans under the jurisdiction of the
Veterans Health Administration (VHA), Department of Veterans Affairs
(VA). Your staff indicated two additional draft bills would be
considered but we did not receive those two bills in time to include
them in this testimony. With exception to the aforementioned draft
legislation, this statement outlines our positions on all of the
proposals before you today. The comments are expressed in numerical
sequence of the bills, and we offer them for your consideration.
H.R. 1448--The VA Hospital Quality Report Card Act of 2007
H.R. 1448 would establish a ``hospital report card'' covering a
variety of activities of inpatient hospital care occurring in the
medical centers of the Department. We support this bill, because it is
consistent with trends occurring in private sector healthcare. We
believe that veterans under VA care have the same rights as private
sector patients to review the quality and safety of the care they
receive while hospitalized. We do note, however, that the purposes of
this bill do not cover the grand majority of overall patient care
workload in VA healthcare, namely primary (outpatient) care and
extended care services provided in VA's nursing home care units and its
various contracted programs. Nevertheless, this is a good bill and one
that is supported by DAV. We do note for the Committee's purposes, that
the term ``VA hospital'' was supplanted by the term ``VA medical
center'' in prior legislation. You may wish to consider conforming this
bill accordingly, should the Committee decide to approve and report it.
H.R. 1853--The Jose Medina Veterans Affairs Police Training Act of 2007
H.R. 1853 would require the Secretary of Veterans Affairs to ensure
that officers of the VA police service be trained with respect to
officers' interactions with veterans possibly suffering from mental
illnesses. While DAV does not have a resolution dealing with this
issue, we consulted with the National Alliance for Mental Illness
(NAMI) and its NAMI Veterans Council, an advocacy group that, like DAV,
is deeply concerned about VA mental health programs and veterans who
benefit from them. NAMI fully supports the concept of adequate training
being provided to VA police, who are sworn federal police officers
charged with providing physical and personal security at all VA
healthcare facilities. We concur with NAMI's views on this issue. We
would suggest that the bill be amended, however, to ensure that
properly credentialed mental health practitioners (principally those
whom VA employs within the VHA to care for veterans with mental
illnesses) be designated as training resources for the purposes of this
bill.
H.R. 1925--To direct the Secretary of Veterans Affairs to establish a
separate Veterans Integrated Service Network for the Gulf Coast
region of the United States
H.R. 1925 would establish a 22nd Veterans Integrated Service
Network (VISN) in the western Panhandle of Florida, far south Alabama,
and eastern Mississippi, within 1 year of date of enactment.
DAV does not have a resolution from our membership addressing this
issue. It should be noted however, that the bill raises valid questions
on the relevance and effectiveness of current VISN boundary alignments.
These VA jurisdictional lines have been in place with only one
adjustment for the past 12 years. These boundaries were generally
formed based on veteran patient care referral patterns established in
the eighties, and it should be recalled that VA has revolutionized its
patient care system over the past dozen years.
It is unclear if VA has reviewed whether the current alignment is
optimal or may need adjustment. Also, it should be noted that some
parts of the geographic area encompassed by the bill's intent is still
in transition in terms of VA physical assets, with no major affiliated
VA medical centers and only one significant VA facility in Florida, the
Pensacola Outpatient Clinic, one in Alabama, the Mobile Outpatient
Clinic and one Mississippi VA medical center, in Jackson. Distances and
access to these facilities is challenging for the veterans of the
region, especially for specialized VA services that had generally been
provided by the New Orleans, Louisiana VA facility until Hurricane
Katrina destroyed it in 2005. It is also important to note that the
Florida Panhandle area is not a part of VISN eight, constituting the
remainder of the State of Florida excepting a few counties along its
northern border. With most of this area now embedded within VISN 16,
the VA system's largest VISN (encompassing parts of eight States), the
proponent of this bill makes a valid argument that perhaps a new
alignment is in order.
H.R. 2005--Rural Veterans Health Care Improvement Act of 2007
Section 2 of this bill would improve reimbursement rates for
veterans for their travel expenses related to VA medical care. It would
reimburse veterans at the same rate paid to federal employees, by
increasing it from 11 cents per mile to 48.5 cents per mile.
For several years, we have urged VA to correct the inequity in its
travel reimbursement program and include a line item in the budget to
make a fair adjustment in travel pay while retaining sufficient funding
for direct medical care. 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.
Adequate travel expense reimbursement is directly tied to access to
care for many veterans and not a luxury.
The VA beneficiary travel program is intended by Congress to assist
veterans in need of VA healthcare to gain access to that care. While
the mileage reimbursement rate is currently fixed, 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.
DAV Resolution No. 212 is a longstanding resolution 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 the House
and Senate bills titled the ``Veterans Travel Fairness Act,'' offer a
fair and equitable resolution to this situation which we have been
concerned for many years. We urge this Subcommittee to approve and
enact legislation this year to reform the VA beneficiary travel
program.
Section 4 of this measure would establish a grant program to
provide innovative transportation options to veterans in remote rural
areas. The bill tasks the Director of VA's Office of Rural Health to
create a program that would provide grants of up to $50,000 to
veterans' service organizations and State veterans' service officers to
assist veterans with travel to VA medical centers and to improve
healthcare access in remote rural areas. The bill authorizes $3 million
per year for the grant program through 2010.
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 to receive VA medical care. Since that time, the
DAV National Transportation Network has become a very significant and
successful partnership between VA and DAV. We have donated 1,959 vans
to VA facilities at a cost exceeding $39 million. Since its inception,
these vans, their DAV volunteer drivers and medical center volunteer
transportation coordinators have transported more than 10 million
veterans over 397 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. Although as an organization,
the DAV does not accept federal funds such as the grant program;
however, knowing first hand the value and effectiveness of such a
program, we would not oppose this section of the bill.
Section 3 of this bill would establish at least one and no more
than five Centers of Excellence to research ways to improve care for
rural veterans. The centers would be based at VA medical centers with
strong academic connections. The Office of Rural Health would establish
between one and five centers across the country with the advice of an
advisory panel.
Existing VA research, education clinical centers, and various
centers of excellence have proven to be a valuable resource to educate
sick and disabled veterans as well as VA healthcare providers on new
and effective treatment regimes. We are hopeful the proposed Rural
Health Research, Education and Clinical Care Centers will strive to
strike the balance we seek when providing better outreach and high
quality VA medical care to veterans residing in rural and remote areas.
To examine alternatives for expanding care for rural veterans,
section 5 of this measure would require the VA to conduct demonstration
projects through the recently created VA Office of Rural Health to
establish partnerships between the VA, Centers for Medicare and
Medicaid Services, and the Department of Health and Human Services to
coordinate care in critical access hospitals and community health
centers. In addition, VA would be required to expand coordination with
Indian Health Service for Native American veterans, and a report to
Congress on these test projects would be due in 2 years.
While these initiatives are laudable, we recommend the VA office of
Rural Health be given ample opportunity to discharge the
responsibilities specified by Congress in Public Law 109-461 which
would include developing, refining, and promulgating policies, best
practices, lessons learned, and innovative and successful programs to
improve care and services for veterans who reside in rural areas of the
United States. In addition, we urge this Subcommittee to provide
oversight and urge the Department of proceed with expeditious
implementation by the Department.
H.R. 2172--The Amputee Veteran Assistance Act
This measure seeks to improve VA's prosthetics programs by
requiring all VA orthotic/prosthetic laboratories and clinics to be
certified by either of the two leading boards in these fields, the
American Board for Certification in Orthotics and Prosthetics or the
Board of Orthotics and Prosthetic Certification, within 5 years of the
enactment of this bill, and allow disabled veterans to obtain new
devices and seek care for the repair and servicing of their existing
prosthetic devices from outside the VA system when VA facilities are
unable to perform the required service or repairs due to a lack of
technology or capability or when a suitable VA facility is not within a
55 mile radius.
The bill would also require a complete review and a report to
Congress by VA of its prosthetic laboratories and clinics to determine
the need to modernize such facilities to ensure that the VA is capable
of servicing and repairing the most technologically advanced prosthetic
devices. Also, VA would be required to complete a review and a report
to Congress on VA prosthesists to determine what kinds of training and
education will be needed to ensure that its prosthesists have the
required knowledge to service and repair the latest prosthetic devices.
The DAV agrees that the Department's prosthetics program should be
able to provide all necessary prosthetic services, devices, and
supplies for the proper treatment of service-connected disabled
veterans. We believe much of the bill's requirements are already being
addressed and implemented by VA. We are concerned however, with the
bill's requirement for VA to enter into one contract with one non-VA
entity to repair and service prosthetic devices in certain
circumstances. In addition to the arbitrary nature of a 55-mile radius
as a requirement to contract for the service and repair of prosthetic
devices, VA currently utilizes numerous service and repair contractors
to allow a more personalized and convenient care to veteran in need of
prosthetic and orthotic devices.
H.R. 2173--To amend title 38, United States Code, to authorize
additional funding for the Department of Veterans Affairs to
increase the capacity for provision of mental health services
through contracts with community mental health centers, and for
other purposes
This measure would allow the VA to provide mental health services
through contracts with community mental health centers, and authorizes
appropriations of $150 million from fiscal years 2008 through 2010 for
such contracts.
First and foremost, DAV's position on contracted or fee-based care
is well known. We believe that VA purchased care is an essential tool
in providing timely access to quality medical care. Current law limits
the indiscriminant use of VA purchased care to specific instances so as
not to endanger VA facilities' ability to maintain a full range of
specialized inpatient services for all enrolled veterans and 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, spinal cord injury or chronic mental
health problems.
Second, as VA's contract workloads have grown significantly at a
cost of about $3 billion each year, it has not been able to monitor
this care, consider its relative costs, analyze patient care outcomes,
or even establish patient satisfaction measures for most contract
providers. This measure does not include provisions to address our
concerns that VA has no systematic process for contracted care services
to ensure that:
care is safely delivered by certified, licensed,
credentialed providers;
continuity of care is sufficiently monitored, and that
patients are properly directed back to the VA health-care system
following private care;
veterans' medical records accurately reflect the care
provided and the associated pharmaceutical, laboratory, radiology and
other key information relevant to the episode(s) of care; and
the care received is consistent with a continuum of VA
care.
Any bill seeking to contract for care outside VA without addressing
these concerns would essentially shift medical resources and veterans
from VA to the private sector to the detriment of the VA healthcare
system and eventually sick and disabled veterans themselves. VA
operates under constant pressure to do more with less and we believe
the expansion of the current form of VA contracted care would benefit
some veterans at the cost of eroding VHA's patient resource base,
undermine the Department's ability to maintain its specialized service
programs, and endanger the well-being of veteran patients under care
within the system.
We are concerned that this bill does not provide any consideration
for judicious use of contract care nor does it address our concerns
regarding the lack of a systematic process for contract care. Such a
measure could place at risk VA's well recognized qualities as a
renowned and comprehensive direct provider of healthcare.
H.R. 2192--To amend title 38, United States Code, to establish an
Ombudsman within the Department of Veterans Affairs
This measure would require VA to assign an Ombudsman to act as a
liaison for veterans and their family members to navigate the VA
healthcare and benefits system. We appreciate the intent of this bill;
however, we believe VA has taken actions to address these issues by
providing assistance and outreach to newly returning veterans through a
cadre of case managers, transition patient advocates, patient
representatives, peer counselors, suicide prevention coordinators, and
other special purpose assistance to guide veterans through the VA
healthcare benefit systems.
VA's actions noted above raise questions concerning the purposes of
the proposed Office of the Ombudsman, given the fact that some of these
positions have only recently been filled or that VA is in the midst of
recruiting or training personnel to fill these positions. We urge the
Subcommittee to provide oversight on the effectiveness of these new
programs before authorizing the additional Office as proposed by this
legislation.
H.R. 2219--Veterans Suicide Prevention Hotline Act of 2007
This measure would require the VA to award a grant to a private,
nonprofit entity to establish and operate a national toll-free suicide
prevention hotline. It would establish a 3-year authority for this
program, at a cost of $7.5 million, to be paid from VA's Medial
Services Appropriation.
There is already in existence a federally funded 24-hour, toll-free
suicide prevention service comprised of over 120 individual crisis
centers across the country. This service is available to all persons in
need or in suicidal crisis. Individuals seeking help can call the
National Suicide Prevention Lifeline (NSPL) at 1-800-273-TALK (8255).
From the toll free number, they will be seamlessly routed to the
certified provider of mental health and suicide prevention services
nearest to the call of origination.
We agree with testimony provided by Mr. Jerry Reed, Executive
Director of Suicide Prevention Action Network USA (SPAN USA), before
the Senate Committee on Veterans' Affairs on May 23, 2007, that we
could build upon what Congress has already funded with the NSPL.
As it was pointed out during that hearing, once a veteran in need
calls the number, an option could be provided for that veteran to be
transferred to a VA call center if the individual wants the services
and support of the VHA. We also agree that the VA should be providing
up-to-date information to non-VA crisis centers on all VA suicide
prevention counselors, hospitals, medical centers, outpatient clinics,
and peer support groups and, where appropriate, this national network
of crisis centers should reliably transfer cases to the VHA call
center. It is our understanding that VHA's mental health program office
is discussing the possibility of joining the existing system rather
than mounting an independent VA suicide prevention service. We concur
with that concept and urge VA to move forward in lieu of Congress
passing this bill.
H.R. 2378--Services to Prevent Veterans Homelessness Act
This bill would direct the VA to provide financial assistance for
supportive services for very low-income veterans' families in permanent
housing. Under the bill VA would provide grants to certain eligible
entities such as private nonprofit organizations or consumer
cooperatives to provide various supportive services.
The DAV supports the intent of the bill to better address homeless
veterans' needs, and to help them move toward independent living.
Furthermore, unlike the companion bill in the Senate, this measure
authorizes appropriation and does not divert resources from VA's
medical care account. However, as well-intentioned as this measure may
be, we are concerned that a grant under which healthcare and counseling
services would be provided by private providers versus VA providers
raises questions about cost, quality, continuity and safety similar to
our views on other proposals with these goals.
H.R. 2623--To amend title 38, United States Code, to prohibit the
collection of copayments for all hospice care funished by the
Department of Veterans Affairs
VA is the only public healthcare system that charges copayments to
hospice patients, and the DAV is greatly concerned particularly as the
number of veteran deaths has been increasing to a current average of
1,800 per day. Congress initially addressed this issue, but only to a
limited extent. section 204 of Public Law 108-422, the Veterans Health
Programs Improvement Act of 2004, exempted veterans who receive hospice
care from the requirement to pay copayments, but only if the hospice
care were being provided at a nursing home.
The DAV recommends the fulfillment of Congress's original intent in
Public Law 108-422 by exempting veterans from paying copayments when
they receive VA hospice care in any authorized setting. We thank
Ranking Member Miller for introducing this measure and Chairman Michaud
for including it in today's hearing, which seeks to prohibit the
collection of copayments for all hospice care furnished by the VA.
Veterans are subject to inpatient copayments if they seek inpatient
hospice care at facilities without nursing home beds, or if the hospice
care must be provided in an acute care setting as a result of clinical
complexity. Moreover, veterans choosing to remain at home for their
hospice care are subject to outpatient primary care copayments. While
the DAV supports H.R. 2623, we recommend that its scope be broadened to
include exempting veterans from copayments for hospice care provided in
any treatment setting by amending section 1710 of Title 38 United
States Code.
Mr. Chairman, again, the members and auxiliary of DAV appreciate
being represented at this hearing today, and I appreciate being asked
to testify on these bills. Mr. Chairman, this concludes my testimony. I
and other members of the DAV Legislative Staff will be pleased to make
ourselves available to you and your staffs for further discussion of
our positions on any of these issues, in hopes of working toward
compromise on measures that we can eventually support. I will be
pleased to respond to any of your or other Committee Members'
questions.
Statement of Carl Blake, National Legislative
Director, Paralyzed Veterans of America
Mr. Chairman and members of the Subcommittee, on behalf of
Paralyzed Veterans of America (PVA), I would like to thank you for the
opportunity to testify today regarding the proposed legislation. We
appreciate the fact that you continue to address the broadest range of
healthcare issues possible to best benefit veterans. We particularly
support any focus placed on meeting the complex needs of the newest
generation of veterans, even as we continue to improve services for
those who have served in the past.
H.R. 1448, THE ``VA HOSPITAL QUALITY REPORT CARD ACT''
Although PVA has no objection to the requirements for a Hospital
Quality Report Card Initiative outlined in this legislation, we remain
concerned that this wealth of information will go unused. Collecting
this information and assessing it without acting on any findings from
that information would serve no real purpose. We would hope that the
congressional committees will use this information published in these
reports each year to affect positive change within the VA. However, we
must emphasize that additional resources should be provided to allow
the VA to properly compile this information as we believe that this
could be a major undertaking.
H.R. 1853, THE ``JOSE MEDINA VETERANS AFFAIRS POLICE TRAINING ACT''
PVA supports H.R. 1853, the ``Jose Medina Veterans Affairs Police
Training Act of 2007.'' H.R. 1853 will compliment the training that is
currently in place for VA police officers. Some of the current
personnel in the VA police force nationwide may have little or no
specific training to work with emotionally distressed veterans. A
majority of VA officers must deal with veterans with various degrees of
emotional problems. In conversations with some of the VA officers at
the VA Headquarters here in Washington, D.C., they have informed us
that they have been told to be ready to deal with the large number of
new veterans returning from the Iraq and Afghanistan war who may have
significant mental health problems.
The current style of conduct as a VA officer is considered
``situational enforcement''. While regular law enforcement officers
take action upon a violation of the law, VA police officers evaluate a
given situation to determine if the situation presents a danger to
veterans, medical staff, other individuals, or the officer. If the
situation is or could become harmful to individuals who are present, or
to government property, the VA officer then takes action.
All new officers receive initial training at the VA police officers
training academy. After that training any future training is at the
discretion of the Chief of Police at each VA location. The Chief will
decide what training is required and how much training each officer
receives. One VA Chief we spoke with told us that his officers receive
training primarily on how to handle veterans age 60 to 70, as that is
the age group of most veterans that they see at the VA medical center.
PVA believes that VA police officers across the system should have
mandatory, standardized, training to help them address the new
challenge of dealing with the newest generation of veterans, along with
the older veteran population. This bill would certainly support this
idea ensuring that specific training to help VA police officers
understand how to best handle the new Iraq and Afghanistan veterans and
how to accommodate them as they come to the VA for services.
H.R. 1925 (New VISN in the Gulf Coast Region)
PVA opposes H.R. 1925, a bill that would establish a new Veterans
Integrated Service Network (VISN) in the Gulf Coast region. This would
encompass counties in Florida, Alabama, and Mississippi. PVA has
serious concerns about the precedent that this legislation would set.
The VA currently uses the VISN structure as a management tool for the
entire VA healthcare system. It makes no sense for the Congress to
legislate how the VA should manage its system. Furthermore, this sets a
dangerous precedent whereby any member could decide that a VISN, or
some similar network structure, should be redrawn in such a way to
support his or her own district.
However, we certainly believe that the current network alignment
could be reassessed and possibly realigned. There is certainly nothing
that suggests that 21 service networks is the optimal structure. But
where does the VA draw the line when establishing its healthcare system
structure? With the current 21 VISN's, the VA seems to do a good job of
managing a massive healthcare system.
H.R. 2005, THE ``RURAL VETERANS HEALTH CARE IMPROVEMENT ACT''
PVA generally supports H.R. 2005, the ``Rural Veterans Health Care
Improvement Act.'' This bill would enhance the implementation of the
rural health requirements of P.L 109-461 enacted last year. However, we
still have some concerns about how best to address the needs of
veterans who live in rural areas. PVA recognizes that there is no easy
solution to meeting the needs of veterans who live in rural areas.
These veterans were not originally the target population of men and
women that the VA expected to treat. However, the VA decision to expand
to an outpatient network through community-based outpatient clinics
reflected the growing demand on the VA system from veterans outside of
typical urban or suburban settings.
PVA fully supports the provisions of this legislation which would
align the mileage reimbursement rate afforded to eligible veterans with
the rate that all federal employees get when they are on travel. It is
wholly unacceptable that veterans have to live with the 11 cents per
mile reimbursement rate that the VA currently provides when all federal
employees receive 48 cents per mile. In fact, PVA believes that some of
the difficulty in providing care to veterans in limited access areas,
specifically rural areas, might be eliminated with a sensible
reimbursement rate. We believe that veterans would be less likely to
complain about access issues as a result of their geographic location
if they know that they will not have to foot the majority of the travel
expense out of their own pocket. This is a change that has been long
overdue, and we urge the Subcommittee and all of Congress to take
immediate action to correct this inequity.
We also support the creation of rural health research, education,
and clinical care centers. These centers would essentially serve as
centers-of-excellence for rural healthcare. This could allow the VA to
address the needs of rural veterans through broad application of the
``hub-and-spoke'' principle. This is the same structure utilized in the
spinal cord injury service. A veteran can get his or her basic care at
a community-based outpatient clinic (spoke). However, if the veteran
requires more intensive care or a special procedure, he or she can then
be referred to the larger rural research, education, and clinical care
center (hub). This would ensure that the veteran continues to get the
best quality care provided directly by the VA, thereby maintaining the
viability of the system. It will also allow the VA to develop
excellence within the actual VA healthcare system, instead of farming
out these services to the private sector. Likewise, PVA supports the
provisions to allow for transportation grants to veterans service
organizations to assist veterans access the VA healthcare system. We
are all familiar with the success of the Disabled American Veterans'
(DAV) van program that provides transportation to medical facilities
for disabled veterans who have appointments. This provision would
further support similar programs and allow other organizations to play
an equally useful role.
PVA has concerns about the demonstration projects that will
establish partnerships between the VA and the Centers for Medicare and
Medicaid Services to seek care in critical access hospitals or at
community health centers. Principally, we believe that this legislation
is ``jumping the gun'' by getting ahead of the Office of Rural Health,
which is responsible for determining if solutions, such as this
proposed demonstration project, are feasible. We think that this new
office in the VA should be given time to do its job before Congress
begins legislating solutions to the problems with rural healthcare for
veterans. This is certainly not to say that Congress should not
pressure the VA to get the office operating expeditiously.
Although we do not necessarily have a problem with the reporting
requirements contained in the legislation, they seem to be redundant.
PVA believes that similar requirements were placed on the VA with the
creation of the Office of Rural Health in legislation enacted during
the 109th Congress. We do not see the need for this requirement if the
new office at VA will be fulfilling this task once it gets up to speed
anyway.
H.R. 2172, THE ``AMPUTEE VETERAN ASSISTANCE ACT''
PVA has serious concerns about the provisions of this proposed
legislation. PVA strongly opposes the provision of Section 2 of H.R.
2172 that would allow the VA to contract for service and repair of
prosthetic devices. We interpret this legislation to mean that the VA
can contract with a single entity to provide these services and
repairs. This is absolutely a bad idea. By using a single entity, the
pool of devices and services available will be severely limited.
A one-size-fits-all approach to prosthetics cannot be applied. As
an example, prosthetics departments that serve PVA members needing
wheelchairs often, if not always, contract with several different
vendors to provide those wheelchairs. Because every PVA member, and
every disabled veteran for that matter, is different, the equipment
they need varies. Although an Invacare power chair may be suitable for
one spinal cord injured veteran, a different spinal cord injured
veteran might be better served by a Jazzy chair. Two uniquely different
veterans cannot be expected to use the same equipment simply because it
might streamline processes for the VA. We believe that giving the VA
the authority outlined in this provision would have a significant
negative impact on the severely disabled veterans who are the highest
users of VA prosthetics services.
PVA has no objection to the provision of the legislation that would
require certification of VA orthotic-prosthetic laboratories with the
American Board for Certification in Orthotics and Prosthetics or the
Board of Orthotics and Prosthetic Certification. However, we believe
that the VA already meets these requirements, but if this provision
will reinforce this action, then we have no problem with it.
H.R. 2173 (Mental Health Services)
PVA opposes H.R. 2173 which would authorize VA to contract with
community mental health centers to meet the needs of veterans dealing
with mental illnesses. As we testified earlier this year, we oppose any
effort to allow the VA to contract out care when it can do a better and
more cost effective job in its own system. Furthermore, by allowing the
VA to send these veterans out of the system to receive their care, it
effectively relieves itself of the obligation it has to these men and
women. The VA must be appropriated adequate funding (steps that are
finally beginning to take place) and it must be provided in a timely
manner if it is going to have any chance of meeting these veterans
needs.
Moreover, Congress must continue to conduct aggressive oversight to
ensure that funding specifically allocated for mental health
initiatives is properly spent. As explained in the Government
Accountability Office (GAO) report of November 2006, the VA did not
allocate all of the funding it planned to commit in FY 2005 for new
mental health initiatives, nor did it spend all of the funds planned
for FY 2006. VA must be held accountable to ensure that it lives up to
the goals established in its National Mental Health Strategic Plan.
Until such time as the VA meets these goals, the burden for mental
healthcare should not be shifted to the community.
H.R. 2192 (VA Ombudsman)
PVA supports H.R. 2192, a bill that would establish an Office of
the Ombudsman in the VA. We believe that this office could certainly
improve the transition of service members and their families from the
Department of Defense to the VA. The office can be an important
information tool for the VA. We do find it unfortunate, however, that
such an office would be necessary as the VA as whole should be
responsible for fulfilling this role through outreach.
H.R. 2219, THE ``VETERANS SUICIDE PREVENTION HOTLINE ACT''
The incidence of suicide among veterans, particularly Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, is a
serious concern that needs to be addressed. PVA principally supports
this legislation. Any measure that will reduce the incidence of suicide
among veterans is certainly a good thing.
However, we must emphasize a couple of important points. First and
foremost, there need to be absolute standards established that ensure
that the individuals staffing this hotline are adequately trained to
handle the complex issues associated with individuals contemplating
suicide. We certainly support the idea that this service should be
staffed by veterans, but they must have the proper training to deal
with these cases. Simply having the shared experience of military
service is not enough. This legislation seems to address this concern,
but the VA cannot be let off the hook for ensuring that this is handled
properly.
Secondly, clear steps for referral into VA mental health clinics
and other VA facilities with related services must be outlined. The
private entities responsible for the operation of the suicide
prevention hotline must understand how to refer veterans dealing with
these problems into programs that will provide the services they need.
These services are essential to helping the veteran overcome the
suicidal feelings he or she may be dealing with.
H.R. 2378, THE ``SERVICES TO PREVENT VETERANS HOMELESSNESS ACT''
PVA has no objection to the provisions contained in the proposed
legislation. Clearly, the most important factor in combating the
problem of homelessness among veterans is preventing homelessness in
the first place. This legislation would seem to accomplish that task by
offering financial assistance to organizations or entities that provide
permanent housing and support services to very low income veteran
families. In the mean time, we believe that additional resources should
be invested in programs that actually target veterans and their
families who are experiencing homelessness as well. With more than
200,000 veterans on the street on any given night, it is time to make
real, meaningful efforts to end this problem.
H.R. 2623
PVA fully supports H.R. 2623, a bill which would prohibit the VA
from collecting copayments from veterans receiving hospice care whether
in an inpatient or outpatient setting. As we recall, the VA actually
supported similar legislation during the 109th Congress. This
legislation only makes sense as it will align with current statute that
prevents VA from collecting copayments from veterans receiving hospice
care in a nursing home setting.
We look forward to working with the Subcommittee to develop
workable solutions that will allow veterans to get the best quality
care available. I would like to thank you again for allowing us to
testify on these important measures. I would be happy to answer any
questions that you might have.
Statement of Dennis M. Cullinan, Director,
National Legislative Service, Veterans of Foreign Wars of the United
States
MR. CHAIRMAN AND MEMBERS OF THIS COMMITTEE:
On behalf of the 2.4 million men and women of the Veterans of
Foreign Wars of the U.S. (VFW) and our Auxiliaries, I would like to
thank you for the opportunity to testify before you today on a wide
range of important veterans healthcare bills.
H.R. 1488, the VA Hospital Quality Report Card Act
The VFW is pleased to support the VA Hospital Quality Report Card
Act, legislation that would require VA to develop and implement a
system to measure data about its healthcare facilities.
This data would be of great service. It would allow veterans to
compare the quality of service VA provides, letting them make informed
judgments about their healthcare. It would allow VA to identify areas
of improvement, and it would provide essential data for Congress to
better use its essential oversight authority.
H.R. 1853, the Jose Medina Veterans Affairs Police Training Act
The VFW supports this legislation which would require VA police
officers to undergo training on how to deal with patients and visitors
who are suffering from mental illnesses.
Given the large numbers of returning veterans who are suffering
from mental illnesses of various degrees, extra training for VA
employees on how to deal with these patients is entirely appropriate.
This is especially true for those patients who are vulnerable and
suffering the most. The extra training will ensure that wounded
warriors are treated with dignity and respect.
H.R. 1925
The VFW has no objection to H.R. 1925, legislation that would
establish a new Veterans Integrated Service Network (VISN) in the Gulf
Coast Region. The regions in this area share many similar geographic
things in common and, perhaps, aligning them all in one vision will
allow them to better serve the veterans' population.
H.R. 2005, Rural Veterans Health Care Improvement Act
The VFW is pleased to support the Rural Veterans Health Care
Improvement Act, legislation that aims to solve one of the greatest
problems facing the large number of veterans who live in remote
locations: access to care. It aims to improve services including
transportation for disabled vets, research and partnerships with small
communities.
It would require VA to create centers of excellence for rural
healthcare veterans and to establish a grant program for groups that
help transport veterans from rural areas. It also includes a provision
that would create demonstration projects for potential partnerships
with local hospitals and community health centers, as well as for
Native American veterans.
We are strongly supportive of section 2, which would increase the
mileage reimbursement rate veterans receive for their travel expenses
related to VA healthcare to the rate provided to all federal employees.
The current deductible for travel expenses is so limiting that most
veterans receive little, if any, compensation for their travels. With
so many veterans facing drives of hundreds of miles for even basic
care, this is clearly the right thing to do.
H.R. 2172, Amputee Veteran Assistance Act
The VFW is supportive of H.R. 2172, a bill to require that all
Department of Veterans Affairs orthotic-prosthetic laboratories,
clinics, and prosthesists are certified by either the American Board
for Certification in Orthotics and Prosthetics or the Board of
Orthotics and Prosthetic Certification. However, the VFW is not sure if
changing the rules of VA's prosthetic program is needed, and we have
concerns that the certification requirements that would affect all
service and repair programs for prosthetics and orthotics is necessary.
VA continues to be on the forefront of advancement in this most
important area, allowing hundreds of our wounded warriors the ability
to regain their mobility or to become whole.
We are also concerned that some efforts to create a certification
process could lead toward a standardization process that aims for one-
size-fits-all solutions, instead of a personalized approach necessary
to deal with each veteran's particular disability. Medical decisions
must be made on the individualized needs of a veteran and what works
best.
H.R. 2173
We support the intent of this legislation, which would allow the VA
secretary to enter into contracts for service with community mental
healthcare centers, but we do have some concerns.
With the number of returning service members who are suffering from
mental health conditions, it is clear that VA can and must do more. VA
has made great strides from where they were a few years ago in
providing care, but the system is far from perfect. This legislation
aims to fill in the gaps, by allowing VA to utilize local resources,
presumably in places where there are gaps in the availability of care--
whether through a high demand or a dearth of providers.
We remain concerned, however, with an over-reliance on contract
care. Especially in the mental health area contract care could lead to
some extensive continuity of care problems. Among other things, VA
would have to determine some way to ensure that no veteran falls
through the cracks when going from the department to a local provider.
Further, it would be absolutely critical that patient records be
transferable among all providers so that all information is provided to
all involved healthcare givers. We have concerns, given VA's state-of-
the-art medical records, that this is feasible in dealing with the
private sector.
We need to do more for these wounded warriors, but we need to make
sure that what we're doing really is in their best interest.
H.R. 2219, Veterans Suicide Prevention Hotline Act
The VFW supports this legislation which would establish a grant
program to an organization to staff and run a suicide prevention
hotline targeted and staffed by veterans and armed forces personnel.
We understand that VA is in the process of establishing a similar
hotline, so it may be necessary to determine how much overlap is
between the programs. It is clear, however, that the program would be
beneficial.
This is a critical issue, especially with the difficulties so many
of our men and women who have worn the uniform are facing. Anything we
can do to extend a helping hand, especially when they are suffering and
in a time of such need, is essential.
H.R. 2623
The VFW offers our support for this legislation, which would exempt
patients seeking hospice care from paying copayments. This is a
compassionate idea that relieves a burden on the veteran and their
loved ones at a critical time.
This concludes my testimony and I will be happy to respond to any
questions you may have.
Statement of Barry Hagge, National Secretary,
Vietnam Veterans of America
Good morning, Chairman Michaud, Ranking Member Miller, and members
of this Subcommittee. Thank you for giving Vietnam Veterans of America
(VVA) the opportunity to offer our comments on several veterans'
health-related bills up for discussion here today.
All of these bills, with the possible exception of H.R. 1853, are
extremely important. With a few reservations, they are worthy of your
consideration and our support.
The topic of accessibility to VA medical services for veterans who
live in rural areas has been percolating of late. We believe that H.R.
2005, the ``Rural Veterans Health Care Improvement Act of 2007,''
offers pragmatic solutions to address the problems of access to
healthcare experienced by too many rural veterans. The bill would
increase travel reimbursement for veterans who travel to VHA facilities
to the rates paid to federal employees. The current reimbursement rate
was established decades ago and does not adequately compensate for the
costs of gasoline, ``wear and tear'' on the vehicle or increased
insurance that might be necessary in order to travel to distant medical
centers. In the same vein, the grant program for rural veterans'
service organizations to develop transportation programs could be an
innovative way to strengthen community resources that may already
assist with veterans' travel needs.
The establishment of centers of excellence for rural health
research, education, and clinical activities, another component of this
bill, should fill a gap in VA healthcare and should lead to innovation
in long-distance medical and telehealthcare. These centers have brought
the synergies of clinical, educational and research experts to bear in
one site. Such centers have allowed VA to make significant
contributions to the fields of geriatric medicine and mental illness.
It would require demonstrations of rural treatment models.
Demonstrations on treating rural veteran populations would be extremely
useful in assessing effective ways to offer healthcare to individuals
who are generally poorer, more likely to be chronically ill, and
almost, by definition, more likely to have challenges in access to
regular healthcare.
And establishing partnerships--with the Indian Health Service and
with the Department of Health and Human Services--also should add to
greater cooperation and collaboration in meeting the needs of rural
veterans.
We would caution, however, that we would not like to see these
demonstration projects exploring more opportunities to do widespread
contracting out of veterans' healthcare services. Demonstration models
should be assessed according to a number of outcomes such as quality of
care, cost, and patient satisfaction and the results reported to
Congress.
H.R. 1448, the ``VA Hospital Quality Report Card Act of 2007,'' is
a quality control measure that would help with accountability and
issues regarding follow-up care and timely visits. It would require the
VA to provide grades for its medical centers on measures such as
effectiveness, safety, timeliness, efficiency, patient-
``centeredness,'' and equity. Health-care quality researchers have long
thrived trying to objectively define some of these measures.
As members of this Subcommittee are aware, the VA has a number of
performance measures it regularly assesses in order to reward its
medical center and network directors, among others. Some of these
outcomes, such as immunizations for flu, foot care and eye care for
diabetics, set the ``benchmark'' for care in the community. In addition
to these internal performance measures, VHA voluntarily submits to
Joint Commission on Accreditation of Healthcare Organization,
Commission on Accreditation of Rehabilitation Facilities, and managed
care quality review standards.
VVA understands the importance of quality measurement; there is an
expression with which we agree: ``What's measured, matters.'' We also
agree that VA officials should be held to the highest degree of
accountability, and whatever measures are available to allow this to
better occur we wholeheartedly endorse. However, before enacting this
clearly well-intended legislation, which could require significant
retooling of quality measurement systems in the VA, the Committee
should hold a hearing to identify gaps and deficiencies in current
performance and quality measurement systems. It would also be useful to
understand how report cards would be used and reported to improve VHA
processes and performance rewards. Would poor grades be dealt with by
changes in management? By withholding bonuses to senior executives?
With more funding? How would good grades be rewarded? Such questions
should be addressed before requiring a significant new quality
measurement program to be installed.
H.R. 1853, the ``Jose Medina Veterans Affairs Police Training
Act,'' would require VA police to receive training in interacting with
patients and visitors with severe mental illness. Most VA police are in
daily contact with veterans with mental illness, often dealing with
stressful situations that are liable to exacerbate symptoms.
Sensitivity training in confronting any individuals in crisis could
potentially assist officers in peacefully de-escalating or defusing
volatile situations, thus avoiding the use of force.
VVA does not have a position on H.R. 1925, which would establish a
Gulf Coast Veterans Integrated Service Network.
H.R. 2172, the ``Amputee Veterans Assistance Act,'' would require
that all VA orthotic-prosthetic laboratories, clinics, and prosthesists
are certified by either the American Board for Certification in
Orthotics and Prosthetics or the Board of Orthotics and Prosthetic
Certification. We endorse this bill because, very simply, as more and
more catastrophically wounded veterans are returning home minus arms
and legs, it is incumbent on us to ensure that they are receiving
quality prosthetics and orthotics.
The VA already has the authority to contract with community mental
health providers; however, under the strain of thousands of returning
troops in need of mental health services, the VA is struggling to
implement provisions of its mental health strategic plan, including
providing ``round-the-clock'' access to care. The funding authorized in
H.R. 2173 for the provision of mental healthcare from community
providers--$50 million--would greatly assist the VA in filling the
programmatic gaps it recognized in both its strategic plan and in its
budget submission for FY 2008.
Community mental health providers should be selected based on
quality of care indicators such as compliance with standards for either
the facility or its clinical personnel (what credentials/training are
required for the clinical personnel?) Standards for community providers
should be no less rigorous than those required for similar VA
facilities. And the VA must provide vigorous oversight of the care
these community facilities provide veterans.
We should also note that mental health providers across the country
are eager to assist returning veterans in dealing with their demons.
Passage of 2173 should help give them the opportunity.
VVA endorses H.R. 2192, which would establish an Office of the
Ombudsman within the Department of Veterans Affairs. Although most of
the duties of an ombudsman are the responsibility of program managers
and assistant secretaries, veterans and their families who are
sometimes frustrated by bureaucratic runarounds or non-answers often
encountered at VA medical centers or regional offices will have a
champion--if H.R. 2192 is enacted and sufficiently funded.
VVA very much supports H.R. 2219, the ``Veterans Suicide Prevention
Hotline Act of 2007,'' which would authorize and fund the establishment
of a national toll-free suicide prevention hotline. As many of those in
this room are aware, up to one-third of the thousands of veterans of
the fighting in Iraq and Afghanistan have screened positive for mental
illness. As more of these veterans return home from ongoing deployments
in Southwest Asia, the acute symptoms of these illnesses, including
post-traumatic stress disorder, depression and anxiety, are likely to
manifest resulting in more preventable losses of life.
In a report published last month (May 10, 2007), the VA's Office of
Inspector General recommended that VA provide such a hotline (VA OIG
Report No. 06-03706-126). The VA's response indicated that the Veterans
Health Administration's Office of Mental Health Services was developing
a hotline that would be rolled out November 30, 2007 and fully
implemented by January 30, 2008. Enacting this legislation will better
ensure that the VA meets these goals.
The provision should assure that contracted services for the
hotline call for a minimum percent of vets hired--including veterans
who have recently returned from deployments abroad--over and above the
3% required for government contracts.
VVA supports, too, H.R. 2378, the ``Services to Prevent Veterans
Homelessness Act.'' If veterans at risk of becoming homeless can be
identified and assisted before they are turned out of their apartment,
if they can be given the modest assistance they need to maintain their
independence, if they have access to the supportive services they need
to maintain their dignity, it is entirely possible that hundreds will
be saved from having to live with no permanent address, and no roof
over their head.
That some 200,000 military veterans, including growing numbers of
men and women who served in Iraq and on the ``Global War of Terror''
are homeless is a national scandal. It should shock you into action.
And indeed, Congress has responded, but often with too little in the
way of resources that can make a real difference.
VVA supports the provisions in H.R. 2623 that would prohibit the
collection of copayments for all hospice care furnished by the VA.
Hospice care is a service that allows individuals with terminal illness
to reject extraordinary measures for prolonging life and, instead,
accept ``comfort care.'' The last year of life is known to be far more
expensive than those that precede it. It is unfortunate, then, to
penalize veterans and their families by charging co-payments for
hospice care when those same veterans might have elected to receive,
free-of-charge, acute, in-patient care that was far more expensive and
ultimately fruitless. The VA should be encouraging its patients to
prepare living wills and advanced directives that specify their choices
for end-of-life care and educate veterans with terminal illness about
hospice. Relieving veterans of copayments for hospice care seems one
means to better ensure that they are able to choose hospice for their
end-of-life care.
Members of this Subcommittee, VVA welcomes your comments and your
questions.
Statement of the Honorable Michael Kussman, M.D., MS, MACP,
Under Secretary for Health, Veterans Health Administration,
U.S. Department of Veterans Affairs
Good Morning Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me here today to present the
Administration's views on nine bills that would affect Department of
Veterans Affairs (VA) programs that provide veteran healthcare benefits
and services. With me today is Walter A. Hall, Assistant General
Counsel. Mr. Chairman, with the exception of section 2 of H.R. 2005, VA
has not had sufficient time to prepare cost estimates for the bills on
today's agenda. As soon as these become available, we will supply them
for the record. In addition, with the short time available to prepare
for this hearing, we were not able to provide views on all of the bills
reflected on the agenda. We can provide those views for the record.
H.R. 1448--VA Hospital Quality Report Card Act of 2007
Mr. Chairman, I will begin by addressing H.R. 1448. This bill would
require VA to establish a Hospital Quality Report Card Initiative
(``Initiative'') to, among other things, help inform patients and
consumers about the quality of care in VA hospitals. Under the
Initiative, the Secretary would be required to publish, at least bi-
annually, reports on the quality of VA's hospitals that include
quality-measures data that allow for an assessment of healthcare
effectiveness, safety, timeliness, efficiency, patient-centeredness;
and equity.
In collecting and reporting this data, the Secretary would have to
include very extensive and detailed information (i.e., staffing levels
of nurses and other healthcare professionals; rates of nosocomial
infections; volume of various procedures performed, hospital sanctions
and other violations; quality of care for specified patient
populations; the availability of emergency rooms, intensive care units,
maternity care, and specialty services; the quality of care in various
hospital settings, including inpatient, outpatient, emergency,
maternity, and intensive care unit settings; ongoing patient safety
initiatives; and, other measures determined appropriate by the
Secretary). VA would be allowed to make statistical adjustments to the
data to account for differences relating to characteristics of the
reporting hospital (e.g., size, geography, and teaching status) and
patient characteristics (e.g., health status, severity of illness, and
socioeconomic status). In the event VA makes such adjustments, there
would be a concomitant obligation to establish procedures for making
that data available to the public.
The bill would require the Secretary to disclose the entire
methodology (for the reporting of the data) to all organizations and VA
hospitals that are the subject of any information prior to making such
information available to the public. Each report submitted under the
Initiative would have to be available in electronic format, presented
in an understandable manner to specified populations, and presented in
a manner that allows for a comparison of VA's hospital quality with
local hospitals or regional hospitals. The Department would also need
to establish procedures to make these reports available to the public,
upon request, in a non-electronic format (such as through a toll-free
telephone number).
In addition, H.R. 1448 would require the Secretary to identify and
acknowledge the analytic methodologies and limitations on the data
sources used to develop and disseminate the comparative data and to
identify the appropriate and inappropriate uses of such data. The bill
would further mandate the Secretary, on at least an annual basis,
compare quality measures data submitted by each VA hospital with data
submitted in the prior year or years by the same hospital to identify
and report actions that would lead to false or artificial improvements
in the hospital's quality measurements.
This measure would further require the Secretary to develop and
implement effective safeguards to: protect against the unauthorized use
or disclosure of VA hospital data reported under this measure; protect
against the dissemination of inconsistent, incomplete, invalid,
inaccurate, or subjective VA hospital data; and ensure that
identifiable patient data is not released to the public. In addition,
the Secretary would need to evaluate and periodically report to
Congress on the effectiveness of this initiative and its effectiveness
in meeting the purposes of this Act. And such reports would have to be
made available to the public. Finally, this legislation would direct
the Secretary to use the results of the evaluations to increase the
usefulness of this initiative.
H.R. 1448 would authorize to be appropriated to carry out this
section such sums as may be necessary for each of Fiscal Years (FY)
2008 through 2017. The effective date for this bill and its
requirements would be 18 months after the date of the bill's enactment.
Mr. Chairman, VA supports the intent of this bill but opposes the
bill as written. H.R. 1448 is too prescriptive in its requirements, and
much of the information that would be required by H.R. 1448 is already
available through other avenues, such as The Joint Commission's
(previously known as the Joint Commission on Accreditation for
Healthcare Organizations) website that provides standardized
comparative data in a form that has been tested for consumer
understandability and usefulness. Moreover, VA is in the process of
compliance with Executive Order 13410, which requires transparency of
quality measures in Federal healthcare programs. We would welcome the
opportunity to meet with the Committee members to help them understand
what is available already, how the members might better access the
information, and how we can help veterans and the public better access
that information.
H.R. 1853--Jose Medina Veterans Affairs Police Training Act of 2007
H.R. 1853 would require the Secretary to ensure, not later than 8
months after the date of enactment, all VA police officers receive
training on how to interact with visitors and patients at VA medical
facilities who have, or who exhibit symptoms of, mental illness. The
purpose for this mandate is the bill's express finding that there has
been, and will continue to be, an increase in the incidence of post-
traumatic stress disorder (PTSD) among veterans who served in past and
present combat theaters and thus in their concomitant need for VA
mental health treatment and services.
We do not support H.R. 1853 because it is unnecessary. By statute,
the Secretary is already required to provide VA Police Officers with
training that emphasizes effective management of situations involving
patients. To carry out that mandate, VA provides specialized training
to VA Police Officers in dealing with disruptive and other unusual
behaviors. VA officers also must successfully complete an 80 hour basic
entry level training course at their medical centers as well as a 200
hour residential basic police officer training course at the VA Law
Enforcement Training Center. Included in the residential course is a
17.5 hour block of training in Behavioral Science that includes such
topics as introduction to mental illness, communications/conflict
management, verbal judo, crisis intervention/conflict resolution and
the dynamics of the suicidal individual. Much of this training is
taught by VA psychologists. Moreover, VA officers must also complete a
biannual refresher training program.
H.R. 1925--VISN for Gulf Coast Region
H.R. 1925 would require the Secretary to establish, not later than
1 year after enactment, a separate ``Veterans Integrated Services
Network (``VISN'') for the Gulf Coast region of the United States. This
new VISN would be comprised of specified counties located in Florida,
Alabama, and Mississippi.
VA does not support H.R. 1925. We find no justification for
establishing a separate VISN for a service area that does not have the
workload needed to make that organizational change cost-effective or to
require that level of management. The current facilities and referral
patterns in this area provide the best access for the veterans. VISNs
were originally created around referral patterns and geographic
boundaries. In addition, VISNs work together along their borders to
ensure access to healthcare for veterans in those areas. The Gulf Coast
region is one area where VISNs seven, eight and 16 have worked very
well together in managing care for veterans in the area. Therefore, VA
sees no reason to add an additional Network for this region.
H.R. 2005--Rural Veterans Health Care Improvement Act of 2007
H.R. 2005 is intended to improve VA's ability to meet the
healthcare needs of rural veterans. section 2 of this bill would amend
VA's beneficiary travel program by requiring VA to pay or reimburse
eligible veterans at the same per diem rates and mileage rates that
apply to Federal employees using privately owned vehicles for official
travel.
Section 3 would require the Secretary, through the Director of the
Office of Rural Health, to establish up to five Rural Health Research,
Education, and Clinical Centers of Excellence (``Centers''). The bill
sets forth detailed requirements that would govern the Secretary's
designation and placement of such Centers. It also would limit
designation of Centers to those facilities found by a peer review panel
to meet the highest competitive standards of scientific and clinical
merit and also found by the Secretary to have met the requirements
specified in the legislation.
Section 4 would require the Secretary to establish a grant program
for State Veterans' Service Agencies and Veterans' Service
Organizations for purposes of providing veterans living in remote rural
areas with innovative means of travel to VA medical centers (and to
assist them with their other medical care needs). A grant awarded under
this section could not exceed $50,000. Grant recipients would not be
required to provide matching funds as a condition for receiving a
grant. This section would require the Secretary to prescribe
regulations to implement this program and also authorize to be
appropriated $3 million for each of FYs 2008 through 2012 to carry out
this program.
Section 5 would require the Secretary, through the Director of the
Office of Rural Health, to carry out demonstration projects to examine
alternatives for expanding care to veterans in rural areas. In so
doing, the Secretary would be required to establish partnerships with
the Department of Health and Human Services (HHS) to coordinate care
for veterans in rural areas at both critical access hospitals and
community health centers. VA would also be obliged to coordinate with
HHS' Indian Health Service to expand care for Native American veterans.
The bill would institute annual reporting requirements, the first
of which would have to include the results of the statutorily mandated
assessment of VA's fee-basis program on the delivery of care to
veterans residing in rural areas, along with the results of VA's
extensive outreach program to OEF/OIF veterans living in rural
veterans.
Mr. Chairman, while we appreciate the impetus for H.R. 2005, we do
not support the bill. In accordance with Congress' mandate in the
``Veterans Benefits, Health Care, and Information Technology Act of
2006,'' VA recently established the Office of Rural Health (ORH) within
the Veterans Health Administration. Part of that office's charge is to
determine how we can best continue to expand access to care for rural
veterans. Presently, ORH is developing a strategic plan for operations
and is considering a proposal to create new research centers. We would
request the Congress wait until these assessments are complete before
requiring action in this area. We will keep the Committee abreast of
ORH's activities and findings as available.
VA is working closely with other organizations in a variety of
areas, including outreach, clinical care, education, expanded services,
care coordination, and telemedicine, to improve the quality of
healthcare available to those living in rural areas. The Department of
Health and Human Services (HHS) and the Department of Veterans Affairs
(VA) signed a Memorandum of Understanding (MOU) in February 2003 to
encourage cooperation and resource sharing between the Indian Health
Service (IHS) and the Veterans Health Administration (VHA) to deliver
quality healthcare services and enhance the health status of American
Indian and Alaska Native (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.
Therefore, a Congressional mandate to encourage cooperation with HHS
and IHS is not necessary.
Moreover, while we acknowledge there has been a significant
increase in fuel prices, beneficiary travel payments are paid out of
funds appropriated for healthcare treatment and services. In our view,
VA should use medical care funds for furnishing direct patient care in
the manner that best serves the most veterans. It is also important to
note that increasing the beneficiary travel payment and reimbursement
rates would benefit only the limited categories of veterans who are
eligible for those benefits e.g., veterans whose travel is in
connection with treatment for a service-connected disability. For that
reason, the amendments to the beneficiary travel program that are set
forth in H.R. 2005 may not advance the Congress' general objective of
improving access to care for rural veterans.
We further note that the travel benefits program for Federal
employees is distinct and on the whole inapposite to VA's beneficiary
travel benefits program. It is unclear, based upon the text of the
bill, if the limitations and conditions on Federal employee eligibility
for travel pay would be applied to veterans. Federal employees do not
automatically qualify for reimbursement of expenses they incur while on
official travel. They must meet certain criteria to be eligible for
such reimbursement, particularly in connection with the use of a
privately owned vehicle. The criteria and conditions for reimbursement
that apply to Federal employees (e.g., travel order) would not be
appropriate to patients traveling to VA facilities for care and
treatment, and transposing such a system would prove to be very complex
and difficult to manage. VA estimates the cost of section 2 of H.R.
2005 to be $253 million for FY 2008 and $7 billion over a 10-year
period.
H.R. 2172--Amputee Veteran Assistance Act
Mr. Chairman, the next bill on today's agenda is H.R. 2172. This
bill would require the Secretary to ensure, not later than 5 years
after enactment, that all VA orthotic-prosthetic laboratories and
clinics are certified by either the American Board for Certification in
Orthotics and Prosthetics or the Board of Orthotics and Prosthetic
Certification.
This bill would also require the Secretary to seek to enter into a
contract with a non-VA entity for the service and repair of a
prosthetic device for a veteran in the following situations:
If the Secretary determines that VA facilities are unable
to perform the necessary service or repair due to a lack of technology
or for any other reason that the Secretary determines prevents such
service or repair in a timely manner; or
The veteran in need of such service or repair resides at
a distance greater than 55 miles from the nearest suitable VA facility
capable of furnishing the service or repair.
The bill would further require the Secretary to develop and carry
out a plan to inform disabled veterans at least twice a year of the
technological advances made in the field of prosthetics. The above-
discussed contracting and information related requirements would both
have to be implemented not later than 6 months after the date of the
bill's enactment.
Additionally, H.R. 2172 would require the Secretary to conduct and
complete a review of all VA orthotic-prosthetic laboratories and
clinics to ensure that the Department is capable of serving and
repairing the most technologically advanced prosthetic devices. Such
review would need to be conducted and completed not later than one year
after the bill's enactment. No later than 6 months after completion of
that review, the Secretary would need to submit a report to Congress on
the Secretary's findings and any recommendations to address
deficiencies in capability that were identified during the mandated
review.
Finally, no later than 1 year after the bill's enactment, this bill
would require the Secretary to conduct and complete a review of VA's
prosthetists and orthotists to determine what level and kinds of
training and education will be needed to ensure they are qualified to
service and repair the most technologically advanced prosthetic
devices. No later than 6 months after that review is completed, the
Secretary would be required to submit a report to Congress on the
Department's findings and any recommendations to address identified
deficiencies in education, training, or qualification.
VA does not support H.R. 2172 because it is unnecessary. VA's
policies already meet or exceed the requirements in the bill. In 2003
VA mandated all prosthetic and orthotic laboratories be accredited by
the American Board for Certification in Orthotics and Prosthetics or
the Board of Orthotics and Prosthetic Certification. Today, all 58 of
our laboratories are accredited and we require all contractors be
accredited by these organizations as well. As a prerequisite of
attaining accreditation, each facility had to employ at least one
certified Prosthetist/Orthotist to oversee all work. Today, 131 out of
our 186 prosthetists/orthotists are certified and we are actively
encouraging all staff to attain this certification. Both ABC and BOC
require all certified practitioners maintain certification through 5-
year cycles of continuing education units, including education in new
and emerging technology. VA will continue to conduct site visits to all
prosthetic and orthotic laboratories to ensure they meet quality
standards and maintain their accreditation.
VA uses over 600 non-department entities for fabrication, service
and repair of prosthetic devices. Veterans will continue to have their
choice of contracted providers, including the VA. VA is informing
veterans of new developments with Open Forums, routine newsletters and
press releases, and a dedicated web link devoted to the care and
treatment of amputees.
As a technical matter we point out that H.R. 2172 would amend
chapter 31 of title 38, United States Code, which governs vocational
rehabilitation benefits administered by the Veterans Benefits
Administration, not chapter 17 of the same title, which governs the
provision of healthcare benefits, including prosthetic care and
services.
H.R. 2173--Authorization for Vet Centers to contract for Mental Health
Services
will now discuss H.R. 2173. This bill would amend VA's readjustment
counseling authority in 38 U.S.C. Sec. 1712A to permit the Secretary to
enter into contracts with community mental health centers (deemed
qualified by the Secretary) for the provision of mental health services
as part of VA's readjustment counseling program.
VA does not support H.R. 2173. Currently, VA's authority to provide
mental health services to veterans receiving readjustment counseling
services under section 1712A of title 38, United States Code, is
limited to mental health services that are necessary to facilitate the
successful readjustment of a veteran to civilian life and limited to
the provision of counseling, training and mental health services
described in 38 U.S.C. Sec. Sec. 1782 and 1783 (bereavement counseling)
for the veteran's immediate family members. It is not clear if the
bill, in creating a new subsection wholly unrelated to the existing
provisions governing VA's contracting authority under section 1712A,
means to encompass mental health services beyond those currently
authorized and those which have traditionally been provided under VA's
readjustment counseling mission (in contrast to VA's clinical mission).
As already alluded to, Vet Centers currently have authority to
contract with private sector community mental health agencies for the
provision of readjustment counseling services and related mental health
services. For more complex mental health needs, Vet Centers readily
refer patients to VA medical facilities. Furthermore, H.R. 2173 would
obfuscate and blur the special service mission of the Vet Centers as
defined by law. These services are deliberatively set apart from
medical facilities to promote more than medical readjustment services
for combat veterans in an easy to access, community-based setting.
H.R. 2192--Establishement of Office of Ombudsman within the Department
H.R. 2192 would establish an Office of the Ombudsman (herein
referred to as the ``Office'') within the Department and require the
Secretary to designate an Ombudsman to carry out the duties of the
Office. The Ombudsman would act as a liaison for veterans and their
family members with respect to the receipt of healthcare and benefits
administered by VA.
This measure would also require the Secretary to ensure the
services of the Office are available to all veterans and their family
members and would further direct the Secretary to make available to
each veteran, and to the family members of all veterans, information on
contacting and using the services of the Office. Lastly, H.R. 2192
would authorize the disclosure of information provided by veterans or
their family members only to the extent necessary to carry out the
duties of the Office.
VA does not support H.R. 2192. Of particular concern is the
provision that would authorize the Ombudsman to act as a liaison for
veterans and their family members with respect to the receipt of
healthcare. VHA has instituted a variety of measures to support our
patients and their families, including appointing patient advocates in
our Medical Centers, benefits counselors, OEF/OIF Coordinators, and
Transition Patient Advocates for those seriously injured in combat. Vet
Center counselors also contribute to resolving situations on behalf of
veterans. VSO representatives, likewise, serve ably as counselors and
mentors and many State Departments of Veterans Affairs contribute in
this area. VBA has also has extensive initiatives and programs aimed at
assisting claimants with respect to receipt of benefits, including the
Transition Assistance Program (TAP), the Benefits Delivery at Discharge
(BDD) Program, and expanded outreach to veterans, dependents, and
survivors. Adding another layer of oversight and involvement could
create a confusing situation for patients and families, who might
become unsure whom to consult. A new Office of the Ombudsman could also
produce confusion within VA in terms of assignments and
responsibilities, since the bill, as written, does not delineate
between the role the new Office would fill vis-a-vis other offices
within VA.
H.R. 2219--Veterans Suicide Prevention otline Act of 2007
Mr. Chairman, H.R. 2219 would require the Secretary to award one
grant for a period of not more than 3 years to an eligible entity to
establish, publicize, and operate a national toll-free telephone number
to serve as a suicide prevention hotline targeted to, and staffed
predominately by, veterans of the Armed Forces.
Under H.R. 2219, the grantee would be required to perform the
following functions:
enter into a contract with a telecommunication carrier
for the use of such a national toll-free number;
select; train; and supervise personnel to answer incoming
calls and to provide counseling and referral services to callers;
ensure that sufficient staffing is provided so that the
hotline services are available to callers at all times;
assemble and maintain a current database of information
to be used to refer callers to local service providers and of
information about the availability of shelters for homeless callers;
publicize the hotline to potential callers; and
certify the capacity of, and provide supplemental
training for, any local crisis center operating as a subcontractor of
the grantee.
H.R. 2219 would further provide that to be eligible to receive the
grant under this section, a private, nonprofit entity would have to
prepare and submit a detailed application to the Secretary addressing a
number of specified areas. The selected grant recipient would, in turn,
be required to submit an annual report to the Secretary, in the form
and with such information as the Secretary may require. The grantee
would have to include in that report the volume of calls to the
hotline, the demand for specific types of referrals, and the number of
trained volunteers answering the hotline. Finally, payments awarded to
the grantee would be subject to annual approval by the Secretary and to
the availability of appropriations for each FY.
For purposes of the grant award, H.R. 2219 would authorize to be
appropriated $2,500,000 each year for FYs 2008, 2009, and 2010.
VA does not support H.R. 2219. VA is already developing a
comprehensive program for suicide prevention including a national 24
hour toll-free hotline. The services under development in VA are more
comprehensive that those proposed in H.R. 2219. VA is proposing to
administer the services with VA mental health professional staff, not
outside contractors, to provide mechanisms for accessing the electronic
health records of veteran-callers as part of the response to crisis
calls, and to establish strong interactions between the national
hotline and the suicide prevention coordinators in each medical center
to provide for continuity of care. While we respect the idea of peer-
to-peer counseling, which is employed with great effectiveness in our
Vet Centers, VA believes it is more appropriate from a clinical
standpoint to staff VA's national hotline with trained healthcare
professionals.
H.R. 2378--Services to Prevent veterans Homelessness Act
H.R. 2378 is a measure intended to prevent low income veterans
transitioning to, or residing in, permanent housing from falling back
into their former homeless condition. Subject to the availability of
appropriations provided for the bill's purpose, H.R. 2378 would require
the Secretary to provide financial assistance to eligible entities to
provide and coordinate the provision of supportive services for very
low-income veteran-families occupying permanent housing or
transitioning from homelessness to permanent housing. The bill would
further require the Secretary to establish a formula for determining
the rate of payments to be made to eligible entities providing
supportive services under this section. The rate would have to be
adjusted at least annually to reflect changes in the cost of living. In
calculating the rate payment formula, the Secretary would be authorized
to consider geographic cost of living variances, family size, and the
cost of services provided.
To be eligible to receive funding, H.R. 2378 would require eligible
entities to submit a detailed application to the Secretary. This bill
would also authorize the Secretary to give preference to an entity
providing or coordinating the provision of supportive services for very
low-income veteran families who are transitioning from homelessness to
permanent housing.
This measure would require the Secretary to provide training and
technical assistance to entities receiving payments under this program
on the planning, development, and provision of supportive services to
the targeted families. Such assistance could be provided either
directly, or through grants or contracts with appropriate public or
nonprofit private entities.
As to funding, H.R. 2378 would make available out of the amounts
appropriated for medical care $25 million for each of FYs 2008, 2009,
and 2010, of which not more than $750,000 could be used to provide
technical assistance.
VA generally supports H.R. 2378 but we strongly recommend that the
bill be modified to allow VA to establish additional criteria,
specifically clinical indicators, to ensure this program reaches
veteran families requiring additional support to end their
homelessness. H.R. 2378 would require additional staffing resources for
VHA's Homeless Program Office in the Office of Mental Health Services.
This concludes my prepared statement. I would be pleased to answer
any questions you or any of the members of the Subcommittee may have.
Statement of Andy Behrman, Chair, Rural Health Policy Board,
National Rural Health Association
It is my distinct pleasure to submit my comments for the record in
regard to H.R. 2005, the Rural Veterans Health Care Improvement Act of
2007. As the Rural Health Policy Board Chair for the National Rural
Health Association (NRHA), and as a veteran, I have long been an
advocate for appropriate change and improvement to our VA healthcare
delivery system. It is a priority for me and a priority for the NRHA.
The NRHA is a national nonprofit, non partisan, membership
organization whose mission is to improve the health of rural Americans
and to provide leadership on rural health issues. The members of the
NRHA have long maintained concern for the health and mental healthcare
needs of rural veterans.
The members of the National Rural Health Association (NRHA) have
maintained a special concern for the health and mental healthcare needs
of rural veterans for many years. 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.
Since our Nation's founding, rural Americans have always responded
when our Nation has gone to war. 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 their
proportion of the population. Though only 19% of the nation lives in
rural areas, 44% of U.S. Military 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. Unfortunately, this is simply not true. Access to
the most basic primary care is often difficult 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 veteran's care in rural areas.
Additionally, we must all be mindful of long-term needs. 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, long-
term healthcare planning is critical. The wounded veterans who return
today won't need care for just the next few fiscal years, they will
need care for the next half century.
In my testimony to the Committee on April 18, 2007, I presented
recommendations that NRHA believes to be prudent in terms of developing
a new approach to serving our rural veterans. These recommendations
include:
1. Increasing Access by Building on Current Successes
Community Based Outreach Centers (CBOCs) open the door for many
veterans to obtain primary care services within their home community.
Additionally, Outreach Health Centers meet the needs of many rural
veterans. NRHA applauds the success of these programs and supports
their expansion.
2. Increasing Access By Collaborating with Non-VHA Facilities
Many rural veterans cannot access VHA care simply because VHA
facilities are too far away. Linking the quality of 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
collaboration with:
Federally Qualified Community Health Centers. These
centers serve millions of rural Americans and provide community-
oriented, primary and preventive healthcare. And, most importantly, are
located where rural veterans live. A limited number of collaborations
between the VHA and Community Health Clinics already exist and have
proven to be prudent and cost-effective solutions to serving eligible
veterans in remote areas. These successful models should be expanded to
reach all of rural America.
Critical Access Hospitals. These facilities provide
comprehensive and essential services to rural communities and are
specific to rural states. If these facilities are linked with VA
services and models of quality, access to care would be greatly
enhanced for thousands of rural veterans.
Rural Health Clinics. These clinics serve populations in
rural, medically underserved areas. In many rural and frontier
communities, these clinics are the only source of primary care
available.
3. Increasing Traumatic Brain Injury Care
Currently, it appears that Traumatic Brain Injury (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 access to it is extremely limited for
rural veterans--expansion is needed.
4. Targeting Care to Rural Veterans
A. Needs of the Rural Family. 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 transitions back into civilian life.
The 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.
B. Needs of Rural Women Veterans. More women serve in active duty
than at any other time in our Nation's history. And more women are
wounded or are war casualties than ever before in our nation's history.
Targeted and culturally competent care for today's women veterans
is needed. Rural providers should also be trained to meet the unique
needs of rural, minority, and female veterans.
5. Improving 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 on-going mechanism to study and articulate
the needs of rural veterans their families.
We are grateful to Mr. Salazar for introducing HR 2005 and are
grateful for the Committee's consideration of the bill. This
legislation provides important relief for rural veterans and clearly
addresses our second and fifth recommendations. We hope the Committee
will consider this as a strong and positive step toward addressing the
many challenges--especially access challenges--faced by rural veterans.
To that end, we hope that this Committee will also address other
ways to improve access to healthcare for our rural veterans. While the
VA has provided outstanding service to our veterans over the years (and
I have been one of those recipients), the need to increase access to
services has become a major concern to the VA, and a critical concern
to veterans living in rural communities throughout the United States.
Efforts to increase service points for rural veterans have, in
large part, been hindered by the VA Administration itself. The VA has
thwarted attempts to collaborate with organizations that are located
where rural veterans reside (such as community health centers, critical
access hospitals, and rural health clinics) because of a false
assumption that quality of care standards in rural communities are
inferior. To the contrary, the standards of healthcare in rural America
are high. In fact, community health centers, for example, have been
rated as the number one most efficient and effective program in all of
HHS. CHS must meet the highest standards of care, and in many cases,
they musts also be Joint Commission accredited. All facilitates must
meet federal standards of care.
We must never forget that many veterans forgo care entirely because
of access difficulties to VA facilities. Often, however, local quality
care is available within a veteran's own community. In many cases,
these rural centers, as well as critical access hospitals and rural
health clinics, are the only providers in a large geographic area. Our
goal is not to mandate care to our veterans, but to provide them a
choice, a local choice. We applaud Congressman Salazar and this
Committee for taking steps toward providing our honored veterans with
such a choice.
Thank you again for this opportunity. The NRHA looks forward to
working with you and this Committee to improve rural healthcare access
for the millions of veterans who live in rural America.
Statement of the Honorable Silvestre Reyes,
a Representative in Congress from the State of Texas
Chairman Michaud, Ranking Member Miller, and distinguished members
of the Subcommittee, I would like to thank you for the opportunity to
testify before you in support of my bill HR 2172 the Amputee Veteran
Assistance Act. As a veteran and former member of this Committee, many
of you know me well and are aware of my commitment to Veteran issues.
Today as Chairman of the Intelligence Committee and a member of the
Armed Services Committee much of my time is devoted to ensuring that
our troops have the necessary equipment and timely intelligence they
need to fight the wars in Iraq and Afghanistan and to return home
safely. However, I believe it is also critically important that our
troops have confidence that if they are wounded in battle that they
will be cared for in a manner that reflects the great sacrifices they
have made for our country.
The wars in Iraq and Afghanistan are placing great strain not only
on our armed forces but on the Veterans Administration (VA) as well.
The VA has not experienced this level of casualties since the Vietnam
War. Despite the committed work of many healthcare professionals within
the VA, the system is having a tough time dealing with this new influx
of wounded veterans, while addressing the needs of our others veterans
who honorably served in previous conflicts.
As you know, since the beginning of the wars in Iraq and
Afghanistan, more than 500 of our brave men and women in the armed
forces have suffered major amputations resulting from wounds and
injuries received in combat. Many of them have suffered multiple
amputations. Our wounded servicemen and woman are now receiving world-
renowned care and access to some of the most modern prosthetic
technology available under the Department of Defense (DOD) healthcare
system. Some of our amputee soldiers have even been able to return to
duty. However, others, because of their own unique situations, are
transitioning to the VA, a system they will be part of for the rest of
their lives. I want to assure that the VA is well prepared to provide
service and care for their advanced prosthetic devices. Some recent
amputee veterans and veteran support groups have expressed reservations
that the VA is currently too focused on convalescent care and does not
have the resources and training to help these wounded men and women
return to the active lives they led before their wounds.
During her testimony before the Senate Committee on Veteran Affairs
last March, Major Tammy Duckworth, an Iraq war amputee and Director of
the Illinois Department of Veteran Affairs, spoke about her
difficulties transferring from the DOD healthcare system to the VA. She
noted that the care she received as an inpatient at Walter Read Army
Medical Center was exceptional, but her experiences with her local VA
prosthetic facility were less positive. She pointed out that the VA
prosthetics departments were ``many decades behind'' in technology and
that VA staff, while eager to be helpful, lacked the knowledge and
training to treat amputees at high tech levels set at Walter Reed and
other major DOD healthcare facilities.
The Amputee Veteran Assistance Act is an important step toward
addressing some of these shortcomings in the VA system. I would like to
emphasize that this bill is not an indictment of the VA. The VA has
played an important role in research and development in the field of
prosthetics for many decades and should be commended for its efforts.
Instead, it is a step toward giving VA personnel the training and
resources they need to do their jobs better, while addressing the
immediate concerns of our amputee veterans. It is my hope that this
bill will help create a more personalized approach for our veterans.
The field of prosthetics is as much of an art as it is a science. Each
amputee veteran is a unique case with his or her own specific needs. My
bill is not an attempt to create a ``one size fits all'' solution but
to better prepare the VA to address a wide range of demands and give
our amputee veterans greater options in the mean time.
This legislation will require that all VA prosthetic facilities and
prosthesists be certified within 5 years by either the American Board
for Certification in Orthotics and Prosthetics or the Board of
Orthotics and Prosthetic Certification. Many of the VA facilities and
prosthesists are already board certified but some are still lagging
behind. It also allows amputee veterans to seek care for the repair and
servicing of prosthetic devices from outside the VA system when VA
facilities are unable to perform the required service or repairs or
when a suitable VA facility is not available within a 55 mile radius.
The VA will also be required to conduct a study to provide
recommendations on modernizing its facilities and training its
prosthesists so that it will be able to address the high tech needs of
these amputee veterans. This report will allow us to get a better
handle on what kind of resources the VA will need to address these
problems. It also requires the VA to implement a plan to inform amputee
veterans twice a year about the latest innovations in the field of
prosthetics. Advances in the field of prosthetics continue rapidly and
many amputee veterans may not be aware of some of the new options out
there for them.
I know you will all agree that providing for our brave men and
women in uniform who have sacrificed so much for our great nation is
imperative. Today we have an opportunity to demonstrate to our disabled
veterans our firm commitment to providing them with all possible means
for living a full and rewarding life. Thank you for giving me the
opportunity to testify before the committee. I will be pleased to
answer any questions you might have.
United States Ombudsman Association
Des Moines, Iowa, 50325
June 13, 2007
Hon. Michael H. Michaud
Chairman, Subcommittee on Health
U.S. House of Representatives
Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, DC 20515
Dear Representative Michaud:
On behalf of the United States Ombudsman Association (USOA), thank
you for your invitation to comment on H.R. 2192, proposed legislation
to establish an ombudsman within the Department of Veterans' Affairs.
I have served as President of the USOA for 2 years and am the
Deputy Ombudsman in the State of Iowa--Office of Citizens' Aide/
Ombudsman. My short curriculum vitae is appended.
The USOA, a non-profit association, does not receive any federal
funds and does not participate in any federal contract or grant, nor
has it done so for the previous two fiscal years.
Founded in 1977, the USOA is our Nation's oldest and largest
organization of ombudsmen working in government to address citizen
complaints. The membership of the USOA includes practicing ombudsmen at
all levels of government, some of whom have general jurisdiction over
multiple agencies and subject matters, and others who have jurisdiction
over a specified subject matter or agency. (Detailed information
regarding the USOA can be found at the Association's website: http://
www.usombudsman.org/.)
As a matter of good public policy, the USOA supports the
establishment of independent ombudsman offices for the investigation
and resolution of complaints involving administrative agencies in
government at all levels. An ombudsman can serve as an independent
office not only to address individual concerns, but also to identify
systemic problems and recommend improvements in policies, practices,
and procedures. An ombudsman can also help in the important effort to
provide public and, indeed, legislative oversight of administrative
agencies in government.
From this perspective we have reviewed the proposed legislation and
offer these comments.
Key to the ability of an ombudsman to function effectively is
independence. An ombudsman whose position, budget, staff, and
investigations can be controlled or supervised by persons who (or whose
actions or decisions) may be the subject of an investigation is not
independent and will not be perceived as being independent. To the
extent possible, an ombudsman should be structurally separated from the
entities that are subject to the ombudsman's review or investigations.
An ombudsman should be free to hire and fire staff, within the larger
employment structure, manage the budget, select and prioritize the
issues to be investigated and determine how they should be
investigated. This independence allows the ombudsman to act and to be
viewed by the public as acting as an impartial official who reports
findings and recommendations based on objective review of the facts and
the applicable law.
Structural Location
H.R. 2192 establishes the ombudsman within the Department of
Veterans' Affairs. The USOA believes that the best way to make an
ombudsman independent is by situating the ombudsman's office in the
legislative branch of government. If that arrangement is not feasible,
then we believe that everything reasonably possible should be done to
maximize an ombudsman's independence within the branch of government or
agency where the office is situated.
Appointment, Supervision, Term, and Removal
H.R. 2192 provides for the Secretary of the Department to designate
the ombudsman. It does not specifically state to whom the Ombudsman
reports for supervision or direction on job duties. Assuming that the
ombudsman reports to the Secretary, the USOA believes that can
compromise the independence of the ombudsman because the Secretary sets
policies and makes decision relevant to the Department's programs and
is the person ultimately accountable for decisions made by departmental
staff. The ombudsman needs to be able to function without fear or
concern that shat he/she says in regards to supervisory officials might
affect his/her job.
For this reason, the USOA believes it would be best for the
ombudsman to be appointed by Congressional action. If that is not
feasible, an alternative is for the ombudsman to be appointed by the
President, with the advice and consent of the Senate (like an Inspector
General) or a Congressional Committee.
Furthermore, the term of the office should be set in such a manner
that it does not coincide with administrative terms of office. In
addition, removal or dismissal from office within the term should be
limited to ``just cause,'' with relevant definitions specified in the
legislation.
We urge inclusion of these provisions under subsection (a) to
reinforce the independence of the ombudsman.
Ombudsman's Staff
Based on the experience of USOA members, we recommend a provision
for the ombudsman to appoint at least a deputy or assistant ombudsman,
to maintain consistent functioning of the office, in the event the
ombudsman is absent or the position is vacant.
Authority to Investigate
Subsection (b), pertaining to duties of the office, states only
that the ombudsman ``shall act as a liaison for veterans and their
family members.'' One of the hallmarks of an ombudsman function is the
authority to investigate the agency which it oversees. The proposed
legislation is silent in this regard. The USOA recommends that specific
language be included in the legislation granting the ombudsman the
authority to investigate complaints related to the healthcare program
and benefits administered by the Department.
Authority to Access Information
H.R. 2192 is also silent regarding the ombudsman's ability to
gather relevant information, including information which may be
confidential by law. The duty to investigate ought to include the
authority to have access to information and to issue subpoenas when
necessary. While usually an ombudsman will be able to obtain
information from an agency on an informal basis, there may be instances
when the agency may resist or deny information. Therefore, we recommend
adding such a provision regarding this authority. In addition, the
provision may require the ombudsman to keep confidential any
information which is confidential by law.
Authority to Issue Public Reports
Another important function that is also missing from H.R. 2192 is
the authority to report the investigative findings and recommendations
for improvements. Since ombudsmen do not have enforcement authority
they rely on the ability to persuade an agency to take corrective
action. The option to publicly criticize an agency enhances that
ability. In addition, public reports can educate and inform those
interested in or affected by the issues involved. An ombudsman cannot
be effective without the duty to investigate and report. In addition,
the ombudsman should submit an annual report to Congressional members
and other officials with policy and operational oversight over the
Department of Veterans' Affairs.
We recommend adding these duties to subsection (b) of the proposed
legislation.
Confidentiality and Immunity
Subsection (d) provides for information provided to the ombudsman
by veterans or their family members to be disclosed only as necessary
to carry out the duties of the office. We recommend expanding this
provision to grant the ombudsman immunity from being compelled to
testify or produce complaint and investigative records in any legal
proceedings, except as necessary to enforce or defend the authority of
the office.
Closing
Thank you for allowing the USOA this opportunity to comment on the
proposed legislation. We applaud your consideration of creating the
ombudsman function, in the interest of improving the delivery of
necessary services to our veterans and their families.
Sincerely,
Ruth Cooperrider
President
United States Ombudsman Association, and
Deputy Ombudsman
State of Iowa--Office of Citizens' Aide/Ombudsman
U.S. Department of Veterans Affairs
Washington, DC.
August 19, 2007
The Hon. Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
This letter is in response to your invitation to submit for the
record the Department's views on two discussion drafts and H.R. 2623
and H.R. 2699. We received these legislative items too late to address
them in the statement we submitted to the Subcommittee in connection
with the June 14, 2007, legislative hearing.
Discussion Draft on Readjustment Counseling Services and Mental Health
Section 1 of this discussion draft would require the Secretary to
establish a program to provide readjustment counseling and mental
health services to eligible veterans through contracts with community
mental health centers. Eligible veterans would include combat-theater
veterans who seek VA care within the 2-year period after their
discharge or release from service, who served in Operational Enduring
Freedom or Operation Iraqi Freedom, and who reside in an area where the
Secretary has determined the Department is incapable of providing
readjustment and mental health services.
This provision would cover community mental health centers which:
(1) meet qualification standards determined by the Secretary; (2)
require appropriate staff to complete a VA clinical and cultural
training program; and (3) employ a qualified veteran for the duration
of the contract. These centers would also be required to submit
information relating to the program's workload to the Secretary on an
annual basis.
Section 1 would further require the Secretary to establish a
program to provide support and assistance to the immediate family
members of eligible veterans. Such assistance would include the
provision of education materials and classes on mental health issues
(including signs and symptoms of post traumatic stress disorder). This
provision would also require the Secretary to provide individual
counseling and mental health services (up to 2 years) to immediate
family members, if requested.
Section 1 would also require the Secretary to establish a 5-year
pilot program in at least four Veterans Integrated Service Networks
(VISNs) to provide confidential readjustment counseling and mental
health services to combat theater veterans at non-VA facilities. Under
the pilot program, veterans would receive a voucher, coupon, or card
that could be used to receive five visits with any provider on a
Department-approved list.
For the reasons discussed below, the Department opposes section 1.
First, it would blur the distinction between VA's readjustment
counseling services and mental health services and work at cross-
purposes with the existing programs. Additionally, these services are
authorized by separate authorities and employ different eligibility
criteria. These benefits should not be coupled because they are
conceptually and operationally very distinct areas of treatment.
VA's authority to furnish readjustment counseling services includes
authority to furnish limited mental health services necessary for
effective treatment of the veteran's readjustment problems. Vet Centers
provide professional treatment for combat-related Post Traumatic Stress
Disorder (PTSD), depression, and substance abuse and, if necessary,
refer the veteran to VA facilities for treatment of additional or more
complex mental health needs. VA's readjustment counseling services
encompass many other unique social and psychological readjustment
services separate from mental health services. Readjustment counseling
is considered to be a special, ``more-than-medical,'' community-based
counseling service providing an array of services to combat theater
veterans to facilitate a successful readjustment from combat to
civilian life. Vet Centers also have authority to furnish limited
counseling, education, and training services to the veteran's immediate
family members when such services are needed for the effective
treatment and readjustment of the veteran. Family readjustment services
include outreach, early intervention educational services, and family
counseling. Family counseling is provided through the Vet Centers to
treat any psychological, social or other military-related readjustment
problems of the veteran whether those problems are service connected or
not. We note that family services currently provided through Vet
Centers are available throughout the life of the veteran. section 1
would provide individualized counseling and mental health services for
immediate family members for no more than 2 years, a significant
reduction of the current benefit.
Comprehensive mental health services are furnished as medically
needed to all enrolled veterans, regardless of combat-status, as part
of VA's standard medical benefits package. VA already has authority to
furnish certain family members with counseling, training, and education
services. However that authority is extremely limited by statute and
extends only to those family members of veterans receiving treatment
for a service-connected condition. That authority also requires a nexus
between the services furnished to the family members and the effective
treatment of the veteran.
While we certainly appreciate that a veteran's family member may
have his or her own mental health needs apart from the veteran's, we
believe it is beyond the Department's statutory mission to furnish
treatment or services to family members whose individual mental health
needs are unrelated to the Department's ability to effectively treat
the veteran.
Second, VA already has authority to contract for both readjustment
counseling services and mental health services. Currently, VA contracts
for readjustment counseling and related readjustment services with
private sector community mental health agencies and other professional
entities. We see no justification for limiting the entities with which
VA may contract for these services, as the bill would do. Of note, most
of our contract providers are located in rural areas. In providing
mental health services, VA collaborates with publicly supported clinics
in furtherance of VA's Mental Health Strategic Plan. Several existing
contracting related authorities can be used to ensure a veteran
receives needed mental health services if VA cannot timely provide the
needed services in a timely manner. In this regard, section 1 is
duplicative of VA's existing contract authorities and on-going
activities.
Third, section 1 is not necessary because Vet Centers already
provide veteran-peer outreach and counseling. In 2004, VA began an
aggressive outreach effort, which included the hiring of combat-theater
veterans of Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF) to provide outreach services and peer-counseling to their
fellow veterans. To date, the Vet Center program has hired 100 OEF and
OIF outreach workers.
The Vet Center program is also undergoing the largest expansion in
its history. The planned expansion complements the efforts of the Vet
Center outreach initiative, discussed above, by ensuring sufficient
staff resources are available to provide the professional readjustment
services needed by the new veterans as they return home. In fiscal year
(FY) 2006, VA announced plans for establishing two new Vet Centers in
Atlanta, Georgia, and Phoenix, Arizona, and augmenting staff at 11
existing Vet Centers, bringing the current number of Vet Centers to
209. In February 2007, VA announced plans to increase the number of Vet
Centers to 232 and augment the staff at 61 existing Vet Centers. The
following communities will be receiving new Vet Centers: Montgomery,
Alabama; Fayetteville, Arkansas; Modesto, California; Grand Junction,
Colorado; Orlando, Fort Meyers, and Gainesville, Florida; Macon,
Georgia; Manhattan, Kansas; Baton Rouge, Louisiana; Cape Cod,
Massachusetts; Saginaw and Iron Mountain, Michigan; Berlin, New
Hampshire; Las Cruces, New Mexico; Binghamton, Middletown, Nassau
County and Watertown, New York; Toledo, Ohio; Du Bois, Pennsylvania;
Killeen, Texas; and Everett, Washington.
In May 2007, VA announced a plan to add 100 new staff positions to
the Vet Center program in FY 2008. Together with the 100 OEF and OIF
outreach specialists hired in FY 2004 and 2005, these program
expansions represent an increase in Vet Center staffing by 369
positions since 2004, a 39% increase.
Fourth, while well-intended, the pilot program required by section
1 could result in harm to a participating veteran. In most cases, five
sessions is too few to ensure an adequate course of evidence-based
treatment is delivered safely and effectively. A participating veteran
may believe, in error, that upon completing the fifth visit that he or
she has received a full course of treatment and no longer requires
further assistance from the Department. The draft bill's arbitrary
limit of five visits could create an unreasonable expectation on the
part of the patient that he or she should be able to resolve their
readjustment or mental health problems in that timeframe.
Moreover, the pilot program would fragment care and impede VA's
ability to ensure veterans in the program receive the benefits of
continuity of care. In sharp contrast, VA-furnished readjustment
services and mental health services are delivered in a manner promoting
the veteran's continuity of care. Under the readjustment counseling
program, VA conducts site-visits to contract providers to verify the
quality of readjustment counseling services being rendered to veterans.
With respect to mental health services currently provided through
Department medical facilities, these services are fully integrated. Of
utmost importance, the patient's medical data are maintained in the
VA's electronic health record system, which further helps prevent
fragmentation and ensure continuous high-quality care.
Finally, the Vet Center program reports the highest level of
veteran satisfaction recorded for any VA program. For the last several
years, over 99% of veterans consistently using the Vet Centers reported
satisfaction with services received and indicated they would recommend
the Vet Center program to other veterans. In view of the Vet Center's
authorities and accomplishments, we oppose section 1 because it would
amend the Vet Center program in a way that adds no value and results in
substantial confusion between these benefits and those separately
furnished under VA's mental health programs.
Section 2 of this discussion draft would authorize the Secretary to
make a grant to a qualified entity to conduct workshop programs in the
performing arts, public speaking, writing, and culinary arts to further
the readjustment of veterans. Qualified entities would include a
nonprofit private entity with expertise in conducting workshop programs
or one that the Secretary determines has a program that is likely to
improve the readjustment of veterans. A grant under this section could
not exceed $100,000 for any calendar year and would need to be used
exclusively for the benefit of veterans. section 2 would also authorize
$2 million to be appropriated to carry out this section each fiscal
year.
VA does not support section 2. It is not clear what appropriation
it is intended that VA use for this authority. We would oppose using
medical care funds for services that would not constitute medical care.
Second Discussion Draft on Programs for Homeless Veterans
Homeless Providers Grant and Per Diem Program
Section 1 would amend the Department's Homeless Providers Grant and
Per Diem Program (the ``Program'') by requiring the Secretary to
furnish funding assistance to grantees on an annual basis; currently
the grantees receive per diem payments based on the provider's daily
cost of care. It would also require the Secretary to annually increase
the annual rate of payment to reflect anticipated changes in the
grantee's cost of furnishing services and to take into account the cost
of providing services in a particular geographic area. section 1 would
further authorize the Secretary to establish a maximum annual amount
that could be paid to a provider under the Program. Currently, the
statutory cap on the per diem amount is the same that applies to per
diem payments made to State homes.
Section 1 would also eliminate the current requirement that VA
adjust the per diem rate to exclude other sources of income a provider
receives for the purpose of furnishing services to homeless veterans.
However, section 1 would permit the Secretary to continue collecting
such information as needed to determine the provider's cost of care.
section 1 would also allow grantees to use VA payments to match, or in
combination with, other payments or grants for which the grantee is
eligible.
The Department does not support section 1 in its entirety. Although
payment on an annual basis would appear to ease the administrative
burden of calculating daily per diem rates, it would not offer any
incentive to providers for maintaining the census and level of services
throughout the year for which the funding amount is awarded. Providing
the grantee with an annual lump-sum payment would lessen a provider's
accountability concerning the use of VA grant funds. This concerns us
greatly. Also, this measure is unnecessary because the Department
recently modified its system for determining per diem rates under the
Program. This should make it much easier to determine the per diem
rates and alleviate the administrative workload for both VA and the
grantee.
However, VA supports the provision in section 1 that would
establish a maximum rate that could be paid to grantees, VA's grant
program for State homes and the grant program for homeless providers
are too dissimilar to justify linking the maximum payment level as is
currently done by statute. And VA has no objection to eliminating the
requirement to adjust a grantee's per diem payment by excluding other
sources of income from the provider's estimated daily cost of care. We
note, however, that this provision would not prohibit a provider from
receiving payments from VA and other sources that together exceed the
grantee's actual cost of providing care or services to homeless
veterans. We would therefore recommend that section 1 be modified to
prevent a grantee from being able to receive more than 100 per cent of
its actual daily cost of care.
The Department estimates the total cost of section 1 to be
$88,388,137 for fiscal year 2008 and $1,479,329,118 over a 10-year
period.
Dental Benefit for Homeless Veterans
Section 2 would eliminate the current requirement that in order to
receive one course of dental services an eligible veteran must also be
receiving care or services for a period of 60 consecutive days in one
of the specified treatment settings (domiciliary care, care in a
therapeutic residence, community residential care, care from a grantee
under the Program).
VA strongly opposes section 2. Without the 60-day treatment
requirement, there is no means to ensure the homeless veteran gets his
or her other medical needs addressed. The availability of the dental
benefit often provides the only opportunity to connect a homeless
veteran to other VA programs that can provide the veteran with more
vital care. Also, a single course of dental care in the absence of
other medical services does little to help homeless veterans lift
themselves from their plight. Most homeless veterans suffer from
substance or alcohol abuse problems and/or serious mental health
conditions. These conditions make it difficult, if not impossible, for
them to find and keep permanent housing and to secure gainful
employment. If these veterans receive not only the one-course of dental
care services but also medical services to help them rise above their
homelessness, everyone's interests are served. VA data support this
position: homeless veterans have a better rate of treatment success and
experience longer stays in permanent housing if they complete their
residential treatment programs. We therefore find no justification for
changing the current program eligibility criteria,
The Department estimates the cost of section 2 to be $8.1 million
for fiscal year 2008 and $98.1 million over a 1 a-year period.
VISN Staffing
Section 3 would require the Secretary to ensure that each VISN
office assigns at least one full-time employee of the Veterans Health
Administration (VHA) to oversee and coordinate VA's programs for
homeless veterans. VA regards section 3 as unnecessary. VHA has already
assigned a full-time employee to coordinate homeless veterans programs
in every VISN and has fully funded those positions.
Grants to Repair and Replace Homeless Providers' Facilities
Section 4 would authorize the Secretary to make emergency grants,
pursuant to criteria and requirements prescribed by the Secretary, to
entities receiving grants under the Homeless Providers Grant and Per
Diem Program for the purpose of repairing or replacing a grantee's
facility that is damaged or destroyed by a major disaster.
VA supports section 4. Grantees receiving VA grants and per diem
for furnishing care to homeless veterans under the Program lost their
capacity to continue providing care and services (including
transitional beds) in the aftermath of Hurricane Katrina. Desperately
trying to find beds for their displaced veterans, the grantees whose
facilities were damaged turned to VA for additional assistance. To
assist them, VA had to rely on other departments which administer
Federal laws and regulations managing the Federal response to disasters
and national emergencies. This situation resulted in delays, which in
turn lengthened the time displaced homeless veterans had to survive
without services previously furnished by the grantee. All-but foremost
the displaced homeless veterans previously served by the grantee--would
benefit if VA were able to provide financial assistance to grantees in
these types of catastrophic situations more quickly. However, we note
that if a grantee's facility cannot be replaced or repaired, VA would
still not have authority to award grants out-of-cycle to maintain
capacity in the area(s) affected. We note that the costs for emergency
activities of this nature are not typically available within existing
funding levels.
Pilot Program for Permanent Housing
Section 5 would require the Secretary to conduct a 5-year pilot
program to award grants to public or nonprofit entities with
established single-room occupancy facilities for the purpose of (1)
acquiring and operating single-room occupancy housing solely for the
benefit of homeless veterans and (2) providing rental assistance on
behalf of homeless veterans. Section 5 would also establish detailed
reporting requirements and authorize $10 million for fiscal year 2008
and each subsequent fiscal year to carry out this pilot program.
VA does not support section 5. As a general matter, VA's statutory
mission appropriately does not encompass permanent housing for homeless
veterans. In our view, section 5 is a measure far better suited to the
expertise, capacity, and mission of the Department of Housing and Urban
Development. If enacted, VA estimates the cost of section 5 to be $5
million in fiscal year 2008 and $93 million over a 10-year period.
H.R.2623 Elimination of Co-payments for Hospice Care
H.R. 2623, as ordered reported, would exempt a veteran who is
receiving inpatient or outpatient hospice care from all copayment
requirements that would otherwise apply.
We support this measure.
H.R. 2699 amendments to VA's Homeless Providers Grant and Per Diem
Program
Elimination of Adjustments to Per Diem Rate
Section 1 would repeal the requirement that the Secretary adjust
the amount of per diem payable to a grantee under the Homeless
Providers Grant and Per Diem Program by excluding income the grantee
receives from other sources to provide services to homeless veterans.
We refer the Committee to our comments on the discussion draft bill
that included a similar provision and our concern that a grantee could
receive more than 100% of its cost of care.
Demonstration Program for Members of the Armed Forces
Section 2 would require the Secretary to conduct, through September
3D, 2011, a demonstration program (at a minimum of three sites) for the
purpose of identifying active duty members who are at risk of becoming
homeless after they are discharged or released from service. The
Secretary would also be required to provide (directly or by contract)
referral, counseling, and supportive services to service members
participating in the demonstration program. section 2 would also
require the Secretary of Veterans Affairs to consult with the Secretary
of Defense (and other appropriate officials) in developing the criteria
for inclusion in the demonstration program. Finally, section 2 would
authorize $2 million to be appropriated to carry out this demonstration
project.
VA does not support section 2. There exist no reliable criteria for
identifying which active duty members are at risk of becoming homeless
once they leave the military, nor is there any reliable means for
developing such criteria. VA could not carry out such a program.
Referral and Counseling Demonstration Program
Section 3 would expand. from 6 to 12, the number of sites
participating in the Department of Labor's on-going demonstration
program of furnishing referral and counseling services to veterans at
risk of becoming homeless upon their release from certain institutions
(e.g., penal institutions and long-term mental health facilities).
section 3 would also eliminate this program's demonstration status and
authorize it through September 30, 2011.
We defer to the views of the Secretary of Labor, who administers
this program. We are aware, however, that this demonstration program
has been very successful at reducing recidivism rates among the
participating veterans and we therefore applaud Labor's success with
this program.
Grants for Staffing Service Centers
Section 4 would permit service centers receiving grants under the
Homeless Providers Grant and Per Diem Program to use those funds to
meet mandated staffing levels. VA has no objection to section 4.
Domiciliary Care
Section 5 would require the Secretary to take appropriate actions
to ensure that the domiciliary care programs of the Department are
adequate to meet the capacity and safety needs of women veterans. VA
does not support section 5 because it is unnecessary. The Department
has on-going efforts to ensure the domiciliaries are able to meet the
unique needs of women veterans and to ensure their privacy and safety
while in that setting. Finally we note that the measure would also
eliminate the authorization for appropriations for fiscal years 2003
and 2004 currently found in law. That authorization does not expire as
may be suggested by the caption for section 5.
The Office of Management and Budget advises that there is no
objection to the transmittal of this letter in regard to the program of
the President.
Sincerely yours,
R. James Nicholson
Secretary
U.S. Department of Veterans Affairs
Washington, DC.
January 10, 2008
The Hon. Michael H. Michaud
Chairman
Subcommittee on Health
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
In accordance with the requirements of section 212(c) of Public Law
109461, enclosed is the Department of Veterans Affairs' (VA) plan to
improve access to quality long term care and mental health services for
veterans residing in rural areas.
Similar letters have been sent to other leaders on the House and
Senate Committees on Veterans' Affairs.
Sincerely yours,
James B. Peake, M.D.
Enclosure
----------
Department of Veterans Affairs
Veterans Health Administration
Plan to Increase Access to Quality Long-Term Care and
Mental Healthcare for Enrolled Veterans Residing in Rural Areas
January 2008
Table of Contents
I.
INTRODUCTION
II.
BACKGROUND
A.
The Office of Rural Health
B.
Definition of Urban/Rural/Highly Rural
C.
Demographics
D.
Current Services
III.
PLAN
A.
Goal
B.
Long-Term Care Initiatives
C.
Mental Health Initiatives
IV.
BARRIERS TO RURAL HEALTH CARE
A.
Long-Term Care
B.
Mental Health
V.
CONTINUOUS IMPROVEMENT
ATTACHMENTS
Attachment A
Veteran Enrollee and Patients by Urban/Rural/Highly Rural Designations
Attachment B
Veteran Enrollee Drive Time Access Standards
Attachment C
Acronyms
I.
INTRODUCTION
On December 22, 2006, the Information Technology Act of 2006,
Public Law 109-461, was signed into law. Section 212 of this law
established the Office of Rural Health (ORH) and, among other things,
requires the Director of the Office of Rural Health to develop a plan
to improve the access and quality of care for enrolled veterans in
rural areas.
Specifically, section 212(c) states the plan shall include:
(l)
Measures for meeting the long-term care needs of rural veterans; and
(2)
Measures for meeting the mental health needs of veterans residing in rural
areas
This plan addresses the specific actions underway in regards to
mental health (MH) and long-term care (LTC). The plan includes a
systematic evaluation of the current state of MH and LTC service
provided by the Veterans Health Administration (VHA) and presents a
strategy to increase access, either by enhancing existing services or
developing new initiatives, to further advance access to quality MH and
LTC services for veterans residing in rural areas.
II.
BACKGROUND
A.
The Office of Rural Health (ORH)
VA's Office of Rural Health was established in March 2006, in
compliance with P.L 109-461 section 212 Sec. 7308(c) under the VHA
Office of the Assistant Deputy Under Secretary for Health (ADUSH) for
Policy and Planning.
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. The office is accomplishing this by
assessing the delivery of services with a range of VHA program offices
to ensure the needs of rural veterans are being considered as program
development and implementation takes place. As a program office, the
role of the ORH is to provide policy, guidance, and oversight within
VHA to enhance the delivery of care by creating greater access,
engaging in research, promulgating best practices and developing sound
and effective policies to support the unique needs of enrolled veterans
residing in geographically rural areas.
As specified in the Public Law, one of the key responsibilities of
ORH is to conduct, coordinate, promote, and disseminate research into
issues affecting veterans who reside in rural areas. With a strong
collaboration between ORH and internal VHA program offices, ORH is also
responsible to develop, refine, and promulgate policies, best practices
and innovations to improve services. ORH will translate lessons learned
into policy and facilitate broader execution through Patient Care
Services (PCS).
B.
Definition of Urban/Rural/Highly Rural
There is no single, universally preferred definition of rural that
is used across either government or private sector agencies.\1\
Currently, more than 15 definitions of rural are used by Federal
programs. The two most commonly used classification systems are from
the U.S. Census Bureau and the Office of Management and Budget. In
order to be consistent with most commonly used definitions, VHA adopted
a census bureau based classification system, where our definitions are:
---------------------------------------------------------------------------
\1\ Choosing Rural Definitions. March 2007. Rural Policy Research
Institute Issue Brief. Mueller, et. al.
Urban: A veteran (or clinic) located in a Census defined
---------------------------------------------------------------------------
urbanized area.
Rural: A veteran (or clinics) not designated as urban.
Highly Rural: A veteran (or clinic) that is defined as rural
and located in counties with less than 7 civilians per square
mile.
For this plan, the term rural will refer to both rural and highly
rural populations.
C.
Demographics
The Census Bureau estimates approximately eight percent of the
general population are veterans. In FY 2006, the Veterans Health
Administration (VHA) had almost 7.9 million enrollees and served about
4.8 million unique patients. In fiscal year 2006, VHA identified
approximately 39% (1,878,624) of the veteran patients served resided in
rural areas and another one and six tenths percent (79,464) resided in
highly rural areas. Of our enrollee population, approximately 36%
(2,850,173) resided in rural areas and 1.5 percent (118,685) resided in
highly rural areas (Attachment A).
D.
Current Services
Long-Term Care (LTC)
Health care services, both within and outside VA, exist along a
continuum consisting of: (1) ambulatory care, which is predominantly
offered as primary care (through Geriatric Primary Care or Geriatric
Evaluation and Management programs when available) with use of urgent
care and referrals for specialty services; (2) acute care which
encompasses hospital-based acute and intensive/critical care; and (3)
long-term care. Long-term care is a spectrum of medical and non-medical
services provided for a prolonged period of time, to eligible persons
with chronic, disabling conditions, delivered in institutional and non-
institutional settings and can be either provided, purchased, or
coordinated by VA. VHA provides long-term care through programs managed
by the Office of Geriatric and Extended Care (GEC) and the Office of
Care Coordination (GCC).
The GEC provides oversight for the majority of VHA's LTC programs.
While LTC services are provided to veterans of all ages, the elderly
comprise a major proportion of those needing LTC (two-thirds of the
population using VHA LTC are over the age of 75). These LTC programs
provide a continuum of increasingly resource-intensive services ranging
from outpatient Geriatric Primary Care to institutionalized nursing
home care. Veterans can receive services in one or more of VHA's LTC
care programs concurrently based on need.
Veterans whose care needs exceed the resources for continued
support in the home may require placement in settings where
professional staff on site can support necessary self-care and health
needs: VA operated nursing home care units, VA contracted community
nursing homes, and the State Veterans Homes provide this form of long-
term care. A final form of long-term care is offered to those whose
disease process is anticipated to result in death. Palliative care
focuses on the comfort-physical, mental, and spiritual-of-patients. The
most well known form of palliative care is hospice, which is palliative
care provided when death is expected in 6 months or sooner. VA provides
hospice and palliative care in a continuum of environments, both
institutionally and in-home care, as well as linking with community
services through participation in Hospice-Veteran Partnerships to
improve veterans' access to community hospice care in rural areas.
VHA's strategic direction since the enactment of the Veterans
Millennium Health Care and Benefits Act, P.L. 106-117 (Nov. 30, 1999),
has been to develop and offer community and home-based alternatives to
nursing home care. When veterans are unable or limited in their ability
to come to a VA facility for care, this strategic direction is to bring
care closer to the veterans and to enhance the veteran's ability to
remain in his or her customary place of residence. To meet this need,
VA has several non-institutional programs, including Home Based Primary
Care (HBPC), which provides comprehensive longitudinal care by an
interdisciplinary team in the homes of veterans with complex chronic
disabling disease. Additional initiatives to increase rural veterans'
access to care include establishing satellite HBPC programs at remote
sites such as Community Based Outpatient Clinics (CBOC) and an
expansion of the Office of Care Coordination's Care Coordination Home
Telehealth (CCHT) program into 155 VA facilities and clinics
nationwide. CCHT uses home telehealth technologies to enhance and
extend care and case management in the home for veteran patients with
chronic diseases. These veterans are monitored at home using telehealth
technology that transmits vital sign measurements and symptoms to a VA
care coordinator. CCHT reduces clinical complications, increases access
to care when it is needed, and prevents or delays elderly veterans from
being admitted into long-term institutional care.
Other non-institutional LTC services that are available include,
but are not limited to, Community Residential Care (including Medical
Foster Home), Adult Day Health Care, Homemaker/Home Health Aide,
outpatient respite services, and purchased skilled home care. To
develop future opportunities for greater access to care for veterans,
collaborations with other Federal entities such as the Administration
on Aging, Indian Health Service, and the Health Resource Services
Administration have been established.
Mental Health
Comprehensive and effective mental healthcare is a top priority for
VA. VA is making changes to address veterans' needs and is investing
significantly to improve access to mental health services for veterans
residing in rural areas and throughout the country. Mental health
services are 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 can manage a full
range of mental healthcare needs. VA also provides readjustment
services through the Vet Center program, which is designed to provide
quality readjustment counseling and some related mental health
services, for combat veterans and family members (to the extent
necessary for successful readjustment for the veteran).
The advancement of technology has increased the range of specialty
mental health services that can be provided in rural areas, creating
greater access for these veterans. VA's Office of Care Coordination
(OCC), in collaboration with the Office of Mental Health Services
(OMHS), has developed telemental health programs, which involve the use
of health information and telecommunications systems to enable delivery
of care when veteran patients and clinicians are separated by
geographical distance. Telemedicine equipment has been deployed to VA
facilities and their corresponding CBOCs, thus building an
infrastructure to provide expert telemental healthcare where direct
access to mental health specialists is unavailable. The advantages of
telemental health are that it improves access to mental health
services, reduces the need for travel by patients and is associated
with preliminary evidence that it reduces the ``no show'' rate in
clinics.
Additionally, VHA has implemented care coordination home telehealth
(CCHT) to support the care of veteran patients with chronic mental
health conditions in their homes and local communities. Another example
of VA telemental health programs is the collaboration with the Indian
Health Service where VA provides services on several reservations.
VA OMHS is also meeting the needs of rural veterans through the
pilot implementation of the Mental Heath Intensive Case Management--
Rural Access Network for Grouth Enhancement (MHICM-RANGE) program,
where VA provides community based support for veterans with severe
mental illness. Other programs include the use of referrals for fee-
based mental health services in Community Mental Health Centers and a
program that sends VA mental health providers to Community Mental
Health Centers where they can use laptop computers for Computerized
Patient Record System (CPRS) access. Still other efforts include
integrating psychologists into the Home Based Primary Care program and
adding mental health professionals to the staffs of CBOCs.
III.
PLAN
The Office of Rural Health (ORH) has collaborated with an array of
subject matter experts within VHA program offices to develop a plan to
improve access to quality mental health and long-term care for veterans
residing in rural areas. This plan takes the results from an internal
programmatic assessment and either expands current services to increase
focus on rural veterans or identifies new initiatives to meet the long-
term care and mental health needs of rural veterans. The performance
period is FY 2008.
A.
Goal: To increase access to quality mental health and long-term care
services for veterans residing in rural areas.
B.
Long-Term Care Initiatives
1.
Expand access to VA's innovative non-institutional LTC services for
veterans residing in rural areas by supporting the Office of Geriatrics and
Extended Care (GEC) and the Office of Care Coordination (OCC) in
implementing additional programs that serve rural veterans. Programs
include:
a.
Home Based Primary Care (HBPC)
b.
Care Coordination Home Telehealth (CCHT)
c.
Medical Foster Home program
Milestone: During FY 2008 establish CCHT programs in all 21 Networks and at
most facilities
2.
Conduct a baseline assessment of the average daily census (ADC) in non-
institutionalized settings for veterans residing in rural areas for the
following programs:
a.
Home Based Primary Care (HBPC)
b.
Care Coordination Home Telehealth (CCHT)
c.
Medical Foster Home program
Milestone: Completion of baseline by 4th Quarter, FY 08 and completion of
plan by 1st Quarter FY 09
3.
Fund at least two studies or demonstration projects that address issues of
long-term care, institutional or non-institutional, access or quality for
veterans residing in rural areas.
Milestone: Develop a Request for Proposals (RFP) and select projects by 4th
Quarter, FY 08
4.
Create an Office of Rural Health Web site to give veterans greater access
to information and research.
Milestone: 4th Quarter, FY 08
5.
Establish a Rural Health National Advisory Committee (RHNAC) to examine
ways to improve and enhance VA services for enrolled veterans residing in
rural areas through evaluation of current program investment, policy, and
barriers to providing services as well as the development of strategies to
improve services. The RHNAC will be comprised of experts within the
federal, non-federal, academic, and veteran community.
Milestone: Charter developed by 3rd Quarter, FY 08
6.
Develop strategies and incentives to support recruitment and retention of
staff to provide geriatric care in rural settings, including those
stationed on a full-time basis within rural settings, those who rotate
between facilities, and those utilizing telehealth services for care
delivery.
Milestone: Ongoing activity in FY 08
C.
Mental Health Initiatives
1.
Expand the Mental Health Intensive Case Management-Rural Access Network
Growth Enhancement (MHICM-RANGE) pilot program into additional rural areas
where need is identified.
Milestone: 3rd Quarter, FY 09
2.
Increase the capacity to provide telemental health services from VA
facilities over the FY 07 baseline.
Milestone: Ongoing initiative, FY 08
3.
Evaluate strategies and the feasibility of implementing VA collaborations
with non-VA entities to expand telemental health linkages between VA
providers and patients in community settings.
Milestone: Assessment by 4th Quarter, FY 08
4.
Through VHA's Strategic Planning process, assess rural geographic areas
identified as underserved markets based on VHA's drive time access
standards to primary care (which includes access to mental health services)
and develop plans for addressing gaps in care.
Milestone: 4th Quarter, FY 08
5.
Require each VA medical center or clinic to develop plans for the delivery
of VA mental health services by using on-site providers, telemental health,
referral to other facilities, or referral to community providers as
appropriate.
Milestone: Implementation of plans by 4th Quarter FY 08
6.
Assess the degree to which CBOCs defined as rural or small (<1500 unique
veterans) provide timely delivery of mental health services completing an
initial evaluation within 24 hours of veteran referral and for a full
diagnostic and treatment planning evaluation for non-urgent cases within 14
days.
Milestone: 4th Quarter FY 08
7.
Develop metrics to serve as quality monitors for the delivery of mental
health services in rural areas, in collaboration with mental health
services.
Milestone: Development of metrics by 4th Quarter FY 2008
8.
Fund at least two studies or demonstration projects that address issues of
mental healthcare, access or quality for veterans residing in rural areas.
Milestone: Develop a Request for Proposals (RFP) by 4th Quarter, FY 08.
Select and begin initiatives by 4th Quarter, FY 08
9.
Create an Office of Rural Health Web site to give veterans greater access
to information and research.
Milestone: 4th Quarter, FY 08
10.
Develop strategies and incentives to support recruitment and retention of
staff to provide mental healthcare in rural settings, including those
stationed on a full-time basis within rural settings, those who rotate
between facilities, and those utilizing telemental health services for care
delivery.
Milestone: Ongoing activity in FY 08
11.
Develop a Rural Health National Advisory Committee (RHNAC) to examine ways
to improve and enhance VA services (including mental health services) for
enrolled veterans residing in rural areas through evaluation of current
program investment, regulatory policy, and barriers to providing services
as well as the development of strategies to improve services. The RHNAC
will be comprised of experts within the federal, non-federal, academic, and
veteran community.
Milestone: Charter developed by 3rd Quarter, FY 08
IV.
BARRIERS TO RURAL HEALTH CARE
The ORH has systematically identified barriers to delivery of
accessible high quality care in rural America. Initial findings
include:
A.
Long-Term Care
Meeting access and quality standards in rural areas is a challenge
for both VA and non-VA healthcare systems. This is because rural
veterans live farther from Veterans Administration Medical Center-
based, tertiary care options (which are largely in urban areas in order
to meet the needs of the larger concentrations of veterans), greater
delay and disease exacerbation before care is accessed, less local
availability to specialty and geriatrics expertise, and greater
likelihood referrals to tertiary care centers will be unfulfilled. The
intrinsic challenges of providing LTC in less populous areas and over
wider geographic distances are exacerbated by the worsening undersupply
of trained professionals that characterizes rural settings.
Additional challenges to rural, elderly veterans include: limited
transportation services; frail, elderly primary care givers with few
resources; preferential relocation to urban areas of younger family
members who might otherwise provide non-professional support services
and care giving; higher poverty rate; a lower level of awareness of
those services that may be available, and more constricted financial
resources.
B.
Mental Health
The provision of mental healthcare in rural settings has
historically been a challenge for all health systems and providers,
including VA. While Community Based Outpatient Clinics (CBOCs) have
been the anchor for VHA's efforts to expand access to veterans in rural
areas, there are notable challenges in providing mental health services
in rural communities, 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. However, telemental health at remote clinics, where
feasible, has proven to be convenient and is generally well accepted by
veterans.
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 specialty services. The range of specialty care services
is highly dependent on the services available in the local community.
Constraints on the expansion of telehealth in VHA, as in
all organizations, include clinical (e.g. clinician buy-in and training
of clinicians), technical (e.g. interoperability of technologies,
telecommunications bandwidth availability, a national video-
telecommunications, and adequate scheduling systems) and business
processes (e.g. clinical coding and reimbursement systems).
While these barriers exist, the ORH will leverage VA's capabilities
and develop partnerships with governmental and non-governmental
entities to provide the best solutions to the challenges that rural
veterans face. Areas of focus include: technology expansion,
transportation, research and evaluation, workforce recruitment and
retention, and education and training. By using a data-driven
decisionmaking and collaborative approach to develop policies and
practices that expand and adapt current initiatives, as well as
developing new models of care delivery, the ORH will improve access to
high quality healthcare care for rural veterans.
V.
CONTINUOUS IMPROVEMENT
VA's plan to increase access and quality mental health and long-
term care services to veterans residing in rural areas will be
implemented, evaluated, and undergo continuous improvement. Prior to
implementation of initiatives outlined in the plan, the Office of Rural
Health will consult with the Office of Geriatric and Extended Care, the
Office of Care Coordination, and the Office of Mental Health Services
within the Office of Patient Care Services, and other VA offices as
appropriate, to assess feasibility and identify barriers that could
affect the successful implementation of the initiatives.
----------
Attachment A
Veteran Enrollee and Patients by Urban/Rural/Highly Rural
Designations
----------------------------------------------------------------------------------------------------------------
Rural &
Total Enrollees Urban Rural Highly Rural Highly Rural
Enrollers Enrollees Enrollees Enrollees
----------------------------------------------------------------------------------------------------------------
7,848,282 4,879,424 2,850,173 118,685 2,968,858
----------------------------------------------------------------------------------------------------------------
100.0% 62.2% 36.3% 1.5% 37.8%
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Rural &
Total Patients Urban Rural Highly Rural Highly Rural
Patients Patients Patients Patients
----------------------------------------------------------------------------------------------------------------
4,877,733 2,919,645 1,878,624 79,464 1,958,088
----------------------------------------------------------------------------------------------------------------
100.0% 59.9% 38.5% 1.6% 40.1%
----------------------------------------------------------------------------------------------------------------
----------
Attachment B
Veteran Enrollee Drive Time Access Standards
Access standard for Primary Care (includes mental health).
Seventy percent of enrollees within a market meet the following
drive time standards:
30 Min.--Urban
30 Min.--Rural
60 Min.--Highly Rural
----------
Attachment C
Acronyms
ADC--Average Daily Census
CBOC--Community Based Outpatient Clinics
CCHT--Care Coordination Home Telehealth
CPRS--Computerized Patient Record System
GEC--Office of Geriatric and Extended Care
HBPC--Horne Based Primary Care
LTC--Long-Term Care
MH--Mental Health
MHICM-RANGE--Mental Health Intensive Case Management--Rural Access
Network Growth Enhancement
NHC--VA Nursing Home Care
OCC--Office of Care Coordination
OMHS--Office of Mental Health Services
ORH--Office of Rural Health
PCS--Patient Care Services
RFP--Request for Proposals
RHNAC--Rural Health National Advisory Committee
VA--Department of Veterans Affairs
VHA--Veterans Health Administration
Program Analysis Officer
GS-340-15
Office of the Assistant Deputy Under Secretary for Health for Policy
and Planning
Veterans Health Administration
Department of Veterans Affairs
Under the general guidance of the Assistant Deputy Under Secretary
for Health (ADUSH) for Policy and Planning, incumbent provides
leadership, advice and subject-matter expertise in tasks, projects and
assignments related to rural health policy development, analysis,
decision making, and implementation activities affecting the entire VA
healthcare system. Incumbent serves as Director, Office of Rural
Health.
Incumbent functions in a supervisory capacity in contributing to
attainment of Department of Veterans Affairs (VA) and Veterans Health
Administration (VHA) goals and objectives with regard to rural health.
In this capacity, the incumbent works very closely with other key
Departmental Officials on cross-cutting programs and issues and is
responsible for the for the planning, direction, coordination,
development, and implementation of rural health programs and projects.
DUTIES AND RESPONSIBILITIES
Directs and leads the development and implementation of the
Veterans Health Administration Office of Rural Health to address
healthcare needs of veterans in the rural and highly rural areas.
Researches, plans, develops, implements, and evaluates policy and
programs to improve the access and delivery of healthcare services in
rural and highly rural areas for the planning and implementation of
appropriate healthcare to improve access and improve the quality of
healthcare services and enhance the access and delivery of healthcare
in rural and highly rural areas for veterans.
Addresses key issues, such as,
improves communication and coordination among key VA
health providers and medical administrators within and across the VHA
and other government healthcare providers, such as, the DHHS in the
rural and highly rural areas;
enhances access to select services, (e.g., prescription
drugs, non-emergency medical transportation, chronic disease management
programs, mental health and long term healthcare);
improves travel times and evaluates transportation needs;
provides quality health assessment data to promote
information-based health policy and planning; and
Investigates and improves the capacity of VA rural and
highly rural healthcare from infrastructure to staffing needs.
As the focal point within VHA and the Department for monitoring
rural health issues and coordinating Department-wide efforts to
strengthen and improve the delivery of veterans health services to
populations in rural areas, the Director
coordinates rural health activities within the
Department;
oversees the collection and analysis of information
regarding the special problems and needs of rural healthcare providers;
maintains a clearinghouse for the collection and
dissemination of information and research related to veterans rural
health services;
manages rural health services outreach projects and
network development, and support;
conducts or provides contracts for the conduct of
specific rural health studies and activities directed toward specific
rural issues; and
responds to inquiries on rural health matters from the
Congress and the public and private sectors.
Directs the conduct of complex qualitative and/or quantitative
analysis to assess patient care trends and anomalies in rural and
highly rural settings.
Leads and coordinates technical, professional and administrative ad
hoc teams established to conduct comprehensive studies on patient care
in rural and highly rural settings; the conclusions of which are
recommended to management for decisions, relative to the design and
development of new, or the curtailment or modification of existing
patient care delivery.
Serves as the primary link between the Assistant Deputy Under
Secretary for Health (ADUSH) for Policy and Planning and other
executive staff and key offices within the Veterans Health
Administration (VHA), the Office of the Under Secretary for Health and
other appropriate offices, congressional offices and Committees, and
other Federal agencies, and a wide variety of external groups and
organizations with regard to rural and highly rural health issues.
Counsels the ADUSH for Policy and Planning and key management in
the development and implementation of policies, plans, guidelines, and
proposals for patient care in rural and highly rural settings. He/she
develops written documents for a wide range of matters, including the
development or the implementation of policies, practices, or other
operational and management activities. Conclusions, findings,
recommendations and reports are in many instances used by top VA
management to make management decisions and to develop policy.
Acts as a representative of the ADUSH for Policy and Planning on
interpretation of policy, in public relations issues, and in
reconciling conflicting interpretations and differences among the Rural
and Highly Rural staff nation-wide.
Serves as a member of various Committees as designated by the ADUSH
for Policy and Planning with Administrative and other key officials,
other government agencies, and organizations outside the Federal
Government and represents the ADUSH for Policy and Planning.
The incumbent plans, organizes, and carries through to completion
program plans, program/policy analyses, data collection, legislative
interpretation, and analytical studies involving Federal and VA
programs and policies on patient care in rural and highly rural
settings.
Coordinates special studies and projects with other agencies within
the Department to ensure involvement of the appropriate Departmental
officials, as well as involvement by outside groups. Provides technical
and policy advice on healthcare financing and rural healthcare
proposals reflecting the Administration's objectives and priorities.
Promotes effective communication and coordination of departmental
activities with other Federal agencies and outside organizations.
Communicates the policies and positions of the Department to
governmental and private organizations concerned with the provision of
veterans' healthcare in rural areas.
Explains a variety of policies and/or procedures to VA officials
and resolves problems of a highly complex nature. May resolve issues
independently or make recommendations for resolution. Coordinates
critical and sensitive office correspondence with top management of the
Department.
Directs comprehensive studies from which to analyze and evaluate
the needs, strategic plans, and goals of the Office of Rural Health,
and makes recommendations for new directions, initiatives, policies and
procedures. S/he participates in senior management decisions regarding
strategic planning and priority-setting for these activities.
Ensures coordination of reports, evaluations and follow up actions.
Identifies deficiencies or problems and consults with the ADUSH for
Policy and Planning for problem resolution
Supervises the staff of the Office of Rural Health. Plans and
assigns work to be accomplished. Evaluates performance; gives
instructions on work and administrative matters; interviews and selects
candidates for subordinate positions; hears and resolves employee
problems; and takes disciplinary measures and recognizes noteworthy
contributions as warranted.
Identifies and makes provisions for the training of staff as
needed. Assures that staff in the Office of Rural Health maintain state
of the art knowledge in this program area. Assures and oversees that
staff are remaining current with the availability of relevant
literature, and also with applicable regulations, manual, and other
related policies. Maintains competency of self and existing staff and
encourages use of resources and continuing education courses.
Performs other duties, as assigned.
SCOPE
The incumbent is a national level resource, responsible for
directing and supervising the conduct of complex analysis, design,
development, technical support work; providing assistance to VA Central
Office and Field units throughout the VHA system; and utilizes existing
tools and/or recommends the development of new processes and
applications to troubleshoot problems and meet specified business
needs, having a cross organizational affect on Department-wide
administrative policies and programs, as they relate to providing
medical services in an effective environment to veterans nationwide.
The incumbent will have expert knowledge of analytical and
evaluative methods plus a thorough understanding of how regulatory or
enforcement programs are administered to select and apply appropriate
program evaluation and measurement techniques in determining the extent
of compliance with rules and regulations issued by the agency, or in
measuring and evaluating program accomplishments. This may include
evaluating the content of new or modified legislation for projected
impact upon the Agency's programs and resources.
EFFECT
The incumbent directs the completion of significantly complex
administrative, technical and analytical projects such as qualitative
and quantitative studies of patient care delivery in rural and highly
rural settings; data analysis to determine customer satisfaction with
care provided in rural and highly rural settings; development of tools
and metrics to monitor the outcomes of newly established or implemented
policies and procedures to enhance patient care in rural and highly
rural settings. The work significantly affects Department-wide VHA
business requirements, veterans using VHA medical facilities,
stakeholders and end user customer satisfaction.
This incumbent will be skilled in planning, organizing, and
directing team study work and in negotiating effectively with
management to accept and implement recommendations, where the proposals
involve substantial agency resources or may require change in
procedures.
The incumbent will have a mastery of advanced management and
organizational principles and practices along with a comprehensive
knowledge of planning, program and budget regulations, guidelines and
process, and thorough knowledge of the Agency's planning, acquisition,
and management process to prepare long-range and short-range planning
guidance in accordance with broad agency program policies and
objectives.
ORGANIZATIONAL SETTING
The incumbent reports directly to the Director of Policy Analysis
and Forecasting, an SES position and is accountable to the VHA
Assistant Deputy Under Secretary for Health for Policy and Planning,
who encumbers a SES Position.
SUPERVISORY & MANAGERIAL AUTHORITY EXERCISED
The incumbent directs and supervises a staff of highly analytical
and technically skilled specialist, and professionals, which may
include contract staff. Decides methodologies to use in achieving
program objectives or to determine which goals and objectives to
emphasize. In addition, he/she serves as an active team member for
projects encompassing the development, maintenance and improvement of
patient care in rural and highly rural settings.
The incumbent plans work to be accomplished by subordinates, sets
and adjusts short-term priorities, and prepares schedules for
completion of work; assigns work to subordinates based on priorities,
selective consideration of the difficulty and requirements of
assignments, and the capabilities of employees; gives advice, counselor
instruction to employees on both work and administrative matters;
evaluates subordinate performance and identifies developmental and
training needs for employees, providing or arranging for needed
development and training; finds ways to improve production or increase
the quality of the work of subordinates and develops performance
standards for supervised staff'; hears and resolves minor complaints
from employees, referring group grievances and more serious unresolved
complaints to a higher-level management; Prepares and updates position
descriptions and performance plans for subordinate employees;
interviews applicants, develops criteria for selection of best
candidate and recommends or makes selection; and approves/disapproves
leave, makes work assignments, resolves work conflicts and implements
established or management approved policies, as it relates to customer
service and support.
PERSONAL CONTACTS
Nature of contacts: Contacts include VA program officials
representing VACO VHA, Staff Offices, OI&T, VHA field offices, VA
Medical Centers, VISN Offices, Congressional Offices, etc. Contacts
also include communication media, consultants, affiliated universities,
professional organizations and associations. Contacts take place in
planned or unscheduled meetings, including presentations, conferences,
hearings, etc. As requested, the incumbent prepares reports or
responses for Congress, executive branch agencies such as the Office of
Management and Budget, Agency for Health Care Policy and Research and
foundations such as Academy Health, or media audiences, working through
appropriate VA offices. Meets and addresses constituency, advocacy and
national and local veterans groups, as well as Congressional staff and
professional associations
Purpose of Contacts: Contacts are designed to meet several
objectives, including: developing appropriate collaborative
relationships for sharing information among colleagues and agencies
with similar interests; communicating information about the Office of
Rural Health's programs, plans, and strategies; obtaining information
from well-known rural health experts; to influence managers or other
officials to accept and implement findings and recommendations on
organizational improvement or program effectiveness; and to effectively
provide advice and counsel to management on the resolution of patient
care in rural and highly rural settings problem issues. The incumbent
may encounter resistance due to such issues as organizational conflict,
competing objectives, or resource problems. He/she must be familiar
with congressional and legislative activities bearing upon VHA Rural
Health Care program activities.
DIFFICULTY OF TYPICAL WORK DIRECTED
The highest graded non-supervisor work directed, which requires at
least 25% of this position's duty time, is GS-14 or higher, or
equivalent.
The incumbent directs and supervises the work of approximately two
subordinate employee's performing highly analytical, specialized,
technical and administrative work.
This position manages through subordinate supervisors and/or
contractors who each direct workloads comparable to GS-12 or higher.
Identifying the nature of issues or problems in planning,
organizing, and determining the scope and depth of rural health
studies, and discerning the intent of legislation and policy statement
and how to translate the intent into program actions is extremely
complex.
The incumbent provides high-level operational and program
management leadership. The work is highly varied, visible, and subject
to an exceptional level of scrutiny by stakeholders and advocacy groups
within and outside the system.
TRAVEL
Position requires 25% overnight travel.
OTHER CONDITIONS
The attention paid to the Office of Rural Health is very
significant. The incumbent must carefully coordinate the myriad efforts
of the Office's diverse portfolio, ensuring attention to all these
politically sensitive issues. All this must be accomplished in an
environment of extraordinary oversight of activities by advocates
within and outside the Department. The incumbent must deal with
demands, expectations, and oversight at a very high level.
This work requires familiarity with a broad range of topics and
current issues related to the provision and outcomes of rural
healthcare, and to the conduct of research on those issues. This
includes general knowledge of concepts and methods drawn from
healthcare administration, scientific review and evaluation, public
health, and other health organizations. The incumbent must be a
critical thinker with excellent writing and organizational skills.
Requires expert level knowledge of the principles and practices of
the following disciplines as they relate to rural health: healthcare
management, resource management, and policy development, in order to
provide consultation/advice to the ADUSH for Policy and Planning in
healthcare administration and organizational management matters.
The incumbent is responsible for extensive coordination and
integration of work efforts related to rural health policy development
associated with a national healthcare delivery system. The incumbent
makes major recommendations that have a direct and substantial impact
on current and future rural healthcare initiatives. The incumbent must
be thoroughly familiar with the Department's programs, objectives,
operations, and the interrelationships among these as well as those of
other federal agencies, Congress, etc.
Mastery of program and organizational analysis principles, methods,
practices and techniques; analytical methods; and interpersonal
relations practices. Skill to apply this mastery in developing new
methods and approaches in planning, integrating and evaluating rural
health programs for the agency. Knowledge and skill to advise other
specialists in and outside the agency, as well as top managers and
decisionmakers, on issues of developing, communicating, or enhancing
program matters involving interaction with all of the agency's publics,
both nationally and internationally.
Because of the sensitivity inherent in analyses and recommendations
made by the VHA Office of Rural Health, the incumbent is expected to
elicit a high and sustained level of collaboration and trust with VA
program managers. The incumbent must also demonstrate marked qualities
of diplomacy, patience, and persistence, professional deportment, and
discretion suited to all levels of VA management. The incumbent
develops and implements systems and processes to gather and analyze the
information needed to make strategic and tactical decisions.
OTHER SIGNIFICANT FACTS
Customer Service: Incumbent meets the needs of customers while
supporting VA missions. Consistently communicates and treats customers
(veterans, their representatives, visitors, and all VA staff) in a
courteous, tactful, and respectful manner. Employee provides the
customer with consistent information according to established policies
and procedures. Handles conflict and problems in dealing with the
customer constructively and appropriately.
ADP Security: Incumbent protects printed and electronic files
containing sensitive data in accordance with the provisions of the
Privacy Act 1974 and other applicable laws, federal regulations, VA
statutes and policy, and VHA policy. Employee protects the data from
unauthorized release or from loss, alteration, or unauthorized
deletion. Follows applicable regulations and instructions regarding
access to computerized files, release of access codes, etc., as set out
in the computer access agreement that the employee signs.