[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]


 
                   CLOSING THE HEALTH GAP OF VETERANS 
                     IN RURAL AREAS: DISCUSSION OF 
                   FUNDING AND RESOURCE COORDINATION 

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 19, 2009

                               __________

                            Serial No. 111-8

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                               ----------
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48-422 PDF                       WASHINGTON : 2009 

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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
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               HENRY E. BROWN, JR., South 
VIC SNYDER, Arkansas                 Carolina, Ranking
HARRY TEAGUE, New Mexico             CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas             JERRY MORAN, Kansas
JOE DONNELLY, Indiana                JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California           GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia               VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia

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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both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
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                            C O N T E N T S

                               __________

                             March 19, 2009

                                                                   Page
Closing the Health Gap of Veterans in Rural Areas: Discussion of 
  Funding and Resource Coordination..............................     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    26
Hon. Cliff Stearns...............................................     2
    Prepared statement of Congressman Stearns....................    26

                               WITNESSES

U.S. Department of Veterans Affairs:
    Adam Darkins, M.D., Chief Consultant, Care Coordination, 
      Office of Patient Care Services, Veterans Health 
      Administration.............................................    16
        Prepared statement of Dr. Darkins........................    34
    Kara Hawthorne, Director, Office of Rural Health, Veterans 
      Health Administration......................................    19
        Prepared statement of Ms. Hawthorne......................    36

                                 ______

Disabled American Veterans, Joy J. Ilem, Assistant National 
  Legislative Director...........................................     3
    Prepared statement of Ms. Ilem...............................    27
National Rural Health Association, Graham L. Adams, Ph.D., State 
  Office Council Chair, and Executive Director, South Carolina 
  Office of Rural Health.........................................     5
    Prepared statement of Dr. Adams..............................    31

                       SUBMISSION FOR THE RECORD

Brown, Henry E., Jr., Ranking Republican Member, Subcommittee on 
  Health.........................................................    40

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Hon. Eric K. Shinseki, 
      Secretary, U.S. Department of Veterans Affairs, letter 
      dated March 30, 2009, and VA responses.....................    42


                   CLOSING THE HEALTH GAP OF VETERANS
                     IN RURAL AREAS: DISCUSSION OF
                   FUNDING AND RESOURCE COORDINATION

                              ----------                              


                        THURSDAY, MARCH 19, 2009

            U. S. House of Representatives,
                            Subcommittee on Health,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:11 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Michaud, Teague, Rodriguez, 
Donnelly, McNerney, Halvorson, Perriello, Stearns, and Moran.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call the Subcommittee on 
Health back to order.
    I would like to thank everyone for participating in the 
hearing. I would ask, while I give my opening remarks, for our 
first two witnesses to please come forward.
    The purpose of today's hearing is to provide oversight of 
U.S. Department of Veterans Affairs' (VA's) rural health 
funding, spending, and resource coordination. The hearing will 
explore whether resources are used efficiently to narrow the 
health disparity of veterans living in rural areas.
    In general, we know that nearly two million veterans reside 
in rural areas. This includes nearly 80,000 veterans who live 
in highly rural areas.
    According to the VA Health Services Research and 
Development Office, rural veterans have worse physical and 
mental health-related issues.
    I commend the VA for their efforts in improving rural 
health. This includes building new Community-Based Outpatient 
Clinics (CBOCs), rural outreach clinics, and Vet Centers in 
rural and highly rural areas. It also includes pilot programs 
such as the Traveling Nurse Corps, the mobile health care 
pilots, which are in place in four mobile clinics and 24 
predominantly rural counties in Colorado, Nebraska, Wyoming, 
Maine, Washington, and West Virginia.
    I also applaud the advances made in telehealth through the 
numerous pilot programs that have been implemented today.
    To help the VA efforts, the Appropriation Committee 
provided $250 million in September of 2008 to establish and 
implement new rural health outreach and delivery initiatives.
    Through today's hearing, we seek to better understand how 
the VA has allocated and plans to allocate this $250 million. 
The hearing will also address concerns about the lack of 
coordination and duplicative efforts by various offices in the 
VA that deal with rural health.
    On today's first panel, we have the Disabled American 
Veterans who will share their thoughts on VA's progress in 
improving rural health. We also will hear from the South 
Carolina Office of Rural Health about local challenges and 
recommendations for closing the rural health gap.
    Finally, the VA Office of Care Coordination and the Office 
of Rural Health (ORH) will report on the Department's current 
efforts on rural health.
    I look forward to hearing your testimony on both panels. 
And now I would recognize Mr. Stearns for an opening statement.
    [The prepared statement of Chairman Michaud appears on
p. 26.]

            OPENING STATEMENT OF HON. CLIFF STEARNS

    Mr. Stearns. Thank you, Mr. Chairman.
    I ask unanimous consent for my colleague, Congressman Henry 
Brown, who is the Subcommittee Ranking Member, his opening 
statement be made part of the record.
    Mr. Michaud. Without objection, so ordered.
    [The prepared statement of Congressman Brown appears on
p. 40.]
    Mr. Stearns. Okay. I am here today on Mr. Brown's behalf. I 
am pleased to be here this morning for our Health Subcommittee 
hearing on ensuring that our veterans living in rural areas are 
receiving the quality health care they certainly deserve.
    Today's hearing affords us the chance to examine how the 
Department of Veterans Affairs is spending some of the funds 
allocated to them in the fiscal year 2009 Appropriations Act.
    Specifically, we are focusing on funds that were marked to 
help further the VA's rural health initiative in areas such as 
mobile health clinics and telemedicine.
    My colleagues, we are all aware of the health care gaps 
that exist for veterans that reside in the rural areas. We know 
that almost 40 percent of veterans enrolled in VA health care 
live in rural or highly rural areas and that 44 percent of our 
veterans returning from Iraq and Afghanistan also reside in 
these rural areas.
    Veterans living in rural America are statistically shown to 
have lower quality of life scores and are more likely to suffer 
from treatable diseases. Clearly this is an issue we must 
address and monitor very closely.
    I applaud the VA's current outreach efforts to recruit and 
retain more health care providers to serve in rural areas and 
to pursue innovative health care methods such as telemedicine. 
We are moving in the right direction, but we must stay the 
course and VA must fulfill the goals it has set.
    I welcome our panel of witnesses and look forward to 
hearing more about how VA has and intends to further distribute 
the funds allocated to them under the fiscal year 2009 
Appropriations Act so that we can truly, truly begin closing 
the health care gap for our Nation's rural veterans.
    Also, on behalf of Mr. Brown, my colleague, I would like to 
extend a special welcome to one of our witnesses on the first 
panel, Dr. Graham Adams. He serves as the Chief Executive 
Officer and provides overall supervision and direction for the 
South Carolina Office of Rural Health.
    Thank you, Mr. Chairman.
    [The prepared statement of Congressman Stearns appears on
p. 26.]
    Mr. Michaud. Thank you very much, Mr. Stearns.
    I will apologize up front. I do have to leave for another 
meeting shortly, so I want to apologize up front. We will start 
the first panel.
    On the first panel, we have Joy Ilem who represents the 
Disabled American Veterans (DAV), as well Dr. Graham Adams who 
is the Chief Executive Officer (CEO) of the South Carolina 
Office of Rural Health.
    Once again, I want to thank both of you for coming here 
this morning. I look forward to hearing your testimony as well 
as working with you as we move forward to do what we have to to 
make sure that our veterans in rural areas get the adequate 
health care in the timely fashion that they need.
    So without any further ado, Ms. Ilem.

   STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE 
  DIRECTOR, DISABLED AMERICAN VETERANS; AND GRAHAM L. ADAMS, 
   PH.D., EXECUTIVE DIRECTOR, SOUTH CAROLINA OFFICE OF RURAL 
 HEALTH, AND STATE OFFICE COUNCIL CHAIR, NATIONAL RURAL HEALTH 
                          ASSOCIATION

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Mr. Chairman and Members of the Subcommittee, 
thank you for inviting DAV to testify today. We value the 
opportunity to discuss our views on funding and coordination of 
care for rural veterans.
    We recognize that rural health is a difficult national 
health care issue not isolated to VA. We also appreciate that 
many sick and disabled veterans in rural areas face multiple 
challenges in accessing VA health care services, even private 
services under VA contract or fee basis.
    We deeply appreciate the due diligence of this Subcommittee 
and Congress by enacting legislation, which authorized VA to 
establish the Office of Rural Health and the resources it has 
provided to carry out its mission.
    It appears VA is reaching across the Department to lay the 
foundation for improving the delivery and coordination of 
health care services to rural veterans. And DAV is pleased and 
congratulates VA on its progress to date.
    VA's appointment of rural care consultants in all its 
Veterans Integrated Service Networks (VISNs), establishment of 
three rural health resource centers, and a number of new rural 
outreach clinics harnessing telehealth and other technologies 
to reduce barriers to care are all positive steps forward.
    In VA's 2009 Appropriations Act, Congress approved $250 
million to support new and existing rural health care 
initiatives and $200 million to increase fee-basis services. It 
appears that VA has distributed $22 million to its VISNs for 
rural health care improvements with an additional $24 million 
being used to establish the pilot programs, new outpatient 
clinics, provide outreach to rural veterans returning from the 
wars in Iraq and Afghanistan, and activate a number of mobile 
health clinics, including a fleet of 50 mobile Vet Centers.
    We appreciate the Subcommittee's interest in conducting 
this oversight hearing and we are interested in learning more 
from VA about the specific instructions issued to the field 
guiding the use of these new funds for rural care, what 
monitoring is being conducted related to the use of those 
funds, and the degree and type of reporting requirements that 
have been imposed related to the number of veterans served as 
well as the information on access, quality of care, and 
workforce issues.
    Although VA is off to a good start, we believe it faces a 
number of challenges. In our testimony, we have offered a 
series of recommendations we hope the Subcommittee will 
consider as it continues its work in this important area.
    Initially we suggest VA be required to provide more 
thorough reporting to this Subcommittee to enable meaningful 
oversight of the use of the funds provided and to properly 
evaluate the implementation phase of rural health initiatives.
    Without this type of oversight, we are concerned that the 
funds Congress provides may simply be melded into VA's 
equitable resource allocation system without the means of 
measuring whether these new funds will be allocated in 
furtherance of Congress' intent, specifically to enhance health 
care services and health outcomes for rural and highly rural 
veterans and particularly our newest generation of war 
veterans.
    Reports to Congress should include standardized and 
meaningful measures of how VA rural health care capacity has 
changed with workload changes reported on a quarterly or semi-
annual basis and disclosure of other trends that reveal whether 
the rural health initiatives and funds allocated for them are 
truly achieving their purposes.
    Health workforce shortages and recruitment and retention of 
health care personnel are also a significant challenge to rural 
veterans' access to VA care and the quality of that care.
    The Institute of Medicine recommended that the Federal 
Government initiate a comprehensive effort to enhance the 
supply of health care professionals working in rural areas.
    We believe VA's Office of Academic Affiliations in 
conjunction with ORH should develop a specific initiative aimed 
at taking advantage of VA's affiliations to meet clinical 
staffing needs in rural locations.
    Finally, DAV is concerned about the organizational 
placement of the Office of Rural Health within Veterans Health 
Administration's (VHA's) Office of Policy and Planning and 
recommends it be placed closer to the operational arm of VA 
management.
    We also suggest increasing staffing levels for the office 
and urge Congress to continue to provide appropriate financial 
support to ensure VA sustains these new activities without 
diminishing resources for VA's specialized medical programs in 
accordance with DAV Resolution 177.
    In summary, DAV believes VA is working in good faith to 
improve access and medical services to veterans living in rural 
areas and we are hopeful that with continued oversight from 
this Subcommittee, supported by appropriate resources, rural 
veterans will be better served by VA in the near future.
    That concludes my statement and I am happy to answer any 
questions you or Members may have. Thank you.
    [The prepared statement of Ms. Ilem appears on p. 27.]
    Mr. Michaud. Thank you very much for your testimony.
    Dr. Adams.

              STATEMENT OF GRAHAM L. ADAMS, PH.D.

    Dr. Adams. Thank you, and I appreciate the opportunity to 
speak this morning.
    I am Graham Adams, CEO of the South Carolina Office of 
Rural Health, Past President of the National Organization of 
State Offices of Rural Health, and a Trustee on the Board of 
the National Rural Health Association, the NRHA.
    The NRHA is a national nonprofit organization whose mission 
is to improve the health of the 62 million Americans who call 
rural home. The NRHA has long focused efforts on improving the 
physical and mental health of our rural veterans and I 
appreciate this opportunity to testify once again.
    Since our Nation's founding, rural Americans have always 
responded when our Nation has gone to war. Simply put, rural 
Americans serve at rates higher than their proportion of the 
population. Nineteen percent of the Nation lives in rural 
areas, yet 44 percent of U.S. military recruits are from rural 
America.
    And sadly, according to a 2006 study, the death rate for 
rural soldiers is 60 percent higher than the death rate for 
soldiers from cities and suburbs.
    Mr. Chairman, because of this great level of service, it is 
incumbent upon each of us to do more for our rural veterans.
    There is a national misconception that all veterans have 
easy access to comprehensive care. Unfortunately, this is 
simply not true. Access to rural veterans can be extremely 
difficult and access for rural veterans in need of specialized 
mental or physical care can be daunting.
    In brief, because there is a disproportionate number of 
rural Americans serving in the military, there is also a 
disproportionate need for veterans' care in rural areas.
    Program expansion and resource coordination are critical to 
improve the care of rural veterans. We must be mindful of long-
term costs and needs because the wounded veterans who return 
today will not need care for just the next few fiscal years. 
They will need care for the next half century.
    The National Rural Health Association supports the five 
following recommendations.
    One, access must be increased by building on current 
successes. Community-based outreach centers or CBOCs and vet 
outreach centers open the door for many veterans to obtain 
primary care within their home community. The NRHA applauds the 
success of these programs, but there are simply too few of 
these centers.
    In my State of South Carolina, there are only eleven CBOCs 
and three vet outreach centers despite the fact that South 
Carolina is one of the top 20 States in which veterans reside.
    Two, access must be increased by collaborating with non-VHA 
facilities. Because rural VA facilities are too few and far 
between, many rural veterans simply forego care. If critical 
preventative care or follow-up treatment is not received, a 
veteran will undoubtedly become sicker and in need of more 
costly care. This must change.
    The NRHA's goal is not to mandate care to our rural 
veterans, but to provide them a choice, a local choice.
    The NRHA strongly supports ``The Rural Veterans Access to 
Care Act,'' which was signed into law last October. The Act 
establishes a 3-year pilot program which will allow some of the 
most under-served rural veterans the choice to access their 
care from a local provider. Despite the limitations of this 
program, it is a strong and important step in the right 
direction, but more must be done.
    Linking the quality of VA services with rural civilian 
services can vastly improve access to health care for rural 
veterans. As long as quality standards of care and evidence-
based treatment for rural veterans is adhered to, the NRHA 
strongly supports collaboration with community health centers, 
critical access hospitals, and other small rural hospitals and 
rural health clinics.
    Three, access must be increased to mental health and brain 
injury care. Currently it appears that traumatic brain injury 
or TBI will most likely become the signature wound of the 
Afghanistan and Iraqi wars. Such wounds require highly 
specialized care. The current VHA TBI case manager's network is 
vital, but access to it is extremely limited for rural 
veterans. Expansion is needed.
    Additionally, 85 percent of mental health shortages are in 
rural America. Vet Centers do offer mental health services, but 
the services are not consistently available at a local rural 
level.
    Four, care for rural veterans must be better targeted. 
Returning veterans adjusting to disabilities and the stresses 
of combat need the security and support of their families in 
making their transitions back into civilian life.
    The Vet Centers do a tremendous job in assisting veterans, 
but their resources are limited. Additionally, because more 
women serve in active duty than in any other time in our 
Nation's history, better targeted care is needed for rural 
women veterans.
    And, five, improvements must continue with the VA Office of 
Rural Health. The National Rural Health Association calls on 
Congress and the VA to fully implement the functions of the VA 
Office of Rural Health.
    Efforts to increase service points have not always been 
embraced by the VA. It is our hope that the Office of Rural 
Health and the newly formed VA Rural Health Advisory Committee 
will work to eradicate previous barriers and expand access 
options for the betterment of our rural veterans.
    The NRHA also strongly encourages greater coordination 
between the rural health coordinators housed in each VISN and 
State level officials in each State Office of Rural Health.
    Mr. Chairman, thank you again for this opportunity. The 
NRHA's full recommendations can be found in my written 
testimony. I look forward to working with you and this 
Committee to improve the rural health care access for millions 
of veterans who live in rural America, and I ask that my full 
statement be submitted into the record.
    Thank you.
    [The prepared statement of Dr. Adams appears on p. 31.]
    Mr. Teague [presiding]. Yes. Thank you.
    Hearing no questions, it is so ordered.
    First, thank you for sharing your concerns about the 
organizational placement of the Office of Rural Health. You 
recommend that the office be moved from the VA's Office of 
Policy and Planning to an operational arm of the VA system.
    Please explain how you think moving the Office of Rural 
Health to an operational arm would improve the planning and 
coordination capabilities of the Office of Rural Health.
    Ms. Ilem. Thank you for the question.
    I think that we are concerned that there is a number of 
bureaucratic levels that the office is required to go through 
to the implementation phase under probably Mr. Feely's office. 
Direct access to that office with, and talking to the VISN 
directors and the local Medical Center directors directly is 
going to be, I think, critical during the implementation phase 
of this program.
    I think they need to coordinate with Office of Policy and 
Planning and continue--I mean, there are a number of 
initiatives that they are starting which, you know, cross 
throughout the departments. At the same time, we would like to 
see the office have that direct access to make sure that these 
things get implemented in a very expeditious manner.
    Mr. Teague. Okay. Also, as you know, the VA received $250 
million in the 2009 appropriation. What are your views of the 
types of services and programs that the VA should support with 
this funding and do you agree with how the VA has spent it so 
far?
    Ms. Ilem. Just in reviewing very briefly this morning, the 
VA's testimony, I have not had a chance to look at it 
thoroughly, but it appears that they have a number of programs 
that have been initiated, many of them just at the very 
beginning stages, trying to establish many of these clinics, 
probably working with their coordinators in each of the VISNs 
and a variety of other functions.
    So I think that they have a tall task ahead of them in 
terms of the things that they have scheduled to do.
    So I think that they need to just continue to keep working 
on the programs that they have set forth as indicated in their 
testimony and I think many of those are the right direction. It 
is just a tall order and it seems like a lot of things are just 
at the very beginning stages.
    Mr. Teague. Dr. Adams, in your testimony, you highlighted 
the need for rural providers to be trained because of the 
unique needs of rural, minority, and female veterans.
    I'm from a large rural district in New Mexico and we have a 
lot of the same needs that you were discussing.
    I was just wondering if you might be able to expand a 
little bit on this and tell us a little more about the needs.
    Dr. Adams. Yes, sir. So often in a physician or a 
provider's medical training, they receive excellent clinical 
training, but they do not have the other cultural competency 
trainings that are so key when you work with disadvantaged 
populations, be it women, minorities, others. And I think 
especially when working with these populations, you do need to 
have special sensitivity to those issues.
    I also think that in States and regions that have a high 
minority population, where possible, the providers serving 
those populations need to be reflective. So trying to achieve 
greater diversity in ethnicity and race among those providers 
that are providing care would be a good thing and could be 
accomplished through contracting or cooperative arrangements 
with other non-VHA facilities such as community health centers, 
rural health clinics, and critical access hospitals.
    Mr. Teague. I would just like to say that, coming from the 
2nd District of New Mexico, which is bigger than the State of 
Pennsylvania, and has almost 200,000 veterans, I am encouraged 
to hear how you are addressing similar concerns across the 
country.
    Mr. Rodriguez from Texas.
    Mr. Rodriguez. Thank you very much. First of all, thank 
you, Mr. Chairman.
    Let me point out that my district is one of the largest in 
the Nation. I have 785 miles along the Mexican border. I have 
two major cities, but within my district, I do not have any VA 
clinics or facilities.
    We have had a serious problem with the ones that the VA has 
contracted out in the past who are not willing to work with the 
VA now because of the fact that they had not gotten paid the 
way they should.
    And now they have gotten some new contracts, but one of 
them came, and this is probably not to this panel, but to the 
other, is that there is some other contractor in between that I 
guess is getting 15 percent from the top before the other 
person even gets paid, which does not make any sense 
whatsoever.
    And I still have not seen any results in my district in 
terms of the efforts of some of the pilot programs and trying 
to get some mobile units out there. That has not happened.
    I have a large number of veterans in my district. It has 
extremely rural areas where people have to go a long ways. A 
straight shot on I-10 is 550 miles between one side of the 
district and the other. And the major facilities are in San 
Antonio and El Paso, but my district is in between.
    I have problems with the contracting that has gone on with 
some of the local providers. In one case, they actually stopped 
providing services because the VA was not timely in reimbursing 
them. They just said, ``look, I have had enough, I am not going 
to deal with this.''
    And the other, we had two groups, two community-based 
outpatient clinics that they used to work with that are 
unwilling to work with them now because of past experiences 
with them.
    I just wanted to see if you might comment as to how do we 
get past some of the things that have happened in the past and 
how do we make sure that they deliver in the future.
    Dr. Adams. I believe that creating incentives, financial 
and other, for VA facilities, be it CBOCs and vet outreach 
centers, to coordinate and to work with non-VHA facilities will 
go a long way to creating those partnerships.
    And in some cases, veterans are being seen in these 
facilities already. And the non-VHA facilities that I 
mentioned, rural health clinics, community health centers, and 
critical access hospitals, these are all fully qualified, fully 
staffed facilities that are providing care at the local 
community, all of which receive some kind of enhanced 
arrangement from Medicare to provide services, but 
unfortunately not for veterans.
    So if that linkage could be put in place, I think that you 
will see care increased dramatically and there will certainly 
be things that have to be worked out, but you have folks that 
are in the field right now that are willing to see veterans if 
only a mechanism existed to do so.
    Mr. Rodriguez. That mechanism that you are referring to, 
would that require any form of additional legislation or is 
that something that is already in place that we could just 
require them to do?
    Dr. Adams. I cannot speak exactly as to what authority the 
VA has. But if the authority would allow and if the intent were 
there, there are partners on the provider side that are more 
than willing to see these veterans as long as they are 
reimbursed fairly and they are in these communities. There is 
no sense in reinventing the wheel, building another facility, 
investing additional taxpayer dollars when you have points of 
access already there.
    Mr. Rodriguez. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Teague. Next I need to apologize to the gentleman from 
Kansas. I am sorry. This was my first time to Chair this 
Subcommittee and I guess it is showing in going out of order 
here. I would like to present, at this time, Congressman Moran 
from Kansas.
    Mr. Moran. Because you are new to the Committee, you do not 
know how offended I am, how difficult I am to get along with.
    Mr. Chairman, I am delighted to be here and I am happy to 
be able to visit with these witnesses at your leisure, at your 
convenience.
    I thank Mr. Michaud and this Subcommittee for having this 
hearing. The pilot program is a piece of legislation that I 
have worked on really since I came to Congress and I am 
delighted that Mr. Michaud has indicated a willingness to have 
a hearing.
    My staff met with folks from the VA and others yesterday 
for the beginning implementation conversation and we are 
generally pleased that the VA is paying a lot of attention to 
this topic. And I think it is important for all of us to stay 
on point to make sure that it is implemented in a way that 
demonstrates the value of this pilot program.
    Dr. Adams, in the testimony of the Disabled American 
Veterans, in Ms. Ilem's testimony, she indicated concerns about 
veterans who may seek health care for convenience with a 
private provider, that they may not receive the protections of 
the VA system, patient safety and other protections that are 
indicated in the VA system.
    Do you have any concerns about how a veteran would be 
treated in the private system with their hometown doctor and 
hospital as compared to being treated more directly in the VA 
system with a VA provider? And if you do have those concerns, 
do you have suggestions of what it is that we ought to be 
paying attention to in order to make sure those concerns are 
addressed? Dr. Adams.
    Dr. Adams. Thank you.
    I do not have concerns. Certainly the VA with the system 
that they have, they provide excellent care in those 
facilities. The problem is there just are not enough of those 
facilities.
    So if we can create linkages where there is reasonable 
requirements for electronic medical records (EMRs) for quality 
of care, then there is no reason that those veterans cannot 
receive high quality care in non-VA facilities.
    All these facilities meet every quality requirement of the 
Federal Government that is put upon them. So these are highly 
trained folks doing the work that they need to do and they do 
not currently have to abide by all the VA rules. But as long as 
there were reasonable, and I stress reasonable, requirements in 
place, I do not know why those partnerships could not exist.
    Mr. Moran. In my early days in Congress, our outpatient 
clinic was staffed by a physician in her private practice. She 
ultimately left the system and no longer provided services to 
veterans through her clinic as an outpatient clinic of the VA.
    The concern, the criticism, and the difficulty was related 
to medical records, to technology, and the inability to connect 
in getting answers from the VA and, in our case, in Wichita.
    At least my sense is that much of that has been resolved. 
Am I missing something or are we headed--the VA seems to be 
probably one of the better utilizers of technology in the 
entire medical delivery system.
    Dr. Adams. I think that is correct. The VA has an excellent 
electronic medical record system. All the dollars that are 
contained within the American Recovery and Reinvestment Act 
(ARRA) are going to allow even more facilities in rural 
communities, non-VHA facilities that do not have EMR now, that 
do not have electronic medical records now, to have that in 
place.
    So I think that the ability for information to be exchanged 
in a Health Insurance Portability and Accountability Act 
(HIPAA) compliant, safe way is going to be less and less of an 
issue once all of these facilities have some form of electronic 
medical records.
    Mr. Moran. Has anyone in the VA's Office of Rural Health 
ever contacted you? Do they reach out to people in your 
position to seek advice and suggestions?
    Dr. Adams. I do have to say the Office of Rural Health has 
been very supportive and very helpful with entities like the 
National Rural Health Association. I think from a staff 
perspective, they have done a great job of creating good will 
and seeing where those partnerships could exist.
    I get the sense it might be a little bit higher up the food 
chain, if you will, within the VA that some of this resistance 
occurs.
    And from my perspective at a State level, each of the VISNs 
has, I believe it is called a rural health coordinator. I do 
not know who that person is. I have never been contacted by 
that person. I have tried to go on the VA Web site and identify 
that person. I cannot do that.
    So I would strongly urge for those rural health 
coordinators, if that is the correct term, that are located 
within each VISN to be more proactive reaching out to the State 
level rural health officials in each State.
    Mr. Moran. I will try to ask Ms. Hawthorne a similar kind 
of question when she is our witness.
    There is a Rural Veterans Advisory Committee commissioned 
now and I want to hear about how it is interacting with the VA 
and what difference it is making.
    My time has expired. I thank the Chairman for his 
indulgence and appreciate your consideration.
    Mr. Teague. Well, once again, I would like to apologize to 
Congressman Moran and I appreciate his patience with me in my 
learning process here.
    And next is the Congressman from California, Jerry 
McNerney. Do you have a question, please, sir?
    Mr. McNerney. Thank you, Mr. Chairman.
    First of all, I would like to thank the witnesses for 
coming forth today.
    Mrs. Ilem, is that correct?
    Ms. Ilem. Ilem.
    Mr. McNerney. Ms. Ilem. You suggested more oversight by the 
Committee and I think that is probably a good idea. But I was 
wondering if you had--and you also mentioned standardized 
reporting.
    Do you have specific recommendations or specific ideas for 
standardizing the interchange between the Committee and the 
witnesses or the reporting entities?
    Ms. Ilem. I think VA would be able to do that fairly 
easily. I think if there is a request from the Committee to do 
that, I am sure they would be willing to provide that.
    And I think the main thing would be not just a data dump, 
but something that you could really read and be able to make a 
true assessment to see, is capacity improving, what are the 
workloads, what are they doing.
    In briefly looking at their testimony, I think they have a 
number of reporting requirements that they are requiring from 
the field. And if they can tally up that information in a very 
sensible way that would be easy for the Committee to review, I 
think would just be just another opportunity to really have the 
oversight that is needed.
    Mr. McNerney. Okay. Well, thank you.
    Any ongoing suggestions you have on standardizing that 
would be appreciated by the Committee.
    Ms. Ilem. Sure.
    Mr. Mcnerney. You also mentioned more physicians as one of 
the major problems. Do you see that as the major problem or are 
there other related problems to the shortage of physicians in 
rural areas?
    Ms. Ilem. I think that is one of the issues. I mean, there 
are so many factors involved in rural health care issues that 
the Nation is grappling with in general, including VA.
    I think that is just obviously one of the keys to have the 
willingness for qualified people to be in the rural areas and 
available to these veterans, but I think it is one of many 
things that are necessary.
    Mr. McNerney. Thank you.
    Dr. Adams, I want to say I have both rural and suburban 
areas in my district and I appreciate your mentioning 
disproportionate share of active-duty members and veterans from 
rural areas.
    I was just at a funeral in a town of mine, about a 60,000-
person town, and it is their eighth fatality in the War on 
Terror. So they certainly are paying their share or more than 
their share.
    And I also appreciate your suggestion to let non-VA 
organizations partner up with VA organizations to provide the 
best possible care to our servicemembers.
    I would like to see, speaking of standardized, I would like 
to see a standardized approach to that so that we can move 
forward aggressively and provide those services in a way that 
would benefit everyone.
    One of the questions I have is, do you see the telenet 
being helpful in filling the gap between rural and urban 
service capabilities?
    Dr. Adams. I think telemedicine, telehealth is a great tool 
to provide some services in more isolated rural communities. 
Specifically things like telepsychiatry, it can be fairly 
effective with.
    I think that while telemedicine and things like a mobile 
clinic are great steps in the right direction, they do not 
nearly provide the continuity of care that a full-time provider 
or a facility would in those rural communities.
    And, again, we have a very robust network throughout the 
country of folks that are already in place to serve the 
underserved and to serve vulnerable populations. And I think we 
all could agree rural veterans are a vulnerable population.
    So providing linkages with those folks, I think, again will 
increase access to care dramatically. Telemedicine is a 
wonderful thing and I think it can be used in conjunction with 
some additional agreements in place at the local level.
    Mr. McNerney. Thank you.
    Ms. Ilem, do you have any comments on telemedicine?
    Ms. Ilem. We agree telemedicine is another great 
opportunity to be used in the arsenal of ideas looking at all 
of these issues that can help to improve services in those 
communities.
    Mr. McNerney. Thank you.
    I am going to yield back, Mr. Chairman.
    Mr. Teague. Thank you, Congressman McNerney. I appreciate 
those comments.
    At this time, I would like to call on the lady from 
Illinois, Congresswoman Deborah Halvorson.
    Mrs. Halvorson. Thank you, Mr. Chairman.
    And I would like to start with Dr. Adams. In your 
testimony, you highlighted the need for rural providers to be 
trained to meet the unique needs of the rural minority and 
female veterans.
    Everywhere and every panel that comes before us, they talk 
about the need for women veterans and the fact that more and 
more are coming back and there is going to be a huge need. This 
is going to really complicate a complicated issue even more.
    What do you suggest we do when there is already a need for 
more rural services and now we are going to need more help with 
the women population coming back?
    Dr. Adams. I think that can largely be addressed through 
increased mental health and behavioral health services. Every 
veteran that comes back has issues potentially with combat 
situated problems. And the females who come back often have 
family burdens. They have children. They have different roles 
than a male typically plays in our society and they have 
different expectations when they come home.
    So I think a lot around family counseling, marital and 
other family counseling being available for the family as a 
whole, not just for the veteran, is key. So often when it was 
just a male veteran population, they did not have some of those 
expectations when they returned home. I think you are finding 
that more and more with returning female veterans.
    Mrs. Halvorson. And if I could ask both of you to comment 
on this one. So you feel that we should be treating the entire 
family because I know that there has been some discussion, 
which has completely caught me off guard, about women who have 
children while a veteran and how these children are not 
veterans, but, yet, we have to find a way to take care of them. 
And there has been a lot of discussion about that.
    What are your views on these are veterans, they have served 
our country, and now we are debating whether to even take care 
of their children?
    Ms. Ilem. I would just start out by saying thank you for 
the question on women veterans and bringing it up. And I think 
it is great that Dr. Adams included that in his statement.
    This is an issue that VA is working very hard to address 
right now through their Office of Women's Health Program and 
the Center for Women Veterans.
    VA indicates an increasing number of women veterans 
returning from war and high rates of use among this Operation 
Enduring Freedom/Operation Iraqi Freedom population coming to 
VA with the changing demographic.
    I think that it will be really important in the next year 
for the Office of Rural Health to also reach out to Dr. Patty 
Hayes' office at VA to really make sure that within the rural 
health question and initiative that these issues are addressed 
with respect to women veterans. I think that is great.
    Some of the programs that VA has specifically for women 
veterans are really important in terms of post-deployment 
issues and some of the things that Dr. Adams has referred to in 
their post-deployment readjustment. So we want to be able in 
the rural health communities for those veterans to have that 
access to VA's unique specialties and providing those types of 
services or training local people that are seeing them to be 
able to do that.
    And with respect to the child care issues, this has been a 
longstanding issue in the women's community that this is a 
barrier, but we see it not only as a barrier for now just 
women, there are so many single veterans in general other than 
just women. Both men and women can have child care issues and 
primary care responsibilities.
    And I think you are referring to the pilot program 
recommended by Congresswoman Stephanie Herseth Sandlin.
    Mrs. Halvorson. Yes.
    Ms. Ilem. We think that when we look at all the research 
that is put out there, that this is one of the big barriers. So 
certainly if there is an opportunity to provide, not VA 
directly providing child care, but providing some sort of chit 
for them to access child care so that they can attend their 
appointments, especially if they have post-deployment issues 
that require extensive mental health sessions. You know, it 
really would not be appropriate for them to bring their 
children.
    So we just hope that that is a consideration, that the 
Subcommittee will take up as it looks at that bill further.
    Mrs. Halvorson. Did you have anything to add, Dr. Adams?
    Dr. Adams. Beyond child care, I do think that the 
counseling resources should be available to the families as 
well because so often if the veteran returns home with either 
psychosocial or severe physical issues, the family are the 
caretakers and they are the ones that are bearing the burden 99 
percent of the time.
    So I think resources should be available to them because so 
often in our rural communities, mental health and behavioral 
health services are just not available. They are not available 
for the general population.
    And at least in my State, our local community mental health 
centers will not see veterans. They will not see them because 
they feel that, first of all, they are overburdened, but, 
second, they feel like they should be seen at the VA 
facilities.
    So, again, creating a linkage and incentives for that to 
occur, I think, is vital in providing veterans and their 
families the services that they need locally.
    Mrs. Halvorson. Thank you.
    Mr. Teague. I thank the Congresswoman from Illinois for 
those questions because they needed to be asked and I thank the 
witnesses for addressing them.
    And now at this time, I would like to recognize the 
gentleman from Indiana, Congressman Donnelly.
    Mr. Donnelly. Thank you, Mr. Chairman.
    In regards to TBI, Dr. Adams, you had mentioned that 
earlier, and this is for both you and Ms. Ilem, there are 
approximately four centers throughout the country, polytrauma 
centers to help with this through the VA system. And if you get 
in a very rural area, it is hard to get treatment for this.
    Would you fully support the opportunity for our vets to 
receive treatment at either one of our centers in the VA system 
or to go to a place like the Chicago Rehabilitation Institute 
where they can go and receive very intensive additional care 
for this injury?
    And there are similar facilities throughout the country. I 
wanted to find out what you think of expanding the range of 
places where our vets can go.
    Dr. Adams. I absolutely think that creating additional 
access points makes sense. And, yes, we all want the quality of 
the VA system to be held intact and we want to make sure that 
the veteran's health information is kept private, but all these 
things can occur in private settings. And it is of little 
solace to those that need the care who cannot get it knowing 
that there are four centers that do this and do it excellent if 
they cannot get there.
    Accessing additional facilities, as you mentioned, that 
have the expertise, to me makes great sense and it is really 
just a matter of choice and access, making sure that these 
veterans get care no matter where it is as long as it is of 
high quality and it meets reasonable standards.
    Ms. Ilem. I would just mention, obviously for the most 
critical cases that are just coming back, the major polytrauma 
centers, the way they are going, the VA has established also in 
each of their VISNs a level two. So it would depend, you know, 
certainly on the level of the injury and the needs of that 
veteran. And I know that they have options to outsource that 
care if necessary and working with the family.
    Of course, we want, you know, veterans to have the best 
care and for those that are really working with these very 
unique injuries and the polytraumatic injuries they are seeing 
from the wars in Iraq and Afghanistan. So I do not think, you 
know, we are opposed to in certain circumstances, you know, 
making that available.
    Certainly the family, there is a lot of family issues, we 
want the families to be available and to be with them. And we 
know that many have had to relocate, giving up, you know, jobs 
and a variety of other things that have made it very difficult 
or leave one parent at home and not be able to stay in their 
local area.
    So I think those things should be taken under consideration 
for VA with the unique circumstance of the family.
    Mr. Donnelly. Okay. And, again, this would be for both of 
you. In terms of listing here is the problem with outsourcing 
some care for veterans when you have local doctors or local 
facilities, what do you find the biggest barriers, cost, the 
technology in the health clinic? What are the kind of things 
that make it most difficult for rural vets to be able to 
receive assistance locally as opposed to having to get in a van 
and travel 3 hours to the VA clinic?
    And the VA clinics are extraordinary places, but if you can 
save yourself a 3-hour trip, it would be a lot better off. What 
are the kind of things preventing it from happening?
    Dr. Adams. From my perspective, the largest barrier is that 
except for in a few isolated pilots, the VA will not pay for 
care at these local facilities. So----
    Mr. Donnelly. Excuse me. Will not pay at all or at an 
appropriate level, what you consider an appropriate level?
    Dr. Adams. Well, to my knowledge, unless a veteran resides 
in one of these areas where they have a rural pilot, a veteran 
cannot go to, say, a community health center or just a private 
doctor, be seen, and have that care reimbursed by the VA.
    Mr. Donnelly. So it is not that the doctor or the clinic 
itself will not meet a payee number set by the VA, the VA just 
will not participate?
    Ms. Ilem. My understanding is that VA has the option 
through its fee-basis program to, if there are geographic 
barriers and a number of certain circumstances, they can 
authorize fee-basis care based on the individual circumstances 
of the veteran and location and a variety of other factors. But 
they do that on an individual basis.
    So VA does currently have that authority. The problem we 
have heard is that through the distribution of the dollars for 
fee-based programs, they oftentimes are only allotted a certain 
amount of money for those fee-basis programs.
    So they are very judicious in how they allow veterans to 
use that program. And if there is an opportunity to get them to 
the nearest clinic, even though it may be several hours away, 
that is where they want them to go.
    But I think looking as part of the establishment of the 
Office of Rural Health, there was a request to look at the fee-
basis program and I know there has been some increased funds in 
the 2009 appropriation for increasing fee basis. And I would 
assume that the Office of Rural Health is really looking at the 
fee-basis issue and to use it appropriately when necessary, 
especially when you have some very elderly veterans or somebody 
with TBI that it would be very difficult for them to make 
extensive trips to and from a facility and a number of trips if 
required by their medical condition.
    Mr. Donnelly. Okay. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Teague. Thank you, Congressman from Indiana. I 
appreciate that.
    And, also, Joy Ilem and Dr. Adams, thank you for your 
participation. I think that the information and knowledge that 
we received from you today will be helpful as we make the 
decisions that we have to make down the road. I really do want 
to thank you for participating.
    Dr. Adams. Thank you.
    Ms. Ilem. Thank you.
    Mr. Teague. Now, at this time, I would like to call panel 
number two to come to the table. We have Dr. Adam Darkins who 
is the Chief Consultant, Office of Care Coordination, Veterans 
Health Administration, U.S. Department of Veterans Affairs, and 
Kara Hawthorne, Director of the Office of Rural Health, 
Veterans Health Administration, U.S. Department of Veterans 
Affairs.
    Once again, thank you for being here today and taking a 
part in this. Dr. Darkins, we will start with you, please.

   STATEMENTS OF ADAM DARKINS, M.D., CHIEF CONSULTANT, CARE 
COORDINATION, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH 
 ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND KARA 
 HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                STATEMENT OF ADAM DARKINS, M.D.

    Dr. Darkins. Good morning, Mr. Chairman. Thank you for the 
opportunity to testify before the Committee today.
    My testimony covers funding and resource coordination 
issues associated with the expansion of telehealth programs 
within the Department of Veterans Affairs or VA and how they 
help meet the health needs of veterans in rural areas.
    Health care delivery in rural areas is a challenge as we 
have just heard, one that the VA is confronting directly. 
Telehealth involves the use of information telecommunications 
technology to increase access to care and reduce travel.
    In fiscal year 2008, VA's telehealth programs provided care 
to over 100,000 veterans in rural areas. These telehealth-based 
services involve real-time videoconferencing, store-and-
forwards telehealth, and home telehealth.
    Real-time videoconferencing services in VA known as care 
coordination and general telehealth provide specialty services 
to veterans in both VA medical centers and in community-based 
outpatient clinics.
    The main focus of this program is in providing mental 
health services in rural areas and in 2008 provided services to 
20,000 veterans at over 171 sites of care. These services 
included provision of care to 2,000 returnees from Operations 
Enduring Freedom and Operation Iraqi Freedom.
    Store-and-forwards telehealth, care coordination, store-
and-forwards known in VA, involves the acquisition, 
interpretation, and management of digital imaging screening and 
assessment purposes of patients.
    These services were provided to over 62,000 veterans in 
rural areas in 2008 and were predominantly to provide care for 
diabetic eye disease screening and for skin diseases.
    To enable veterans with chronic diseases to live 
independently in their own homes and in local communities, VA 
provides home telehealth services. In financial year 2008, 
these services known as care coordination home telehealth 
services in VA supported 35,000 veteran patients to remain 
living independently in their own homes. Forty percent of these 
patients were in rural areas.
    VA is very sensitive to the increasing need for services in 
the home, particularly in rural areas, and is preparing for the 
future demand by expanding the range of these services it 
provides as well as other telehealth services.
    And I am going to describe briefly some ways in which this 
is happening in the next year.
    Firstly, we are formalizing and implementing a national 
program using telehealth to help support the 41,096 veterans 
with amputations who receive care from VA.
    Secondly, we are instituting a program to expand the use of 
telehealth in both home telehealth and in general telehealth to 
support spinal cord injury and disorder services and to make 
this renowned specialist care more available, especially in 
rural areas.
    Thirdly, we are completing the necessary work to implement 
VA's Managing Overweight and/or Obesity for Veterans Everywhere 
Program known as MOVE. And this is going to be incorporated 
with home telehealth and will help it expand into rural areas.
    Fourthly, we are completing a home telehealth technologies 
program for supporting veterans challenged by substance abuse 
issues.
    And the last one I would like to focus on is establishing a 
national telemental health center which will coordinate 
telemental health services nationally. Its particular emphasis 
will be on bipolar disorders and on post-traumatic stress 
disorder and on making those services widely available.
    In implementing telehealth solutions to serve veteran 
patients in rural areas in the ways I have described, 
collaborations with colleagues within and outside VA is vitally 
important. We collaborate with mental health, medical surgical 
services, rehabilitation, prosthetics, spinal cord injury, and 
spinal disorders amongst many other offices who provide 
invaluable expertise that ensures VA's telehealth services are 
appropriate, safe, effective, and cost effective.
    Telehealth is a marriage between clinical care and 
technology and another key ongoing collaboration is that we 
have with information technology colleagues in order to 
underpin a robust and sustainable infrastructure to deliver 
care nationwide.
    In financial year 2009, VA is piloting an extension of its 
preexisting polytrauma telehealth network to create a clinical 
enterprise videoconferencing network. This will facilitate the 
extension of polytrauma, post amputation, spinal cord injury 
care and specialists mental health services to rural areas.
    These efforts combined with VA's personal health record, my 
healthy vet, leverages new technologies to benefit our 
patients.
    VA's Office of Rural Health provides a focus we welcome to 
address the needs of veteran patients in rural areas and 
dovetails services into the spectrum of health care provision 
necessary to support these veterans.
    VA has a longstanding relationship with the Joint Working 
Group on Telehealth, an interagency group. Cross-fertilization 
of telehealth practices with other Federal partners assists us 
in developing services, for example, those we deliver to meet 
the needs of populations such as those in American Indian, 
Alaska native, and Pacific Islander communities.
    VA has three telehealth training centers and has trained 
over 6,000 staff to ensure workforce is competent using those 
modalities wherever possible that are virtual.
    The safety and efficacy of VA's telehealth programs is 
substantiated by a national quality management program that 
reduces utilization and shows high levels of patient 
satisfaction with the telehealth programs.
    Key to the development of telehealth in VA is the energy, 
expertise, and dedication from various staff from different 
backgrounds. They are united in their commitment to serve 
veteran patients.
    It is a privilege to work with such colleagues throughout 
VA and engage in implementing ground-breaking services for 
those who served our Nation and for whom we are committed to 
serving, whether they live in rural, highly rural, or urban 
locations. This remains VA's mission and one we gladly accept.
    Mr. Chairman, that concludes my prepared statement. I am 
pleased to address any questions the Committee may have for me.
    [The prepared statement of Dr. Darkins appears on p. 34.]
    Mr. Teague. Okay. Thank you.
    Next, Kara Hawthorne, please.

                  STATEMENT OF KARA HAWTHORNE

    Ms. Hawthorne. Thank you.
    Good morning, Committee Members. Thank you for the 
opportunity to discuss VA's work to enhance the delivery of 
health care to veterans in rural and highly rural areas.
    I would like to request that my written statement be 
submitted for the record.
    VA's Office of Rural Health referred to as the ORH is 
empowered to coordinate policy efforts across to promote 
improved health care for rural veterans.
    VA has embraced a national strategy of outreach to ensure 
veterans, regardless of where they live, can access the 
expertise and experience of one of the best health care systems 
in the country.
    In partnership, Congress and VA can do even more. We 
appreciate Congress' support and interest in this area and we 
are happy to report that portions of the $250 million included 
in this year's appropriation have already been distributed to 
the field to support new and existing projects.
    Specifically, the ORH has allocated $24 million to sustain 
fiscal year 2008 programs and projects, including the rural 
health resource centers, mobile health care clinics, outreach 
clinics, the VISN Rural Consultant Program, and mental health 
and long-term care projects.
    In December 2008, VA provided almost $22 million to VISNs 
across the country to improve services for rural veterans. This 
funding is part of a 2-year program and will focus on projects 
in line with the ORH strategic vision to increase access and 
enhance quality, education, and training, information 
technology use, workforce recruitment and retention, and to 
strengthen collaboration with our non-VA partners.
    VA distributed resources according to the proportion of 
rural veterans within each VISN. VISNs were provided program 
guidance and directed to identify programs or projects that 
would support the ORH vision to enhance care delivery and 
outreach for veterans in rural areas, and also that they are in 
line with guidelines provided in Public Law 110-329 to increase 
the number of access points, to accelerate telemedicine 
deployment, to explore collaborations with non-VA partners, and 
to fund innovative pilot projects.
    The Office of Rural Health instructed VISNs to include 
funding, validation, and reporting with a breakdown by target 
to facilitate distribution and tracking, as well as execution 
and evaluation plans. VISNs are required to report their 
accomplishments based on these factors to us quarterly.
    In February 2009, the ORH distributed guidance to the VISNs 
and program offices concerning allocation of the remaining 
funds as early as May to enhance rural health care programs.
    A cross-sectional group of VA program offices came together 
to develop a process and a method to allocate the additional 
funds.
    Together we developed a request for proposal. VISNs and 
program offices were each eligible to apply for this funding. 
And, again, we focus on the ORH's six key areas, access, 
quality, technology, workforce, education and training, and 
collaboration strategies.
    We also required proposals include an evaluation component 
with specific measures to explain how the proposed work will 
increase access and the quality of care to our rural veterans.
    ORH, along with the other program offices in the panel and 
other relevant program directors across VA, will be reviewing 
these proposals in early April. Proposals that recommend new 
technologies or those that sought to extend current enterprise 
programs needed to justify how these alternative solutions 
would be interoperable and embody the essential clinical, 
technology, and business processes to ensure compatibility with 
existing programs.
    Affected program offices will be involved in the review of 
these applications to ensure that continuity and consistency 
within the program areas.
    VA's ORH during its short existence has produced a number 
of programs that are actively improving the delivery and 
coordination of health care services to rural veterans. Some 
examples include expanding the existing home-based primary care 
and the medical foster home programs into rural VA facilities, 
developing the Geri Scholars Program to support geriatric 
providers in rural areas, supporting expansion of community-
based supports for veterans with severe mental illness, opening 
ten new rural outreach clinics, and also establishing the 
mobile health care pilot in 24 predominantly rural counties.
    The VA's Office of Rural Health is reaching across the 
Department to coordinate and support programs aimed at 
increasing access for veterans in rural and highly rural 
communities.
    And thank you once again for your support to appear today 
and I am prepared to address any additional questions that you 
may have.
    [The prepared statement of Ms. Hawthorne appears on p. 36.]
    Mr. Teague. I do have some questions, but due to the fact 
that we are fixing to go vote, I will submit my questions in 
writing and defer to the Congressman from Kansas, sir.
    Mr. Moran. Mr. Chairman, thank you very much. You have more 
than overcome your slight earlier in the morning.
    Thank you both for being here.
    One of the things that seems so clear to me as we have 
finally begun the process of increasing the funding for 
veterans' health care is that the challenge we now face within 
the VA system is hiring and retaining health care 
professionals.
    So as we add additional resources that make health care 
perhaps more accessible and higher quality, what is the VA able 
to do, what do you need from Congress in regard to the 
employment of people who perform health care services?
    There is a shortage, generally. My hospitals, my 
communities all struggle to hire necessary health care 
professionals, from physical therapists to psychologists to 
psychiatrists to nurses.
    My question is and my guess is and certainly my experience 
is that this is a more difficult challenge in rural communities 
than it is in urban or suburban settings, and is there a 
concerted effort at the VA to overcome the health care 
professional shortage, particularly in rural areas, but just 
generally?
    Ms. Hawthorne. Thank you for your question.
    You are correct. It is a national problem getting rural 
providers and the VA is addressing this. We have begun some 
initiatives to help recruit providers in the rural areas. We 
are linking in with non-VA entities to help advertise to entice 
them to come to VA.
    Let me tell you specifically about one exciting new 
initiative that we are undertaking with the Office of Academic 
Affiliations.
    We are expanding the rural residency for physicians into 
more rural facilities. So what we are doing is we are able to 
now provide supportive services so that the physicians can 
practice in rural areas because what we have learned is that 
providers who do their residencies in rural areas are more 
likely to stay and work in rural areas. So that is one of the 
examples.
    The other one, as I mentioned in my oral testimony, is the 
Geri Scholars Program. Finding specialists that concentrate on 
geriatric services is difficult in urban and rural areas. So we 
are providing some extra training to the gerontologists about 
our rural veterans and I am hoping that they will disseminate 
that information among their peers in the rural communities 
where they practice.
    Mr. Moran. Is the VA capable of compensating health care 
providers in a way that we are not at a disadvantage to the 
private sector?
    Ms. Hawthorne. I am not able to answer that question 
directly, but I can take it back and get a more thorough answer 
for you.
    [The VA subsequently provided the following information:]

        Yes, with the flexibilities VHA has and the addition, several 
        years ago, of market pay for physicians we can be competitive. 
        However, salaries alone don't do this. It is the flexibility 
        and use of incentives that makes VHA successful in remaining 
        competitive.

    Mr. Moran. Please do. I thank you for that. And if so, is 
there a request to Congress that we do something about how we 
allocate the resources, the increased resources in a way that 
actually allows the VA to hire more providers?
    Dr. Darkins. Could I just----
    Mr. Moran. Absolutely, Doctor.
    Dr. Darkins. Certainly salary is one of the factors in 
terms of recruitment and retention of staff. Equally well, my 
understanding is, preferentially people from different 
disciplines are working within VA because the culture is very 
attractive. There is the training, which my colleague just 
commented on, VA provides substantial training for all health 
care professionals.
    We are also finding, certainly in the area that I work in, 
telehealth, the benefits from our ability to link some of these 
rural practitioners into their specialist colleagues and the 
educational aspects that go with this. To be able to link 
practitioners directly into training and keep them up-to-date 
helps prevent that isolation.
    So the cost is certainly something. These other factors 
really, I think, make VA a place where people are very proud to 
work in terms of the services they are now delivering.
    Mr. Moran. That is, you know, a very accurate description. 
Communities that have only one physician find it very difficult 
to retain that physician. You want colleagues. Doctors do not 
want to be on call 7 days a week, 24 hours a day. There is a 
collaboration and just a professional necessity of having 
colleagues in your presence.
    The comment by our earlier panelist about not being able to 
find out who the--apparently each VISN has a rural coordinator 
and, yet, unable to find out who that person is. Do we have 
those rural coordinators in every VISN? Are they accessible? 
What are they doing? What is the status of that program?
    Ms. Hawthorne. Sure. Yes, sir. We do have a VISN rural 
consultant in each VISN and this was actually something that 
the Committee had foresight to put into the Public Law that 
established the Office of Rural Health.
    Some of the VISNs have full-time positions and some of them 
are not full time, but part of their responsibility is not only 
to facilitate information exchange between the fields and the 
VACO Central Office of Rural Health, but also to collaborate 
with the community, with community partners.
    So they are seeking out potential collaborations for direct 
care, for education and training, and building those 
relationships.
    I will look into your specific VISN and find out who that 
VISN coordinator is and make sure that they are in touch with 
the State Office of Rural Health and actually urge all of our 
VISN rural consultants to reach out to the State Offices of 
Rural Health.
    Mr. Moran. Thank you for that.
    And point out that a couple of instances over a long period 
of time, we have tried, I have been involved in efforts, this 
Committee has been involved in efforts, to encourage the VA to 
employ the services of certain health care providers, 
chiropractic care, physical therapy. It always seems like there 
is a push to get the VA to accept certain segments of the 
medical profession.
    And I just would remind you that in both those instances, 
physical therapy, chiropractic care, that in rural America, 
those professionals are very important. They fill a real need. 
And I would encourage your efforts on behalf of rural health 
care to recognize this, not to be narrow in the way that we 
define who can be a provider.
    I think there is some reluctance to pursue the 
opportunities that I see there with a wide array of services 
that are more available in rural America in certain 
subcategories of professionals than there are just--than 
sometimes what we look for.
    Let me finally, and, again, my time has expired, the 
Chairman has been very kind, but let me just thank you, Ms. 
Hawthorne, for your meeting with my staff.
    Implementation of the legislation that we have been talking 
about is a high priority of this Committee. Many Members come 
from rural areas. It is a high priority with me.
    You were very gracious and it appears to me that you are 
very interested in seeing that this occur in a timely and 
appropriate fashion and I am very grateful for your attitude 
and approach and look forward to working with you.
    Thank you, Mr. Chairman.
    Mr. Teague. Thank you, sir, for those very pertinent 
questions and appropriate issues that needed to be addressed.
    At this time, I would like to ask the Congressman from 
California, Mr. McNerney, if he has some questions.
    Mr. McNerney. Well, I do, Mr. Chairman. Thank you for 
giving me the gavel here.
    And I want to follow-up a little bit on some of the 
questions by my colleague from Kansas. I certainly recognize 
the shortage, critical shortage of health care professionals in 
rural areas. And it is not just for VA services. It is a 
general problem. So we need to look at how to entice 
physicians, health care professionals of all kinds to come into 
rural areas.
    One of the problems we are facing in California is that our 
prisons are severely overcrowded resulting in poor health care 
for prisoners. And now they are suggesting, the courts are 
about to mandate that we open up health care facilities in our 
area that will pay far more than the VA can and that will draw 
physicians further away from VA use and applications to prison. 
And that is very controversial. I am sure you can imagine. So 
it is an area that we need to look at and maybe address at this 
level.
    One of the things that struck me about your testimony, Dr. 
Darkins, was the sort of difference in tone about telehealth 
from the prior panel. They certainly acknowledged the need for, 
the value of telenet, but your testimony was a little bit 
farther than that. It was not just the value, but how it could 
be used in several areas, vets with amputations, vets with 
spinal cord injuries, weight problems, post-traumatic stress 
and so on.
    One of the things I am concerned about with telenet is the 
lack of personal touch. I mean, you have a screen in front of 
you and you can see the physician.
    How effective is that in terms of reaching a veteran with 
these sorts of problems as opposed to having someone that can 
actually touch their hands and look them straight in the eye? 
You know, how much difference is there in terms of the 
effectiveness of the treatment if we go that way because it is 
clear to me that telehealth is a very effective tool? We are 
not going to be able to get all the physicians we need no 
matter how hard we try. So how effective is this treatment?
    Dr. Darkins. Thank you very much.
    In terms of the VA's use of telemedicine, let me just say 
it is not a panacea to be able to provide all services. 
Absolutely it has to fit into a spectrum of care in which it is 
there with face-to-face services as well. So it is part of a 
spectrum of services.
    VA's experience makes it a nationwide leader if not in 
certain areas, an international leader. There are certain 
benefits the VA has to make sure happens and develop very large 
networks. VA has had an ongoing commitment from leadership 
toward telehealth. It has been seen as a way to deliver 
specialist services, particularly out into rural communities.
    Secondly, we do not have barriers from State licensure 
which allow us to develop large networks and to put these 
enterprise services into place. So it is very much the scale at 
which it is being done in VA that is so important. I think VA's 
experience is much higher than elsewhere because we have really 
an integrated health care system and are doing telehealth on an 
enterprise level.
    In terms of your specifics, that has been something of 
enormous importance as we have taken telehealth forwards to be 
able to be quite clear that this is the right care for 
patients, it is what they want.
    What we find is that telehealth services are really seen 
across the board by patients as being really directly 
equivalent in many cases to delivering face to face. We find 
sometimes people prefer to have face to face, but if you take 
into consideration the travel, sometimes the inconvenience, we 
are finding that people say they really enjoy the telehealth 
services.
    It is not enough to be able to say anecdotally. We have 
good evidence from surveys we have done. Our home telehealth 
patients show an 86 percent satisfaction score with these 
services. They help them live independently in their own homes. 
We have 37,000 patients currently who otherwise might be in 
nursing homes if it were not for these services.
    Mr. McNerney. What sort of equipment is needed for home 
telehealth that a person might not ordinarily have?
    Dr. Darkins. Well, we are very sensitive to the fact that 
we are dealing with an aging population and may not be the most 
technology savvy. So we use simple technologies, which are push 
button.
    The current connectivity is largely through telephone land 
lines, simple to use and communicate backward and forwards. And 
we are seeing a 20-percent reduction of utilization, so 
reducing hospital visits, and reducing hospital admissions 
using these technologies. They are really helping people with 
chronic disease to be able to stay living independently in 
their own homes and communities.
    Mr. McNerney. Do they need like a big screen TV or, I mean, 
what physical equipment do they need in the house?
    Dr. Darkins. They are small, little, unobtrusive boxes. 
There are three different ways in which this is generally done.
    One way is to do videoconferencing into the home so 
somebody can directly see that provider. It means they get much 
more of that face-to-face contact. Obviously a physical 
examination cannot be done.
    Mr. McNerney. Right.
    Dr. Darkins. Second is to be able to monitor people's vital 
signs, pulse, weight, blood pressure, temperature. It is 
possible, thereby, to be able to remotely care for conditions 
like heart failure. Very simply, if somebody puts on weight and 
gets symptomatic, it is possible to intervene early and prevent 
hospital admission.
    And the third area really is to be able to use what are 
known as disease management dialogs, to ask the kind of 
questions of a patient each day that they might be asked of 
their provider if they came into a clinic.
    So we are finding this is really targeting care. We can 
expedite admission of people to hospital or referral to clinics 
based on this personal care each day which takes place from a 
VA provider back in the VA Medical Center.
    Mr. McNerney. Thanks.
    If the Chairman will indulge me one more question, what do 
we need to do here to make sure that the VA can provide these 
sort of home-based services, make them available? Do we need to 
provide equipment or people, service people to come in and 
install, or what do we need to do here?
    Dr. Darkins. Well, I would say in this area at the moment, 
VA is very much on the leading edge of being able to take this 
forward. These are emerging technologies that have been used 
elsewhere but not as widely in the VA.
    Patients are very accepting. Patients show high scores of 
satisfaction. We are working with the vendors that provide the 
technologies to standardize the systems, which is very 
important to be able to standardize the data, and thereby, data 
exchange.
    There is not an issue in terms of our use of equipment or 
having equipment to be able to do this. I think our main issues 
as we go forward are really just those human being issues. You 
touched on earlier is it as good to be able to be using 
telehealth technologies as face to face.
    So paradoxically we find a lot of the work is actually on 
relationships because in the end, it comes down to 
relationships. So I think the things I would say is one 
limiting factor is being absolutely sure we have a robust 
information technology backbone. We are working very hard with 
our information technology colleagues and the outside vendors 
to ensure that they are in place.
    And the second is relationships, helping veteran patients 
to be accepting, which they are, of this technology, but also a 
provider population for whom this is a new way of delivering 
care as well. So those are really our main challenges are those 
human challenges rather than the technology.
    Mr. McNerney. Thank you, Mr. Chairman.
    Mr. Teague. Thank you, Congressman McNerney from 
California, for that.
    Dr. Darkins and Kara Hawthorne, I want to thank you again 
for coming and testifying before our Subcommittee and thank you 
for the input that you have had. There will be some other 
questions submitted in writing.
    And with that, that concludes the hearing this morning. 
Thank you.
    [Whereupon, at 11:27 a.m., the Subcommittee was adjourned.]



















                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud,
                    Chairman, Subcommittee on Health
    The Subcommittee on Health will now come to order. I thank everyone 
for attending this hearing. The purpose of today's hearing is to 
provide oversight of the VA's rural health funding spending and 
resource coordination. The hearing will explore whether resources are 
used efficiently to narrow the health disparities of veterans living in 
rural areas.
    In general, we know that Americans living in rural areas tend to be 
in poorer health and are more likely to live below the poverty level 
compared to the rest of the country. This is magnified by the shortage 
of health professionals. In fact, while a quarter of the U.S. 
population lives in rural areas, only 10 percent of physicians practice 
in rural areas.
    Focusing on the rural veteran population, we know that among all VA 
health care users, 40 percent of nearly 2 million veterans reside in 
rural areas. This includes nearly 80,000 veterans who live in highly 
rural areas. And according to the VA Health Services Research and 
Development Office, rural veterans have worse physical and mental 
health related to quality of life scores compared to their urban 
counterparts.
    I commend the VA for their efforts to improve rural health. This 
includes building new CBOCs, Rural Outreach Clinics, and Vet Centers in 
rural and highly rural areas. It also includes pilot programs such as 
the traveling nurse corps, and the mobile health care pilot which 
places four mobile clinics in 24 predominantly rural counties in 
Colorado, Nebraska, Wyoming, Maine, Washington, and West Virginia. I 
also applaud the advances made in telehealth through the numerous pilot 
programs which have been implemented to date.
    To help the VA's efforts, the Appropriations Committee provided 
$250 million in September of 2008 to establish and implement a new 
rural health outreach and delivery initiative. Through today's hearing, 
we seek a better understanding of how the VA has allocated and plans to 
allocate the $250 million. The hearing will also address concerns about 
the lack of coordination and the duplicative efforts by the various 
offices in the VA that deal with rural health.
    Today, the Disabled American Veterans will share their thoughts on 
VA's progress in improving rural health. We will also hear from the 
South Carolina Office of Rural Health about local challenges and 
recommendations for closing the rural health gap. Finally, the VA's 
Office of Care Coordination and the Office of Rural Health will report 
on the Department's current efforts on rural health. I look forward to 
hearing their informative testimonies.

                                 
                Prepared Statement of Hon. Cliff Stearns
    Thank you, Mr. Chairman.
    I'm pleased to be here this morning for our Health Subcommittee's 
hearing on ensuring our veterans living in rural areas are receiving 
the quality health care they deserve.
    Today's hearing affords us the chance to examine how the Department 
of Veterans Affairs is spending some of the funds allocated to them in 
the FY2009 Appropriations Act. Specifically, we are focusing on funds 
that were marked to help further the VA's rural health initiatives in 
areas such as mobile health clinics and telemedicine.
    We are all well aware of the health care gaps that exist for 
veterans residing in rural areas--we know that almost 40 percent of 
veterans enrolled in VA health care live in rural or highly rural 
areas, and that 44 percent of our veterans returning from Iraq and 
Afghanistan also reside in rural areas. Veterans (and people in 
general) living in rural America are statistically shown to have lower 
quality of life scores and are more likely to suffer from treatable 
diseases. Clearly, this is an issue we must be addressing and 
monitoring closely.
    I applaud the VA's current outreach efforts to recruit and retain 
more health care providers to serve in rural areas and to pursue 
innovative health care methods such as telemedicine. We are moving in 
the right direction, but we must stay the course and the VA must 
fulfill the goals it has set.
    I welcome our panel of witnesses and look forward to hearing more 
about how the VA has and intends to further distribute the funds 
allocated to them under the FY09 appropriation so that we can truly 
begin closing the health care gap for our Nation's rural veterans.

                                 

                   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 oversight hearing of the Subcommittee. We value the 
opportunity to discuss our views on funding and resource coordination 
as related to health care gaps for veterans residing in rural and 
highly rural areas. This is an issue of significant importance to many 
DAV members and veterans in general.
    Approximately 40 percent of veterans enrolled for Department of 
Veterans Affairs (VA) health care are classified by VA as rural or 
highly rural. Additionally, 44 percent of current active duty military 
servicemembers, who will be tomorrow's veterans, list rural communities 
as their homes of record. Research shows that when compared with their 
urban and suburban counterparts, veterans who live in a rural setting 
have worse health-related quality-of-life scores; are poorer and have 
higher disease burdens; worse health outcomes; and are less likely to 
have alternative health coverage. Such findings anticipate greater 
health care demands and thus greater health care costs from rural 
veteran populations.
    Over the past several years through authorizing legislation and 
additional appropriations Congress has attempted to address unmet 
health care needs of veterans who make their homes in rural and remote 
areas. With nearly half of those currently serving in the military 
residing from rural, remote and frontier areas, access to VA health 
care and other veterans services for them is perhaps VA's most 
perplexing challenge. We recognize that rural health is a difficult 
national health care issue and is not isolated to VA's environment. We 
also appreciate that many service-connected disabled veterans living in 
rural areas face multiple challenges in accessing VA health care 
services, or even private services under VA contract or fee basis. 
Shortage of health care providers, long travel distances, weather 
conditions, geography and financial barriers all negatively impact 
access and care coordination for many rural veterans, both the service-
connected and nonservice-connected.
    Section 212 of Public Law 109-461 authorized VA to establish the 
Veterans Health Administration (VHA) Office of Rural Health (ORH). We 
deeply appreciate the due diligence of this Subcommittee and Congress 
as a whole in exerting strong support for rural veterans by enacting 
this public law.
    As required by the Act, the function of the ORH is to coordinate 
policy efforts across VHA to promote improved health care for rural 
veterans; conduct, coordinate, promote and disseminate research related 
to issues affecting veterans living in rural areas; designate in each 
Veterans Integrated Service Network (VISN) rural consultants who are 
responsible for consulting on and coordinating the discharge of ORH 
programs and activities in their respective VISNs for veterans who 
reside in rural areas; and, to carry out other duties as directed by 
the Under Secretary for Health. In the Act, VA also was required to do 
an assessment of its fee-basis health care program for rural veterans 
to identify mechanisms for expanding the program and the feasibility 
and advisability of implementing such mechanisms. There were also a 
number of reports to Congress required including submission of a plan 
to improve access and quality of care for enrolled veterans in rural 
areas; measures for meeting the long term care and mental health needs 
of veterans residing in rural areas; and, a report on the status of 
identified and opened community-based outpatient clinics (CBOCs) and 
access points identified from the May 2004 decision document associated 
with the Capital Asset Realignment for Enhanced Services (CARES) plan. 
Finally, the Act required VA to conduct an extensive outreach program 
to identify and provide information about VA health care services to 
veterans of Operations Iraqi and Enduring Freedom (OIF/OEF) who live in 
rural communities for the purpose of enrolling these veterans into the 
VA health care system prior to the expiration of their statutory 
eligibility period (generally, 5 years following the date of military 
discharge or completion of deployments).
    In addition to establishing the ORH, in 2008 VA created a 13-member 
VA Rural Health Advisory Committee to advise the Secretary on issues 
affecting rural veterans. This panel includes physicians from rural 
areas, disabled veterans, and experts from government, academia and the 
non-profit sectors. We applaud former VA Secretary Peake for having 
responded to our recommendation in the Fiscal Year (FY) 2009 
Independent Budget (IB) to use VA's authority to form such a Committee. 
Recently, this new Committee held its second scheduled meeting. We hold 
high expectations that the Rural Veterans Advisory Committee will be a 
strong voice of support for many of the ideas we have expressed in 
previous testimony before Congress, and joined by our colleagues from 
AMVETS, Paralyzed Veterans of America, and the Veterans of Foreign Wars 
of the United States, in the IB.
    We are pleased and congratulate VA on its progress to date in 
establishing the necessary framework to begin to improve services for 
rural veterans. It appears that ORH is reaching across the Department 
to coordinate and support programs aimed at increasing access for 
veterans in rural and highly rural communities. We note, however, that 
the ORH has an ambitious agenda but only a minimal staff and limited 
resources. The ORH is still a relatively new function within VA Central 
Office and it is only at the threshold of tangible effectiveness, with 
many challenges remaining. Given the lofty goals of Congress for rural 
health improvements, we are concerned about the organizational 
placement of ORH within the VHA Office of Policy and Planning rather 
than being closer to the operational arm of the VA system. Having to 
traverse the multiple layers of VHA's bureaucratic structure could 
frustrate, delay or even prevent initiatives established by this 
office. We believe rural veterans' interests would be better served if 
the ORH were elevated to a more appropriate management level in VA 
Central Office, with staff augmentation commensurate with its stated 
goals and plans.
    We understand that VA has developed a number of strategies to 
improve access to health care services for veterans living in rural and 
remote areas. To begin, VA appointed rural care designees in all its 
VISNs to serve as points of contact in liaison with ORH. While we 
appreciate that VHA designated the liaison positions within the VISNs, 
we expressed concern that they serve these purposes only on a part-time 
basis. We are pleased that VA is conducting a pilot program in eight 
VISNs to determine if the rural coordinator function is apropos of a 
part-time or a full-time position.
    VA reported that its approach to improving services in rural areas 
includes leveraging existing resources in communities nationwide to 
raise VA's presence through outreach clinics, fee-basis, contracting, 
and use of mobile clinics. Additionally, VA testified it is actively 
addressing the shortage of health care providers through recruitment 
and retention efforts; and harnessing telehealth and other technologies 
to reduce barriers to care. Also, in September 2008 VA announced plans 
to establish new rural outreach clinics in Houston County, Georgia, 
Juneau County, Alaska, and Wasco County, Oregon. VA plans to open six 
additional outreach clinics by August 2009 in Winnemucca, Nevada, 
Yreka, California, Utuado, Puerto Rico, Lagrange, Texas, Montezuma 
Creek, Utah, and Manistique, Michigan.
    VA also reported that it has conducted other forms of outreach and 
developed relationships with the Department of Health and Human 
Services (HHS) (including the Office of Rural Health Policy and the 
Indian Health Service), and other agencies and academic institutions 
committed to serving rural areas to further assess and develop 
potential strategic partnerships. Likewise, VA testified it is working 
to address the needs of veterans from OIF/OEF by coordinating services 
with the HHS' Health Resources and Services Administration community 
health centers, and that these initiatives include a training 
partnership, technical assistance to community health centers and a 
seamless referral process from community health centers to VA sources 
of specialized care.
    In August 2008, VA announced the establishment of three ``Rural 
Health Resource Centers'' for the purpose of improving understanding of 
rural veterans' health issues; identifying their disparities in health 
care; formulating practices or programs to enhance the delivery of 
care; and, developing special practices and products for implementation 
VA system-wide. According to VA, the Rural Health Resource Centers will 
serve as satellite offices of ORH. The centers are sited in VA medical 
centers in White River Junction, Vermont; Iowa City, Iowa; and, Salt 
Lake City, Utah.
    Given that 44 percent of newly returning veterans from OEF/OIF live 
in rural areas, the IB veterans service organizations believe that 
these veterans, too, should have access to specialized services offered 
by VA's Readjustment Counseling Service, through its Vet Centers. In 
that regard we are pleased to acknowledge that VA plans to roll out a 
fleet of 50 mobile Vet Centers this year to provide access to returning 
veterans and outreach at demobilization sites on military bases, and at 
National Guard and Reserve units nationally.
    The issue of rural health is an extremely complex one and we agree 
with VA that there is not a ``one-size-fits-all'' solution to this 
problem. To make real improvements in access to the quality and 
coordination of care for rural veterans, we believe that Congress must 
provide continued oversight, and VA must be given sufficient resources 
to meet its many missions, including improvements in rural health care.
    In regard to funding for rural health, VA acknowledged in 2008 that 
it had allocated almost $22 million to VISNs to improve services for 
rural veterans. VA noted this funding is part of a two-year program and 
would focus on projects including new technology, recruitment and 
retention, and close cooperation with other organizations at the 
federal, state and local levels. These funds are being used to sustain 
current programs, establish pilot programs and establish new outpatient 
clinics. VA distributed resources according to the fraction of enrolled 
veterans living in rural areas within each VISN. It is DAV's 
understanding that VISNs with less than three percent of their patients 
in rural areas received $250,000, those with between three and six 
percent received $1 million, and those with six percent or more 
received $1.5 million.
    The ORH has testified VA allocated another $24 million to sustain 
these programs and projects into 2009, including the Rural Health 
Resource Centers, mobile clinics, outreach clinics, VISN rural 
consultants, mental health and long-term care projects, and rural home-
based primary care, and has convened a workgroup of VISN and Central 
Office program offices to plan for the allocation of the remaining 
funds. In February 2009, ORH distributed guidance to VISNs and program 
offices concerning allocation of the remaining funds as early as May to 
enhance rural health care programs.
    Concurrently, Public Law 110-329, the Consolidated Security, 
Disaster Assistance, and Continuing Appropriations Act, 2009, approved 
on September 30, 2008, included $250 million for VA to establish and 
implement a new rural health outreach and delivery initiative. Congress 
intended these funds to build upon the successes of the ORH by enabling 
VA to expand initiatives such as telemedicine and mobile clinics, and 
to open new clinics in underserved and rural areas. Notably, the bill 
also includes $200 million for fee-basis services.
    Health workforce shortages and recruitment and retention of health 
care personnel are also a key challenge to rural veterans' access to VA 
care and to the quality of that care. The Institute of Medicine of the 
National Academy of Sciences report ``Quality through Collaboration: 
The Future of Rural Health'' (2004) recommended that the Federal 
Government initiate a renewed, vigorous, and comprehensive effort to 
enhance the supply of health care professionals working in rural areas. 
To this end, VA's deep and long-term commitment to health profession 
education seems to be an appropriate foundation for improving these 
situations in rural VA facilities as well as in the private sector. 
VA's unique relationships with health profession schools should be put 
to work in aiding rural VA facilities with their human resources needs, 
and in particular for physicians, nurses, technicians, technologists 
and other direct providers of care. The VHA Office of Academic 
Affiliations, in conjunction with ORH, should develop a specific 
initiative aimed at taking advantage of VA's affiliations to meet 
clinical staffing needs in rural VA locations. While VA maintains it is 
moving in this general direction with its pilot program in a traveling 
nurse corps, VA's pilot program in establishing a ``nursing academy,'' 
initially in four sites and expanding eventually to 12; its well-
founded Education Debt Reduction Program and Employee Incentive 
Scholarship Program; and, its reformed physician pay system as 
authorized by Public Law 108-445, none of these programs was 
established as a rural health initiative, so it is difficult for DAV to 
envision how they would lend themselves to specifically solving VA's 
rural human resources problems. We do not see them as specific 
initiatives aimed at taking advantage of VA's affiliations to meet 
clinical staffing needs in rural VA locations.
    The DAV has a standing resolution from its membership, Resolution 
No. 177, fully supporting the right of rural veterans to be served by 
VA, but insists that Congress provide sufficient resources for VA to 
improve health care services for veterans living in rural and remote 
areas. We thank VA and this Subcommittee for supporting this specific-
purpose funding for rural care without jeopardizing other VA health 
care programs. Furthermore, we appreciate the Subcommittee's interest 
in conducting this oversight hearing to learn more from VA about the 
specific instructions issued to field facilities guiding the use of 
these new funds, what Central Office monitoring is being provided over 
the use of those funds, and the degree and type of reporting 
requirements that have been imposed. Such information would serve 
everyone's interest in ascertaining how many additional veterans 
received care at VA's expense that otherwise would not have received 
care were it not for the new resources made available for rural 
veterans, as well as gathering data on how their health outcomes have 
been affected as a measure of the quality of that care.
    VA's previous studies of rural needs identified the need for 156 
priority CBOCs and a number of other new sites of care nationwide. A 
March 30, 2007, report submitted to Congress also required by Public 
Law 109-461, indicates 12 CBOCs had been opened, 12 were targeted for 
opening in FY 2007, and five would open in FY 2008. In June 2008, VA 
announced plans to activate 44 additional CBOCs in 21 states during FY 
2009. Of the over 750 CBOCs VA operates, 353 CBOCs are doing real-time 
video conferencing (predominantly tele-mental health), while 130 CBOCs 
are transmitting tele-retinal imaging for evaluation by specialists in 
VA medical centers. Such services greatly enhance patient care, extend 
specialties into rural and highly rural locations, and drastically cut 
down on long-distance travel by veterans. VA directly staffs 540 
clinics, and the remainder of these CBOCs are managed by contractors. 
At least 333 of VA's CBOCs are located in rural or highly rural areas 
as defined by VA. In addition, VA is expanding its capability to serve 
rural veterans by establishing rural outreach clinics. Currently 12 VA 
outreach clinics are operational, and more are planned. These are major 
investments by VA and we appreciate both VA and Congress for supporting 
this level of extension of VA services into more and more communities.
    While we applaud the VHA for improving veterans' access to quality 
care and its intention to spread primary and limited specialty care 
access for veterans to more areas, enabling additional veterans access 
to a convenient VA primary care resource, DAV urges that the business 
plan guiding these decisions generally first emphasize the option of 
VA-operated and staffed facilities. When geographic or financial 
conditions warrant (e.g., highly rural, scarceness, remoteness, etc.), 
we do not oppose the award of contracts for CBOC operations or leased 
facilities, but as a contributor to the IB for FY 2010 we do not 
support the general notion that VA should rely heavily or primarily on 
contract CBOC providers to provide care to rural veterans.
    We understand and appreciate those advocates on this Subcommittee 
and in Congress in general who have been successful in enacting 
authority for VA to increase health care contracting in rural areas 
through a new multi-VISN pilot program enacted in Public Law 110-387. 
However, in light of the escalating costs of health care in the private 
sector, to its credit VA has done a remarkable job of holding down 
costs by effectively managing in-house health programs and services for 
veterans. While some service-connected and nonservice-connected 
veterans might seek care in the private sector as a matter of personal 
convenience, they may well lose the safeguards built into the VA system 
by its patient safety program, prevention measures, evidence-based 
treatments, national formulary, electronic health record, and bar code 
medication administration (BCMA), among other protections. These unique 
VA features culminate in the highest quality care available, public or 
private. Loss of these safeguards, ones that are generally not 
available in private sector systems or among individual practitioners 
or group practices (especially in rural areas), would equate to 
diminished oversight and coordination of care, lack of continuity of 
care, and ultimately may result in lower quality of care for those who 
need quality the most.
    For these reasons, we urge Congress and VA's ORH to closely monitor 
and oversee the development of the new rural pilot demonstration 
project from Public Law 110-387, especially to protect against any 
erosion or diminution of VA's specialized medical programs and to 
ensure participating rural and highly rural veterans receive health 
care quality that is comparable to that available within the VA health 
care system. We are pleased that the ORH reported it is coordinating 
with the Office of Mental Health Services to implement this pilot 
program. We ask VA, in implementing this demonstration project, to 
develop a series of tailored programs to provide VA-coordinated rural 
care (or VA-coordinated care through local, state or other Federal 
agencies, as VA has previously claimed it would be doing) in the 
selected group of rural VISNs, and to provide reports to the Committees 
on Veterans' Affairs of the results of those efforts, including 
relative costs, quality, satisfaction, degree of access improvements 
and other appropriate variables, compared to similar measurements of a 
like group of rural veterans in VA health care. To the greatest extent 
practicable, VA should coordinate these demonstrations and pilots with 
interested health profession academic affiliates. We recommend the 
principles outlined in the Contract Care Coordination section of the FY 
2010 IB be used to guide VA's approaches in this demonstration, and 
that it be closely monitored by VA's Rural Veterans Advisory Committee, 
with results reported regularly to Congress.
    We also recommend that VA be required to provide more thorough 
reporting to this Subcommittee to enable meaningful oversight of the 
use of the funds provided and the implementation of the authorizing 
legislation that serves as a foundation to this work.
    We urge the Subcommittee to consider legislation strengthening 
recurring reporting on VA rural health as a general matter. We are 
concerned that funds Congress provided to VA to address shortages of 
access in rural areas will simply be dropped into the VA ``Veterans 
Equitable Resource Allocation'' (VERA) system, absent means of 
measuring whether these new funds will be obligated in furtherance of 
Congress's intent--to enhance care for rural and highly rural veterans, 
with an emphasis on outreach to the newest generation of war veterans 
who served in the National Guard and hail from rural areas. Reports to 
Congress should include standardized and meaningful measures of how VA 
rural health care capacity or ``virtual capacity'' has changed; VA 
should provide recorded workload changes on a quarterly or semi-annual 
basis, and disclose other trends that reveal whether the rural health 
initiatives and funds allocated for them are achieving their designed 
purposes.
    In closing, DAV believes that while VA may be working in good faith 
to address its shortcomings in rural areas, it clearly still faces 
major challenges and hurdles. In the long term its methods and plans 
may offer rural and highly rural veterans better opportunities to 
obtain quality care to meet their specialized health care needs. 
However, we caution about the trend toward privatization, vouchering 
and contracting out VA health care for rural veterans on a broad scale. 
As VA's ORH develops its policies and initiatives, DAV cannot stress 
enough the importance of communication and collaboration between this 
office, other VA program offices and field facilities, and other 
Federal, State or local organizations, to reach out and provide VA 
benefits and services to veterans residing in rural and highly rural 
areas. As noted above, we are concerned that the current staffing level 
assigned to ORH will be insufficient to effectively carry out its 
mission. Moreover, DAV believes ORH's position in VHA's organizational 
structure may hamper its ability to properly implement, guide and 
oversee VA's rural health initiative. Also, Congress should monitor 
VA's funding allocation to ensure rural health needs do not interfere 
with other VA medical obligations. Finally, we are hopeful with 
continued oversight from this Subcommittee and, with these principles 
in mind; rural veterans will be better served by VA in the future.
    Mr. Chairman, this concludes my statement. I would be happy to 
address questions from you or other Members of the Subcommittee.

                                 
             Prepared Statement of Graham L. Adams, Ph.D.,
     Executive Director, South Carolina Office of Rural Health, and
     State Office Council Chair, National Rural Health Association
    I am Graham Adams, CEO of the South Carolina Office of Rural 
Health, a Past-President of the National Organization of State Offices 
of Rural Health and a trustee on the Board of the National Rural Health 
Association. The NRHA provides leadership on the issues that affect the 
health of the 62 million Americans who call rural home and has long 
focused efforts on improving the physical and mental health of our 
rural veterans. I appreciate the opportunity to speak before you today 
to discuss this very important issue.
    Since our Nation's founding, rural Americans have always responded 
when our Nation has gone to war. Whether motivated by their values, 
patriotism, or economic concerns, the picture has not changed much in 
230 years. Simply put, rural Americans serve at rates higher than their 
proportion of the population. Though only 19 percent of the Nation 
lives in rural areas, 44 percent of U.S. Military recruits are from 
rural America. And, sadly, according to a 2006 study of the Carsey 
Institute, the death rate for rural soldiers is 60 percent higher than 
the death rate for those soldiers from cities and suburbs. Given this 
great commitment to service on behalf of rural communities, we need to 
do more to closely examine the health care barriers that face rural 
veterans. Developing solutions specific to rural veterans and their 
unique needs must be a priority.
    There is a national misconception that all veterans have access to 
comprehensive care. Unfortunately, this is simply not true. Access to 
the most basic primary care is often difficult in rural America. Access 
for rural veterans can be daunting. Combat veterans returning to their 
rural homes in need of specialized care due to war injuries (both 
physical and mental) likely will find access to that care extremely 
limited. What this means, is that because there is a disproportionate 
number of rural Americans serving in the military, there is a 
disproportionate need for veteran's care in rural areas.
    Veterans that live in rural communities face great challenges when 
trying to receive care. Lack of an adequate number of Community Based 
Outpatient Clinics (CBOCs), Outreach Health Centers or other approved 
sources of care make it difficult for rural veterans to receive timely, 
appropriate care. According to the VA website, my home state of South 
Carolina only has 11 CBOCs, and 3 Vet Outreach Centers. This is 
especially concerning given that South Carolina is one of the top 
twenty states in which veterans reside. Scarcity of mental health and 
family counseling services is also a problem for rural veterans in need 
of these services.
    The NRHA believes that both program expansion and resource 
coordination is critical to improve the care of our rural veterans and 
makes the following recommendations:
1.  Increase Access by Building on Current Successes
    Community Based Outreach Centers (CBOCs) open the door for many 
veterans to obtain primary care services within their home communities. 
Additionally, Outreach Health Centers meet the needs of many rural 
veterans. NRHA applauds the success of these programs and supports 
their expansion.
2.  Increase Access by Collaborating with Non-VHA Facilities
    Approximately 20 percent of veterans who enroll to receive health 
care through the VHA live in rural communities. With an ever-growing 
number of veterans returning home to their rural communities after 
military service, these rural health care systems must be prepared to 
meet their needs. While CBOCs and Veteran Outreach Centers provide 
essential points of access, there are not enough of these facilities in 
rural communities. Furthermore, CBOCs do not provide a full range of 
care and the low volume of veterans in some communities may never be 
able to support one of these centers. Simply put, more providers are 
needed to serve the increasing number of rural veterans. Collaboration 
with existing rural health care facilities provides an effective and 
timely solution to this problem.
    Linking the quality of VA services with rural civilian services can 
vastly improve access to health care for rural veterans. Our goal is 
not to mandate care to our veterans, but to provide them a choice, a 
local choice. As long as quality standards of care and evidence-based 
medicine guide treatment for rural veterans, the NRHA supports 
collaboration with:

       Federally Qualified Community Health Centers (FQHCs). 
These centers serve millions of rural Americans and provide community-
oriented, primary and preventive health care. More importantly, FQHCs 
are located where rural veterans live. A limited number of 
collaborations between the VHA and Community Health Centers already 
exist and have proven to be prudent and cost-effective solutions to 
serving eligible veterans in remote areas. These successful models 
should be expanded to reach all of rural America.
       Critical Access Hospitals and other small rural 
hospitals. These facilities provide comprehensive and essential 
services to rural communities and are specific to rural states. If 
these facilities are linked with VHA services and models of quality, 
access to care would be greatly enhanced for thousands of rural 
veterans.
       Rural Health Clinics. These clinics serve populations in 
rural, medically underserved areas and comprise a vital piece of the 
safety-net system. In many rural and frontier communities, RHCs are the 
only source of primary care available. Furthermore, many RHCs are more 
than willing to see these rural veterans if only a mechanism existed to 
do so.

    The above rural health facilities are the cornerstone of primary 
and preventive quality health care in rural America. Each is required 
to meet Federal requirements for quality, provider credentialing and 
the use of health information technology. Current collaborations with 
the VHA in Wisconsin, Missouri and Utah are strong examples of success. 
Expanding the levels of collaboration will vastly increase access to 
care in a cost-effective manner.
    The NRHA is pleased that the Rural Veterans Access to Care Act was 
signed into law last October. This act establishes a 3-year pilot 
program in several rural regions of the country to allow the most 
underserved rural veterans to take advantage of existing quality rural 
health providers, such as Critical Access Hospitals, community health 
centers and rural health clinics. The pilot project is relatively small 
and requirements to qualify are rigid--a veteran must live at least 60 
miles from a VA primary care facility like an outpatient clinic, 120 
miles from a VA hospital or 240 miles from a VA specialized-care 
facility when seeking that care. Despite these defects, this 
legislation is a strong and important step in the right direction, but 
so much more must be done.
3.  Increase Access to Mental Health and Brain Injury Care
    Currently, it appears that Traumatic Brain Injury (TBI) will most 
likely become the signature wound of the Afghanistan and Iraqi wars. 
Such wounds require highly specialized care. The current VHA TBI Case 
Managers Network is vital, but access to it is extremely limited for 
rural veterans--expansion is needed.
    Additionally, mental health needs of combat veterans deserve 
special attention and advocacy as well. Access to mental health 
services is a problem in many small rural communities. In fact, 85 
percent of all mental health shortages are found in rural America. A 
lack of qualified mental health professionals, shortage of psychiatric 
hospital beds and the negative stigma of mental illness, often result 
in many rural residents not getting the care they so desperately need. 
These problems are exacerbated for veterans who live in rural 
communities.
    Although Vet Centers provide mental health services, they are not 
consistently available at the local, rural level. More resources are 
needed in order to contract with local mental health providers, hire 
additional mental health providers and/or contract with Critical Access 
Hospitals (CAHs) and other small rural hospitals.
4.  Target Care to Rural Veterans
    A.  Needs of the Rural Family. Rural veterans have an especially 
strong bond with their families. Returning veterans adjusting to 
disabilities and the stresses of combat need the security and support 
of their families in making their transitions back into civilian life. 
The Vet Centers do a tremendous job in assisting veterans, but their 
resources are limited. The NRHA supports increases in funding for 
counseling services for veterans' and their families.
    B.  Needs of Rural Women Veterans. More women serve in active duty 
than at any other time in our Nation's history. And more women are 
wounded or are war casualties than ever before in our Nation's history.

    Targeted and culturally competent care for today's women veterans 
is needed. Rural providers should also be trained to meet the unique 
needs of rural, minority, and female veterans.
5.  Improving Office of Rural Veterans
    The NRHA calls on Congress and the VA to fully implement the 
functions of the newly created Office of Rural Veterans to develop and 
support an on-going mechanism to study and articulate the needs of 
rural veterans and their families.
    Additionally, efforts to increase service points for rural veterans 
have, in large part, not been fully supported by the VA Administration 
itself. The VA has not consistently supported attempts to collaborate 
with rural health. It is my hope that with a new Administration and the 
newly formed VA Rural Health Advisory Committee, previous barriers will 
be eradicated and the Office of Rural Veterans will lead the way in 
expanding access options for rural veterans. Furthermore, the NRHA 
strongly encourages greater coordination between the Rural Health 
Coordinators housed in each VISN and state-level rural health officials 
in their region. Specifically, quarterly meetings with State Office of 
Rural Health and State Rural Health Association officials would be 
prudent.
6.  Explore ways to coordinate benefits for dual eligible veterans
    As the veteran population ages, a growing number of veterans are 
eligible for both VHA health benefits and Medicare. The combination of 
two partial benefits packages should ensure the best possible care for 
our veterans, but the copayments and Medicare Part D requirements may 
not be affordable for many veterans. Coordination of benefits would 
allow veterans to utilize the different resources offered to them 
effectively to receive high quality care close to home.
7.  Increase research on defining the rural veteran population
    Without good research about the rural veteran population, we cannot 
possibly expect to ensure their good health. Epidemiological studies 
are needed to identify the locations and populations of veterans in 
various rural areas of the country. These studies must provide 
information about race, gender, place of residence, health care needs, 
service-related health issues and service utilization. Only about 39 
percent of veterans are enrolled in VA health care benefits; quality 
research would provide information about how to best serve the veteran 
population who are currently not enrolled. The NRHA would encourage the 
VA to collaborate with the six Federal Office of Rural Health Policy/
HRSA-funded Rural Health Research Centers to explore this research.
Conclusion
    While many opportunities for improvement exist in providing care to 
veterans in rural communities, the VA is to be commended for the 
excellent service provided in many of its facilities. However, we must 
never forget that many veterans forgo care entirely because of access 
difficulties to VA facilities. Providing health care in rural 
communities requires unique solutions, whether it is to veterans and 
their families or the general population. Adopting some of the 
strategies referenced in this written testimony would aid in addressing 
these rural needs.
    Additionally, we must all be mindful of long-term needs and costs 
of our sailors and soldiers. The wounded veterans who return today 
won't need care for just the next few fiscal years, they will need care 
for the next half century.
    Thank you again for this opportunity. The NRHA looks forward to 
working with you and this Committee to improve rural health care access 
for the millions of veterans who live in rural America.

                                 

                Prepared Statement of Adam Darkins, M.D.
                  Chief Consultant, Care Coordination,
    Office of Patient Care Services, Veterans Health Administration,
                  U.S. Department of Veterans Affairs
    Good morning, Mr. Chairman. Thank you for the opportunity to 
testify before the Committee about addressing the health care needs of 
Veterans in rural areas. This initiative recognizes our continuing 
commitment to provide services to Veterans no matter where they live. 
My testimony today covers issues associated with funding and resource 
coordination with respect to how the Department of Veterans Affairs 
(VA) is implementing telehealth programs at the enterprise level to 
meet the needs of Veterans in rural areas.
    Health care delivery in rural areas challenges all health care 
systems, including VA, but we are not discouraged by this challenge, 
and we are confronting it directly. Telehealth, which involves the use 
of information and telecommunications technologies to deliver services 
in situations where the patient and the provider are geographically 
separated from one another, offers one solution to this challenge. 
Telehealth provides health care to underserved rural areas and involves 
35 clinical specialties in VA. In Fiscal Year (FY) 2008, VA's 
enterprise telehealth programs provided care to over 100,000 Veterans 
in rural and highly rural areas. These telehealth-based services 
involve real-time video conferencing, store-and-forwards telehealth and 
home telehealth.
    VA provided real-time video-conferencing, also known as Care 
Coordination/General Telehealth (CCGT), to 32,000 Veterans in rural 
areas and 2,000 in highly rural areas in FY 2008. Of these, 1,900 
Veterans from rural areas served in Operation Enduring Freedom or 
Operation Iraqi Freedom (OEF/OIF) and 112 OEF/OIF Veterans live in 
highly rural areas. The majority of CCGT services were for mental 
health conditions. The responsiveness and availability of mental health 
care services for our clients is a priority. In FY 2008, 19,000 
Veterans received tele-mental health services in rural areas and 1,500 
in highly rural areas. CCGT services were available to Veterans at 171 
sites in rural or highly rural areas.
    Store-and-forwards telehealth, known as Care Coordination/Store-
and-Forwards (CCSF), involves the acquisition and interpretation of 
clinical images for screening, assessment, diagnosis and management. 
These services were provided to 61,776 Veterans in rural areas and 
2,911 in highly rural areas during FY 2008. CCSF services were 
predominantly delivered to screen diabetic eye disease (tele-retinal 
imaging) and prevent avoidable blindness in Veterans, 50,908 of whom 
were in rural areas and 2,536 in highly rural areas. Of the 219 sites 
at which tele-retinal screening took place in FY 2008, 54 of these 
sites were in rural or highly rural clinics. The remainder of CCSF 
activity mainly covered tele-dermatology.
    To help Veterans continue living independently in their own homes 
and local communities, VA provides home telehealth services, known as 
Care Coordination/Home Telehealth (CCHT). CCHT services cover a range 
of chronic conditions including diabetes, chronic heart failure, 
hypertension and depression. In FY 2008, over 35,000 Veterans received 
home telehealth-based care. More than 16,000 Veterans received these 
services for non-institutional care. VA recognizes we treat an older 
population, one that will have increasing need of home-based primary 
care, and we are preparing now for future demand. Currently, 37,000 
Veterans receive CCGT for non-institutional care, chronic care 
management, acute care management and health promotion or disease 
prevention. Thirty-eight percent of these patients in VA are in rural 
areas and 2 percent are in highly rural areas. All together, between 30 
and 50 percent of telehealth activity in VA supports Veterans in rural 
and highly rural areas, depending upon the area of telehealth. Data 
from the first quarter of FY 2009 show ongoing growth in all areas of 
telehealth with commensurate growth in rural and highly rural areas.
    VA is undertaking a range of initiatives in FY 2009 that are 
targeted at sustaining this growth of telehealth services and expanding 
access in rural and highly rural areas. These initiatives focus on the 
clinical, technology and business processes that are underpinning the 
safe, effective and cost-effective implementation of telehealth in VA 
to support Veteran care. For example, Care Coordination Services (CCS) 
is collaborating with the Office of Rehabilitation Services to 
formalize the clinical processes necessary to use telehealth to support 
the 41,096 Veterans with amputations receiving care from VA. Telehealth 
enhances access to care in rural areas as close to Veterans' homes and 
local communities as possible, if the Veteran wishes to use the 
services. CCS is also working with our colleagues in the Spinal Cord 
Injury and Disorder Service to implement CCGT services to make 
specialist care more widely available, including in rural areas. We 
have recently completed the necessary work to implement VA's Managing 
Overweight and/or Obesity for Veterans Everywhere (MOVE!) program 
within CCHT programs. This development will expand the reach of this 
successful and groundbreaking program for weight management to Veterans 
in rural and highly rural areas. We anticipate making a program for 
supporting Veterans with substance abuse issues via home telehealth 
available during FY 2009.
    CSS is collaborating with the Office of Mental Health Services to 
establish a national Tele-mental Health Center. This center will 
coordinate tele-mental health services nationally with an emphasis on 
making specialist mental health services, such as those for post-
traumatic stress disorder and bipolar disorder, available in rural 
areas. CSS is also proposing an innovative approach for consideration 
by our colleagues in VA's Office of Rural Health to directly fund VISNs 
in support of enterprise-wide telehealth programs to expand their reach 
into rural areas and to increase the number of Veterans served. CSS is 
working with VA's Medical/Surgical Service to further extend tele-
retinal imaging. CSS is seeking funding from the Office of Rural Health 
to support five additional sites in rural areas. We are currently 
implementing a pilot program we hope to expand nationally for tele-
dermatology in five Veterans Integrated Service Networks (VISNs) in 35 
sites, 20 of which are in rural areas.
    VA is known for its significant work in creating and 
institutionalizing an award winning electronic medical record that has 
propelled VA into the 21st century. VA is very fortunate to have a 
workforce of clinicians who are so receptive to new technology and who 
readily embraced the use of VA's electronic health record (EHR). The 
EHR underpins all that we do in telehealth in VA. With telehealth, as 
with the implementation of the EHR, it is necessary to ensure 
clinicians and patients are educated and accepting of a new approach to 
health care. VA has three training centers for telehealth located in 
Boston, MA; Salt Lake City, UT; and Lake City, FL. These centers have 
trained over 6,000 staff to. ensure we have a workforce competent in 
telehealth and to develop and sustain these services. Always cognizant 
of the issues involved in training staff in rural areas, our training 
centers have partnered with VA's Employee Education System to use 
virtual training modalities wherever possible, including bi-monthly 
national satellite broadcasts that can be viewed remotely, an annual 
virtual national meeting, and web-based courses that cover our 
enterprise telehealth applications.
    Telehealth technologies are constantly developing as new 
functionalities become available. VA is working in this evolving 
environment to improve usability of the technologies for both patients 
and clinicians. VA has developed robust interoperable national IT 
platforms to support the commercial-off-the-shelf (COTS) telehealth 
devices that interface with patients. In FY 2009, VA is piloting an 
extension of its pre-existing Polytrauma Telehealth Network to create a 
clinical enterprise videoconferencing network (CEVN). The CEVN will 
facilitate the extension of polytrauma, post-amputation, spinal cord 
injury care and specialist mental health care to rural areas. These 
efforts, combined with My HealtheVet, which offers Veterans access to 
their personal health record any time, anywhere, leverage new 
technologies to benefit our clients.
    VA is also extending its enterprise telehealth programs to American 
Indian/Alaskan Native and Pacific Islander communities. VA currently 
operates seven such programs, with four more awaiting connectivity and 
11 in deployment for 15 Tribes in four VISNs. VA is one of several 
agencies working to improve care in these areas through telehealth. We 
have maintained a longstanding relationship with other Federal partners 
through the Joint Working Group on Telemedicine, which is an excellent 
forum for sharing practices and concepts for expanding care.
    In order to substantiate the safety and efficacy of care delivery 
through its enterprise telehealth networks, we have introduced quality 
management programs for CCHT, CCGT and CCSF. In FY 2009, these quality 
management programs are being combined for all three areas of 
telehealth to create a single assessment process in which the policies 
and procedures of telehealth programs are assessed biannually in each 
VISN. In addition, VA collects routine outcomes data for program 
management purposes. These systems allow us to quantify, validate and 
monitor the benefits of these approaches to clinical care. The data 
indicate VHA's enterprise telehealth programs are associated with 
substantial reductions in hospital admissions (more than 20 percent 
reductions compared to non-telehealth users) and high levels of patient 
satisfaction (mean scores above 85 percent).
    Many areas of telehealth are still emerging technologies that we 
are committed to mastering. Our focus will always remain on the needs 
of Veterans. VA's strategy has been to adopt a systematic enterprise 
approach with the aim of providing the right care in the right place at 
the right time to Veterans in rural, highly rural and urban settings. 
This approach of developing VA's telehealth network has resulted in 
sustained growth. By remaining client-centric, we provide dynamic, 
flexible, and responsive specialist care to underserved areas. Key to 
the development of telehealth in VA is the energy, expertise and 
dedication of staff from various backgrounds who resolve the ongoing 
clinical, technology and business issues that arise. Given the 
commitment of VA to serving the needs of Veterans and meeting the 
challenges of those requiring care in rural and highly rural areas, the 
development of telehealth is not solely a technical exercise; we are 
driven to deliver caring, compassionate and appropriate care in the 
least restrictive and most accessible manner possible.
    In drawing to a close, I would like to acknowledge the challenges 
of providing health care services in rural areas, particularly with 
respect to meeting specialist care. Telehealth is part of a spectrum of 
services that includes obligate needs for in-person provision of 
ambulatory care and clinical procedures. It is a privilege to work with 
colleagues throughout VA and engage in implementing telehealth to 
provide groundbreaking services to those who have served our Nation and 
to whom we are committed to serving, whether they live in rural, highly 
rural or urban locations where access to care presents a challenge for 
them. This remains VA's mission and it is one we gladly accept.
    Mr. Chairman, this concludes my prepared statement. I am pleased to 
address any questions the Committee may have.

                                 
                 Prepared Statement of Kara Hawthorne,
                   Director, Office of Rural Health,
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Good morning, Mr. Chairman. Thank you for the opportunity to 
discuss the Department of Veterans Affairs' (VA's) work to enhance the 
delivery of health care to Veterans in rural and highly rural areas. VA 
continues our commitment to provide service to Veterans in remote 
geographic areas, and we look forward to working with the Committee to 
better promote services and care.
    VA's Office of Rural Health (ORH) was authorized in December 2006 
by Sec.  212 of Public Law 109-461 and is empowered to coordinate 
policy efforts across VHA to promote improved health care for rural 
Veterans. Development of this office started in early April 2007, and a 
Director was named in October 2007. As the Secretary has said, rural 
health is a difficult national health care issue, but one that we will 
meet directly, with an eye toward becoming the leader in this field. 
Veterans and others who reside in rural areas face a number of 
challenges associated with obtaining health care. VA has embraced a 
national strategy of outreach to ensure Veterans, regardless of where 
they live, can access the expertise and experience of one of the best 
health care systems in the country. In partnership, Congress and VA can 
do even more. We appreciate Congress' support and interest in this 
area, and we are happy to report portions of the $250 million included 
in this year's appropriation have already been distributed to the field 
to support new and existing projects.
    ORH has allocated $24 million to sustain Fiscal Year 2008 programs 
and projects, including the Rural Health Resource Centers, Mobile 
Clinics, Outreach Clinics, VISN Rural Consultants, mental health and 
long-term care projects, and rural homebased primary care. ORH worked 
with representatives throughout VA and the Veterans Health 
Administration (VHA), including VISN Directors, Program Chiefs, the 
Office of General Counsel, the Office of Information Technology, VHA's 
Chief Business Office, and the VHA Chief Financial Office, to develop 
strategy, guidance and measures for allocating the remaining funds. ORH 
has adopted an inclusive approach that reaches across business lines 
throughout the organization.
    In December 2008, VA provided almost $22 million to VISNs across 
the country to improve services for rural Veterans. This funding is 
part of a 2-year program and will focus on projects including new 
technologies, recruitment and retention, and close cooperation with 
other organizations at the Federal, State and local levels. VA will use 
funds to sustain current programs, initiate pilot programs and 
establish new outpatient clinics. VA distributed resources according to 
the proportion of Veterans living in rural areas within each VISN; 
VISNs with less than three percent of their patients in rural areas 
received $250,000, those with between three and six percent received $1 
million, and those with six percent or more received $1.5 million.
    VISNs were directed to identify programs or projects that would 
develop innovative strategies, care delivery models, educational 
initiatives, technology uses and other approaches to enhance health 
care service delivery and outreach for rural Veterans. ORH provided 
examples, including programs or projects that: a) assess and anticipate 
the current and future health care needs of rural Veterans; b) address 
solutions that may be adapted for use by, or have value for, all VA 
facilities; c) emphasize collaborations with other VHA facilities, as 
well as public and private entities; or d) programs that would meet the 
legislative requirements of the Consolidated Security, Disaster 
Assistance, and Continuing Appropriations Act, 2009 (Public Law 110-
329) or the Veterans' Mental Health and Other Care Improvements Act of 
2008 (PL 110-387). ORH instructed VISNs to include funding validation 
and reporting with a breakdown by target (e.g., medical administration, 
medical services, medical facilities, information technology, etc.) to 
facilitate distribution and tracking. VISNs are required to report 
their accomplishments based upon this funding quarterly. This report 
must include a description of the program, the purpose and objectives, 
and supporting documentation (including the demographics of the service 
area, the execution plan and the evaluation plan). ORH supplied 
evaluative criteria to VISNs, including how objectives compare to 
legislative requirements, how significant the potential and likely 
impacts of the program are for rural Veterans, whether there is 
programmatic relevance and adherence to the award's intent, and whether 
the budget is appropriate for the proposal. These measures allow us to 
validate the benefits of our services to Veterans.
    In February 2009, ORH distributed guidance to VISNs and Program 
Offices concerning allocation of the remaining funds as early as May to 
enhance rural health care programs. Both program offices and VISNs were 
eligible to apply for this funding, which would support programs in six 
key areas of focus, including access, quality, technology, workforce, 
education and training, and collaboration strategies. Projects could 
include leveraging existing, proven initiatives, such as increasing 
access points in rural and highly rural areas (i.e., establishing 
outreach clinics in areas not meeting VA's drive time standards, or 
developing mobile clinics), structured initiatives to expand feebasis 
care, developing collaborations with Federal and non-Federal partners, 
accelerating telemedicine deployment or funding innovative pilot 
programs. ORH, along with the program review panel consisting of 
relevant program directors across VA, will be reviewing these proposals 
in early April 2009 by considering their capacity for meeting 
legislative requirements, their relevance for rural and highly rural 
populations, their ability to assess and anticipate current and future 
health care needs of rural Veterans, their potential for adaptation or 
use by all VA facilities, their collaborations with other VHA 
facilities, the evidence-base to support the program, their clear 
articulation of potential impacts, and their definition of Veterans' 
needs being addressed. Proposals that recommended new technologies or 
those that sought to extend current enterprise programs needed to 
justify how these alternative solutions will be interoperable and 
embody the essential clinical, technology and business processes to 
ensure compatibility with existing programs. Affected program offices 
will be involved in the review of these applications to ensure 
continuity and consistency within the program area.
    Proposals must include a clearly defined purpose and objectives, 
implementation strategies (including Veteran populations affected, 
service area demographics, and collaborators), specific program 
evaluation measures (including cost, quality, access, outcomes, policy 
effectiveness, and other criteria, such as measures established by VA's 
Office of Quality and Performance) and budget justifications. ORH will 
review proposals based on the following criteria: the program's 
objectives, feasibility, innovation, budget, personnel, service area 
environment, evaluation, and the recommendations of relevant program 
offices. All programs receiving funding will be required to submit 
either monthly or quarterly reports that assess the number of Veterans 
served, the funded amounts for all initiatives, program evaluation 
measures, and additional evaluation measures as defined by ORH. ORH 
will notify award recipients by May and begin disbursing funds at that 
time.
    At the start of this Fiscal Year, VA opened three Rural Health 
Resource Centers: one in White River Junction, Vermont; another in Iowa 
City, Iowa; and the last in Salt Lake City, Utah. These centers develop 
special practices and products for use by facilities and networks 
across the country. Each Resource Center is identifying disparities in 
health care for rural Veterans within their regions. These Centers 
essentially serve as field-based clinical laboratories capable of 
experimenting with new outreach and care models. They also serve a 
crucial function in enhancing academic affiliations with nursing and 
medical schools and support direct outreach to Veterans.
    As an example of the work the Centers are doing, the Eastern Rural 
Health Resource Center in White River Junction hosted a conference with 
nearly 100 participants on March 13-14 titled, ``New Horizons in Human 
Health: Bringing Leading-Edge Medicine to Rural Communities.'' This 
conference was a collaborative effort between the Togus VA Medical 
Center, Eastern Maine Health Care, the Maine Institute for Human 
Geriatrics and Health, and the University of New England. The Resource 
Centers are also working with ORH to develop an evaluation methodology 
for the Maine Mobile Health Care Clinic to answer questions about the 
effectiveness of mobile clinics and their impact on Veteran enrollment 
and use. The Central Region's Rural Health Resource Center is 
conducting a telephone-based survey designed to assess structural and 
functional capabilities of community-based outpatient clinics (CBOCs) 
in urban and rural settings. Finally, the Western Region has hired a 
Native Consultant to help the Center examine the current health care 
policies for rural American Indian/Alaskan Native and rural Native 
Hawaiian Veterans. The report produced for each population will discuss 
next steps for policy development and prioritize recommendations for 
further work.
    VA's ORH, during its short existence, has produced a number of 
programs that are actively improving the delivery and coordination of 
health care services to rural Veterans. VA is actively expanding the 
existing Home-Based Primary Care and Medical Foster Home programs (part 
of VA's Community Residential Care Program) into rural VA facilities 
with startup funding for Fiscal Year 2008 and partial funding for 
Fiscal Year 2009. Home-Based Primary Care provides comprehensive, 
interdisciplinary care to Veterans with chronic, complex diseases that 
worsen over time. This is a cost effective program for providing 
primary care services in the home, including palliative care, 
rehabilitation, disease management and coordination of care. Home-Based 
Primary Care can reduce Veteran travel time, which can avoid 
exacerbating chronic conditions.
    ORH has also helped develop the ``Geri'' scholars program, in 
collaboration with VHA's Office of Geriatrics and Extended Care, to 
target VA geriatric providers in rural areas and provide them with an 
intensive course in geriatric medicine and a tailored training program 
on providing geriatric medicine in rural VA clinics with curricula and 
supportive activities based on a needs assessment of each participant. 
Currently, there is a severe shortage of VA physicians with training or 
certification in geriatric medicine, and VA currently lacks training 
for primary care clinicians in key aspects of geriatrics and extended 
care to older Veterans living in rural areas. This new training program 
consists of intensive didactic training in core issues related to the 
health care needs of older patients, mentoring curricula to support a 
model quality improvement process at each participating rural CBOC, and 
web-based education for interdisciplinary health care teams at CBOCs. 
Graduates of this program will disseminate this work within their home 
facility.
    ORH is supporting expansion of the Mental Health Care Intensive 
Care Management-Rural Access Network for Growth Enhancement (MHICM-
Range) Initiative to provide community-based support for Veterans with 
severe mental illness. VA has been adding mental health staff to CBOCs, 
enhancing our capacity to provide telemental health services and using 
referrals to Community Mental Health Services and other providers to 
increase access to mental health care in rural areas. ORH collaborated 
with the South Central Mental Illness Research, Education and Clinical 
Center in VISN 16 to fund four research studies investigating clinical 
policies or programs that improve access, quality and outcomes of 
mental health and substance abuse treatment services for rural and 
underserved Veterans.
    VA has also taken the lead in opening new rural health care 
facilities, such as Rural Outreach Clinics. Last September, VA 
announced the opening of ten new Rural Outreach Clinics this Fiscal 
Year; four of these are currently operational, including sites in 
Houlton, ME; Perry, GA; Juneau, AK; and The Dalles, OR. VA utilizes 
Rural Outreach Clinics to offer services on a part-time basis, usually 
a few days a week, in rural and highly rural areas where there is 
insufficient demand for full-time services or it is otherwise not 
feasible to establish a full-time CBOC. Rural Outreach Clinics offer 
primary care, mental health services, and specialty referrals. Each 
Rural Outreach Clinic is part of a VA network and meets VA's quality 
standards. Veterans use Rural Outreach Clinics as an access point for 
referrals to larger VA facilities for specialized needs.
    VA recently announced a Mobile Health Care Pilot Project in VISNs 
1, 4, 19, and 20. The vans associated with this program will be 
concentrated in 24 predominately rural counties, where patients would 
otherwise travel long distances for care. VA is focusing on counties in 
Colorado, Maine, Nebraska, Washington, West Virginia and Wyoming. This 
pilot will collaborate with local communities in areas our mobile vans 
visit to promote continuity of care for Veterans. It will also allow us 
to expand our telemedicine satellite technology resources and is part 
of a larger group of mobile assets. ORH is developing evaluation 
methodologies and measures to determine the effectiveness of this 
program and to identify areas for improvement.
    Vet Centers also provide services and points of access to Veterans 
in rural communities. Vet Centers welcome home Veterans with honor by 
providing quality readjustment counseling in supportive, non-clinical 
environments. By the end of FY 2009, VA will have 271 Vet Centers and 
1,526 employees to address the needs of Veterans; any county in the 
country with more than 50,000 Veterans will have services available 
through a Vet Center. A fleet of 50 Mobile Vet Centers are also being 
put into service this year and will provide access to returning 
Veterans and outreach to demobilization military bases, National Guard 
and Reserve locations nationally.
    Recruiting providers in rural areas is a challenge for VA as well 
as the civilian community. ORH is working with VHA's Office of Academic 
Affiliations to develop a program expanding health profession training 
in rural VA facilities. The Rural Health Training Initiative selection 
process will be implemented this spring, with trainees scheduled to 
matriculate at rural health care access points beginning July 1, 2010.
    VA is expanding the use of Internet-based venues for health care 
related job postings in addition to recruiting from the VA job board 
(VA Careers), which links to USAJobs.gov, and other job boards. The VHA 
Healthcare Retention & Recruitment Office is hiring recruiters who will 
concentrate on recruitment of health care providers for rural areas and 
as well as establishing a national contracts with search firms that 
target physician recruitment. This Office is developing other 
collaborative relationships with organizations focused on rural 
recruitment such as the National Rural Recruitment & Retention Network 
(www.3Rnet.org), increasing training courses specifically for practices 
related to rural recruitment issues, and hiring recruiters whose 
primary aim will be recruitment of physicians.
    Similarly, VA has conducted outreach and developed relationships 
with the Department of Health and Human Services (including its Office 
of Rural Health Policy and the Indian Health Service), other agencies 
and academic institutions committed to serving rural areas. VA has also 
reached out through ORH to government and nongovernmental 
organizations, including the National Rural Health Association, the 
National Organization of State Offices of Rural Health, the National 
Institute of Mental Health Office of Rural Mental Health, the National 
Cooperative Health Networks, the Rural Health Information Technology 
Coalition, the Rural Assistance Center, the Rural Health Resource 
Center, the Georgia Health Policy Center, various rural health research 
centers, and other organizations to further assess and develop 
potential strategic partnerships. ORH is working in close collaboration 
with the Department of Health and Human Services to address the needs 
of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 
Veterans to coordinate services with the Department of Health and Human 
Services' Health Resources and Services Administration Community Health 
Centers. These initiatives include a training partnership, technical 
assistance to Community Health Centers, and a seamless referral process 
from Community Health Centers to VA medical centers.
    Importantly, VA is conducting ``in-reach'' within VA to identify 
needs and services relevant for rural Veterans. ORH works closely with 
the following offices and groups within the Veterans Health 
Administration (VHA): the Office of Mental Health Services, the Office 
of Care Coordination, the Office of Geriatrics and Extended Care, the 
Readjustment Counseling Service, the VHA Business Office, the VHA 
Finance Office, the Office of Academic Affiliations, the Healthcare 
Recruitment and Retention Office, the Office of Health Information, the 
National Center for Patient Safety, the Office of Public Health and 
Environmental Hazards, the Office of Quality and Performance, the 
Office of Research and Development, the Employee Education System, and 
the Office of Operations and Management. ORH also works closely with 
the Department's Office of Policy and Planning, Office of Information 
and Technology and Office of General Counsel.
    Last year, Congress passed Public Law 110-387, the Veterans' Mental 
Health and Other Care Improvements Act of 2008. Section 107 of Public 
Law 110-387 directs VA to conduct a pilot program in at least three 
VISNs to evaluate the feasibility and advisability of providing OEF/OIF 
Veterans with peer outreach and support services, readjustment 
counseling services, and other mental health services through 
arrangements with, among others, community mental health centers. VA's 
Office of Mental Health Services and ORH are in the process of 
implementing this pilot program. The pilot will be conducted in a 
number of stages evaluating:

       the identification of rural areas that are beyond the 
reach of VA's mental health services for Veterans but have other mental 
health providers capable of providing high quality services;
       the willingness and capability of these entities for 
providing outreach and treatment services for returning Veterans;
       the feasibility of developing performance based 
contracts with these entities that meet the requirement of Section 107; 
and
       the use of services and the outcomes of care provided 
through these contracts.

    Section 403 of the law requires VA to conduct a pilot program that 
would provide non-VA care for highly rural enrolled Veterans in five 
VISNs. VA is working to implement this pilot while resolving two 
questions. First, VA must develop a regulation to define the ``hardship 
provision'' in Section 403(b)(2)(B). Second, we must reconcile how VA 
has traditionally defined ``highly rural'' (based on Census data as 
discussed above) and how the statute defines it. VA's next steps 
involve identifying qualifying communities, identifying local providers 
willing and able to participate, and beginning with acquisition and 
exchanges of medical information as well as addressing pharmacy 
benefits and performance criteria for contracts and care. However, it 
is important to note VA already has the authority to contract with the 
most appropriate provider when VA is unable to provide necessary 
services. During FY 2008 VA expended $248 million for inpatient and 
outpatient services, including long term and home health care, 
purchased by contract in rural areas. An additional $1.04 billion was 
expended on a fee-for-service basis in rural areas for Veteran health 
care.
    Mr. Chairman, VA's Office of Rural Health is reaching across the 
Department to coordinate and support programs aimed at increasing 
access for Veterans in rural and highly rural communities. We work 
closely with the Office of Care Coordination and our colleague, Dr. 
Darkins, in this regard. Thank you once again for the opportunity to 
discuss VA's continuing efforts for rural Veterans. We are prepared to 
address any additional questions you might have.

                                 
                 Statement of Hon. Henry E. Brown, Jr.,
                       Ranking Republican Member,
                         Subcommittee on Health
    Thank you Mr. Chairman.
    I appreciate your holding this hearing to take a close look at how 
the Office of Rural Health is working and being funded.
    Congress took a significant step in 2006 when we created a new 
Office of Rural Health within VA to address the unique needs of 
veterans living in rural areas. And, I appreciate your holding this 
hearing to take a close look at how this new office is working and 
being funded.
    It is important that new and emerging technologies are being 
considered to help effectively bridge the distance gap. The expanded 
use of telehealth, while not a cure-all, can alleviate some of the 
distance-based challenges in the areas of primary care, mental health 
and even long-term or home-based care. I expect that our VA witnesses 
will provide us with details on what is currently being accomplished in 
this area and what we can anticipate in the future.
    Equally important to the use of new technologies, we must also 
expand partnerships with the local health care community to provide 
care closer to the veteran's home. Last year, the Rural Veterans Access 
to Care Act, legislation sponsored by my good friend and colleague, 
Jerry Moran, was enacted into law as a pilot program in Public Law 110-
387. Although this hearing is not focused on this important measure, 
Chairman Michaud has assured me that we will have a future hearing 
dedicated to the implementation of the law later in the year.
    In closing, I would like to extend a special welcome to one of our 
witnesses on the first panel, Dr. Graham Adams. He serves as the CEO 
and provides overall supervision and direction for the South Carolina 
Office of Rural Health. Dr. Adams has consistently worked 
collaboratively with clinicians, administrators, educations, 
legislators, community and civic leaders and state and Federal agencies 
to improve access to quality health care in rural communities.
    I am looking forward to listening to and learning from his 
experiences and that of all of our witnesses.
    And, with that, Mr. Chairman, I yield back.

                                 
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                     March 30, 2009

Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20240

Dear Secretary Shinseki:

    Thank you for the testimony of Dr. Adam Darkins, Chief Consultant 
to the Office of Care Coordination, Veterans Health Administration, and 
Ms. Kara Hawthorne, Director of the Office of Rural Health, Veterans 
Health Administration, at the U.S. House of Representatives Committee 
on Veterans' Affairs Subcommittee on Health Oversight Hearing on 
``Closing the Health Gap of Veterans in Rural Areas: Discussion of 
Funding and Resource Coordination'' that took place on March 19, 2009.
    Please provide answers to the following questions by May 11, 2009, 
to Jeff Burdette, Legislative Assistant to the Subcommittee on Health.

    1.  To date, the VA has awarded about $46 million of the $250 
million appropriated for the rural health initiative. Why did the VA 
choose to phase the grant award instead of fully allocating the $250 
million up front?
    2.  Of the $46 million awarded to date, $22 million was awarded to 
the VISNs based on the number of rural veterans living in the VISN. The 
VISN awards ranged from as little as $250,000 to $2.5 million. How did 
the VA determine the size of the grant award? Is $250,000 sufficient 
funding for the VISNs to accomplish what you outlined in your 
testimony?
    3.  The VA will require the VISNs to submit a quarterly report to 
track the funding use and to report on their accomplishments. When is 
the next quarterly report due? Will this information be provided in the 
required quarterly report to the Appropriations Committee on the uses 
of $250 million?
    4.  Of the $46 million awarded to date, $24 million went to sustain 
FY 2008 Office of Rural Health programs and projects. Please submit for 
the record the funding amounts associated with the programs that 
received this money.
    5.  To allocate the remaining funds from the appropriated $250 
million, the VA has set up a program review panel consisting of 
relevant program directors across the VA. Please identify the panel 
members.
    6.  Please also walk us through the timeline for awarding funding. 
Please explain how the VA will determine its success or shortcomings in 
meeting the original intent of the appropriated funding or establish 
and implement a rural health outreach and delivery initiative.
    7.  How will the VA ensure that local VISNs and program offices 
leverage this funding to help close the rural health gap?
    8.  How does the Office of Rural Health ensure that its efforts do 
not duplicate that of other offices in the VA, such as the Office of 
Care Coordination?
    9.  In your testimony, you highlighted the outreach and the ``in-
reach'' the Office of Rural Health has conducted. Please expand on this 
and explain the specific nature of the collaboration and coordination 
that has resulted from these relationships.

    In addition, please answer the following questions for 
Representative Ciro Rodriguez.

    1.  Your testimony reported that VISNs with less than 3 percent 
rural veterans received $250,000, VISNs with 3 to 6 percent received $1 
million, and VISNs with more than 6 percent received $1.5 million to 
sustain current programs, initiate pilot programs, and establish new 
outpatient clinics. Please provide any details available on how much 
VISN 17 and VISN 18 received and what specific programs in those VISNs 
are to receive portions of these allocated funds.
    2.  What were the recommendations for enhancing rural veteran 
access to health care resulting from the March 13-14 conference in 
White River Junction entitled ``New Horizons in Human Health: Bringing 
Leading Edge Medicine to Rural Communities''? Which recommendations are 
being considered for Department-wide implementation?
    3.  Are there any plans to open a Rural Outreach Clinic in Texas 
District 23 (VISNs 17 and 18), such as the ones mentioned in your 
written testimony?
    4.  Why was VISN 18 not selected for the Mobile Health Care Pilot 
Project mentioned in your testimony?
    5.  To what degree has the VA considered or used mobile surgery 
units and screening units, such as those provided by Mobile Medical 
International, for operational/surgical, ambulatory, or medical 
screening in remote rural areas? Are these types of units being 
considered for use in VISN 18?
    6.  Based on your statements about the section 403 Pilot Program, 
when do you expect these issues to be resolved and the pilot program 
actually implemented?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by May 11, 2008.

            Sincerely,

                                                 MICHAEL H. MICHAUD
                                                           Chairman

CW/jb
                                 ______
                                 
                   Prepared Questions for the Record
                         Hon. Michael Michaud,
                   Chairman, Subcommittee on Health,
                  House Committee on Veterans' Affairs
           Closing the Health Gap of Veterans in Rural Areas:
            Discussion of Funding and Resource Coordination
                             March 19, 2009
    Question 1: To date, VA has awarded about $46 million of the $250 
million appropriated for the rural health initiative. Why did VA choose 
to phase the grant award instead of fully allocating the $250 million 
up front?
    Response: The Department of Veterans Affairs (VA) chose to disburse 
funds from the $250 million included in this year's budget 
appropriation in phases to ensure the funds were allocated properly to 
achieve the greatest possible advances in reducing the health care gap 
for rural Veterans. VA recognized there were immediate needs in rural 
and highly rural areas across the country and provided initial seed 
money (approximately $22 million) with specific guidelines on 
allocation to Veterans Integrated Service Networks (VISN) to support 
their rural health programs in compliance with Public Law (P.L.) 110-
329, the Consolidated Security, Disaster Assistance, and Continuing 
Appropriations Act, 2009.
    On March 19, 2009, VA testified that $24 million of the $250 
million allocated to VA for a rural health initiative in P.L. 110-329 
was being used to support continuing programs from fiscal year (FY) 
2008 into FY 2009. VA has since decided to fund these programs out of 
the Office of Rural Health's (ORH) base budget. Consequently, of the 
$250 million included in this year's appropriations bill, VA has only 
allocated approximately $22 million. The remaining funds will be used 
to support programs proposed by program offices and VISNs; these 
proposals have been reviewed for merit and feasibility by a panel and 
have been approved by Veterans Health Administration (VHA) leadership. 
ORH has informed the recipients of these funds and disbursements are 
underway.
    As rural solutions are market driven, VA wanted to provide VISNs 
and program offices more planning time and the opportunity to compete 
for the remaining funds to support their initiatives that resolve local 
health issues and hold promise for regional or national adoption. These 
proposals would support programs in six key areas of focus including 
access, quality, technology, workforce, education and training, and 
collaboration strategies.
    Additionally, projects could include leveraging existing proven 
initiatives (such as increasing access points in rural and highly rural 
areas by establishing outreach clinics in areas not meeting VA's drive 
time guidelines or deploying mobile clinics); structuring initiatives 
to expand fee-basis care; developing collaborations with Federal and 
non-Federal partners, accelerating telemedicine deployment, or funding 
innovative pilot programs.
    Question 2: Of the $46 million awarded to date, $22 million was 
awarded to the VISNs based on the number of rural Veterans living in 
the VISN. The VISN awards ranged from as little as $250,000 to $2.5 
million. How did VA determine the size of the grant award? Is $250,000 
sufficient funding for the VISNs to accomplish what you outlined in 
your testimony?
    Response: ORH worked with the Deputy Under Secretary for Health for 
Operations and Management to ensure the unique interests of rural 
Veterans were considered. In December 2008, VA provided $21.75 million 
directly to VISNs to help them immediately implement programs to 
improve services for rural Veterans. This funding is part of a 2-year 
program focusing on initiatives such as new technologies, provider 
recruitment and retention incentives, and cooperation with other 
organizations at the Federal, State and local levels. Facilities are 
using these funds to sustain current programs, initiate pilot programs, 
and establish new outpatient clinics.
    VA distributed the initial resources according to the proportion of 
Veterans living in rural and highly rural areas within each VISN: VISNs 
with less than 3 percent of their patients in rural areas received 
$250,000; those with between three and 6 percent received $1 million; 
and those with 6 percent or more received $1.5 million. VISNs were 
directed to identify programs that could develop innovative strategies, 
care delivery models, educational initiatives, technology uses and 
other approaches to enhance health care service delivery and outreach 
for rural Veterans in compliance with P.L. 110-329.
    For the three VISN's that received $250,000, the initial seed money 
was adequate based on their unique rural health needs. If more funds 
are required, those VISNs can apply for additional funds under the 
February 2009 ORH Funds Distribution Program Guidance.
    Question 3: VA will require the VISNs to submit a quarterly report 
to track the funding use and to report on their accomplishments. When 
is the next quarterly report due? Will this information be provided in 
the required quarterly report to the Appropriations Committees on the 
uses of $250 million?
    Response: Senate Appropriations Report No. 110-428, which 
accompanied the Military Construction and Veterans Affairs and Related 
Agencies Appropriations Act, 2009, directed VA to report quarterly to 
the House and Senate Committees on Appropriations on new rural health 
initiatives implemented as a result of the funding. The current report 
is nearing final clearance through VA leadership and VA expects to 
furnish it by May 30, 2009. This report will contain additional 
information on the VISN funding allocations.
    Question 4: Of the $46 million awarded to date, $24 million went to 
sustain FY 2008 Office of Rural Health programs and projects. Please 
submit for the record the funding amounts associated with the programs 
that received this money.
    Response: ORH, in conjunction with VHA program offices, supported a 
range of initiatives in FY 2008, and VA has allocated funds to sustain 
those programs in FY 2009 out of ORH's base budget. VA originally 
testified that a portion of the $250 million included in P.L. 110-329 
would be used to fund these efforts. The chart below provides specific 
amounts for each initiative.


------------------------------------------------------------------------
              ORH Funded Initiatives                  FY 2009 Funding
------------------------------------------------------------------------
Veterans Rural Health Resource Centers                       $6,600,000
------------------------------------------------------------------------
VISN Rural Consultants                                       $1,200,000
------------------------------------------------------------------------
Veterans Rural Health Advisory Committee                       $300,000
------------------------------------------------------------------------
Rural Outreach Clinics                                       $3,600,000
------------------------------------------------------------------------
Rural Mobile Health Care Clinics                             $2,100,000
------------------------------------------------------------------------
Home Based Primary Care Rural Expansion                      $1,500,000
------------------------------------------------------------------------
Medical Foster Home Expansion                                  $600,000
------------------------------------------------------------------------
Geri Scholars Program                                          $500,000
------------------------------------------------------------------------
Idea Award Funding                                           $2,000,000
------------------------------------------------------------------------
Contract Support                                             $5,000,000
------------------------------------------------------------------------
Veterans Sessions Educational Sessions                         $600,000
------------------------------------------------------------------------
TOTAL FUNDING                                               $24,000,000
------------------------------------------------------------------------

    Question 5: To allocate the remaining funds from the appropriated 
$250 million, VA has set up a program review panel consisting of 
relevant program directors across VA. Please identify the panel 
members. Please also walk us through the timeline for awarding funding.
    Response: ORH requested that both VISNs and program offices submit 
proposals to fund additional initiatives to support rural and highly 
rural Veterans within their areas of operations. The deadline for 
proposals was March 20, 2009. A panel with representatives from program 
offices across VA is reviewing proposals for compliance with P.L. 110-
329 and prioritizing them based on merit and feasibility. ORH presented 
its final selection to VHA leadership on April 14, 2009, and submitted 
selected proposals to the appropriate program offices for review and 
concurrence to ensure the project(s) were consistent with the program 
office mission and plans. Based on the overwhelming response from the 
VISNs and program offices, ORH projects the remaining funds will be 
fully allocated during the third quarter of FY 2009.
    The ORH P.L. 110-329 Review Panel membership includes rural health 
resource center directors, VISN rural consultants, key program office 
representatives, senior VA staff professionals (including chief 
officers, deputy chief officers, network directors, and deputy 
directors), and other subject matter experts.
    Question 6: Please explain how VA will determine its success or 
shortcomings in meeting the original intent of the appropriated funding 
or establish and implement a rural health outreach and delivery 
initiative.
    Response: A key requirement of the ORH funding guidance is that 
project objectives must be consistent with ORH's mission and that they 
adhere to the legislative requirements of P.L. 110-329. In addition to 
the stated primary requirements, ORH will evaluate project development 
and execution through review of the periodic project reports.
    All programs receiving funding will be required to submit quarterly 
reports that assess the number of Veterans served, key program 
indicators, and additional evaluation measures as defined by ORH. 
Specifically, all funded projects are required to adhere to the 
reporting requirements detailed below:

    a.  Quarterly reports that present a summary of issues and 
accomplishments, the numbers of Veterans served, funded amounts for all 
initiatives, and program evaluation measures (specific to each project) 
as proposed in each project proposal using a standard format;
    b.  A final report that summarizes the entire period of 
performance, due at the end of the performance period;
    c.  Stated deliverable(s) from proposal; and
    d.  Additional reports, which may be required as stipulated during 
award negotiations.

    Question 7: How will VA ensure that local VISNs and program offices 
leverage this funding to help close the health care gap?
    Response: ORH is working with VISNs and program offices to identify 
projects and programs that will develop innovative strategies and care 
delivery models to enhance health care delivery and outreach to rural 
Veterans. VISN and program office initiatives are expected to support 
projects in six key areas of focus: access, quality, technology, 
workforce, education and training, and collaboration strategies. To 
support their efforts ORH has supplied evaluative criteria to VISNs, 
including how objectives compare to legislative requirements, how 
significant the potential and likely impacts of the program are for 
rural Veterans, whether there is programmatic relevance and adherence 
to the award's intent, and whether the budget is appropriate for the 
proposal. Additionally, each project is required to submit a list of 
measures that they will be monitoring to determine program 
effectiveness.
    Question 8: How does the Office of Rural Health ensure that its 
efforts do not duplicate that of other offices in VA, such as the 
Office of Care Coordination?
    Response: ORH is conducting ongoing ``in-reach'' within VA to 
identify needs and services relevant for rural Veterans. Soon after ORH 
was created, VA conducted an assessment to determine the most 
challenged areas in terms of drive time access. ORH also spent time 
developing and building a robust infrastructure to continue to learn 
about rural Veterans and how best to serve this population through the 
development and execution of pilot projects, promotion of rural health 
issues through education, training and information dissemination, 
engagement in VISN level strategic planning, and relationship building 
with community partners.
    ORH also immediately began collaborating with, and learning from, 
the already established VHA program offices and VA staff. ORH sought to 
learn what services were already provided and to use the input and 
guidance to assist ORH in identifying necessary actions and how best to 
deploy ORH funds. ORH recognized there were successful programs already 
in place and did not want to use resources to duplicate services.
    ORH continues working with offices and groups across VA to ensure 
efforts are unique and consistent with program offices' goals and 
missions.
    Question 9: In your testimony, you highlighted the outreach and the 
``in-reach'' the Office of Rural Health has conducted. Please expand on 
this and explain the specific nature of the collaboration and 
coordination that has resulted from these relationships.
    Response: ORH has collaborated with other offices within VA to 
identify current or emerging solutions for rural Veterans. For example, 
by working with the Deputy Under Secretary for Health for Operations 
and Management, ORH was able to fund 10 additional rural outreach 
clinics, while cooperation with the Readjustment Counseling Service 
helped deploy 4 mobile health clinics in rural areas. ORH's work with 
the Office of Patient Care Services resulted in plans to expand 
telehealth, geriatrics and extended care initiatives, and mental health 
initiatives. Specifically, VA is actively expanding the existing home-
based primary care and medical foster home programs into rural VA 
facilities with start-up funding for FY 2008 and partial funding for FY 
2009. ORH has also helped develop the Geri Scholars program, in 
collaboration with the VHA Office of Geriatrics and Extended Care, to 
target VA geriatric providers in rural areas. ORH is also supporting 
expansion of the Mental Health Care Intensive Care Management-Rural 
Access Network for Growth Enhancement initiative to provide community-
based support for Veterans with severe mental illness. VA has added 
mental health providers to community based outpatient clinics (CBOC), 
enhancing capacity to provide tele-mental health services and using 
referrals to community mental health services and other providers to 
increase access to mental health care in rural areas.
    Recognizing rural communities have limited capital for health 
information technology investment, the likelihood for rapid changes in 
technology, and the absence of national technical standards pose 
additional challenges; ORH has worked closely with the VHA Chief 
Information Office to expand My HealtheVet, which offers Veterans 
access to their personal health record any time, any where. ORH is also 
investing in health information exchanges and regional health 
information organizations that have been created in many localities to 
test the electronic exchange of protected health information, and VA is 
establishing connections with these successful networks.
    Most importantly, ORH has used the expertise and guidance of 
representatives throughout VA--including VISN directors, chief officers 
of different programs, the Office of General Counsel, the Office of 
Information Technology, VHA's Chief Business Office, and VHA's Chief 
Financial Office--to develop strategies, guidance, and measures for 
allocating ORH's appropriated funds. This inclusive approach reaches 
across business lines throughout the organization.
                          Hon. Ciro Rodriguez
    Question 1: Your testimony reported that VISNs with less than three 
percent rural Veterans received $250,000, VISNs with three to six 
percent received $1 million, and VISNs with more than six percent 
received $1.5 million to sustain current programs, initiate pilot 
programs, and establish new outpatient clinics. Please provide any 
details available on how much VISN 17 and VISN 18 received and what 
specific programs in those VISNs are to receive portions of these 
allocated funds.
    Response: VISN 17 received $1 million in initial funding. Of this, 
$333,334 has been obligated to three initiatives. The first is the 
expansion of home health services. This initiative will expand services 
using existing contracts with home health agencies and includes the 
Southern Oklahoma counties of Bryan and Choctaw and the Northern Texas 
counties of Cooke, Delta, Fannin, Grayson, Hopkins, Hunt, Lamar and Red 
River. The second initiative expands telemedicine access for mental 
health compensation and pension (C&P) exams for rural Veterans in the 
Central Texas Veteran Health Care System. This project will install 
additional telemedicine equipment for C&P exams at the CBOC in 
Brownwood and Palestine, TX. The third initiative expands contract 
nursing home care to rural Veterans who do not have access to VA 
nursing homes and will cover a service area of 15 rural counties 
through contracts with 20 non-VA nursing homes. VISN 18 received $1 
million in funding to be used to support fee-basis programs that 
provide care to rural and highly rural Veterans who are eligible for 
fee-basis care. These programs will strive to decrease the drive time 
for rural and highly rural Veterans.
    Question 2: What were the recommendations for enhancing rural 
Veteran access to health care resulting from the March 13-14 conference 
in White River Junction entitled, ``New Horizons in Human Health: 
Bringing Leading Edge Medicine to Rural Communities''? Which 
recommendations are being considered for Department-wide 
implementation?
    Response: The following recommendations were discussed at the New 
Horizons in Human Health: Bringing Leading Edge Medicine to Rural 
Communities meeting and are being considered for broader 
implementation:

       Considering the use of existing medical resources in 
remote locations rather than attempting to build new VA facilities in 
these areas;
       Expanding telehealth presence in rural areas to overcome 
transportation barriers;
       Integrating VA rural health efforts with other Federal 
rural initiatives (such as partnering with federally qualified health 
centers and rural health centers);
       Reducing VA administrative barriers to private sector 
partnership (for example, contracting regulations); and
       Making VA more of a two-way player when it comes to 
sharing medical information across systems.

    Question 3: Are there any plans to open a Rural Outreach Clinic in 
Texas District 23 (VISNs 17 and 18), such as the ones you mentioned in 
your written testimony?
    Response: VHA has not developed plans to open a Rural Outreach 
Clinic in Texas District 23. However, VISN 17 awarded a contract to 
LifeLine Mobile for a mobile clinic, based out of Laredo and McAllen, 
TX which will visit designated cities every other week. The mobile 
clinic will provide primary care, mental health care, immunizations and 
education services to Veterans living in Texas in Rio Grande City 
(Starr County), Roma (Starr County), Zapata (Zapata County), Falfurrias 
(Brooks County), Hebbronville (Jim Hogg County), and Port Isabel 
(Cameron County). Veterans living in the southern end of District 23 
including the counties of Kinney, Maverick, Uvalde, Medina, Zavala, 
Dimmit and Bexar are proximate to the contract awarded for the LifeLine 
Mobile Clinic, and may have opportunities to use these services. South 
Texas Veterans Health Care System (VAHCS) has done a market analysis of 
the 11 counties they support and the West Texas VAHCS (VISN 18) 
continues to review care services support opportunities within its area 
of Congressional District 23.
    Question 4: Why was VISN 18 not selected for the Mobile Health Care 
Pilot Project mentioned in your testimony?
    Response: In FY 2008, a mobile fleet strategic plan workgroup was 
established to assess VHA assets and to develop ORH pilot project 
initiatives. ORH worked in collaboration with the workgroup to draft a 
request for proposals to initiate a rural mobile health care clinic 
pilot project to enhance the delivery of care for Veterans in rural 
areas. ORH received applications from VISNs 1, 4, 10, 17, 18, 19, 20, 
and 21 requesting funds for both purchases and operations. The process 
was competitive and an interdisciplinary team scored and ranked 
applications. The application process focused on three critical issues: 
the geographic area to be served, the projected impact, and operational 
plans. The application rating criteria covered five areas:

       Improving access to services in rural area;
       Soundness of operational plan;
       Collaborations with community and other partners;
       Use of telemedicine;
       Innovation and program uniqueness; and
        Veteran population.

    The four-member review panel recommended VISNs 19, 1, and 4, in 
rank order, to receive funding for purchase and operations. Based on 
this competitive process, VISN 18 did not rank high enough relative to 
the other VISN applicants to be considered for funding.
    Question 5: To what degree has VA considered or used mobile surgery 
units and screening units, such as those provided by Mobile Medical 
International, for operational/surgical ambulatory, or medical 
screening in remote areas? Are these types of units being considered 
for use in VISN 18?
    Response: Rural health mobile clinics funded by ORH provide primary 
and mental health care, screening and limited specialty care. They are 
not designed to provide higher intensity care such as surgical 
procedures. Currently, VISN 18 is not pursuing such units.
    Question 6: Based on your statements about the section 403 Pilot 
Program, when do you expect these issues to be resolved and the pilot 
program actually implemented?
    Response: Section 403 of Public Law 110-387 requires VA to conduct 
a pilot program that would provide non-VA care for highly rural 
enrolled Veterans in five VISNs. VA is working to implement this pilot 
while resolving two issues: 1) VA must develop a regulation to define 
the ``hardship provision'' in Section 403(b)(2)(B); and 2) VA must 
reconcile how it has traditionally defined ``highly rural'' and how the 
statute defines it. VA's next steps involve identifying qualifying 
communities, identifying local providers willing and able to 
participate, and beginning with acquisition and exchanges of medical 
information, as well as addressing pharmacy benefits and performance 
criteria for contracts and care.
    On March 17, 2009, VA met with staff from both the House and Senate 
Committees on Veterans' Affairs to provide an update on the pilot 
program. VA and the Committees staffs discussed the hardship provision 
from (b)(2)(B) and the statute's definition of ``highly rural''. VA 
proposed potential approaches to resolve these concerns and we are 
awaiting guidance from both Committees. In the interim, VA continues to 
work on this pilot program in accordance with the statute.

                                  
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