[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 3051,
H.R. 6153, AND H.R. 6629
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 9, 2008
__________
Serial No. 110-102
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois 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 STEVE SCALISE, Louisiana
TIMOTHY J. WALZ, Minnesota
DONALD J. CAZAYOUX, Jr., Louisiana
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
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
DONALD J. CAZAYOUX, Jr., Louisiana VERN BUCHANAN, Florida
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
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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
__________
September 9, 2008
Page
Legislative Hearing on H.R. 3051, H.R. 6153, and H.R. 6629....... 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 29
Hon. Jeff Miller, Ranking Republican Member, prepared statement.. 29
Hon. Phil Hare................................................... 1
Prepared statement of Congressman Hare....................... 29
WITNESSES
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D.,
FAAFP, Principal Deputy Under Secretary for Health, Veterans
Health Administration.......................................... 18
Prepared statement of Dr. Cross.............................. 40
______
American Legion, Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission.......................... 11
Prepared statement of Mr. Wilson............................. 38
Disabled American Veterans, Joy J. Ilem, Assistant National
Legislative Director........................................... 9
Prepared statement of Ms. Ilem............................... 32
Johnson, Hon. Eddie Bernice, a Representative in Congress from
the State of Texas............................................. 3
Prepared statement of Congresswoman Johnson.................. 30
Salazar, Hon. John T., a Representative in Congress from the
State of Colorado.............................................. 4
Prepared statement of Congressman Salazar.................... 31
Shea-Porter, Hon. Carol, a Representative in Congress from the
State of New Hampshire......................................... 6
Prepared statement of Congresswoman Shea-Porter.............. 31
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior
Analyst for Veterans' Benefits and Mental Health Issues........ 13
Prepared statement of Dr. Berger............................. 39
SUBMISSIONS FOR THE RECORD
American Veterans (AMVETS), Raymond C. Kelly, National
Legislative Director, statement................................ 49
Brain Injury Association of America, Susan H. Conners, President/
Chief Executive Officer, statement............................. 50
Hodes, Hon. Paul W., a Representative in Congress from the State
of New Hampshire............................................... 51
National Military Family Association, Inc., Barbara Cohoon,
Deputy Director, Government Relations, statement............... 51
Paralyzed Veterans of America, statement......................... 54
Schraa, James C., Psy.D., Neuropsychologist, Licensed
Psychologist, State of Colorado, Craig Hospital, Englewood, CO. 57
Veterans of Foreign Wars of the United States, Christopher
Needham, Senior Legislative Associate, National Legislative
Service, statement............................................. 58
Wounded Warrior Project, Anna Frese, Family Outreach Coordinator
for Brain Injury, statement.................................... 59
LEGISLATIVE HEARING ON H.R. 3051,
H.R. 6153, AND H.R. 6629
----------
TUESDAY, SEPTEMBER 9, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Committee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Snyder, Hare, Berkley,
Salazar, Miller, and Brown of South Carolina.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I would like to call this hearing to order.
And I would like to thank everyone for coming today. Today's
legislative hearing is an opportunity for Members of Congress,
veterans service organizations (VSOs), the U.S. Department of
Veterans Affairs (VA), and other interested parties to provide
their views and discussion on the legislation that has been
introduced within the Subcommittee's jurisdiction. I do not
necessarily agree or disagree with these bills before us today,
but I believe that this is an important part of the legislative
process that will encourage frank discussion of new ideas.
We have three bills before us today. Congressman Salazar's
bill, H.R. 3051, the ``Heroes at Home Act of 2007,'' H.R. 6153,
Congresswoman Johnson's bill, the ``Veterans' Medical Personnel
Recruitment and Retention Act of 2008,'' and H.R. 6629,
Congresswoman Shea-Porter's bill, the ``Veterans Health Equity
Act of 2008.'' I look forward to hearing the views of our
witnesses on these bills before us. Due to the late inclusion
of H.R. 6629 we do not expect to have written testimony today.
However, I would ask the witnesses if they would submit their
views in writing on H.R. 6629 within ten legislative days after
the ending of this hearing.
[The prepared statement of Chairman Michaud appears on
p. 29.]
Mr. Michaud. I would like to ask Mr. Hare if he has an
opening statement.
OPENING STATEMENT OF HON. PHIL HARE
Mr. Hare. I do. Thank you, Mr. Chairman. First, let me
thank you and Ranking Member Miller for holding this hearing
today.
The three bills before us today address important issues, all
of which have huge impacts on the welfare of our Nation's
veterans.
Secondly, I would like to thank the sponsors of these
bills, the three Members that are testifying before the
Subcommittee today. Mr. Salazar is a fellow Committee Member
and I know from sitting next to him over the past 2 years that
he is a tireless advocate for veterans, especially the many
rural veterans that live in his large district in the State of
Colorado. His bill addresses family caregivers of veterans
suffering from Traumatic Brain Injuries (TBI), and also
telehealth services. These are crucial matters that are
directly in line with Mr. Salazar's passion for improving the
lives of veterans and their families.
Ms. Johnson is also a big supporter for veterans. For
fifteen years she worked at the Dallas VA Medical Center (VAMC)
as a medical and psychiatric nurse. Appropriately, her bill
aims to help VA recruit and retain more nurses and other
healthcare professionals.
Ms. Shea-Porter and I came into Congress at the same time,
and I know without a doubt that there is nobody more dedicated
to serving our veterans than she is. It is a paradox then that
her home State, the great State of New Hampshire, does not have
a VA Medical Center. Her bill attempts to resolve this
injustice.
Third, I would like to thank all of our witnesses for
testifying today, including Dr. Cross of the VA, and each
representative of the three VSOs present. I would also like to
congratulate the Disabled American Veterans (DAV) for recently
electing Raymond Dempsey, a fellow Illinoisan, as National
Commander. Speaking on behalf of this great State of Illinois I
take pride in knowing that such a well respected organization
is under the leadership of Mr. Dempsey.
Mr. Chairman, thank you again for holding this important
hearing. I look forward to our witnesses testifying this
morning. Thank you.
[The prepared statement of Congressman Hare appears on p.
29.]
Mr. Michaud. Thank you very much, Mr. Hare, for your
opening statement. Mr. Miller.
Mr. Miller. Thank you very much, Mr. Chairman. I apologize
for being late. I would like to just submit my opening
statement for the record.
[The prepared statement of Congressman Miller appears on
p. 29.]
Mr. Michaud. Without objection so ordered.
Now I would like to thank our first panel for coming here
this morning. I look forward to your testimony. We will start
off, in the order that you arrived, with Congresswoman Johnson
of Texas to introduce her piece of legislation first. Thank
you.
STATEMENTS OF HON. EDDIE BERNICE JOHNSON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS; HON. JOHN T. SALAZAR, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO; AND HON.
CAROL SHEA-PORTER, A REPRESENTATIVE IN CONGRESS FROM THE STATE
OF NEW HAMPSHIRE
STATEMENT OF HON. EDDIE BERNICE JOHNSON
Ms. Johnson. Thank you very much, Mr. Chairman, and other
distinguished members of the panel. I will submit my written
statement and try to summarize.
As has been said, I worked as a professional psychiatric
nurse at the Veterans Administration Hospital for fifteen years
before entering public office, and I opened the psychiatric
unit. And I know how important the psychiatric unit became day
after day as veterans started coming back from active wars.
Recently there were four suicides of psychiatric patients at
the VA hospital that made the front page of the paper. The VA
hospital is in my district so I went to visit to see what the
problem was. And they explained that the real problem is they
are not attracting enough professional nurses to do what they
need done to observe psychiatric patients. As you know,
psychiatric patients are supposed to be observed at least every
fifteen minutes. It is also very important for consistency. It
is important that they develop a relationship with the nurses.
And the nurses remain the profession with the most trust of the
public.
They are using part-time nurses because the work in the VA
hospital for nurses is a little more stringent than in other
facilities. And they identified their problem as not having
nurses in the Medical Personnel Recruitment and Retention Act.
And it actually came out because nurses were so tight, there
was such a shortage, that they thought that this would give
more even distribution of nurses to other facilities as well.
But they found that they lost many, many nurses because of the
work. It is just hard in facilities like the VA.
It does not take much to observe that. You can go into a
private facility and if you find a professional nurse they are
usually seated at the desk. You go into a VA hospital and they
are usually walking, taking care of patients. So it is really a
difference, and I can tell you that from experience.
So I came back to see what I could do. They specifically
asked for this type of legislation. And I saw where Senator
Akaka had introduced a bill, it is Senate Bill 2969, that
address the same problem. And so this simply is a companion
bill to his. It is an urgent need. Very early I put an
amendment on one of the bills to see that when patients were
admitted to psych, admitted, coming directly from war, that
they got a psychiatric evaluation by professionals right away
because most of them come back with post traumatic stress
disorder (PTSD) even if they do not have head injuries, and
many are coming back with head injuries. The earlier they are
diagnosed, the earlier the intervention, the better the
outcome.
When I worked at the VA hospital, there were long-term
patients because at the time the modality was not experienced
enough to
have very early intervention. Consequently, we had a number of
long-time, chronic patients. The approach has changed now. But
in order to make it successful, the professionals must be
available. And this legislation directly addresses that issue
by placing nurses in the same category of physicians and
dentists, and other therapists, so that their pay rate pays
them back into it. So that their pay will be on the scale that
it had been on the professional level.
I know that this is asking for additional money, probably
not right away but in the scale as it comes. But if we want to
give the appropriate attention to those people that have given
much of their lives in defending this country, I think it is
only right to make sure that they have adequate care, and a
large enough and professionally qualified staff; especially
nurses, who spend more time with the patient than any other
professional. They are in their care, they are there 24 hours.
And especially on a psychiatric ward you cannot depend on
people coming in part-time, hitting it one time this week and
another time next month. You have got to have consistency.
I see that my time is up and I will be available for any
questions.
[The prepared statement of Congresswoman Johnson appears on
p. 30.]
Mr. Michaud. Thank you very much, Congresswoman.
Congressman Salazar, thank you for introducing your piece of
legislation and for your ongoing commitment to our veterans. I
open it up for your comments.
STATEMENT OF HON. JOHN T. SALAZAR
Mr. Salazar. Well, thank you Mr. Chairman, Ranking Member
Miller, and Members of the Subcommittee. I surely enjoy being a
Member of this wonderful Committee and all the work that we all
do for veterans. I appreciate the trip that we took to Iraq.
That was a very enlightening trip.
Mr. Chairman and Ranking Member Miller, first I would like
to thank Dr. Jim Schraa, a neuropsychologist at Craig Hospital,
and Anna Frese, with the Wounded Warrior Project, who submitted
testimony for the record on the bill that I introduced, H.R.
3051, the ``Heroes at Home Act,'' on July 17, 2007.
The purpose of this bill is to improve the diagnosis and
treatment of traumatic brain injury in current and former
members of the Armed Forces. The program will be located in VA
healthcare centers across the Nation. This is especially
important in rural districts like mine where making healthcare
accessible is a constant challenge. H.R. 3051 addresses the
needs for access to care by expanding the U.S. Department of
Defense (DoD) and VA telehealth, and telemental health
programs. Ultimately the bill will ease the burden on our
veterans suffering from TBI and the families who care for them.
Our Committee has heard testimony from many veterans, VSOs,
and the VA on mounting cases of TBI, PTSD, and other invisible
wounds of war. I think that many of us agree that veterans are
often worse off with those unseen injuries than those with
visible, physical injuries. Unlike injuries that can heal,
brain injuries are often permanently disabling. In addition,
TBI can sometimes take
years to develop and diagnose. Even when discovered, the road
to recovery is long and is borne by families of our brave men
and women in uniform.
We have also heard of the link between TBI and other mental
conditions such as epilepsy. A DoD study after Vietnam found
that 15 percent of soldiers with a penetrating TBI developed
epilepsy soon after their injury. H.R. 3051 creates a program
to train family members of the TBI patients to become their
personal care attendants. Participants going through the
program would also become certified and receive compensation
from the VA so that they can focus their energy on caring for
their loved one.
By taking place at home with family, the healing process is
made more comfortable for our veterans. The cost to the VA for
having someone cared for at home is less than having them at a
medical facility and allows the VA to allocate the resources
they have to serve more veterans. We have soldiers in Iraq and
Afghanistan spending longer periods of time in harm's way and
away from their families, and with this in mind we need to
ensure that there are programs in place to care for them when
they return home.
A program that provides quality care for our veterans and a
financial benefit for the family seems appropriate for the
difficult economic times our country is facing. Most
importantly, the bill will help us reach our goal of ensuring
our veterans the best care.
Mr. Chairman, I still have 2 minutes and I anticipated some
of the questions that you might have. If you do not mind, I
would like to address some of those. I know that one of the
questions is how much is this going to cost? The Congressional
Budget Office has not scored this bill. However, the cost of
having someone cared for at home is much less than having them
at a medical institution. In fiscal year 2006, San Diego VAMC
spent $825,000 for Personal Care Attendants (PCA) services for
52 veterans. This year they expect the service's cost to be $1
million. They are currently providing home care services to 56
individuals. I believe that it is much less expensive to take
care of these veterans at home with family members. We must
keep in mind that a family member rate is less than $16 per
hour versus a professional at a medical facility that may be
charging $30 or more.
The training will actually take place at home. Currently
the Department operates a similar PCA training and
certification program for the spinal cord injury (SCI), SCI
population out of San Diego. Senate Bill 3421, the ``Veterans
Benefits Healthcare and Information Technology Act of 2006,''
includes a provision which, in section 214, requires the
establishment of a pilot program to improve caregiver
assistance. I think that the language specifically mentions
caregiver training and certification as part of the pilot and
authorizes $10 million over the next 2 years.
With that, Mr. Chairman, I think my time is up. I do
appreciate your time.
[The prepared statement of Congressman Salazar appears on
p. 31.]
Mr. Michaud. Thank you very much, Mr. Salazar. Ms. Shea-
Porter, I want to thank you for coming this morning and
presenting your piece of legislation, and thank you for
fighting for our veterans as well.
STATEMENT OF HON. CAROL SHEA-PORTER
Ms. Shea-Porter. Mr. Chairman, thank you for the
opportunity to speak to your Subcommittee about a critical
inequity facing New Hampshire veterans, the lack of full
service in State healthcare. New Hampshire has not had a full-
service veterans hospital since 2001. New Hampshire is the only
State without a full-service VA hospital or comparable
facility. Veterans in Alaska and Hawaii receive care at
military hospitals on base. While New Hampshire may be a small
State, it has a veteran population of 130,000. Unlike many New
England States whose populations are declining for veterans,
New Hampshire's veterans population is projected to grow over
the next 10 years.
Because New Hampshire does not have a full-service veterans
hospital, our veterans are forced to travel out of State for
some medical care. Veterans traveling from the most northern
parts of the State can travel for 3 hours to Manchester and
then be forced to travel another hour to Boston if referred
there for care. Then they have to wait while everybody on that
van receives their care. So we are sending our sickest and our
most vulnerable to Boston to wait all day after traveling
several hours to get to the central meeting point. This
routinely happens. In 2007, 704 of our veterans were
transferred out of State for acute care. Three-hundred forty-
six of those veterans were sent to Boston.
I have been calling for the VA to either restore the
Manchester facility to full-service hospital care, or allow New
Hampshire vets to receive care locally since I came to
Congress. I have been working with both the VA and my
colleagues to realize that goal. Chairman Filner visited the
Manchester facility earlier this year and held a series of
events, including a round table hearing in which we heard about
the serious burdens placed on the New Hampshire veterans and
their families simply because we do not have a full-service
hospital. And again, I would like to emphasize, the only State
in the country.
Despite these efforts, the administration refuses to either
provide local access to care or restore the full-service
hospital care to New Hampshire. I met with Secretary Peake at
the Manchester VA Medical Center in June to express my interest
in working with him to either restore the facility to a full-
service hospital or provide local access. Unfortunately, after
our meeting, Secretary Peake told the local press that there
would be no full-service hospital in Manchester.
The administration's failure to act is just unacceptable.
New Hampshire veterans deserve the best care possible and the
current system is not delivering that. That is why I introduced
H.R. 6629, the ``Veterans Health Equity Act of 2008.'' This
legislation will ensure that veterans have access to at least
one full-service VA hospital, or that they can receive care
locally. That would mean that the VA would have to do one of
two things, either restore the facility to a full-service
hospital or provide more local care providers. The men and
women in our local VA facility have done a herculean job caring
for these vets despite the limits placed on them. The
administration has recently shown some willingness to allow
radiation therapy to be provided locally, but this is not
enough. Our veterans, regardless of whether they need radiation
therapy, men-
tal health services, acute care, or anything else, need and
deserve the care their counterparts in every other State
receive. It is unconscionable that we deny them this full-
service care and instead we offer ad hoc services.
Mr. Chairman, I appreciate your leadership in providing the
best healthcare for our Nation's veterans. I am sure you and
other members of your Subcommittee appreciate the challenges
created by the lack of the full-service hospital. I look
forward to working with you and the Subcommittee to address
these challenges. Again, thank you for the opportunity to come
and speak to you about this important issue and I look forward
to answering any questions that you might have. Thank you.
[The prepared statement of Congresswoman Shea-Porter
appears on p. 31.]
Mr. Michaud. Thank you very much, Congresswoman. And once
again I would like to thank our first panel for your
willingness to come before us this morning. Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman. Ms. Shea-Porter, you
only talk about the 48 contiguous States and you do not talk
about Alaska. You talk about Hawaii, but what about the
territories as well? Is there a reason----
Ms. Shea-Porter. Well my understanding, and again we were
just looking at the ones coming from our States, but they can
receive access at military bases. And so when we looked at just
the 50 States, and because that was the best comparison that we
could make, we are the only State without it. And the others
have access to military base hospitals. And so, it has really
created a tremendous burden on these vets, especially as I
indicated the oldest and the sickest. Because they are the ones
who are being sent the farthest. And up until now, the families
were not properly reimbursed for the travel. And when you look
at who generally has to travel, it is an extra burden on the
family and the community. If an 80-year-old man, for example,
needs to go to the VA and he has got a 5-hour trip, that means
his wife is probably about 80 years old herself, needs to find
help to bring him at least to the first part to the Manchester
VA, where they can then head off to Boston.
So the burden is awful and is unfair. And New Hampshire
veterans are aware of this. And here is the other problem. We
need people to enlist in the service. And we have young men and
women in New Hampshire looking at that and saying, ``You know,
that just does not seem fair.'' And so, if we also want to make
sure we recruit and bring our fine New Hampshire men and women
into the service, we need to make sure that they know we will
keep our promise to them and our commitment, and care for them
when they return.
Mr. Miller. So, it is your understanding that veterans in
American Samoa and the Virgin Islands have access to military
hospitals?
Ms. Shea-Porter. Well, I do not know what they do. I am
just looking at the 50 States. And as I said, we are looking
strictly at our 50 States and saying, ``What do they do in
every other State?''
Mr. Miller. Actually, you said the 48 contiguous States.
Ms. Shea-Porter. Well, that is because the other two have
comparable care. And what I am asking for is either or. I am
just asking for comparable care. I am not saying it has to be a
full-service VA hospital as long as they allow contracts
locally so that our servicemen and women are not forced to take
on an undue burden.
Mr. Miller. Thank you. That is all.
Mr. Michaud. Mr. Hare. Questions? Mr. Brown. Ms. Berkley.
Okay. I just have one. Thank you, Mr. Salazar, for answering
the question I had for you. I appreciate that.
Ms. Shea-Porter, you had mentioned that Secretary Peake
said no hospital. Did Secretary Peake at least acknowledge that
there is a concern with veterans accessing healthcare? Is he
willing to do some type of comparable care, whether it is
contracting our services in different regions of New Hampshire?
Ms. Shea-Porter. Well, actually I could not get an answer
from him. I finally said to him, ``Mr. Secretary, are you
saying yes or no?'' and he said, ``Neither.'' And so, you know,
I could not get an answer. But I do know that shortly
thereafter they talked about providing radiation care in the
community. But this really has been a long festering problem.
And when we looked at the numbers of veterans from other
States, and we looked at their ability, there cannot be any
explanation for it. You know, we have looked at the stats and
there is just no explanation for New Hampshire being without
some kind of care there.
And, again, I am not insisting that they build a full-
service VA hospital. I want to do whatever is the most
economical and practical. But we have to keep our commitments
to our veterans and that is why I am sitting here today. We owe
it to these New Hampshire vets.
Mr. Michaud. Now, you mentioned the time it takes for
veterans to travel to Boston. My concern is access to
healthcare and Maine, as you know, is a very rural State and we
have to travel long distances. Normally, when we say it is
going to take 4 hours to travel from one end to Togus, that is
at, the speed limit. When you say it is going to take 4 hours,
how does that traffic affect your veterans traveling? Is it 4
hours because of congestions? Or is it 4 hours depending on
what time they go during the day?
Ms. Shea-Porter. Right. Well, when they start off, and the
furthest point from my district could be an hour and a half to
2 hours from the tip of the district down. And it is not that
heavy. I mean, it is New Hampshire. It does not look like
Washington traffic for sure, but the roads are slower, because
if you get in front of a car. So you add that time. And then
when they get to Manchester and they have to take a van, and
that is when the traffic really becomes very difficult. And so
many of our older vets simply must travel in a van for a number
of reasons. Their unfamiliarity with the roads and with urban
districts and driving in cities, they are elderly, and they are
ill. And it is pretty hard to find people in your neighborhood
who are happy about driving 4 hours to Boston, you know, and
going through, and picking their way through that traffic in
that very heavily congested area in an area that they are not
familiar with.
So that means they have to come to Manchester and be loaded
on the van. And there are other people who are receiving
services as well. And so they come to an urban VA, which is
very busy, and they have to wait all day. And so these trips
are absolutely exhausting them. They can go, you know, for
hours and hours and hours. From Manchester to the VA can take
an hour and a half. It does take an hour and a half, it can
take 2 hours. Add that in addition to the 2 to 3 hours, you
know, each way, 5 hours, and then the wait. And you get a sense
of what we are putting them through. And again, they are our
oldest and our sickest that are being sent down.
Mr. Michaud. Thank you very much. Once again, I would like
to thank our first panel for your testimony this morning. I
look forward to working with you as we work to make sure our
veterans get the adequate healthcare that they need. Once
again, thank you very much.
I would like to welcome the second panel. As they come, it
is Joy Ilem who works for the Disabled American Veterans (DAV),
Joseph Wilson from the American Legion, and Dr. Thomas Berger
from the Vietnam Veterans of America (VVA). I would like to
thank our second panel for your willingness to come today and
to give your testimony on the bills that we have heard from our
first panel.
I would like to start off with Ms. Ilem.
STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS; JOSEPH L. WILSON, DEPUTY
DIRECTOR, VETERANS AFFAIRS AND REHABILITATION COMMISSION,
AMERICAN LEGION; AND THOMAS J. BERGER, PH.D., SENIOR ANALYST
FOR VETERANS' BENEFITS AND MENTAL HEALTH ISSUES, VIETNAM
VETERANS OF AMERICA
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you Mr. Chairman and Members of the
Subcommittee. Thank you for inviting the Disabled American
Veterans to testify at this legislative hearing. We appreciate
the opportunity to provide our views on the bills under
consideration by the Subcommittee today.
DAV supports the provisions in H.R. 3051, which would
establish a program for training and certification of family
caregivers of servicemembers and veterans with traumatic brain
injury, and authorize these personal care attendants to receive
compensation for such services. This program would allow these
family members to have standardized and consistent training and
to receive compensation that recognizes their efforts that will
help to ensure the stability of the family at an extremely
difficult and vulnerable time. We note, however, this section
of the bill only addresses veterans with traumatic brain
injuries but could also benefit other catastrophically injured
veterans with long-term personal assistance needs, such as
veterans with spinal cord injuries or severe physical trauma
without brain injury. If successful, we would like to see this
provision related to training and support for caregivers
expanded to other catastrophically disabled veterans requiring
caregiver assistance.
DAV also supports provisions in the bill requiring outreach
to educate and make veterans and the public aware of the
symptoms of PTSD and TBI, and make available best practices for
these conditions to non-VA healthcare providers. Often a family
member is the first to notice cognitive changes in the
veterans' behavior and mood. Thus informing the general public
is an important element of this bill. Likewise, we appreciate
the dissemination of best practices on TBI and PTSD to non-VA
providers to help ensure that veterans who may seek care
outside the VA and DoD systems benefit from their expertise.
Mr. Chairman, DAV also supports but with some concerns
Section 4 of this bill to assess the feasibility of using
telehealth technology to assess cognitive functioning of
military members and veterans who have sustained TBI, with a
priority in rural areas. We support efforts to assess new web-
based diagnostic tools for the prevalent cognitive conditions
that are emerging among our returning veterans. However, we ask
the Subcommittee to ensure that any partnership with the
private sector to expand telemedicine in rural areas include
coordination through VA's Office of Rural Health and be
supplemented by appropriate resources.
On a final note, we ask the Subcommittee to also consider
expanding this measure to include a standardized and more
comprehensive package of support services for caregivers,
including financial support, health and homemaker services,
respite, education, training, and other necessary relief
services. Family members of severely injured veterans often
shoulder great and lifelong responsibility as home and
institutional caregivers, giving up or severely restricting
their own employment and educational advancement, and social
opportunities. Not surprisingly, family caregivers often suffer
severe financial and personal hardships as a consequence of
providing care to a severely disabled veteran. Yet, in their
absence, an even greater burden of direct care would fall to VA
and DoD at significantly higher cost to the Government and
reduced quality of life for these veterans who have sacrificed
so much.
H.R. 3051 would provide welcome relief to family caregivers
of severely disabled veterans and is consistent with DAV
Resolution 165 and recommendations of the fiscal year 2009
Independent Budget. Therefore, we support this measure and urge
the Subcommittee to work toward its enactment.
The next bill for discussion is H.R. 6153, the ``Veterans
Medical Personnel Recruitment and Retention Act of 2008.''
Along with our partners in The Independent Budget, DAV has
called for improvements in VA policies and procedures used to
recruit and retain highly qualified VA clinical staff. VA needs
new authority to achieve and sustain its goal to be competitive
with private sector providers and become a preferred employer
for physicians, nurses, dentists, and other medical personnel
needed to care for our enrolled veterans.
This bill aimed at providing meaningful financial and
professional incentives to encourage VA medical personnel to
pursue full careers in the VA healthcare system is timely and
appropriate given all of the challenges VA faces to maintain
delivery of timely, high quality, comprehensive healthcare
services to our Nation's veterans. The Independent Budget
conveys a series of recommendations that are fully consistent
with the intent of this bill. Therefore, DAV has no objection
to its enactment.
Mr. Chairman, on the final bill under consideration, since
we did not have a chance to really review that thoroughly, we
will be happy to submit in writing our views on that final
bill. Thank you.
[The prepared statement of Ms. Ilem appears on p. 32.]
Mr. Michaud. Thank you. Mr. Wilson.
STATEMENT OF JOSEPH L. WILSON
Mr. Wilson. Mr. Chairman and Members of the Subcommittee,
thank you for this opportunity to present the American Legion's
views on these three important pieces of legislation.
H.R. 3051, the ``Heroes at Home Act of 2007.'' This bill
seeks to improve the diagnosis and treatment of traumatic brain
injury in members and former members of the armed services, to
review and expand telehealth and telemental health programs of
the Department of Defense and Department of Veterans Affairs,
and for other purposes. Section 2 of H.R. 3051 requests the
Secretary of VA to establish a program on training and
certification of family caregivers of veterans and members of
the active-duty armed forces with traumatic brain injury as
personal care attendants.
Pursuant to Section 744(a)(2) of Public Law 109-364, the
Veterans Traumatic Brain Injury Family Caregiver Panel was
established in 2007. The 15-member panel was created by the DoD
to operate under the Department of Health as a Subcommittee to
advise and specifically provide DoD and VA with independent
advice and recommendations on the development of training
curricula to be utilized by the above mentioned family members
on techniques, strategies, and skills for care and assistance
for such individuals with TBI, or traumatic brain injury. The
panel was convened on occasions, to include a recent townhall
meeting to discuss matters related to the development of this
curriculum and to hear from the public about the issue.
Now, the American Legion asserts that the advice of this
subcommittee, incorporated into the provisions of this piece of
legislation, is vital and that its absence may deprive such a
bill of an effective stance and approach to treatment and care
of TBI. The American Legion, in its continuing efforts to
increase access and quality of care to all eligible and
potentially eligible veterans, supports this proposal as it
would help to accomplish this ongoing challenge.
H.R. 6153, the ``Veterans Medical Personnel Recruitment and
Retention Act of 2008.'' This bill seeks to amend Title 38 of
the United States Code to enhance the capacity of VA to recruit
and retain nurses and other critical healthcare professionals
in addition to addressing other issues. The American Legion
applauds this proposal to amend the methods of hiring and
retain an additional medical personnel of various disciplines
to adequately equip VA medical facilities to ensure the
adequacy and quality of treatment and care. The American Legion
supports the proposal requested in section 2(j), which seeks to
amend 7451(c)(2) to allow critical fields
such as nurse anesthesiologists to exceed rate limitations on
authorized competitive pay.
Although VA has various anecdotal programs in place to
include recruitment, relocation, and retention incentives for
these hard to fill positions, there remains a shortage of such
nurses and specialty medical physicians. The overall response
to the question of shortage indicated that salaries and delays
in appointments were key causative factors. The American
Legion, during its VA Medical Center site visits to 49
facilities in 2008, encountered various recruitment issues,
including such delays in the appointment of nursing assistants.
Management attributed these delays to the 3- to 4-month hiring
process. By the time management completed the hiring process,
applicants had accepted a position in the private sector.
Also in their site visits, the American Legion
representatives ascertained other areas with difficulty
recruiting. These included mental health positions,
specifically psychologists and psychiatrists, dermatology,
gastroenterology, orthopedics, and anesthesia. A study
published in the New England Journal of Medicine ascertained
there were shorter inpatient delays and lower complication
rates in hospitals with higher staffing levels while there were
longer inpatient stays and increased urinary infections,
gastrointestinal bleeding, pneumonia, and shock or cardiac
arrest in hospitals with lower staffing levels.
We hereby urge Congress to act on this piece of legislation
by incorporating it into the VA system to prevent the
healthcare system from being included in the casualties of the
projected shortage of medical professionals through the year
2020.
And I will briefly comment on H.R. 6629, the ``Veterans
Health Equity Act of 2008.'' The bill seeks to amend Title 38,
United States Code, to ensure that veterans in each of the 48
contiguous States are able to receive services in at least one
full-service hospital of the Veterans Health Administration
(VHA) in the State or receive comparable services provided by
contract in the State. The American Legion wholeheartedly
concurs with one proposal portion of this bill, which urges the
Secretary of VA to allow veterans equal access to full-service
hospitals. However, in Section 2, the terminology, ``certain
States,'' leaves question of an alternative or adverse motive
unfavorable to proposals to further enhance access and quality
of care across the board within the VA healthcare system. In
addition, under Section 2 the proposal to insert the language,
``access to full-service hospitals in certain States,'' once
again does not warrant unanimous support for this piece of
legislation. The term ``certain'' implies some States as
opposed to all.
The purpose of this piece of legislation, which is also the
leading opening statement of the bill, seems to be contradicted
by Section 2, which includes such language as stated in the
above mentioned paragraph. The uncertainty of this legislation
leads the American Legion to avoid a position on this bill.
Mr. Chairman and Members of the Subcommittee, the American
Legion sincerely appreciates the opportunity to submit
testimony. Thank you.
[The prepared statement of Mr. Wilson appears on p. 38.]
Mr. Michaud. Thank you very much. Dr. Berger.
STATEMENT OF THOMAS J. BERGER, PH.D.
Mr. Berger. Mr. Chairman, Ranking Member Miller, and
distinguished Members of this Subcommittee and guests, the
Vietnam Veterans of American, VVA, thanks you for the
opportunity to present our views on these important pieces of
legislation affecting the healthcare of America's troops and
veterans. With your permission, I shall try and keep my remarks
brief and to the point.
In general, Vietnam Veterans of American supports the
intent of H.R. 3051. But remember, medical experts say that
traumatic brain injuries are the signature wound of the Iraq
War in particular and in fact TBIs have become so commonplace
that we are yet again focused on them today in this hearing.
Certain TBI symptoms, such as seizures, can be treated with
medications. But the most devastating effects, such as
depression, agitation, and social withdrawal are difficult to
treat with medication, especially when there is loss of brain
tissue. In troops with documented TBIs, the loss of brain
function is often compounded by other serious medical
conditions that affect physical coordination and memory
functions. These patients need a combination of psychological
and physical treatment that is difficult to coordinate in a
traditional medical setting, even when properly diagnosed at an
early date. And we must remember that both concussive and
contusive brain injuries are never just isolated injuries. Over
time, without proper diagnoses, care, and treatment, TBI can
affect nearly everything about the survivor, including one's
cognitive, motor, auditory, olfactory, and visual skills,
perhaps ultimately resulting in behavioral modifications and
definitely not a mental illness. Families say that they
struggle with the military and the VA medical systems that were
unprepared for these wounded. In some cases, new equipment and
specially trained staff needed for the most catastrophic cases
are not available, or have not kept pace with the advances in
battlefield medicine that kept these servicemembers alive. In
addition, there are issues about intensity and drain of needed
family support that will be hard to sustain, as well as the
significant issues regarding the complexity of the medical and
other specialized needs that need to be addressed with TBIs. Of
all the War's medically challenging injuries, brain injuries
require the most personal involvement, dedication, and cost
over time.
As you are well aware, one of the recommendations of the
Dole-Shalala Commission was to significantly strengthen support
for families. This will not be an easy task, but VVA believes
that H.R. 3051 can be a key step in achieving this
recommendation and providing a mechanism for empowering the
families of brain-injured servicemembers if, and only if, the
VA can develop effective implementation strategies for
certification, competency evaluations, and meaningful outcome
measurements to carry it out. As they say, the devil remains in
the details. And part of our concern, of course, lies with the
fact that there is so much variation amongst the States'
regulations relative to training, certification, outcome
measurements, et cetera, for brain-injured persons. It will be
a difficult task. But if the VA can pull it off, it certainly
holds hope for family members.
Regarding H.R. 6629, we certainly, we did not submit any
written testimony but we certainly support equitable pay and
hiring processes that will permit our professional staff at the
VA facilities to at least achieve comparable pay and salaries
with those in the private sector to provide the care that is
needed by our veterans.
Regarding the, excuse me, that was not H.R. 6629. That was
H.R. 6153. On H.R. 6629, we just got that on Friday and we have
not had an opportunity. Now we have heard some background
information and we will submit written testimony in 10 days.
Thank you very much for the opportunity to do this.
[The prepared statement of Dr. Berger appears on p. 39.]
Mr. Michaud. Thank you very much, doctor. Once again, I
would like to thank the panel. A couple of questions. Ms. Ilem,
you had raised concerns with implementing the caregivers'
training program in each of the VA Medical Centers due to the
lack of capacity, and recommend that the program be limited to
polytrauma centers and other units within the Defense and
Veterans Brain Injury Network to ensure the training is high
quality. Do you have any suggestions on how we can address, the
challenges you highlighted so that the program can be
implemented in all VA Medical Centers?
Ms. Ilem. Well, we did note that so that, you know,
initially because we felt that probably that is where the
families would be. You know, where those patients would be and
have the initial opportunity to work with those families. So to
keep consistency, you know, hopefully to be able to develop
some best practices to make sure it is consistent, standardized
training, to do that, and then to, you know, be able to press
that out, if necessary, you know, depending on, you know, the
need for that. But since so many of those veterans are either
going to the Veterans Integrated Services Network (VISN) area,
one of the polytrauma, you know, level one polytrauma centers,
or then, you know, to their VISN level polytrauma center we
felt that would be the most appropriate place to start just to
maintain that high quality and consistency of training.
Mr. Michaud. Mr. Wilson, I did not expect you to comment on
the Congresswoman's legislation, but since you did and did not
take any position on it, would you, having heard her testimony,
agree that it is important for veterans, regardless of where
they live, to have access to healthcare? I can understand the
concern with building a brand new hospital. I want to make sure
that veterans get the services they need versus bricks and
mortar. But it appears that the concern is that there is a
large number of veterans who have to travel 4 hours to get the
care that they need. Would you agree that it is important that,
if there is care that is needed, whether it is fee-for-service
or otherwise, that that be provided?
Mr. Wilson. Well, in terms of access, and from my
experience in traveling throughout various VISNs in this
Nation, and even to include Puerto Rico, there is an issue with
access in addition to New Hampshire. The American Legion does
not exclude any one particular VA Medical entity within the VA
healthcare system. That's where we have concerns regarding the
overall piece of legislation itself. However, there were
portions, in regards to the access of care, level of care, and
quality of care at New Hampshire. And I am sure someone can
attest to access as an issue. Let's use Nevada, because with
Nevada has a large catchment area. There is an issue with
traveling to various VA medical facilities in Nevada. And I can
name quite a few, actually, in regards to access. We have ``A
System Worth Saving'' booklet, our annual publication that we
disseminate to Congressional Members. You can read it in the
2008 publication, regarding access issues. So we do support the
issue of improving access to care. However, regarding that it
is not a competition here. We would like to take all VA medical
facilities to that level of quality access and care.
Mr. Michaud. Thank you. Mr. Miller. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman, I just have a couple of
quick questions here on, for the VVA on H.R. 3051. You
highlight the need to ensure that VA develop effective
implementation strategies for certification, competency,
evaluation, and meaningful outcome measurements. I wonder if
you could expand on that point? And then, is there additional
legislative text that you would recommend adding to the bill to
ensure that the provisions in the bill are implemented
effectively?
Mr. Berger. Thank you, sir. In regard to the first part of
the question, I refer to my comment that there is a great deal
of variation amongst the States relative to private and not-
for-profit institutions or agencies that offer these kinds of
services, particularly in rural areas across the country. And I
am not hinting that they are bad in this State or they are
better in this State, I am just saying there is no
standardization across the country.
My own personal experience in working both with Easter
Seals of Illinois and United Cerebral Palsy brings this to the
forefront. The standards for caregivers for brain-injured
persons in these organizations in two parts of the country were
extremely different. I think that if the VA were to develop a
standardized process, for lack of a better term, not to run
through everything that I said, this would help greatly. And
then the family members could take advantage of this.
We are going to have a problem down the road, particularly
in rural areas, with family caregivers taking care of folks if
they do not receive proper, standardized training.
Mr. Hare. I just wanted, maybe all three of you could
comment on this, on H.R. 6153, supporting the legislation. Are
there other health professionals who are not included in H.R.
6153 who face recruitment and retention challenges and would
benefit from flexibilities provided in the bill? For example, I
know the Paralyzed Veterans of America (PVA) in their statement
for the record identified a shortage of spinal cord injury
disease nurses and the need to apply the specialty pay
provisions to the groups. So I guess what I am asking you, are
there other health professionals that ought to be included in
the bill, or concerns that you may have with that?
Mr. Wilson. In regards to specialty medical positions, I do
not want to, I cannot specify further than what I have recorded
on paper. However, speaking from our various site visits I can;
we will soon disseminate the ``System Worth Saving''
publication in which you could actually read for yourself from
the horse's mouth, if I can say in retards to the various
shortages. The concern, in discussion, comes from management
within each respective VA medical facility.
Mr. Berger. Mr. Hare, I would certainly add those
specialized social workers that deal with brain injury and
seizure disorders.
Ms. Ilem. I would agree with PVA's statement and I am not,
any other ones have not been brought to our attention, that
have been missed. But if we are made aware of any of those we
will certainly forward those on.
Mr. Hare. Thank you very much. Thank you, Mr. Chairman.
Mr. Michaud. Thank you, Mr. Hare. Mr. Snyder.
Mr. Snyder. Thank you, Mr. Chairman. Mr. Wilson, I wanted
to follow up a little bit on this issue that Mr. Michaud asked
about with regard to Carol Shea-Porter's bill. Because I think
we are all in agreement, you know, we want access for all
veterans. It is just, I guess it is the reality of the human
condition is we tend to nibble off things that we can, you
know, bite-sized morsels and move on. I mean, we have a bill
coming out on the floor I think tomorrow, or this week, or
something, Jerry Moran's bill. It came out through this
Committee and it, what do we call it, highly rural areas
because we recognize that distances in rural areas are, can
make it prohibitive. So I, while I understand we are trying to
equalize everything, I would also hope we would recognize there
may well be a peculiar nature of New Hampshire.
I have traveled in Nevada a fair amount. I have traveled
some in New Hampshire. It can be hard to get around New
Hampshire some times of the year. I had trouble walking in New
Hampshire at certain times of the year. I just want us to
appreciate that driving 100 miles in certain parts of the
country is probably a whole lot different than driving 100
miles in New Hampshire in the wintertime. And so I do not think
we should be afraid of doing something that helps one State
that for probably historical reasons never got themselves a VA
hospital for whatever reasons in years ago in the past. I do
not think we should not be willing to deal with that problem
hoping that somehow we are going to correct all of the problems
of access to healthcare before we deal with New Hampshire. That
does not seem a very good approach. And I use as a model as
somebody already did the highly rural area we are trying to, as
a pilot, that Jerry Moran's bill, which I think you all
supported. I think the American Legion did support Jerry
Moran's bill and it does not deal with nationally. So thank
you, Mr. Chairman.
Mr. Michaud. Thank you, Dr. Snyder. Ms. Berkley.
Ms. Berkley. I have no questions of the witnesses but I
want to thank you for taking time out and coming to testify.
Mr. Michaud. Mr. Salazar.
Mr. Salazar. Thank you, Mr. Chairman. Mr. Berger, do you
believe that H.R. 3051 actually begins to implement the
provisions of the Dole-Shalala recommendations?
Mr. Berger. I think that particular recommendation about
support for the family is contained in the bill, yes, sir.
Mr. Salazar.. Let me just read you a little bit of the
statement that was submitted for the record by Anna Frese, who
is with the Wounded Warrior Project. She talks about her
brother, Retired Army Sergeant Eric Edmundson, who was
seriously injured in Iraq in October 2005 and is currently
living at home receiving 24/7 care from her father, Edgar
Edmundson. This is what the father experienced. ``Upon learning
of Eric's lifelong challenges, our father resigned his position
at work in order to provide Eric the full-time care that he
needed. This decision did leave him and our mother with one
less income, and in times of need they had to dissolve their
personal and retirement savings. Just as importantly, now at 53
years old, my father is no longer covered by health
insurance.'' So these are the kinds of issues that families
face----
Mr. Berger. Yes, sir.
Mr. Salazar [continuing]. Eespecially in rural communities
where they do not have facilities close by. It seems to me that
soldiers or patients who have gone through some kind of
traumatic brain disorder can actually recover better and have a
better quality of life by having family caregivers. Is that
correct?
Mr. Berger. That is absolutely correct, sir.
Mr. Salazar. Thank you. I would ask for Mr. Wilson and Ms.
Ilem to comment on that as well?
Mr. Wilson. I have no comment currently. Please refer to
our book, ``A System Worth Saving.''
Ms. Ilem. We would agree that the family caregiver issue,
just as you have noted, in talking with family members you see
how their lives are impacted and DAV is very supportive of
doing everything we can to support the caregiver to make sure
veterans have the best care possible, and in the best
environment for those veterans.
Mr. Salazar.. Well as you know, VA does not support H.R.
3051 because they say there are current provisions and existing
efforts that accomplish the goals of the caregivers training
program and outreach for PTSD and TBI patients. Would you
comment on that?
Mr. Berger. Again----
Mr. Salazar. Are the programs that are already in place
sufficient?
Mr. Berger. I do not believe that they are, sir.
Mr. Wilson. I also disagree that they are. The Veterans
Traumatic Brain Injury Family Caregiver Panel, which is in
place, has not been fully effective in resolving that issue of
that disconnect, of that family, or family member, or even an
associate being a caregiver to that particular patient. As I
stated in the testimony, maybe the two in a contiguous effort,
or maybe the two actually in consortium may be able to decrease
the gap there and allow for more continuous care.
Mr. Salazar. Ms. Ilem.
Ms. Ilem. In just briefly looking over VA's testimony, I
think they indicated that they are providing their
certification and training for these family caregivers through,
you know, already an outside third party that is doing that.
And I think in just, you know, looking at that this morning,
you know, the concern would be with these very special cases of
TBI and the very high-care needs of these veterans and the
family members, you know, if we are really understanding and
making sure that they can go the distance to provide that care
as well, to make sure that they are taking care of themselves.
We would like to have VA, you know, at the forefront because
these are some very specific, you know, service connected
injuries that are occurring, for them to be at the forefront of
providing the training and certification to make sure that they
have, you know, the really overview and the quality of that
care that they hold so high in esteem in VA.
Mr. Salazar.. Would any of you wish to comment on how you
feel that this would actually save the VA some additional
monies by being able to take care of these veterans at home?
Mr. Berger. Certainly, sir, your testimony threw out some
dollar figures that I think are absolutely right in line. I do
not think you can put a dollar value on the care that can be
given by family members who are properly trained to care for
these brain-injured troops. And so I will leave it at that. I
do not think you can put a price tag on it.
Mr. Wilson. In regards to TBI itself, there are other
issues arising from TBI, to include blind eye injury and PTSD.
If TBI is left untreated, it becomes difficult to distinguish
from other disorders. For example, a lay person who does not
understand the symptoms, or in denial, can attribute to the
breakdown in his/her family. That is also an added issue. And
after reading this particular piece of legislation, we were in
agreement at the American Legion that this was something that
needed to be implemented.
Mr. Salazar.. Ms. Ilem.
Ms. Ilem. I think without question the costs would be
higher if left to the Government to provide, you know, full-
time in-house care versus at home. But I think that most
importantly it is the quality of life. And if the family wants
to provide that care for their loved one, then they should be
provided the resources they need and the support that they need
to provide the best care to that veteran. But I think cost
aside, the quality of care issue is probably the most
important.
Mr. Salazar. Thank you all for your testimony. I yield
back, Mr. Chairman.
Mr. Michaud. Thank you very much, Mr. Salazar. Once again,
I would like to thank all three of you for your testimony here
this morning.
The last panel is Dr. Cross, who is the Principal Deputy
Under Secretary of Health, and will be accompanied by Walter
Hall and Joleen Clark. I want to thank you all, for coming here
today to give your testimony on the two pieces of legislation
we have, and the third piece that was added at the last moment.
Without any further ado, Dr. Cross.
STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A.
HALL, ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL,
U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JOLEEN M. CLARK, CHIEF
OFFICER, WORKFORCE MANAGEMENT AND CONSULTING, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Cross. Good morning Mr. Chairman and Members of the
Subcommittee, and thank you for inviting me here today to
present the administration's views on two bills under
consideration, H.R. 3051, the ``Heroes at Home Act of 2007,''
and H.R. 6153, the ``Veterans Medical Personnel Recruitment and
Retention Act of 2008.'' VA recently received H.R. 6629, the
``Veterans Health Equity Act of 2008,'' and is not prepared to
address the bill today but we will be happy to submit our views
and cost estimates on the bill for the record. VA is still
preparing cost estimates on the other two bills on today's
agenda. As soon as those become available, we will supply them
for the record. Also, I want to say I am accompanied today by
Mr. Walter Hall, Assistant General Counsel, and Mrs. Joleen
Clark, our Chief Officer for Force Management and Consulting.
[As of January 12, 2009, the VA failed to provide the
Administration views on H.R. 3051, H.R. 6153, and H.R. 6629.]
I will begin with H.R. 3051. section 2 would require VA to
establish a program to train and certify family members of
veterans and servicemembers with traumatic brain injury, which
is also called TBI, as personal care attendants. VA supports
using family members as caregivers for these veterans, but
believes VA's current home healthcare program already
accomplishes this in a more efficient and effective manner than
would be possible under the bill. Implementing section 2, as
written, could give rise to potential conflicts concerning the
veteran's care between the family member, the caregiver, and
the VA, with the veteran. This would place VA in an untenable
position. We strongly urge the Congress to allow VA to continue
to obtain caregiver services under the Home Healthcare Program,
which uses a third party to provide for the training and
payment of personal care attendants.
Subsection 3 of H.R. 3051 would require VA to conduct a
comprehensive outreach to enhance the awareness of veterans and
the general public about the symptoms of post traumatic stress
disorder and TBI and available VA healthcare services. VA
already has an extensive and expanding outreach program in
place to inform veterans and the general public about PTSD and
TBI, as well as the services we provide to veterans with these
injuries. We, therefore, think this statutory mandate is not
necessary.
Section 4 would require DoD and VA to jointly establish a
demonstration project to assess the feasibility and
advisability of using telehealth technology to assist cognitive
functioning of Members and former Members of the Armed Forces
who have sustained head trauma in order to improve the
diagnosis and treatment of TBI. VA supports the goals of this
provision, but cannot support this section as written because
it is too prescriptive. VA and DoD should be allowed more
flexibility in executing the demonstration project and would be
pleased to work with the Subcommittee's staff to develop
legislative language that would enhance its value.
I turn now to H.R. 6153, the ``Veterans Medical Personnel
Recruitment and Retention Act of 2008.'' We support many
provisions that would contribute to VA's mission, such as the
expansion of VA's education assistance program outlined in
section 4. Similarly, we endorse several measures that would
improve VA's ability to provide comparable pay and benefits to
nurses, physicians, and executives. Other sections of the bill
need only minor adjustments, such as the authority to add nurse
assistants to the list of so-called hybrid occupations. We
believe this authority should apply to healthcare delivery
occupations in general.
However, there are some provisions that would negatively
impact patient care and VA must oppose. Subsection 2B would
change the probationary period for full and part-time
registered nurses from 2 years to the equivalency of 4180
hours. Part-time Title 38 employees, including RNs, do not
serve probationary periods. These apply only to full-time
permanent employees. We see no benefit in creating a
probationary period for part-time nurses, since it would not
make them the equivalent of tenured employees for purposes of
discipline or discharge.
VA also opposed section 2C, which would limit temporary
part-time employments of hybrid nurses, specifically licensed
practical nurses, LPNs, and licensed vocational nurses, LVNs,
to no more than 4180 hours. Currently, the part-time hybrid
appointments may be for periods exceeding 1 year.
Operationally, this change could severely limit VHA by
preventing us from appointing highly qualified LPNs and LVNs
who only want to work on a part-time basis.
Finally, we oppose Subsection 2M since it appears to create
a windfall by extending premium paid benefits for employees
performing occasional work. We also note subparagraph 2 would
not be limited to registered nurses, which we understand is the
intent of this provision. It would also apply to other
employees. We are similarly concerned that Subsection 3B, which
would amend the ``Baylor Plan,'' could provide an unwarranted
bonus structure.
Mr. Chairman, this concludes my prepared statement. I am
happy to answer any questions that you or the Subcommittee may
have.
[The prepared statement of Dr. Cross appears on p. 40.]
Mr. Michaud. Thank you very much, Dr. Cross. You noted that
VA refers interested family members to home health agencies
that VA contracts with. How many referrals has VA made and does
VA pay for the training?
Dr. Cross. Under our program right now, VA currently
contracts with more than 4,000 home health agencies that are
approved by the Centers for Medicare and Medicaid Services and/
or State licensed. And many of these have expertise in training
and certifying home health aides. Many of them also are found
in rural settings and we can engage them there. I do not have
for you the exact number of individuals within that program.
Mr. Michaud. Could you provide that for the Committee?
Dr. Cross. Yes, sir.
Mr. Michaud. Of the referrals, how many, have completed the
certifications as well.
Dr. Cross. Yes, sir.
[The following information from VA was subsequently
received:]
In situations where a veteran will require long-term or
lifetime care or assistance in the requirements of daily
living, VA provides counseling and training to family members
and other caregivers who are capable and willing to take on
this responsibility. VA is not authorized to pay these
individuals and, for practical and legal reasons that were
discussed in our testimony and at the hearing, we do not
believe VA should be the appropriator or payer.
When it is clinically necessary and appropriate, VA has
arrangements with local contractors who will provide caregiver
training to family members and qualify them to be a State
certified caregiver. Following State certification, the family
member caregiver may become a certified, salaried employee of
that contractor or another entity that provides caregiver
services. The decision for referral to a contractor is made on
a case-by-case basis. VA has no data on the number of
individuals who elect to use this process.
Mr. Michaud. Does the VA provide respite care while the
family caregiver is in training programs so that the family can
continue to care for the needs of the veteran?
Dr. Cross. Yes. Our respite program is more broadly
construed. It can be for any number of reasons. It would not be
limited to just that one reason.
Mr. Michaud. In your testimony you identified language on
the telehealth demonstration as being too prescriptive and
detailed. Can you expand on that? What type of flexibility do
you need?
Dr. Cross. We are working with DoD and the Center of
Excellence already, and we want to continue doing that, and
intend to do so. Some of the language in the bill relating to
using telehealth for educational purposes is kind of a mixed
approach, using something that we use for diagnosis and
treatment for what appeared to be a more broad reaching
outreach effort. And we use other modalities for that. We did
not think that was a well constructed component within the
bill.
Other portions of the bill relating to the reporting
requirements would be substantial. We can work with your staff,
sir, to try and mitigate that. I think clearly on the intent,
we have the same intent.
Mr. Michaud. Good. Thank you. On H.R. 6153 you mention that
it is hard to recruit occupations that this provision would
help with. Can you give us, some of the top five occupations
that you are referring to?
Dr. Cross. I will ask Ms. Clark to comment.
Ms. Clark. Each year we do a, what we call Successions
Strategic Plan and we have the networks update their plans. And
we have what we call our top ten critical occupations. And
those this year are the traditional ones, nurses, physicians,
pharmacists, LPNs. We do have an administrative one in there,
human resources, occupational therapists, physical therapists,
medical technologists. Of the physicians there is several
occupations that were mentioned, actually, earlier in some of
the testimony. Gastroenterologist, anesthesiologist,
psychiatrist, there are a few others. And then inpatient
nursing areas, we do have a few that we target and certified
registered nurse anesthetists are also one of those
occupations.
Mr. Michaud. Thank you. You mentioned in your testimony
that VA is facing worsening pay compensation issues within the
ranks of senior pharmacy program managers in VHA, and that
special incentive pay provisions for pharmacist executives
would not address the retention need for the agency in the long
run. Could you explain what that need might be, number one? And
number two, what are you doing to try to address that need?
That is, I know actually, in VISN 1, they are looking at
building a brand new community-based outpatient clinic (CBOC)
in the Bangor area, but also we have a private college that is
interested in working collaboratively with VA for a pharmacy
program, which would be a great opportunity to work
collaboratively with higher ed. If you can, explain what the
needs are and what are you doing to help address those needs.
Dr. Cross. Sir, I will comment briefly on it and ask Ms.
Clark to add. In consultation with my Chief of Pharmacy for
this testimony today, we are holding our own fairly well in
most places for pharmacists at the staff level. Certainly it
remains a concern that we have to watch closely, because it is
a competitive environment. This provision was related to the
executive level and we have some challenges there in terms of
long lag times, absences, and difficulty in recruiting.
To follow on to your other comment, though, and what we are
doing, we do a great deal of effort in recruiting and reaching
out to individuals including schools. And I will ask Ms. Clark
to comment on some of that.
Ms. Clark. We are quite competitive with the pharmacists,
the staff pharmacists, because we can set special salary rates
depending on the area. So that is not as big a concern. We do
have to be vigilant so that we stay on top of it and keep those
salaries competitive. As Dr. Cross mentioned, it is our
executive rank, because there is not special salary rates for
those executive rank. And so to try to get people to take those
positions is really hard when they can get special salary rates
and make almost as much as a staff pharmacist at those levels.
So it is an issue and it is a problem to try to get those
salaries, something, some kind of other compensation for that
level.
Mr. Michaud. Is it more of a problem in rural areas than?
Ms. Clark. Well, the rural areas pretty much are just like,
with setting salaries, are pretty much the same across the
country. You can set them based on the local market and what
the local market dictates. And if that dictates paying
relocation incentives, retention incentives, because you have a
hard time keeping people in that area, you can pay those things
on top of the salaries. So there is mechanisms, you know, in
place for the staff pharmacists or the staff level employee.
Mr. Michaud. Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman. PVA expressed concern
that the development of programs to address the needs for
veterans with mild or subclinical TBI have not been fully
developed or implemented. Could you respond to PVA's concern?
Dr. Cross. We have done a tremendous amount of work in
regard to TBI. Let me just highlight a couple of key points. We
started this program back in the mid-eighties, creating special
centers for TBI which we have now modified to call polytrauma
centers. There were four of them. We are getting ready to open
up, we are getting ready to build a fifth one in San Antonio.
That was not enough. We have expanded those to create centers
at our Medical Centers, and reaching out even into our smallest
parts of our program by providing levels of expertise regarding
TBI at those sites. We have done something that is unique in
the United States. We are screening for mild TBI and we have
developed the screen in such a way as to be more sensitive than
specific.
Our intent was to not miss anyone. And so we designed the
program with some elements from DoD to create that screening
program. We have screened thousands and thousands at this time.
And when they screen positive we put them into a special
program. And what is more, we are reaching out to the ones that
we have not seen yet because we are concerned that there are
people who might need these services that we have not even
addressed. We are calling every single veteran from Operation
Iraqi Freedom and Operation Enduring Freedom who has not been
to one of our facilities and contacting them by phone and
saying, ``Hey, how are you doing? Can we help you?''
Mr. Miller. I think PVA is still saying the milder
subclinical issue has not been addressed.
Dr. Cross. Well, perhaps there is always more to be done.
And I value my colleagues in PVA's opinion. I take that very
seriously. I would be happy to have an engagement to go over
what we are doing currently because we have been pretty fast
moving on this, and there is a lot that has been done in the
past year or two.
Mr. Miller. Thank you, great idea. I think that, just
sitting down and having a conversation with them may clear up
some misconception. Also, on H.R. 6153, their concerns were
expressed that hiring and promotion processes under Title 38
hybrid is facing extraordinary delays because of boarding the
process. My question is, are the concerns valid? Are there
really problems with the boarding process?
Dr. Cross. Frankly, there are some concerns that I have
about how long it takes to bring someone on once we identify an
individual that is interested in the job. I should give you
just a couple of numbers and I will ask Ms. Clark to comment on
the process a little bit. But we have had some success. We have
expanded the number of nurse anesthetists. We added in net
several thousand additional nurses to the VA last year. I have
the most recent statistics yesterday. And Ms. Clark, can you
comment?
Ms. Clark. Yes, I will just add on to that. This year in
2008, we are projected in VHA to hire over 40,000 new
employees, which is approximately a 49 percent increase in
hiring over last year, over 2007. So it is like 13,000 more
that are being hired just because of the increase in services
that we are now adding. So that does add an extra burden. With
that, we do realize that it takes too long. We have added
different steps in the process with credentialing because we
think it is important to have all our staff credentialed and
make sure they are credentialed properly. So it has added some
timeframe.
We went through what we call process redesign to look at
all the steps and see where things can be cut out, and we are
working actively. Last year we started it. This year we are
going full force with it again. We have even included a
performance metric within all of our network directors
performance plan that after somebody is identified they have to
be brought on, or not brought on, but be offered the position
within 30 days. You know, usually they have to give a notice to
their employer but they can start effectively then if they
wanted to, actually, after that 30-day timeframe. And it has
been very successful in some areas. Some areas are still
struggling. But they all are improving their timeframes.
Mr. Michaud. Thank you. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman. Dr. Cross, I just wanted
to, just a couple things on H.R. 3051. You, in your testimony,
you identified the language of the telehealth demonstration as
being too prescriptive and detailed. I wonder if you could
maybe expand on the point and explain what flexibilities that
you think are needed?
Dr. Cross. I think if you could just leave it up to us to
design a demonstration project, working with our colleagues in
DoD we could come to a very workable, practical approach to
this. In fact, the truth is we are already doing much of this
in terms of collaboration. There has never been, in my
experience, I have been in the military 20, 25 years before
coming to the VA, I have never seen as much interaction and
collaboration between these two organizations as exists now. We
are in meetings with them at some level virtually every single
day. So we can work this through. And I think sometimes the
people on the ground can put this together better than anyone
else.
Mr. Hare. Well let me just say that, you know, last spring
we heard of internal VA emails identifying 12,000 annual
suicide attempts, an estimated suicide rate of 6,570 per year
across our veterans population. And these statistics to me show
that current efforts are not enough to help with the hundreds
of thousands of returning Iraq and Afghanistan veterans. So I
would really urge the VA to not be complacent with current
activities and to implement a comprehensive strategy and share
best practices with non-VA healthcare practitioners. I think
this bill goes a long way. And I commend my colleague for
introducing the bill. And I would I would like to see, you
know, and I agree with what Mr. Miller said earlier, that the
working together between the VA and the VSOs to come up with
something that is actually going to work here. And as you know,
I am very troubled by the numbers of that as I know you are.
And whatever we can do that will help, whether it is, you know,
and again, I think this bill goes a long toward doing just
that. But I would really like to see a collaborative effort
here on behalf of the VA and the VSOs to come up with something
that A will work. And when you design this demonstration
project, I was just wondering if I could go back to that for a
second. When you say, how long is that going to take, do you
think, to be able to design that project and before we----
Dr. Cross. The demonstration on telehealth?
Mr. Hare. Yes.
Dr. Cross. And the cognitive assessment? I met with my
staff on this, the experts. I did not actually get a timeframe.
I would have to get back to you with an answer to be accurate.
[The following information from VA was subsequently
received:]
Question: What is the projected timeframe for developing the
joint DoD and VA demonstration project to assess the
feasibility and advisability of using telehealth technology to
assess cognitive functioning of Members and former Members of
the Armed Forces who have sustained head trauma, in order to
improve diagnosis and treatment of traumatic brain injury?
Response: A timeframe has not yet been established. However,
the DoD and VA have made significant progress in the area of
interoperability since the National Defense Authorization Act
designated DoD as the lead agency and VA as the collaborating
agency in this initiative. The two departments have developed
an in-depth interoperability plan for the demonstration project
that includes verification of an existing evidence-based and
validated telehealth application to assess cognitive function.
In developing the timeframe, DoD and VA will need to allow
sufficient time for both departments to develop the project's
clinical scope, arrange technology support, determine location
and necessary personnel, and consider legal and regulatory
issues before the actual demonstration project is underway.
Mr. Hare. Thank you, Mr. Chairman.
Mr. Michaud. Mr. Salazar.
Mr. Salazar. I do appreciate your having this hearing
today, first of all. Dr. Cross, you state that whether the
caregiver compensation is for caregivers as a VA employee
versus the benefit, that raises significant legal issues
relating to liability, taxation, the VA relationship and
responsibilities to the veteran, and the caregiver, can you
explain that and expand on that a little bit?
Dr. Cross. Well, I will do my best but I think my counsel,
Mr. Hall, will probably do a better job than I can so I will
turn it over to him.
Mr. Salazar. And before you answer that, can you also
address the issue of, how this bill adheres to what the Dole-
Shalala recommendations were. And, are you saying that they
were just spitting in the wind when they made these
recommendations because you were already doing all of this? Or
could you expand on that a little bit as well?
Dr. Cross. Let me, I wanted to have a chance to respond to
that. Because we support the intent of this. And in fact, that
bill, you know, those provisions have been out and under
discussion for some time now. And so, yes, we have already been
acting on many of these things. Outreach for PTSD and TBI, we
have, I listed just in the written testimony several paragraphs
of our measures that we have instituted. The suicide prevention
hotline, Mr. Hare's comment about suicide, tremendously
important issue for us. The clinical guidelines, we are
publishing them, working with DoD every day to refine them and
develop them further. We call in the Institute of Medicine to
help us with TBI and PTSD issues. Telehealth, we have got tens
of thousands of patients now receiving support from telehealth.
So, yes, we are taking these very seriously. We did not wait
for today to start on this. And that is why we phrased our
comments the way we did. But our intent is very much consistent
with what you have here. And I will ask Mr. Hall to expand on
the fine points of that distinction.
Mr. Salazar. Let me just follow-up on it. So in other words
what you are saying is, we do not need the legislation to
address the issues. We are already doing everything Dole-
Shalala recommended, is that correct?
Dr. Cross. Well, the training for family members was not
one of those. We think that there are significant issues that
have to be addressed there and the way that the bill was
phrased to provide the support directly was problematic for us.
And we wanted to continue using what we have found to be the
more effective, efficient working well mechanism using these
healthcare agencies across the United States.
Mr. Salazar. Well, are you currently providing compensation
for family members, not only the training part of it, but
family members when they have to quit their jobs to take care
of someone who has PTSD or traumatic brain injury?
Dr. Cross. I will ask Walt to correct me if I am off base
here but the home health agencies that we contract with can
hire the family member and do so.
Mr. Salazar. Okay.
Mr. Hall. Yes, sir. That is what in fact is going on now,
is that we contract with the home healthcare provider who then
hires the family member, provides them the training, then
supervises the care that they give to the veteran. That puts
them in the position of being responsible for assuring the
quality, assuring the liability coverage of the caregiver, the
family member, in case, and making sure that the quality of the
care that they are getting meets the standards that are
required.
The way the legislation is phrased it says that VA will
compensate the caregiver. It does not say exactly what the
status of the employee, or the caregiver, will be. Will they be
VA employees? Will they be responsible to VA? Will VA be
responsible for them as far as things like insurance liability,
liability for care, if the care that they are not giving
somehow, the care that they give somehow injures the veteran?
What is the liability? If it is a VA employee then of course
the VA is responsible for that liability regardless of the
relationship between the caregiver and the veteran. It is just
a, it raises a number of issues like that. If it is
compensation, is it compensation to the veteran? Or is it
compensation to the caregiver? Do they become a VA beneficiary,
for example, like somebody receiving compensation and pension
would be receiving? If, and then that raises the case of VA's
responsibility for overseeing that care. What is the quality of
that care? Are they doing the job that the veteran needs? If
they are not what is VA's recourse? Do we terminate the
compensation, and what is the mechanism for doing that? It just
raises a lot of----
Mr. Salazar. So then what you are saying, you do not really
have any oversight over the caregivers that you currently have?
I mean, that is what I heard you say, is it not? Because of the
liability issue?
Mr. Hall. No.
Dr. Cross. First of all, of course, as I pointed out in the
written testimony I think, we look for those home healthcare
agencies that are approved by the Centers for Medicare and
Medicaid Services and State licensed.
Mr. Salazar. Okay. But they assume the liability in case
something goes wrong?
Dr. Cross. Correct.
Mr. Salazar. And you have oversight over those caregivers?
Mr. Hall. Yes, sir. They are responsible under the contract
that we have with them to provide care to a certain standard.
Mr. Salazar. And what is your recourse if they do not?
Mr. Hall. Then we are able to, under the, we have recourse
under the contract, either to demand damages or payment from
them, or to terminate the contract.
Mr. Salazar. Thank you, Mr. Chairman.
Mr. Michaud. Thank you very much, Mr. Salazar. I just have
one follow up question, Dr. Cross. Actually, the three of us
and Ranking Member Miller, had the chance to go to Iraq and
visit with the troops, and talk to the individuals over there
about healthcare. One of the issues that, I actually asked
several of the generals we met with is, what they are doing
personally to help, destigmatize PTSD, or traumatic brain
injury. We got, the normal response that we get. But the
interesting thing is, at one facility after we went out and did
our photo shoot out front, someone with lesser command came up
to me and very discreetly said, you know, ``We need more
help.'' They are not getting the help that they need to, to the
soldiers.
You mentioned that you are working with the DoD on a daily
basis. What are you doing to help with that destigmatization?
For instance, a couple of days ago when I was in Indiana, we
had a veteran who called a Congressman, as well as the press,
and said he was going to kill himself during our meeting at the
CBOC. We were able to take care of that. But, there is a big
problem out there. Are you working with other groups? What
actually came to my attention when you look at a lot of our
athletes, which are looked at as heroes as well, when you look
at the concussion that athletes have, which is mild TBI, are
you working with the other organizations such as, sports, to
see what they can do to help destignmatize issues such as TBI
or PTSD?
Dr. Cross. Thank you for that question, sir. The stigma is
very real. We recognize that. We do not deny that. And we take
it very seriously. Let me tell you three or four of the things
that we are doing in conjunction with your experience in Iraq.
I do not think many people necessarily who are experiencing
depression are anxious to go sit in a waiting room that says
psychiatry or mental healthcare. We recognize that so we
created a nationwide initiative which we have already executed
to insert our mental healthcare, a portion of it into primary
care clinics, where the patients have already been and are
already usually comfortable. We start the process right there,
make the diagnosis, make the first contact, break the ice, so
to speak, right in that setting. Then we are doing education.
If you go out on the metro here in Washington, or watch some of
the buses going by, you will see a sign. It says, it is a 1-800
number, ``Call it for help.'' It is from the VA. If you call
that number and press 1 as it tells you, it takes you to our
facility at Canandaigua, New York. And when you, and you can
call them anonymously you do not have to give them a name, but
they will encourage you to do that. And that is our suicide
prevention hotline in which we have had like, I think 50,000 or
60,000 calls since we have opened it. Now, many of those were
not veterans. Many of them were people just calling for
information. But some of them were significantly asking for
help and we have done many rescues.
Our Vet Centers are a key tool that we have, where you have
combat veterans talking to combat veterans. Combat veterans on
our staff, and they have a totally different record system and
create a real sense for that individual of privacy and
confidentiality, and a lack of bureaucracy, perhaps, that would
be different from a large hospital. So those are several of the
things that we are doing.
We recognize that issue. We think it is very important, and
that is why we are putting these programs, and have already put
those programs in place.
Mr. Michaud. I know it is out of your jurisdiction, but
actually I was reading an article somewhere where they had, I
think, the Dallas Cowboy Cheerleaders overseas to bring morale
to the troops. During your discussions, I am just wondering
whether it might be worthwhile with your discussion with DoD
whether or not you do have these athletes who will admit that
they have mental health problems and could really help with
destigmatization of this issue.
Dr. Cross. Sir, even while we are speaking right now there
is a conference going on, I believe, back at my headquarters
and the tape, it is not an athlete but it is a movie star. They
are doing a press release with a videotape of Gary Sinise. I
think that was Lieutenant Dan. And talking about the issues of,
you know, how we are encouraging folks to come in and get help.
John Elway was also involved with us on some public releases
that we have done. He has been very helpful, and others as
well. And I hesitate because I might leave somebody out, but a
number of them have been very helpful.
Mr. Michaud. Okay. Well, thank you very much. Lastly, I
know you are going to provide written testimony on
Congresswoman Shea-Porter's, legislation. She already made
clear--well, the Secretary did--that they are not going to get
a hospital, but it appears that there is a problem with her
veterans getting service. If you are opposed to her legislation
if there is a way that we can look at addressing her concerns,
you know, as well it would be very helpful.
[As of January 12, 2009, the VA failed to provide the
administration views on H.R. 3051, H.R. 6153, and H.R. 6629.]
Dr. Cross. Of course, sir, and we will do that.
Mr. Michaud. Okay. Well, once again I want to thank you Dr.
Cross for your testimony, but also for your ongoing support for
taking care of our veterans. You have always been a gentleman
and I really appreciate working with you and your staff as
well. If there are no other questions, we will adjourn the
hearing. Thank you very much.
[Whereupon, at 11:31 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud, Chairman,
Subcommittee on Health
I would like to thank everyone for coming today.
Today's legislative hearing is an opportunity for Members of
Congress, VSOs, the VA and other interested parties to provide their
views on and discuss legislation that have been introduced within the
Subcommittee's jurisdiction in a clear and orderly process.
I do not necessarily agree or disagree with the bills before us
today, but I believe that this is an important part of the legislative
process that will encourage frank discussions and new ideas.
We have three bills before us today.
I look forward to hearing the views of our witnesses on these bills
before us. I also ask that witnesses submit their views for the record
on H.R. 6629.
Prepared Statement of Hon. Jeff Miller, Ranking Republican Member,
Subcommittee on Health
Thank you, Mr. Chairman, for holding this legislative hearing.
Today, we will hear testimony on three legislative proposals--
H.R. 3051, which would require VA to establish a program to train,
certify and compensate family members of veterans and servicemembers
with Traumatic Brain Injury (TBI) as personal care attendants;
H.R. 6153, the Veterans' Medical Personnel Recruitment and
Retention Act of 2008; and
H.R. 6629, which would require that veterans in the 48 contiguous
states have access to full service medical care through at least one VA
hospital in the state, or through a contract with other health
providers in the state.
Providing the highest quality of care for our wounded warriors
suffering with a TBI, the recruitment and retention of the very best VA
healthcare providers, and access to care for every veteran regardless
of where they live are issues that our Subcommittee has been focusing
on throughout the year.
VA has recently developed and implemented many new programs and
policies to address the needs of veterans with TBI, help recruit and
retain its corps of healthcare professionals and enhance access to
care. I want to commend the Department for their ongoing efforts.
However, during this critical time, we must continue to look at where
gaps in services still exist and what more can be done to ensure that
our veterans receive the highest quality healthcare services.
I want to thank all of our witnesses for being here today. I look
forward to a productive discussion and the opportunity to fully examine
the legislative proposals before us. I am hopeful that this debate will
help guide our actions on developing legislation that will best serve
our Nation's veterans.
Thank you Mr. Chairman, I yield back.
Prepared Statement of Hon. Phil Hare
First, I would like to thank Chairman Michaud and Ranking Member
Miller for holding this hearing. The three bills before us today
address important issues, all of which have huge impacts on the welfare
of our Nation's veterans.
Second, I would like to thank the sponsors of these bills, the
three members that are testifying before us today.
Mr. Salazar is a fellow Committee Member and I know from sitting
next to him over the past 2 years, that he is a tireless advocate for
veterans, especially the many rural veterans that live in his large
district in Colorado. His bill addresses family caregivers for veterans
suffering from TBI, and also telehealth services. These are crucial
matters and are directly in line with Mr. Salazar's passion for
improving the lives of veterans and their families.
Ms. Johnson is also a big supporter of veterans. For 15 years she
worked at the Dallas VA Medical Center as a medical and psychiatric
nurse. Appropriately, her bill aims to help VA recruit and retain more
nurses and other healthcare professionals.
Ms. Shea-Porter and I came into Congress at the same time, and I
know without a doubt, that there is nobody more dedicated to serving
our veterans than she is. It is a paradox then that her home state, the
great State of New Hampshire, does not have a VA medical center. Her
bill attempts to resolve this injustice.
Third, I would like to thank all our witnesses for testifying
today, including Dr. Cross of the VA and each representative of the
three VSOs present. I would also like to congratulate the Disabled
American Veterans for recently electing Raymond E. Dempsey, a fellow
Illinoisan, as National Commander. Speaking on behalf of the great
state of Illinois, I take great pride in knowing that such a well-
respected organization is under the leadership of Mr. Dempsey.
Mr. Chairman, thank you again for holding this important hearing.
Prepared Statement of Hon. Eddie Bernice Johnson,
a Representative in Congress from the State of Texas
Thank you, Mr. Chairman, and Members of the Subcommittee, for the
opportunity to testify today on issues related to veterans.
Millions of veterans nationwide receive treatment in the VA
healthcare system. A significant number of these veterans have returned
from war--including the wars in Afghanistan and Iraq--with serious
injuries, including traumatic brain injury. Quite understandably, a
large number of troops are also suffering from psychiatric disorders,
such as post-traumatic stress disorder.
It is our duty to ensure that our veterans, who have so
courageously served our country, receive the medical support they
deserve. The VA system must be able to successfully compete for the
best healthcare providers in the United States. Today, I speak in
support of the Veterans' Medical Personnel Recruitment Act of 2008,
because it gives the VA the tools to recruit and retain the very best
medical and professional employees.
This legislation will raise salaries for nurses, physicians,
dentists, senior executives and pharmacist executives. It will
streamline pay systems, making them easier to understand and to
implement. It will provide incentives to retired employees to return to
the VA system by removing annuity and salary offsets, thereby
encouraging the qualified workers most familiar with the VA system to
return to work. The legislation will also increase education benefits
for new VA hires and current staff.
I worked as a medical and psychiatric nurse at the Dallas VA
Medical Center for 15 years, and I can attest to the unparalleled role
nurses play in all medical facilities. Nurses are often the medical
professionals with whom patients have the most contact, and they are
repeatedly cited by patients as the medical professionals they trust
the most. There is a nursing shortage in our country, and if we want
the VA to attract the very best nurses, we must provide the proper
incentives.
Standardizing the definition of ``emergency'' will facilitate more
consistent and equitable use of emergency mandatory overtime. By
clarifying VA regulations regarding work schedules, overtime and
emergency duty the Veterans' Medical Personnel Recruitment and
Retention Act will offer nurses more schedule flexibility and provide
for the VA to become a more employee-friendly place to work. The
legislation will also make it easier for the VA to hire and retain
part-time nurses and to allow full-time nurses to transition to part-
time work schedules.
The Veterans' Medical Personnel Recruitment and Retention Act will
strengthen the VA system, helping to make the VA the healthcare
employer of choice. Our veterans, who have so courageously served our
country, deserve its passage and implementation.
Mr. Chairman, this concludes my testimony I will be happy to answer
any questions that you may have.
Prepared Statement of Hon. John T. Salazar,
a Representative in Congress from the State of Colorado
Thank you Mr. Chairman.
First I would like to thank Dr. Jim Schraa, a Neuropsychologist at
Craig Hospital, and Anna Frese, with the Wounded Warrior Project, who
submitted testimony for the record.
On July 17, 2007 I introduced H.R. 3051 the Heroes at Home Act.
The purpose of this bill is to improve the diagnosis and treatment
of traumatic brain injury in current and former Members of the Armed
Forces.
The program will be located in VA healthcare centers across the
Nation.
This is especially important to rural districts like mine where
making healthcare accessible is a constant challenge.
H.R. 3051 addresses the need for access to care by expanding both
DoD and VA telehealth and telemental health programs.
Ultimately this bill will ease the burden on our veterans suffering
from TBI and the families who care for them.
Our Committee has heard testimony from many veterans, Veteran
Serving Organizations and the VA on the mounting cases of TBI, PTSD and
other invisible wounds of war.
Many agree that veterans are often worse off with these unseen
injuries than those with visible physical injuries.
Unlike other injuries that can heal, brain injuries are often
permanent and disabling.
In addition, TBI can sometimes take years to develop and diagnose.
Even when discovered the road to recovery is long and is borne by
the families of our brave men and women in uniform.
We have also heard of the link between TBI and other mental
conditions such as epilepsy.
A DoD study after Vietnam found that 15 percent of soldiers with a
penetrating TBI developed epilepsy soon after their injury.
H.R. 3051 creates a program to train the family members of TBI
patients to become their personal care attendants.
Participants going through the program would become certified and
receive compensation from the VA so that they can focus their energy on
caring for their loved ones.
By taking place at home with family, the healing process is made
more comfortable for our veterans.
The cost to the VA for having someone cared for at home is less
than having them at a medical facility and allows the VA to allocate
the resources they have to serve more veterans.
We have soldiers in Iraq and Afghanistan spending longer periods of
time in harms way and away from their families.
With that in mind we need to ensure that there are programs in
place to care for them when they return home.
A program that provides quality care for our veterans and a
financial benefit for their families seems appropriate for the
difficult economic times our country is facing.
Most importantly, this bill will help us all reach our goal of
ensuring our veterans the best care possible.
Mr. Chairman, I thank you and the Members of this Subcommittee for
the opportunity to introduce legislation that improves the lives of our
veterans suffering with TBI.
Prepared Statement of Hon. Carol Shea-Porter,
a Representative in Congress from the State of New Hampshire
Mr. Chairman.
Thank you for the opportunity to speak to your Subcommittee about a
critical inequity facing New Hampshire's veterans--the lack of full
service, in state healthcare.
New Hampshire has not had a full service veterans' hospital since
2001. New Hampshire is the only state without a full-service VA
hospital or comparable facility. Veterans in Alaska and Hawaii receive
care at military hospitals on base. While New Hampshire may be a small
state, it has a veteran population of over 130,000. Unlike many New
England states whose veterans populations are declining, New
Hampshire's veterans population is projected to grow over the next 10
years.
Because New Hampshire does not have a full service veterans'
hospital, our veterans are forced to travel out of state for medical
care. Veterans traveling from the most northern parts of the state can
travel for 3 hours to Manchester and then may be forced to travel
another hour to Boston, if referred there for care.
This routinely happens. In 2007, 704 of our veterans were
transferred out-of-state for Acute Care. Three hundred forty-six of
those veterans were sent to Boston.
I have been calling for the VA to either restore the Manchester
facility to full-service hospital care or allow NH vets to receive care
locally since I came to Congress. I have been working with both the VA
and my colleagues to realize that goal. Chairman Filner visited the
Manchester Veterans facility earlier this year and held a series of
events including a roundtable during which we heard about the serious
burdens placed on the New Hampshire veterans and their families because
we do not have a full-service hospital.
Despite these efforts, the administration refuses to either provide
local access to care or restore full service VA hospital care to New
Hampshire. I met with Secretary Peake at the Manchester Veterans
Administration Medical Center in June to express my interest in working
with him to either restore the facility to a full-service hospital or
provide local access. Unfortunately, after our meeting Secretary Peake
told the local press that there would be no full-service hospital in
Manchester.
The Administration's failure to act is unacceptable. New
Hampshire's veterans deserve the best possible care and the current
system is not delivering that. This is why I introduced H.R. 6629, the
Veterans Health Equity Act of 2008.
This legislation will ensure that veterans have access to at least
one full-service hospital, or that they can receive care, the same care
they would get in a VA hospital, in the state. This would mean that the
VA would have to do one of two things, either restore the Manchester
facility to a full-service hospital, or partner with more local health
providers to make sure our Veterans can receive the care they need, in
New Hampshire.
The men and women in our local VA facility have done a herculean
job of caring for our vets despite the limits to access imposed on New
Hampshire vets. The Administration has very recently shown some
willingness to allow radiation therapy to be provided locally. But this
is not enough.
Our veterans--regardless of whether they need radiation therapy,
mental health services, acute care or anything else--need and deserve
the care their counterparts in every other state receive. It is
unconscionable that we deny them this full service care and instead
offer them ad hoc services.
Mr. Chairman, I appreciate your leadership in providing the best
possible healthcare for our Nation's veterans. I am sure you and the
other Members of your Subcommittee appreciate the challenges created by
the lack of full service hospital care in New Hampshire. I look forward
to working with you and the Subcommittee to address these challenges.
Thank you again for giving me the opportunity to testify on this
important issue. I look forward to answering any questions you may
have.
Prepared Statement of Joy J. Ilem,
Assistant National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this legislative hearing of the Committee on Veterans'
Affairs Subcommittee on Health. DAV is an organization of 1.3 million
service-disabled veterans, and devotes its energies to rebuilding the
lives of disabled veterans and their families.
You have requested testimony today on two bills primarily focused
on healthcare services for injured military servicemembers and
veterans, and personnel issues affecting healthcare employees of the
Veterans Health Administration (VHA) of the Department of Veterans
Affairs (VA). We appreciate the opportunity to provide our views on
these measures to the Subcommittee.
H.R. 3051--the Heroes at Home Act of 2007
In general, this bill seeks to improve the diagnosis and treatment
of traumatic brain injury (TBI) and raise awareness about post-
traumatic stress disorder (PTSD) among current military servicemembers
and veterans; provide support to families of severely injured veterans;
and, expand telehealth and telemental health programs of the Department
of Defense (DoD) and VA.
Section 2 of the bill would require VA, in collaboration with the
Secretary of Defense, to develop a program of training and
certification of family caregivers and other personal care attendants
of veterans and still-active members of the Armed Forces with TBI, at
every VA medical center. The curricula developed would incorporate the
standards and protocols of national brain injury care specialist
organizations and, to the degree possible, would require use of, and
would expand the curricula developed under, the John Warner National
Defense Authorization Act for Fiscal Year 2007 (Public Law 109-364).
Certification received by family caregivers or others would qualify
them to be compensated for personal care services rendered to the
injured veteran or servicemember. Training would be provided at no cost
to the veteran or caregiver, but would be borne by VA or reimbursed
through TRICARE.
Section 3 of the bill would require VA to conduct comprehensive
outreach to enhance awareness among veterans and the general public
about the symptoms of PTSD and TBI and the services provided by the VA.
It would further require VA to make information available to non-VA
practitioners on best practices in treatment of TBI and PTSD.
Section 4 of the bill addresses telehealth and telemental health
services of DoD and VA, and would require the Secretaries to jointly
establish a demonstration program to assess the feasibility of using
telehealth technologies to evaluate cognitive functioning among
servicemembers who have sustained head trauma. In addition, the bill
would require an assessment of telehealth tools to obtain information
regarding the nature and symptoms of brain injury, the use of
technology to rehabilitate those with TBI, and the usefulness of
applying such technology to dissemination of educational material to
veterans and servicemembers. The funds for the demonstration would be
drawn from the DoD-VA healthcare Sharing Incentive Fund and the results
of the demonstration would be reported in the administration's joint
report to Congress on sharing initiatives between the two Departments.
Another study the bill would require is an ongoing review of telehealth
and telemental health services, to include the number of servicemembers
and veterans who have used such services and the extent to which the
National Guard and Reserve components of the armed forces use them, in
addition to identifying improvements for such programs. The report
would also require best practices of civilian mental health providers
assisting veterans and former servicemembers and demonstrate the
feasibility and advisability of partnering with civilian mental health
facilities to provide telehealth and telemental health programs.
While modern protective gear and battlefield medicine have greatly
improved from previous conflicts, the intensity of polytrauma injuries,
including TBI, presents great challenges to DoD and VA in meeting
servicemembers and veterans acute, rehabilitative and long-term care
health needs. As you well understand, Mr. Chairman, the most severe of
these injuries may require a lifetime of care. The family members of
military polytrauma casualties typically appear at the bedside of their
loved one and remain with them throughout their acute treatment and
extensive rehabilitative periods. A survey conducted on behalf of the
President's Commission on Care for America's Returning Wounded Warriors
(Commission) found that ``. . . 33 percent of active duty, 22 percent
of reserve component, and 37 percent of retired/separated
servicemembers [who were injured] report that a family member or close
friend relocated for extended periods of time to be with them while
they were in the hospital.'' \[1]\
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\[1]\ The President's Commission on Care for America's Returning
Wounded Warriors. Final Report: Serve, Support, Simplify. July 2007: 9.
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Family members of severely injured veterans often shoulder a great
and lifelong burden as home and institutional caregivers, giving up or
severely restricting their own employment and educational advancement
and negatively impacting social interactions that are taken for granted
in the normal course of life. The Commission's survey also found that
``21 percent of active duty, 15 percent of reserve component, and 24
percent of retired/separated servicemembers [who were injured] say
friends or family gave up a job to be with them or act as their
caregiver.'' \[2]\ Not surprisingly, family caregivers often suffer
severe financial and personal hardships as a consequence of providing
care to a severely disabled veteran. Yet, in their absence, an even
greater burden of direct care would fall on DoD and VA, at
significantly higher financial cost to the Government and a reduced
quality of life for severely wounded war veterans.
---------------------------------------------------------------------------
\[2]\ Ibid.
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DAV testified before the Senate Committee on Veterans' Affairs
earlier this year in support of S. 2921, a bill that would require VA
to develop a pilot program to train and certify family caregivers of
traumatically brain injured veterans. We are very enthusiastic about
bolstering the financial support for these vulnerable families and
believe that this is also an idea that will improve the quality of care
our veterans receive. We agree with the intent of H.R. 3051 that this
common-sense program could be started without being a pilot--since
family caregivers of severely injured veterans are already shouldering
a great deal of the care these veterans receive. This program would
allow these family members to have up-to-date and consistent training
and to receive compensation that recognizes their services and will
better ensure the stability of the family at an extremely difficult and
vulnerable time. The needs of these veterans and their families are
urgent. However, we believe that initially, the training and
certification process may need to be limited to sites that have these
capabilities in place--most likely in the polytrauma centers and other
units within the Defense and Veterans Brain Injury Network. We ask the
Subcommittee to consider this aspect of the bill and modify it
accordingly to ensure the training provided is of high quality and
focused on the particular needs of these families.
Similar to the provision for a training and certification program
in S. 2921, section 2 of the Heroes at Home Act would address veterans
with traumatic brain injuries but would also be beneficial for other
catastrophically injured veterans with long-term personal assistance
needs, such as veterans with spinal cord injuries or severe physical
trauma without brain injury. Indeed, an educational proposal to assist
family caregivers of all veterans with catastrophic injuries who would
be taking on personal assistance duties was originally recommended by
the Commission on Care for America's Returning Wounded Warriors. If
successful, we would like to see this provision related to training
caregivers expanded to other catastrophically disabled veterans
requiring caregiver assistance.
Section 3 of H.R. 3051 would require that VA conduct outreach
activities targeted at increasing recognition of symptoms and public
awareness that resources are available within VA to treat traumatic
brain injury and PTSD. Veterans may not be the first to recognize the
changes in their own behavior consequent to their exposure to
concussive and traumatic events. Indeed, even with the high rates of
prevalence expected for both TBI and PTSD, some veterans will not
recognize their own symptoms until weeks or months after repatriation,
if ever. \[3]\ Often, a family member notices changes in a veteran's
behavior and mood; thus, informing the general public is also an
important element of this bill. DAV believes that there must be a
systematic means of educating veterans and their families about these
problems and how to find support. We acknowledge that some veterans are
receiving care for war-related disabilities outside of the VA and
military systems, so we appreciate the requirement in the bill that VA
would disseminate best practices on both mild-to-moderate TBI and PTSD
to non-VA providers.
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\[3]\ Invisible Wounds of War: Psychological and Cognitive
Injuries, Their Consequences, and Services to Assist Recovery. Ed's:
Tanielian, T; Jaycox, L. RAND Center for Military Health Policy
Research: 2008
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Mr. Chairman, DAV also supports, but with some concern, section 4
of this bill to improve and expand telehealth and telemental health in
VA and DoD. DAV certainly agrees that it is a challenge for VA and DoD
to place resources everywhere veterans want and need to receive care.
Tele-medicine has played a vital role in filling gaps in care in a
number of communities--particularly in rural and frontier communities
that lack access to a full continuum of care, and in some cases even
basic healthcare services. We support efforts to assess new web-based
diagnostic tools for the prevalent cognitive conditions that are
emerging among our returning veterans. However, this section also
contains a provision that would require VA and DoD to study ways that
civilian providers might be used to enhance telehealth services offered
to injured veterans and servicemembers. DAV has long held the position
that contracting for healthcare outside VA should be attempted
judiciously so as not to undermine VA's high-quality and specialized
health and rehabilitative programs, and only when community-based care
is coordinated and of high quality. Thus, we ask the Subcommittee to
carefully consider the results of the required study in this bill
before advancing any legislative mandate for VA or DoD to significantly
expand tele-medicine into the private sector. Any such expansion should
include coordination through the VA Office of Rural Health and would
also need to be attended by new resources outside VA's Medical Care
appropriation to garner full DAV support.
While we support this bill, we would ask the Subcommittee to also
consider the needs of veterans with less severe traumatic brain
injuries. Mild-to-moderate brain injuries are prevalent among the Iraq
and Afghanistan deployments--possibly as many as 320,000 veterans may
be affected, yet of those reporting a probable TBI, 57 percent had not
been evaluated by a clinician for that injury according to the recent
RAND report. Key findings of the study also noted that about half of
those who need treatment for PTSD, depression or probable TBI seek care
for those conditions, and only slightly more than half who receive
treatment get minimally adequate care. \[4]\ The DoD and VA must be at
the forefront of efforts to improve the diagnosis, treatment,
management and surveillance of all brain injuries to ensure high-
quality and consistent care is obtained for all servicemembers and
veterans who suffer from concussive blasts in Iraq and Afghanistan.
This bill would acknowledge the enormous debt the Nation owes, not only
to injured veterans, but to their family caregivers, whose lives may be
forever altered. However, we ask the Subcommittee to also consider
expanding this measure to include the broader slate of initiatives DAV
supports for family caregivers. DAV supports legislation to provide
comprehensive supportive services, including financial support, health
and homemaker services, respite, education and training and other
necessary relief to immediate family member caregivers of veterans
severely injured, wounded or ill from military service.
---------------------------------------------------------------------------
\[4]\ Ibid.
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With these cautionary notes, DAV believes the ideas in the bill are
worthy and if implemented carefully, could provide relief and support
for sick and disabled veterans, particularly those with invisible
wounds of war, including TBI and PTSD, and would provide welcome relief
to family caregivers of the severely disabled. With exceptions noted,
most of the proposals are consistent with recommendations of the Fiscal
Year 2009 Independent Budget. Thus, DAV supports this bill and urges
the Subcommittee to work toward its enactment.
H.R. 6153--Veterans' Medical Personnel Recruitment and Retention Act of
2008
Along with our partners in the Independent Budget, DAV has called
for improvements in VA policies and procedures used to recruit and
retain highly qualified VA clinical staff. Also for the past several
years our organizations have expressed concerns that VA needs new
authority to achieve and sustain this goal, to be competitive with
private sector providers and become a preferred employer of physicians,
nurses, dentists and other personnel needed to care for enrolled
veterans. With increasing numbers of veterans turning to VA for their
healthcare and--particularly at a time of ongoing military engagements
in Iraq and Afghanistan--VA needs the best and the brightest to meet
the increasingly complex medical needs of an aging veteran population,
veterans severely disabled during wartime service, and enrollees
suffering from chronic disease. This bill, aimed at providing
meaningful financial and professional incentives to encourage VA
clinicians to pursue full careers in the VA healthcare system appears
to be timely and appropriate given all of the challenges VA faces to
maintain its effectiveness as a provider of comprehensive healthcare
services.
Section 2 of the bill would provide authority to the Secretary of
Veterans Affairs to establish additional ``hybrid title 38-title 5''
occupations (32 such occupations have been established by previous Acts
of Congress in section 7401, title 38, United States Code, including
psychologist, physician assistant, licensed vocational or practical
nurse, social worker, and numerous technical health fields). Under this
section, the Secretary would be required to report any such
reclassification of VA occupations to the Office of Management and
Budget (OMB) and to both House and Senate Committees on Veterans'
Affairs. This section would also add ``nurse assistant'' as a specific
new occupational class in this hybrid category. Section 2 would clarify
probationary periods and appointment policies for full-time and part-
time registered nurses. The section also would authorize VA on a case-
by-case basis to reemploy Federal annuitants with temporary
appointments in selective healthcare occupational fields under sections
7401 and 7403, title 38, United State Code, without offsetting their
retirement annuities for which they would remain eligible under title
5, United States Code. This section would provide VA additional
authority to raise compensation of personnel employed in the immediate
Office of the Under Secretary for Health; provide VA pharmacist
executives eligibility for special incentive pay; and provide
clarification on compensation policy for VA physicians, including
comparability pay adjustments and market pay provisions in chapter 74,
title 38, United States Code. Finally, it would provide additional
policy clarifications on nurse compensation caps, special compensation
for nurse executives; locality salary systems for VA nurses; part-time
nurse compensation rules; weekend premium rules, as well as clarified
direction on the use and disclosures of wage surveys in nurse locality
compensation determinations.
Section 3 of the bill would add a new section 7459, title 38,
United States Code, to specify VA policy on VA's use of overtime by VA
nurses, in effect reversing VA's
practice of requiring ``mandatory overtime,'' and extending specific
protections to VA registered nurses, licensed practical or vocational
nurses, nursing assistants (and other nursing positions designated by
the Secretary for purposes of these protections), under the Civil
Rights Act 1964, from discrimination or any adverse action based on
their refusal to work required overtime. Under this section, the VA
Secretary would be provided an emergency exigency power in certain
circumstances to require a nurse to work overtime, but the section
defines the term ``emergency'' within narrow grounds. Section 3 also
clarifies language on weekend duty and other alternative work schedules
for VA nurses, and would provide a number of associated technical and
conforming amendments.
Section 4 of the bill would reinstate the former Health
Professionals Educational Assistance Scholarship Program, an authority
that expired in 1998, and would extend its coverage to employees
appointed under paragraphs (1) and (3) of section 7401, title 38,
United States Code. It would add ``retention'' as an additional purpose
of VA's Education Debt Reduction Program, and would increase the
amounts of assistance to eligible VA employees. The section also would
establish a loan repayment program targeted to VA clinical research
personnel who come from disadvantaged backgrounds.
Mr. Chairman, while DAV has no national resolution adopted by our
membership that addresses these specific matters, The Independent
Budget for Fiscal Year 2009, sponsored by DAV, Veterans of Foreign Wars
of the United States (VFW), American Veterans (AMVETS) and Paralyzed
Veterans of America (PVA), conveys a series of recommendations that are
fully consistent with this bill. Therefore, DAV would have no objection
to its enactment.
Mr. Chairman and Members of the Subcommittee, as you may know, our
DAV advocacy campaign, Stand Up For Veterans, is well underway. Its
purpose is to generate greater public awareness and support for
strengthening Federal policies to provide greater healthcare assistance
to veterans disabled in the ongoing wars in Iraq and Afghanistan, as
well as to sick and disabled veterans from prior eras and conflicts. In
this effort, our campaign has focused on TBI, post-deployment mental
health challenges (including PTSD), women veterans' health, family
caregiver support, and reforms in budgeting that will bring sufficient,
timely and predictable funding to VA healthcare. DAV has been pleased
by Congressional responsiveness to many of the proposals emanating from
our campaign that we have shared and discussed with Members of this
Subcommittee and others in Congress. We appreciate that responsiveness
and encourage the Congress to complete a significant package of
veterans' health legislation before adjournment.
Mr. Chairman, this concludes my statement on these two bills, and I
would be happy to answer questions on these issues from you or other
Members of the Subcommittee.
SUPPLEMENTAL STATEMENT
H.R. 6629, the Veterans Health Equity Act of 2008
This measure would seek to ensure availability of at least one
full-service hospital of the Department of Veterans Affairs (VA)
Veterans Health Administration (VHA), or comparable services through
contract, in each of the 48 contiguous States.
Congresswoman Shea-Porter provided an opening statement for the
Subcommittee at the September 9th hearing explaining the
reasons for the introduction of this measure (H.R. 6629). Ms. Shea-
Porter noted that New Hampshire was the only State that did not have
access to a VA full-service medical center and that the most ill
veterans in her state routinely had to drive or be transported to
Boston for more comprehensive healthcare services. She stated that she
was particularly concerned that the sickest and generally very elderly
veterans with complex and chronic health problems were subjected to
having to first report to the VA's Manchester facility--which could be
up to a 3 hour drive--and then having to continue on for another hour
to get to the Boston VA Medical Center (VAMC) or other VA provider
sites. Finally, the Congresswoman noted that it may not be fiscally
responsible, given the veterans' population in her state, to have VA
provide a full continuum of hospital services and that contracting for
such services may be the best option. Her main concern was that sick
and disabled veterans in New Hampshire are having to make unnecessarily
long trips to Boston area VAMCs to get the care they need for complex
health conditions.
Convenient access to comprehensive VA healthcare services remains a
problem for many of our Nation's sick and disabled veterans. While VA
must contract or use fee basis to provide care to some veterans, it
maintains high quality care and cost
effectiveness by providing health services within the system. According
to VA, the Manchester VAMC of New Hampshire provides urgent care,
mental health and primary care services, ambulatory surgery, a variety
of specialized clinical services, hospital based home care and
inpatient long-term care. In addition, community-based outpatient
clinics (CBOCs) are located in Somersworth, Tilton, Portsmouth and
Conway.
In light of the escalating costs of healthcare in the private
sector, to its credit, VA has done a remarkable job of providing high
quality care and holding down costs by effectively managing in-house
health programs and services for veterans. However, outside care
coordination is poorly managed by VA. When it must send veterans
outside the system for care, those veterans lose the many safeguards
built into the VA system through its patient safety program, evidence-
based medicine, electronic health records, and bar code medication
administration program (BCMA). The proposal in H.R. 6629 to use broad-
based contracting for necessary hospital services in the New Hampshire
area concerns us because these unique internal VA features noted above
culminate in the highest quality care available, public or private.
Loss of these safeguards, which are generally not available in private
sector systems, equate to diminished oversight and coordination of
care, and, ultimately, may result in lower quality of care for those
who deserve it most. However, we agree that VA must ensure that the
distance veterans travel, as well as other hardships they face, be
considered in VA's policies in determining the appropriate locations
and settings for providing VA healthcare services.
In general, current law places limits on VA's ability to contract
for private healthcare services in instances in which VA facilities are
incapable of providing necessary care to a veteran; when VA facilities
are geographically inaccessible to a veteran for necessary care; when
medical emergency prevents a veteran from receiving care in a VA
facility; to complete an episode of VA care; and for certain specialty
examinations to assist VA in adjudicating disability claims. VA also
has authority to contract to obtain the services of scarce medical
specialists in VA facilities. Beyond these limits, there is no general
authority in the law to support broad-based contracting for the care of
populations of veterans, whether rural or urban.
DAV believes that VA contract care for eligible veterans should be
used judiciously and only in these authorized circumstances so as not
to endanger VA facilities' ability to maintain a full range of
specialized inpatient and outpatient services for all enrolled
veterans. VA must maintain a ``critical mass'' of capital, human, and
technical resources to promote effective, high-quality care for
veterans, especially those with complex health problems, such as
blindness, amputations, spinal cord injury, or chronic mental health
problems. Putting additional budget pressures on this specialized
system of services without making specific appropriations available for
new VA healthcare programs only exacerbates the problems currently
encountered.
Nevertheless, after considerable deliberation, and in good faith to
be responsive to those who have come forward with legislative proposals
such as H.R. 6629, to offer alternatives to VA healthcare, we have
asked VA to consider developing a series of tailored demonstration
projects and pilot programs to provide VA-coordinated care (or VA-
coordinated care through local, state, or other Federal agencies) in a
selected group of communities that are experiencing access challenges,
and to provide to the Committees on Veterans' Affairs reports of the
results of those programs, including relative costs, quality,
satisfaction, degree of access improvements, and other appropriate
variables, compared to similar measurements of a like group of veterans
in VA healthcare. To the greatest extent practicable, VA should
coordinate these demonstration pilots with interested health
professions' academic affiliates. We suggest the principles of our
recommendations from the ``Contract Care Coordination'' section of the
FY 2009 Independent Budget be used to guide VA's approaches in this
effort. Also, any such demonstration pilot projects should be funded
outside the Veterans Equitable Resource Allocation (VERA) system, and
their expenditures should be monitored in comparison with VA's historic
costs for care.
Veterans service organization representatives from the local areas
involved, and other experts need a seat at the table to help VA
consider important program and policy decisions, such as those
described here, that would have positive effects on veterans who live
in these areas. VA must work to improve access for veterans that are
challenged by long commutes and other obstacles in getting reasonable
access to a full continuum of healthcare services at VA facilities and
explore practical solutions when developing policies in determining the
appropriate location and setting for providing VA healthcare services.
As a final note, we believe VA must fully support the right of all
enrolled veterans to have reasonable access to healthcare and we insist
that funding for alternative care approaches and outreach be
specifically appropriated for this purpose, and not be the cause of
reductions in highly specialized VA medical programs within the
healthcare system.
Prepared Statement of Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
views on these two important pieces of legislation.
H.R. 3051, Heroes at Home Act of 2007
This bill seeks to improve the diagnosis and treatment of traumatic
brain injury in members and former members of the Armed Forces; to
review and expand telehealth and telemental health programs of the
Department of Defense (DoD) and the Department of Veterans Affairs
(VA), and for other purposes.
Section 2 of HR 3051 requests the Secretary of VA establish a
program on training and certification of family caregivers of veterans
and members of the active duty Armed Forces with Traumatic Brain Injury
(TBI), as personal care attendant. Pursuant to section 744(a)(2) of
Public Law 109-364, a Veterans' Traumatic Brain Injury Family Caregiver
Panel was established in 2007.
The 15 member panel was created by the DoD to operate under the
Department of Health as a Subcommittee to advise and specifically
provide DoD and VA with independent advice and recommendations on the
development of training curricula to be utilized by the above mentioned
family members on techniques, strategies, and skills for care and
assistance for such individuals with TBI. The panel has convened on
occasions, to include a recent townhall meeting, to discuss matters
related to the development of a this curriculum and to hear from the
public about the issue.
The American Legion asserts that the advice of this Subcommittee
into the provisions of this piece of legislation is vital, and that its
absence may deprive such a bill of an effective stance and approach to
treatment and care of TBI. The American Legion, in its continued
efforts to increase access and quality of care to all eligible and
potentially eligible veterans, supports this proposal, as it would help
to accomplish this ongoing challenge.
H.R. 6153, Veterans' Medical Personnel Recruitment and Retention Act of
2008
This bill seeks to amend Title 38 of the United States Code to
enhance the capacity of VA to recruit and retain nurses and other
critical health-care professionals, in addition to addressing other
issues. The American Legion applauds this proposal to amend the methods
of hiring and retaining additional medical personnel of various
disciplines to adequately equip VA Medical facilities to ensure the
adequacy and quality of treatment and care.
The American Legion supports the proposal request in section 2(j),
which seeks to amend 7451(c)(2), to allow critical fields such as nurse
anesthesiologists, to exceed rate limitations on authorized competitive
pay. Although VA has various antidotal programs in place, to include
recruitment, relocation, and retention incentives for these hard-to-
fill positions, there remains a shortage of such nurses and specialty
medical physicians.
The overall response to the question of shortage indicated that
salaries and delays in appointments were key causative factors. The
American Legion, during its VA Medical Center site visits to 49
facilities in 2008 encountered various recruitment issues, including
such delays in the appointment of nursing assistants. Management
attributed these delays to a three to 4 month hiring process. By the
time management completed the hiring process, applicants have accepted
a position in the private sector.
In their site visits the American Legion representatives
ascertained other areas with difficulty recruiting; these included
mental health positions, specifically psychologists and psychiatrists;
Dermatology; Gastroenterology; Orthopedics; and, Anesthesia. A study
published in the New England Journal of Medicine ascertained there were
shorter inpatient stays and lower complication rates in hospitals with
higher staffing levels, while there were longer inpatient stays and
increased urinary infections, gastrointestinal bleeding, pneumonia and
shock or cardiac arrest in hospitals with lower staffing levels. Thus
planning and adequate staffing up front can
help curtail long term care costs and unnecessary complications to the
veteran patients down the road.
We hereby urge Congress to act on this piece of legislation by
incorporating it into the VA system to prevent the Healthcare system
from being included in the casualties of the projected shortage of
medical professionals through the year 2020.
Mr. Chairman and Members of the Subcommittee, The American Legion
sincerely appreciates the opportunity to submit testimony and looks
forward to working with you and your colleagues on the abovementioned
matters and issues of similarity. Thank you.
Prepared Statement of Thomas J. Berger, Ph.D., Senior Analyst for
Veterans' Benefits and Mental Health Issues, Vietnam Veterans of
America
Mr. Chairman, Ranking Member Miller, Distinguished Members of this
Subcommittee, and guests, Vietnam Veterans of America (VVA) thanks you
for the opportunity to present our views on H.R. 3051, the ``Heroes at
Home Act of 2007,'' that is designed to improve the diagnosis and
treatment of TBI (traumatic brain injury) for servicemembers and
veterans, and to review and expand the telehealth and telemental health
programs DoD and VA. With your permission, I shall keep my remarks
brief and to the point.
First, VVA thanks you, Mr. Chairman and Mr. Miller as well as
distinguished Members of this Subcommittee for your active concern in
regard to Traumatic Brain Injury (TBI) and related mental health
problems of our troops and veterans, and for your leadership in holding
this hearing today.
In general, Vietnam Veterans of America supports the intent of H.R.
3051. However, medical experts say that traumatic brain injuries are
the ``signature wound'' of the Iraq war in particular, a by-product of
the explosions caused by I.E.D. roadside blasts and suicide bombers.
TBIs have become so commonplace that they, in fact, form the basis for
today's hearing.
Although TBI may share some symptoms with post traumatic stress
disorder, it is markedly different than PTSD, which is triggered by
extreme anxiety, and permanently resets the brain's fight-or-flight
mechanism. Battlefield medics and corpsmen can often miss traumatic
brain injuries, and many troops don't know the symptoms or won't
discuss their problems for fear of being sent home stigmatized with
mental illness. The same is true for those who return to the U.S. for
garrison duty or exit their term of military service and become
veterans.
Certain TBI symptoms, such as seizures, can be treated with
medications, but the most devastating effects--depression, agitation
and social withdrawal--are difficult to treat with medication,
especially when there is loss of brain tissue. In troops with
documented TBI, the loss of brain functions is often compounded by
other serious medical conditions that affect physical coordination and
memory functions. These patients need a combination of psychological
and physical treatment that is difficult to coordinate in a traditional
medical setting, even when properly diagnosed at an early date. And we
must remember that both concussive and contusive brain injuries are
never just isolated injures. Over time without proper diagnoses, care
and treatment, TBI can affect nearly everything about the survivor
including one's cognitive, motor, auditory, olfactory and visual
skills, perhaps ultimately resulting in behavioral modifications, not a
mental illness.
As more and more troops return home damaged from the war, their
families must contend with not only the physical desolation of their
loved ones, but come to grips with the new emotional reality of their
lives which have changed drastically and not necessarily for the
better. Take for example, a 35-year old soldier or Marine who returns
home with what is diagnosed with traumatic brain injury (TBI). His/her
impairment affects the future of the entire family. His or her spouse
and children have to deal with his/her ability to concentrate, the mood
swings, the depression, the anxiety, even the loss of employment. As
you can well imagine, the economic and emotional instability of a
family can be as terrifying and as real as focusing or simply waking in
the middle of the night and crying because of nightmares. In cases of
severely brain-damaged casualties, spouses, parents and siblings may be
forced to give up careers, forsake wages, and reconstruct homes to care
for their wounded relatives, rather than to consign them to the
anonymous care of a nursing home or assisted living facility.
Families say that they also struggle with military and VA medical
systems that were unprepared for these wounded. In some cases new
equipment and specially trained staff needed for the most catastrophic
cases are not available or have not kept pace with the advances in
battlefield medicine that kept these servicemembers
live and brought them home safely. In addition, there are issues about
the intensity and drain of needed family support that will be hard to
sustain, as well as significant issues regarding the complexity of the
medical and other specialized needs that need to be addressed. Of all
the war's medically challenging injuries, brain injuries require the
most personal involvement and cost over time.
TBI also presents a most puzzling challenge, especially in mild to
moderate cases. Symptoms can be hidden or delayed, diagnosis is
difficult, and evidence-based treatments are as of yet largely
undetermined. Very few medical facilities are capable of providing even
the most basic level of care for brain-injured patients, forcing most
to seek treatment miles from home, if they can find it at all, and we
must remember that over forty percent of our troops deployed in Iraq
and Afghanistan come from rural America.
As you are well aware, one of the recommendations of the Dole-
Shalala Commission was to ``significantly strengthen support for
families.'' This will not be an easy task, but VVA believes H.R. 3051
to be a key step in achieving this recommendation and providing a
mechanism for empowering the families of brain-injured servicemembers
IF the VA can develop effective implementation strategies for
certification, competency evaluations, and meaningful outcome
measurements to carry it out. As they say, ``the devil remains in the
details''.
I thank you again for the opportunity to offer VVA's views on this
proposed legislation, and I shall be glad to answer any questions you
might have.
Prepared Statement of Gerald M. Cross, M.D., FAAFP,
Principal Deputy 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
two bills, H.R. 3051, the ``Heroes at Home Act of 2007,'' and H.R.
6153, the ``Veterans' Medical Personnel Recruitment and Retention Act
of 2008.'' I am accompanied by Mr. Walter A. Hall, Assistant General
Counsel, and Ms. Joleen Clark, Chief Officer, Workforce Management and
Consulting, Veterans Health Administration.
H.R. 3051. ``Heroes at Home Act of 2007''
H.R. 3051 includes several provisions intended to enhance care and
services to veterans and particularly new OEF/OIF veterans suffering
from traumatic brain injury. section 2 of H.R. 3051 would require VA to
establish a program to train and certify family members of veterans and
servicemembers with traumatic brain injury (TBI) as personal care
attendants. VA would be responsible for developing curricula for
training family caregiver personal care attendants and for determining
the eligibility of family members to participate in the program. A
family caregiver who is certified as a personal care attendant would be
eligible for compensation from VA for care provided to a veteran or
servicemember.
Mr. Chairman, VA does not support section 2 because VA already has
a program in place that accomplishes the goals of that section in a far
more efficient and effective manner. To keep VA from being in the
position of having to directly oversee the quality of care provided by
individual caregivers, including family members, VA uses a third-party
to obtain needed caregiver services. Implementing the bill, as written,
would not only be impractical but also inadvisable. The resulting
arrangement could well give rise to potential conflicts concerning the
veteran's care between the family member-caregiver and the veteran,
placing VA in an untenable position. We strongly urge the Congress to
let us continue to obtain caregiver services as we currently do under
our Home healthcare Program.
This bill provides that certified family caregivers shall be
eligible for compensation but it does not state the nature of such
compensation - is it payment for services provided so that the
caregivers are VA employees or is it a benefit and, if so, is it to the
veteran/servicemember or to the caregiver? Whether the compensation is
for employment or is a benefit raises significant legal issues relating
to liability, taxation and VA's relationship and responsibilities to
both the patient and the caregiver. We also note the bill would make VA
responsible for compensating caregivers of both veterans and active
duty members of the Armed Forces. That responsibility to pay
compensation may be that only relationship VA has with active duty
members.
Under our program, VA currently contracts with more than 4,000 home
health agencies that are approved by the Centers for Medicare and
Medicaid Services (CMS) and/or are state licensed. Many of these
agencies have expertise in training and certifying home health aides,
including family members. Many operate in rural communities. VA refers
interested family members to these agencies and, after their training,
these family caregivers become paid employees of the agencies. VA
provides remuneration pursuant to agreements with the home health
agencies, thus compensating family caregivers indirectly. Importantly,
VA also ensures that these home health agencies meet and maintain
training and certification requirements specific to caregivers of TBI
patients. For the reasons we have discussed, this model is preferable
to that which would be required by section 2.
Subsection 3(a) of H. R. 3051 would require VA to conduct
comprehensive outreach to enhance the awareness of veterans and the
general public about the symptoms of post traumatic stress disorder
(PTSD) and TBI and available VA health and other services. Mr. Chairman
given the extensive and expanding outreach program that we already have
in place to inform veterans and the general public about PTSD and TBI
and the services we provide to veterans with these symptoms and
injuries, this statutory mandate is not necessary. Let me take a moment
to describe just some of the exciting new efforts underway to reach out
to returning veterans.
VA is making intensive outreach efforts to veterans as they leave
active duty. Upon return from deployment, every eligible veteran
receives a letter from the Secretary of Veterans Affairs informing him
or her of the availability of VA services near his or her home. VA is
currently sending out follow-up letters to all of those returning
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans
who have not come to VA for care, to reinforce the point that care is
available through the Department. As of January 2008, more than 796,000
letters had been mailed. On April 24 of this year, the Secretary
announced the creation of a ``Combat Veteran Call Center'' to begin
contacting the nearly 570,000 recent combat veterans who have not used
VA healthcare services to ensure they know about VA's medical services
and other benefits.
In addition, the Vet Center program reaches out to returning
veterans in their communities. Informing combat veterans and family
members about the availability of readjustment counseling services is
one of the primary missions of the Vet Center program. In response to
the growing numbers of veterans returning from combat in OEF/OIF, the
Vet Centers initiated an aggressive outreach campaign to welcome home
and educate returning servicemembers at military demobilization and
National Guard and Reserve sites. The Vet Center program also provides
access to other VHA and Veterans Benefits Administration (VBA)
programs. To augment this effort, the Vet Center program recruited and
hired 100 OEF/OIF veterans to provide the bulk of this outreach to
their fellow veterans. Outreach provided by fellow combat veterans
promotes a peer relationship that helps veterans with PTSD and other
readjustment problems overcome any perceived stigma that may be
associated with asking for professional assistance. Vet Center staff
also participate with VAMC representatives in all onsite and call
center Post-Deployment Health Reassessment events across the country,
and provide outreach throughout the local community at events that
feature veterans and family members. This is essential for making
effective contact with veterans who have already returned to their home
communities and are resuming normal family and work life.
VA is preparing a series of public service announcements to inform
veterans about various VA services. As a first action, VA has released
a series of posters and other public service announcements on VA's
Suicide Prevention Hotline. Additionally, VA is using non-traditional
approaches to disseminate outreach information, including presentations
about mental health issues that are played on the Music Television
Channel (MTV) and targeted at young OEF/OIF veterans and their
families. VA is also developing a comprehensive nation-wide TBI
awareness educational campaign that targets active duty servicemembers
and veterans, media and the general public, Congress, Veterans Service
Organizations, State VA Offices, and a variety of other key stakeholder
groups. Some primary messages included in this campaign are
identification of the symptoms of mild/moderate TBI, how to access VA
screenings and treatment, and the benefits and advantages of receiving
care from VA versus that of the private sector. Lastly, VA's National
Center for PTSD website, www.ncptsd.va.gov, posts regularly updated
Fact Sheets and other information on PTSD available for the general
public.
Mr. Chairman, VA also believes that Subsection 3(b), which would
require VA to share best practices developed for the treatment of PTSD
and TBI with non-VA health practitioners, is redundant of activities
already in place and therefore unnecessary. VA's reports and other
documentation on best practices are generally a matter of public
record. Moreover, VA participates in healthcare conferences where best
practices are exchanged and works continually with national
organizations to share medical information. The following are a few
examples of VA's sharing of best practices:
VA's Clinical Practice Guidelines, including topics
such as PTSD, depression, and substance use disorder treatment
are publically available on the Internet.
Local VA medical centers and Mental Illness Research
Education and Care Centers (MIRECCs) are collaborating with the
States in educating practitioners on issues of military culture
and best practices for treatment of returning veterans.
VA is involved in national meetings, such as the
August 2008 ``Conference and Policy Academy on Returning
Veterans and their Families'', which was a collaboration among
the Substance Abuse and Mental Health Services Administration
(SAMHSA), the Department of Defense, and VA. The meeting was
designed to help the states and communities develop effective
plans and best practices for helping returning veterans and
their families. VA staff made presentations on VA care during
the Conference phase and provided consultative support to State
teams during the Policy Academy.
VA's National Center for PTSD has a web based
curriculum ``PTSD 101'' providing education on best practices
in PTSD assessment and treatment available to non-VA
practitioners on VA's National Center for PTSD website
(www.ncpted.va.gov.)
The clinical experience and advances in
rehabilitation methodologies at the Polytrauma Rehabilitation
Centers (PRC) have been shared with the DoD/VA Senior Oversight
Committee (SOC), which functions as the main conduit by which
lessons learned are distributed within DoD and VA.
VA and the Defense Center of Excellence for
Psychological Health and TBI are collaboratively developing
Clinical Practice Guidelines for mild TBI, which will be
published and available to the public in late 2008.
In June of this year, VA's Office of Rehabilitation
Research and Development, in collaboration with DoD, sponsored
a State-of-the-Art Conference on Approaches to TBI: Screening,
Treatment, Management, and Rehabilitation.
Section 4 would require DoD and VA to jointly establish a
demonstration project to assess the feasibility and advisability of
using telehealth technology to assess cognitive functioning of members
and former members of the Armed Forces who have sustained head trauma,
in order to improve the diagnosis and treatment of TBI. In selecting
sites, priority would be given to locations providing services in rural
areas. This section would require, among other things, that the
demonstration project address the use of telehealth technology to
assess the feasibility of obtaining information regarding the nature of
any brain injury incurred by a servicemember or veteran and any symptom
of TBI in such individuals. Mr. Chairman, VA supports the goals of this
provision but cannot support the section as written.
Section 4, as written, is too prescriptive and detailed. VA and DoD
should be allowed more flexibility in executing the demonstration
project. The technology is evolving and new ideas for utilizing the
telehealth networks are emerging. DoD and VA should be given every
opportunity to discover the possibilities of maximizing the technology
rather than focusing on the enumerated requirements currently specified
in section 4. We would be pleased to work with Subcommittee staff to
develop legislative language that would make the project more tenable
and productive.
VA is continuing to develop cost estimates for H.R. 3051 and will
have the results for the Subcommittee as soon as possible.
H.R. 6153. ``Veterans' Medical Personnel Recruitment and Retention Act
of 2008''
H.R. 6153 contains several provisions intended to enhance VA's
ability to recruit and retain nurses and other health-care
professionals. Many of these provisions would be helpful, and we can
support them. However, several of the provisions would not be helpful
or are otherwise flawed.
Authority to Extend Hybrid Status to Additional Occupations
Subsection 2(a) of the bill would amend section 7401(3) to add
``nurse assistants'' to the list of so called hybrid occupations for
which the Secretary is authorized to appoint and to determine
qualifications and rates of pay under title 38. In addition, it would
authorize the Secretary to extend hybrid status to ``such other classes
of healthcare occupations as the Secretary considers necessary for the
recruitment and retention needs of the Department'' subject to a
requirement to provide 45 days' advance notice to the Veterans' Affairs
Committees and OMB. Before providing such notice, VA would be required
to solicit comments from labor organizations representing employees in
such occupations.
VA favors such a provision. Nursing Assistants are critical to the
Veterans Health Administration's (VHA) ability to provide care for a
growing population of older veterans, who are high-acuity patients and/
or frail elderly requiring 24-hour nursing care.
Turnover data, 10.5 percent for 2006 and 11.1 percent for 2007,
illustrate the great difficulty VA experiences in retaining this
occupation. It is increasingly critical for VHA to be able to quickly
and easily employ these nurse extenders. The same holds true for other
hard-to-recruit healthcare occupations. This bill would give the
Secretary the ability to react quickly when it is determined that these
authorities would be useful in helping in recruiting and retaining a
critical occupation without seeking additional legislative authority.
However, the bill language should be modified to specifically apply to
occupations that clearly involve the delivery of healthcare. In
addition, because this authority involves the conversion of title 5
occupations to title 38 hybrid, the 45-day notice requirement should be
modified to add OPM. Thus, we recommend modifying subsection 2(a) of
the bill to read:
(a) SECRETARIAL AUTHORITY TO EXTEND TITLE 38 STATUS TO
ADDITIONAL POSITIONS.
(1) IN GENERAL.-Paragraph (3) of section 7401 of title 38,
United States Code, is amended by striking ``and blind
rehabilitation outpatient specialists.'' and inserting in its
place the following: ``blind rehabilitation outpatient
specialists, and such other classes of healthcare occupations
as the Secretary considers necessary for the recruitment and
retention needs of the Department who:
(A) are employed in the administration (other than
administrative, clerical, and physical plant maintenance and
protective services employees);
(B) are paid under the General Schedule pursuant to section
5332 of title 5;
(C) are determined by the Secretary to be providing either
direct patient care services or services incident to direct
patient care services; and
(D) would not otherwise be available to provide medical care
and treatment for veterans.
(2) The Secretary's authority provided in paragraph (1) is
subject to the following requirements:
``(A) Not later than 45 days before the Secretary appoints
any personnel for a class of healthcare occupations that is not
specifically listed in this paragraph, the Secretary shall
submit to the Committee on Veterans' Affairs of the Senate, the
Committee on Veterans' Affairs of the House of Representatives,
the Office of Management and Budget and the Office of Personnel
Management notice of such appointment.
``(B) Before submitting notice under subparagraph (A), the
Secretary shall solicit comments from any labor organization
representing employees in such class and include such comments
in such notice.''
Probationary Periods for Part-Time Nurses
Subsection 2(b) provides for probationary periods for part-time
(PT) Registered Nurses (RN) and revises the probationary period for
RNs, both fulltime (FT) and PT, from 2 years to its equivalency in
hours, 4180. It also provides that a PT appointment of a person who
previously served on a FT basis in a ``pure'' title 38 position
(7401(1)), and completed a probationary period in the FT position would
not have to serve a probationary period in the PT ``pure'' title 38
position. VA opposes this provision because it is technically flawed
and would not be helpful.
Part-time title 38 employees, including RNs, do not serve
probationary periods. Probationary periods apply to full-time,
permanent employees. We see no benefit to creating a probationary
period for part-time nurses. Moreover, a probationary period for PT RNs
would not make them the equivalent of tenured employees, for example
for purposes of discipline or discharge.
Prohibition on Temporary Part-Time Nurse Appointments In Excess of
4,180 Hours
Subsection 2(c) would amend section 7405(f)(2) to limit temporary
part-time appointments of hybrid (Licensed Practical Nurse (LPN) and
Licensed Vocational Nurse (LVN)) nurses to no more than 4180 hours. VA
opposes this provision. Currently, all part-time hybrid appointments
may be for periods exceeding 1 year. The purpose of this restriction on
LPNs and LVNs is not apparent. Operationally, it could hamstring VHA
when it determines using that part-time LPNs and LVNs best serve
patient care needs. The result could be to deprive VA of highly
qualified LPNs and LVNs wishing to work only on a part-time basis, for
example, for personal and family reasons.
Reemployed Annuitant Offset Waiver
Subsection 2(d) generally provides that annuitants may be
temporarily reemployed in a title 38 position without being subject to
having their salary offset by the amount of their annuity.
VA instead favors a Government-wide policy on waivers of this
offset. Under current law, VA must obtain a waiver for individuals on a
case-by-case basis, or obtain delegated waiver authority from the
Office of Personnel Management (OPM). VA has done this for some
critical occupations. The Administration has submitted a bill, which VA
favors, to provide agencies with the authority to grant offset waivers
to facilitate the temporary part-time reemployment of annuitants, which
has been introduced as H.R. 3579/S. 2003. With many VA employees at or
near retirement eligibility the potential for significant losses of
mission-critical leaders and technical experts is a significant threat
to VA's capability to deliver high quality healthcare to our Nation's
veterans. VA access to retired title 38 healthcare providers, without
financial penalty, would enhance our ability to meet these challenges
and maintain the continuity of quality patient care, including support
in times of disaster. As explained by OPM, 3579/S. 2003 ``would allow
Federal agencies to rehire recently retired employees to assist with
short-term projects, fill critical skill gaps and train the next
generation of Federal employees.''
Minimum Rate of Basic Pay for section 7306 Appointees Set to Lowest
Rate of Basic Pay for SES
Subsection 2(e) would amend section 7404(a) to add a provision
setting the basic pay of non-physician/dentist section 7306 employees
at not less than the lowest rate of basic pay for the Senior Executive
Service (SES). This amendment would be effective the first pay period
that is 180 days after enactment.
VA supports the principle of pay equity with SES rates for its
section 7306 non-physician/dentist executives as a tool needed to meet
the challenge of recruitment and retention. However, we recommend some
modifications in the bill's language.
Equity in pay for executive level managers and consultants is
essential to attracting and retaining candidates for key positions. The
pay schedule for 38 USC Sec. 7306 appointees is now capped at the pay
rate for Level V of the Executive Schedule (currently $139,600).
Locality pay is paid up to the rate for Level III (currently $158,500).
Individuals appointed under 38 USC Sec. 7306 serve in executive level
positions that are equivalent in scope and responsibility to positions
in the SES. By comparison, employees in the SES receive a significantly
higher rate of basic pay. The maximum SES pay limitation is the rate
for Level II (currently $172,200) when OPM has certified that an agency
meets all regulatory criteria for certified performance appraisal
systems, including the employing agency makes meaningful distinctions
based on performance.
We estimate the costs of this provision to be $225,290 in FY 2009
and $2,466,862 over a 10-year period.
We recommend modifying this proposal to state that the basic pay of
non-physician/dentist section 7306 employees be set at the rates of pay
for SES employees under section 5382 of title 5. This modification
would allow VA executive pay to track the full range of SES pay. The
SES pay system conditions pay up to EL II on OPM certification that an
agency's SES rating system meets all regulatory criteria for certified
performance appraisal systems. In this regard we note that VHA
uses the same rating system for its section 7306 executives as it uses
for its SES members. OPM has certified VA's SES performance appraisal
system in the past, and it is currently certified by OPM through
calendar year 2009. For consistency, we also recommend that the bill be
modified to require that the Secretary make the same certification for
the rating system covering section 7306 employees. Thus, we suggest
that subsection 2(e)(3) be modified to read as follows:
``(3) Positions to which an Executive order applies under
paragraph
(1) and are not described by paragraph (2) shall be paid
basic rates of pay in accordance with section 5382 of title 5
for Senior Executive Service positions and not greater than the
rate of basic pay payable for level III of the Executive
Schedule; or if the Secretary certifies that the employees are
covered by a performance appraisal system meeting the
certification criteria established by regulation under section
5307(d), level II of the Executive Schedule.''
Comparability Pay Program for section 7306 Appointees
Subsection 2(f) would amend section 7410 to add a new subsection to
establish ``comparability pay'' for non-physician/dentist section 7306
employees of not more than $100,000 per employee in order to achieve
annual pay levels comparable to the private sector. Similar to
provisions for RN Executive Pay in section 7452(g), it would provide
that ``comparability pay'' would be in addition to other pay, awards
and bonuses; would be considered base pay for retirement purposes;
would not be base pay for adverse action purposes; and could not result
in aggregate pay exceeding the annual pay of the President.
VA supports the concept of comparability pay for its non-physician/
dentist executives. However, at this time we cannot support this
proposal because it is a potentially precedent-setting departure from
the unitary approach to government-wide SES pay. The Department is
evaluating alternative proposals that may be more appropriate in
addressing the comparability pay issues of these executives.
We estimate the cost of this provision to be $1,165,500 for FY 2009
and $12,761,900 over a 10-year period.
Special Incentive Pay for Department Pharmacist Executives
Subsection 2(g) would further amend section 7410 to authorize
recruitment and retention special incentive pay for pharmacist
executives of up to $40,000. VA's determination of whether to provide
and the amount of such incentive pay would be based on: grade and step,
scope and complexity of the position, personal qualifications,
characteristics of the labor market concerned, and such other factors
as the Secretary considers appropriate. As with RN Executive Pay and
comparability pay added by subsection (l), it would provide that
``comparability pay'' would be in addition to other pay, awards and
bonuses; would be considered base pay for retirement purposes; would
not be base pay for adverse action purposes; and could not result in
aggregate pay exceeding the annual pay of the President.
This provision would provide a retention incentive to about 40
positions: pharmacy benefit managers (PBM), consolidated mail
outpatient pharmacy (CMOP) directors and VISN formulary leaders (VFL).
Although VA is facing worsening pay compression issues within the ranks
of senior pharmacy program managers in the VHA, we cannot support this
provision because it will not address the Department's retention needs
in the long-term. The Department is evaluating alternative proposals
that will be more appropriate in addressing the recruitment and
retention needs of our pharmacy executives.
We estimate the cost of this provision to be $1,391,500 for FY 2009
and $16,324,220 over a 10-year period.
Physician/Dentist Pay
Section 2(h) concerns physician/dentist pay. VA supports this
provision.
Paragraph (1) would provide that the title 5 non-foreign cost of
living adjustment allowance for physicians and dentists would be
determined as a percentage of base pay only. This would clarify the
application of the title 5 non-foreign cost of living adjustment
allowance to VHA physicians and dentists. The VA physician/dentist pay
statute, 38 U.S.C. Sec. 7431, does not address how the allowance is
determined for physicians and dentists. We recommend that this
provision be amended to clarify that it is applicable only to these
physicians and dentists employed at Department facilities in Alaska,
Hawaii, and Puerto Rico. These are the only Department facilities to
which the title 5 non-foreign cost of living adjustment allowance is
applicable.
Paragraph (2) would amend section 7431 (c)(4)(B)(i) to exempt
physicians and dentists in executive leadership provisions from the
panel process in determining the amount of market pay and tiers for
such physicians and dentists. In situations where physicians or
dentists occupy executive leadership positions such as chief officers,
network directors, and medical center directors, the consultation of a
panel has some limitations. The small number of physicians and dentists
who would qualify as peers for the executive leaders results in their
serving on each other's compensation panels and, in some cases, on
their supervisor's panel. Providing the Secretary with discretion to
identify executive physician/dentists positions that do not require
that panel process would resolve these issues.
Paragraph (3) would provide an exception to the prohibition on the
reduction of market pay for changes in board certification or reduction
of privileges, correcting an oversight in the recent revision of the
physician/dentist pay statute. This modification would allow VA to
address situations where there is a loss of board certification or an
adverse reduction in clinical privileges. No costs are associated with
this provision.
RN and CRNA Pay
Subsections 2(i) and 2(j), relate to RN and Certified Registered
Nurse Anesthetist (CRNA) Pay.
Section 2(i) would amend the cap for registered nurse to maximum
rate of EL V or GS-15, whichever is greater. The current cap is the
rate for EL V. Subsection (j) would amend section 7451 (c)(2) to exempt
CRNAs from the current cap of EL V.
It is important for pay caps to be both fiscally responsible and
sufficient to promote employee recruitment and retention. These
proposals are not consistent with these principles. We note the
alternative GS-15 cap would be meaningless inasmuch as it already is
lower than the existing cap that is set at EL V, with a difference of
about $15,000. Moreover, it is unclear whether this alternative cap
would be at the GS-15 rate before locality pay or after locality pay.
The CRNA cap would leave CRNA pay rates completely uncapped, which
would allow rates to potentially exceed those of physicians and
dentists, the title Executive Schedule (Levels I-V), or the VA 7306
Schedule.
We would support this provision if the bill were amended to modify
section 7451(c)(2) to read: ``The maximum rate of basic pay for any
grade for a covered position may not exceed the rate of basic pay
established for positions in level IV of the Executive Schedule under
section 5315 of title 5.'' This would increase the cap from level V to
level IV for both RNs and CRNAs, consistent with the pay cap that
applies to the GS locality pay system. We estimate the cost of this
provision to be $4,803,964 for FY 2009 and $56,357,188 over a 10-year
period.
Subsection 2(k) would make amendments to the RN locality pay system
(LPS). These provisions are not helpful and unnecessary. No costs are
associated with this provision.
Paragraph (1) would require the Under Secretary for Health to
provide education, training, and support to VAMC directors in the
``conduct and use'' of LPS surveys. We are concerned that this
provision's focus on facility-conducted surveys is at odds with Public
Law Number 106-419, which enabled VAMCs to use third-party salary
surveys whenever possible rather than VA-conducted surveys. The use of
third-party surveys is in fact the preference of the Department. We
recommend modifying this provision to read: ``The Under Secretary for
Health shall ensure appropriate education and training are available
with regard to the conduct and use of surveys, including third party
surveys, under this paragraph''. This would cover both types of
surveys. Paragraph (2) would require the annual report VAMCs must
provide to VA Central Office to include the methodology for every
schedule adjustment. These reports form the basis for the annual VA
report to Congress. We are concerned that this provision, especially in
conjunction with proposed paragraph 3, could result in the
inappropriate disclosure of confidential salary survey data, contrary
to current section 7451 (d)(5). It also would impose an onerous burden
inasmuch as VHA has nearly 800 nurse locality pay schedules. We do note
that VA policy does provide for how these surveys are to be obtained or
conducted.
Paragraph (3) would require the most recent VAMC report on nurse
staffing to be provided to any covered employee or employee's union
representative upon request. This provision should be modified to
specify at what point the report must be provided. It would not be
appropriate to provide an individual a copy of the VAMC report before
Congress receives the VA report.
Subsection 2(I) would increase the maximum payable for nurse
executive special pay to $100,000. This provision would make the amount
of nurse executive pay con-
sistent with the Executive Comparability Pay in subsection 2(f). For
the same reason we oppose subsection 2(f), we do not support this
proposal. We estimate the cost of this provision to be $316,250 for FY
2009 and $3,710,053 over a 10-year period.
The caption for subsection 2(m) suggests it provides for
eligibility of part-time nurses for certain nurse premium pay. However,
many of the substantive amendments are not limited to part-time nurses,
or to all registered nurses.
VA opposes subsection 2(m) as seriously flawed, unnecessary, and
costly.
Subparagraph (1)(A) would amend section 7453 (a) to make part-time
nurses eligible for premium pay under that section. However, part-time
nurses already are eligible for section 7453 premium pay where they
meet the criteria for such pay.
Subparagraphs (1)(B) and (1)(C) would require evening tour
differential to be paid to all nurses performing any service between 6
pm and 6 am, and any service on a weekend, instead of just those
performing service on a tour of duty established for those times to
meet on-going patient care needs. Under current law, these
differentials are limited to the RN's normal tour of duty and any
additional time worked on an established tour.
The ``tour of duty'' in the current law reflects the requirement of
ensuring adequate professional care and treatment to patients during
off and undesirable tours. The limitation of tour differential and
weekend pay only for service on a ``tour of duty'' rewards those
employees who are subject to regular and recurring night and weekend
work requirements. If that is changed to ``period of service'', any
employees performing night or weekend work on an occasional or ad-hoc
basis would also be entitled to this premium pay in addition to
overtime pay, providing an inappropriate windfall for performing
occasional work.
Subparagraph (2) would authorize title 5 VHA employees to receive
25 percent premium pay for performing weekend work on Saturday and
Sunday. We understand the purpose of this provision is to limit the
expansion of weekend premium pay to non-tour hours to registered
nurses. However, it does not fully achieve that purpose. Pursuant to
section 7454(a) and (b)(2), physician assistants, expanded-function
dental auxiliaries, and hybrids are also entitled to weekend pay under
section 7453. The expansion of weekend pay would apply to them as well.
In addition, because physician assistants and expanded-function dental
auxiliaries are entitled to all forms of registered nurse premium pay
under section 7453, the expansion of the night differential premium pay
would also apply to them. Furthermore, where VA has authorized section
7453 night differential for hybrids, the expansion of the night
differential premium pay would apply to them as well.
Subsection 2(n) would add additional occupations to those exempt
from the 28th step cap on title 38 special salary rates: LPNs, LVNs,
and unspecified ``other nursing positions otherwise covered by title
5''. Notwithstanding the exemption, under current statute, title 38
special salary rates cannot exceed the rate for EL V. The language
``nursing positions otherwise covered by title 5'' is unclear as to
what positions it would include. RNs are appointed under title 38,
LPNs/LVNs are hybrids, and section 2(a)(2) of the bill would convert
nursing assistants to hybrid. Moreover, it is not apparent why only
these positions and not all positions authorized title 38 special rates
would be exempted. Using the same formula for the cap on title 5
special rates would afford VA the most flexibility in establishing
maximum rates for title 38 special rates. Adopting the title 5 fixed
percentage formula would render the section 7455(c)(2) report for
exceeding 94 percent of the grade maximum unnecessary, so we propose
deleting it. Thus we recommend amending section 7455 to read as
follows:
(a)(1) Subject to subsections (b), (c), and (d), when the
Secretary determines it to be necessary in order to obtain or
retain the services of persons described in paragraph (2), the
Secretary may increase the minimum rates of basic pay
authorized under applicable statutes and regulations, and may
make corresponding increases in all rates of the pay range for
each grade. Any increase in such rates of basic pay--
* * * *
(c) An increased minimum rate established under subsection
(a) may not exceed the maximum rate of basic pay (excluding any
locality-based comparability payment under section 5304 of
title 5 or similar provision of law) for the grade or level by
more than 30 percent, and no rate may be established under this
section in excess of the rate of basic pay payable for level IV
of the Executive Schedule.
Subsection 3(a)(1) would add new section 7459, imposing
restrictions on nurse overtime. section 7459 generally would prohibit
mandatory overtime for nurses (RNs, LPNs, LVNs, nursing assistants, and
any other nurse position designated by the Secretary). It would permit
mandatory overtime by nurses under certain conditions: an emergency
that could not have been reasonably anticipated; the emergency is non-
recurring and not due to inattention or lack of reasonable contingency
planning; VA exhausted all good faith, reasonable attempts to obtain
voluntary workers; the affected nurses have critical skills and
expertise; and the patient work requires continuity of care through
completion of a case, treatment, or procedure. VA could not penalize
nurses for refusing to work prohibited mandatory overtime. Section 7459
provides that nurses may work overtime hours on a voluntary basis.
VA favors this mandatory overtime restriction with the caveat that
first and foremost, VA needs to be able to mandate overtime where
issues of patient safety are identified by facility leadership. We note
VAMCs currently have policies preventing RNs from working more than 12
consecutive hours and 60 hours in a 7 day period pursuant to section
4(b) of PL 108-445.
Subsection 3(b) would amend 38 U.S.C. 7456 (the ``Baylor Plan''),
which authorizes VA to allow nurses who perform two 12-hour regularly
scheduled tours of duty on a weekend to be paid for 40 hours. This
work-scheduling practice typically would be used when facilities
encounter significant staffing difficulties caused by similar work
scheduling practices in the local community. Currently, VA has no
nurses working on the Baylor Plan. The proposed revision would
substitute scheduled ``periods of service'' for ``regularly scheduled
12-hour tour of duty.'' The purpose and effect of this amendment are
unclear. VA would oppose a revision of this authority if it were to
mandate that all work on 12 hour regular weekend tours of duty
automatically be considered Baylor Plan tours such that it would
mandate that any nurse who works two 12-hour shifts on a weekend in
addition to their regular tour of duty to get paid for 40 hours, in
addition to premium pay for the extra work, such as overtime; and to
mandate that nurses are not on the Baylor Plan but who routinely work
12-hour shifts under compressed work schedules that fall on weekends
are entitled to 40 hours of pay for the 24 hours worked on the weekend
in addition to pay for the remaining 16 hours.
Subsection 3(b)(2)(A), in eliminating the requirement that service
be on a ``tour of duty'' appears to make the Baylor 1,248 hourly rate
divisor apply to all service on the weekend instead of just non-
overtime hours. It is not appropriate for non-Baylor weekend work
hours, and VA opposes this provision.
Subsection 3(b)(3) would delete section 7456(c), the current Baylor
Plan requirement, which provides for a 5-hour leave charge for each 3
hours of absence that reflects the relative value of the truncated
Baylor tour, in effect increasing the value of leave for affected
employees. VA opposes this provision as providing an unwarranted
windfall.
Subsection 3(c) would amend section 7456A to change the 36/40
alternate work schedule to a 72/80 alternate work schedule, so that
under the schedule six 12-hour ``periods of service'' anytime in a pay
period would substitute for three ``12-hour tours of duty'' in each
week of the pay period. Similar changes would be made to section
7456A's overtime, premium pay and leave provisions.
VA is experiencing planning problems with the use of the current
36/40 schedule. That problem stems from the 36/40 language requiring
three 12-hour tours in a work week and because VA defines ``work week''
as Sunday-Saturday. Changing ''work week'' to ``pay period'' only makes
the problem occur every 2 weeks instead of every week, so we do not
view that as helpful. We do support changing the 36/40 alternate work
schedule to a 72/80 alternate work schedule, so that the six 12-hour
tours can occur anytime in a pay period, providing more work
scheduling/planning flexibility. VA will soon undertake a pilot in
which all hours worked on tours of duty that begin in a work week (even
if they end in the following work week) will be considered part of the
work week for the purpose of the 36/40 alternate work schedule. We
think this may help resolve the problem.
Section 4 would make amendments to VA's Education Assistance
Programs. VA supports these proposals.
Subsection 4(a) would amend section 7618 to reinstate the Health
Professionals Educational Assistance Scholarship Program through the
end of 2013. This program expired in 1998. The Health Professional
Scholarship Program would help reduce the nursing shortage in VA by
obligating scholarship recipients to work for 2 years at a VA
healthcare facility after graduation and licensure.
This proposal would also expand eligibility for the scholarship
program to all hybrid occupations. This would be helpful in recruiting
and retaining employees in the several hard-to-fill hybrid occupations.
We estimate the cost of this provision to be $725,000 in FY 2010 with a
5-year total of $21,380,000.
Subsection 4(b) would make certain amendments to the Education Debt
Reduction Program. It would amend section 7681(a)(2) to add retention
as a purpose of the program and amend section 7682(a)(1) to make it
available to ``an'' employee, in lieu of ``recently appointed.'' It
would also increase the authorized statutory amounts in section 7683 to
$60,000 and $12,000, respectively.
The ``recently appointed'' requirement limits eligibility to
employees who have been appointed within 6 months. VA's experience has
been that this is not a sufficient period. In several instances,
employees applying just missed the 6 month deadline. In many cases it
takes more than 6 months for employees to become aware of this very
helpful recruitment and retention program. VA also supports the
increased amounts in light of increased education costs since the
program was enacted. We estimate the cost of this provision to be
$5,400,000 for FY 2010 and $77,352,000 over a 10-year period.
Subsection 4(c) would authorize VA researchers from ``disadvantaged
backgrounds'' to use authorities in the Public Health Service Loan
Repayment Program. This program presently is not available to Federal
employees other than those working for the National Institutes of
Health (NIH). Clinicians with medical specialization and research
interests who might otherwise consider career clinical care or clinical
research opportunities with VHA are therefore less likely to do so
because VA employees are not eligible for the LRP program. These same
research-focused, entry-level professionals have historically been the
highest caliber and most sought-after candidates. VA researchers should
be able to participate in this much sought-after program. VHA's
Education Debt Reduction Program (EDRP) is only available for employees
hired for permanent title 38 positions. Those in time-limited clinical
research training positions such as the Research Career Development
Awards (which historically have served as entryways to VA careers in
clinical care and research) are not eligible. There are no costs
associated with this proposal; it would not increase the funding of
this program, but simply authorize VA researchers to participate in it.
Mr. Chairman, this concludes my prepared statement. I will be happy
to answer any questions that you and the Members of the Subcommittee
might have.
Statement of Raymond C. Kelly, National Legislative Director, American
Veterans (AMVETS)
Chairman Michaud, Ranking Member Miller, thank you for holding this
important hearing today. AMVETS is pleased to provide our views on H.R.
3051, the Heroes at Home Act of 2007, and H.R. 6153, the Veterans
Medical Personnel Recruitment and Retention Act of 2008.
H.R. 3051 will establish two separate programs. First it will
provide training and certification of family caregivers for veterans
and members of the Armed Forces with Traumatic Brain Injury (TBI). Once
a family member has been deemed eligible for the certification they
also become eligible for compensation for the care they provide. H.R.
3051 will also establish a DoD-VA demonstration project to test the
feasibility of using telehealthcare to care for servicemembers and
veterans who have or could have TBI.
TBI is the signature wound of the current conflicts in Iraq and
Afghanistan. Identifying, treating, and caring for servicemembers who
have TBI ranks at the top of AMVETS' priorities; therefore, AMVETS
fully supports H.R. 3051, which will provide training and certification
for family members of servicemembers who are affected by the unique
nature of TBI. Family members are a natural choice for caring for
patients who need daily in-home care. Because of the desire to help,
family members will become caregivers. Providing them with the proper
training and certification will give them the confidence they need to
fully care for their loved one and reduce VA's need to provide
additional home healthcare.
H.R. 3051 will also broaden the use of telehealth and telemental
health services. VA is a national leader in the development and use of
telehealth programs. Nearly 200,000 veterans have been seen this year
by specialists from the convenience of their local CBOC. Evaluating,
diagnosing and treating mental health conditions related to TBI through
telehealth will improve the lives of our servicemembers who have
sustained head injuries. AMVETS supports the provision that will
establish the telehealth and telemental health demonstration project.
It is critical that VA and DoD make every effort to make receiving
treatment for our servicemembers and veterans as convenient and as
effective as possible, and the use of telehealth will ensure that
veterans in remote locations or veterans who may have trouble traveling
any distance will receive the attention and care they need and deserve.
H.R. 6153, the ``Veterans' Medical Personnel Recruitment and
Retention Act of 2008'' would give the Department of Veterans Affairs
an enhanced ability to recruit and retain nurses and other critical
healthcare professionals at VA facilities. The Veterans Health
Administration (VHA) is the largest direct provider of healthcare
services in the Nation and adequate staffing is necessary to provide
the care our veterans deserve. It is for this reason that AMVETS wholly
supports H.R. 6153.
Critical shortages of healthcare professionals, such as registered
nurses (RN), registered nurse anesthetists, physical and occupational
therapists, speech pathologists, pharmacists, and physicians make it
difficult to fill positions in the best of circumstances. Add to this
the difference between VA compensation and private sector salaries and
it becomes evident why the VA is understaffed.
One recruitment and retention tool in H.R. 6153 would be to
increase pay for critical jobs. Currently VA medical professionals'
salaries are not in line with what other facilities can pay. This has
resulted in understaffed hospitals. By increasing the limitation on
special pay for nurse executives from $25,000 to $100,000, for example,
the VA has a tool to recruit new professionals as well as provide
retention incentives for those already employed by VA facilities.
Another recruitment tool provided for in H.R. 6153 is limits on
mandatory overtime and more flexible work schedules. It also improved
education assistance programs and loan repayment plans. Combined with
increased pay for certain positions, these tools would expand VA's
ability to recruit and retain employees which would translate into
improved care for our Nations' veterans. AMVETS wholly supports H.R.
6153.
Mr. Chairman, this concludes my testimony. I will be happy to
answer any questions regarding our opinion on these matters.
Statement of Susan H. Conners, President/Chief Executive Officer,
Brain Injury Association of America
The Brain Injury Association of America (BIAA) and its nationwide
network of state affiliates representing survivors of traumatic brain
injury (TBI), their families, researchers, clinicians and other
professionals, strongly supports The Heroes at Home Act of 2007 (H.R.
3051) and urges the United States House Committee on Veterans' Affairs
to approve this important legislation in a timely manner.
The Heroes at Home Act of 2007 (H.R. 3051) would significantly
improve support for family caregivers of returning servicemembers with
traumatic brain injury (TBI). This important bill proactively
acknowledges the reality that a brain injury impacts the entire family,
not just the individual.
Importantly, this legislation acknowledges the critical role played
by family caregivers in facilitating recovery from brain injury and
addresses the pressing need to increase support for these caregivers
through programs providing access to training, certification and
financial compensation for their work as personal care attendants.
Family care is the most important source of assistance for people
with chronic or disabling conditions, including people with brain
injury. Yet, research has found that all too often, the traumatic brain
injury of a spouse or close relative places extreme stress on family
caregivers, frequently resulting in adverse physical and emotional
outcomes for the caregivers themselves. Unfortunately, despite these
documented physical hardships and psychological stress, family
caregivers receive little support.
Specifically, stress reaction is known to occur in situations where
the demands of the environment exceed an individual's resources. One
critical component that has been found to be related to caregiver
burden is whether or not the caregiver perceives the effects of the
injury to exceed the caregiver's resources to manage the situation. In
other words, perceived stress has consistently predicted negative
outcomes for the caregiver.\i\ A lack of financial resources and social
supports are some of the common perceived stresses impacting family
caregivers of loved ones with TBI.
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\i\ Chwalisz, Kathleen. ``Perceived Stress and Caregiver Burden
after Brain Injury: A Theoretical Integration.'' Rehabilitation
Psychology, Vol. 37, No. 3, 1992. pp 189-203.
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One longitudinal study found that 47 percent of family caregivers
of individuals with TBI had altered or given up their jobs at 1 year
postinjury, and 33 percent at 2 years postinjury, decreases in both
employment and financial status were reported over a 2-year time period
postinjury \ii\. Particularly in light of the fact that
caregivers often report severe financial strain and frequently must
give up their jobs in order to take care of their loved one with TBI,
increased financial support and access to respite care for family
caregivers of returning servicemembers with TBI is vital and long
overdue.
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\ii\ Hall KM, Karzmark P, Stevens M, Englander J, O'Hare P, Wright
J. Arch Phys Med Rehabil. 1994 Aug;75 (8): 876-84.
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Again, the Brain Injury Association of America enthusiastically
endorses The Heroes at Home Act of 2007 (H.R. 3051) and strongly
encourages the Committee to approve this legislation.
Sincerely,
Susan H. Connors
President/Chief Executive Officer
Statement of Hon. Paul W. Hodes,
a Representative in Congress from the State of New Hampshire
I strongly support my colleague Carol Shea-Porter's bill, H.R.
6629, the Veterans Health Equity Act. Her bill would ensure that New
Hampshire's veterans have access to the healthcare they have earned. I
thank Chairman Michaud for holding this important hearing that
highlights the lack of adequate access to healthcare for New
Hampshire's veterans.
New Hampshire is the only state in the continental United States
that does not have a full service Veterans Affairs Medical Center
(VAMC). In my district alone, there are over 66,000 veterans, making up
13 percent of the population. New Hampshire's many veterans deserve the
same access to healthcare services as veterans in other states across
the country.
Seven years ago, the Manchester VAMC suspended various inpatient
and outpatient services and was downgraded from a full-service VAMC.
Now, veterans in New Hampshire must travel to surrounding states like
Maine, Vermont or Massachusetts to receive VA healthcare services.
This travel causes both physical and financial hardships for our
wounded veterans. Without a full service VAMC in state, New Hampshire's
veterans are forced to drive across state lines, traveling farther and
paying more at the pump with record gas prices to access the healthcare
they earned.
Recently, the Secretary of Veterans Affairs James Peake visited New
Hampshire and announced that the VAMC in Manchester will not return to
a full service VAMC. I was extremely disappointed in Secretary Peake's
shortsighted remarks. More wounded warriors are returning home from the
Wars in Iraq and Afghanistan as veterans with physical and mental
wounds, with Post Traumatic Stress Disorder and Traumatic Brain Injury,
stretching our veteran's healthcare system.
With so many soldiers fighting abroad, we should not be turning our
backs on veterans at home when they need it most. New Hampshire is the
only state in the continental U.S. without a full service VA. With
record high gas prices, we shouldn't ask Granite State veterans to
drive long distances just to get the care they have earned. I strongly
support H.R. 6629, the Veterans Health Equity Act, which would ensure
that veterans across the country will receive the same access to
healthcare that they deserve, no matter which state they live in.
Statement of Barbara Cohoon, Deputy Director, Government Relations,
National Military Family Association, Inc.
Chairman Michaud and Distinguished Members of this Subcommittee,
the National Military Family Association (NMFA) would like to thank you
for the opportunity to present written testimony for the record on
`Heroes at Home Act of 2007.' We thank you for your focus on the many
elements necessary to ensure quality healthcare and mental healthcare
for our wounded/ill/injured servicemembers, veterans, and the families
who care for them; and, recognizing the important role caregivers play
in the care of their loved one.
NMFA will discuss several issues of importance to wounded/ill/
injured servicemembers, veterans, and their families in the following
subject areas:
I.
Wounded Servicemembers Have Wounded Families
II.
Who Are the Families of Wounded Servicemembers?
III.
Caregivers
IV.
Mental Health
Wounded Servicemembers Have Wounded Families
NMFA asserts that behind every wounded servicemember and veteran is
a wounded family. Spouses, children, parents, and siblings of
servicemembers injured defending our country experience many
uncertainties. Fear of the unknown and what lies ahead in future weeks,
months, and even years, weighs heavily on their minds.
Transitions can be especially problematic for wounded/ill/injured
servicemembers, veterans, and their families. The Department of Defense
(DoD) and the Department of Veterans Affairs (VA) healthcare systems,
along with State agency involvement, should alleviate, not heighten
these concerns. It is NMFA's belief the government must take a more
inclusive view of military and veterans' families. Those who have the
responsibility to care for the wounded servicemember must also consider
the needs of the spouse, children, parents of single servicemembers,
siblings, and especially the caregivers. According to the VA,
`informal' caregivers are people such as a spouse or significant other
or partner, family member, neighbor or friend who generously gives
their time and energy to provide whatever assistance is needed to the
veteran.''
Who are the families of Wounded Servicemembers
In the past, the VA and the DoD have generally focused their
benefit packages for a servicemember's family on his/her spouse and
children. Now, however, it is not unusual to see the parents and
siblings of a single servicemember presented as part of the
servicemember's family unit. In the active duty, National Guard, and
Reserves almost 50 percent are single. Having a wounded servicemember
is new territory for family units. Whether the servicemember is married
or single, their families will be affected in some way by the injury.
As more single servicemembers are wounded, more parents and siblings
must take on the role of helping their son, daughter, sibling through
the recovery process. Family members are an integral part of the
healthcare team. Their presence has been shown to improve their quality
of life and aid in a speedy recovery.
NMFA recently gathered information about issues affecting our
wounded servicemembers, veterans, and their families through our
Healing Adventure Operation Purple Camp in August and a focus group
held this March at Camp Lejeune. They said following the injury,
families find themselves having to redefine their roles. They must
learn how to parent and become a spouse/lover with an injury. Spouses
talked about the stress their new role as caregiver has placed on them
and their families. Often overwhelmed and feeling as if they have no
place to turn to for help.
Caregivers
Caregivers need to be recognized for the important role they play
in the care of their loved one. Without them, the quality of life of
the wounded servicemembers and veterans, such as physical, psycho-
social, and mental health, would be significantly compromised. They are
viewed as an invaluable resource to DoD and VA healthcare providers
because they tend to the needs of the servicemembers and the veterans
on a regular basis. And, their daily involvement saves DoD, VA, and
State agency healthcare dollars in the long run.
Caregivers of the severely wounded, ill, and injured servicemembers
who are now veterans have a long road ahead of them. In order to
perform their job well, they must be given the skills to be successful.
This will require the VA to train them through a standardized,
certified program, and appropriately compensate them for the care they
provide. NMFA is pleased with the `Heroes at Home Act of 2007'
legislation that will provide for the training, certification, and
compensation for injured servicemembers or veterans with TBI. TBI has
become the signature wound of this current conflict; however, the
legislation should be flexible and allow for the expansion of training,
certification, and compensation to encompass other injuries. Often, our
wounded servicemembers and veterans present with more than one type of
injury. This legislation places VA in an active role in recognizing
caregivers' important contributions and enabling them to become better
caregivers to their loved ones. It is a win-win for everyone involved.
The VA currently has eight caregiver assistance pilot programs to
expand and improve healthcare education and provide needed training and
resources for caregivers who assist disabled and aging veterans in
their homes. These pilot programs are important, but there is a strong
need for 24-hour in-home respite care, 24-hour supervision, emotional
support for caregivers living in rural areas, and coping skills to
manage both the veteran's and caregiver's stress. These pilot programs,
if found
successful, should be implemented by the VA as soon as possible and
fully funded by Congress. However, one program missing is the need for
adequate child care. Veterans can be single parents or the caregiver
may have non-school aged children of their own. Each needs the
availability of child care in order to attend their medical
appointments, especially mental health appointments. NMFA encourages
the VA to create a drop-in child care for medical appointments on their
premises or partner with other organizations to provide this valuable
service.
Mental Health
Families' needs for a full spectrum of mental health services--from
preventative care and stress reduction techniques, to individual or
family counseling, to medical mental health services--will continue to
grow. It is important to note if DoD has not been effective in the
prevention and treatment of mental health issues, the residual will
spill over into the VA healthcare system. The need for mental health
services will remain high for some time even after military operations
scale down and servicemembers and their families transition to veteran
status. The VA must be ready. They must partner with DoD and State
agencies in order to address mental health issues early on in the
process and provide transitional mental health programs. They must
maintain robust rehabilitation and reintegration programs for veterans
and their families that will require VA's attention over the long-term.
NMFA is especially concerned with the scarcity of services
available to the families as they leave the military following the end
of their activation or enlistment. They may be eligible for a variety
of health insurance programs, such as TRICARE Reserve Select, TRICARE,
or VA. Many will choose to locate in rural areas where there may be no
mental health providers available. We ask you to address the distance
issues families face in linking with mental health resources and
obtaining appropriate care. Isolated veterans and their families do not
have the benefit of the safety net of services and programs provided by
MTFs, VA facilities, CBOCs, and Vet Centers. NMFA recommends the use of
alternative treatment methods, such as telemental health. The `Heroes
at Home Act of 2007' provision for telemental health will provide an
additional benefit to this population. Another solution is modifying
licensing requirements in order to remove geographical practice
barriers that prevent mental health providers from participating in
telemental health services outside of a VA facility.
NMFA appreciates the `Heroes at Home Act of 2007' inclusion of an
outreach and public awareness provision. The VA must educate their
healthcare and mental health professionals, along with veterans'
families of the effects of mild Traumatic Brain Injury (TBI) in order
to help accurately diagnose and treat the veteran's condition.
Veterans' families are on the ``sharp end of the spear'' and are more
likely to pick up on changes contributed to either condition and relay
this information to VA providers. VA mental and healthcare providers
must be able to deal with polytrauma--Post-Traumatic Stress Disorder
(PTSD) in combination with multiple physical injuries. NMFA appreciates
Congress establishing the National Center of Excellence and the Defense
Center of Excellence. Now, it is very important for DoD and VA to
partner in researching TBI and PTSD. We believe the VA needs to educate
their civilian healthcare providers on how to identify signs and
symptoms of mild TBI and PTSD. And, as the VA incorporates Project
Hero, they must educate civilian network mental health providers about
our military culture.
NMFA strongly suggests standardized training, certification, and
compensation for caregivers of injured servicemembers or veterans with
TBI.
NMFA recommends the use of alternative treatment methods, such as
telemental health; and, the modification of licensing requirements to
remove geographical practice barriers that prevent mental health
providers from participating in telemental health services outside of a
VA facility.
The VA must educate their healthcare and mental health
professionals, along with veterans' families of the effects of mild
Traumatic Brain Injury (TBI) and Post-traumatic Stress Disorder (PTSD)
to help accurately diagnose and treat the servicemember's condition.
The VA needs to encourage more education for civilian healthcare
providers on how to identify signs and symptoms of mild TBI and PTSD.
NMFA recommends spouses and parents of returning servicemembers and
veterans need programs providing education on identifying mental
health, substance abuse, suicide, and traumatic brain injury.
NMFA recommends Congress require Vet Centers and the VA to develop
a holistic approach to veteran care by including their families in
providing mental health counseling and programs.
NMFA would like to thank you again for the opportunity to present
testimony for the record on the `Heroes at Home Act of 2007' for
servicemembers, veterans, and their families. Military families support
the Nation's military missions. The least their country can do is make
sure servicemembers, veterans, and their families have consistent
access to high quality mental healthcare in the DoD, VA, and within
network civilian healthcare systems utilizing alternative treatment
methods, such as telemental health. Wounded servicemembers and veterans
have wounded families. The caregiver must be supported by the VA by
providing training, certification, and compensation for the care of
their loved one. The system should provide coordination of care DoD,
VA, and State agencies working together to create a seamless
transition. We ask Congress to assist in meeting that responsibility.
Statement of Paralyzed Veterans of America
Chairman Michaud, Ranking Member Miller, and Members of the
Subcommittee, Paralyzed Veterans of America (PVA) is pleased to present
our views concerning H.R. 6153, the ``Veterans Medical Personnel
Recruitment and Retention Act of 2008,'' and H.R. 3051, the ``Heroes at
Home Act of 2007,'' which will improve the diagnosis and treatment of
Traumatic Brain Injury (TBI) for members and former members of the
Armed Forces.
H.R. 6153, THE ``VETERANS MEDICAL PERSONNEL RECRUITMENT AND RETENTION
ACT OF 2008''
PVA's primary concern, and the basic reason for our existence, is
the health and welfare of our members and our fellow veterans. The
thousands of Department of Veterans Affairs (VA) healthcare
professionals and all of those individuals necessary to support their
efforts are at the core of VA's primary mission. These individuals
serve on the frontline every day, caring for America's wounded veterans
from Iraq and Afghanistan and seeing to the complex medical needs of
our countries older veterans from previous wars. PVA believes that VA's
most important asset is the people it employs to care for those who
have served our Nation.
Mr. Chairman, when PVA testified on May 22, 2008 concerning the
human resources challenges facing the Department of Veterans Affairs',
we applauded the Subcommittee for its timely and well placed interest
in the issues concerning VA healthcare personnel. PVA continues to
believe that Congress must assist VA efforts to recruit and retain its
corps of healthcare professionals as the demand for healthcare
increases both because of the ongoing Global War on Terrorism and the
aging of the veteran population from previous wars. The current serious
national short fall in the supply of physicians, nurses, pharmacists,
therapists and psychologists threatens VA staffing as competition for
experienced medical personnel and newly licensed professionals
continues to increase. H.R. 6153 is a step in the right direction.
The United States is currently in the tenth year of a critical
nursing shortage which is expected to continue through 2020. The
shortage of registered bed-side nurses and registered nurse specialists
is having an impact on all aspects of acute and long-term care.
America's nursing shortage has created nurse recruitment and retention
challenges for medical-care employers nationwide and is making access
to quality care difficult for consumers.
The gap between the supply of and the demand for nurses may
adversely affect the VA's ability to meet the healthcare needs of those
who have served our Nation. According to VA, it employs more than
64,000 nursing professionals, and has one of the largest nursing staffs
of any healthcare system in the world. Of that 64,000, VA has 43,000
registered nurses, 12,000 licensed practical nurses, and 9,000 nursing
assistants. VA also says that approximately 4,300 nurses retire or
leave each year. VA must be able to recruit the best nurses, and retain
a cadre of experienced, competent nurses. Providing high quality
nursing care to the Nation's veterans is integral to the healthcare
mission of VA.
During PVA's previous testimony, we asked for the Subcommittee's
consideration of specially pay for nurses providing care in VA's
specialized service programs such as: spinal cord injury/disease (SCI/
D), blind rehabilitation, mental health and brain injury. PVA is
disappointed that the Subcommittee chose not to include such specific
language in H.R. 6153.
Mr. Chairman, veterans who suffer spinal cord injury and disease
require a cadre of specialty trained registered nurses to meet their
complex initial rehabilitation and life-long sustaining medical care
needs. PVA's data reveals a critical shortage of registered nurses who
are providing care in VA's SCI/D center system of care. The complex
medical and acuity needs of these veterans, makes care for them ex-
tremely difficult and demanding. These difficult care conditions become
barriers to quality registered nurse recruitment and retention. Many of
VA's SCI/D nurses are often placed on light duty status because of
injuries they sustain in their daily tasks. When this happens it
becomes a significant problem because it places additional patient care
responsibility on those SCI/D nurses not on light duty. PVA believes
SCI/D specialty pay is absolutely necessary if nurse shortages are to
be overcome in this VA critical care area. We strongly encourage your
committee to include a Title 38 specialty pay provision that will
assist VA's efforts to recruit and retain nurses in these specialized
areas.
PVA is concerned about the VA's current ability to maintain
appropriate and adequate levels of physician staffing at a time when
the Nation faces a pending shortage of physicians. Recent analysis by
the Association of American Medical Colleges (AAMC) indicates the
United States will face a serious doctor shortage in the next few
decades. The AAMC goes on to say that currently, ``744,000 doctors
practice medicine in the United States, but 250,000--one in three--are
over the age of 55 and are likely to retire during the next 20 years.''
The subsequent increasing demand for doctors, as many enter retirement,
will increase challenges to VA's recruitment and retention efforts. PVA
believes H.R. 6153 will allow VA to be more competitive in recruiting
doctors for the VA system.
Mr. Chairman, the Veterans Health Administration has made great
strides over the last decade to improve the quality of care it provides
to our Nation's veterans. Despite these gains, VA now finds itself in a
precarious situation if it expects to retain its position as a vastly
improved healthcare system. As stated earlier, H.R. 6153 is only a
first step in meeting the challenges associated with maintaining a
highly qualified medical care workforce for VA. Competition to hire
medical care professionals, during a national period of low supply, is
making it more-and-more difficult for VA to successfully recruit and
retain qualified personnel. This Subcommittee and VA must be vigilant
in developing programs that will provide professional healthcare
workers to care for our veterans.
H.R. 3051, ``THE HEROES AT HOME ACT OF 2007''
Traumatic Brain Injuries (TBI) have become an important topic as a
result of the wars in Afghanistan and Iraq. In fact, The Independent
Budget, co-authored by PVA, AMVETS, Disabled American Veterans (DAV)
and the Veterans of Foreign Wars (VFW), identified treatment for
veterans with TBI as a critical issue for 2008 and beyond. PVA welcomes
the Subcommittee's action on H.R. 3051.
TBI, Spinal Cord Injury, and other serious injuries account for
almost 20 percent of the combat casualties sustained by U.S. soldiers,
airman and Marines in OEF/OIF. Explosive blast pressure waves from
improvised explosive devices (IEDs) violently shake or compress the
brain within the closed skull and cause devastating and often permanent
damage to brain tissues. There has been universal recognition that
veterans with severe TBI will need a lifetime of intensive services to
care for their injuries. However, PVA is concerned that, at all levels,
development of programs to address the needs of veterans with mild,
subclinical TBI have not been fully developed or implemented.
DoD and VA experts note that TBI can also be caused without any
apparent physical injuries if a person is in the vicinity of these IED
detonations. Veterans suffering from this milder form of TBI may not be
readily detected; however, symptoms can include chronic headaches,
irritability, disinhibition, sleep disorders, confusion, executive
functioning and memory problems, and depression, among other symptoms.
With tens of thousands of IED detonations now recorded in Iraq alone,
it is believed that many OEF/OIF servicemembers have suffered mild, but
pathologically significant, brain injuries (including multiple
concussions) that have gone undiagnosed and largely untreated thus far.
TBI and its associated symptoms may be detected later only if proper
screening is conducted.
PVA is concerned about emerging literature that strongly suggests
that even mildly injured TBI patients may have long-term mental and
physical health consequences. According to DoD and VA mental health
experts, mild TBI can produce behavioral manifestations that mimic Post
Traumatic Stress Disorder (PTSD) or other conditions. And TBI and PTSD
can be coexisting conditions. Much is still unknown about the long-term
impact of these injuries and the best treatment models to address mild-
to-moderate TBI. We believe VA should conduct more research into the
long-term consequences of brain injury and development of best
practices in its treatment; however, we suggest that any studies
undertaken include older veterans of past military conflicts who may
have suffered similar injuries that thus far have gone undetected,
undiagnosed or misdiagnosed, and untreated. Their medical and social
histories could be of enormous value to VA researchers interested in
the likely
long-term progression of these new injuries. Likewise, such knowledge
of historic experience could help both the DoD and VA better understand
the policies needed to improve screening, diagnosis, and treatment of
mild TBI in combat veterans of the future. This is where PVA sees great
potential for the demonstration project of Telehealth and Telemental
programs proposed in H.R. 3051. We would caution the Subcommittee,
however, to ensure that this program is a supplement to regular VA
programs and not used as one more way for VA to move veterans'
healthcare further away from VA facilities.
Individuals suffering from mild brain injury often present complex,
difficult-to-assess complaints and conditions that can masquerade as
other diagnoses. This complexity requires an integrated, personalized
recovery plan coordinated by a cadre of specialists with expertise in
TBI to diagnose and manage their medical, psychological, and
psychosocial needs.
Although VA has initiated new programs and services to address the
needs of severe TBI patients, gaps in services still exist. The VA's
Office of the Inspector General (OIG) issued a report in July of 2006,
titled ``Health Status of and Services for Operation Enduring Freedom/
Operation Iraqi Freedom Veterans after Traumatic Brain Injury
Rehabilitation.'' The report assessed healthcare and other services
provided for veterans and active duty patients with TBI, and then
examined their status approximately 1 year following completion of
rehabilitation.
The report found that better coordination of care between DoD and
VA health-care services was needed to enable veterans to make a smooth
transition. According to the report, the goal of achieving optimal
function of each individual requires further interagency agreements and
coordination between the DoD and VA. PVA believes the true measure of
success will be the extent to which those most severely injured
veterans are eventually able to recover, reenter their communities, or
at minimum, achieve stability of function at home or in the least
restrictive, age-appropriate continuing care facilities provided by VA
to meet their needs and preferences.
PVA strongly supports the provisions of H.R. 3051 which provide
training and certification for family caregiver personal attendants at
no cost to the family. Providing the ability for family members to care
for their loved ones injured in conflict will assist in keeping the
families strong while properly caring for the veteran. Though PVA
remains concerned about whether VA has addressed the long-term
emotional and behavioral problems that are often associated with TBI,
and the devastating impact on both the veteran and his or her family,
we believe this program may help address these concerns. As noted in
the July 2006 OIG report, ``these problems exact a huge toll on
patients, family members, and healthcare providers.'' The following
excerpt from the report is especially telling:
In the case of mild TBI, the [veteran's] denial of problems
which can accompany damage to certain areas of the brain often
leads to difficulties receiving services. With more severe
injuries, the extreme family burden can lead to family
disintegration and loss of this major resource for patients.
The OIG recommendations included improving case management for TBI
patients to ensure lifelong coordination of care; improving
collaborative policies between the DoD and VA; starting new initiatives
to support families caring for TBI patients, including providing access
to VA or contract caregivers; and recommending that rehabilitation for
TBI patients be initiated by the DoD when clinically indicated. We
fully concur with the OIG's recommendations and recognize that
supporting these patients for a lifetime of care and service will be a
continuing challenge for VA.
VA now requires a case manager be assigned to each OEF/OIF veteran
enrolled in VA healthcare. The case manager's duty is to communicate
and coordinate all VA benefits and services. Also, VA has created
liaison and social work positions in DoD facilities to assist injured
servicemembers with their transitions to veteran status and to provide
advice and assistance to them and their families in accessing VA
services. PVA commends VA for its efforts to improve the knowledge and
skills of VA clinicians through educational initiatives defining the
unique experience and needs of this newest generation of combat
veterans. We also acknowledge VA's dedication and commitment to meeting
the needs of veterans with TBI through high quality services at its
polytrauma-TBI lead centers, for ongoing research into this
debilitating injury, and for establishing effective services with
academic and military affiliates to fill gaps in service when and where
they are found. However, we are concerned about media reports from
veteran patients with TBI and their family members who claim that VA
TBI care is not up to par in certain locations, prompting them to seek
rehabilitation services from private facilities. VA must ensure that
its TBI network provides excellent care to all veterans irrespective of
their degree of impairment. VHA's current continuing education programs
should be enhanced to ensure that all VA providers are knowledgeable
about the spectrum of clinical presentation and treatment of veterans
with combat-related TBI.
We encourage VA and Congress to ensure that severely wounded TBI
veterans are receiving the best treatment and rehabilitation care
available and that the needs of their family caregivers be met with
innovative and effective programs.
Mr. Chairman, this concludes our remarks. PVA will be happy to
respond to any questions you or Members of the Subcommittee may have.
Statement of James C. Schraa, Psy.D., Neuropsychologist, Licensed
Psychologist, State of Colorado, Craig Hospital, Englewood, CO
Severe traumatic brain injury is a family injury in the sense that
it converts the loved ones of the brain injured servicemembers into
caregivers and personal care attendants. After acute rehabilitation,
the family members must substitute their judgment, planning and memory
functions for the cognitive abilities and emotional control that their
loved one has lost. Positive outcomes following severe traumatic brain
injury are strongly associated with ongoing family support and
involvement. Unfortunately, providing care giving and a safe structure
for the severely brain injured is associated with the experience of
high levels of stress and very high divorce rates. The civilian
literature also establishes that brain injury substantially increases
the frequency of bankruptcy.
The vast majority of Americans would agree that supporting our
troops includes helping families to successfully cope with the
behavioral and adjustment challenges that persist following severe
traumatic brain injury. Americans want their military servicemembers
with severe brain injuries to have as much quality of life as possible.
This is clearly associated with keeping them with their families and in
their own communities. The Medicare cost literature amply documents
that maintaining patients in the community is also cost effective. The
most expensive cases in terms of long-term medical costs are the
chronically institutionalized disabled. Thus, Representative Salazar's
Bill, H.R. 3051 not only reflects the loyalty we feel to our fellow
citizen soldiers, but also represents a cost-effective approach to
reduce healthcare costs (references available on request). It should
also be noted that divorce involving patients with severe brain
injuries results in increased long-term costs to government agencies
for establishing and managing guardianships and conservatorships.
The literature on urban versus rural health-related quality of life
establishes that the rural veteran population experiences lower
physical and mental quality of life. Numerous studies have established
that members of the National Guard and Reserve experience higher rates
of emotionally based symptoms and problems related to alcoholism. Fewer
supports in rural communities contribute to poorer coping in all at-
risk groups including soldiers with traumatic brain injury. Rural VA
clinics and Veteran Centers in rural communities constitute tremendous
improvements for veterans but they usually do not include specialty
care. Therefore, in all states with dispersed rural populations,
initiatives to improve telemedicine are needed. Rural veterans with
moderate to severe traumatic brain injuries will clearly be in need of
ongoing consultation for the foreseeable future. Given the difficulties
that this group of brain injured veterans has with driving and
transportation, telemedicine outreach projects to increase their access
to services should be supported.
I have had the experience of working with patients with severe
traumatic brain injuries and spinal cord injuries for 26 years at Craig
Hospital. Our experience is that supporting and maintaining families in
the community is the most cost effective approach to long-term care,
and the approach that affords the highest quality of life. There is
literature from the Workers' Compensation Reinsurance industry which
establishes that maintaining brain injured patients with their families
in the community is the most cost effective treatment approach.
Therefore, I strongly recommend that you consider passing H.R. 3051.
H.R. 3051 is superior to S. 2921 because it will help keep more
families with a brain injured servicemember intact, and prevent the
institutionalization of more soldiers with severe brain injury than the
provisions of S. 2921
Respectfully submitted,
James C. Schraa, Psy.D.
Neuropsychologist
Licensed Psychologist, State of Colorado
Craig Hospital, Englewood, CO
Statement of Christopher Needham, Senior Legislative Associate,
National Legislative Service, Veterans of Foreign Wars of the United
States
Mr. Chairman and Members of the Subcommittee:
Thank you for the opportunity to provide testimony for this
legislative hearing. The 2.3 million men and women of the Veterans of
Foreign Wars of the U.S. appreciate the voice you give them at these
important hearings.
H.R. 3051, the Heroes at Home Act
The VFW strongly supports the Heroes at Home Act. This legislation
would dramatically improve the delivery of healthcare for those
veterans suffering from traumatic brain injury. We thank Representative
Salazar and the original cosponsors of this legislation for its
introduction, and we urge its passage.
We especially appreciate section 2 of the legislation. It would
create a family caregiver program to train families or friends of
veterans suffering from the effects of severe traumatic brain injuries.
The newest generation of war veterans is presenting VA with many
new healthcare challenges. Advances in technology and battlefield
medicine are allowing many hundreds of men and women to survive
injuries that previously would have been fatal. This, however, is
coming at a price; many of them are grievously wounded and suffering
from complex and intertwined ailments that are stretching VA's ability
to adapt. Once the worst of their ailments are addressed, a great
number of these men and women are returning home to their immediate
families. In some cases, this is a spouse and in other cases--
especially given the relatively young age of many of these men and
women--to their parents.
The impact on these families is daunting. Their loved ones have
complex physical and emotional difficulties and they must battle the
bureaucracy of VA and DoD to ensure that everything the veteran is due
comes to him or her. These families often have to put their lives on
hold, delaying work, their education, relationships and other aspects
of their life because of their veteran's illnesses and conditions, and
the demands their intensive care require. With the complexity of the
overlapping bureaucracies, some veterans fall through the cracks and do
not receive the pays or compensation they need to cover their care.
Further, in cases where parents--as opposed to spouses--are providing
care, they may not be eligible for the full range of services and
benefits the two departments provide.
Section 2 would go a long way toward fixing these problems,
training and certifying family and friends to serve as caregivers,
which would make them eligible for compensation for their time and
service.
Section 3 would require the Secretary to conduct outreach to
educate veterans and the public about PTSD and TBI, as well as to
provide information about the range of services VA can provide for
their treatment. Additionally, it would require VA to release
information about the best practices it develops so that healthcare
practitioners can learn from VA's experiences when dealing with these
conditions for all Americans in the civilian world. Both are worthy
provisions.
Section 4 of the bill would expand telehealth and telemental health
options through a pilot program that primarily focuses on rural areas.
It would determine the feasibility of using these technologies to
assess the cognitive function of service men and women and veterans, as
well as to help with rehabilitation. This is a good goal and a creative
approach to solving the difficulties some veterans experience when
trying to access their care. Should the program work, it would be of
great benefit to many thousands of veterans suffering from these
conditions.
H.R. 6153, the Veterans' Medical Personnel Recruitment and Retention
Act
The VFW is happy to offer our support to this legislation, which
would improve VA's ability to recruit and retain nurses and other
healthcare practitioners. This is a continuing challenge for VA and one
that is shared by all healthcare facilities. With the nursing shortage
around the country, it is critical that VA have the tools and
flexibilities it needs to adapt and be competitive in the marketplace
as the workplace of choice for high quality healthcare providers.
This bill would improve pays for various healthcare specialties,
including specific targeting for nurse executives and part-time nurses.
It also revises rules relating to overtime and weekend duty and work
schedules, which could help ease the burden many nurses face.
Additionally, it reinstates the health professional educational
assistance scholarship program, which is an excellent recruitment
benefit that would make VA more attractive to various healthcare
providers.
We believe that its passage would improve VA's abilities to recruit
and retain high-quality healthcare providers. This can only serve to
better the care VA provides to this Nation's veterans. For this reason,
we support this bill.
H.R. 6629
We understand that this bill was introduced to address a specific
problem in New Hampshire. New Hampshire is the only one of the
contiguous 48 states that lacks a full-service veterans hospital. As a
result, veterans seeking certain types of basic care are forced to
travel to hospitals in other states, whether in White River Junction,
Vermont or near Boston, Mass.
This bill would require VA to either run a full-service hospital in
each of the 48 contiguous states or it would require VA to fully
contract out for all healthcare services. It is the latter part that
causes us to have some qualms with the bill.
First, we believe that New Hampshire veterans deserve better. Many
face long drives for basic care. In 2007, for example, over 700
veterans were transferred out-of-state for acute care. If they live in
the northern part of the state, this could mean a travel time of 4
hours one-way just for basic services that the Manchester VA should
otherwise be able to provide. Only recently has the Secretary announced
that Manchester will begin offering radiation therapy, meaning that
veterans who needed this for the treatment of cancer had to travel
hours for care. Clearly, this is unacceptable.
We believe, however, that the mechanism of this bill could create
some further inequities. Should the contracting provisions be in force,
a veteran living across the border from the White River Junction VA
Medical Center in Lebanon, NH would be entitled to contract care for
any service they would need. Presumably, they could call up their
private physician and have an appointment in a matter of hours or days.
The same veteran, should they live five miles to the west in Vermont,
would be required to wait in line for their turn at the White River
Junction Medical Center. That is not fair.
We have supported contracted care in limited cases, namely where VA
is otherwise unable to provide care--particularly in the case of
specialized services. This legislation, though, could lead to wide-
spread contracting, which we oppose.
VA already has the authority to provide fee-basis care, and it uses
it with great success in many areas, especially in some remote parts of
the west. We would urge the Committee to use its oversight authority to
ensure that VA is doing the right thing for New Hampshire's veterans.
If VA does not believe that the Manchester Medical Center requires full
services, then we need the Committee to ensure that veterans who need
these specific services receive contracted care when they would
otherwise have to travel these long distances. We need to adapt the
lessons VA has learned from other areas to New Hampshire, even if most
people have not previously considered New Hampshire to be a large state
or one that would require significant travel.
This concludes my statement. I would be happy to answer any
questions you may have.
Statement of Anna Frese, Family Outreach Coordinator for Brain Injury,
Wounded Warrior Project
The men and women of the Armed Forces have been providing an
example of service, to their country, for over 200 years. Many families
have watched and supported their loved one as they head off to fulfill
the missions assigned to them. Unfortunately, in the process of
fulfilling those missions, not all loved ones return home as they left.
The need has presented itself, to assist in supporting the service of
the family member, whose chosen mission is to care for and provide a
quality of life to their loved one that has been seriously injured
while in service to their country.
I thank the Committee for allowing me the opportunity to
respectfully submit this testimony for the record and I strongly
support this direly needed legislation. My name is Anna Frese and I
currently am working with the Wounded Warrior Project (WWP) as a Family
Outreach Coordinator for Brain Injury. My understanding for the urgent
need of H.R. 3051 does not just come from working with the Wounded
Warrior Project, but also what I witness daily as sister of Retired
Army Sergeant Eric Edmundson, who was seriously injured in Iraq in
October of 2005, and is currently living at home receiving 24/7 total
care from our father, Edgar Edmundson.
Our family made the decision to bring Eric home and care for him.
This decision was made knowing that it was what Eric would want. As our
father says, ``My son went to war, he honored himself, he honored his
family, and he honored his Nation. He went to war, did his duty and got
injured. As a parent, Eric, in my eyes is not a handicapped person, he
is not a 100 percent disabled Veteran; Eric in my eyes is a 28 year old
husband, a father and a young man with a whole life ahead of him. I as
a parent need to honor him, and see to it that his needs are met.''
It is important for Eric's young family that Eric be home, and be
an active part in daily life. Eric is not only dealing with medical or
rehab issues, he needs to be home to help deal with everyday issues so
that he is meeting his responsibilities and being included, involved
and helping to keep his small family intact. Anyone can be trained to
take care of medical needs, but when you are 28 years old, a husband
and father with responsibilities and a desire to get your life back--it
goes a lot deeper than pills and therapy. You need to be around people
that know you, understand you, and are willing and able to be there for
you.
Our father sees it as his duty to ensure not only that Eric's short
term goals are met but that a focus remains on his long term goals as
well. He focuses on helping Eric in maintaining a high morale and self-
esteem which is paramount in the achievement of reaching his goals.
Some long term goals to getting his life back include his hobbies of
hunting and fishing--and our family sees that there is no reason that
he can't have those as a regular part of his life.
The decision to bring Eric home came with sacrifice and changes on
many levels. Ours is just one of many families that have adapted to the
``new normal'' with changes in family infrastructure, in relationships
with friends and extended family, in finances, in hopes, plans and
goals for the future. Upon learning of Eric's lifelong challenges, our
father resigned his position at work, in order to provide Eric the
full-time care that was needed. This decision did leave him and our
mother with one less income, and in times of need they had to dissolve
their personal and retirement savings. Just as importantly, now at 53
years old my father is no longer is covered by health insurance.
The financial and emotional stress of not having the ability to
maintain ones physical health is not only reflected in our family, but
again in many of the families caring for their severely injured
Veteran. By the Committee supporting H.R. 3051, family caregivers will
have the option of receiving training by the VA, certifying them to
receive compensation for the care they are providing their Veteran.
This compensation will possibly allow some to better manage their own
lives and health, so that they will be there for their loved one in the
future.
One constant statement that I hear not only from my father, but
other family caregivers who have made the same decision as ours, is
that they are grateful. They are grateful to have the opportunity to
spend time and enjoy the life of their loved one. So many Servicemember
and Veterans have persevered through immeasurable odds, and families
see it as their time to persevere and provide as much joy and quality
of life as possible.
The family caregivers of these returning wounded warriors
appreciate the concern, and acknowledge the recommendations that are
trying to provide for the many others caring for their loved one. These
warriors need someone at their side who knows them, understands them,
and someone who is willing to be there for them and speak for them, in
order for him to fully recover--or recover as much as possible.
Families just wish it to be known they are committed to being by their
Veterans side no matter what; the need is just too urgent. This
legislation will allow family caregivers to follow through on that
commitment.