[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
SERVING VIRGINIA'S RURAL VETERANS
=======================================================================
FIELD HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
July 19, 2010
FIELD HEARING HELD IN BEDFORD, VA
__________
Serial No. 111-92
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
58-059 WASHINGTON : 2011
___________________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Printing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer
Contact Center, U.S. Government Printing Office. Phone 202-512-1800, or
866-512-1800 (toll-free). E-mail, [email protected].
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
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
July 19, 2010
Page
Serving Virginia's Rural Veterans................................ 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 53
Hon. Thomas S.P. Perriello....................................... 2
WITNESSES
U.S. Department of Veterans Affairs:
Patricia Vandenberg, MHA, BS, Assistant Deputy Under Secretary
for Health for Policy and Planning, Veterans Health
Administration............................................... 38
Prepared statement of Ms. Vandenberg....................... 76
Daniel F. Hoffman, FACHE, Network Director, Veterans Affairs
Mid-Atlantic Health Care Network, Veterans Integrated
Services Network 6, Veterans Health Administration........... 40
Carol Bogedain, MS, RD, CPHQ, FACHE, Interim Medical Center
Director, Salem Veterans Affairs Medical Center, Veterans
Health Administration........................................ 41
______
American Legion, Michael F. Mitirone, Commander, Department of
Virginia....................................................... 20
Prepared statement of Mr. Mitrione........................... 63
DaVita, Inc., Kevin Trexler, Division Vice President............. 9
Prepared statement of Mr. Trexler............................ 61
Disabled American Veterans, Clarence Woods, Commander, Department
of Virginia.................................................... 24
Prepared statement of Mr. Woods.............................. 67
Southwest Virginia Community Health Systems, Inc., Howard
Chapman, Executive Director, and Member, Virginia Community
Healthcare Association......................................... 8
Prepared statement of Mr. Chapman............................ 55
Thackston, Major General Carroll, USA (Ret.), Mayor, South
Boston, VA, and Former Adjutant General, Virginia Army National
Guard.......................................................... 5
Prepared statement of General Thackston...................... 53
Tucker, Lynn, Museville, VA...................................... 26
Prepared statement of Ms. Tucker............................. 74
Veterans of Foreign Wars of the United States, Daniel Boyer, Post
Commander, Grayson Post 7726, VFW Past State Commander......... 22
Prepared statement of Mr. Boyer.............................. 65
SUBMISSION FOR THE RECORD
Halifax Regional Health System, South Boston, VA, Chris A.
Lumsden, Chief Executive Officer, statement.................... 79
SERVING VIRGINIA'S RURAL VETERANS
----------
MONDAY, FEBRUARY 14, 2010
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 9:00 a.m., at
the Bedford County Board of Supervisors Meeting Room, County
Administration Building, 122 East Main Street, Bedford,
Virginia, the Hon. Michael H. Michaud [Chairman of the
Subcommittee] presiding.
Present: Representatives Michaud and Perriello.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I'll call the Subcommittee on Health of the
Committee on Veterans' Affairs to order, and I'd ask the first
panel to come up.
First of all, I'd like to thank everyone for attending this
hearing, especially the veterans who are here with us today. I
would also like to express my sincere gratitude to the Bedford
County Board of Supervisors for their hospitality in hosting
this hearing.
Today's hearing would not have been possible without Mr.
Perriello's tireless advocacy for veterans living in Virginia.
He is a welcomed Member of the Subcommittee on Health of the
Committee on Veterans' Affairs. He also brings a new energy and
enthusiasm for tackling the unique challenges facing veterans.
I really got to know Mr. Perriello when we took a trip to
Afghanistan together to learn more about the health care
provided to the men and women who are wearing the uniform so
proudly. And as Chairman of the Subcommittee and a
representative of rural communities in the State of Maine, Mr.
Perriello and I share an interest in making sure our rural
veterans receive the care they deserve.
Our veterans, whether they live in rural Maine or rural
Virginia, face common challenges. Most notably, access to care
is an issue for veterans living many miles or hours away from
the closest U.S. Department of Veterans Affairs (VA) medical
facility. Given these challenges, it is important that our
rural veterans have access to health care.
When you look at access to health care, there are many
tools out there that can help, such as telemedicine, telehealth
and VA's new pilot program that provides enhanced contract
care.
This year we held several important hearings focused on
rural health. For example, this past April we held a hearing on
VA's implementation of the Enhanced Contract Care Pilot
Program. To our surprise, we learned the VA planned to create
pilot programs within the Veterans Integrated Service Networks
(VISNs), that were selected under the original legislation,
VISNs 1, 6, 15, 18 and 19.
At this hearing in April, we made it clear that Congress's
intent was to have VA implement this pilot program VISN-wide
within those VISNs. And when you look at the scoring that was
provided by VA to the Congressional Budget Office (CBO) on how
many veterans would be affected by that program, these scores
indicated that it would be VISN-wide.
Unfortunately, we just were informed a few days ago that VA
does not plan on honoring Congress's intent and will only be
implementing a pilot program in selected locations within the
VISNs. I'm deeply concerned about this recent development and
look forward to hearing from the VA today on this very
important issue.
Next, in June of this year we held a hearing on innovation
of wireless health technology solutions as a way to help
overcome rural health care challenges. At this hearing, we
heard from the Director of Rural Network Development in the
University of Virginia Health System, who provided testimony on
the unique needs of veterans of the Appalachia and the
importance of innovation in telemedicine and wireless mobile
health applications.
Again, I want to thank Mr. Perriello for inviting us here
today, and I appreciate this opportunity to hear directly from
the veterans of Central and Southern Virginia about their local
health care needs. I look forward to the testimony of the
different panels we have here today.
Once again, I want to thank Mr. Perriello for all that you
have done and are doing for our veterans across this Nation and
in your State of Virginia. I would now turn it over to you for
your opening statement and also to introduce the first panel.
[The prepared statement of Chairman Michaud appears on
p. 53.]
OPENING STATEMENT OF HON. THOMAS S.P. PERRIELLO
Mr. Perriello. Thank you very much, Mr. Chairman. I really
appreciate the sacrifices you've made to come down here and be
part of this, and also to the Committee counsel, both the
Democratic and Republican Committee counsel present. The four
of us did travel together to Afghanistan, not only to look at
the security situation, but to look at the seamless transition
or how to create a more seamless transition from the forward
operating bases through our holding hospitals and back into the
VA system. Far too many are lost within those seams, as we all
know.
We've made dramatic advances in battlefront medicine since
the Vietnam and prior ages, which means we're able to keep a
lot of soldiers and airmen alive that would not have survived
before. That also means we're seeing a complexity of physical
and emotional issues back on the home front once they have
returned.
And one of the things that I want to thank in particular--
and the community here across Central and Southern Virginia has
been great on this--is that in previous eras sometimes within
the veteran service organization community, we have seen
generational battles, one set of veterans against another. We
have seen an unbelievable unity of veterans of--to make sure
that we are doing everything we can with our returning Office
of Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
vets, and I think it's a testimony to the veterans service
organization (VSO) community and the unity across generations
that we have been able to respond in such a dramatic way, still
much more to be done, to make sure that those folks, as they're
coming back, are getting the best care that they can. And
again, I think everyone here up in diocese has been interested
in understanding that.
As Mr. Michaud noted, he and I both represent quite rural
districts with high degrees of patriotism and service through
our armed forces. And one of the things that he and I both
advocate heavily is trying to get more of the health care to
the veteran instead of just the veteran to the health care,
ways that through telemedicine, through primary care within our
communities, which we'll hear a lot about today, through
community-based outpatient clinics (CBOCs), and other ways we
can try to get services to veterans instead of putting the
burden on them.
This hearing in many ways is another example of that. We
want to get out in the field to make sure that we're making it
as easy as possible to bring the Committee's processes to the
veterans instead of veterans always having to come up to
Washington to do so, though many of you have given up your time
on that front. So we wanted this hearing--I wanted this hearing
here in Bedford because, of course, no community has given more
in terms of sacrifice. The great tradition of the Bedford Boys
and the wonderful D-Day memorial that's here, even with the
controversy that's unfortunately going on, remains just an
unbelievable statement of the--of the events of Normandy and D-
Day that should never be forgotten and continue to inspire.
I remember one of the first programs that I attended up
there--I believe it was a July 4th ceremony--hearing the story
of a mother who had just lost her son in Iraq, who that son had
grown up visiting Bedford and then eventually D-Day Memorial,
and that had inspired him to enlist and continue that tradition
that we have seen. So there's so much to be proud of here in
Bedford. But we also see the challenges of course in the
system.
Now, this Subcommittee is on Health. I just want to make
one brief comment about the Economic Opportunity Subcommittee
of the Veterans' Affairs Committee that I also serve on, which
is simply that the unemployment levels for our returning
veterans right now is astronomical. Some put it at or above 20
percent unemployment.
So of course as people are coming back, not only might they
be facing, say, a foreclosure on their home, their job is not
there, challenges in their marriage, because we know what a
strain that these extended deployments can put on our military
families, perhaps physical and mental challenges as well in the
health sector, to also be in an environment where we see not
only general unemployment, but we see employers actually
resisting hiring veterans. We hear the tragic stories of a
veteran saying they won't even put their service on their
resume because employers are concerned whether it's perceptions
of post-traumatic stress disorder (PTSD) or perceptions of how
quickly people are getting called back up, or seeing various
hurdles to veterans getting employment when they should be the
first in line.
So we are working on a number of proposals on that
Subcommittee as well, which won't be the immediate focus of
this panel, that includes not only the most rapid
implementation of Senator--of the GI Bill, modern GI Bill that
our own Senator and many others on this Committee fought for,
to modernize access to 4-year colleges, but we're also hearing
from a lot of veterans that, you know, a 4-year college isn't
for me right now, I need to get 12 months of vocational and
skills training so I can get a decent wage and support my
family, and trying to expand and streamline some of the
vocational skills, training programs, some of the hiring
programs, to make it more appealing for businesses to hire
veterans and other issues. So those are things we continue to
fight on there.
Here in this Committee again, we are particularly focused
today on issues of rural health, and I have been very blessed
by the expertise of the people sitting in front of me and many
others to talk on a daily basis about the issues that we face
in terms of access to care, access to specialty care, costs
involved and other things.
And with that I want us to move to the first panel, and
first introduce Major General Carroll Thackston who, in
addition to being a former Adjutant General of the Virginia
Army National Guard, is also the Mayor of South Boston,
Virginia. He has been a tremendous servant both in uniform and
also in the community. And along with him we have Dr. Roger
Browne and Colonel Ted Daniel, both retired military. Dr.
Browne is a general practice doctor in the South Boston area.
Ted Daniel is the Town Manager. We've also worked together.
These three gentlemen are tremendous public servants in
every sense of the word, and we have worked together
extensively on what I think is one of the most appealing,
competitive proposals for offering primary care through local
facilities. It's a project that has been painstakingly put
together, has tremendous support both from the local medical
community, the hospital community, the elected officials and
the veterans community, African American, white, young and old
in the area, and I think it exemplifies so much what this
Committee set out to do with this pilot project, and I'm
looking forward to them speaking.
We also have joining us Howard Chapman, the Executive
Director of Southwest Virginia Community Health System and the
Virginia Community Health Care Association, to talk some about
their experiences, as well as Kevin Trexler, who's the Division
Vice President for DaVita, who is going to talk some about
dialysis and a number of other issues and ways that some of our
private contractors are interacting with the VA system.
So, with that, I will have more to say in response, but I
really appreciate all of our panelists being here to
participate, all the work that went into your opening
statements and look forward to what you have to say this
morning. I yield back to the Chairman.
Mr. Michaud. We'll start with General Thackston.
STATEMENTS OF MAJOR GENERAL CARROLL THACKSTON, USA (RET.),
MAYOR, SOUTH BOSTON, VA, AND FORMER ADJUTANT GENERAL, VIRGINIA
ARMY NATIONAL GUARD; ACCOMPANIED BY ROGER BROWNE, M.D., USA
(RET.), SOUTH BOSTON, VA (INTERNAL MEDICINE PHYSICIAN); COLONEL
TED DANIEL, USA (RET.), TOWN MANAGER, SOUTH BOSTON, VA; HOWARD
CHAPMAN, EXECUTIVE DIRECTOR, SOUTHWEST VIRGINIA COMMUNITY
HEALTH SYSTEMS, INC., AND MEMBER, VIRGINIA COMMUNITY HEALTHCARE
ASSOCIATION; AND KEVIN TREXLER, DIVISION VICE PRESIDENT,
DAVITA, INC.
STATEMENT OF MAJOR GENERAL CARROLL
THACKSTON, USA (RET.)
General Thackston. Thank you, Congressman Perriello, Mr.
Chairman. Good morning, ladies and gentlemen. I'm Carroll
Thackston and the Mayor of South Boston, as Mr. Perriello so
said. I have served over 10 years, both as Vice Mayor and Mayor
of our town, which numbers about 8,500 in population.
I'm also a retired Major General of the United States Army,
having spent over 40 years, the last 4\1/2\ years as the
Adjutant General of the Virginia National Guard. I served on
active duty for about 6 years, spent 35 years in the National
Guard. And so with this background I have a good understanding
of the National Guard operations, their goals and objectives
and the problems, current and future, facing the National
Guard. So my main focus this morning will be about the National
Guard and its varying components and its probable impact on the
Department of Veterans Affairs.
As I'm sure you are all aware, the Total Force Policy has
been in effect since post-Vietnam and treats the three
components of the Army and Air Force, that is, the regular
forces, the National Guard and the Reserves, as a single force.
Unlike the impact of Vietnam veterans on the VA system, this
total integration and increased reliance on combat and combat
support units of the National Guard throughout the 1990s, and
the war on terror creates a whole new dynamic for Veterans
Affairs.
So before I discuss some of my concerns about the Guard and
increasing impact on the VA, I would like to tell you about our
local effort to help veterans of Halifax County and the
immediate nearby counties. For the past 3 years several of us
have worked with a small group of local Halifax veterans,
primarily Vietnam veterans. We have worked to establish a
primary care facility in South Boston to serve local area
veterans. We have met many times, and we have travelled many
miles in pursuit of our goal.
At this point, we are aggressively seeking designation as a
rural locality under the VA's Enhanced Contract Care Pilot
Program. If successful, Halifax Regional Hospital's new primary
care facility located in South Boston will serve as a pilot
project for contract care within VISN 6. Our group has also met
numerous times with Congressman Perriello, his staff and VA
representatives. We have travelled to Washington and were able
to meet with Secretary Shinseki. And most recently participated
in a lengthy teleconference that included Deputy Assistant
Under Secretary Vandenberg and numerous VA staffers.
In January of this year, Dr. Roger Browne, a member of our
group, testified during Roundtable discussions of the Committee
on Veterans' Affairs on ``Meeting the Unique Health Care Needs
of Rural Veterans.'' Dr. Browne is credentialed as a specialist
in internal medicine. He's treated Halifax County veterans for
over 30 years, and has personal experience as a brigade surgeon
for the 198th Light Infantry Brigade in Vietnam in 1968 and has
provided our group with the leadership and the credibility to
clearly identify the quality of primary health care our
veterans need and deserve.
At the finish line we hope to have a new and modern primary
care center in South Boston operating as a VA primary care
contractor, providing all Halifax County veterans, both old and
young, regular forces, Guard and Reserve, with the quality
primary care, medical care that they have earned and are
entitled to, both legally and morally.
There were 1,127 veterans in Halifax County enrolled in the
VA system at the end of fiscal year 2009. There are 2,954
civilian veterans in Halifax County according to the most
recent census data. We want all of them participating in the VA
health system, and we want a local facility that is convenient
for them and their families. We want to ensure that our growing
population of veterans that are returning from current tours of
active duty, are assimilated back into their home communities
with the assurance that convenient quality VA medical care is
there for them.
Now, as a former Adjutant General of the Virginia National
Guard from June 1994 to October of 1998, I have some deep
concerns about the coming impacts of the VA system as a result
of the extensive use of National Guard combat and combat
support units during Operation Iraqi Freedom and Operation
Enduring Freedom in Afghanistan.
During my tenure as the Adjutant General, in spite of
actively seeking overseas operations for our 10 National Guard
divisions, the National Guard was more or less relegated to
homeland security and domestic crises. As I'm sure you are
aware, this is not the situation the Guard finds itself in post
9/11.
Let me give you some examples. In Virginia, we have 7,838
members currently assigned to the Army National Guard, which is
102 percent of our authorized strength. Since 9/11, 8,862 Army
Guard personnel and over 700 Air National Guard personnel have
been deployed, 81 Purple Hearts have been awarded to Virginia
Guardsmen, and ten of our men and women have been killed in
action. There are currently 630 Virginia National Guard and
Virginia Air National Guard men and women on active duty.
If we go to the national scene, the total number currently
on active duty from the Army National Guard and the Army
Reserve is 90,144. The Navy Reserve is 6,354, excuse me, the--
the Air National Guard and Air Force Reserve, 14,457, Marine
Corps Reserve, 4,917, and the Coast Guard Reserve, 787. This
brings the total number of National Guard and Reserve personnel
currently activated to 118,659, including both units and
individual augmentees. These figures are current as of July 13.
And when you consider the continuing participation of the war
effort since 2001, the total number of National Guard and
Reserve numbers is substantial.
So in conclusion, when we consider the huge influx of
citizen soldier veterans created by the increase of Guard and
Reserve forces under the Total Concept Policy, and the
prosecution of the extensive combat operations in the Middle
East, there is an enormous workload headed for the Department
of Veterans Affairs. When you also consider the demands being
placed on the Department of Veterans Affairs by the intense
combat environment and multiple tours of duty, combined with
the efforts to increase VA medical care eligibility for
veterans, I believe that the VA will have to expand its network
of health care facilities to meet these increased demands.
News reports last week indicate that the VA is adopting new
rules regarding post-traumatic stress disorder that will, in my
opinion, drastically increase the clinical workload for the VA.
Reports in this newspaper article cite a 2009 Rand Corporation
estimate that nearly 20 percent of the returning veterans, or
300,000, have symptoms of PTSD or major depression. It will be
interesting to see how these estimates are updated to reflect
the new rules announced last week.
The education our group has received in pursuing a contract
primary care facility for Halifax County has clearly
enlightened us on the tremendous strides that the VA has made
since the mid-1990s with the establishment of the VISN and the
CBOCs, community-based outreach clinics, but we are absolutely
convinced that the VA will need to rely on the numerous
professional and highly qualified private sector medical
facilities to meet the incoming demands for VA medical health
care.
Expanding the CBOC system may be prudent and wise, but the
full utilization of contract medical facilities such as the one
in South Boston will be essential to meeting these demands,
both on time and on cost. Our research has shown considerable
savings in time and fuel by veterans using more convenient and
accessible primary care locations. Only through an aggressive
primary care program that is structured to include all
qualified veterans will the VA be able to cultivate a climate
of preventive medicine and early detection for serious
illnesses.
The VA Medical Center will always be the bedrock of VA
medical care to take care of the most serious medical problems
of our veterans and the VISN/CBOC system is a proven winner, in
our opinion. But we still believe that contract primary care
using existing private-sector facilities is going to be
critical to the VA. So we in South Boston, in Halifax County,
are prepared to lead the way.
And that concludes my--do we get a chance later on to
answer questions?
Mr. Michaud. Yes.
General Thackston. Again, we thank you very much for the
opportunity to be here today.
[The prepared statement of General Thackston appears on p.
53.]
Mr. Michaud. Thank you very much, Major General, for your
testimony. And we're looking forward to working with you as we
move forward in addressing the concerns that we have heard
about veterans access to applicable health care services in
rural areas. Thank you very much for your service to this great
Nation.
Mr. Chapman.
STATEMENT OF HOWARD CHAPMAN
Mr. Chapman. I'm Howard Chapman. I'm the Executive Director
for the Southwest Virginia Community Health Systems. We're
Federally-funded health centers, community health centers
(CHCs) that receive Federal support located across the
Commonwealth of Virginia. There are approximately 24
organizations with just over 110 sites.
Southwest Virginia Community Health Systems offers primary
care and preventive services, but in addition, we have
provisions for an integrated model of mental health in a
primary care setting, which works well with depression and even
substance abuse. It's a collaboration between the primary care
doctor as well as the mental health provider.
We provide some degree of medication assistance through the
Federal Drug Pricing Program and 340B. We also have a
medication assistance program that uses the patient assistance
programs through the different pharmaceutical companies. We
have worked to provide some limited transportation, and all
this in regard to trying to deliver good primary care services
in rural areas and knock down the barriers.
One of the groups that do have a lot of barriers in their
way are the veterans in our area. So we very much try to take
advantage of being able to provide them the same level of
services that we do the rest of the community.
We have been a CBOC operation, and our contract was
terminated in May of 2009. We had actually been working in that
capacity since 2005 and had built--we had just over 800
patients enrolled within our CBOC operation. We actually had
been one of the first CBOCs in the Nation. Back during
President Reagan's Administration, in the early 1990s,
Secretary Sullivan made the announcement on the Capitol steps.
And much along the line of, again, trying to develop and extend
health care services to veterans, they actually tied the
program to a program in Tuskegee, Alabama, that was looking to
serve nonveterans in a VA hospital. And various veterans
organizations, they take back full Congress and asked to appeal
before we ever saw the first patient. But what we had done was
been able to work with our local veterans that were
anticipating having these services in their community and
directly affecting their lives.
We worked for probably another 10 years or so to actually
get those services started back, and it was going very well. We
were very pleased with it. We did have some issues with the
Veterans Administration in how they actually had set up some of
the process. Rather than a direct link in using the VistA
system that they have as their medical record, we were given
sort of a dial-type virtual private network (VPN), which was
extremely slow, really dragged out the length of the
appointment for the veterans. And, you know, even in assessing
things like that, we needed to do the preventive measures
that--that they had in their process, it's really cumbersome to
work your way through this system. It could have been made a
whole lot easier through an integrated medical record that
would have allowed us to use our existing electronic medical
record (EMR) and dumped information into their system.
All of the technology things that happen, you know, it
seems the veterans administration are behind on doing a lot of
that. VistA is old technology, and I know they've talked about
moving into a Web-based system, but, you know, it needs to be
upgraded as we are moving toward this whole area of health
information exchange and that type of thing.
I just want to close by telling you that at the close of
our--our CBOC contract, the Veterans Administration announced
the meeting in February, and the morning that they had that
meeting, the temperatures were down in the single digits. They
had done the melding on Wednesday. Most of the veterans did not
get their announcement until Friday or Saturday. And they had
asked us for space to accommodate 50 to 60 veterans. They had
more than 250 that showed up. So again, the concern about
veterans and the health care that they receive is really, you
know, tremendous, a tremendous effort.
We have maintained and kept a lot of those patients just
because it's an hour and a half, either to the Salem VA or the
Mountain Home VA in Johnson City, and again they have set up a
couple of VA staff, CBOC in Bristol. There's actually one in
Atkins. And all of this has a considerable amount of cost in
regard that they don't own the building but lease the space.
And the renovations and things that they have had to do have
been again money that's sort of lost in regard to VA paying for
renovations and constructions that, you know, we can as
Community Health Systems across the State of Virginia provide
pretty much immediate access through a contracted arrangement
to at least 110 sites across the State of Virginia. Most of the
centers are Joint Commission on Accreditation of Health care
Organizations (JCAHO), accredited. They meet high quality
standards, and we're very willing to work with the Veterans
Administration to see that happen.
One other thing I would note is that we do have a Statewide
contract for TRICARE that allows service to military families.
And the other benefit behind using a community health center is
not only for the veteran and the services through the VA, but
we have a sliding fee scale for the families and children and
spouses of these veterans, that we can offer the same level of
service based on their ability to pay by total family income
and total family size.
So we think it's a great benefit for the veterans. I think
it opens up immediate access for the veterans and their
families, and we would very much like to see the CBOC continue
and be back in line to be able to serve the veterans in our
community.
[The prepared statement of Mr. Chapman appears on p. 55.]
Mr. Michaud. Thank you very much, Mr. Chapman, for your
testimony. I look forward to asking the questions that we will
have for you.
STATEMENT OF KEVIN TREXLER
Mr. Trexler. Mr. Chairman, distinguished Members of the
Subcommittee, I'm grateful for the opportunity to provide
testimony on behalf of DaVita. I manage more than 80 clinics in
Virginia, DC, and Maryland. I am also a veteran. I served as a
naval officer 6 years on an attack submarine. At this time, I
will summarize my written statement and look forward to
responding to any questions you may have.
DaVita is a leading provider of dialysis services in the
United States. It provides treatment to more than 117,000
patients each week in more than 1,500 centers, and represents
nearly one-third of all patients with end-stage renal disease
or ESRD. We are also a recognized leader in achieving excellent
clinical outcomes, consistently demonstrating outcomes that are
among the best when compared to national averages. Our
testimony today addresses the Subcommittee's interest in
understanding the quality of and access to dialysis care
provided to veterans in rural and underserved areas.
DaVita is privileged to care for more than 2,000 of our
Nation's veterans in our dialysis clinics across the country.
Our dialysis providers deliver dialysis treatment in veterans'
communities when the VA cannot provide reasonable access or
lacks in-house capability to provide this life-saving
treatment.
More than 20 percent of veterans with ESRD in rural
Virginia have no treatment options within 20 miles of their
home. We consider ourselves a partner with the VA and are
committed to providing excellent quality, exceptional clinical
performance and outstanding customer service to all these
veterans whom we serve.
Veterans receiving dialysis treatment are frail patients
often with multiple illnesses and cannot survive without
dialysis or kidney transplant. Thus patient access to care is
critical. Patients receive three treatments per week, every
week of the year, often 4 hours at a time. Both provision of
the treatment and the financial aspects of the dialysis
treatment are unique. Dialysis and all it entails is expensive,
but in fact it is only about a third of the total cost for
unmanaged end-stage renal disease patients. I will address both
of these issues and suggest a way to improve the health status
for these extremely sick veterans and the VA's desire to reduce
total costs of purchased care. DaVita recognizes and supports
the VA's goal for standardizing reimbursement for the purchase
of non-VA provided health care services and reduce costs in a
way that--that will ensure that we can continue to provide care
for all of our veterans in rural areas. I'd like to share two
ways that dialysis providers and the VA can have win-win
approach to these issues.
First, here in Virginia we provide care to veterans through
VA established existing negotiated contracts. These contracts,
if continued, will continue to provide mutually agreed upon
sustainable reimbursement.
Second, we propose to the VA that they implement a patient-
centered, integrative care management dialysis program for the
ESRD veterans. Results of this would be improved clinical care
for the patients and lower total costs to this system. In
Medicare demonstration projects, we have been able to improve
clinical outcomes and reduce hospitalizations. Dialysis is only
about a third of the cost for end-stage renal disease patients.
The majority of the costs come from emergency room visits and
hospital stays.
An integrated care program would focus on all the clinical
needs of the veteran, and would provide lab, pharmacy,
medication therapy management, vascular access care,
vaccination, case management and access to diet and nutrition
counselors and nephrologists. The VA currently does not receive
any clinical data about its dialysis patients. In the
integrated care model, we fix that in the system, but would
provide an interface between our extensive databases and our
integration systems.
In response to the VA's request for dialysis care
innovation, DaVita will also submit a proposal that reflects
our expertise in providing and remotely monitoring dialysis
care in the patient's home that would be of particular benefit
to patients in rural areas.
On behalf of DaVita, I'd like to thank you again for your
interest in the care we provide to our veterans and commitment
to ensuring that veterans in rural areas continue to receive
the quality of and access to care that they have earned. We're
grateful to the Subcommittee for its leadership in seeking new
ways to promote quality care for all veterans and especially
the unique population of veterans with kidney disease whom we
serve. I'd be happy to answer any questions you may have.
[The prepared statement of Mr. Trexler appears on p. 61.]
Mr. Michaud. Thank you very much.
Once again I want to thank the panel for testimony this
morning and I look forward to working with you as we move
forward.
Major General Thackston, I have a quick question. As you
heard, both Mr. Perriello and myself are very concerned about
access to health care for veterans who live in rural America.
Rural health care issues are extremely important and over and
over again we continue to get legislation that contracts out VA
services.
At the same time we have heard some concerns from the VSO
community. And as a Major General and a former Adjutant General
of the Virginia National Guard, are you concerned that we might
no longer need the VA medical facilities, or do you feel there
always will be a need for the larger medical facilities.
General Thackston. Yes, sir, I certainly feel there will
always be a need for that. What we are concerned with--like
yesterday I ran into a lady and I told her where I was going
this morning. She said, ``Oh, thank goodness.'' She lived down
in Clarksville. She said, ``My father is a World War II
veteran, and he has to have somebody drive him to the VA
Medical Center in Richmond.'' So there's literally hundreds of
people like that in rural areas, as I'm sure you know.
The other thing we're quite concerned with is the
relaxation of the criteria that will qualify veterans for the
PTSD as well as--Dr. Browne, if you take a minute, wants to
explain a little something about how the criteria for heart
disease has been expanded, which will cover a number of Vietnam
veterans. Have we got time for that?
Mr. Michaud. Yes, we will. Before we turn over to Dr.
Browne, when you look at, for instance, community health
centers and other qualified health care clinics and hospitals
in rural areas, and where they're currently located using
Federal dollars, in a lot of cases, they're in the same area as
access points recommended in the Capital Asset Realignment for
Enhanced Services Process in 2004.
Do you feel that veterans will be less likely to visit
community health clinics versus a VA facility, or do you think
they'll be more likely to use a community health clinic since
it's in their community.
General Thackston. You mean community health clinics?
Mr. Michaud. Yes.
General Thackston. Yes, sir, I feel like they'll be more
likely, because, for example, this new primary health care
center we have in South Boston, we have had all kinds of people
that are qualified to go there, but our veterans can't unless
they pay, and they have to go to Richmond, Salem, or Durham. So
I feel like if we have this expanded network, they will
certainly be used to a great extent. And we have done a rather
exhaustive study to talk about the costs and reimbursement for
travel that VA pays for many of these veterans who go to
McGuire and Durham. And we have these clinics that will
certainly save the VA money, and it will save our veterans
time. You know, a lot of them have to take a day off from work,
and a lot of them have to get somebody to drive them.
But to answer your question, for serious illnesses and all,
they will still go to the major VA centers, but we'd like to
think this community-based, the CBOCs as well as what we are
trying to establish, will serve an important need.
Mr. Michaud. Dr. Browne.
Dr. BROWNE. Well, I agree. I got started in this because
I've practiced medicine down there for a long time. I would
like to point out to the Subcommittee that this is a moving
target. When I go to the barbershop, I wonder whose head
they're cutting when I see all that silver stuff falling on the
sheet. I used to be young and strong. Nobody knew when we were
in Vietnam what was going to happen with this Agent Orange
business, which is a massively expanded load. Who knows about
all these other issues.
Plus, if a veteran becomes 30-percent disabled from a
service-connected illness, then he becomes or she becomes
enabled to go for any illness, and people age and they get
problems. So we think, like the rest of the country, as the
veteran population ages, their demand for services will
increase. And that's been my experience. In internal medicine,
most of the patients are elderly, and many, many, many of them
are veterans.
So we see this as a way to integrate to--also to minimize
the number of unnecessary visits to the mother center. If
people get chest pain, where do they go? What is it? Well, it
could be nothing. Somebody needs to sort of triage these
people. And we see this as a way to improve the quality of
health care, to intervene with simple measures, to get one-on-
one treatment, and to improve the quality of referrals to the
VA center, to utilize those physicians better.
As you know, there's going to be a shortage in this
country, not only of primary care doctors, but there may be of
other doctors and nurses. There's going to be a competition
between the VA systems and other health systems for qualified
people. This is a way for the VA to immediately expand its
staff by incorporating CBOCs and--and willing other
participants and treat, splint them where they lie, treat them
forward.
Mr. Michaud. Thank you.
Mr. Chapman, what have you found to be the biggest barrier
to working collaboratively with the VA system in the Community
Health Care Centers.
Mr. Chapman. I think working in the VistA system with the
restraints that we had by using the dial-up. Had it been pretty
much a live connection, where our providers could have done
that real-time would have definitely speeded the process. Again
even further to have had the ability to use our own electronic
health record and then download the information or send it to
the VistA system--we're not taking anything out of their
system. We're actually adding information to their system--it
would have greatly enhanced the ability for us to have been
able to have done those services.
You know, if I could follow up on maybe a couple of the
questions in regard to rural America. You know, again, in rural
Virginia, by the 2000 census data, we have some communities in
Southwest Virginia that 14 percent of the householders do not
have vehicular transportation. So that trip, an hour and a half
to the nearest VA hospital is almost impossible for some of
these veterans.
You know, 12 percent of the households lack basic telephone
service. So while we all take for granted that we carry cell
phones, a lot of people out there just don't have that, that
ability. And so, you know, we think there are a lot of barriers
to serving the veterans and making these services accessible in
the communities and the places that they live really is a great
benefit for the veterans.
The VA hospital uses the, I think, all open-access
scheduling. Everyone is given the 8:00 appointment. And again,
these veterans do go and they sit all day, primarily, before
they're seen. And that gets to be a real hindrance, to be able
to ask a friend or a relative or a neighbor to take you to the
VA hospital and, you know, and be there for a day.
We've actually used the same scheduling with the veterans
that we did for our regular patients. They were given a 2:00
appointment, and they were seen on or around 2:00. They may
have been delayed somewhat, but again it did allow the veterans
to be able to take advantage of sort of scheduling their time
and knowing what they could do and not wasting a day for health
conditions.
Mr. Michaud. You mentioned, I think, in 2005 to 2009 that
you took care of 800 VA patients.
Mr. Chapman. We have never done any marketing. We've sort
of just let word spread about the program itself. And again, we
had some degree of existing capacity that we were able to
enroll about those 800 veterans. We were actually moving toward
probably having two or three providers that would just have
been able to serve the veterans themselves rather than just
fall to spreading it across all of our medical providers, and
we think that would have worked out a little better for the
arrangement. It would have given us access for, on heavy days,
some of the other providers. All of them would have been
potential, but we would have had two or three primary providers
that would have been just serving the veterans. And we think
that would have made a little better situation than what we
had.
Mr. Michaud. Have you looked at the cost of providing
health care services? Since you no longer, I understand, have
the 800 veterans, has the cost per patient gone up.
The second question, relates to quality of care. Is it fair
to assume that some of those 800 veterans are no longer getting
VA health care because of the travel distance? What were some
of the comments from the veterans who might have stayed there
or gone to VA and then ultimately quit?
Mr. Chapman. We did actually maintain a lot of those
veterans, primarily because again the CBOC-VA staff/CBOC in
Bristol, which again, you know, it's 40 miles away. And some of
the comments we got from the veterans is, if I've got to drive
40 miles, I'll drive the other half-hour and go to the VA
hospital anyway, because if I need other testing, things like
that done.
You know, probably in October or November of 2009, one of
the veterans had commented that they were backlogged, and I
think it was by about 1,200 patients or more, that they were
having to schedule appointments, try to get enrolled in the VA
system at the Bristol CBOC.
You know, they've built three others from some of what they
took away from the community health centers, and the VA staff
models now, again with the extensive amount of money going into
renovation and things, the facilities that the VA did not own,
and the--and bring their own providers in. The one in Marion or
Atkins, Virginia, I think the last count I had, they were open
maybe 2 days a week, and last count I had, they were about 6
months behind on--on a wait list of about 6 months to get a
veteran enrolled in that program. So there's still a lot of
access issues from the standpoint of the VA.
The VA hospital in Johnson City and in Salem are extremely
busy. They don't have the capacity to be able to take these.
When you see waiting lists of 6 months or more in getting a
veteran enrolled, it really indicates that there is a need for
more services out in some of these rural communities.
Mr. Michaud. Thank you.
Mr. Trexler, in your testimony you talked about the
capabilities of remotely monitoring the patient in their home.
Can you explain to the Subcommittee what type of technology
veterans might need in their home to be able to be monitored
properly?
Mr. Trexler. It would be telephonic, just by phone or also
video conferencing.
And there's another part of this program I want to stress
that particularly applies to rural locations. We would provide
predialysis education to all the patients, and our research
shows that patients who are educated choose what's called a
home modality, the ability to receive dialysis treatment in
their home 30 percent of the time versus an uneducated patient
will only choose it six percent of the time. So this would be
another component of the program that would help veterans have
access. They won't have to travel three times a week far away
to receive this treatment. They can do it in the comforts of
their home.
In addition to that, we also have a program to provide
medications to be delivered directly from the center to the
patient's home, once again reducing the number of times these
veterans would have to go to the pharmacy, oftentimes have to
go to multiple pharmacies to get all of their medications they
require for dialysis, and also improve the adherence because
we'll get a report that will alert us when the patient runs out
of medication or when they should run out, so we can remind
them to refill that and also check to see if they've used all
of their medication.
And a third major component of this is by providing better
education, we reduce the number of crashes into our hospitals,
so the patients have a gradual transition into dialysis as
opposed to having an acute illness that causes them to go in
the hospital, and the benefits of this are reduced total costs
and improved outcomes and mortality in the first year of
dialysis.
Mr. Michaud. And my last question is--and I know this is an
important issue for Medicare/Medicaid patients, and an issue
the Committee is somewhat familiar with--about dialysis
reimbursement rates. VA is looking at adopting the Centers for
Medicare and Medicaid Services reimbursement rates. In Maine,
we have the oldest population per capita in the country. We're
number one for the loser on Medicare. We're number two for the
loser on Medicaid. Sixteen percent of our population, near the
top among States. We're near the top. We're a rural State. For
reimbursement rates, we're second from the bottom for Medicare.
And that's actually a concern, making sure that providers will
be able to adequately take care of their patients. And one of
the reasons why we're near the top for high insurance premiums
is because there's a lot of cost shifting that's occurring
because of low reimbursement rates.
Do you have a brief comment on reimbursement rates for
dialysis treatment and what might that do for some of the
facilities that are in rural areas, which tend to have higher
numbers of Medicare/Medicaid patients.
Mr. Trexler. I want to focus my testimony on what would we
would do to provide access for rural veterans and also to
improve the quality. We've submitted other testimony that
provides more extensive comments about any proposed changes of
reimbursement. I'll just briefly summarize them by saying that
any change could have unintended consequences, and it could be
negatively affecting the access of care in the rural
communities for all the reasons that you mentioned. But I'd
just urge the Committee to make sure you are researching that,
because no one wants to see any reduction in the access to care
for our veterans. They've certainly earned it, and I thank the
Committee for your support, asking the questions and doing the
research.
Mr. Michaud. Mr. Perriello.
Mr. Perriello. Thank you very much, Mr. Chairman.
Thank you again to all the panelists. A few questions to
run through.
First, just so I understand, for General Thackston and Dr.
Browne, right now with the existing facilities, someone with
private insurance, Medicare/Medicaid, could attend, but a
veteran could not; is that correct.
General Thackston. Correct.
Mr. Perriello. And to what extent have you and Mr. Chapman,
to the extent you all are still serving some of those veterans,
are you already seeing a change in or any trend lines in the
amount of care or upticks that you're seeing, or is this
something 5 years off or 10 years off in terms what you're
expecting for some of the changes that you have predicted.
General Thackston. You want to answer that?
Dr. Browne. Well, I can't answer that question at this
point. We don't have the information. As you know, we have
researched everything pretty well, and I can't answer that,
don't have enough data for that. But I expect that if--if you
read what's in the various literature, General Shinseki's
decision to include certain new illnesses with Agent Orange,
that alone is going to massively impact the Veterans
Administration. I don't see how they'll be able to cope with
it, frankly. But that alone will clog up the system beyond
belief, in my opinion.
Mr. Perriello. One of the concerns we've heard in the past
is the issue or issues that arise when you handle both a
veteran and a nonveteran population in the same physical area.
To what extent did you see that, Mr. Chapman, and to what
extent has that been thought through or considered in the South
Boston context?
Mr. Chapman. Again, we basically were using the existing
providers we had in working through the--pretty much the
excessive stacking and had some degree or capacity to observe
those. We really think it would probably have been better to
have had more or less a provider or two. Now, I don't think
there's a difference between, you know, a veteran and a
nonveteran in the same facility. I think, again, we would have
been better off to have a couple providers that would have been
just dedicated to serving the veterans, and then, you know, in
high demand times we could have had the other providers serve
as backup to those staff. But we do extended hours, again real
convenient for the veterans and that type thing, and we didn't
see a problem with that.
I think, again, you know, veterans were appreciative of the
services. Again, they were appreciative of being able to come
in and appointed a time slot and really great patient
satisfaction from the veterans in regard to services that they
were receiving.
Mr. Perriello. One of the things that I have been so
excited about with the project you all have put together is not
just the, you know, the level of detail and the community
engagement with it, but it seems to me one of the reasons to
support the pilot program is just to try different things. What
we know is we are going to see a different world than we saw 20
years ago in terms of the scale, in terms of the types of
problems, the complexity, and so it seems like part of the goal
of this Committee, both before I joined it and now, is to say
we have to try some different things.
So if you are saying to a group of people here's what we
are going to test by the South Boston facility, by the primary
care facility, and if it works, we will know X, if it doesn't
work, we know Y, what do you say for us who have to look at
this across the country that we could learn from what you all
are putting forward?
Dr. Browne. Well, one of the things, if we get this far, if
you grant us permission, is we intend to have a board, made up
of consumers, veterans, who will meet quarterly and they will
assess the performance of this. And we would invite
representatives from the VA to serve on that, and these
veterans would make a decision about how this clinic is working
and to meet their needs. And if you met some of the people that
we'll put on that, on that small group of five, seven people so
it can function, and periodically review that and make a report
to the VA or to you, whoever you wish, and then we'll assess
how things go on as a pilot program.
As far as the veterans are concerned, I took care of plenty
of those. They came in my office. They didn't wear a veterans
t-shirt. They were amongst the people out there. We treated
them the same. The only difference in my office was sometimes
we had a huge difference in insurances. It was a matter of
processing the patient.
In view of whether you put this clinic here, if you want a
separate entranceway, we can accomplish that, or separate
person to deal with that. As you know, Mr. Loftis is interested
in getting a couple of disabled veterans to work in this clinic
and provide computer access and to process these veterans. We
even think that we should be able to enlist veterans at these
local clinics. A lot of them won't go to Richmond. So who
knows. I think it's a moving target.
Colonel Daniel. I'd like to add that, as the General
pointed out in his presentation, we know we have some 1,100,
1,200 veterans that are currently enrolled. We know we have
close to 3,000. And from the beginning we have said, why aren't
all eligible veterans taken care of? We have some younger
veterans that are sitting back. They're not getting the primary
care. They aren't getting educated. That's going to result in
long range costs to the VA if they have ailment, diseases.
As far as evaluating the effectiveness of our program in
South Boston, we're going to be very closely monitoring the
increase in the number of people who are going to step forward
and enter the system to take advantage of it. So we'll see an
increase.
South Boston is situated where we are more or less equal
distance between Salem, Richmond, and just a little bit closer
to Durham. Most of our veterans historically have gone to
Durham and Richmond as opposed to Salem. The CBOC that's over
in Danville of course is in the VISN system where its primary
medical center is Salem. The amount of Halifax veterans that
are currently going to that CBOC, we don't see any change in
that. They're convenient to it. They're enrolled in it. We see
them go there. But we see the increasing workload that will be
coming as a result of more veterans qualifying and coming into
South Boston. We see an increase in primary care, primarily in
the area of preventive maintenance, follow-up.
Again, the Chairman's question was what is the future of
the VA centers. My personal opinion is that it is solid. There
will always be a requirement for it. Our veterans love the
centers. They prefer a center to go to. And the CBOC system is
fantastic, and the whole VISN. But our position is that the
increasing workload is going to require taking advantage of
every asset you have, and local community primary care centers
like in South Boston will be able to provide tremendous
advantages to the veterans and to the VA, and that's why we're
looking forward to be participating in the pilot program. We
think we can prove that.
General Thackston. Mr. Perriello, you were there when the
ribbon was cut on the facility we are talking about. It's an
ultramodern building. We feel like there will be no cost
overhead, this type thing, when veterans use it. So, while the
CBOCs do a great job, we're talking about something totally
different. We are talking about a clinic that's run by the
Halifax primary, Halifax Regional Hospital, and no overhead to
worry about. We put a couple of volunteers in there with
computer connections to the VA centers in Richmond, Durham and
Salem, and we just see it as win-win situation along with the
CBOCs.
Mr. Perriello. Let me ask one with question of you all.
Then we'll wrap this up pretty quickly.
Mental health capacity, what capacity do you have in South
Boston? And related to that, one of the things that we found in
the CHC system is we have been doing more mental health work
through telemedicine, and somewhat surprisingly we actually
have a higher show rate for mental health appointments through
telemedicine than through going in. Some of that is obviously
it's easier access to it.
To what extent is there either the capacity in South Boston
or the technological capacity to do, to be connecting up with
mental health experts in the VA system?
Dr. Browne. From a technological standpoint our little
hospital is on the cutting edge of computer technology, in
fact, probably ahead of the VA.
As far as psychiatric care, there are two psychiatrists
with a large support staff and a mental health group that's in
there. So I don't anticipate any problem. Many people who have
experience in combat know about PTSD. It's no stranger. So a
lot of other physicians with a small amount of education could
easily take care of identifying.
And of course this is a way to integrate between the VA--we
don't see this as two separate issues. We see this as
supporting the VA, following their guidelines, giving them
support, but yes, we have the staff to deal--and that's who
I've sent a lot of people that have PTSD who weren't in the
military. We use the psychiatrist.
Mr. Perriello. Well, I really see this as being one of
those demands that's going to grow tremendously, and creating
capacity there both in the CHC community, but particularly the
veterans community, that's going to be crucial.
When my brother was being recruited very heavily as a high
school athlete, his coach told him, ``Go where you're wanted
the most because they'll find a way to make it work for you.''
And I think in this case, as we look at the pilot programs we'd
be hard pressed to find a place around the country that has
done more work saying we want this to happen here, we want to
prove it can work here. I think the work you all have done to
put this together is tremendous, and I appreciate that.
And I have some questions for Mr. Trexler, but I'll ask
those offline about quantitative numbers. We have gone back and
forth with dialysis from assuming it was better to do it in the
home to bringing people to the clinics, back to the home. The
upfront costs tends to, of course, be higher to prepare it in
the home, but we're starting to see that being something that
pays off over time. So I'm going to want to run through some
numbers with you both in the Medicare context as well as the VA
context, which we can do off line.
But, again, I just want to thank all the panelists for
their work in the community. Thank you very much.
Mr. Michaud. I, too, want to thank the panel.
I have just one more quick question for Mr. Chapman. With
the community health clinics, is your primary bulk funding from
the Federal Government?
Mr. Chapman. Community Health Centers in general are about
a third Federal Government. The other two-thirds we generate
through contracts and people service arrangements with
patients. So virtually it's about a third of our operating
budget comes from Federal sources.
Mr. Michaud. And your fee for the services, is that usually
on a sliding fee scale?
Mr. Chapman. It is based on a sliding fee scale. We're
limited to what the insurance companies will pay and contract
arrangements and that type of thing, so it's much like the
physician's office down the street.
Mr. Michaud. How does a contract with the VA system work?
Is it more lucrative for you, or if you look at a veteran who
might go in if you were paying on a sliding fee scale, is he
paying more because you have a contract with the VA system, or
is it about the same or----
Mr. Chapman. Well, actually ours is on--in Southwest
Virginia we don't have a lot of managed care. And the VA
contract was on a capitative basis. So once we had done the
physical and had them enrolled, we assumed responsibility for
their primary care. That was probably in the neighborhood of
about $30 per member per month, and that assumed, you know,
taking care of pretty much the whole round of services that we
deliver through primary care.
Mr. Michaud. Great.
Once again, I'd like to thank the panel for your testimony
this morning as well as for answering questions. We'll probably
have some additional questions which we'll provide in writing.
So, once again, thank you very much. You've been very helpful.
General Thackston. Thank you for the opportunity.
Mr. Michaud. I'd like to invite the second panel up, and
I'll turn it over to Mr. Perriello to once again introduce the
second panel.
Mr. Perriello. Thank you very much, Mr. Chairman.
Before I introduce the panel, I want to introduce Martha
Woody from my staff.
Martha, if you'll stand up.
Any veterans that are here today to talk about a specific
case of theirs, Martha does our casework. She's based out of
the Martinsville office and previously worked with the VA, so
she understands the inside of the system as well as the
veterans. So if anybody wants to grab her, I may ask her to
just stand outside for a few minutes. So anyone who came
because they're having a particular issue with the VA, I want
to be sure that you have a chance to talk to Martha.
I'll introduce Ericke Cage, my legislative counsel from
Halifax County who handles my Veterans Affairs' Committee work
on the policy side. So if it's a policy question, obviously
you're welcome to talk to me about both case and policy work,
but I want to be sure that you understood that our team was
here and can be pulled aside, because these hearings will go on
for a while, so if you want to grab him at any point.
With that, I'll invite the second panel to come up: Michael
Mitrione, Commander, Department of Virginia, for the American
Legion, and thank him for his tremendous leadership with the
Legion.
Dan Boyer from the National Legislative Committee, Past
Commander, Department of Virginia for the VFW, for the Veterans
of Foreign Wars of the United States. Again we've really
enjoyed working with the VFW staff on some of the vocational
skills training and employment issues as well as on the health
issues.
Clarence Woods, the Commander for the Department of
Virginia for Disabled American Veterans (DAV), who--several of
these men made quite a trek today to get here and were
commenting on just how beautiful our area is. So it's always
nice to show off a little bit the beauty of the Blue Ridge and
the community.
And I particularly want to thank Lynn Tucker for her
participation. She'll talk as a veteran caregiver the amount
that her sons have sacrificed, that she has sacrificed. As you
will hear, it is just tremendous. And rather than just focus on
making sure that her family is getting the care they deserve,
she's also made sure that she wants to speak out for others who
are going through a similar process.
And one of the things that we know is that unlike in, say,
the Vietnam era where most fighters were going over as single
individuals and quite young, we're seeing people go over now
where it's an entire family that's involved, particularly
extended deployments. An older fighting force is more likely to
be married. I think Ms. Tucker's words about the experience in
military families and caregivers is one that you will
particularly want to hear.
Again, I want to thank all the panelists.
Mr. Mitrione, if you can get us started.
STATEMENTS OF MICHAEL F. MITIRONE, COMMANDER, DEPARTMENT OF
VIRGINIA, AMERICAN LEGION; DANIEL BOYER, POST COMMANDER,
GRAYSON POST 7726, VFW PAST STATE COMMANDER, VETERANS OF
FOREIGN WARS OF THE UNITED STATES; CLARENCE WOODS, COMMANDER,
DEPARTMENT OF VIRGINIA, DISABLED AMERICAN VETERANS; AND LYNN
TUCKER, MUSEVILLE, VA (VETERAN CAREGIVER)
STATEMENT OF MICHAEL F. MITIRONE
Dr. Mitrione. Mr. Chairman, Members of the Subcommittee,
thank you for giving me the opportunity to address the issue of
concern to many of the 750,000 veteran families living in
Virginia. The American Legion greatly appreciates and salutes
your efforts on behalf of the residents of Virginia. In my next
article to our members I will be mentioning the efforts of your
Committee to address the availability of VA care in our
outlying areas.
A written copy of my testimony was provided as requested.
However, given the short time to prepare, it covers these
topics from a general perspective. I used the intervening time
to discuss the subject with many of the members directly
impacted by your issue of interest, and we'll use the time
available to me this morning to provide a more focused
viewpoint. Boiled down to its essence, the issue can be
expressed in three words: ``time and distance.'' Fortunately,
emergency care is not an issue since the VA has provisions for
covering expenses and life-threatening situations. The issue is
in outpatient care.
Virginia houses three VA medical centers, two outpatient
clinics, and 10 CBOCs. However, as might be expected economy of
scale dictates that these scarce resources be placed in areas
of high density population. This naturally tends to exclude a
large percentage of our population who choose to live various
distances from these population centers. To reach adequate
medical care facilities, therefore, hours can be spent
travelling to and from their homes. In many cases this involves
the time not only of the veterans themselves but, as we have
heard, the availability of volunteers willing to spend their
time transporting them. In times of adverse weather conditions,
these time frames can be more than double or triple.
Not only do eligible veterans have to travel long distances
to obtain medical care, but sometimes artificial boundaries
make that travel distance even longer. For example, a Legion
member advised me there is a VA clinic 19 miles from his house,
but because of some artificial line of demarcation he's
required to travel 56 miles to another care facility. That of
course raises the question why such boundaries exist. Active-
duty military can obtain care from any military facility. It
would, therefore, seem logical that if a veteran has a valid VA
card, medical care should be available from whatever facility
is available.
The American Legion realizes that the government has
limited resources and cannot be expected to build and staff an
extensive network of CBOCs across the landscape. As part of the
American Legion's efforts on behalf of the veterans, we make it
part of our mission to conduct site visits to VA medical
facilities across the country under our National System Worth
Saving Program in order to assess the quality of VA care. In
fact, one such visit is scheduled in Virginia for next year,
and special attention needs to be paid to rural areas due in
part to the fact that many Reserve and Guard units from rural
areas have been called up to support war efforts in the Middle
East.
In addition, thousands of volunteer hours are spent by
concerned Legion members in VA facilities across the State.
Their interaction with veterans within the VA systems provides
valuable insight and allows us to develop resolutions provided
to our Congressional representatives. Discussions with a number
of members represent--result in a recommendation that might
provide an easier and more cost-effective solution to the
problem of accessibility to medical care and worthy of the
study by the VA or other appropriate agency.
Senior citizens and retired military now have the option of
being treated by doctors instead of clinics of their choice. If
the VA had a system of issuing medical cards to eligible
veterans that could be honored by health care providers, it
would appear that geographical locations would no longer be an
issue. Company sponsored health plans provide a list of health
care professionals authorized to provide services. The VA might
be able to do likewise.
The American Legion welcomes the opportunity to work with
this Committee, veterans of VA and rural health care providers
to improve timely access to quality primary and specialty
health care services for veterans living in rural areas. Mr.
Chairman and Subcommittee, I wish to thank you again for your
time.
[The prepared statement of Mr. Mitrione appears on p. 63.]
Mr. Michaud. Thank you. Mr. Boyer.
STATEMENT OF DANIEL BOYER
Mr. Boyer. Mr. Chairman and Members of the Subcommittee, I
am honored to be here today to represent members of the
Veterans of Foreign Wars of the United States here in Bedford
and around our wonderful State of Virginia.
I come before you with profound gratitude for what the VA
is striving to achieve on behalf of our veterans. No agency or
department is perfect. And yet I know that with the support of
the Congress and this Committee, the VA is making strides
forward and is working diligently to care for all generations
of veterans. With these thoughts in mind, I would like to
address the rural health care challenges we are facing here in
Southwest Virginia.
Access to VA services in rural areas is always a primary
concern, and that is no different in our region. From my
hometown of Galax, Virginia, we have the Salem VA Hospital that
is approximately 100 miles to the northeast. Also located in
our region is the Johnson City, Tennessee, VA Hospital, and
that is approximately 125 miles to the west.
Either of these can be quite a journey, particularly when a
veteran has two noncontiguous appointments. It can be a
frustrating process for veterans to travel long distances for
multiple appointments spread throughout the day. Thus, we are
very thankful for our community-based outpatient clinic or CBOC
in Hillsville, Virginia, and we believe that the addition of a
second CBOC in Marion, Virginia, although limited to 3 days a
week, will provide even greater assistance.
There is clearly a need for the VA to open more clinics in
rural areas. And the onus is on the VA to find solutions for
our veterans, whether it be through additional private
contracting, private and public partnerships, collaboration at
multiple levels of government, or other creative means to make
sure veterans are getting the care they deserve.
Another area that will potentially improve access to care
is telehealth. The VFW believes that this is a major
opportunity to improve health care outcomes, particularly in
rural communities. Though there are privacy issues and
technological limitations that must be addressed, they should
not delay any expansion of telehealth services. This
Subcommittee held a hearing that spent considerable time
discussing rural broadband and wireless expansion, and we
encourage the Committee to continue expanding the body of
evidence that clearly supports a robust telecommunications
infrastructure in our rural communities.
We're also concerned that many cases of traumatic brain
injury (TBI) are not being properly diagnosed. We are obviously
playing catch-up in our understanding of TBI, and access to
medical professionals who can properly diagnose TBI is a
problem nationwide. As you might imagine, veterans living in
rural communities are especially vulnerable to misdiagnoses and
ill-suited treatment. And the VA needs to make sure a
sufficient network of doctors is in place to take what we are
learning and put it to use in these communities. Moreover,
post-diagnosis treatment can be time-consuming and can hinder
efforts to treat rural veterans suffering with TBI. This is a
serious issue that the VA and this Committee need to tackle
head on.
Closely tied to TBI is our concern for proper diagnosis and
treatment of mental health conditions. We applaud VA for
raising awareness on mental health issues and for working to
reduce the stigma attached to seeking mental health treatment.
We urge the Congress to provide continuous oversight of VA
mental health programs to assure that the need for counseling
and other types of treatment is being met here and in all the
rural areas of the country. At the Salem, Virginia, facility
alone, nearly 2,500 veterans have received diagnoses that may
be caused by PTSD.
One concrete step that can be taken to ensure all veterans
who struggle with mental health conditions receive timely and
professional care is to staff our rural CBOCs to provide
inpatient mental health counseling among other specialty
services. Specifically strong outreach and education programs
will be necessary to help eliminate the stigma of mental
illness and other barriers that dissuade many from seeking
care. We also need meaningful post-deployment health
assessments that will incentivize servicemen and women to
provide honest responses so they can receive appropriate types
of care and secure benefits, which they have earned.
Routine examinations should include mental health
assessments. VA staff should be fully competent to identify
warning signs, should be aware of all available programs and
should fully utilize them. We all know that suicide among our
veterans is higher in rural communities. The VA suicide hotline
is an effective tool for those who call. But we should work to
ensure every veteran who is at the end of his or her rope knows
there is a helping hand.
Again it comes back to outreach. These programs must be
visible in the everyday lives of veterans. We know this is
especially challenging in highly rural areas, and we hope the
VA will redouble their efforts with regard to rural outreach,
not only for the suicide prevention hotline, but for all their
programs.
One way the VA is reaching out to address these and other
issues is through Mobile Vet Centers (MVCs) that are literally
going to where our rural vets live and work, ensuring access to
services is provided where it is needed. However, it is with
some dismay that I tell you I have not seen or heard of one
being in our community. With that in mind, the VFW hopes that
the VA is devoting proper time and attention to evaluating
successes of MVCs and considering additional resources, if
there is a demand for more Mobile Vet Centers.
In rural areas, simple word of mouth is still one of the
primary ways information is distributed. The VA should not
overlook hometown newspapers, local VSO chapters and other
means tailored to our older veterans. Though they should employ
e-mail alerts, social media and other electronic means to reach
out, they should not expect these to reach every generation of
veterans. We want to be a resource for the VA to reach rural
veterans, and the potential to boost outreach by using VFW
posts and those of other veteran service organizations cannot
be overstated.
Another helpful opportunity for collaboration would be to
use local VFW posts to conduct local screenings and wellness
events. Just because a Mobile Vet Center is not available, that
shouldn't mean the VA can't send a doctor or medical
professionals to a rural area. Speaking on behalf of the VFW
here in Virginia, if the VA sends us a doctor, we can supply
the patients and the physical space needed to screen for mental
illness and TBI along with other physical conditions such as
glaucoma, hearing, diabetes and other illnesses. Such
opportunities would provide a platform for further
collaboration and would be a positive contact with rural
communities where there is no VA presence. Everyone benefits
when mutually interested parties work together. We hope that
the VA would take seriously the many benefits of increased
cooperation with the VSO community.
The Independent Budget said it best when it stated that,
``Health workforce shortages and recruitment and retention of
health care personnel are a key challenge to rural veterans'
access to VA care and to the quality of that care.'' The VA
must aggressively train future clinicians to meet the unique
challenges rural veterans face. The VA already has existing
partnerships with over 100 schools of medicine in the United
States. Not to apply them or expand upon them if needed would
essentially squander this vast resource. We cannot allow that
to happen.
The VFW is also concerned that the men and woman who serve
in our Guard and Reserve are not fully utilizing VA benefits
that they have earned. Demobilizing members of the Reserve
component or the Guard are often so preoccupied with thoughts
of family and home that they fail to even mention existing
health conditions, not to mention ones that will certainly
develop down the road as a result of their service. Local VFW
posts often fund and facilitate going away and coming home
parties for Guard and Reserve units. We have successfully used
these events to offer assistance with their VA paperwork
through the Virginia Department of Veterans Services, and we
will continue to support our returning warriors through events
and other outreach efforts.
Finally, I would like to bring attention to the success of
our Virginia Wounded Warrior Program. Rural veterans are a
primary target population of the Virginia Wounded Warrior
Program. I hear and know of very positive things about this
program, and we hope that the VA will continue to look at this
hallmark State program and redouble their efforts to work with
all layers of government, local, State and other Federal
entities to provide integrated total solutions for not just our
wounded warriors, but for all who have served and their
families.
Mr. Chairman, I again thank you for the honor of presenting
our priorities to you. I would be happy to try to answer any
questions that you or the Members of the Subcommittee may have.
[The prepared statement of Mr. Boyer appears on p. 65.]
STATEMENT OF CLARENCE WOODS
Mr. Woods. Mr. Chairman, Ranking Member Brown and Members
of the Subcommittee, thank you for inviting the Disabled
American Veterans Department of Virginia to testify at this
oversight hearing of the Subcommittee focused on the Department
of Veterans Affairs and the health care needs of rural veterans
in the Commonwealth of Virginia.
As an organization of 1.2 million service-disabled war
veterans with 38,000 members and 59 chapters located throughout
the Commonwealth, rural health is an extremely important topic
for DAV, and we value the opportunity to be here today.
Mr. Chairman, our former VISN statements were provided to
the Subcommittee on July 15th. That testimony details a number
of positions that we have taken by our national DAV
organization on rural health issues, and I have been told that
most of those positions are well known to you. So I will not
focus or remark on those points. However, the DAV Department of
Virginia subscribes to all those positions, and they are backed
by the national resolution adopted by our leadership in the DAV
2009 National Convention in Colorado.
Virginia's specific concerns as requested by Mr.
Perriello's office, we wanted to provide the Subcommittee our
local and regional perspectives and concerns on rural health
care in the Commonwealth of Virginia.
In our Veterans Integrated Service Network, VISN, the rural
health initiatives are centrally funded for only 2 years. The
DAV Department of Virginia is concerned that the VA medical
center directors will not continue to support these initiatives
once this protected and fenced funding ends, and that they
might be tempted to rob Peter to pay Paul within the medical
centers by utilizing funds needed by other VA programs and
applying them to the rural initiatives. We believe that the
rural initiatives should remain centrally funded and not be
made to compete with other VA health care programs or the cause
of a reduction in medical center programs.
Sick and disabled veterans in Virginia have been waiting
patiently for many years to see new Virginia Community Based
Outpatient Clinics or CBOCs, as they're called, to be opened in
the rural areas of our State. Currently we have approved two
CBOC projects that are taking far too long. Each of these CBOCs
is now more than a year overdue in opening. It is our opinion
that efforts are not being made to open new CBOCs
expeditiously, and projected opening dates are usually delayed
by a bureaucratic system that we believe can be improved. Also
for those that are open in Alexandria, Bristol,
Charlottesville, Danville, Fredericksburg, Harrisonburg,
Hillsville, Lynchburg, Norton, Tazewell, Virginia Beach and
Winchester, VA space planning is needed and should be improved.
In our experience VA space configuration does not include
making space available for the occasional visiting clinician,
but only provides space for authorized permanent employees.
When visiting clinicians come to provide services to our rural
veterans in mental health, podiatry and other specialties, they
either have nowhere to see their patients or space for them is
very cramped.
VA space planners need to do a better job of providing for
itinerant providers within CBOC space configurations. Allowing
more space than needed by permanent VA staff also provide us an
opportunity in future years to expand services sooner than
having to wait additional years for clinic construction
projects after the need is identified.
We believe the CBOCs need to provide more services on site
in order to obviate to veterans needing to travel long
distances to major VA Medical Centers for services that they
cannot receive in the CBOCs. The DAV, Department of Virginia,
believes this problem can be solved by VA building what's
called super CBOCs or larger and more extensive outpatient
facilities in rural areas. This should not come at the expense
of reducing service at our major VA Medical Centers.
Over the past year, we have noted that Veterans Health
Administration (VHA) is now working on system redesign,
reforming the VHA as the new patient-focused medical home. We
believe this kind of logic could also be applied to VHA-
Veterans Benefits Administration (VBA) system redesign. We
believe that there are many opportunities between VHA and VBA
to work together in both the health and benefit area, but they
are being missed because of lack of coordination between the
two systems.
Mr. Chairman, this concludes my testimony, and I'll be
happy to answer any questions from you or any other Member of
the Subcommittee.
[The prepared statement of Mr. Woods appears on p. 67.]
Mr. Michaud. Thank you very much for your testimony.
Ms. Tucker, I want to thank you very much as well for
coming here today, and I'm looking forward to your testimony
this morning.
STATEMENT OF LYNN TUCKER
Ms. Tucker. Thank you for having me. I'm glad to be here.
My name is Lynn Tucker, and I'm here to testify on behalf of my
son, Private First Class Benjamin Tucker, a lifelong resident
of the rural community of Museville and the Fifth Congressional
District of Virginia.
Ben enlisted in the United States Marines in May 2004. Ben
served for 22 months before tragedy struck in the form of a
dirt bike accident, leaving him with a traumatic brain injury.
Ben is classified by the Veterans Administration as 100-percent
disabled.
I am here to testify on behalf of Ben's two brothers,
Corporal Jonathan Tucker and Lance Corporal Clayton Tucker, who
served two tours as Marines in Iraq. They suffer from the
effects of repeated IED (improvised explosive device) and RPG
(rocket-propelled grenade) blasts and the deaths of many
friends. I am also here to testify on behalf of all veterans
needing care from the VA.
My testimony today is based as a caregiver to Ben who lives
at home in Museville. Ben's story reveals what should be our
concerns for all veterans, particularly those representing
rural areas. The concerns are access to primary and specialty
care, effective and efficient communication within the VA,
approval and remittance of payments from the VA for medically-
related items and services.
Problems in any of these areas affect rural veterans like
Ben, Jonathan and Clay by limiting medical choices, causing
travel hardships and contributing to an overall breakdown in
the quality of care and life. What we need to remember here is
that these individuals and all veterans made a commitment to
serve and to protect our liberties without the knowledge of the
ultimate outcome.
Access to primary and specialty care is imperative for all
veterans and especially difficult for rural veterans. For Ben,
who requires frequent specialized care, this is quite a
challenge. Ben lives 45 minutes from the Danville CBOC, 1 hour
and 15 minutes from the Salem VA, and 3 hours from the Richmond
VA. Only the Richmond VA can provide all the different types of
care Ben needs and is the least accessible.
In October 2006, Ben returned home after almost a year in
hospitals and was totally dependent for all his care, as he had
no voluntary movement and was fed by a gastric tube. He was
eligible for 15 hours weekly with the VA home health aid
program. Due to his rural location, locating and retaining
certified nursing assistants (CNAs) with the selected VA vendor
was often impossible. Months would pass with no nursing help
and no help from the VA in locating a vendor with nurses
willing to drive the extra distance for a rural client.
Just this last year we were able to retain a reliable,
caring nurse through the VA when a new vendor was selected.
With Ben's monthly VA disability payments, another CNA was
employed after a period of 4 months with no nursing help.
Overall, low payroll compensation, with the added expense of
the additional driving, discourages CNAs from accepting rural
clients.
Ben has a Codman shunt in his brain to drain excess fluid
and requires care from a neurosurgeon. The Salem VA does not
have a neurosurgeon. Therefore, Ben has continued to see a
Roanoke neurosurgeon practicing with Carilion Hospitals.
Getting approvals for appointments is so time-consuming we have
stopped applying for approval of routine visits and use Ben's
Medicare insurance and pay the balance. This is not an
appropriate solution for veterans and conveys that the VA does
not have an appropriate system in place to care for their own.
Many veterans' families that our family is associated with
express concerns about waiting for approval and appointments
with primary care doctors and specialists. Per two VA clinic
staffers in Salem with the intake of more veterans from Iraq
and Afghanistan, the situation is growing worse by the day. Do
VA administrators understand the situation? Effective
communication is a barrier for veterans seeking care and
necessary assistive equipment. Communication between VA
staffers within the administration often results in long delays
or unnecessary denial.
During the summer of 2006, Ben applied for a grant to help
pay for custom wheelchair van. This request was submitted to
the Roanoke Regional VA office. The form was passed along
through the VA from person to person until somewhere a copy was
made and the copy was passed along instead of the original.
After several weeks inquiries were made of the VA on Ben's
behalf with no results. It was not until the family actually
traced the path of the grant form, with the help of Kay Austin
of the Paralyzed Veterans of America, that it was determined
the form was in fact on the desk of a VA employee where it had
laid for 2 months. The employees stated the original was
needed, but had not tried to locate the original or call for a
new original. Ms. Austin faxed a new form, and a second
completed copy was delivered personally to the VA employee.
Veterans often have to wait for needed medications to be
refilled. Just this past month Ben needed renewal on a
medication that took over 12 days to resolve. The CBOC in
Danville received my request by fax and the receipt was
confirmed by a nurse. Three of the medications arrived in the
mail, but the one in question was not on Ben's prescription
list in My HealtheVet. I called the CBOC and left a message on
the nurse line. No one called. Inquiries confirmed that the
message was retrieved off the voice mail but no action was
taken.
Finally, the nurse called to say we need to contact
Richmond for approval. In all it took 12 days for the CBOC to
tell me to call Richmond. Consider this: If you needed
medication for your hypertension, would you be willing to forgo
that for 12 days? Is that not harmful to your health.
Living in a rural area, with the nearest pharmacy 30
minutes away and the nearest VA pharmacy an hour and 15 minutes
away, this problem is compounded. Simple communication would
have alleviated the waste of time, energy and driving to fill
this prescription.
In September 2008, a back sling was requested for Ben by
the Richmond VA Physical Therapy Department to the Richmond VA
Prosthetics Department. A picture and an Internet link were
provided to the employee. After months, many phone calls, e-
mails with the link again, three improper slings were
delivered.
Calls were made to the Guldmann vendor in Texas for the
sling, attempting to provide Ben with the needed equipment.
After calling the Guldmann headquarters and being given the
information for Guldmann Mid-Atlantic, on March 4, 2009, the
correct bath sling was delivered overnight for free by Guldmann
Mid-Atlantic after hearing the difficulty of trying to procure
the sling for Ben.
A veteran in a rural location cannot easily travel to a VA
center and resolve issues in person. VA employees must respond
to e-mails and calls and act appropriately to resolve the issue
of payment. Veterans should not spend days, weeks, or months
waiting by the phone.
During 2008, a recumbent stepper was requested to Salem VA
by a physical therapist for Ben. Ben was taken to the Salem VA
and evaluated by a doctor who approved the request. After
months, calls were made about the equipment and found the
request had never reached the prosthetics department. Shortly,
the Salem VA called, explaining that Ben needed the evaluation
he had already completed. The doctor never entered the
evaluation into the computer and never forwarded the request to
the prosthetics department.
Once this issue was resolved and several months passed,
calls were made again, checking the progress of the request and
again it was denied. The Danville CBOC was notified but no one
notified us. Efforts were made to begin tracking the
documentation to determine why the request was denied. The VA
employee who denied the request was very exasperated and
actually said, ``Why am I in the middle of this?'' The employee
could not grasp why he had to defend his decision nor could he
present procedural or policy issues related to the denial.
After a lengthy discussion debating the need for the
equipment due to Ben's rural location and his physical
condition, the request was approved and the equipment was
delivered.
Payments from the VA for medical services or equipment
outside the VA system are slow to nonexistent, and this traps
the veterans between the VA and the outside vendor. After Ben's
van was delivered in November of 2006, the VA owed a payment to
the dealer it had already approved. After several weeks the
dealer contacted his family asking for help in obtaining the
payment from the VA. Phone calls were made seeking this payment
to no avail. Several weeks later the dealer requested the
payment from Ben. The payment for the van finally reached the
dealer on February 20, 2007, 3 months after the delivery of the
van to Ben.
The van is not the only example of poor payment practices.
Ben currently has collections against him for medical bills the
VA agreed to pay. At first we paid some of the bills ourselves
until realizing this wasn't an exception, but the norm. A great
deal of time has been spent tracking many payments with the
hospital and the VA not willing to communicate with each other.
Currently all collection calls are referred to the VA.
Ben was referred to physical therapy at the Carilion Clinic
in Rocky Mount. During one of his appointments I was called to
the front desk because the center did not have the
authorization number to pay for his therapy. It was necessary
to contact the VA from the front desk of the facility in order
that Ben could complete his appointment. Otherwise Ben or his
family would have had to agree to pay for the therapy.
Ben spent almost 5 months in 2006 at Craig Hospital in
Colorado after we paid over $14,000 to have him flown back. On
his return trip home, the VA agreed to pay for the flight
because it was necessary for him to be evaluated by the Salem
VA before returning home. On the day before the flight, the air
ambulance company asked for a credit card number because the VA
could not locate or approve payment for the flight. Once again
many phone calls were made, adding to an already tense
situation.
In May 2006, my husband and I sat in a meeting with the
Richmond VA after Ben was discharged by the Marines in April.
Ben was an active-duty Marine for 22 months, 2 months short of
eligibility for VA coverage, with no TRICARE insurance and his
VA claim not processed. The VA employee wanted to know how the
bill of approximately $40,000 a month was to be paid if Ben
continued to stay in the polytrauma unit. With no help from the
VA, we investigated and obtained COBRA insurance with TRICARE
for Ben, and the VA was paid.
As a taxpayer and citizen of the United States of America,
it is striking how we take for granted the lives of those who
voluntarily put theirs on the line. Ben, Jonathan, Clay and all
veterans enlisted without knowledge of the outcome. They made a
commitment to their country. Where is their country now? Where
will our country be when all veterans return from Iraq and
Afghanistan? Will they, too, be burdened with forms, phone
calls, red tape and delays? Will they, too, be turned away and
not cared for? We cared to send them.
Thank you for allowing me to come today.
[The prepared statement of Ms. Tucker appears on p. 74.]
Mr. Michaud. Thank you very much, Ms. Tucker, for sharing
your story with the Subcommittee. And we also want to thank
your sons for their service to this great Nation of ours.
Mr. Perriello.
Mr. Perriello. Thank you, Chairman.
Ms. Tucker, how many hours do you think you've spent
processing, appealing the cases involving your sons.
Ms. Tucker. It's countless hours, especially in the very
beginning, getting his VA claim processed, dealing with the
van, dealing with getting nursing care. At one point I was
noting, you know, how much time I was spending, and, you know,
it was just totaling up. It was making me very frustrated
because at that time I needed to be taking care of Ben, not
being on the phone, arguing with one person after another or
sitting, simply sitting on hold.
Once you call into the regional office, sometimes you can
just sit there on hold for 20 minutes waiting for a person to
answer. And that's just too many hours. It shouldn't happen. It
shouldn't happen. It shouldn't happen to do it that way at all.
Mr. Perriello. And in terms of most of these claims, are
they going through the Roanoke office, benefits claims.
Ms. Tucker. As you can see, they went through different
offices. Salem's currently--I mean, Ben is currently under the
Salem VA, so we deal with them a lot. But there are some things
coming from Richmond because of the situation. We were going to
the Danville CBOC, but what happened in that situation was we
started getting bounced between the three in a triangle
sometimes, just trying to get care. It was hard to figure out
who do I call.
So as of this past month, I disenrolled Ben from the
Danville CBOC and started taking him back to Salem. That way
we'll only have two places to deal with instead of three.
Mr. Perriello. As you know, there was a much needed
investigation, Inspector General investigation into the Roanoke
office, which has a very bad track record on claims. Many
people working there are great people who are putting in
countless hours to help veterans. There were both systemic
failures and personal failures there.
Have you seen any improvement of late? Are you seeing the
same pattern of behavior with the various claims you are
fighting.
Ms. Tucker. I don't see any improvement over the last 4
years. Like my testimony said, we're coming up on the fifth
anniversary of when Ben was injured. And over that time period,
I do not see any improvement in communication with the VA. And
I know at the beginning, when I was trying to file some claims,
I was talking to someone on the phone with the regional office,
and I was saying, ``If I have it overnighted would that help?''
And he said, ``Not really. The mailroom is about 3 weeks
behind.'' So once it hits the building, that's where you get
the problem.
Mr. Perriello. As you have gone through this, have you had
apologies from people in the system for the delays and the
mistakes or not.
Ms. Tucker. Sometimes, yes, you know, I have had apologies.
I have met some people who are very helpful. Some people I know
I can call on to help me to get through some things. I have
also run into some people that were, quite frankly, incompetent
and should not have been in that position. I had worked for
some people who simply just were lackadaisical and just cannot
get back with me.
Mr. Perriello. With the processes that are going forward,
what are some of the--aside from dealing with the VA itself, as
a veteran caregiver, what are some of the challenges you have
faced over that time period besides the obvious pain and
frustration of the delays and bureaucracy that we have talked
about that you face as a caregiver.
Ms. Tucker. Well, of course, as Ben's mother, and our
family, all our family, you know, it is traumatic to see
someone you love so much be hurt. And through that time he has
had global aphasia and he cannot communicate to us. He does not
understand language, I'm being told. He cannot even answer
``yes'' or ``no.'' So it's very frustrating for him and for us,
trying to keep him comfortable and happy. When he does get
upset and frustrated, we have to keep trying things, much as
you would a small infant, trying to figure out what is he upset
about, until we, you know, can find out how--how to make him
comfortable and not so frustrated.
Mr. Perriello. I have met your son, and I know what he goes
through, but I also know what you go through. And, you know, a
mother's love is tireless, but it's really incredible what you
have done, again, not just to take care of him, but also keep
an eye on his brothers and to speak up for so many veterans.
One of the things we have done--and Chairman Michaud has
worked on this, as well--is trying to get more supportive
caregivers, whether that's extending training benefits or
health benefits, other things to caregivers who so often,
whether it's a spouse or a mother or, you know, parent, may
have to leave a job just to be taking care full-time and
knowing that, in many cases, that's a higher quality of care
and a more 24-7 service and where we can help get some medical
training to the family members and benefits with the family
member.
We have had some strides in that area, but we'll continue
to work obviously with your specific case as well as trying to
look at where we allow those gaps that families fall through,
and of course for those who have been willing to make the
ultimate sacrifice or at least put themselves in a position
where that might happen.
We're also seeing in general that because again, as I
mentioned earlier, these great advances in battlefront
medicine--I know in Ben's case it was not battlefront, but we
are seeing people come back who are very young, and we're
looking at not a couple years of care, but we're talking about
a lifetime of care. So we need to be incredibly caring but also
creative about how we think about ensuring not just a minimum
standard of living but a high quality of life for veterans and
their family members, and we'll continue to work with you, with
you on that.
A couple of questions for the others on the panel. One of
the things that many of you touched on is while we do have a
long way to go in terms of access to care for our rural
veterans, we have also made some strides in recent years.
And one of the things that I would like to ask that Mr.
Boyer commented on is what's working in terms of getting
information out. I do believe that the vans, the rural vans are
parked out back. I came in the front, so I didn't see them.
What's working? What do we need to do more of to make sure
that veterans know what benefits already exist as well as
trying to fill those gaps.
Mr. Boyer. Continued outreach and all means of
communication.
In my particular case, my VSO is constantly contacted by
mostly elderly veterans, inquiring about what they're eligible
for. You know, this is just my observation. I think that World
War II veterans and, to a degree, Korean War veterans, when
they were demobilized, made a promise to themselves to never
get involved again. Mostly for their working lives they did not
do that, and now in their declining years and limited resources
and no other insurance, they want to know, well, what am I
eligible for in the VA, and they're at a loss. When you tell
them and show them what they're eligible for and they look at
the paperwork, what they have to fill out, you know, their eyes
tend to glaze over.
So we in the VSO community have to be helpful. The Virginia
Department of Veterans' Services has some 28 field agents
around the State whose primary purpose is to help the veterans
fill out the paperwork. Since they are semi-experts, if they do
the paperwork, it has a chance to be evaluated successfully. I
just would encourage--you know, in rural areas word of mouth is
still the--the primary issue, not only for elderly veterans,
but also for the National Guard and the Reserve, fellows who
have been demobilized and come back to their rural communities,
they face the same problem the elderly veterans do but for a
different reason. They're just not aware of what is available
although it may have been discussed when they were
demobilizing.
For example, there's a program called Benefits Delivery at
Discharge. But they're just not concentrating. They have their
minds on other things. We have to continue to try to reach out
through all the means of communication.
Dr. Mitrione. In asking that kind of question, what kind of
services, satisfaction factor, I kind of, like, looked out in
the southwestern tip, because I thought that was probably one
of the more remote areas, and I got very good vibrations, very
good reports from the--the Hills people, that went out to the
Hillsville, the Tazewell, the Norton, people down in South Hill
who were very satisfied with the RV that came down, provided
services down there.
I think in some cases you see that we have a system that's
being swamped by requests for services. I think veterans
organizations such as the VFW, I know that in--in American
Legion, we're putting a lot of emphasis on our service officer
program. We have started training sessions across the State,
trying to get qualified people, trying to reach out to veterans
who can come to these--these specialists, and these specialists
take the--their claims. They try and marshal them through the
system. I think that the--the veterans organizations provide a
very valuable service in that respect.
But, again, it's an organization just like any other, not
only government, but I think, in many cases, corporate, where
there are inefficiencies that need to be addressed, and there
are people who maybe aren't the best. They aren't suited for
the job they're in, and those people need to be sought out and
told if you are not happy here, you can get a job somewhere
else and be happy.
Mr. Perriello. Well, we certainly will have a zero
tolerance policy, but we also want to build on the successes.
One of the ones that you mentioned, Mr. Boyer, and I'll
head back to you, is the Virginia Wounded Warrior Project. And
I certainly have been very impressed by their work, and in
particular their ability to engage some of the younger veterans
who have shied away in some cases from some of the traditional
outlets. What lessons can we learn from them that might be
something we could take to scale?
Mr. Boyer. Collaboration. The Wounded Warrior Program is
beginning its third year with the General Assembly providing $2
million per year and supported by $150,000 or so per year in
private funds. We have an executive director, but it's
administered through--we have five regional consortia where we
have a regional director, and the services are implemented
through community service boards, which are already in
existence.
It's a collaborative effort. We have partnered with the VA.
The VISN 6 Director sits on the Wounded Warrior Executive
Board. The rural health teams in VISN 6 have made contacts with
our regional directors and attended a couple events. They are
looking for ways to join together to provide the services that
particularly rural veterans, National Guardsmen and Reservists
are not aware of, and many of them, you know, need them
desperately.
Mr. Woods. One of the things that we are doing in the DAV
is for the Guard and the troops coming back, we have meetings
in Richmond, meet with them when they come back, give them
handouts, let them know what's available to them. A lot of the
kids come back and they really don't realize what kind of
benefits are available. So before they get out in the outlying
areas, we try to catch them and do a brief--we give them some
booklets, give them some phone numbers, say if they have any
problems, contact us so we can get somebody within your area.
Because in the outlying areas we have, in the DAV, they can
assist them, so they don't have to worry about traveling when
they get the information they need.
Mr. Perriello. The good news is we have increased funding
for the VA in general significantly over the last couple years,
and one of the areas is rural health where we have been able to
see this. But just like the primary care facility we talked
about earlier, I think now has to be a time of some
experimentation as well, because we are dealing with so many
new factors, whether it's the new veterans coming in or, as you
said, a generation reaching a different type of need, Korean/
Vietnam vets hitting into that aging level where some who were
not enlisting before are coming in.
So I think one of the things we want the capacity to do is
to try different outreach efforts, try different collaboration
efforts, try work with, you know, different VSOs as partners.
And the more we can get rapid feedback from you as you have
gone out and done repeatedly and say, hey, this is a program
we're getting good feedback on--the CBOC is an example of that,
where we have got overwhelmingly positive feedback from CBOC.
So there's some real concerns, not just Ms. Tucker's, but
in one case we have lost someone who was doing a lot of the
mental health work, and that just sets you back in a tremendous
way. Sometimes that's just a person needing to move on, and in
some case that's a systemic failure. But overall people seem to
be pleased with the direction we are going with the CBOCs. The
same way with outreach. I just hope you will continue to do the
diligent job you have done in letting us know in real-time,
hey, this isn't working, we like the idea of the vans, but we
haven't seen the vans here.
One of the things that we spent a lot of time on last year
was the implementation of the new Post-9/11 GI Bill, and that
was a substantial new investment in our veterans, but it was
also complicated because we were doing it for the first time.
In working with the VSOs, we were able to take what could have
been a real logistical nightmare in terms of payments and other
things, and I think we were able to implement that relatively
smoothly and now have about 250,000 veterans enrolled in the
new GI Bill.
So in the same way as we roll out some of the new rural
health proposals and outreach, I just really appreciate the
real-time feedback we're getting and hope to build on that and
see areas that we need to do it and again have a zero tolerant
strategy for those who are vigilant with our veterans.
With that, I yield back.
Mr. Michaud. Ms. Tucker, once again, thank you for sharing
your story.
I am concerned about the daily challenges that you face as
a mother caring for your son, Ben. VA is supposed to have a
case manager to help families maneuver through the VA health
care system. Did your family have a case manager assigned? And
if so, do you have any recommendations of how we can have case
managers do a better job?
Ms. Tucker. Okay. Over the years we did have several
different social workers that were there to help us. At the
very beginning, I became aware that the social worker that was
trying to help us just could not handle what I needed her to
do. So when we were in the Richmond VA, on Mondays, Ben and I,
I would put him in his wheelchair, and we'd walk the halls
looking for help, people to tell me just what do I do, because
I had no idea. I was overwhelmed. You know, like others had
mentioned the forms. You look at them, and you do--our eyes
glaze over, because you don't know how you're ever going to
fill in all those blanks, pull all of that information
together.
So I did occasionally, you know, run across someone that
could really help me. Now I have two people in the VA I know I
can go to, that can point me in the right direction, like
Rhonda Fletcher at the Salem VA is one person, Kamisha Thornton
at the Richmond VA another one. Those two people have been able
to help me.
One of the people that couldn't help me, in the beginning
actually, when I went back to the Richmond VA, they put her in
a management position. And I do not understand how, when she
could not help me on a lower level, why she is now in a
management position. You know, that's one of the problems with
the VA. Supervision needs to be able to see that their workers
are getting their cases handled, their jobs done.
Mr. Michaud. You said you had several----
Ms. Tucker. Yes, because we have moved around so much. We
were in the Richmond VA. We dealt with Salem VA. And we've
dealt with the Hampton VA. And every time we go to a different
VA, you end up with a different social worker following you
around. It's not just one person. And so sometimes you run into
people that just cannot help you, and you know that pretty
quickly.
One thing that has saved me is the fact that I am a
certified public accountant. I was chief financial officer of a
company before I left my job to care for Ben. So I was used to
negotiating, you know, complicated forms and organizations and
different things like that.
One of the horrors that I thought of as I've gone along is
like with aging veterans that are standing there that may be 70
years old, 80 years old, and they need help, and how are they
going to get the help, you know, if they're not able to push
for it, they're not able to write the payments? If they end up
hitting a caseworker like some that I've gotten, that
absolutely do not do their job, then they will be dead before
they get help.
Mr. Michaud. Other than probably simplifying the forms,
when you did actually get Ben to the VA system, were there
waiting times, for instance, you coming in at 10:00, and
waiting until 2:00 or 3:00? Or were they pretty prompt in that
area?
Ms. Tucker. That I haven't run into, extreme waiting times.
I haven't in the clinics. You know, sometimes they have to put
appointments off. Like I said, with Ben, sometimes the Salem VA
cannot provide his care. I then would have to go outside to get
it. But waiting time for appointments has not been a huge
problem. I've usually always had, like, a 2:00 or 11:00, not
just a ``come in 8:00 in the morning'' type of situation.
Mr. Michaud. Mr. Woods, in your testimony you noted the
system between the VHA and the VBA should be redesigned. You
further stated that there are many opportunities for VHA and
VBA to work together. Could you expand upon that point? What
are the missing opportunities between the VHA and VBA?
Mr. Woods. We feel that they are missing the opportunity to
work together. You know, even though one is providing the
benefit and the other is providing the administrative part, if
they can link those two things together and not have a
disconnect where one has to get the paperwork and the other one
has to take out a medical evaluation, if they could work
together, pull those two things together, it would cut down the
lead time where a veteran has to wait to get the claim back.
We don't feel they're working close enough together. This
person has to have it in so many days, and they have to work it
before they get it to the other area. If they were connected
together, we feel that would cut down a lot of the lead time,
something they need to look at. Just our thoughts. We feel they
need to look at that.
Mr. Michaud. Okay. As was stated earlier on the first
panel, and you have touched upon it, if you look within the VA
system, with the new rules as it relates to Agent Orange, as it
relates to post-traumatic stress disorder, look at actually
increasing access to health care for veterans that are Priority
8 veterans, you look at the fact that this Administration is
sending more troops to Afghanistan, clearly there's going to be
more of a burden upon the VA system to be able to handle this
all at once, and on top of that, a process where we're hearing
a lot of complaints about delays in getting, you know,
veterans' paperwork processed in a timely manner, has any of
the VSOs in your organizations looked at ways that the VA might
be able to streamline the process to make it more efficient
and--but haven't actually moved forward in that regard?
Mr. Boyer. If I may address that, the VFW strongly believes
that the administration is not going to make improvement in
processing paperwork as long as that system is using pencils.
If they go to electronic records processing with a link between
the U.S. Department of Defense (DoD) and the VA, until they do
that, they're not going to make headway in processing all these
benefit claims.
In the State of Virginia we have an automated electronic
data processing system. It's been demonstrated. We're finishing
the demonstration this year. We have discussed it with the VA.
I've talked to our Congressional delegation in Virginia about
the need for electronic data processing. Everybody agrees
there's no momentum, nothing is happening concretely. It's
talk, agreement, no action.
Mr. Mitrione. We believe that this is a technology that's
here. I mean, I know that if an individual fails to include a
1099 miscellaneous on his income tax, the Internal Revenue
Service definitely knows about it regardless of where it came
from. So from the VA system, why they cannot take care of or at
least incorporate this same kind of technology--you know, they
may be moving in that direction. They may not be moving fast
enough to get it done.
Mr. Michaud. On the subject of collaboration to let our
veterans know what they're entitled to, how closely do the VSOs
work with the State? We've actually invited the Virginia
Department of Veterans' Services to come testify today. They
chose not to. Disappointing in that fact.
But I think we could learn a lot from the State, and in
other field hearings that we've had the State has testified.
How do you feel that the State is doing as far as helping
veterans move forward with their issues?
Mr. Woods. What we have is we have 130 service officers
throughout the Commonwealth dealing in our different chapters
that work the cases, veterans come through. They get certified
once a year so they know how to fill out the claims and what
they need to send them forward. The ball is being dropped
someplace within the system. After you send the information in,
it's not being processed in a timely manner. We feel the
backlog is causing that.
But the service officers are really doing what they're
taught to do, what information they need on the form, how to
fill the forms out. There are so many different forms that
you've got to go through, you've got to know how to fill them
out. If you fill the forms out wrong, it's going to get kicked
out. It's going to be frustrating. By having a service officer
filling it out, you eliminate that.
I think if we continue that process, the VSO starts doing
what they're supposed to do, we're going to limit some of this
backlog.
Mr. Boyer. Mr. Chairman, if I might address that question,
as Chairman of the Joint Leadership Council of the Veterans
Service Organizations, I worked directly with the Virginia
Department of Veterans' Services. And I would like to say that
the Department of Veterans' Services has a very comprehensive
program. We have 28 field agents scattered around the State
whose primary purpose is to work with veterans and help them
access the VA system. We would like to have more, but, you
know, funding, funding is an issue.
The Department of Veterans' Services manages the Virginia
Wounded Warrior Program. The Executive Director works for the
Virginia Department of Veterans' Services. And that is an
effort that they have been pushing very, very strongly. There
is a concerted effort within the Department to increase the
outreach to veterans, and it's only limited by the amount of
funds available.
Ms. Tucker. I was just going to say that the VBA has been
so helpful with Ben's case. If I hadn't been directed toward
them when I did, I would have been very buried under the forms.
It's a shame that we have so many that you have to have service
organizations like that to help you.
And one of my sons is currently switching to the VBA
because the service organizations, the State that it was using,
you know, just didn't seem to help at all, didn't seem to
advocate on his behalf. So the VBA is going to take over his
case now.
Mr. Michaud. Once again, I want to thank all of you for
coming this morning. I really appreciate your willingness to
inform the Subcommittee on what's happening in Virginia on
rural health care for our veterans.
And once again, Ms. Tucker, I want to thank you for telling
us your story, and it definitely has not fallen on deaf ears in
this Subcommittee. I really appreciate your willingness to come
out. I know it can't be easy. I know at times it is extremely
frustrating being in your position, trying to take care of Ben.
But it's always extremely frustrating on this side when we
provide the VA with what we think are adequate resources, but
we're still continuing to hear problems veterans have to go
through. Hopefully, we'll be able to eventually have a system
where, when the veterans need help, they'll get it, and they'll
get it in a timely way.
So once again, I want to thank this panel's willingness to
come out this morning.
Mr. Perriello. Thank you all.
Mr. Michaud. We'll invite the third panel to come forward.
Mr. Perriello. Thank you, Mr. Chairman.
If the third panel will come up.
Assistant Deputy Under Secretary for Policy and Planning,
Patricia Vandenberg, who I have had the pleasure of meeting
with by phone, but we were meeting in person earlier today for
the first time, and we'll continue to talk with her. She is the
Acting Director of the Office of Rural Health for the Veterans
Health Administration, U.S. Department of Veterans Affairs. We
are happy to have her down in the district today.
We also have Daniel Hoffman with us, who is the Network
Director of VISN 6, Veterans Health Administration, U.S.
Department of Veterans Affairs; as well as Carol Bogedain, the
Interim Director of the Salem VA Medical Center (VAMC), which I
have had the pleasure of touring before and hope to get back to
again, and which services many, many of the veterans in Central
and Southern Virginia. We do split some with Richmond and
Durham, but again, probably the bulk of the Salem area, and we
have generally heard very positive reviews of everything going
on over at Salem.
So we appreciate the three of them being here today and
look forward to your testimony.
STATEMENTS OF PATRICIA VANDENBERG, MHA, BS, ASSISTANT DEPUTY
UNDER SECRETARY FOR HEALTH FOR POLICY AND PLANNING, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY DANIEL F. HOFFMAN, FACHE, NETWORK DIRECTOR,
VETERANS AFFAIRS MID-ATLANTIC HEALTH CARE NETWORK, VETERANS
INTEGRATED SERVICES NETWORK 6, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; AND CAROL BOGEDAIN, MS,
RD, CPHQ, FACHE, INTERIM MEDICAL CENTER DIRECTOR, SALEM
VETERANS AFFAIRS MEDICAL CENTER, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF PATRICIA VANDENBERG, MHA, BS
Ms. Vandenberg. Thank you.
For the record, I would like to acknowledge that we have a
Director at the Office of Rural Health, Dr. Mary Beth Skupien.
She began her service to the VA on July 6. She is coming to us
from the Indian Health Service, where she has served both as a
care provider and nurse practitioner, as well as in a variety
of administrative positions. She had a nursing practice and has
a doctorate in public health from Johns Hopkins. So I'm
delighted to have her on the team.
I will continue to be actively involved in all matters
pertaining to the Office of Rural Health and, most
particularly, the implementation of Section 403. So we decided
that it is most appropriate for me to be here today to address
the Subcommittee.
We appreciate this opportunity of you inviting us here
today to discuss the progress the Department of Veterans
Affairs has made in implementing Section 403 of Public Law 110-
387, as well as the VA's efforts to increase access to quality
health care for veterans living in rural and highly rural
communities in Virginia.
I'm accompanied today by Mr. Daniel Hoffman, the Network
Director, and Ms. Carol Bogedain, Interim Director of the Salem
VA.
Mr. Perriello. If you could move the microphone closer,
there are some hands going up in the back.
Ms. Vandenberg. As you know, the VA is required to conduct
a pilot program to provide health care services to eligible
veterans through contractual arrangements with non-VA
providers. This statute directs that the pilot program be
conducted in at least five VISNs. The VA has determined that
VISNs 1, 6, 15, 18, and 19 meet the statute's requirements.
This program will explore opportunities for collaboration with
non-VA providers to examine innovative ways to provide health
care for veterans in remote areas.
Immediately after Public Law 110-387 was enacted, the VA
established a cross-functional workgroup with a wide range of
representatives from various offices as well as VISN
representatives to identify issues and develop an
implementation plan. The VA soon realized that the pilot
program could not be responsibly commenced within 120 days of
the laws enactment as required. In March and June of 2009, VA
officials briefed Congressional staff on these implementation
issues.
VA has made notable strides in preparing for the
implementation of Section 403 with the goal of having the pilot
program operational in late 2010 or early 2011. Specifically,
VA has developed an implementation plan, which contains
recommendations made by the workgroup, analyzed our driving
distances for each enrollee to identify eligible veterans and
reconfigured our data systems, provided eligible enrollee
distribution maps to each participating VISN to aid in planning
for potential pilot sites, developed an internal request for
proposals that was disseminated to the five VISNs, asking for
proposals on potential pilot sites, developed an application
form that will be used for veterans participating in the pilot
program. And we have taken action to leverage lessons learned
from the Healthcare Effectiveness through Resource Optimization
pilot program, HERO, and adapt it for purposes of this pilot
program.
VA has assembled an evaluation team of subject matter
experts to review the proposals from the five VISNs regarding
potential implementation. This team will then recommend
specific locations for approval by the Under Secretary of
Health. We anticipate this process will be completed this
summer.
After sites have been selected, VA will begin the
acquisitions process. Since this process depends to some degree
on the willingness of non-VA providers to participate, VA is
unable to provide a definitive timeline for completion, but
we're making every effort to have these contracts in place by
the fall. This would allow VA to begin the pilot program in
late 2010 or early 2011.
VA is developing information materials for veterans
participating in the pilot program for non-VA providers and for
VA employees and other affected populations so that when the
pilot is implemented all parties will have the information they
need to fully utilize these services. VA is committed to
implementing the program directed by Congress and to maintain
the quality of the care veterans receive.
Other issues such as securing the exchange of medical
information, which was referred to several times this morning,
as well as verifying veterans' eligibility for this pilot
program, coordinating care, and evaluating the success of the
pilot program are also important priorities. And we are working
to ensure that there is appropriate implementation in the pilot
program.
As was referenced by Mr. Thackston and his colleagues, I
appreciated the opportunity to meet with Congressman Perriello
and his staff and interested stakeholders several weeks ago.
The prior panels this morning have addressed important issues
facing veterans in rural communities, and I value the
opportunity to hear their perspectives and will take insights
learned back to the implementation of this pilot.
Thank you again for the opportunity to discuss the status
of the pilot program with you today.
[The prepared statement of Ms. Vandenberg appears on p.
76.]
STATEMENT OF DANIEL F. HOFFMAN, FACHE
Mr. Hoffman. Good morning, Mr. Chairman and Congressman
Perriello. Thank you for the opportunity to share what we in
VA's Mid-Atlantic Health Care Network are doing to reach out to
veterans in our rural areas.
Increasing access for veterans is one of the Secretary's
top priorities for the Department. This has several components
immediately relevant to rural veterans. It means bringing care
closer to home, sometimes even into the veteran's home. It
means increasing the quality in the care we deliver, and it
means providing veterans-centered care in a time and manner
that is convenient to our veterans.
It's my responsibility to increase access for veterans in
North Carolina, Virginia and the southeastern portion of West
Virginia. VISN 6 encompasses more than 88,000 square miles, 53
percent of which is rural or highly rural. The veteran
population for our area is in excess of 1.5 million, and
between October 1, 2009, and June 30, 2010, we have cared for
more than 319,000 veterans.
To meet the growing demand for health care, we have
aggressively worked to increase capacity, we have added to or
enhanced each of our eight medical centers, and we have grown
from two community-based outpatient clinics less than 10 years
ago to a current total of 17. Our plan calls for 11 more to be
added by the end of fiscal year 2013. In all, over the next 3
years, VISN 6 will add more than 1.5 million square feet of
health care space for veterans. With these additional sites of
care, more than 90 percent of our veteran population will be
within 60 minutes of a VA health care facility.
However, our efforts to care for veterans living in rural
areas go beyond bricks and mortar. Our rural health teams are
working diligently to find new and better ways to affect care
in the rural areas. In May of 2009, VISN 6 began laying the
foundation for what is now our rural health program. In July of
2009, clinicians, staff and medical center directors developed
a strategy to bring together the many resources which
contribute to enhancing and integrating our rural health
efforts.
We created eight teams of professionals based out of each
of our eight medical centers made up of pharmacists, nurses,
social workers and others whose focus is to make VA care
available closer to veterans' homes, and sometimes even into
our veterans' homes. These teams are now fully staffed and are
now currently developing and deploying strategies to enhance
care, specifically focusing on areas they serve.
Three of the teams representing Virginia--from Salem,
Richmond, and Hampton--are set up outside today for veterans to
visit. We're also reaching out to partner with and leverage the
many programs already in existence. Our teams are working
closely with the Virginia Wounded Warrior Program, and we are
meeting with universities like Old Dominion, the Eastern
Virginia Medical School and the University of Virginia and Via
Osteopathic School to share the knowledge they have
accumulated. Additionally, we are working with the Indian
Health Service and local tribal councils to provide for our
veterans of Native American heritage.
VISN 6 has reached out to Native American veterans through
the use of a mobile van based clinic you can see and tour
outside. Operating out of this mobile clinic, five VA staffers
provide primary care on five Native American reservations
located in Virginia. Each month the clinic visits the
Chickahominy Tribe, Eastern Chickahominy Tribe, Pamunkey Tribe,
Upper Mattaponi Tribe, and the Rappahannock Tribe.
In line with VA's efforts in other rural areas, we are also
leveraging technology to strengthen our telehealth program
designed to close the geographic gap between providers,
specialists and patients. Currently all of our CBOCs are
equipped with telemedicine, to bring additional services closer
to where our veterans reside.
One of our great success stories is the use of teleretinal
imaging for diabetic retinopathy. This system is now up and
running in 22 sites, and because early detection allows for
early treatment, we have saved many veterans from going blind.
We have also enhanced our telemental health services based out
of the Salem VAMC. This program currently provides telemental
health to veterans in Tazewell, Hillsville, Danville and
Lynchburg. It will be expanded to serve the new Wytheville and
Staunton clinics when they open. This program has served more
than 330 veterans by offering medication evaluation and
management, substance abuse evaluation and treatment and
treatment for both combat and other military trauma.
In our efforts to become the provider of choice for our
women veterans, we have hired a women's health coordinator for
the VISN, one for each State and one in each hospital. They are
overseeing our progress in developing a women-friendly
atmosphere and are working hard to get the message out that
this is not just your grandfather's VA. We have been and will
continue to make huge leaps forward on providing gender
specific care in safe and comfortable environments.
Beyond the use of telemedicine and mobile clinics we are
also using low-tech methods like direct mail. As a trial in
June, we mailed letters to 10,000 women veterans in West
Virginia, inviting them to consider using the VA for their
primary and gender specific care.
The bottom line is that throughout VISN 6 we're working
hard to live up to our motto: ``Excellent service, earned by
veterans, delivered here.'' Thank you again for the opportunity
to share what the men and woman of VISN 6 are doing to help
improve the lives of veterans. I look forward to responding to
any of your questions.
STATEMENT OF CAROL BOGEDAIN, MS, RD, CPHQ, FACHE
Ms. Bogedain. Good morning, Mr. Chairman, Congressman
Perriello. Thank you for inviting me here today to discuss the
programs at the Salem VA Medical Center with respect to
outreach and care for rural veterans.
The Salem VA Medical Center is part of VISN 6 and serves
veterans throughout Virginia for psychiatric care and
Southwestern Virginia for medical and surgical care. We have
community-based outpatient clinics in Lynchburg, Danville,
Tazewell and we have a site of care at Hillsville. And we plan
to open VA staffed CBOC in Wytheville and Staunton in January
of 2011. As a side note, we're having the groundbreaking for
the Wytheville CBOC today. The Vet Center in Roanoke provides
services to our CBOC and support counseling groups in
consultation, and they do travel to other areas.
The Salem VA Medical Center has several programs that
provide services to rural veterans. Our rural health team in
Salem began serving veterans in our catchment areas in May of
2010, and we have 14 staff members who support this initiative,
including both clinical and nonclinical employees. The team
works closely with many of our other outreach programs such as
home-based primary care, telemedicine, our women's health
program, mental health, the OEF/OIF, and other services to
address the needs of rural veterans. The team educates veterans
on eligibility and enrollment and disease specific issues. They
offer pharmacy consultations, provide blood pressure and body
mass index screening and promotes My HealtheVet, which is the
VA's personal electronic health record.
We use visual aids, models and presentations and videos to
educate the veterans for their needs. We're reaching out to
veterans at VA, Community, VSO and other events and
organizations. To date approximately 40 events or visits have
occurred. There's 15 more that have been confirmed and
scheduled and we continue to outreach.
As part of our outreach, the team helps veterans in rural
and VA health care. Veterans have the option of enrolling
either face-to-face with VA staff or filling out a 10-10EZ
Health Application Enrollment Form. We are focusing our
outreach efforts on women, women veterans, and OEF/OIF veterans
in particular. The rural health team is coordinating with our
Veterans Health Clinic to educate women in rural areas.
We have already completed training of our providers in
gender specific care, and we'll also have additional training
provided at the Salem VAMC for the rural health nurses by the
Eastern Virginia Medical School. The rural health team has
attended pre- and post-deployment events in collaboration with
our OEI/OIF program coordinator.
Salem VA Medical Center supports the Volunteer
Transportation Network that runs each Thursday from
Martinsville for veterans who have scheduled appointments at
the Salem Medical Center. We have also recently recruited a
volunteer driver who will operate a shuttle van from the
Danville CBOC to meet the Martinsville van. Between October and
mid-May, the Martinsville van travelled 4,285 miles and
transported 112 veterans during 28 trips to the Salem VA
Medical Center. We have ordered an additional van to be based
in Danville to transport even more veterans.
We also offer a range of specialty programs. Home-based
primary care delivers primary health care in the veteran's home
through an interdisciplinary team of VA specialists. Another
program, telemental health, which we discussed earlier, is
currently used in conjunction with comprehensive on-site
services at are CBOCs to offer specialty mental health
surfaces. We currently offer telemental health care at the
Tazewell, Hillsville, Danville and Lynchburg CBOCs and plan to
provide these services at the new CBOCs in Wytheville and
Staunton.
The Salem VA Medical Center has provided Care Coordination
Home Telehealth to veterans since 2005. This program utilizes
an in-home device to help VA and veterans monitor their health
status on a daily basis.
Congressman Perriello, in conclusion I'd like to address
some of the concerns that you and others have raised in a
conversation that we had last week on our conference call. We
appreciate the opportunity to speak with you and your staff and
to better communicate with our veterans.
We are sending a letter to all of our veterans who use the
Danville CBOC to explain that they can choose a medical home
and identify which hospital they would prefer to use for
services the clinic cannot provide. We will also work to ensure
all Danville providers have the necessary credentialing and
privileging at the Salem, Durham, and Richmond VA Medical
Centers to allow our doctors to order tests, consultations,
medications and any other services our veterans need, and that
process has started. We will also do a better job communicating
with the local VSOs to explain these policies and what we're
doing to improve the care, particularly in Danville.
Thank you for the opportunity to present the many programs
we offer to the veterans in the Salem rural areas, and I look
forward to answering any questions you may have.
Mr. Michaud. Thank you, all three of you, for your
testimony this morning. I appreciate your coming forward.
Mr. Hoffman, you quoted the slogan that you go by. Could
you repeat the motto again?
Mr. Hoffman. What we decided----
Mr. Michaud. No. Could you read your motto----
Mr. Hoffman. Sure.
Mr. Michaud [continuing]. Once again? I didn't know if I
missed it or not.
Mr. Hoffman. Starting from we created eight teams----
Mr. Michaud. No. You said you have a motto.
Mr. Hoffman. Oh, the motto. I'm sorry. I thought you said
the ``model.''
Mr. Michaud. No.
Mr. Hoffman. ``Excellent service earned by veterans
delivered here.''
Mr. Michaud. You heard the testimony of the two previous
panels. You heard Ms. Tucker's concern with her son. If I was
evaluating based upon what you stated, I probably would have to
fail the VA for not living up to the motto. What seems to be
the problem.
Words are cheap. Action is what counts. In my opinion, you
did not live up to that motto. And as I heard from other
veterans earlier as well, there's concern here. So what are you
doing to live up to that motto? What resources do you need?
Where has the VA failed you as a VISN Director? Do you want to
respond?
Mr. Hoffman. First, I would agree with you, we failed Ms.
Tucker. And I would not hold that out as my example of good VA
care. We would hope and in fact we have done very, very good
things in the VA in a lot of cases, but that one I cannot be
proud of. And I'm sure the people that have worked on her would
not be proud of that as well.
One of the things that I have heard in focus groups and
other venues that we're taking much more seriously is--and what
I heard from Ms. Tucker and others, is that we do have case
managers, but we don't have just one. And you were very
perceptive in your question, who is your case manager, and Ms.
Tucker mentioned at least two and others over her last 5 years.
One of the comments that came out of the focus group that
struck me as being critical in all of this is who manages the
case managers on behalf of veterans. I think that's something
we need to do much better. It is, frankly, something that our
whole medical home concept that has been recently implemented I
think will help. We're still in the implementation stages on
that, but essentially it sets up within the medical home, the
medical home chosen by the veteran and their family to increase
case management services on behalf of that veteran.
So, to make invisible the very complex system which is VA,
not just VHA but VBA and all of the other issues, I'd like to
think that the money that we have received already for rural
health will also help in that regard, just being able to make
contact with these folks, getting them enrolled in our system
and then being able to have the opportunity to case manage
we'll also adopt.
I think you also heard issues related to our information
technology functions, and it's something that I think we think
is very important--I know we think is very important from our
leadership point of view, to move as quickly and with alacrity
as possible to not only upgrade our current system which was a
leader for a long period of time in health care, but to
synchronize that with DoD and with the private community.
We're actually engaged in this VISN in a pilot to do just
that in our Hampton facility. Hampton is teaming up with DoD in
Portsmouth and with the Bon Secours Health Care System and with
the State of Virginia who has experience in this area.
Hopefully that will move the process forward to pilot these
things.
Mr. Michaud. To give you an example, I'm going to add to
that. Then I'll ask you a specific question. In Maine, a mill
that I worked at filed bankruptcy, and they shut the mill down
in East Millinocket. I did know that the different drug
companies offered either no- or low-cost prescription drugs for
people who qualify. What I didn't know is that there were over
385 different types of programs within all the drug agents and
drug companies. People had to fill out seven or eight pages in
applications to see if they qualified for any of these specific
programs. When Senator Snowe and I approached Pharmaceutical
Research and Manufacturers of America (PhRMA), we asked them if
they could simplify that. They did. The process boiled down to
four simple questions, and the computer did the rest of the
work.
We heard earlier today about filling out paperwork after
paperwork, getting denied, encountering delays. They're using
pencils. What have you done as a VISN Director to streamline
that process.
I'll be asking the same question of Ms. Vandenberg as well.
It's more than just money. It's about trying to make the
process smoother, more efficient. Have you done anything to
simplify the process by collaborating between VHA and VBA?
Mr. Hoffman. Well, we do work closely with VBA. But I think
both of us--I'm speaking for VBA and I probably shouldn't. But
I think we both feel a little behind the technology curve. One
of the analogies was we feel like we're digging the Panama
Canal with a teaspoon. And all of the comments that have to do
with upgrading our system so that we can automate and share
records more transparently between VBA and VHA would all be
welcomed. We can't really do that independently of the entire
system. But we actively adopt all of the systems that are made
available to us.
Mr. Michaud. Even within VHA I've heard several complaints
on setting up an appointment for a veteran. Once they get
there, they have to wait there all day. In some cases, they
still can't see the doctor. That's concerning, especially when
they have to travel in Maine, for instance, 4 or 5 hours. So
it's not only between VBA and VHA. It's within VHA as well.
So what are you doing to make sure that veterans are not
wasting their time to get adequate health care? Have you
streamlined that process, or is it not a problem within VISN 6.
Mr. Hoffman. No, I would not be so bold as to say it's not
a problem in VISN 6. It is a problem, multiservice scheduling,
and it's one that's frankly been brought up through our
national leadership board to VA, national VA.
Centralizing, coordinating scheduling is something that's
vital for our future. We have tried our own manual work-
arounds, and it's basically a case management issue at this
point where if a given veteran we know needs two or more
appointments at a given location, we will try our best to try
to get those appointments grouped in a tighter time frame, so
if they come in the morning they don't have to stay the whole
day. They can return home by noon.
We don't always succeed in that, and it's not always easy,
because we're doing it manually. You know, it's our case
manager calling the various appointment people and trying to
get those appointments rather than having to collate and neatly
put together in the most economic time, economic fashion for
our veterans.
Mr. Michaud. Have you ever run into the situation, in
contracting out care, where a veteran would have to travel some
distance to get health care?
First of all, I'll use an example I heard this past
weekend, where a veteran had to travel 4 hours for a 15-minute
hearing exam and ultimately couldn't get that hearing exam, and
had to travel another 4 hours back.
When you make your decision to contract out care for a
veteran, are you considering the time it takes a veteran to
actually travel to the VA facility?
Mr. Hoffman. Yes, in short. We consider time, the acuity of
the patient's condition--they just may flat not be able to
travel because of distances that a healthy veteran may be able
to travel--and the type of exam. You know, we fee out, for
example, numerous exams, ophthalmology exams, hearing exams in
various locations. We have even piloted and are piloting a
teleaudiology concept which may have promise for us in the
future for actually doing some of these exams out of our CBOCs
so that we can give one closer to our veterans.
Mr. Michaud. My next question is on the Veterans Equitable
Resource Allocation model. We heard at one of our hearings from
a former VISN director who made reference to the mothership,
the Central Office, not giving adequate funding to the other
medical facilities within the VISN.
I'll use Maine again as an example. When Congress increased
the boundary reimbursement for our veterans, what it cost VA
Togus for reimbursement rates is anywhere between $5 million
and $6 million. However, they received from the mothership
about $1.5 million. So therefore, they're running in the red.
So the problem I have, and my question to you is, are you
providing the adequate resources for the different facilities
within VISN 6, or are you forcing them to live within their
means, meaning that ultimately they cannot hire nurses or must
restrict what services they can provide, whether that is
contracting out care or other services.
Mr. Hoffman. That's a great question. There's probably not
a network director or a director that would say that they have
all the resources that they need. So, by definition, we live
within constrained resources. Both at the VISN level and the
medical center level, if you ask any one of my directors, I
think they would confess that they have to watch their budgets
very, very carefully and make tough choices. And whether
that's--it will never be with any travel. That's a given. But
it will be somewhere in the whole continuum of health care
services. We do our best to allocate appropriately to each
facility based on where the veterans are and their acuity of
care needed.
Mr. Michaud. Ms. Vandenberg, I have several questions for
you as well. I think you remember that Congress is very lenient
anytime there's a new Secretary onboard. Because they're new,
we give them the flexibility to grow into the position.
Secretary Shinseki has been there a year and a half, and I
think it's important for the VA and for the Secretary to start
delivering services. And my concern, as you can imagine, is
going to be about the pilot program, which I will ask you a
specific question about. I will be reading a quote that you
gave us when you testified before our Committee. As I said
earlier, it's more than money. It's about doing things in a way
that provides better services. We heard from panel two about
the need for VHA and VBA to work more collaboratively together.
I gave you an example of a cumbersome process with a lot of
different drug companies.
What is VHA doing to help streamline that process so it
will help with the delays? I agree with what the Secretary is
doing on Agent Orange, PTSD, and increasing access for priority
veterans. The President is escalating the war in Afghanistan by
sending more troops over there. Therefore, they're going to
come back and need more services. My big concern is that the
workload is going to increase exponentially within VHA and VBA.
What are you doing to help streamline that process? Is
there a way you can simplify it similar to what PhRMA did with
the prescription drug issue?
Ms. Vandenberg. Thank you for that question. As you are no
doubt aware, we have had a very systematic approach to system
redesign within the Veterans Health Administration for a number
of years now, and I think we can demonstrate very significant
progress in improving throughput in our clinics as well as
enhancing efficiency in our inpatient services.
Recently, we have begun to team up with VBA to look at
processes where we interface with VBA, in particular the whole
set of steps that it takes to do compensation and pension exams
and the Disability Evaluation System pilot in particular. So we
have a high level commitment at this point to collaborate
systematically with VBA to look at select processes and attempt
to streamline them.
I'd be happy to give you further information on the record.
To follow up, I didn't come prepared today to talk about this
extensively, but I can tell you unequivocally that we are
collaborating with VBA in bringing the vast network of tools
and resources that we have used within VHA to enhance
efficiency and streamline the processes.
With regard to Section 403 implementation, after our April
hearing we went back and reviewed the law, and the
interpretation that came from that is that the law reads, and I
quote, that ``the pilot be carried out within areas selected by
the Secretary for the purposes of the pilot program in at least
five Veteran Integrated Service Networks.'' We interpreted this
statutory language to mean that it was permissible for VA to
implement the pilot program within specific areas.
I understand that that continues to be a concern to you,
sir, and I look forward to the opportunity to brief you and
other Members of the Subcommittee and other Members of Congress
and your staff in more detail as to the analysis that we have
conducted with regard to the requirements that we would face if
the pilot program is implemented on a VISN-wide basis.
Mr. Michaud. The CBO requested from the VA certain
information when the legislation was passed. One of the
questions that they asked was the number of total patients
within those VISNs who are going to be affected by this
legislation. For VISN 6, 267,189 is the number of total
patients that were going to be affected by this legislation.
When they did the fiscal note, they came up with the estimate.
I believe it was $100 million. The intent was for full VISN
participation.
When you were before the Subcommittee earlier, I want to
quote your comments in regards to that. You stated, and I
quote, ``So I'm just wanting to acknowledge that I hear you. I
further appreciate the intent and just practically speaking
obviously we are going to honor the intent. We are obviously
going to go back and apprise the Under Secretary of Health of
the need for us to think more broadly and make whatever
adjustments are necessary then in the next steps of the
process.'' So in looking out for fiscal year 2011 we expected,
as I mentioned earlier, to spend at least $100 million on this
pilot. Now that we are going to go back and reset our
parameters, we may need to amend that estimate.
I guess my question then is, when did the VA reach the
decision that the implementation of the pilot program is only
going to be in selected areas? When was that decision made?
Since, clearly, your testimony at the last hearing indicates
you were going to go back and reassess it, and you would
probably have to come up with a different estimate for cost.
When did you make that decision?
Ms. Vandenberg. That decision----
Mr. Michaud. Who made that decision, as well? When and who?
Ms. Vandenberg. That decision is still pending in the
Department at this point. We have revisited the requirements of
the law. We have reevaluated the implications of VISN-wide
implementation both from an economic standpoint as well as from
the contracting standpoint, and that decision is still under
consideration.
Mr. Michaud. Well, my other question is all about access to
quality care. We heard earlier today from Mr. Chapman from
Southwest Virginia Community Health Systems. If you look at the
needs of our veterans in rural areas, in a lot of areas
community health centers are located, where we need that help.
What is the VA doing to focus on contracting with community
health centers that want to participate, or accommodate
veterans in those regions who want to participate? What are you
doing to reach out to them?
I can see a huge problem when you look at Agent Orange,
PTSD, Priority 8 veterans, escalation of the war in
Afghanistan. It's not going to get easier for the VA, it's
actually going to get harder. And, quite frankly, those that
are going to take the brunt of the frustration over VA not
being able to provide adequate services in a timely fashion to
our veterans in rural areas, will be the VA employees in those
regions. And that's very unfortunate, because I think in the
past, VA employees have taken a lot of criticism primarily
because they have not received adequate funding from our
previous administration or Congress.
This Committee and Congress have been very generous in
trying to meet the needs of VA, but we can't meet the needs of
VA if we're not given the proper information or if VA is not
implementing the laws as they are intended to be implemented.
And I can go into the nursing home issue, as well, where VA did
something totally different from the intent of the law on
reimbursement for nursing homes.
Ms. Vandenberg. With regard to community health centers in
particular, in our VA planning process we have identified the
location of those resources and have communicated that
information as part of the planning process to the network
directors in the annual planning exercise. Our planning
approach is a top-down, bottom-up. And, therefore, we have
afforded the network directors the opportunity to identify what
resources within their VISN would optimally meet the
requirements that they have for providing care to veterans, and
so there have been a number of collaborative efforts.
The situation that was cited earlier is one that I am
somewhat familiar with, having convened our Veterans Rural
Health Advisory Committee in Johnson City. And we heard during
the course of that recent meeting in March a review of that
circumstance.
So there is no prohibition to using community health
centers at this point in time, and your observation that we
might need to do something more systematic is one that I will
take back to the Under Secretary.
Mr. Michaud. There might be no prohibition, but the
prohibition is going to come when Mr. Hoffman has to live
within his budgetary needs. I want to make sure that Mr.
Hoffman and other VISN directors and medical facility directors
are able to provide the services that they need for their
veterans. And that's where the problem is going to be.
If we have to provide more resources, that's one issue, but
if we are not told of what's out there, the problem that we are
facing as elected officials with jurisdiction over VA is to see
how we can change the system to make it work for our veterans
so that we will not have to hear stories from Ms. Tucker about,
going through what she had to go through with Ben. That's what
we are all here for, and I know that's what you're here for, as
well.
The other issue is to make sure that what legislation we do
pass is implemented in the way that it was intended to be
implemented. If it isn't, then we're going to hear complaints
from veterans.
We want to work with you. We want to make sure that you
have the resources available. But we also want you to work with
us and let us know where I believe we can make changes. I'm
getting to a point now where we might want to look at other
ways to deliver services, such as asking the U.S. Department of
Health and Human Services to bring forward a proposal where our
veterans can go to them directly to access health care, because
we're starting to hear more and more concerns within the VA
system. And with the increased need for veterans' health care
because of Agent Orange, PTSD, and expansion of Priority 8
enrollment, it's going to get worse and not better unless we
can actually streamline that particular process.
We want to be able to take care of the problems before they
become too severe. And, ultimately, when you look at the
increase in the amount of suicides, not only within the
veterans community but also within the active military, it is
increasingly too great. We want to be able to provide Mr.
Hoffman with the resources that he needs. He needs to have the
resources so he can distribute them in a way that's fair and
equitable, but also, streamlining the process is going to be, I
think, extremely important as well.
Mr. Perriello.
Mr. Perriello. Thank you, Mr. Chairman.
First, Ms. Bogedain, thank you for being on the call and
for the responsiveness. We have, as you know, had a largely
positive response to the CBOC in Danville. We've had an
overwhelmingly positive response to Salem.
Again, we want a zero tolerance policy there for where
problems arise. But one of the confusions as we do develop some
of these new programs like the CBOC is the question of, does
that mean that I have to switch my specialty care from one
hospital to another? I think that has been a barrier for some
people participating in what seems to be a step in the right
direction.
So I just want to commend you for a rapid response, and
we'll continue to follow up with you on that and other concerns
that we hear about with the hospital, and again, we have been
really enjoying a rapid response and open line of communication
with you.
Ms. Vandenberg, you know, I was thinking about this old
``Saturday Night Live'' skit, while Chairman Michaud was
talking, where Jon Lovitz is playing a movie agent advising an
old war film actor, and the war film actor keeps saying,
``Well, maybe I made too many of these war movies.'' And Jon
Lovitz says, ``I guess you have.'' He says, ``Well, tell me
what you really think.'' He says, ``Well, you know, I think
it's time to hang it up.'' He says, ``What are the reviews
saying?'' ``Well, the reviews say you're the worst actor I've
ever seen, and now I get 10,000 letters a day saying the
same.'' ``So tell me where I stand really.''
And I think that the point here is that sometimes there are
two interpretations of a law, and sometimes it seems clear to
me that there's just a breakdown of communication or something
people don't want to hear.
In this case, through the multiple hearings that we've had,
it seems clear to me--and I am new to politics--that the
Committee feels very strongly that this is a pilot program that
we want to test and test as broadly as possible to see and we
believe that's coming from the grassroots up from communities.
And it seems that the VA has taken every opportunity to try to
crush, delay, and minimize this plan.
Now, this is a situation where the VA may be right and
Congress may be wrong, and I offer you this proposal: There is
no easier group to blame than Congress. So if this is something
that goes forward and does not work, I think it will not be
difficult for the VA to say it's Congress's fault. We're
clearly on the record believing in this program. If, however,
it succeeds, no one ever believes what we do works anyway, and
the Administration, and more importantly, the VA will be able
to claim very aggressively the success of this program.
I really do believe this is something where, again, we may
be wrong, but I think our intent is very clear, which is that
we believe it's right. We believe that accessing more primary
care in these areas is a positive thing. What I feel like we've
tried to do is put forward the most positive cases that we can
find.
Now, I think that's often the case out of what you might
call colloquial interest for Members of Congress, but out of
all the communities that I could represent, I do my due
diligence, and I look at the ones that I think can sustain it
versus ones that are flash-in-the-pan ideas and have that
response.
So I guess, you know, to play what's turning into a bit of
a bad-cop, good-cop scenario, it seems like we're offering you
an opportunity for something where the downsides can all fall
on us, the upsides can go to the Administration. And the
question is, you know, at the end of the day, what is the
reason not to try a larger number of these within the VISNs
that already qualify if--or try to run a pilot where the goal
is to figure out if this works, not to figure out how to make
the case against it? Why would we not try a broader set of data
points to have in the study?
Ms. Vandenberg. I'm glad to see the direction you took in
the beginning when you were talking about the old actor. I
thought, ``Oh, goodness, we're getting very personal here.''
Mr. Perriello. No, I was not directing to you.
Ms. Vandenberg. I'm just teasing.
All I can say today is that I hear you loud and clear, and
I will take this message back to the Under Secretary and to the
Secretary.
Last Thursday I was part of the team briefing the Secretary
on a range of issues on access, was focused on access, and the
work was done in my Office for Policy and Planning, and it's an
issue that we are and will continue to give extensive
consideration. So I hear you. I will take the message back
tomorrow.
Mr. Perriello. We appreciate that. I also want to commend
Secretary Shinseki. I think the thing at the VA, first of all,
there's obviously just a lot of day-to-day things going on with
the uptick, not only the transition, but the uptick in demand.
But I think what he has tried to do in his leadership style is,
excuse me, to take big problems and try to check them off one--
not one at a time, but definitely have a focus.
I know in the first year, getting the new GI Bill
implemented and implemented well was a huge focus. And I think
it was an unbelievable accomplishment, given how quickly that
was implemented. People say, you know, that the public sector
can't do that, but I think the fact that the--the general put
so much into it--our Committee was following it--really was,
again, a big accomplishment.
And I know that his focus has been the backlog since then,
among other--veteran homelessness, jobs and other things. But
the issue of the backlog--and we have tried to take a big chunk
of that on, with moving Agent Orange funding forward and doing
some of the investigations and other things.
I think when it comes to the issue of rural health, we
already have a lot of pieces on the table that suggest we are
already taking a big swing at the bat on this. When you look at
the CBOC starting to take off, when you look at some of the
things we have done in terms of telemedicine and other areas, I
think, you know, if you start to put that together, you really
are looking at something we can be really proud of looking back
in a couple of years. I think there's so many people that want
to do this right, and it's our belief that this can be a very
significant component of that.
Again, we don't know at the outset for sure what's going to
work. We believe that the new challenge is so big with the
changing demographics of our veterans that we're going to need
to try four or five things, what combination of telemedicine,
CHC, primary care through private-sector vendors, CBOCs,
bumping up our hospital care, what combination of those things
will meet the challenge.
So I appreciate that you understand the intent as you did
in the April hearing. We really hope that this is something
that we can look at again and champion as a success and not
just be up here, you know, expressing our frustration. But,
again, it is something where we feel like our intent is clear.
And I do have a place near and dear in my heart for the
facility in South Boston. There's no question about it. My bias
is clear. But I also think it's indicative of a larger issue,
which is that we believe there are opportunities like that
around, and that it would be a shame to delay or hold off on
that.
So we appreciate your continuing conversation with us and
look forward to hopefully have a very positive resolution to
this specific and general case.
I yield back.
Mr. Michaud. Let me once again thank this panel for coming
forward. I look forward to working with you.
Hopefully you heard loud and clear the concerns the two
previous panels brought forward, and you can look at ways to
work collaboratively to help streamline that process. I know a
lot of the issues relate to the technology, but the bottom
line, I know for me as a Member of Congress, is to make sure
that our veterans get the health care that they need when they
need it, and I know that's what the VA hopes to do as well. We
look forward to working with you so we can do what's right for
the men and women who serve in the military and put their lives
on the line each and every day for this great Nation of ours.
So I want to thank Ms. Vandenberg, for coming forward
today, and I look forward to working with you.
If there are no other questions, I will adjourn the
hearing.
Thank you very much. I want to thank all the veterans and
everybody in the audience for coming as well. Thank you.
[Whereupon, at 12:10 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
The Subcommittee on Health will now come to order. I would like to
thank everyone for attending this hearing, especially the veterans who
are with us today. I would also like to express my sincere gratitude to
the Bedford County Board of Supervisors for their hospitality in
hosting this hearing.
Today's hearing would not have been possible without Mr.
Perriello's tireless advocacy for our veterans living in Virginia. He
is a welcomed member of the Subcommittee on Health for Veterans'
Affairs who brings new energy and enthusiasm for tackling the unique
challenges facing our rural veterans.
As a Congressman who represents rural communities of Maine, Mr.
Perriello and I have a shared interest in ensuring that our rural
veterans receive the care that they deserve. Our veterans, whether they
live in rural Maine or rural Virginia, face common challenges. Most
notably, access to care is an issue where veterans live many miles and
hours from the closest VA medical facility. Given this challenge, it is
important that our rural veterans have access to such tools as
telemedicine, telehealth, and the VA's new pilot program to provide
enhanced contract care.
This year, we held several important hearings focused on rural
health care. For example, this past April, we held a hearing on VA's
implementation of the enhanced contract care pilot program. To our
surprise, we learned of VA's plans to create a pilot within a pilot
program, where only those veterans in select communities within VISNs
1, 6, 15, 18, and 19 would have access to enhanced contract care. At
this hearing, we clearly conveyed Congress's intent for VA to implement
this pilot program VISN-wide. Unfortunately, we were just informed a
few days ago that VA does not plan on honoring Congress's intent and
will only implement the pilot program in select locations within the
five VISNs. I am deeply concerned by these recent developments and look
forward to hearing from the VA today on this issue.
Next, in June of this year, we held a hearing on innovative
wireless health technology solutions as a way to help overcome rural
health care challenges. At this hearing, we heard from the Director of
the Rural Development Network of the University of Virginia Health
System, who provided poignant testimony on the unique needs of the
veterans of Appalachia and the importance of innovations in
telemedicine and wireless mobile health sensors and applications.
Again, I'd like to thank Mr. Perriello for inviting us here today
and I appreciate this opportunity to hear directly from our veterans of
central and southern Virginia about their local health care needs. I
look forward to the testimonies of our witnesses today.
Prepared Statement of Major General Carroll Thackston, USA (Ret.),
Mayor, South Boston, VA, and Former Adjutant
General, Virginia Army National Guard
Good morning ladies and gentlemen. I am Carroll Thackston and I am
the Mayor of South Boston, Virginia. I have served over ten years as
both Vice-Mayor and Mayor of our town which numbers 8,500 in
population. I am also a retired Major General, United States Army,
having served for over 40 years, the last 4\1/2\ years as the Adjutant
General of the Virginia National Guard.
I served on active duty for over six years, but spent 35 years in
the National Guard. With this background, I have a good understanding
of National Guard operations, goals and objectives, and the problems,
current and future, facing the National Guard.
My main focus this morning will be about the National Guard and its
probable impact on the Department of Veterans' Affairs. As you are
aware, the Total Force Policy has been in effect since post-Vietnam and
treats the three components of the Army and Air Force--the Regular
forces, the National Guard and the Reserves as a single force. Unlike
the impact of Vietnam veterans on the VA system, the total integration
and increased reliance on the combat and combat support units of the
National Guard throughout the 90's and the War on Terror creates a
whole new dynamic for Veterans' Affairs.
Before I discuss some of my concerns about the Guard and its
increasing impact on the VA, I would like to tell you about our local
efforts to help the veterans of Halifax County and immediate nearby
counties. For the past three years several of us have worked with a
small group of local Halifax veterans, primarily Vietnam veterans, to
establish a primary care facility in South Boston to serve local area
veterans. We have met many times and traveled many miles in pursuit of
our goal. At this point, we are aggressively seeking designation as a
rural locality under the VA's Enhanced Contract Care Pilot Program. If
successful, the Halifax Regional Hospital's new Primary Care Facility
located in South Boston will serve as a pilot project site for contract
care within VISN 6. Our group has met numerous times with Congressman
Perriello, his staff, and VA representatives. We traveled to Washington
and were able to meet with Secretary Shinseki, and most recently
participated in a lengthy teleconference that included Deputy Assistant
Undersecretary Vandenberg and numerous VA staffers. In January of this
year, Dr. Roger Browne, a member of our group, testified during the
Roundtable Discussion of the Committee on Veterans' Affairs on
``Meeting the Unique Health Care Needs of Rural Veterans.'' Dr.
Browne's credentials as a specialist in internal medicine who has
treated Halifax County veterans for over 30 years and his personal
experience as Brigade Surgeon for the 198th Light Infantry Brigade in
Vietnam in 1968 have provided our group with the leadership and
credibility to clearly identify the quality primary health care our
veterans need and deserve. At the finish line, we hope to have our new
and modern Primary Care Center in South Boston operating as a VA
primary care contractor providing all Halifax County veterans, both old
and young, Regular forces or Guard and Reserve, with the quality
primary medical care that they have earned and are entitled to, both
legally and morally. There were 1,127 veterans in Halifax County
enrolled in the VA system at the end of fiscal year 2009. There are
2,954 civilian veterans in Halifax County according to the most recent
census data. We want all of them participating in the VA health system,
and we want a local facility that is convenient for them and their
families. And we want to insure that our growing population of veterans
that are returning from current tours of active duty are assimilated
back into their home communities with the assurance that convenient,
quality VA medical care is there for them.
As a former Adjutant General of the Virginia National Guard, I have
deep concerns about the coming impacts to the VA system as a result of
the extensive use of National Guard combat and combat support units
during Operations Iraqi Freedom and Operation Enduring Freedom in
Afghanistan. During my tenure as Adjutant General, in spite of actively
seeking overseas operations for our ten National Guard Divisions, the
Guard was more or less relegated to Homeland Security and domestic
crises. That is not the situation the Guard finds itself in post 9-11.
In Virginia, we have 7,838 members currently assigned to the Army
National Guard which is 102% of its authorized strength. Since 9-11,
8,862 Army National Guard personnel and over 700 Air National Guard
personnel have been deployed. Eighty-one (81) Purple Hearts have been
awarded to Virginia Guardsmen and ten (10) Guardsmen have been killed
in action. There are currently 630 Virginia Army National Guard and
Virginia Air National Guard on active duty.
On the national scene, the total number currently on active duty
from the Army National Guard and Army Reserve is 90,144; Navy Reserve,
6,354; Air National Guard and Air Force Reserve, 16,457; Marine Corps
Reserve, 4,917; and the Coast Guard Reserve, 787. This brings the total
National Guard and Reserve personnel currently activated to 118,659,
including both units and individual augmentees (DoD News Release 7-14-
10--National Guard (in Federal Status) and Reserve Activated as of July
13, 2010)
These figures are current as of July 13th. When you consider the
continuing participation in the war efforts since 2001, the total
number of National Guard and Reserve members is substantial.
So, in conclusion, when we consider the huge influx of citizen
soldier veterans created by the integration of Guard and Reserve forces
by the Total Concept Policy and the prosecution of extensive combat
operations in the Middle East, there is an enormous workload headed for
the Department of Veterans Affairs.
When you consider the demands being put on the Department of
Veterans Affairs by that intense combat environment and multiple tours
of duty, combined with the effort to increase VA medical care
eligibility for veterans, I believe the VA will be required to expand
its network of health care facilities to meet those increased demands.
News reports last week indicate that the VA is adopting new rules
regarding post-traumatic stress disorder that will, in my opinion,
drastically increase the clinical workload for the VA. Reports cite a
2009 Rand Corporation estimate that ``nearly 20 percent of returning
veterans, or 300,000, have symptoms of PTSD or major depression.'' It
will be interesting to see those estimates updated to reflect the new
rules announced last week.
The education our group has received in pursuing a contract primary
care facility for Halifax County has clearly enlightened us on the
tremendous strides the VA has made since the mid-1990's with the
establishment of the VISN network and CBOCs, or Community Based
Outreach Clinics.
We are absolutely convinced that the VA will need to rely on the
numerous professional, and highly qualified, private-sector medical
facilities to meet the coming demand for VA medical health care.
Expanding the CBOC system may be prudent and wise, but the full
utilization of contract medical facilities such as the one in South
Boston will be essential to meeting those demands--both on-time and on-
cost. Our research has shown considerable savings in time and fuel by
veterans using more convenient and accessible primary care locations.
Only through an aggressive primary care program that is structured to
include all qualified veterans will the VA be able to cultivate a
climate of preventive medicine and early detection of serious
illnesses. The VA Medical Center will always be the bedrock of VA
medical care to take care of the most serious medical problems of our
veterans and the VISN/CBOC system is a proven winner in our opinion.
Contract primary care using existing private sector facilities is going
to be critical to the VA. We in South Boston and Halifax County are
ready to show you the way.
Thank you. May I answer any questions.
Prepared Statement of Howard Chapman, Executive
Director, Southwest Virginia Community Health Systems, Inc.,
and Member, Virginia Community Healthcare Association
Utilizing Community Health Centers as a Vehicle for Increasing Access
to Primary Care for Veterans Through the Rapid Activation of Community
Based Outpatient Clinics (CBOCs)
EXECUTIVE SUMMARY
PROPOSAL: This paper proposes the use of individual community
health centers, or organized networks of community health centers, to
serve as a vehicle for increasing access to primary care for Veterans.
In this model, community health centers would function as Community
Based Outpatient Clinics (CBOCs) as defined by the Department of
Veterans Affairs. This model is based on a strong collaborative
relationship between the Health Resources and Services Administration's
Bureau of Primary Health Care and the Department of Veterans Affairs.
Summary Overview
In May 2004, the Department of Veterans Affairs issued its final
version of its Capital Asset Realignment for Enhanced Services (CARES)
Report. The CARES process was ``initiated in 1998 to provide veterans,
Congress and the American people with a 20-year plan to provide the
infrastructure the VA will need to provide 21st Century veterans with
21st Century medical care.'' \1\
---------------------------------------------------------------------------
\1\ Chapter 1--Statement of Secretary, CARES Report, May 2004.
---------------------------------------------------------------------------
This Report calls for VA systemwide improvements in the use of
vacant space, modernization, operating costs, as well as increasing
access to primary care from 73 percent to 80 percent for all eligible
\2\ veterans. In addressing the need for increased access to primary
care, the CARES Commission originally identified the addition of 250
Community Based Outpatient Clinics,\3\ which would be strategically
located throughout the country. These CBOCs would be in addition to the
existing inventory of both staff model and contracted CBOCs that have
been operating since 1998.
---------------------------------------------------------------------------
\2\ According to the Veterans Administration Primary Care Access
Guidelines.
\3\ CBOCs are outpatient primary care access points that are
generally located in areas of high concentration of veterans
populations, and are 1-2 hours driving time from regionally located VA
Medical Centers.
---------------------------------------------------------------------------
The final Report prioritized 156 CBOCs out of the originally
proposed 250 locations for activation by Calendar 2012.
A crossmatch analysis comparing the 156 prioritized CBOC locations
with current \4\ BPHC grantees indicates that there are approximately
256 BPHC grantees that could potentially provide access to primary care
to 100 percent of the 156 prioritized CBOC locations identified in the
2004 CARES Report. \5\
---------------------------------------------------------------------------
\4\ Cross match conducted August 2004 and includes all BPHC Web
site posted grantees including community health centers (CHC), migrant
health centers (MHC), health center networks (ISDI), health care for
the homeless (HCH), FQHC Look-a-Likes (FQHCLA), healthy communities
access program (HCAP), and healthy schools healthy communities (HSHC)
grantees.
\5\ Cross match analysis does not take into account any increase in
community health centers as a result of President Bush's Initiatives I
or II.
---------------------------------------------------------------------------
Rationale
There are a multitude of rationales supporting a community heath
center--VA CBOC collaboration in addition to the most compelling
resource rationale given above:
The goal of the CBOC program to increase access to
primary care for its Veterans is consistent with the mission of
community health centers and the President's Initiative.
Community health centers offer the wide range of
services that meet or exceed the VA's requirements for CBOCs
including primary care, laboratory, radiology, mental health,
and women's services.
Veteran patient population health demographics are
consistent with the patient health demographics of community
health center patients and the program's efforts to further
develop disease collaboratives.
Community health centers are well suited to meet the
CBOC Performance Measures, as established by the VA, in the
areas of JCAHO accreditation, travel distance, mental health,
patient satisfaction, etc.
There is a growing community health center commitment
to health information technology, high speed internet
connectivity, and an electronic health record which is
consistent with the Veterans Administration's commitment to the
Computerized Patient Record System (CPRS).
Community health centers are organized in BPHC/HRSA
funded networks that can provide the infrastructure and
expertise in information technology, contracting and care
management.
The purpose of this document is to organize the experiences,
requirements, capacities, and issues that could impact the successful
use of community health centers in serving the primary care needs of
our veterans.
Community Health Centers as Vehicles For Increased
Access to Primary Care for Veterans
Background of the CBOC--VA Staffed vs. Contracted
From 1995 to 1998, the Department of Veterans Affairs approved more
than 230 Community-Based Outpatient Clinics (CBOCs). By the end of FY
98, there were 139 CBOCs providing health care to veterans with the
number of CBOCs per Veterans Integrated Service Network (VISN) ranging
from one to 16.
The predominate staffing model for these early CBOCs was based on
the use of VA employees who practiced in VA owned or leased facilities.
During this development period, the VA also began issuing Request for
Proposals on a competitive basis in order to contract with existing,
community based primary care providers in private practice. Some of the
early RFPs were actually awarded to academic medical centers that had
concurrent contractual relationships with the regional VA Medical
Center for graduate medical education training programs. By April 1998
only 26 of the existing 139 CBOCs were contracted CBOCs.
Current BPHC Grantees with CBOC Contracts
There are approximately 13 community health centers with CBOC
agreements across the United States as of August 2004. Eleven of these
agreements are direct agreements between the individual health center
and the local VA Medical Center. Two of the Virginia health centers
participate with the VA as CBOCs through a network master agreement
with the statewide health center owned network. The use of organized
networks as a contracting vehicle has broad applicability, especially
in the areas of pricing, contracting, contract management, compliance,
data collection, reporting, and quality improvement.
Description of Need and Authority--2004 CARES Report \6\
---------------------------------------------------------------------------
\6\ Excerpted from May 2004 CARES Report, Chapter 2, pages 6-8
As recommended by the CARES Commission, the VA completed a rigorous
re-examination of its forecasting Model by expanding the enrollment
base period, completing a lower bound sensitivity analysis, and making
Model improvements. These changes resulted in several recommendations
regarding facilities, operating costs, and access to primary care,
specifically as it concerns the Community Based Outpatient Clinic
program.
[The following is excerpted from May 2004 CARES Report, Chapter 2.
Pages 6-8.]
Commission Recommendations: The CARES Commission made several
recommendations for enhanced access to veterans' health care through
Community-Based Outpatient Clinics (CBOCs). Recognizing the need to
apply uniform criteria and consistent national standards, the
Commission reaffirmed that final decisions regarding the establishment
of new CBOCs should remain under the purview of the Under Secretary for
Health and the Secretary. Under that national framework, the Commission
made several additional recommendations about how VA should prioritize
CBOCs.
The Commission found that the prioritization methodology . . .
disproportionately disadvantaged veterans living in rural areas that
are underserved and lack appropriate access to care. They also sought
flexibility for VISNs to relieve space deficits at parent facilities by
adding new sites of care. Finally, the Commission recommended VA
improve the efficiency of operations at existing sites and supply basic
mental health services at all CBOCs.
Secretary's Response and Implementation: The VA will continue its
ongoing efforts to meet national standards or access to care for our
Nation's veterans by establishing new sites of care through CBOCs. The
Commission made several positive recommendations regarding CBOCs, and
VA will act to ensure they are met. To that end, VA revised its
national criteria for establishment of CBOCs to include emphasis on the
importance of access to care for rural veterans, use of CARES travel
guidelines to assess access to care, the availability of mental health
services, and the flexibility for VISNs to relieve space deficits at
crowded parent facilities by moving care to a nearby outpatient
setting.
These actions complement existing CBOC criteria that include a
focus on caring for Priority 1-6 veterans, ensuring that VISNs have
necessary funds to operate new sites, developing well conceived
business plans before implementing new sites, ensuring new CBOCs will
increase access to care, and other factors. Further, VA will continue
to explore opportunities to improve management of existing CBOCs
through more effective staffing, expanding hours of operation, and
examining opportunities to augment services where appropriate. VA will
proceed with development of new CBOCs through CARES and will prioritize
clinics that meet specific criteria.
Priority criteria include CBOCs that:
1. Are in markets that have large numbers of enrollees outside
of access guidelines and are below VA national standards for
primary care access;
2. Are in markets that are classified as rural or highly rural
and are below VA national standards or primary care access;
3. Take advantage of VA/DoD sharing opportunities;
4. Are associated with the realignment of a major facility;
and
5. Are required to address the workload in existing
overcrowded facilities.
These priorities reflect determination to produce more equitable
access to VA services across the country, particularly in rural and
highly rural areas where there are often limited health care options.
They also reflect the Department's ongoing commitment to strengthening
sharing opportunities with the Department of Defense.
The 156 priority CBOCs listed at the end of this response will be
implemented by 2012 pending availability of resources and validation
with the most current data available. This list reflects VA's
priorities for planning based upon the most current information. As VA
proceeds in implementing CARES and as it engages in future planning,
the locations of these CBOCs may change, but the priorities will remain
constant. VA will enhance access to care in underserved areas with
large numbers of veterans outside of access guidelines and in rural and
highly rural areas. VA also will enable overcrowded facilities to
better serve veterans and will continue to support sharing with DoD.
These principles will remain priorities even if management strategies
to meet them evolve as new data and information becomes available.
Recognizing that resources are not available to open all of these
clinics immediately, VA will manage implementation of CBOCs by applying
the revised CBOC criteria within the existing National CBOC Approval
Process.
These priorities reflect determination to produce more equitable
access to VA services across the country, particularly in rural and
highly rural areas where there are often limited health care options,
ensure a careful and considered implementation that mandates VISNs
develop sound business plans, ensures national criteria are met, and
that resources are available to provide the quality of care veterans
expect from the Department. Resource requirements that must be in place
to open new CBOCs include the capacity to manage specialty referrals
and inpatient needs of new populations.
These priorities do not prohibit VISNs from pursuing other CBOC
opportunities identified in the DNCP. VISNs will be able to propose any
CBOC in the DNCP for activation; however, they must be able to
demonstrate their ability to open priority clinics on schedule before
they can open a clinic that is outside of the priority criteria. VISNs
will immediately begin preparation of proposals for development of
CBOCs for this year.
[End of excerpt.]
Testimony--Veterans Affairs Under Secretary for Health
In his testimony before the Subcommittee on Health, House Committee
on Veterans Affairs on June 27, 2006, then VA Under Secretary of
Health, Dr. Jonathan Perlin recognized the value of community health
centers by acknowledging the potential for collaboration:
``The VA continues to look for ways to collaborate with
complementary Federal efforts to address the needs of health
care for rural veterans . . . . VA services are complemented by
the services of community health centers (CHCs), which are
local, non-profit, community-owned health care providers
serving low income and medically underserved communities. For
nearly forty years, this national network of health centers has
provided primary care and preventive services to communities in
need. Most centers try to arrange specialty care for clients
with hospitals and individual health providers.
As of January 2006, more than 1,000 CHCs provide health care
to community, migrant and homeless veterans and operate in more
than 3,600 communities in every state and territory. Over
37,000 health care professionals work in areas designated as
underserved or experiencing acute provider shortages. Three
hundred sixty-one (361) CHCs are located greater than sixty
minutes away from a VHA access point and are providing care to
rural veterans.
As VA continues to look for ways to enhance access to health
care for rural veterans, targeted partnerships with CHCs to
meet specific, locally defined, health care needs in rural
locations may provide an additional service delivery option to
the array of practices already deployed by VA medical
facilities. VHA will consider current policies and next steps
that would assist VISNs and facilities to explore this
option.''
Basis for Collaboration
Community health centers are uniquely positioned to meet the needs
of the Veterans Administration in providing increased access to primary
care for its Veterans.
Current Collaboration between the Department of Health and
Human Services (HHS) and Department of Veterans Affairs--On
February 25, 2003, the Department of Health and Human Services
and the Department of Veterans Affairs entered into a
Memorandum of Understanding (MOU) to encourage cooperation and
resource sharing between the Indian Health Service (IHS) and
Veterans Health Administration (VHA). Five mutual goals were
established in the MOU (www.vha.ihs.gov). There are current
successful examples of increased access to health care under
this MOU.
Available Inventory of Community Health Centers--The current
inventory of community health center grantees within those
programs supported by the Bureau of Primary Health Care are
operating in all 156 priority locations identified in the CARES
Report for CBOC activation. Activation of these 156 CBOCs would
increase access to primary care for eligible Veterans to the 80
percent level targeted by the Veterans Administration.
Activation of additional CBOCs within BPHC grantee operations
has the potential to exceed the 80 percent target levels for
primary care access.
Compliance with VA Quality Standards--Community health centers
are committed to becoming accredited by the Joint Commission
and are supported by the Bureau of Primary Health Care in
achieving this accreditation. This accreditation standard is
consistent with the Veteran Administration Medical Centers'
accreditation efforts.
Commitment to Information Technology--Community health centers
are increasing their focus and capacity to acquire electronic
health records, integrate disease registries, implement
telemedicine solutions, and improve the overall quality of care
provided to its patients through measurable outcomes. This
growing commitment to information technology is being fueled by
several factors including the successful acquisition,
implementation and support of health information technology
within a health center controlled network.
Experience as a Contracted CBOC--Although somewhat limited in
number, there are specific, successful examples of existing
community health centers acting as a CBOC through the
competitive awarding of a CBOC contract. These contracts have
been awarded to either individual health centers or to a health
center controlled network. These community health center based
CBOCs can provide real time information on the experiences in
serving veterans in a CBOC model, financing, utilization of
services, use of the VA's version of an electronic health
record (CPRS), and overall contract compliance.
Veteran's Administration Commitment to Collaboration--The
CARES Report clearly states the VA's commitment to collaborate
with the Department of Defense in meeting the goals of the
Report. This model is based on the assumption that the VA would
extend their willingness to collaborate with community health
centers as described in Dr. Perlin's testimony previously
discussed, as well as allow for a similar collaboration as
described in its MOU with the Indian Health Service.
Benefits to the Veterans Administration
1. Readily accessible facilities and staffing for the
activation of planned CBOCs.
2. Simplified contracting processes which could decrease the
activation costs of new CBOCs.
3. Improved patient care for veterans through existing
community health center disease management programs and other
enabling services.
4. Improved veteran patient satisfaction through the increased
accessibility of primary care.
5. Improved veteran patient satisfaction through the ability
of community health center CBOCs to serve not only the veteran,
but the veteran's family members for primary care regardless of
their ability to pay for services.
6. Improved veteran patient satisfaction with the provision of
culturally sensitive health care services.
7. Decreased reliance on VA resources for support of
information technology interfacing between community health
centers and the CPRS system.
Benefits to the Community Health Centers
1. Increased patient base with an accompanying revenue source.
2. Improved provider satisfaction with the increased
professional educational opportunities available to VA medical
staff.
3. Contracting, disease management, information technology and
financial management activities do not have to be developed and
managed with new community health center resources, if these
activities are housed within an existing health center network
organization.
4. Improved standing in the community via increased
interaction with veteran organizations such as VFW, AMVETS,
etc.
Considerations for a Health Center--Department of Veterans Affairs CBOC
Model
THE MODEL--The proposed ``model'' advocates for a high level of
formalized collaboration between the Department of Health and Human
Services and the Department of Veterans Affairs allowing community
health centers to be considered the ``primary option'' for locating and
activating a CBOC according to the requirements set forth by the
Veterans Administration. This collaboration would include an agreed
upon process to allow ``qualified and ready'' BPHC grantee community
health centers \7\ to be designated as CBOCs and provide those Scope of
Services currently required by the Department of Veterans Affairs.
Community health centers would have to meet all operating requirements
of the CBOC program and be held to the same performance standards as
existing contracted CBOCs.
---------------------------------------------------------------------------
\7\ The reference throughout this paper to community health centers
is based on current experience and does not imply that other federal
grantee organizations could not serve as a CBOC site.
---------------------------------------------------------------------------
There are numerous issues that would need to be addressed in order
to successfully implement a community health center/Department of
Veterans Affairs CBOC collaboration. Many of these issues concerning
existing Federal contracting laws, acquisition rules, intergovernmental
agency cooperation, Federal budgets, etc. are outside the scope of this
document.
These issues notwithstanding, the following considerations could be
explored based on current community health center CBOC experiences:
Currently, CBOC RFPs and contracts are developed,
issued, and awarded at the individual VA Medical Center or VISN
level. The RFP system is fragmented and is based on individual
VA Medical Center/VISN schedules and budgets. They are governed
by a competitive bidding process. Consideration: Create a
collaborative contract environment that provides BPHC grantees
first right of refusal for announced CBOCs. Only those
community health centers that are deemed ``ready'' may
participate in the contracting process (see below).
Contracts for CBOCs between VISNs may vary in Scope
of Services, and other terms and conditions of an agreement.
Consideration: A national community health center CBOC RFP
could be developed that would minimize the variability in
contract documents and decrease the cost of contracting.
There are varying degrees of willingness within the
VA system to accommodate an outside organization's ability to
interface with the CPRS system. Consideration: A Memorandum of
Agreement could be developed between HHS and Department of
Veterans Affairs that lays the groundwork for ongoing
cooperation in the area of information technology, or the CBOC
program in general, similar to that of the IHS.
Community health centers may be willing to become a
CBOC and become excited about the opportunity without a
realistic assessment of their capacity to serve veterans.
Consideration: A standard readiness assessment could be
developed and conducted at community health centers in order to
properly prepare to accommodate veterans. This may require
technical assistance resources.
Community health centers may not have the
sophistication required to properly analyze the requirements of
a CBOC RFP including the scope of services, financial
management, contract compliance, etc. Consideration: Technical
assistance resources could be identified by the BPHC or NACHC
to serve interested community health centers in support of
these contracting and financial requirements in order to ensure
success.
Mental health in the primary care setting is an
important issue for both the VA and community health centers.
Often times, there is an expectation for CBOCs to provide
mental health services, although the actual Scope of Services
re: mental health varies from filling out an assessment form to
actual staffing requirements. In some instances, however, the
VA has mental health resources that they are willing to provide
in a CBOC facility to serve its veterans even though that
facility is a contracted CBOC for primary care. Consideration:
In those contracted CBOC locations where the VA has a mental
health resource available to see veterans, explore a ``reverse
contract'' whereby the community health center can use that VA
mental health resource for all of the patients being seen at
the community health center. Adjust the contractual
reimbursements accordingly.
The May 2004 CARES Report makes no reference to any
alternative methodology for implementing CBOCs. The Report
relies on existing VA policies and procedures for activating a
CBOC and only references collaboration with the Department of
Defense on a limited basis, mostly for facilities changes.
Consideration: Offer an Addendum to the CARES Report that is
based on a broader view of collaboration with other Federal
agencies that share a common purpose i.e. the BPHC's mission of
increasing access to primary care.
Conclusion
The purpose of this paper was to make an initial attempt at
identifying the potential for increasing access to primary care for
veterans through the use of community health center contracted CBOCs.
It is not meant to be an all-inclusive discussion of the issues nor an
attempt to limit the collaborative opportunities to one group of
federally supported grantees.
Contact Information
Chief Executive Officer
Community Care Network of Virginia
6802 Paragon Place, Suite 630
Richmond, Virginia 23230
Prepared Statement of Kevin Trexler,
Division Vice President, DaVita, Inc.
Mr. Chairman and distinguished Members of the Subcommittee, I am
grateful for the opportunity to provide testimony on behalf of DaVita.
I am Kevin Trexler, Division VP of DaVita. I manage more than 80
dialysis clinics in Virginia, DC, and Maryland. My career path has also
included six years as a deployed Navy-trained advanced degreed nuclear
Submariner, working closely with various military and other
intelligence agencies.
DaVita is a leading provider of dialysis services in the United
States. We treat more than 117,000 patients each week in more than
1,500 centers, which represents nearly one-third of patients with End
Stage Renal Disease--or ESRD--in the United States. We are also a
recognized leader in achieving excellent clinical outcomes,
consistently demonstrating outcomes that are among the best when
compared to national averages. We have a proven track record of success
in providing the best possible patient care through our innovative
approach to collaborating with our many partners. At DaVita we also
recognize the value in supporting the concept of community and
especially those who serve and have served in the military. DaVita
employs over 800 Veterans, as well as many active duty, guard and
reserve troops. We have a long tradition of honoring those teammates at
DaVita who have served, and are serving, as well as their families at
our annual nationwide meeting.
DaVita is privileged to care for more than 2,000 of our nation's
Veterans in our dialysis clinics across the country. Because VA's own
network of dialysis facilities is not sufficient in capacity or
geographic scope to care for many thousands of the Veterans with ESRD,
we and other dialysis providers deliver dialysis treatments in
Veterans' communities when VA cannot provide reasonable access or lacks
the in-house capability to provide this life-saving treatment. More
than 20 percent of those Veterans in rural Virginia have no alternative
treatment options within 20 miles. We consider ourselves a partner of
VA and are committed to providing excellent quality, exceptional
clinical performance, and outstanding customer service to all these
Veterans whom we serve.
Our testimony today addresses the Subcommittee's interest in
understanding the quality of and access to dialysis care provided to
Veterans in rural and underserved areas.
Veterans receiving dialysis treatment are frail patients often with
multiple illnesses. They cannot survive without dialysis or kidney
transplants. Thus, patient access to care is critical. Patients receive
three treatments per week, every week of the year, each one requiring
four hours of staff-assisted care. Moreover, the treatment requires a
highly skilled workforce including a dietitian, a social worker, and
other ancillary service providers, as well as the use of high tech
medical equipment and supplies. Dialysis treatments are dependent on
high-cost pharmaceuticals--including one key drug that is still under
patent and has no generic, less expensive alternatives. Both the
provision of the treatments and the financial aspects of dialysis
treatments are unique.
Veterans with ESRD who live in rural or underserved areas often
have no other treatment options within many miles. Any disruption to a
Veteran's reasonable accessibility of a dialysis center will lead to
longer travel times for their dialysis treatments, which, in turn, can
have a significant impact on health outcomes. A study published in the
April 2008 American Journal of Kidney Diseases found that patients
traveling more than 60 minutes each way for dialysis treatments had
significantly higher mortality levels and a lower health care quality
of life.
Like many rural health care providers, DaVita's ability to receive
sustainable reimbursement is critical to ensuring that access to care
is preserved. The economics of the dialysis industry are very fragile,
particularly in facilities that serve rural areas. The average rural
dialysis clinic operates at a loss. Nearly 90 percent of patients are
Medicare or Medicaid beneficiaries, and these reimbursements are
insufficient to cover the cost of the treatments. Given the
insufficiency of Medicare reimbursement, the dialysis industry relies
on a unique ``social contract'' in which other payors subsidize the
Medicare rates to ensure adequate access to care for all patients.
Here in Virginia, we provide care to Veterans through VA-
established negotiated contracts. During the last 10 months, VA has
awarded negotiated contracts with a number of dialysis providers
throughout the country, covering most areas in which Veterans are
authorized to receive Purchased dialysis care treatments. These
contracts, if maintained, will continue to provide mutually agreed-
upon, sustainable reimbursement. The VA, and not providers, will
ultimately decide if these contracts continue for the complete five-
year duration. The VA has not assured providers that these contracted
rates will remain in effect, which results in the industry concern
about VA's commitment to maintain existing contracts.
DaVita recognizes and supports VA's goal to standardize
reimbursement for the purchase of non-VA provided health care services
and to reduce its costs in a way that would not threaten veterans'
access to care. DaVita believes that there is a way to achieve cost
savings and standardization of payments, while concurrently improving
the health status of Veterans with ESRD who are authorized by VA to
receive their dialysis and kidney-related care in the community. Since
last fall we have proposed to VA that they implement a patient-
centered, integrated care management dialysis program for these
extremely sick Veterans. The result would be:
avoidance of rural clinic closures,
improvement in the health status of Veteran dialysis
patients, and
the creation of a patient-centered approach for
managing the health of Veterans with kidney disease.
It is important to consider that dialysis is only about a third of
the total cost of care for these extremely sick Veterans; the majority
of costs come from avoidable ER visits and hospital stays, and other
costs due to infections and missed treatments. An integrated care
management program would focus on key interventions, such as the
placement of fistulas for dialysis access, which have proven to reduce
the instances of hospitalizations for patients. This not only results
in improved health and quality of life for Veterans, but would also
reduce VA's overall Purchased Care costs for these patients.
In its recently released Broad Agency Announcement, the VA included
a request for industry to submit proposals related to the VA Innovation
Initiative. VA is seeking solutions from the health care industry that
would improve the provision of dialysis care in community clinics and
in Veterans' homes. We are delighted that VA has reached out to the
kidney care provider community and will submit our proposal for
consideration before the end of the month. Because DaVita understands
that investments in prevention and coordination of care leads to
improved outcomes and lower total costs, our proposed coordinated care
program promotes patient-centered care for veterans with ESRD who have
been authorized to receive Purchased Care. This integrated care
management program will combine lab, pharmacy and medication therapy
management, vascular access care, vaccinations, case management and
access to diet and nutrition counselors and nephrologists. The program
will promote utilization of and coordination with VA services where
possible, and will collect and provide clinical data to VA through
Electronic Medical Record technology when possible or in another format
if VA prefers. VA currently does not receive clinical data from
providers in the Purchased Care Program.
In addition, DaVita has expertise in providing and remotely
monitoring dialysis care and treatments in patients' homes that would
be of particular benefit to patients in rural areas. For instance, in-
home biometric monitoring will allow us to monitor a patient's key
health data in a remote setting. If an abnormal value is recorded an
alert will be sent to one of our nurses who can either call or video
conference with the patient to determine what medical actions are
needed. This allows us to get real-time data without sending a nurse to
the house. This system will also allow us to provide educational
materials and reminders--including medication reminders, appointment
reminders, etc--to the patient and care givers.
We also have the ability to take advantage of mail order or in-
center delivery of medications so patients do not have to make extra
trips to the VA or local pharmacy.
An integrated approach would be beneficial in many ways. Patients
in similar programs, such as ongoing Medicare pilots, have experienced
increased quality of life, greater satisfaction with the care they
receive, and higher levels of engagement in their own care. In
addition, they have benefited from preventive care measures such as
immunization, lower rates of infection, greater compliance with
medication therapy regimens, and lower hospitalization rates. VA is
known for its progressive approach to health care delivery, and the
Department can maintain this same approach with dialysis care for
Veterans in the Purchased Care Program by implementing an integrated
care management initiative that benefits both patients and taxpayers.
As you may know, VA is moving to a patient-centered medical home
approach for all VA facilities. This would be the first step in the
Purchased Care Program to mirror what VA intends to accomplish within
VA facilities in the next two years.
On behalf of DaVita, I would like to thank you for your interest in
the care that we provide to Veterans and for your commitment to
ensuring that Veterans in rural areas continue to receive the quality
of and access to the care they have earned. We are grateful to the
Subcommittee for your leadership in seeking new ways to promote quality
care for all Veterans and especially the unique population of Veterans
with kidney disease whom we serve.
I would be happy to answer any questions you may have.
Prepared Statement of Michael F. Mitirone,
Commander, Department of Virginia, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to submit The American Legion's
views on this pressing issue concerning the quality of health care
provided to veterans in rural areas and in particular those in rural
Virginia.
The American Legion, a long time advocate for America's veterans
and their families, has noted the change in demographics of veterans
and also the recent trend of veterans moving to rural and extremely
rural areas of this nation. Even with that conscious decision, these
veterans have earned the right to receive access to ``The Best Care
Anywhere.'' The Veterans' Health Administration (VHA) has endeavored to
provide the required patient services, particularly gender-specific
services, regardless of location, but there is still much to be done.
The American Legion has passed a national resolution supporting
enhancements to VHA's Rural Health Care programs to ensure veterans
receive the timely and quality health care they have earned, regardless
of where the veteran chooses to live.
The American Legion's primary health care evaluation tool is a
program called ``A System Worth Saving.'' This Task Force, first
established in 2003, annually conducts site visits at VA Medical
Centers nationwide to assess the quality and timeliness of VA health
care. In preparing for these visits, The American Legion team
researches General Accountability Office (GAO) reports, VA's Office of
Inspector General (VAOIG) reports, and news articles relating to
potential breakdowns in a system that we consider, ``The Best Care
Anywhere.'' This task force, we believe, is valuable on a national
level to identify trends and improvements made in the VA Health Care
System, as well as identify local issues and areas for improvements.
During the 2010 ``System Worth Saving'' Task Force visits to 32 VA
Medical Centers across the country, a commonly repeated theme regarding
rural areas was the shortage and turnover of personnel, especially
nurses and personnel with specialty training. One of the reasons
reported during Task Force visits for turnover and shortage is a lack
of competitive compensation.
Of the 23.4 million veterans in this country, nearly eight million
veterans are enrolled in the VA Health care system, of which
approximately three million are from rural areas. Rural veterans
comprise about 40 percent of all enrolled veterans, or one of out of
every three enrolled veterans. For many of the three million veterans
living in rural areas, access to health care remains problematic, as
they simply live too far away from the nearest VA Medical Center or
Community Based Outpatient Clinic (CBOC). VA defines urban, rural and
highly rural veterans with the following definitions: urban: any
enrollee located in a census area defined as urbanized; rural:
enrollees not designated as urban; highly rural: those enrollees
defined as rural and reside in counties with less than seven
individuals per square mile. Only two-thirds of rural and highly rural
veterans enrolled in the health care system received VA medical
services in FY 2008. Unfortunately, for many this means that rural
veterans cannot see a doctor or a health care worker to receive the
care that they need due to their geographical limitations. Given these
barriers, it is no surprise that our rural veterans have poorer health
outcomes compared to the general population.
In VHA's Office of Rural Health Strategic Plan for 2010-2014, VA's
strategic goals are to: improve rural access and quality of care,
enhance technologies, improve research studies and analyses, improve
education and training, improve collaboration of service options and
recruiting and retaining medical professionals. VA provides care to
more than 5.5 million veterans each year at over 1,100 locations,
including inpatient hospitals and CBOCs. Demographic shifts and changes
in where veterans live call for continued realignment of the delivery
system with the needs of all veterans enrolled in mind. One of the
continued challenges for VA is determining the locations to build a
major medical center or where it is more feasible to construction
CBOCs, contract services, or telehealth programs.
Men and women from geographically rural and highly rural areas make
up a disproportionate share of servicemembers and comprise about one-
third (31.9) of the enrolled Veterans who served in Operation Enduring
Freedom and Operation Iraqi Freedom (OEF/OIF); many of these
servicemembers are returning to their rural communities. This is due to
the high number of Reserve Component servicemembers who deploy from and
return to their hometowns. This trend of veterans returning to rural
communities will continue and VA must ensure that it is prepared to
meet the increased demand for rural health care services.
The VA relies heavily on the CBOCs to serve the rural veteran
populations. For example, the Marion VA Medical Center in Illinois has
seven CBOCs located in Illinois, Indiana, and Kentucky that provide
services to veterans in 52 counties in three states. Currently there
are 42,000 veterans enrolled in rural CBOCs. The challenge of rural
health care is a national issue. According to the National Rural Health
Association (NRHA), many of the issues are a result of population size,
age structure, health risk factors, economic development, ethnic
composition, technology, and mix of health care providers, all
impacting the health care needs of rural veterans and how they access
health care services.
The American Legion conducted a site visit at the Salem VA Medical
Center in Salem, VA in FY 2004, and at that time patients traveled an
average of 80 miles and waited 30 minutes for specialty care. In FY
2009, there were 23,169 unique users veterans in the Salem VA Medical
Center catchment area with 33,094 enrolled. The rural area of Bedford
is approximately 30 miles from the nearest CBOC and 80 miles away from
the Salem VA Medical Center. Bedford, Virginia has 1,524 veterans
enrolled with only 770 users. There is currently one veteran in
Bedford, VA that is enrolled in the Home Based Primary Care program and
eight veterans that reside in Bedford, VA enrolled in the Care
Coordination Home Telehealth program. The most common fee basis service
for veterans living in the rural areas of Virginia is physical therapy
and neurosurgery. There is an assigned Rural Health Team that provides
outreach and patient education to veterans.
Another example of the difficulty to service rural and highly rural
veterans is the Sheridan VA Medical Center in Wyoming and whose closest
CBOC is 9 hours away. Some of the issues at this and other VAMCs are
that when the roads are affected by rain or snow, the VA Medical
Center's Volunteer Transportation Network vans are unable to go pick up
veterans for their appointments. In some cases, travel times are nearly
20 hours each way to pick up a veteran and the veteran and volunteer
driver must sleep in a homeless shelter each way on the trip. Also,
many veterans who live in rural areas of the United States do not wish
to make the long and tedious drive to the VAMC, even if a volunteer
driver is willing to take them. Some veterans have gone over 30 years
without seeing their primary care provider, but decide to see a doctor
when it is usually too late, such as when cancer or other serious
medical conditions worsen.
At some VA facilities unique approaches are being developed for
assisting veterans and their caregivers. At the Iron Mountain Veteran
Affairs Medical Center in Michigan, management reported that they do
not have an adult day center because of the rural density. The VA is
developing a voucher program so family and friends are able to receive
payment and training to take care of their veterans. This will allow
the veteran to be able to stay out of the VAMC and get the best care
possible.
The American Legion applauded Congress and the Administration's
passage of the Caregivers and Veterans Omnibus Health Services Act this
year. One of the provisions in the law is to increase housing and
transportation assistance for veterans living in rural communities. In
addition, under VA's current mental health strategic plan mental health
services have been expanded to primary care settings in VAMCs and
CBOCs, something The American Legion has called for. The American
Legion continues to urge VA to improve access to quality primary and
specialty health care services using all available means at their
disposal for veterans living in rural and highly rural areas. Veterans
should not be penalized or forced to travel long distances to access
quality health care because of where they choose to live.
Mr. Chairman, while VA is making continued improvements to the
access and delivery of health care to rural veterans, more still needs
to be done. We commend the committee for holding this field hearing in
our community to witness firsthand some of the challenges we and other
rural veterans continue to face across America today.
Mr. Chairman and Members of the Committee that concludes my
testimony.
Prepared Statement of Daniel Boyer, Post Commander,
Grayson Post 7726, VFW Past State Commander, Veterans
of Foreign Wars of the United States
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
It is my honor to be here today to represent members of the
Veterans of Foreign Wars of the United States here in Bedford and
around our wonderful state of Virginia.
I come before you with profound gratitude for what the VA is
striving to achieve on behalf of our veterans. No agency or department
is perfect, and yet I know that with the support of the Congress and
this committee, the VA is making strides forward and is working
diligently to care for all generations of veterans.
With these thoughts in mind I would like to address the rural
health care challenges we are facing here in southwest Virginia.
Access to VA services in rural areas is always a primary concern,
and that is no different in our region. From my hometown of Galax, VA,
we have the Salem VA hospital that is approximately 100 miles to the
north. Also located in our region is the Johnson City, Tennessee, VA
hospital that is approximately 125 miles to the West. Either of these
can be quite a journey, particularly when a veteran has two non-
contiguous appointments. It can be a frustrating process for a veteran
to travel long distances for multiple appointments spread throughout
the day. We are very thankful for our Community-Based Outpatient Clinic
(CBOC) in Hillsville, and we believe that the addition of a second CBOC
in Marion, although limited to three days a week, will provide even
greater assistance. There is clearly a need for the VA to open more
clinics in rural areas, and the onus is on VA to find solutions for our
veterans whether it be through additional private contracting, private-
public partnerships, collaboration at multiple levels of government, or
other creative means to make sure veterans are getting the care they
deserve.
Another area that will potentially improve access to care is
Telehealth. The VFW believes this is a major opportunity to improve
health care outcomes, particularly in rural communities. Though there
are privacy issues and technological limitations that must be
addressed, they should not delay any expansion of telehealth services.
The House Veterans' Affairs Subcommittee on Health recently held a
hearing that spent considerable time discussing rural broadband and
wireless expansion, and we encourage the committee to continue
expanding the body of evidence that clearly supports a robust
telecommunications infrastructure in our rural communities.
We are also concerned that many cases of Traumatic Brain Injury
(TBI) are not being properly diagnosed. We are obviously playing catch-
up in our understanding of TBI, and access to medical professionals who
can properly diagnose TBI is a problem nation-wide. As you might
imagine, veterans living in rural communities are especially vulnerable
to misdiagnoses and ill-suited treatment, and the VA needs to make sure
a sufficient network of doctors is in place to take what we are
learning and put it to use in these communities. Moreover, post-
diagnosis treatment can be time-consuming and can hinder efforts to
treat rural veterans suffering with TBI. This is a serious issue that
the VA and this committee need to tackle head on.
Closely tied to TBI is our concern with proper diagnosis and
treatment of mental health conditions. We applaud VA for raising
awareness on mental health issues and for working to reduce the stigma
attached to seeking mental health treatment. We urge the Congress
provide continuous oversight of VA mental health programs to ensure the
need for counseling and other types of treatment is being met here and
in all the rural areas of the country. At the Salem, VA, facility alone
nearly 2,500 veterans have received diagnoses that may be caused by
PTSD. One concrete step that could be taken to ensure all veterans who
struggle with mental health conditions receive timely and professional
care is to staff our rural CBOCs to provide inpatient mental health
counseling and other specialty services.
Specifically, strong outreach and education programs will be
necessary to help eliminate the stigma of mental illness and other
barriers that dissuade many from seeking care. We also need meaningful
post-deployment health assessments that will incentivize servicemen and
women to provide honest responses so that can receive appropriate kinds
of care and secure benefits they have earned. Routine examinations
should include mental health assessments. VA staff should be fully
competent to identify warning signs, should be aware of all available
programs, and should fully utilize them.
Suicide among our veterans is a national priority and it is
certainly a rural issue as well. Veterans who live in rural communities
often have limited health care access. Having the resources needed to
combat the isolation is critical. The VA's suicide hotline is an
effective tool for those who call, but we should work to ensure every
veteran who is at the end of their rope knows there is a helping hand.
Again, it comes back to outreach. These programs must be visible in the
everyday lives of veterans. We know this is especially challenging in
highly rural areas and we hope the VA will redouble their efforts with
regard to rural outreach--not only for the suicide prevention hotline,
but for all their programs.
One way the VA is reaching out to address these and other issues is
through the Mobile Vet Centers (MVCs) that are literally going to where
our rural vets live and work, ensuring access to services are provided
where it is needed. However, it is with some dismay that I tell you I
have not seen one or heard of one being in our community. With that in
mind, the VFW hopes that the VA is devoting proper time and attention
to evaluating the success of the MVCs and considering adding additional
resources if there is a demand for more Mobile Vet Centers.
In rural areas, simple word of mouth is still one of the primary
ways information is distributed and the VA should not overlook hometown
newspapers, local VSO chapters, and other means tailored to our older
veterans. Though they should employ e-mail alerts, social media, and
other electronic means to reach out, they should not expect this to
reach every generation of veteran. We want to be a resource for the VA
to reach rural veterans, and the potential to boost outreach by using
VFW posts and those of other Veteran Service Organizations cannot be
overstated. Another helpful opportunity for collaboration would be to
use local VFW posts to conduct local screenings and wellness events.
Just because a Mobile Vet Center is not available that shouldn't mean
the VA can't send a doctor or other medical professionals to a rural
area. Speaking on behalf of the VFW here in Virginia, if the VA sends
us a doctor, we can supply the patients and the physical space needed
to screen for mental illnesses and TBI along with other physical
conditions such as glaucoma, hearing, diabetes, and other illnesses.
Such opportunities would provide a platform for further collaboration
and would be a positive contact with rural communities where there is
no VA presence. Everyone benefits when mutually interested parties work
together, and we hope that the VA would take seriously the many
benefits of increased cooperation with the VSO community.
The Independent Budget said it best when it stated that `health
workforce shortages and recruitment and retention of health-care
personnel are a key challenge to rural veterans' access to VA care and
to the quality of that care'. The VA must aggressively train future
clinicians to meet the unique challenges rural veterans face. The VA
already has existing partnerships with over a hundred schools of
medicine in the United States. To not apply them, and expand upon them
if needed, would essentially squander this vast resource. We cannot
allow that to happen.
The VFW is also concerned that the men and women who serve in our
Guard and Reserve are not fully utilizing the VA benefits that they
have earned. Demobilizing members of the Reserve Component are often so
preoccupied with thoughts of family and home that they fail even to
mention existing health conditions, not to mention ones that will
certainly develop down the road as a result of their service. Local VFW
Posts often fund and facilitate going away and coming home parties for
Guard and Reserve units. We have successfully used these events to
boost morale and to offer assistance with their VA paperwork through
the Virginia Department of Veterans Service, and will continue to
support our returning warriors through these events and other outreach
efforts.
Finally, I would like to bring attention to the successes of our
Virginia Wounded Warrior Program. Rural veterans are a primary target
population of the Virginia Wounded Warrior Program. I hear and know
very positive things about the program. We hope that the VA will
continue to look at this hallmark state program and redouble their
efforts to work with all layers of government--local, state, and other
federal entities--to provide an integrated, total solution for not just
our wounded warriors, but for all who have served, and their families.
Mr. Chairman, I again thank you for the honor to present our
priorities to you. I would be happy to answer any questions that you or
the members of the Committee may have.
Prepared Statement of Clarence Woods, Commander,
Department of Virginia, Disabled American Veterans
Mr. Chairman, Ranking Member Brown and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV)
Department of Virginia to testify at this oversight hearing of the
Committee focused on the Department of Veterans Affairs (VA) and the
health care needs of rural veterans in the Commonwealth of Virginia. As
an organization of 1.2 million service-disabled veterans, rural health
is an extremely important topic for DAV, and we value the opportunity
to discuss our views. Also, as requested by Mr. Perriello, a Member of
this Subcommittee, we are incorporating in this statement the
particular concerns of our Department of Virginia (following on page 6
of this statement).
As a partner organization in the Independent Budget (IB) for Fiscal
Year (FY) 2010, DAV believes that after serving their nation in
uniform, veterans should not experience neglect of their health care
needs by VA simply because they live in rural or remote areas far from
major VA health care facilities. The delegates to our most recent
National Convention, held in Denver, Colorado, August 22-25, 2009,
again passed a longstanding resolution on improving health care for
veterans living in rural or remote areas.
In the IB, we have detailed pertinent findings dealing with rural
health care, disparities in health care, rural veterans in general, and
the circumstances of newly returning rural servicemembers from
Operations Enduring and Iraqi Freedom (OEF/OIF). Unfortunately those
conditions remain relatively unchanged:
Rural Americans face a unique combination of factors
that create disparities in health care not found in urban
areas. Only 10 percent of physicians practice in rural areas,
despite the fact that one-fourth of the U.S. population lives
in these areas. State offices of rural health identify access
to mental health care and concerns for stress, depression,
suicide, and anxiety disorders as major rural health
concerns.\1\
---------------------------------------------------------------------------
\1\ L. Gamm, L. Hutchison, et al., eds. Rural Healthy People 2010:
A Companion Document to Healthy People 2010, vol. 2, College Station,
Texas: Texas A&M University System Health Science Center, School of
Rural Public Health, Southwest Rural Health Research Center, 2003.
www.mentalhealthcommission.gov/reports/FinalReport/downloads/
downloads.html
---------------------------------------------------------------------------
Inadequate access to care, limited availability of
skilled care providers, and stigma in seeking mental health
care are particularly pronounced among residents of rural
areas.\2\ The smaller, poorer, and more isolated a rural
community is, the more difficult it is to ensure the
availability of high quality health services.\3\
---------------------------------------------------------------------------
\2\ President's New Freedom Commission on Mental Health, Achieving
the Promise: Transforming Mental Health Care in America, July 2003
\3\ Institute of Medicine, NIH, Committee on the Future of Rural
Health Care, Quality through Collaboration: The Future of Rural Health,
The National Academies Press, 2005.
---------------------------------------------------------------------------
Nearly 22 percent of our elderly live in rural areas;
rural elderly represent a larger proportion of the rural
population than the urban population. As the elderly population
grows, so do the demands on the acute care and long-term-care
systems. In rural areas, some 7.3 million people need long-
term-care services, accounting for one in five of those who
need long-term care.\4\
---------------------------------------------------------------------------
\4\ L. Gamm, L. Hutchison, et al., eds., Rural Healthy People 2010:
A Companion Document to Healthy People 2010, vol. 3, College Station,
Texas: Texas A&M University System, Health Science Center, School of
Rural Public Health, Southwest Rural Health Research Center, 2003.
Given these general conditions of scarcity of resources, it is not
surprising or unusual, with respect to those serving in the U.S.
---------------------------------------------------------------------------
military and to veterans, that----
There are disparities and differences in health
status between rural and urban veterans. According to the VA's
Health Services Research and Development office, comparisons
between rural and urban veterans show that rural veterans
``have the worse physical and mental health related to quality
of life scores. Rural/Urban differences within some Veterans
Integrated Service Networks (VISNs) and U.S. Census regions are
substantial.''
More than 44 percent of military recruits, and those
serving in Iraq and Afghanistan, come from rural areas.
More than 44,000 servicemembers have been evacuated
from Iraq and Afghanistan as a result of wounds, injuries, or
illness, and tens of thousands have reported readjustment or
mental health challenges following deployment.
Thirty-six percent of all rural veterans who turn to
VA for their health care, have a service-connected disability
for which they receive VA compensation.
Among all VA health care users, 40.1 percent (nearly
2 million) reside in rural areas, including 79,500 from
``highly rural'' areas as defined by VA.
Veterans Rural Health Resource Centers are Key Proponents of
Improvements
In August 2008, VA announced the establishment of three Veterans
Rural Health Resource Centers (VRHRCs) 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.
The concept underlining their establishment was to support a strong
ORH presence with field-based offices across the VA health care system.
These offices are charged with engaging in local and regional rural
health issues in order to develop potential solutions that could be
applied nationally in the VA, including building partnerships and
collaborative relationships--both of which are imperative in rural
America. These satellite offices of ORH and their efforts, along with
those of VISN rural health coordinators, can validate the importance of
the work and extend the reach of ORH in Veterans Health Administration
(VHA), to reinforce the idea that the ORH is moving VA forward using
the direct input of the needs and capabilities of rural America, rather
than trying to move forward alone from a Washington DC central office.
Currently, these Centers are under temporary charters, and
recipient of centralized funding not exceeding five years. The nature
of that arrangement has had unintended consequences on the Centers,
including problematic recruitment and retention of permanent staff to
conduct their work. We have been informed that all staff appointments
to the VRHRCs are consequently temporary or term appointments, rather
than permanent career positions, because of reluctance on the part of
the host VA medical centers to be placed in the position of needing to
absorb these personnel costs when Central Office funding ends. If the
concept of field-based rural health satellite offices is to be
successful and sustained, the Centers need permanency of funding and
staff.
Further Beneficiary Travel Increases are Needed
In the FY 2009 Appropriations Act, Congress provided VA additional
funding to increase the beneficiary travel mileage reimbursement
allowance authorized under section 111 of title 38, United States Code,
and intended to benefit certain service-connected and poor veterans as
an access aid to VA health care. VA consequently announced payment of
the higher rate, at 41.5 cents per mile. While we appreciate this
development and applaud both Congress and the VA for raising the rate
considerably, 41.5 cents per mile is still significantly below the
actual cost of travel by private conveyance, and provides only limited
relief to those who have no choice but to travel long distances by
automobile for VA health care. This challenge is particularly acute in
frontier states, and in rural Virginia and other States, where private
automobile travel is a major key to health care access.
Telehealth_A Major Opportunity
The DAV and our partners in the IB believe that the use of
technology, including the World Wide Web, telecommunications, and
telemetry, offer VA a great but still unfulfilled opportunity to
improve rural veterans' access to VA care and services. We note that
this Subcommittee held a hearing on June 24, 2010, in Washington, on
the topic of ``overcoming rural health care barriers: use of innovative
wireless health technology solutions.'' While DAV was not asked to
testify at that particular hearing, we have reviewed and appreciate the
testimonies of other witnesses, and we subscribe to the broad-based use
of telemetry, new monitoring technologies, and the internet to help
relieve burdens in access to VA health care being borne by veterans in
rural and remote areas. We trust the Subcommittee will be using its
findings from the hearing to further its oversight of VA in the use of
telehealth and related technologies in rural America.
The IB veterans service organizations (IBVSOs) understand that VA's
intended strategic direction in rural care is of necessity to enhance
noninstitutional care solutions. VA provides home-based primary care as
well as other home-based programs, and is using telemedicine and
telemental health--but on a rudimentary basis in our judgment--to reach
into veterans' homes and community clinics, including Indian Health
Service facilities and Native American tribal clinics. Much greater
benefit would accrue to veterans in highly rural, remote and frontier
areas if VA were to install general telehealth capability directly into
a veteran's home or into a local non-VA medical facility that a rural
veteran might easily access, versus the need for rural veterans to
drive to distant VA clinics for services that could be delivered in
their homes or local communities. This enhanced cyber-access would be
feasible into the home via a secured Web site and inexpensive computer-
based video cameras, and into private or other public clinics via
general telehealth equipment with a secured internet line or secure
bridge.
Expansion of telehealth would allow VA to directly evaluate and
follow veterans without their needing to personally travel great
distances to VA medical centers. VA has reported it has begun to use
internet resources to provide limited information to veterans in their
own homes, including up-to-date research information, access to their
personal health records, and online ability to refill prescription
medications. These are positive steps, but we urge VA management to
coordinate rural technology efforts among its offices responsible for
telehealth, rural health, and Information Technology offices at the
Department level, in order to continue and promote these advances, but
also to overcome privacy, policy and security barriers that prevent
telehealth from being more available in a highly rural veteran's home,
or into already-established private rural clinics serving as VA's
partners in rural areas.
The ORH: A Critical Mission
As described by VA, the mission of the ORH is to develop policies
and identify and disseminate best practices and innovations to improve
health care services to veterans who reside in rural areas. VA
maintains that the office is accomplishing this by coordinating
delivery of current services to ensure the needs of rural veterans are
being considered. VA also attests that the ORH will conduct,
coordinate, promote, and disseminate research on issues important to
improving health care for rural veterans. With confirmation of these
stated commitments and goals, the DAV concurs that the VHA would be
beginning to incorporate the unique needs of rural veterans as new VA
health care programs are conceived and implemented; however, the ORH is
a relatively new function within VA Central Office (VACO), and it is
only at the threshold of tangible effectiveness, with many challenges
remaining. Given the lofty goals, we remain concerned about the
organizational placement of the ORH within the VHA Office of Policy and
Planning rather than placing it closer to the operational arm of the VA
health care system, and closer to the decision points in VHA executive
management. Having to traverse the multiple layers of the VHA's
bureaucratic structure could frustrate, delay, or even cancel
initiatives established by this staff office. We also note that,
executive direction within the office itself has been problematic, and
that VA has experienced chronic difficulty in recruiting a permanent
director of the office. We have been advised that a new director of ORH
has been retained and assumed office on July 1, 2010.
We continue to believe that, rural veterans' interests would be
better served if the ORH were elevated to a more appropriate management
level in VACO, perhaps at the Deputy Under Secretary level, with staff
augmentation commensurate with these stated goals and plans. We
understand that recently the grade level of the Director of ORH was
elevated to the Senior Executive Service. We appreciate that change but
grade levels of Washington-based executives, do not necessarily
translate to enhanced outcomes and better health for rural veterans.
Rural Health Coordination at the Grassroots
The VHA has established VA rural care designees in all its VISNs to
serve as points of contact and liaisons with the ORH. While DAV
appreciates that the VHA designated the liaison positions within the
VISNs, we remain concerned that they serve these purposes only on a
part-time basis, along with other duties as assigned. We believe rural
veterans' needs, particularly those of the newest generation of war
veterans, are sufficiently crucial and challenging that they deserve
full-time attention and tailored programs. Therefore, in consideration
of other recommendations dealing with rural veterans' needs put forward
in this statement as well as in the IB, we urge VA to establish at
least one full-time rural liaison position in each VISN and more if
appropriate, with the possible exception of VISN 3 (urban New York
City).
Outreach Still Needs Improvement
We note 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.
Outreach Clinics are established to extend access to primary care
and mental health services in rural and highly rural areas where there
is not sufficient demand or it is otherwise not feasible to establish a
full-time Community-Based Outpatient Clinic (CBOC) by establishing a
part-time clinic. Ten Outreach Clinics were funded in fiscal year 2008,
and 30 in fiscal year 2009. While the potential impact would affect
over 997,000 rural and highly rural enrollees that reside within areas
that VA serves, only 2,250 patients were seen by the end of fiscal year
2009.
Without question, section 213 of Public Law 109-461 could be a
significant element in meeting the health care needs of veterans living
in rural areas, especially those who have served in Afghanistan and
Iraq. Among its features, the law requires VA to conduct an extensive
outreach program for veterans who reside in rural and remote areas. In
that connection, VA is required to collaborate with employers, state
agencies, community health centers, rural health clinics, Critical
Access Hospitals (as designated by Medicare), and local units of the
National Guard to ensure that returning veterans and Guard/Reserve
members, after completing their deployments, can have ready access to
the VA health care and benefits they have earned by that service. Given
this mandate is more than three years old, DAV urges VA's recently
created National Outreach Office in the Office of Intergovernmental
Affairs, Office of Public and Intergovernmental Affairs to move forward
on this outreach effort--and that outreach under this authorization be
closely coordinated with VA's ORH to avoid duplication and to maintain
consonance with VA's overall policy on rural health care.
To be fully responsive to this mandate, VA should report to
Congress the degree of its success in conducting effective outreach,
and the result of its efforts in public-private and intergovernmental
coordination to help rural veterans. We note VA is required to develop
a biennial plan on outreach activities and DAV has had the opportunity
to review the December 1, 2008, VA biennial outreach activities report
to Congress. Clearly VA is conducting numerous outreach activities to
veterans of all eras and has a special emphasis on veterans of OEF/OIF.
However, we note the report lacks an overarching strategic plan as well
as any parameters or statistical evidence to determine whether outreach
efforts, individually or collectively, are achieving the desired
results. Strategic planning is essential for successful business
operations and a full understanding of the veteran population is an
important element in providing education and outreach.
Virginia-Specific Concerns
As requested by Mr. Perriello's office, we wanted to provide the
Subcommittee our local and regional perspectives and concerns on rural
health care in the Commonwealth of Virginia.
Rural health initiatives are centrally funded by the VISN for only
two years. Our DAV Department of Virginia is concerned that VA medical
center directors will not support them once this protected, and
``fenced'' funding is stopped, or that they might be tempted to ``rob
Peter to pay Paul'' within the medical centers by utilizing funds
needed by other VA programs and applying them to the rural initiatives.
We believe that rural initiatives should remain centrally funded and
not be made to compete with other medical center programs.
Sick and disabled veterans in Virginia have been waiting patiently
for years to see new VA CBOC being opened in our rural areas. We
currently have two approved CBOC projects that are taking far too long.
Each of these CBOCs is now more than a year overdue in opening. Efforts
are not made to open new CBOCs expeditiously and projected opening
dates are usually delayed by a bureaucratic system. Also, for those
that are open (in Alexandria, Bristol, Charlottesville, Danville,
Fredericksburg, Harrisonburg, Hillsville, Lynchburg, Norton, Tazewell,
Virginia Beach, and Winchester), VA space planning needs improvement.
In our experience, VA's planning configuration does not include making
space available for the occasional visiting clinician but only for
authorized permanent Full Time Employee Equivalence (FTEE.) When
visiting clinicians come to these clinics to provide services (in
mental health, podiatry, and other specialties), either they often have
nowhere to see their patients, or space for them is very cramped. VA
space planners need to do a better job of providing for itinerant
providers within CBOC space configurations. Allowing more space than
needed by permanent staff also provides us an opportunity to expand
services sooner rather than having to wait additional years for clinic
construction projects after the need is identified.
We believe CBOCs need to provide more services on site in order to
obviate veterans' needing to travel long distances to major VA medical
centers for services they cannot receive in CBOCs. The DAV Department
of Virginia believes this problem can be solved by VA's building
``super-CBOCs,'' or larger and more extensive outpatient facilities in
rural areas.
We have noted that VHA is now working on ``systems redesign''
(reforming VHA as the new ``Medical Home''). We believe this kind of
logic could be applied to a VHA-VBA system redesign. We believe there
are many opportunities between VHA and VBA to work together, but they
are being missed.
While Popular, Privatization Is Not a Preferred Option
Section 216 of Public Law 110-329 requires the Secretary to allow
veterans residing in Alaska and enrolled for VA health care to obtain
needed care from medical facilities supported by the Indian Health
Service or tribal organizations, if an existing VA facility or
contracted service is unavailable. It also requires participating
veterans and facilities to comply with all appropriate VA rules and
regulations, and must be consistent with Capital Asset Realignment for
Enhanced Services. In addition, Public Law 110-387, the Veterans'
Mental Health and Other Care Improvements Act of 2008, directs the
Secretary of Veterans Affairs to conduct a three-year pilot program
under which a highly rural veteran who is enrolled in the system of
patient enrollment of the VA, and who resides within a designated area
of a participating VISN may elect to receive covered health services
through a non-VA health care provider at VA expense. The act defines a
``highly rural veteran'' as one who (1) resides more than 60 miles from
the nearest VA facility providing primary care services, more than 120
miles from a VA facility providing acute hospital care, or more than
240 miles from a VA facility providing tertiary care (depending on
which services a veteran needs); or (2) otherwise experiences such
hardships or other difficulties in travel to the nearest appropriate VA
facility that such travel is not in the best interest of the veteran.
During the three-year demonstration period, the act requires an annual
program assessment report by the Secretary to the Committees on
Veterans' Affairs, to include recommendations for continuing the
program.
DAV's concerns regarding the use of non-VA purchased care are the
unintended consequences for VA, unless carefully administered. Chief
among these is the diminution of established quality, safety, and
continuity of VA care for rural and highly rural veterans. It is
important to note that VA's specialized health care programs,
authorized by Congress and designed expressly to meet the specialized
needs of combat-wounded and ill veterans, such as the blind
rehabilitation centers, prosthetic and sensory aid programs,
readjustment counseling, polytrauma and spinal cord injury centers, the
centers for war-related illnesses, and the national center for post-
traumatic stress disorder, as well as several others, would be
irreparably impacted by the loss of veterans from those programs. Also,
the VA's medical and prosthetic research program, designed to study
and, hopefully, cure the ills of injury and disease consequent to
military service, could lose focus and purpose were service-connected
and other enrolled veterans no longer physically present in VA health
care programs. Additionally, title 38, United States Code, section
1706(b)(1) requires VA to maintain the capacity of its specialized
medical programs and not let that capacity fall below the level that
existed at the time when Public Law 104-262 was enacted in 1996.
Unfortunately, some of that capacity has dwindled.
We believe, VA must maintain a ``critical mass'' of capital, human,
and technical resources to promote effective, high-quality care for
veterans, especially those with sophisticated health problems such as
blindness, amputations, spinal cord injury, or chronic mental health
problems. Putting additional budget pressures on this specialized
system of services without making specific appropriations available for
new rural VA health care programs may only exacerbate the problems
currently encountered.
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 veterans might seek care in the
private sector as a matter of personal convenience, as a result of
enactment of vouchering and privatization bills, they would lose the
many safeguards built into the VA system through its patient safety
program, evidence-based medicine, electronic health record, and bar
code medication administration. These unique VA features culminate in
the highest quality care available, public or private. Loss of these
safeguards, ones that are either generally not available in private
sector systems or only partially so, would equate to diminished
oversight and coordination of care, and ultimately may result in lower
quality of care for those who deserve it most.
In general, current law places limits on VA's ability to contract
for private health care services in instances in which VA facilities
are incapable of providing necessary care to a veteran; when VA
facilities are geographically inaccessible to a veteran for necessary
care; when medical emergency prevents a veteran from receiving care in
a VA facility; to complete an episode of VA care; and for certain
specialty examinations to assist VA in adjudicating disability claims.
VA also has authority to contract to obtain the services of scarce
medical specialists in VA facilities. Beyond these limits, there is no
general authority in the law (with the exception of the new
demonstration project described above) to support broad-based
contracting for the care of populations of veterans, whether rural or
urban.
The DAV urges this Committee and the VA ORH to closely monitor and
oversee the functions 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. Especially 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) 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 professions' academic
affiliates. We recommend the principles of our recommendations from the
``Contract Care Coordination'' section of the IB be used to guide VA's
approaches in this demonstration and that it be closely monitored by
VA's Rural Veterans Advisory Committee. Further, we believe the ORH
should be designated the overall coordinator of this demonstration
project, in collaboration with other pertinent VHA offices and local
rural liaison staff in VHA's rural VISNs selected for this
demonstration.
VA's Readjustment Counseling Vet Centers: Key Partners in Rural Care
Given that 44 percent of newly returning veterans from OEF/OIF live
in rural areas, DAV believes that these veterans, too, should have
access to specialized services offered at VA's Vet Centers. Vet Centers
are located in communities outside the larger VA medical facilities, in
easily accessible, consumer-oriented facilities highly responsive to
the needs of local veterans. These centers present the primary access
points to VA programs and benefits for nearly 25 percent of veterans
who receive care at the centers. This core group of veteran users
primarily receives readjustment and psychological counseling related to
their military experiences. Building on the strength of the Vet Centers
program, VA should extend its current pilot program for mobile Vet
Centers that could help reach veterans in rural and highly rural areas
where there is no other VA presence.
VA Should Stimulate Rural Health Professions
Health workforce shortages and recruitment and retention of health
care personnel (including clinicians) are a key challenge to rural
veterans' access to VA care and to the quality of that care. The Future
of Rural Health report 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
deeper involvement in education in the health professions for future
rural clinical providers seems appropriate in improving these
situations in rural VA facilities as well as in the private sector.
Through VA's existing partnerships with 103 schools of medicine, almost
28,000 medical residents and 16,000 medical students receive some of
their training in VA facilities every year. In addition, more than
32,000 associated health sciences students from 1,000 schools,
including future nurses, pharmacists, dentists, audiologists, social
workers, psychologists, physical therapists, optometrists, respiratory
therapists, physician assistants, and nurse practitioners, receive
training in VA facilities.
We believe these relationships of VA facilities to health
professions schools should be put to work in aiding rural VA facilities
with their health personnel needs. Also, evidence shows that providers
who train in rural areas are more likely to remain practicing in rural
areas. 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. The VHA office of Workforce Recruitment and Retention should
execute initiatives targeted at rural areas, in consultation with, and
using available funds as appropriate from, the ORH. Different paths to
these goals could be pursued, such as the leveraging of an existing
model used by the Health Resources and Services Administration (HRSA)
to distribute new generations of health care providers in rural areas.
Alternatively, VHA could target entry level workers in rural health and
facilitate their credentialing, allowing them to work for VA in their
rural communities. Also, VA could offer a ``virtual university'' so
future VA employees would not need to relocate from their current
environments to more urban sources of education. While, as discussed
above, VA has made some progress with telehealth in rural areas as a
means to provide alternative VA care to veterans in rural America, it
has not focused on training future clinicians on best practices in
delivering care via telehealth. This initiative could be accomplished
by use of the virtual university concept or through collaborations with
established collegiate programs with rural health curricula. If
properly staffed, the VRHRCs could serve as key ``connectors'' for VA
in such efforts.
Consistent with our HRSA suggestion above, VA should examine and
establish creative ways to collaborate with ongoing efforts by other
agencies to address the needs of health care for rural veterans. VA has
executed agreements with the Department of Health and Human Services
(HHS), including the Indian Health Service and the HHS Office of Rural
Health (ORH) Policy, to collaborate in the delivery of health care in
rural communities, but we believe there are numerous other
opportunities for collaboration with Native American and Alaska Native
tribal organizations, state public health agencies and facilities, and
some private practitioners as well, to enhance access to services for
veterans. The ORH should pursue these collaborations and coordinate
VA's role in participating in them.
The IB for FY 2009, had expressed the concern that rural veterans,
veterans service organizations, and other experts needed a seat at the
table to help VA consider important program and policy decisions such
as those described in this statement, ones that would have positive
effects on veterans who live in rural areas. The IBVSOs were
disappointed that Public Law 109-461 failed to include authorization of
a Rural Veterans Advisory Committee to help harness the knowledge and
expertise of representatives from federal agencies, academic
affiliates, veterans service organizations, and other rural health
experts to recommend policies to meet the challenges of veterans' rural
health care. Nevertheless, we applaud the Secretary of Veterans Affairs
for having responded to the spirit of our recommendation to use VA's
existing authority to establish such an advisory committee. That new
federal advisory committee has been appointed, has held formative
meetings, and has begun to issue reports to the Secretary. We are
pleased with the progress of the advisory committee and believe its
voice is beginning to influence VA policy for rural veterans in a very
positive direction.
Summary and Recommendations
DAV and our partner organizations in the IB believe VA is working
in good faith to address its shortcomings in rural areas, but still
faces major challenges. In the long term, its methods and plans offer
rural and highly rural veterans potentially the best opportunities to
obtain quality care to meet their specialized health care needs.
However, we vigorously disagree with proposals to privatize, voucher,
and contract out VA health care for rural veterans on a broad scale
because such a development would be destructive to the integrity of the
VA system, a system of immense value to sick and disabled veterans and
to the organizations that represent them. Thus, we remain concerned
about VA's demonstration mandate to privatize services in selected
rural VISNs, and will continue to closely monitor those developments.
With these views in mind, DAV makes the following recommendations
to the Subcommittee and also to the VA, where applicable:
VA must ensure that the distance veterans travel, as well
as other hardships they face, be considered in VA' s policies in
determining the appropriate location and setting for providing direct
VA health care services.
VA must fully support the right of rural veterans to
health care and insist that funding for additional rural care and
outreach be specifically appropriated for this purpose, and not be the
cause of reduction in highly specialized urban and suburban VA medical
programs needed for the care of sick and disabled veterans.
The responsible offices in VHA and at the VA Departmental
level, collaborating with the ORH, should seek and coordinate the
implementation of novel methods and means of communication, including
use of the World Wide Web and other forms of telecommunication and
telemetry, to connect rural and highly rural veterans to VA health care
facilities, providers, technologies, and therapies, including greater
access to their personal health records, prescription medications, and
primary and specialty appointments.
We recommend a further increase in travel reimbursement
allowance commensurate with the actual cost of contemporary motor
travel. The existing gap in reimbursement has a disproportionate impact
on veterans in rural and frontier states.
The ORH should be organizationally elevated in VA's
Central Office and be provided staff augmentation commensurate with its
responsibilities and goals.
The VHA should establish at least one full-time rural
staff position in each VISN, and more if needed.
VA should ensure that mandated outreach efforts in rural
areas required by Public Law 109-461 be closely coordinated with the
ORH. VA should be required to report to Congress the degree of its
success in conducting effective outreach and the results of its efforts
in public-private and intergovernmental coordination to help rural
veterans.
Additional mobile Vet Centers should be established where
needed to provide outreach and readjustment counseling for veterans in
highly rural and frontier areas.
Through its affiliations with schools of the health
professions, VA should develop a policy to help supply health
professions clinical personnel to rural VA facilities and practitioners
to rural areas in general.
Recognizing that in some areas of particularly sparse
veteran population and absence of VA facilities, the VA ORH and its
satellite offices should sponsor and establish demonstration projects
with available providers of mental health and other health care
services for enrolled veterans, taking care to observe and protect VA's
role as coordinator of care. The projects should be reviewed and guided
by the Rural Veterans Advisory Committee. Funding should be made
available by the ORH to conduct these demonstration and pilot projects,
and VA should report the results of these projects to the Committees on
Veterans' Affairs.
Rural outreach workers in VA's rural CBOCs should receive
funding and authority to enable them to purchase and provide
transportation vouchers and other mechanisms to promote rural veterans'
access to VA health care facilities that are distant from these
veterans' rural residences. This transportation program should be
inaugurated as a pilot program in a small number of facilities. If
successful as an effective access tool for rural and highly rural
veterans who need access to VA care and services, it should be expanded
accordingly.
At highly rural VA CBOCs, VA should establish a staff
function of rural outreach worker to collaborate with rural and
frontier non-VA providers, to coordinate referral mechanisms to ease
referrals by private providers to direct VA health care when available
or VA-authorized care by other agencies when VA is unavailable and
other providers are capable of meeting those needs.
Mr. Chairman, this concludes DAV's statement. I would be pleased to
address questions from you or other Members of the Committee.
Prepared Statement of Lynn Tucker, Museville, VA (Veteran Caregiver)
My name is Lynn Tucker. I am here to testify on behalf of my son
Private First Class Benjamin Tucker, a lifelong resident of the rural
community of Museville in the 5th Congressional District of Virginia.
Ben enlisted in the United States Marine Corps in May 2004. Ben served
for 22 months before tragedy struck in the form of a dirt bike accident
leaving him with a traumatic brain injury. Ben is classified by the
Veterans Administration as 100-percent disabled. I am here to testify
on behalf of Ben's two brothers, Corporal Jonathan Tucker and Lance
Corporal Clayton Tucker, who served two tours as Marines in Iraq. They
suffer from the effects of repeated IED and RPG blasts and the deaths
of many friends. I am also here to testify on behalf of all veterans
needing care from the VA. My testimony today is based as a caregiver to
Ben, who lives at home in Museville.
Ben's story reveals what should be our concerns for all veterans,
particularly those representing rural areas; the concerns are: access
to primary and specialty care, effective and efficient communication
within the VA and approval and remittance of payments from the VA for
medically related items and services. Problems in any of these areas
affect rural veterans like Ben, Jonathan and Clay by limiting medical
choices, causing travel hardships, and contributing to an overall
breakdown in the quality of care and life. What we all need to remember
here is that these individuals, and all veterans, made a commitment to
serve and to protect our liberties without knowledge of the ultimate
outcome.
Access to primary and specialty care is imperative for all veterans
and especially difficult for rural veterans. For Ben who requires
frequent specialized care, this is quite a challenge. Ben lives 45
minutes from the Danville CBOC, 1 hour and 15 minutes from the Salem
VA, and 3 hours from the Richmond VA. Only the Richmond VA can provide
all the different types of care Ben needs and is the least accessible.
In October 2006 Ben returned home after almost a year in hospitals
and was totally dependent for all his care as he had no voluntary
movement and was fed by a gastric tube. He was eligible for 15 hours
weekly with the VA Home Health Aide Program. Due to his rural location,
locating and retaining certified nursing assistants with the selected
VA vendor was often impossible. Months would pass with no nursing help
and no help from the VA in locating a vendor with nurses willing to
drive the extra distance for a rural client. Just this last year we
were able to retain a reliable and caring nurse through the VA when a
new vendor was selected. With Ben's monthly VA disability payments
another CNA was employed after a period of 4 months with no nursing
help. Overall low payroll compensation with the added expense of
additional driving discourages CNA's from accepting rural clients.
Ben has a Codman shunt in his brain to drain excess fluid and
requires care from a neurosurgeon. The Salem VA does not have a
neurosurgeon; therefore, Ben has continued to see a Roanoke
neurosurgeon practicing with Carilion Hospitals. Getting approvals for
appointments is so time consuming, we have stopped applying for
approval of routine visits and use Ben's Medicare Insurance and pay the
balance remaining. This practice is not an appropriate solution for
veterans and conveys that the VA does not have an appropriate system in
place to care for their own. Many veterans' families that our family is
associated with express concerns about waiting for approval and
appointments with primary care doctors and specialists. Per two VA
clinic staffers in Salem, with the intake of more veterans from Iraq
and Afghanistan, this situation is growing worse by the day. Do VA
administrators understand this situation?
Effective communication is a barrier for veterans seeking care and
necessary assistive equipment. Communication between VA staffers within
the administration often results in long delays or unnecessary denials.
During the summer of 2006 Ben applied for the grant to help pay for a
custom wheelchair van. This request was submitted to the Roanoke
Regional VA office. The form was passed along through the VA from
person to person until somewhere a copy was made and the copy was
passed along instead of the original. After several weeks, inquiries
were made of the VA on Ben's behalf with no results. It was not until
the family actually traced the path of the grant form, with the help of
Kay Austin of the Paralyzed Veterans of America, that it was determined
the form was in fact on the desk of a VA employee where it had laid for
2 months. The employee stated the original was needed, but had not
tried to locate the original or call for a new original. Then Ms.
Austin faxed a new form and a second completed copy was delivered
personally to the VA employee.
Veterans often have to wait for needed medications to be refilled.
Just this past month, Ben needed renewal on a medication that took over
12 days to resolve. The CBOC in Danville received my request by fax and
the receipt was confirmed by a nurse. Three of the medications arrived
in the mail, but the one in question was not on Ben's prescription list
in My HealththeVet. I called the CBOC and left a message on the nurse
line. No one called. Inquiries confirmed the message was retrieved off
the voice mail, but no action was taken. Finally the nurse called to
say we needed to contact Richmond for an approval. In all it took 12
days for the CBOC to tell me to call Richmond. Consider this: if you
needed medication for your hypertension would you be willing to forgo
that for 12 days? Is that not harmful to your health? Living in a rural
area with the nearest pharmacy 30 minutes away and the nearest VA
pharmacy an hour and 15 minutes away, this problem is compounded.
Simple communication would have alleviated the wasted time, energy, and
driving to fill this prescription.
In September 2008, a bath sling was requested for Ben by the
Richmond VA physical therapy department to the Richmond VA prosthetics
department. A picture and an Internet link were provided to the
employee. After months, many calls, and e-mails with the link again,
three improper slings were delivered. Calls were made to the Guldmann
vender in Texas for the sling attempting to provide Ben with the needed
equipment. After calling the Guldmann headquarters and being given
information for Guldmann MidAtlantic, on March 4, 2009 the correct bath
sling was delivered overnight for free by Guldmann MidAtlantic after
hearing the difficulty of trying to procure the sling for Ben. A
veteran in a rural location cannot easily travel to a VA center and
resolve issues in person. VA employees must respond to e-mails and
calls and act appropriately to resolve the issue at hand. Veterans
should not spend days, weeks, or months waiting by the phone.
During 2008 a recumbent stepper was requested to the Salem VA by a
physical therapist for Ben. Ben was taken to the Salem VA and evaluated
by a doctor who approved the request. After months, calls were made
about the equipment and found the request had never reached the
prosthetics department. Shortly the Salem VA called explaining Ben
needed the evaluation he had already completed. The doctor never
entered the evaluation into the computer and never forwarded the
request to the prosthetics department. Once this issue was resolved and
several months passed, calls were made checking the progress of the
request again and discovered it was denied. The Danville CBOC was
notified but no one notified us. Efforts were made to begin tracking
the documentation to determine why the request was denied. The VA
employee who denied the request was very exasperated and actually said,
``Why am I in the middle of this?'' The employee could not grasp why he
had to defend his decision nor could he present procedural or policy
issues relating to the denial. After a lengthy discussion debating the
need for the equipment due to Ben's rural location and physical
condition, the request was approved and the equipment delivered.
Payments from the VA for medical services or equipment outside the
VA system are slow to nonexistent, and this situation traps the veteran
between the VA and the outside vendor. After Ben's van was delivered
November 13, 2006, the VA owed a payment to the dealer it had already
approved. After several weeks the dealer contacted Ben's family asking
for help in obtaining the payment from the VA. Phone calls were made
seeking this payment to no avail. Several weeks later the dealer
requested the payment from Ben. The payment for the van finally reached
the dealer on February 20, 2007, 3 months after delivery of the van to
Ben.
The van is not the only example of poor payment practices, Ben
currently has collections against him for medical bills the VA agreed
to pay. At first we paid some of the bills ourselves until realizing
this wasn't an exception, but the norm. A great deal of time has been
spent tracking many payments with the hospital and the VA not willing
to communicate with each other. Currently all collection calls are
referred to the VA
Ben was referred for physical therapy at the Carilion Clinic in
Rocky Mount. During one of his appointments I was called to the front
desk because the center did not have the authorization number to pay
for his therapy. It was necessary to contact the VA from the front desk
of the facility in order that Ben could complete his appointment.
Otherwise, Ben or his family would have had to agree to pay for the
therapy.
Ben spent almost 5 months in 2006 at Craig Hospital in Colorado
after we paid over $14,000.00 to have him flown medically. On his
return trip home, the VA agreed to pay for the flight because it was
necessary for him to be evaluated by the Salem VA before returning
home. On the day before the flight, the air ambulance company asked for
a credit card number because the VA could not locate who approved
payment for the flight. Once again, many phone calls were made adding
to an already tense situation.
In May 2006, my husband and I sat in a meeting with the Richmond VA
after Ben was discharged by the marines in April. Ben was an active
duty marine for 22 months, 2 months short of eligibility for VA
coverage, with no TRICARE insurance, and his VA claim not processed.
The VA employee wanted to know how the bill of approximately $40,000.00
per month was to be paid if Ben continued to stay in the polytrauma
unit. With no help from the VA, we investigated and obtained cobra
insurance with TRICARE for Ben and the VA was paid.
As a taxpayer and citizen of the United States of America it is
striking how we take for granted the lives of those who voluntarily put
theirs on the line. Ben, Jonathan, Clay, and all veterans enlisted
without knowledge of the outcome. They made a commitment to their
country. Where is their country now? Where will our country be when all
the veterans return from Iraq and Afghanistan? Will they too be
burdened with forms, phone calls, red tape, and delays? Will they too
be turned away and not cared for? We cared to send them.
Prepared Statement of Patricia Vandenberg, MHA, BS,
Assistant Deputy Under Secretary for Health for Policy and Planning,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good Morning, Mr. Chairman and Members of the Committee. Thank you
for inviting us here today to discuss the progress the Department of
Veterans Affairs (VA) has made in implementing section 403 of Public
Law (PL) 110-387, as well as VA's efforts to increase access to quality
health care for veterans living in rural and highly rural counties in
Virginia. I am accompanied today by Mr. Daniel Hoffmann, Network
Director for the VA Mid-Atlantic Health Care Network (Veterans
Integrated Service Network, or VISN 6), and Ms. Carol Bogedain, Interim
Director for the Salem VA Medical Center. My testimony today will
discuss VA's work in implementing the pilot program required by section
403 of PL 110-387 and our local efforts in the area.
Section 403 of Public Law 110-387
Public Law 110-387, Section 403 requires VA to conduct a pilot
program to provide health care services to eligible veterans through
contractual arrangements with non-VA providers. The statute directs
that the pilot program be conducted in at least five VISNs. VA has
determined that VISNs 1, 6, 15, 18 and 19 meet the statute's
requirements. This program will explore opportunities for collaboration
with non-VA providers to examine innovative ways to provide health care
for veterans in remote areas.
Immediately after Public Law 110-387 was enacted, VA established a
cross-functional workgroup with a wide range of representatives from
various offices, as well as VISN representatives, to identify issues
and develop an implementation plan. VA soon realized that the pilot
program could not be responsibly commenced within 120 days of the law's
enactment, as required. In March and June 2009, VA officials briefed
Congressional staff on these implementation issues.
VA has made notable strides in implementing section 403 of PL 110-
387, with the goal of having the pilot program operational in late 2010
or early 2011. Specifically, VA has:
Developed an Implementation Plan, which contains
recommendations made by the Workgroup on implementing the pilot
program;
Analyzed driving distances for each enrollee to
identify eligible veterans and reconfigured its data systems;
Provided eligible enrollee distribution maps to each
participating VISN to aid in planning for potential pilot
sites;
Developed an internal Request for Proposals that was
disseminated to the five VISNs asking for proposals on
potential pilot sites;
Developed an application form that will be used for
veterans participating in the pilot program; and
Taken action to leverage lessons learned from the
Healthcare Effectiveness Through Resource Optimization pilot
program (Project HERO) and adapt it for purposes of this pilot
program.
VA has assembled an evaluation team of subject matter experts to
review the proposals from the five VISNs regarding potential pilot
sites. This team will then recommend specific locations for approval by
the Under Secretary for Health. We anticipate this process will be
complete this summer. After sites have been selected, VA will begin the
acquisitions process. Since this process depends to some degree on the
willingness of non-VA providers to participate, VA is unable to provide
a definitive timeline for completion, but VA is making every effort to
have these contracts in place by the fall. This would allow VA to begin
the pilot program in late 2010 or early 2011.
VA is developing information materials for veterans participating
in the pilot program, for non-VA providers, for VA employees, and for
other affected populations so that, when the pilot is implemented, all
parties will have the information they need to fully utilize these
services. VA is committed to implementing the program directed by
Congress and to maintaining the quality of care veterans receive. Other
issues, such as securing the exchange of medical information, verifying
veterans' eligibility for this pilot program, coordinating care, and
evaluating the success of the pilot program, are also important
priorities and VA is working to ensure their appropriate implementation
in the pilot program.
VA notes that section 308 of Public Law 111-163, which was signed
by the President on May 5, 2010, amends the requirements of Public Law
110-387 section 403 regarding the ``hardship'' eligibility exception
and the mileage standard.
Local Initiatives
As noted previously, VISN 6 was selected as one of the Networks
that will participate in the pilot program required by section 403 of
PL 110-387. VISN 6 has identified potential locations for consideration
for the pilot program.
Separately, in fiscal year (FY) 2009, VISN 6 received approval and
funding from VA's Office of Rural Health for three programs to improve
access for veterans in rural Virginia. These included a program to
improve effective communication and improving health literacy; a rural
women veterans health care program; and additional mental health
substance abuse coordination. VISN 6 immediately began implementing
these efforts in the summer of 2009, and all VA medical centers in VISN
6, including the Salem VA Medical Center, are benefiting from this
continuing process. The programs are specifically targeted to assist
veterans residing in rural and highly rural counties.
The first project is designed to help VA conduct outreach to
veterans living in rural and highly rural areas and improve health
literacy. We will accomplish this through several strategies. First, we
are identifying veterans with common characteristics or conditions,
such as chronic obstructive pulmonary disease, diabetes, or congestive
heart failure, and we are providing personal or group education on
their health care needs in areas easily accessible to our veterans.
This may occur in a Veterans Service Organization facility, a Vet
Center, or a community-based outpatient clinic (CBOC). Second, we are
conducting patient prescription reviews with the aim of improving
communication and coordination between each veteran and his or her
clinical pharmacist and provider. When veterans better understand the
health care decisions their providers are making, they can be a more
effective partner in making those decisions. We are also expanding the
use of VA's online personal health record, My HealtheVet and enhancing
self-care programs for chronic disease. To better support these
initiatives, VISN 6 recently established rural health teams, which
consist of rural health coordinators, clinical pharmacists, registered
nurses, social workers, medical support assistants, program support
assistants, and drivers. The hiring process for unfilled positions in
the VISN 6 rural health teams is almost complete; all positions have
been recruited and are pending final personnel actions. The teams are
providing regular updates to VISN leadership and are implementing 90
day action plans they developed in May. Each VA medical center in the
VISN has received funding to support these outreach and access efforts.
In total, VISN 6 received $4.89 million for this project.
The second project supported by VA's Office of Rural Health is a
rural women veterans health program. This program is designed to help
increase the number of providers in rural or highly rural areas who are
proficient, skilled and knowledgeable in caring for women veterans. We
have trained at least one provider in this program at each VISN 6 CBOC
and medical center; as of the beginning of July 2010, 150 providers
total have already been trained, and 150 more will be trained before
the end of this fiscal year. The program will also focus on improving
health literacy and the overall health education of women veterans.
VISN 6 received $1.92 million for this effort.
The final project supported by VA's Office of Rural Health is a new
effort to support additional mental health substance abuse
coordination. This program is designed to provide mental health
services including substance abuse treatment for veterans in rural or
highly rural areas through contracts with community partners to
increase access to these services. Our contracting officials are
finalizing this proposal and we expect to begin obligating funds by the
end of the fiscal year. VISN 6 received approximately $2 million for
this program.
Last month, between June 15 and 17, 2010, VISN 6 held a Network-
wide meeting that provided our rural health teams with goals,
objectives and strategic direction. The meeting allowed the teams to
learn more about tele-medicine, home-based primary care programs,
women's health programs, the impact of post-traumatic stress disorder
(PTSD) and traumatic brain injury (TBI) on veterans and their families,
and the various partner programs offered by local governments in North
Carolina and Virginia. This information sharing is critical to
effective implementation of our outreach and access strategies for
veterans in this area.
In summary, these efforts are part of a larger plan by VISN 6 to
improve access to quality health care for veterans in rural and highly
rural areas. The principles of this approach include engaging community
providers and leaders; VA is here to complement their programs, not
compete. Indeed, in fiscal year (FY) 2010 through June, the Salem VA
Medical Center has disbursed more than $15 million for fee-basis
appointments, while the Richmond VAMC has disbursed just under $15
million for fee-basis appointments; across all of VISN 6, more than
$178 million has been disbursed through fee-basis care.
We also need to educate and engage veterans and their families, and
focus on common health issues among our veterans. Finally, quality
health care and positive health outcomes are strongly associated with
improved screening and health maintenance and compliance. These
programs support the strategic goals of the Office of Rural Health. By
improving health literacy and empowering our veterans to become full
partners in their health care decisions, we can deliver the quality
care our veterans have earned.
Conclusion
Thank you again for the opportunity to discuss the status of the
pilot program required by section 403 of PL 110-387 and the work VA is
doing to improve access for veterans in rural Virginia. My staff and I
look forward to answering your questions.
Statement of Chris A. Lumsden, Chief Executive Officer,
Halifax Regional Health System, South Boston, VA
Halifax Regional Health System (HRHS) is non-profit, community
owned and locally governed organization located in South Boston,
Virginia. We are a fully integrated health care provider serving over
100,000 residents over a five county area in southern Virginia. Beyond
our 173-bed acute care hospital, we own and operate two nursing homes,
and Alzheimer's facility, a home health care and hospice agency, and
four primary care clinics in our service region. We have approximately
125 doctors on staff and employ about 1,200 people at HRHS.
The newest primary care clinic, Halifax Primary Care (HPC), was
opened in South Boston in July of 2007. In June, 2009, HPC moved into a
new 10,000 square foot state-of-the-art clinic here in town. The clinic
is currently staffed by five physicians and one mid-level extender with
a support staff of fifteen clinical and clerical employees. The
facility was designed for easy expansion as additional doctors are
recruited and more patients are served from this area.
HRHS and HPC fully support the efforts to provide convenient high
quality medical care to all veterans residing in our service region. If
we meet the criteria and can fulfill the standards required as a
provider of medical services to the veteran population, HPC would
consider it an honor and a privilege to help better serve such a
distinguished constituency of patients. We have been working closely
with the local Veteran's Clinic Steering Committee and hope that South
Boston is approved as veterans primary care site. It will certainly
help those veterans who now must now travel long distances for these
type services.