[Senate Hearing 111-846]
[From the U.S. Government Publishing Office]
S. Hrg. 111-846
VA HEALTH CARE IN RURAL AREAS
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
JUNE 16, 2010
__________
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Roger F. Wicker, Mississippi
Jim Webb, Virginia Mike Johanns, Nebraska
Jon Tester, Montana Scott P. Brown, Massachusetts
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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June 16, 2010
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Johanns, Hon. Mike, U.S. Senator from Nebraska................... 2
Murray, Hon. Patty, U.S. Senator from Washington................. 3
Tester, Hon. Jon, U.S. Senator from Montana...................... 4
Begich, Hon. Mark, U.S. Senator from Alaska...................... 5
WITNESSES
Atizado, Adrian, Assistant National Legislative Director,
Disabled American Veterans..................................... 6
Prepared statement........................................... 8
Ahrens, James F., Chairman, Veterans Rural Health Advisory
Committee, U.S. Department of Veterans Affairs................. 16
Prepared statement........................................... 18
Putnam, Ronald, Veteran Service Officer, Haywood County, North
Carolina....................................................... 20
Prepared statement........................................... 22
Jesse, Robert, M.D., Acting Principal Deputy Under Secretary for
Health, U.S. Department of Veterans Affairs; accompanied by
Glen W. Grippen, Network Director, Veterans Integrated Network
19, U.S. Department of Veterans Affairs........................ 24
Prepared statement........................................... 26
Response to post-hearing questions submitted by:
Hon. Patty Murray.......................................... 32
Hon. Mark Begich........................................... 35
Response to request arising during the hearing by:
Hon. Patty Murray..........................................38, 40
Hon. Mark Begich........................................... 44
Hon. Jon Tester............................................ 51
McManus, Brig. Gen. Deborah, Assistant Adjutant General--Air,
Joint Forces Headquarters--Alaska, and Commander, Alaska Air
National Guard; accompanied by Verdie Bowen, Director, Office
of Veterans Affairs, Alaska Department of Military and Veterans
Affairs........................................................ 53
Prepared statement........................................... 55
Response to post-hearing questions submitted by:
Hon. Daniel K. Akaka....................................... 59
Hon. Mark Begich........................................... 61
Oral statement of Verdie Bowen............................... 66
Winkelman, Dan, Vice President for Administration and General
Counsel, Yukon-Kuskokwim Health Corporation, Alaska............ 62
Prepared statement........................................... 64
Schoenhard, William, Deputy Under Secretary for Health for
Operations and Management, U.S. Department of Veterans Affairs. 66
Response to request arising during the hearing by Hon. Mark
Begich..................................................... 72
APPENDIX
Sampson, Walter G., Vietnam Veteran; prepared statement.......... 77
VA HEALTH CARE IN RURAL AREAS
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WEDNESDAY, JUNE 16, 2010
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:31 a.m., in
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Murray, Tester, Begich, and
Johanns.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. This hearing will come to order. Aloha and
welcome to everyone.
Today, we will discuss VA health care issues in rural
areas. Rural settings are some of the most difficult for VA and
other government agencies to deliver care, I believe, and I
know many of my colleagues on this Committee share the view
that we must utilize all the tools at our disposal in order to
provide access to care and services for veterans in rural and
remote locations. Expanding the use of telehealth technologies,
rural outreach centers, mobile clinics, and other options will
help us to make health care accessible to more veterans and
reduce the burden on those living in rural areas.
VA also has the authority to partner with other government
agencies or to contract with community medical professionals in
order to provide care in local communities. Monitoring and
evaluating the quality of this type of contracted care remains
a challenge and I look forward to hearing more from VA on how
to improve this.
We have worked to make immediate improvements for rural
veterans. Recently, legislation from this Committee was enacted
into law which now provides higher rates of mileage
reimbursement and reimbursement for airfare for veterans who
must travel to reach VA health care facilities. This law will
now provide important incentives that the Department can use to
recruit and retain high-quality health care providers in rural
areas.
I remain concerned about how effectively we are reaching
veterans in rural areas. This is significant and it is a
concern in my home State, where a large rural population cannot
drive to the VA facility on Oahu as they are separated by many
miles of water. This poses a special challenge in helping these
veterans access VA health care.
This Committee has held several hearings on health care in
rural areas. For my part, I have worked to ensure that the
neighbor islands in Hawaii have telemedicine capabilities,
regular visits from medical personnel, and viable outpatient
clinics. We have been largely successful in these efforts and I
will continue to explore new ways to make further improvements.
Today, we will be focusing on States with exceptional
challenges. Our first panel of witnesses will address care and
services for veterans in Montana, which has large areas in
which VA has little or no presence but has a significant
veteran population to serve. Also on the first panel, we have a
witness from Senator Burr's home State of North Carolina, who
can discuss how they are reaching out in rural areas.
The second panel will address issues in Alaska, which is
not just considered rural but actually remote. I do plan to
review all the testimony and will be working with Members of
this Committee and the full Senate to ensure that VA does its
very best to meet the needs of veterans living in rural and
remote areas.
Chairman Akaka. Now, I would like to ask Senator Johanns
for his opening statement. Senator Johanns?
STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEBRASKA
Senator Johanns. Mr. Chairman, thank you, and let me say
good morning and aloha. It is great to be here with you today.
Chairman Akaka. Good morning and aloha.
Senator Johanns. I want to express, if I could, how much I
appreciate the opportunity for the purpose of this hearing to
act as Ranking Member. Senator Burr, as you know, asked me to
pinch hit for him today. With the College World Series kicking
off in Omaha this week, this seems especially appropriate.
I also want to indicate what an honor it is to be the
Ranking Member next to the Chairman. Mr. Chairman, I have great
respect for the work you are doing for our veterans.
Today's topic is one that every single Member of this
Committee, I believe, understands in some form or capacity.
Providing health care to rural veterans is critical, especially
in States that are rural, like Montana, like Nebraska, Alaska,
and I could go on and on.
I thought today it might be appropriate--sometimes we start
with areas where we disagree. Today, I want to start with areas
where we agree and build upon those areas in my comments.
First, I think we all agree that greater use of technology
is essential. Technology provides the ability for medical
professionals to perform remote consultation and even some
medical procedures or examinations in the comfort of a
veteran's own surroundings. That is part of the reason I
introduced a bill last month with Senators Klobuchar and Murray
to help veterans electronically access VA programs. Easier
programs will likely be used more often.
Now, testimony from a similar hearing we held last year
suggested that VA was increasing its use of telehealth and
telemedicine, and I applaud that. I am very interested in
hearing about the progress we have made in the past year and
what we are anticipating in the year ahead.
The challenge of providing care for rural veterans also
raises the opportunity for VA to work in coordination with
providers in our rural communities. Their challenges are often
identical to ours. That is one of the recommendations made by
the Veterans Rural Health Advisory Committee, which is going to
be mentioned, I think, in the testimony today.
In 2008, Congress passed legislation to test the concept of
allowing VA to team up with community providers to care for
veterans who live far away from a VA health care facility. Our
goal here is to have VA deliver timely, quality health care
services to our veterans. I also look forward to hearing where
we are at with this effort of working with our community health
care providers.
Finally, outreach is tremendously important for providing
care to our rural veterans. One of the reasons why Senator Burr
wanted Mr. Putnam, a Veteran Service Officer in North Carolina,
to testify today is to emphasize the importance of working with
folks at the local level to meet the needs of rural veterans.
On a final note, Mr. Chairman, I was pleased to see that
the Office of Rural Health has released its strategic plan
covering the next 5 years. I am a big believer in looking out 5
years and even longer to try to assess where we are at today
and where we need to be going.
The plan outlines several goals and objectives to improve
the delivery of health care to rural veterans. It will give the
Committee a blueprint from which to ensure that VA is indeed
reaching more rural veterans with a concerted strategy. It is
my hope that in 5, 6, and 7 years we can look back and check
off goals being obtained.
So, Mr. Chairman, thank you again for your service to
veterans. Thank you again for this oversight hearing, and I
look forward to our witnesses' testimony. Thank you.
Chairman Akaka. Thank you very much, Senator Johanns. You
have been a great Member of this Committee and have really been
helpful.
Let me now ask Senator Murray to proceed with her
statement.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Well, thank you very much, Mr. Chairman,
Senator Johanns, for holding today's hearing to talk about how
VA is caring for our veterans in rural areas. I want to thank
our witnesses, all of them who are here today, as well. I look
forward to hearing your testimony.
As we all know, the fiscal year 2011 budget includes $250
million to improve access to care in rural areas. It is a good
step forward and I am glad to see that that is in the VA's
budget. But we continue to hear from a lot of our veterans in
rural areas and underserved areas that they are still really
struggling to access basic care today.
When I go home and talk to veterans in Washington State, I
often hear about how they just can't travel several or more
hours on snowy or icy roads, especially during our winter
conditions, just to see a physician. Despite the efforts the VA
has made to increase access to rural veterans through the
establishment of new CBOCs, Vet Centers, and mobile medical
units, all great progress, there are a lot of gaps still with
our rural veterans.
Throughout Eastern Washington State and out on the
peninsula, the VA still doesn't have enough services there to
treat a lot of our veterans. I have been pushing the VA very
hard to open some contract clinics in Omak, Colville, and
Republic and to expand care in Port Angeles. We have got to be
creative with the resources we have and continue to
aggressively find alternate options for care, whether it is
through contract facilities or fee basis or other innovative
programs, to get care to our rural and isolated communities.
This is a critical issue especially because the lack of
access to care means a lot of these veterans put off preventive
care and they don't get the necessary treatment they need. In
fact, we know that the VA has found that rural veterans are in
poorer health than those living in our urban areas. From
recruiting and retaining health care providers in our rural
areas to monitoring and managing the quality of care provided
in non-VA facilities, we all know the challenges are very
complex and there is no silver bullet to any of these issues.
So, I really appreciate this hearing today and I look forward
to hearing from our witnesses about progress that is being made
and how we can do better.
Thank you very much, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Tester, will you proceed with your statement.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. I want to thank you, Mr. Chairman. I
appreciate your leadership in this Committee over the last many
years on this issue and others. We appreciate it very much.
I want to thank the witnesses today, in particular Jim
Ahrens. Jim, it wasn't easy getting here, but I do appreciate
you coming a long way to tell a very important story.
Most of the folks in this room know the numbers. Forty-four
percent of the enlistees in the military come from a rural or
highly rural area, even though only one-quarter of the
population lives in those rural areas. What the folks in this
room may not think about is how this fact should change our
approach in allocating VA dollars and resources. If we put all
our energy into where the general population lives, we will not
live up to our country's promises for all veterans.
It was 3 years ago next month that I held a field hearing
in Great Falls, MT, on the state of health care for rural
veterans. At that point in time, the travel reimbursement for
veterans was 11 cents a mile, not enough to pay for gas. There
were only eight Community-Based Outpatient Clinics serving an
area as big as the Eastern Seaboard. Mental health services
were generally very tough to come by and many folks didn't
understand how to respond to combat stresses, PTSD, and TBI.
American Indian veterans, who have the highest rate of
enlistment of any minority group in the country, were shuffled
between the VA and Indian Health Service. And a lot of folks
who had served this country so honorably were not getting the
quality of health care that they had earned.
I am pleased to say that things have gotten better since
then. We have raised the travel reimbursement rate. We have
expanded the number of CBOCs. We have started to make some
progress to improve mental health awareness and services. We
have done these things by working together, Democrats and
Republicans on this Committee, working with both a Democratic
and a Republican VA Secretary. Veterans in Montana expect you
to check your party politics at the door and focus on doing
what is right and we owe them no less.
But make no mistake about it, there is always room for
improvement, and that is what this hearing is all about. It is
about seeing where to go from here. It is about making it
easier for rural veterans to get to a VA facility for care or
bringing the care closer to the veteran. It is about breaking
down the bureaucracy so that Indian veterans get the care that
they have earned. It is about making sure the VA has a steady
supply of talented health care professionals in rural and
frontier areas of this country.
I can promise folks from the VA that the Chairman and
Senator Burr will be having another hearing on this issue in
the next Congress, too. It is critically important that we do
not let our rural and frontier veterans lose out on the health
care and benefits that they have earned. I will do everything I
can to continue to advocate for them on this Committee and in
the U.S. Senate.
I know that many of the witnesses on the first panel feel
the same way and we will hear from them shortly. I appreciate,
once again, you all being here.
Chairman Akaka. Thank you very much, Senator Tester.
Senator Begich, do you have a statement?
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Mr. Chairman, I will hold my statement
until introducing panel two. But first, I want to thank you for
your willingness to hold this meeting on rural health care. It
is very important, obviously, to many of our States here, but
very much so to Alaska, which is very, very rural in a lot of
ways and access issues are a huge problem.
So, I will hold my comments and look forward to the
testimony of both this panel, and--obviously I am biased, no
offense--to the second panel because there are lots of Alaskans
on the second panel.
Chairman Akaka. Thank you very much, Senator Begich.
I must address one further issue before we continue the
hearing. Dr. Jesse, I know that this is not your fault, but
unfortunately, as the Department's representative today, you
must be the one to take this message back to VA.
I would like to note that the Department's testimony was
submitted over 29 hours late. This is upsetting for me and, I
am sure, for other Members, as well, as it does not allow us
and our staff sufficient time to review the testimony in order
to have a productive hearing. The deadline for submitting
testimony, which is clearly listed in the Committee's rules, is
there to avoid wasting everyone's time.
Frankly, I am very surprised that the Department could not
meet the deadline for this hearing. This is a standard
oversight hearing being held on an issue on which VA has been
proactive and which has been the subject of recent attention,
including hearings and briefings. This should not have been
difficult testimony to develop, which suggests there is a
serious flaw in the Department's processes. In the past, the
Department has been able to meet this deadline without
difficulty and I do not know what has changed to cause this
habitual noncompliance, but I recommend the Department address
this problem immediately so as to avoid any issues during the
next hearing. So please take this message back to the
Department.
Dr. Jesse. Yes, sir, I will.
Chairman Akaka. I thank you.
Before we welcome our first panel and hear their
statements, I recognize Senator Tester and Senator Begich. Both
have been vocal advocates for the concerns of rural veterans.
As our panels today are comprised largely of witnesses from
their home States, I will be passing the gavel to them as they
can each preside over the panel dealing with their home State.
In the meantime, I have a hearing on the Armed Services
Committee, so I need to step out.
I want to thank all of our witnesses for being here today
and I will review all of your testimony in depth.
Senator Tester?
Senator Tester [presiding]. Once again, I want to thank the
Chairman for his leadership and important attention to this
issue.
I want to welcome the witnesses once again. I introduce
Adrian Atizado, the Assistant National Legislative Director for
Disabled American Veterans. Next we have Jim Ahrens, the
Chairman of the Veterans Rural Health Advisory Committee for
the VA and Ronald Putnam, a Veteran Service Officer from
Haywood County in North Carolina. Finally, we have Dr. Robert
Jesse, the Acting Principal Deputy Under Secretary for Health
in the Department of Veterans Affairs. He is accompanied by
Glen Grippen, the Network Director for VISN 19, which does
include the State of Montana.
I want to point out that when we had the field hearing back
in July 2007, which I spoke of in my opening statement, I think
the only person newer on the job than me that day was Glen
Grippen. Glen had been on the job at VISN 19 for 2 weeks at
that point in time, as I recall. I am glad we are both still
around.
Mr. Grippen. One week.
Senator Tester. One week. All right. I am glad we both are
still around, Glen, and I want to thank you all for being here
this morning.
We will start out with the testimony from Adrian.
STATEMENT OF ADRIAN ATIZADO, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
Mr. Atizado. Senator Tester, Members of the Committee, I
would like to thank all of you for inviting DAV to testify at
this hearing on rural veterans health care. As you all know,
DAV is an organization of 1.2 million service-disabled
veterans, and as such, rural health is an extremely important
topic for our membership.
Veterans residing in rural to frontier areas face similar
health care challenges as other citizens in these communities.
Human and financial resources needed to provide quality health
care and access to such care are the central shortcomings.
Access to core services, such as emergency medical care, mental
health and substance abuse services, hospital and long-term
care is severely limited due to historical shortages of
qualified health professionals.
Indeed, this deficit as well as the low-density patient
population means establishing and supporting the types of
specialized care veterans need is a great challenge. Such lack
of resources result in what studies have shown as significant
disparities and differences in health status between rural and
urban veterans.
As a partner organization for the Independent Budget, the
DAV believes that after serving their Nation, veterans should
not experience neglect of health care needs by VA simply
because of where they live. In fact, the delegates to our most
recent national convention again passed a longstanding
resolution to improve health care services for veterans living
in rural and highly rural areas.
DAV believes Congress and VA are creating a potentially
effective infrastructure to improve access and quality of care
for enrolled highly rural veterans. However, we believe that
there are some weaknesses that must be addressed in order to
fully embrace the goal.
The Office of Rural Health, or ORH, is a relatively new
function within VA's central office and it is only at the
threshold of tangible effectiveness with many challenges
remaining. Given its charge, we are mainly concerned about the
staffing and organizational placement of this office. We
believe that rural veterans' interests would be better served
if ORH were elevated to a more appropriate management level
with staff that is augmented commensurate with the office's
responsibilities.
DAV believes that the three Veterans Health Care Resource
Centers are key components of improving health care and health
status of veterans residing in rural to frontier areas. The
concept underlying their establishment was to support a strong
VA Office of Rural Health presence within the enormous VA
Health Care System. Currently, the centers are under temporary
charters with temporary staffs and receive centralized funding,
but only for a 5-year period. The nature of this arrangement
has had unintended consequences, such as in the recruitment and
retention of permanent staff to conduct their work.
If the concept of field-based Rural Health Satellite
Offices is to be successful and sustained, we believe these
centers need permanency of funding and, obviously, staff.
The VHA has also established VA Rural Health Care designees
in all its VISNs to serve as points of contact and liaisons
with the Offices of Rural Health. These VISN rural consultants,
as outlined in the ORHS strategic plan, is crucial and we
remain concerned over the part-time designation of 13
positions, which means only eight are full-time, and these 13
positions have collateral duties. We believe rural veterans'
needs, especially those of the newest generation of war
veterans, are so crucial and challenging that they deserve
full-time attention and tailored programs.
Now, as a final matter, I would like to discuss a need to
foster enhanced telehealth services functionality and
availability that cannot only improve health care access, but
quality of care and health status, as well. VA's pioneering
work in telemedicine has proven to reduce hospital admission,
shorten hospital stays, and lower health care costs, and
according to VA, the agency provides care to over 96,000 rural
veterans through telehealth. But as you consider there are 3.1
million enrolled rural and highly rural veterans, the VA
believes greater expansion of VA telehealth offers a great, but
still unfulfilled, opportunity. Moreover, with the expected
growth in VA's telehealth budget--I believe it is almost over a
doubling of that budget--we urge VA management to coordinate
rural technology efforts among all of its offices responsible
for telehealth to promote advances, but also and more
importantly to overcome privacy, policy, and security barriers
that currently encumber expansion of this program.
DAV hopes VA and Congress will work together to address
these and many other issues that will be laid out before the
Committee today. This concludes my statement and I would be
happy to address any questions that this Committee may have.
[The prepared statement of Mr. Atizado follows:]
Prepared Statement of Adrian Atizado, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman and Members of the Committee: Thank you for inviting
the Disabled American Veterans (DAV) 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. 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 Senator Tester, a Member of this
Committee, we are incorporating in this statement the particular
concerns of our DAV Department of Montana.
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, 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\
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\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
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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\
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\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.
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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\
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\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 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 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 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. 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 tele-mental 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 Veterans Health
Administration (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 is experiencing difficulty in
recruiting a permanent director of the office.
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.
montana-specific concerns
Our DAV Montana past Department Commander furnished information
responsive to Senator Tester's request. With respect to VA, the report
indicates a local challenge in DAV's Transportation Network. VA's local
processing time to qualify a DAV volunteer to drive for the Volunteer
Transportation Network in Montana requires up to 50 days. As a result
DAV Montana has lost potential volunteers, either because of their own
extended travel requirements to facilities to try to qualify, or
because of the lengthy time of processing their requests to volunteer.
The report also indicated inconsistency within VA facilities between
states; for example, the Ft. Harrison VA Medical Center (VAMC) requires
a tuberculin test every year for all its volunteer drivers; in other
states VAMCs do not impose this requirement. Our Montana DAV believes
these kinds of rules should be standardized for DAV volunteer drivers.
The DAV National Organization concurs.
DAV Montana is advocating a renovation project for the Ft. Harrison
facility to convert inpatient ward space to private rooms. Montana DAV
believes this would be a benefit to all enrolled Montana veterans, and
would allow modernization of the rooms at the same time. Currently
challenges in multi-bed ward rooms relate to HIPAA privacy issues,
privacy issues related particularly to women veterans, cross
contamination and infection issues, and lavatory use issues, among
others. Also, privacy for a veteran who has only days or even hours to
live is disrupted by the current Ft. Harrison space configuration and,
for the sake of their families, DAV Montana asks that this project be
approved. The DAV National Organization takes no position on this
recommendation, but we sympathize with the needs of VA facilities to
make infrastructure improvements, many of which are long overdue and
backlogged. Ft. Harrison's situation is but one example of many
reflecting these kinds of unmet needs.
We understand from our Montana correspondent that a ``Consolidated
Patients Account Center (Central Plains Office)'' is being considered
by VA for possible placement in VISN 19. Were this new center located
at Ft. Harrison, it would create almost 400 new VA positions in
Montana. Our Montana DAV reported that VA Ft. Harrison is already
performing consolidated accounts receivable invoicing for several other
VISNs, and asserted that the facility is capable of taking on this
related task. DAV Montana proposes that VA co-locate the new
Consolidated Patients Account Center at Ft. Harrison because closely
similar accounting processes are already being completed at that site.
The DAV National Organization takes no position on this local matter
but commends it to Senator Tester for further consideration.
Our DAV past Department commander also reported a challenge with
regard to veterans who are in need of air travel while under oxygen
therapy. He asks that the Committee inquire of the Federal Aviation
Administration (FAA) to examine current on-board oxygen restrictions
imposed by the Canadian regional carrier that services many small
Montana communities. He asks that special accommodations be made for
disabled veterans and other persons to travel when oxygen therapy is a
medical requirement. While the DAV National Organization has no
national resolution from our membership on this particular matter, we
are sympathetic to this need and would not object to such an inquiry.
Montana DAV also reported on the extreme shortage of qualified
Disabled Veterans Outreach Program (DVOP) specialists, as well as Local
Veterans Employment Representatives (LVERs) in Montana ``One Stop''
locations and other states of limited population but significant
geography.
These DVOPs and LVERs were especially trained to aid veterans who
were disabled or veterans who face a variety of barriers to employment,
or have special needs preventing them from returning to the workforce.
Through the Federal authorization, Montana reported it once had
sufficient available funds in these programs to work with the
individuals and local employers to make sure these veterans received
the help they needed either through local services or additional
education to assist these individuals to return to the workforce. What
they were also able to accomplish was to identify any of those possible
barriers to employment such as depression, TBI, PTSD and other special
needs. These individuals had already networked throughout the
community, county, state or other Federal agencies to help these
veterans with special needs.
According to the Montana DAV report, since the early 1990s, the
U.S. Department of Labor (DOL) used a formula for authorizations for
DVOPs and LVERs in each state based on veteran population. One Stop
locations in the state of Montana initially had a DVOP or LVER at
almost all of its sites. The number of these key veterans outreach and
employment specialists originally was in the high twenties; today, DAV
Montana reports six individuals are on duty.
To date currently in Montana, our correspondent reported many One
Stop locations do not have a representative trained in any of these
barriers that many veterans need to overcome. He also reported the
concern of a funding shortage for special programs in the state to
support the needs of veterans and disabled veterans to return to the
workforce. DAV Montana recommends that the Federal formula on
authorizations for frontier states be changed, or that frontier states
be exempt so that these rural states can gain authorization and funding
for a sufficient number of trained DVOPs and LVERs at each of their One
Stop locations. The DAV National Organization takes no position on this
individual state's shortage; nevertheless, our comments above on
outreach challenges within VA are certainly consistent with this report
from Montana about the DOL veterans outreach programs.
Our Montana Department also reported that the Department of
Transportation (DOT) offers no grant programs for veterans service
organizations to support veterans' transportation to VA medical
appointments. Similar to most of our Departments and many DAV Chapters,
the Department of Montana DAV Volunteer Transportation Network depends
on local fundraising, available grants, and DAV national funds to
support this large program. In Montana during the most recent year,
31,184 volunteer hours were logged over 685,982 miles, with 16,880
individual veterans being transported to VA appointments, involving
nearly 300 volunteers in VA clinics, and local area coordinators in the
medical center in Ft. Harrison, but with only two paid VA employees
(Hospital Services Coordinators). Given the over 5,000 members of the
DAV residing in Montana, the transportation network is reduced from 44
active vans to 36, and currently Montana DAV has four inactive vans
that are being retired due to high mileage and maintenance issues.
Currently, Montana DAV deploys vans from 20 different locations
throughout the state, and has identified four new locations in
expansion planning, of which two vans will be based on Indian
reservations.
The DAV Department of Montana continually seeks grants to support
expanding the transportation program from its early days with only two
privately own vehicles in 1988. Montana DAV approached the local
transportation services coordinators for the state civilian
transportation network, but found that no such grants were available to
a program such as DAV's that was dedicated to the mission of
transporting veterans to VA health care.
Montana DAV raises this issue in hopes that Congress would require
DOT to change its regulations for the acceptance of grant requests from
veterans service organizations to apply for grants that are designed to
help veterans obtain VA services and gain access to VA medical
appointments. The DAV National Organization takes no position on this
request but passes it to the Committee as a matter of information. As
this Committee is aware, the DAV National Organization does not accept
Federal grants, nor do we encourage subordinate entities to accept
Federal grants. In fact, we try to dissuade our Departments and
chapters from applying for any federally appropriated dollars.
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 Committee 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.
Senator Tester. Thank you, Mr. Atizado. I appreciate your
testimony. There will be questions when we are done with the
panel.
Jim Ahrens?
STATEMENT OF JAMES F. AHRENS, CHAIRMAN, VETERANS RURAL HEALTH
ADVISORY COMMITTEE, U.S. DEPARTMENT OF VETERANS AFFAIRS
Mr. Ahrens. Thank you, Senator Tester and Members of the
Committee. I am from Craig, MT, on the Missouri River. It is a
beautiful place, somewhat like Alaska--somewhat. It is my
distinct honor to serve as the Chairman of the Veterans Rural
Health Advisory Committee, and that is a committee of 16 people
across the country who work specifically on rural issues. The
committee recently finished a report and sent it to the
Secretary. He is reviewing it and hopefully we will get it
published fairly soon after the review through the Department.
Let me outline for you just four of the issues from the 13
recommendations we made. I would like to talk a little bit
about those four issues and then give you some observations of
what I think should be carried out by this Senate Committee and
by the VA.
One of our recommendations is to--and you are going to hear
a lot of this--pursue partnerships with State and Federal
agencies and local health service providers to increase the
enrollment of rural and highly-rural veterans and to broaden
their understanding of VA benefits and their programs. It is
interesting to me that all the veterans aren't enrolled. You
can't run a program, or market a program, anyway, unless you
know your customers, and we don't know where our customers are.
We need to ensure that access and continuity of care is
facilitated as close to home as possible. I think this
resonates well with the committee. This is something we really
believe in.
The committee also recommended an implementation of an
enterprise-wide system that facilitates the organization and
scheduling of VA telehealth services. Veterans need to be able
to get into the system easily and use the services. We need to
deliver training programs at the local level to veterans and
their families so that they understand what is going on and
what services are available to them. I have a neighbor who was
in the Korean War, never used the system at all, probably
doesn't even know what is going on in the VA system. We need to
let that person know what is happening.
Now I would like to share with you some of my own
observations. I would be disingenuous if I said they are all my
own. I have talked to a lot of people and they share these.
These are not the recommendations of the Veterans Rural Health
Advisory Committee or the VA, but these are things that people
in the field are thinking about.
Obviously, there have got to be more services in places
where veterans really live. You know, veterans--most of our
disabled veterans, from our data, live in the South and the
West. In the West, anyway, there are not a lot of services in
some of the big areas. Senator Tester can tell you all about
that from Montana.
We need to utilize more interactive telemedicine. They
should focus on rural areas. In other words, recent legislation
to create a tele-mental health program collaborative between
the VA and critical access hospitals, well, that ought to be
expanded. Private hospitals in Montana--every hospital in
Montana has a telemedicine service, but the VA doesn't utilize
that. Whether they can or can't, I don't know, but you could
use it if you wanted to.
Van transportation networks need to be enhanced. Senator
Tester and this Committee did a wonderful thing in increasing
the mileage reimbursement. We ought to raise that to what the
IRS allows. And it should be, I think, given to all enrolled
veterans, including those with other than service-connected
disabilities.
Enhance and promote the Internet utilization of My
HealtheVet for all enrollees.
Offer a secure VISTA, veterans health record, that
providers in the community can use. I don't know how many times
I have talked to local doctors who have somebody in their
office who can't find out what is going on with that patient.
Now, this is fraught with problems--HIPAA, confidentiality, and
all that--but it can be done if we work at it.
Make the VA medical record available immediately to
providers who see veterans in emergencies. You get somebody in
an emergency room and can't even get their record. Perhaps
these records could become available to hospitals and doctors
by adding the staffing function to the 24-hour emergency
suicide hotline which the VA runs. You could put somebody there
and somehow or another some of that information could be given
to the provider or to the hospital just to help the man or
woman who is in an emergency situation.
I think we need to increase the availability of flexible
scheduling at Community-Based Outpatient Clinics. Make it
easier for the people to get into the system.
There should be a closer working relationship with the VA
and Indian Health Service. It is starting, and we have got to
do that. Well, you know the issues. There should also be more
working relationships between the VA and other federally-funded
health care organizations like Community Health Centers, Rural
Health Clinics, Critical Access Hospitals, and smaller
facilities.
Mental health services should be readily available to all
veterans, especially those living in rural areas. TBI--in the
West, there are no facilities, I don't think in Washington,
either, or certainly not in our area to take care of these
people. There are major areas, and this is a growing concern.
All veterans in the 7s and 8s should get enrolled in the VA
medical system, and maybe they could take advantage of the drug
program.
We need resources in local areas to educate people in the
private sector and the VA so that they can work together and
help solve these problems, because we have to be able to bring
this collaborative effort together.
Mr. Chairman, I am out of time. I thank you for the
opportunity to testify and I would be happy to answer questions
at the right time.
[The prepared statement of Mr. Ahrens follows:]
Prepared Statement of James F. Ahrens, Chairman, Veterans Rural Health
Advisory Committee, Cascade, Montana
Chairman Akaka and Members of the Senate Committee on Veteran's
Affairs, It is my pleasure to testify before you today on behalf of
veterans living in rural America.
I currently serve as Chairman of the Veterans Rural Health Advisory
Committee. (VRHAC) The 16 members of the VRHAC are appointed by the
Secretary of the VA. The mission of the Committee is to advise the
Secretary on healthcare issues affecting enrolled veterans residing in
rural areas.
I have been involved in the issues of improving health care to
those residing in rural America for many years. While I was president
of the Montana Hospital Association we developed and implemented the
innovative Medical Assistance Facility (MAF) health care delivery
model. After ten years of demonstrating its effectiveness, the MAF then
became the model for the Critical Access Hospital program. Today there
are over 1300 Critical Access Hospitals (CAH's) in the United States.
This innovative model of delivering health care has saved and
maintained rural America's access to health care.
Access to VA health care services is a critical and growing issue
for rural veterans. There is an increasing need for physical and mental
health services to be delivered at local access points for the rural
veteran. The VA needs to continue to explore and develop innovative
ways to deliver these services.
This Committee is very familiar with issues that face Veterans
nationwide and in particular veteran's health care access issues in
rural areas. Because of your expertise I will not dwell on the
problems, but will attempt to provide you with ideas and programs that
will enhance the health care of veterans and improve the health care
delivery systems in rural America.
Let me begin by enumerating the recommendations of the Veterans
Rural Health Committee. These recommendations were recently provided to
Secretary Shinseki. as part of the VRHAC's Annual Report to the
Secretary. They are as follows:
1. Appoint a robust rural health executive and management team that
demonstrates the requisite expertise, experience, leadership, vision,
and dedication to addressing the needs of rural Veterans. Utilize
contract staff to augment government personnel to ensure access to the
broadest range of expertise possible.
2. Engage the VRHAC as a resource in refining the Rural Health
Strategic Plan.
3. Initiate an internal outreach initiative to further
institutionalize rural health concepts and programs within the VA.
4. Facilitate a formal dialog between the VRHAC and other VA
advisory committees, as well as other significant Federal collaborating
entities (e.g., Department of Defense and Department of Health and
Human Services, Office of Rural Health Policy, et al.).
5. Pursue partnerships with state and Federal agencies and local
health service providers to increase enrollment of rural and highly
rural Veterans and to broaden their understanding of VA benefits and
programs.
6. Ensure that access and continuity of care is facilitated as
close to home as possible for rural Veterans through delivery of
services at VA facilities or through contracted partnerships for
primary care and ancillary health services.
7. Reconsider existing VA cost metrics that may act as
disincentives for expansion of care into rural and highly rural
communities.
8. Leverage the National Health Information Network (NHIN) platform
to demonstrate practical, legal, and sustainable health information
exchanges in partnerships with non-VA physician practices, community
health centers, and other relevant providers in rural areas.
9. Implement an enterprise-wide system that facilities the
organization and scheduling of VA Telehealth services.
10. Develop services that leverage mobile phones and the cell phone
infrastructure to enhance patient-provider health communications,
address health care priorities, and improve efficiency across the VA
health system.
11. Conduct studies of rural and highly rural enrolled and non-
enrolled Veterans to determine their number, demographics, locations,
and unmet health need with a focus on the efficacy of primary care,
mental health, and physical rehabilitation services organized through
small regional rural facilities.
12. Consistently and proactively deliver training to rural
providers serving Veterans and their families with the specific focus
on post-deployment health and mental health needs of rural Veterans.
13. In all recruitment and retention efforts for health
professionals to serve Veterans in rural and highly rural areas, engage
in models of collaboration that add to and to not reduce overall
access, comprehensiveness, and sustainability of health services in
rural communities.
These recommendations were provided to the Secretary after careful
consideration and hours of discussion.
I would now like to share with you some personal recommendations
for improving VA rural health care. Let me point that the term
``personal'' should be taken lightly.
These suggestions are an amalgam of the thoughts of many. Some of
these recommendations are similar to the VRHAC recommendations.
1. There should be more health care services in places where
Veterans actually live in rural America. 2008 VA enrollment data
indicates that most of our rural and highly rural Veterans are in VISNs
in the Midwest. Most of our disabled Veterans and many rural Veterans
live in the South and the West. This information is included the VRHAC
report to the VA Secretary.
2. The VA should utilize more interactive Telemedicine. These
expanded Telemedicine activities should focus on rural areas. The
recent legislation creating the pilot rural tele-mental health program
collaborative between the VA and rural Critical Access Hospitals
(CAH's) is a great start. More effort is needed to build upon the
existing Telehealth systems located in either civilian rural health
facilities or VA facilities.
3. Van transportation networks should be enhanced.
4. The mileage reimbursement rate should be equal to the IRS
payment which currently is fifty cents per mile. Consideration should
be given to expanding this reimbursement to all enrolled Veterans,
including others than those with service-connected disabilities. This
would be especially helpful in recruiting friends as drivers for VA
patients who can't drive or who can't return home immediately after
treatment because of medical issues, e.g. sedation.
5. Enhance and promote the internet utilization of ``My
HealtheVet'' by all possible enrollees.
6. Offer a secure version of VISTA (The Veterans Health Information
Systems and Technology Architecture) medical records package to rural
practitioners who see Veterans.
7. Make this VA medical record available immediately to providers,
who see veterans in Emergencies. Perhaps these records could become
available to hospitals and doctors by adding a staffing function to the
twenty four hour emergency suicide hotline. The Committee might
consider an amendment to Federal HIPPA Privacy regulations in order to
make this happen
8. Increase the availability of flexible scheduling at Community
Based Outpatient Clinics (CBOCS). The VA should make provisions
allowing local health care practitioners to provide care one or two
days a month at the those CBOC's. Rural Veterans appreciate the
expansion of CBOC's in rural areas; however care should be taken not to
recruit critically needed physicians, mental health providers and other
allied health personnel away from existing providers in order to staff
these clinics. If a Veteran gains close access to a primary care
provider but his family loses access to their primary care provider,
the Veteran's burden may increase.
9. There should a closer working relationship between the VA and
the Indian Health Service. This relationship is working well in some
limited areas, but needs to be expanded. Working relationships should
be nurtured between the VA and other federally funded rural health care
organizations such as Community Health Centers, CAH's, and Rural Health
Clinics etc. The standards of care for Federal programs should be
operational and respected across all Federal programs designed to
improve the health care for Veterans and others served by such
programs.
10. Mental health services should be readily available to all
veterans especially those living in rural communities.
11. All Veterans, including 7's and 8's, should be enrolled in the
VA medical system.
12. A new and sustained effort is needed to bridge the services of
the VA and private rural health care systems. Resources are needed to
educate rural health care providers on how to work within each other's
systems and cultures. Rural providers need help in learning how to
navigate through the VA and the VA needs more information on the
quality of care delivered by rural providers. The VA should continue to
utilize physicians and other providers through contracts and fee for
service arrangements, however this arrangement should be expanded to
include ancillary services. There is no reason for a Veteran to be seen
in a CBOC for routine care and then be required to drive 1 to 2 hours
to another VA facility for an MRI when the MRI service is available in
a community facility in the same town where the initial services were
rendered.
Mr. Chairman and Members of the Committee, I want to thank you for
the opportunity to make these points. I hope that by working together
we can assist in providing quality health care services to our Veterans
living in rural areas. I would be happy to address any questions that
you might have at the appropriate time.
Senator Tester. I appreciate your comments and
recommendations.
Mr. Putnam?
STATEMENT OF RONALD PUTNAM, VETERAN SERVICE OFFICER, HAYWOOD
COUNTY, NORTH CAROLINA
Mr. Putnam. Good morning, Senator Tester and Members of the
Committee. I appreciate the opportunity to come here and
testify. I would first like to let everyone know I am a County
Service Officer. I see veterans every day and assist them in
filing for their benefits, both health and other benefits, from
the Veterans Administration.
Haywood County is a remote county in the western part of
North Carolina, 200 square miles. It doesn't compete with
Alaska and Montana, but we are still rural. My county has
57,000 citizens and 7,000 of those citizens are veterans.
I would like to report today on my colleagues that work in
North Carolina, the other County Service Officers. I want to
report to this Committee that the VA medical centers in North
Carolina are all out in the community and starting to work with
these rural teams. Not all the teams are fully staffed. The
team out of the Charles George VA medical center in Asheville
that I am working closely with still lacks a social worker.
However, I want to applaud the VA on actually coming out and
collaborating with the County Service Officers, the State
Service Officers, and the other veterans associations to see
where it is they need to go to find these veterans that are not
receiving VA health care and have not applied.
Second, I would like to bring up that in rural America, all
over rural America, I speak--I am also on the National Service
Officers Committee and a chairman of one of their committees--
across America, we face a generation that is quickly passing:
our World War II and Korean War veterans. Just to shed a little
in-light on the people that the VA is trying to reach with 21st
century technology, just this past year, I handled a claim for
a veteran in Haywood County and the gentleman had a second
grade education. North Carolina provides an opportunity for
veterans to apply for a high school diploma from the Governor
if they had joined the service during wartime and served. So,
in the past 2 years I have made application for eight
individuals and the highest education level of those eight
individuals was a seventh grade education.
These men live in remote, small, mountainous, rural
communities. They don't go anywhere except to church and to the
local feed store. These men find out about things from the
newspaper and if their preacher tells them on Sunday morning.
They also find out from other individuals. I feel that this
social disconnect and the time that these individuals were
brought up in history makes it very difficult for the Veterans
Administration to reach without personal intervention.
Once again, I do applaud the VA for working closely with
county, State, and other Service Officers across the Nation
because we are the front line of the VA. We are funded by local
Governments and this Committee.
I would like to bring up one bill that is in this
Committee, H.R. 3949, an outreach bill. I would like this
Committee to consider it strongly because that bill and those
funds would enable the Service Officers across the Nation to
help the VA to reach these individuals.
I would like to let you know that the team working out of
the Charles George VA medical center in my area have already
been in the field. They came out this past weekend to two
National Guard units and set up shop there. I can't say enough
about how it started. It is getting results on the ground. It
is beginning to work. It is kind of scaring me because it is
actually making sense and they are actually talking to the
people they need to be talking to.
I would just hope that this Committee and this Congress and
this Administration continues to fund that. As my colleagues
here have already mentioned, there are quite a few veterans
that are going to be around a long time--Vietnam-era veterans,
Gulf War veterans--that are going to be with us for some time;
they are not going away and they are not going to move to town.
So we are going to have to go out there and find them.
I appreciate this opportunity again, and I will be willing
to take any questions that you have. Thank you very much.
[The prepared statement of Mr. Putnam follows:]
Prepared Statement of Ronald Putnam, Veteran Service Officer,
Haywood County, North Carolina
introduction
This is the testimony of Ronald L. Putnam for the Senate Committee
on Veterans Affairs on Rural Outreach for Veterans, June 16, 2010. I
would like to thank the Chairman and ranking member and Members of this
Committee for the opportunity to speak on Rural Outreach and to
introduce myself.
My name is Ronald L. Putnam; I am the Haywood County Veteran
Service Officer and the Director of Veterans Services in Haywood
County, North Carolina. I served in the United States Marine Corps, the
North Carolina Army National Guard, Army Reserve, and the North
Carolina Air National Guard, and I retired from the North Carolina Air
National Guard with a total of twenty four years of service. During my
eleven years of active service with the Marine Corps, I served in
combat in Beirut, Lebanon. I served during the first Gulf War as a
Marine Corps Recruiter in Hickory, North Carolina. I was also called to
Active Duty twice in support of Operation Noble Eagle while a member of
the North Carolina Air National Guard. I am a member of the North
Carolina Association of County Veteran's Officers; I am on The
Executive Board, The Education Committee and The Legislative Committee
of that association. I am also a member of The National Association of
County Veterans Service Officers and I am the Chairman of the
Washington Liaison Committee of that association. I am also a member of
several national veteran organizations. I would like the Chairman and
the Members of this Committee to know that I am honored to testify
today and that I also think that it is my duty to do so, to the best of
my ability.
background
As the United States developed into a viable country in our distant
past, most of the country remained rural in nature with a few
population centers. This is particularly true in a large part of the
United States, but applies equally throughout our great Nation. The
population centers developed into cities which, through their very
nature, provide many services to their citizens. This is not unlike the
Veterans Administration and their benefits delivery mission. Those who
live in the population centers or cities are available to receive their
benefits due to their close proximity to the service centers.
Realistically, it is not acceptable to require all of our Nation's
veterans to live in population centers if they wish to utilize the
earned services and benefits that their military service has afforded
them. The Department of Veterans Affairs recognized this issue early on
and began developing Regional Offices and Medical Centers throughout
the Nation. Again, these were developed primarily in the population
centers and those residing in rural America did not have the same
benefit as those living nearer to the services being offered.
As our Nation entered into one conflict and war after another, the
population of veterans surged to historic levels and veteran benefits
grew at the same time. After the end of World War II, many local
governments took it upon themselves to develop veteran services at the
State and County level. This was a good solution in some respects, but
many local governments do not have funding mechanisms in place that can
assist in paying for local services to veterans.
In the late 1970's, many local governments throughout the country
went through tax revolts which severely limited available funding for
discretionary spending. Rural America suffers more in poor budget years
due to the lack of overall funding for services. Sadly, many local
agencies view veteran services as a discretionary budget item. This
resulted in many offices being consolidated into other governmental
offices or eliminated completely; a sad commentary indeed.
Many veterans, particularly combat veterans, choose to live in
rural, even remote areas. The experiences they lived through during
their military service have left many of them with a sense of anger and
inability to deal with other people. The rural areas of our country
have become a sanctuary for many veterans who suffer from Post
Traumatic Stress Disorder and other service-connected disabilities
which adversely affect the veterans. Outreach has been frequently
referred to as a solution to the problem.
Regardless of budget shortfalls and consolidation of services, many
viable local veteran services operations have survived over the years.
They remain in place and stand ready to assist the Federal Government
in benefits delivery and claims management.
solutions
The National Association of County Veterans Service Officers is an
organization made up of local government employees. Our members work
for the local government offices and are tasked with assisting veterans
in developing and processing their claims. County Veterans Service
Offices exist to serve veterans and partner with State Veterans Service
Offices, the National Service Organizations and the Department of
Veterans Affairs to serve veterans. The National Association of County
Veterans Service Officers views the local County Veterans Service
Officer as an extension or arm of government, not unlike the VA itself.
If outreach has been referred to as a possible solution to the
problem of bringing the veterans into the VA system of care, then
NACVSO is a realistic solution to this problem. We live and work with
the veterans of our Nation every day. We are there in the communities.
Our member County Veteran Service Officers are present in 37 of our
50 states and located in over 700 local communities. This readily
available workforce represents approximately 2,400 full-time employees
who are available to partner with Department of Veterans Affairs,
Department of Defense and the Department of Labor to help speed the
process of claims development and transition of our military personnel
to civilian life.
Unfortunately, many of the County Offices in the rural areas have
had severe financial problems in maintaining their offices. If the
Veterans Administration is looking to develop outreach into the local
communities, it only makes sense to look toward developing a closer
relationship with local government at the state and county level. This
could help solve the financial problems of the county offices and at
the same time use the states to ensure compliance with proper use of
funding and oversight for fund disbursement.
recommendations
There have been efforts in play to assist the rural veterans
improve their access to Veterans Administration benefits. Some have
involved legislation. Many bills have been introduced both in the
Senate and the House of Representative to establish outreach programs
in most areas of the country. With the passing of public law 109-461
and 111-163 and your support for H.R. 3949 which is in this Senate
committee would provide for funding to Rural County Veterans Service
Offices to enhance outreach efforts throughout the Nation that would
greatly enhance the efforts of local county and state veteran officials
throughout the country.
The National Association of County Veterans Service Officers
strongly encourages you to support this and other veteran outreach
bills. The veterans who live out in our communities and their
dependents well being, depends on your support.
accomplishments
I would like to report on the VA Rural Health Initiative in my
county. The Public Affairs Officer for VA Rural Health Initiative at
Charles George VAMC in Asheville N.C. Scott Pittillo has visited me on
several occasions to talk about the objective of his departments' goal
of reaching rural Veterans with education about VA Health Care
services. We have talked about ideas to work together with other
Veterans service officers and Veterans organizations to help reach the
rural veterans in Western North Carolina. Although his team is just
getting started it is very encouraging to me to see this kind of
cooperation between the VA and local Veterans representatives.
summary
Although, the objective of the rural health incentive is to reach
rural veterans about their VA Health Care Benefits that they are
eligible for and greatly deserve is a common goal for the VA and all
State, County and National Service Organizations veteran service
officer to work together in achieving this goal we invite this
administration and Congress to join with us in support of our efforts
to reach these unique Veterans. Although a lot of the VA's current
efforts to communicate more closely with veterans by utilizing, modern
media, and technology, I want to remind both this Committee and the
Veterans Administration that their still a number of WWII, Korea, and
Vietnam veterans that have unique education deficiencies and social
disconnects, that make it extremely hard to receive the information
that is being presented on these twenty-first century medians. I will
remind this Committee, the Veterans Administration, and all my
colleagues, that the best communication with these veterans is face to
face interaction with someone who is knowledgeable, well trained, and
willing to assist these men and women that we owe such indebtedness to.
Thank you for your attention to these matters. God bless this Committee
and the United States of American.
Senator Tester. Thank you, Mr. Putnam. I appreciate your
comments.
Dr. Jesse?
STATEMENT OF ROBERT JESSE, M.D., ACTING PRINCIPAL DEPUTY UNDER
SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY GLEN W. GRIPPEN, NETWORK DIRECTOR, VETERANS
INTEGRATED NETWORK 19
Dr. Jesse. Yes. Good morning, Senator Tester, Members of
the Committee, and our apologies for the lateness of our
testimony. I am happy to have the opportunity to present to you
today.
I would like to thank you for inviting us here today to
discuss the current state of VA's care and service for our
veterans in rural areas and specifically in VISNs 19 and 20. I
am accompanied today on this panel by Mr. Glen Grippen, the
Network Director for the Rocky Mountain Network, which is VISN
19, and on the next panel by Mr. William Schoenhard, who is the
Deputy Under Secretary for Operations and Management.
Increasing access for veterans is one of Secretary
Shinseki's top priorities. This means bringing care closer to
home, increasing the quality of care that we deliver, and
providing veteran-centered care in a time and manner that is
convenient to our veterans.
My written testimony covers in great detail VA's national
efforts to improve access, quality, and coordination of care
for our rural veterans, as well as specific initiatives in VISN
19 and 20 that directly relate to our rural veterans.
In the time I have now, I would just like to highlight the
broader work VA is doing for the veterans in rural America. VA
offers a number of important programs designed specifically to
increase access to veterans living in rural areas. VA has
planned and funded more than 350 projects, actually getting
close to 400 at this point, projects and initiatives to help
improve access for rural veterans. Our efforts have supported
many successful projects, including new facilities, home-based
primary care mobile health resources, telehealth, and many
other local initiatives.
Telehealth is one of the major mechanisms by which VA is
increasing access to health care for veterans in rural areas.
All together, there are between 30 and 50 percent of telehealth
activity in VA supports veterans in rural areas, and data from
fiscal year 2009 show ongoing growth in all these areas of
telehealth, and as was mentioned, there is a robust increase in
the budget to cover that activity.
Another key element of VA's strategy for improving services
for veterans in rural areas is a new model of care. VA is
undertaking probably the most significant change in its model
of care delivery since the rapid expansion in the CBOCs
beginning back in the 1990s, and in many ways, this new
approach is a continuation of the same strategy VA has always
pursued, bringing care closer to veterans and making care more
accessible.
We are redesigning our systems around the needs of our
patients, improving care coordination and virtual access
through secure messaging, social networking, telehelp, and
telephone access. An essential component of this approach is
transforming our primary care programs to increase the focus on
health promotion, disease prevention, and chronic disease
management through multidisciplinary teams.
Concerning Montana, VA's Rocky Mountain Network, VISN 19,
actively works to enhance the delivery of health care to
veterans in rural areas in the Rocky Mountain Region. VA
understands that veterans and others who reside in VISN 19's
rural and frontier areas face a number of challenges associated
with obtaining health care, including geography, but also
weather and terrain. For example, VISN 19 is supporting four
projects made possible by the Office of Rural Health that
harness technology and improve access and quality. VISN 19
received $7.3 million from the ORH to develop ten primary care
telehealth outreach clinics that will serve more than 7,000
veterans, and the VA Rocky Mountain Network received four
grants totaling $1.4 million to support non-institutional care
for veterans in that area.
Turning to Alaska, much is happening in VISN 20 to support
veterans in rural areas. The Alaska VA Health Care System has
recently opened or will soon open three clinics, Mat-Su CBOC in
Wasilla, the Homer Outreach Clinic, and the Juneau Outreach
Clinic, which is currently operating part-time in temporary
space and will be moved to a permanent space later this fall.
Alaska VA has also been conducting a project focusing on
collaborations with existing Alaska Native Tribal Health
Corporation facilities and federally-supported Community Health
Centers to provide primary care and mental health services to
Alaska's veterans. VA continues to work to improve the quality
and access of services for this important population.
I would like to thank you all again for the opportunity to
discuss VA's programs for veterans in rural areas. Again, this
is a priority for the Secretary and VA is bringing to bear all
of its resources to ensure that every veteran can access the
care he or she has earned through their service in uniform.
This concludes my prepared statement and my staff and I
look forward to answering your questions. Thank you.
[The prepared statement of Dr. Jesse follows:]
Prepared Statement of Robert Jesse, M.D., Ph.D., Acting Principal
Deputy Under Secretary for Health, Veterans Health Administration, U.S.
Department of Veterans Affairs
Good Morning, Mr. Chairman and Members of the Committee. Thank you
for inviting me here today to discuss the current state of the
Department of Veterans Affairs (VA) care and services for our Veterans
in rural areas, specifically in Veterans Integrated Service Networks
(VISN) 19 and 20. I am accompanied today by Mr. William Schoenhard,
Deputy Under Secretary for Operations and Management; and Mr. Glen
Grippen, Network Director for the Rocky Mountain Network (VISN 19).
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
of the care we deliver; and it means providing Veteran-centered care in
a time and manner that is convenient to our Veterans. This is the
obligation we have, inspired by the service and sacrifice our Veterans
have made on behalf of this Nation.
My testimony will discuss VA's national efforts to improve the
access, quality, and coordination of care for our rural Veterans, then
detail specific initiatives in VISN 19 and VISN 20 that directly relate
to our rural Veterans.
national programs
VA offers a number of important programs designed specifically to
increase access for our Veterans living in rural and highly rural
areas. While the Office of Rural Health (ORH) oversees and administers
many of these critical efforts, VA also uses telehealth as one method
of improving accessibility for these Veterans. VA is also developing
and instituting a revolutionary new model of care that will assist all
Veterans, not just rural Veterans, by providing an even more Veteran-
centric approach to health care. Moreover, the pilot required by Public
Law 110-387 section 403 is specially designed to improve the quality
and availability of contracted care in rural areas when a VA medical
facility is just too far away.
office of rural health initiatives
Since it was established in 2008, the Office of Rural Health (ORH)
has worked to address the significant challenge of serving our Veterans
in rural areas. VA has planned and funded more than 350 projects and
initiatives to address these concerns. Our efforts have supported many
successful projects including: institutional physical expansion in the
form of new community-based outpatient clinics (CBOC) and outreach
clinics; home-based primary care; mobile health care resources; and
many other local initiatives.
CBOCs offer Veterans a full array of exceptional VA services,
including primary care, mental health care, and in some instances, VA
will arrange specialty care services in communities where Veterans live
and work. In FY 2008, ORH established 10 outreach clinics in rural
areas for our Veterans, followed by an additional 30 outreach clinics
in FY 2009. These are part-time clinics that extend access to VA's
primary care and mental health services where there is less patient
demand, or for other reasons it is otherwise not feasible to establish
a full-time CBOC. These outreach clinics are required to collaborate
with the local community to support the continuum of care and can be
either VA-staffed or contracted to a local provider.
ORH has continued to support the expansion of the innovative
program of home-based primary care teams, funding 38 Teams, 14 of which
involve collaboration with the Indian Health Service or Tribal
Organizations. Overall, 30 teams are operational and 8 are still hiring
staff to deliver these benefits to our Veterans. These highly-skilled
medical teams provide comprehensive health care right in the home of
our Veterans with multiple chronic conditions, conditions that would
normally preclude a Veteran from being able to visit a VA clinic. Rural
Mobile Health Care Clinics are now operational in VISNs 1, 4, 19 and
20. These Clinics extend access to primary care and mental health
services in rural areas where it is not feasible to establish a
permanent clinic or hospital. They also offer for our Veterans ongoing
coordination of overall medical care, wellness promotion and
immunizations, health screening, referrals to specialty clinics,
individual counseling, and other important services. Through the end of
the first quarter of FY 2010, these clinics had seen 236 (VISN 1), 104
(VISN 4), 143 (VISN 19), and 123 (VISN 20) unique Veterans,
respectively. The VISN 19 Mobile Clinic is based out of the Cheyenne VA
Medical Center (VAMC) and it conducted its first visit on August 25,
2009, in Sterling, CO. It regularly visits Laramie, Wheatland and
Torrington, WY. The Mobile Telehealth Clinic is staffed with VA health
technicians and nurses providing onsite care to our Veterans and has a
secure tele-video connection with the Cheyenne VAMC. This ensures
Veterans receive the care they have earned through their service in
their community; in essence, we're bringing VA to Veterans.
Rural Health Resource Centers (RHRC) provide an essential resource
that helps VA study what is important for rural Veterans, test new
programs, and educate rural Veterans with the latest information. There
are three RHRCs across the country, with the Western Rural Health
Resource Center located in VISN 19's VA Salt Lake City Health Care
System in Salt Lake City, UT. These Centers perform policy analyses,
design pilot projects, develop collaborations with a range of partners
(such as the Indian Health Service, Tribal Organizations, and academic
affiliates, to name a few), and provide education and updates to health
care providers and Veterans on how VA can better deliver high quality,
accessible health care to rural Veterans. Some focus on specific
populations of Veterans; for example, the Western Region RHRC is
focusing on Geriatric and Native Veteran populations.
VA has also established a dedicated Rural Consultant for each VISN
who enhances the delivery of health care to Veterans in rural areas and
leads activities to build an ORH Community of Practice, promoting
information exchanges and learning within and across VISNs and
supporting a stronger link between ORH and the VISNs.
The mission of the Veterans Rural Health Advisory Committee is to
examine outstanding issues and recommend ways VA and its team can
improve medical services for enrolled Veterans who live in rural areas.
The Committee developed a set of guiding principles which they have
recommended to the Secretary for consideration in developing rural
health policy. The Committee represents a broad cross section of
Veterans and rural health care providers and advocates.
telehealth
Telehealth is another mechanism by which VA is increasing access to
health care for Veterans in rural areas. All together, between 30 and
50 percent of telehealth activity in VA supports Veterans in rural and
highly rural areas, depending upon the area of telehealth. Data from FY
2009 show ongoing growth in all areas of telehealth.
Telehealth involves the use of information and telecommunication
technologies as a tool in providing health care services when the
patient and practitioner are separated by geographic distance. VA has
three robust national telehealth platforms in place to support expanded
health care access for Veterans through telehealth at the VISN,
facility and CBOC level. These platforms are: real-time video
conferencing, store-and-forward telehealth, and home telehealth, which
are discussed in greater detail below. Because of the support of
telehealth by VA and Congressional leadership, more Veterans are able
to realize their benefits. Telehealth provides health care to
underserved rural areas and involves 35 clinical specialties in VA.
Over the past 6 years, telehealth in VA has transitioned from use
in a range of discrete local projects and programs toward a unified,
enterprise level approach that provides routine telehealth services
that are mission critical to the delivery of care to Veterans. VA has
long been acknowledged as a national leader in developing effective and
sustainable telehealth programs that increase access to care. VA's
senior leadership, at both the national and VISN level, are committed
to the expansion of telehealth to enhance access to care for Veteran
patients, especially in rural and remote locations.
The importance of the systems approach VA is taking to its ongoing
telehealth development is that the health care assets that are needed
to provide care in rural areas exist in urban areas, and VA can
leverage its clinical assets through a large interoperable telehealth
network to support care locally. It is important to emphasize that
although telehealth increases access to care, there remains an obligate
need for face-to-face delivery of care. An appropriate balance of both
``physical'' and ``virtual'' clinical services is needed to provide
comprehensive health care to meet the needs of Veterans, including
Veterans in rural areas.
The successful implementation of robust and sustainable telehealth
services that VA entrusts to provide care to Veteran patients must
satisfy stringent clinical, technological and business requirements
that ensure they are appropriate, responsive to the needs of Veterans,
and cost-effective. These requirements include acceptance by patients
and practitioners as well as staff training and quality management
systems. To make sure we deliver safe and effective care, VA has
introduced quality management programs for CCHT, Clinical Video
Telehealth (CVT) and care coordination store-and-forward (CCSF). In FY
2009, these quality management programs were combined for all three
areas of telehealth to create a single assessment process in which the
policies and procedures of telehealth programs are assessed biannually
in each VISN. In addition, VA collects routine outcomes data for
program management purposes. These systems allow us to quantify,
validate and monitor the clinical benefits of these approaches.
VA provided real-time video-conferencing, also known as CVT, to
more than 37,000 Veterans in rural and highly rural areas in FY 2008.
Of these, 2,030 Veterans from rural areas served in Operation Enduring
Freedom or Operation Iraqi Freedom (OEF/OIF) and 112 OEF/OIF Veterans
lived in highly rural areas.
The majority of CVT services were for mental health conditions, but
Veterans also receive rehabilitation, speech pathology, polytrauma and
spinal cord injury care. Ensuring VA is responsive to the needs of our
Veterans and making mental health care accessible is a top priority for
VA. In FY 2009, 21,603 Veterans received tele-mental health services in
rural areas and 1,600 in highly rural areas. CVT services were
available to Veterans at 250 sites in rural or highly rural areas.
Moreover, VA is establishing a National Tele-Mental Health Center. This
Center will coordinate tele-mental health services nationally with an
emphasis on making specialist mental health services, such as those for
Post Traumatic Stress Disorder (PTSD) and bipolar disorder, available
in rural areas.
Store-and-forward telehealth, known as CCSF, involves the
acquisition and interpretation of clinical images for screening,
assessment, diagnosis and management. These images can include
photographs, x-rays, MRI results, and retinal scans, for example. These
services were provided to 61,776 Veterans in rural areas and 2,911 in
highly rural areas during FY 2008. In FY 2009, this workload increased
by 86 percent. CCSF services were predominantly delivered to screen
diabetic eye disease (tele-retinal imaging) and prevent avoidable
blindness in Veterans. Last fiscal year, VA offered tele-retinal
screening services at 283 sites, 78 of which were in rural or highly
rural areas, and today, VA has 310 participating sites, 84 in rural or
highly rural areas. The remainder of CCSF activity primarily covered
tele-dermatology. VA set a goal of a 20 percent increase in use in FY
2010, and just as with CVT, VA is on pace to meet that objective. VA
also has a pilot program underway to expand nationally for tele-
dermatology in five VISNs in 35 sites, 20 of which are in rural areas.
Every Veteran wants to live as independently as possible, but
sometimes health conditions mean this cannot be done safely. To help
Veterans continue living in their own homes and local communities, VA
provides home telehealth services, known as CCHT. CCHT covers a range
of chronic conditions including diabetes, chronic heart failure,
hypertension and depression. Currently, 41,000 Veterans receive CCHT
for non-institutional care, chronic care management, acute care
management and health promotion or disease prevention. Thirty-eight
(38) percent of these patients are in rural areas and two percent are
in highly rural areas.
Concerning specialty care, VA has home telehealth programs in 140
VA medical centers that enable 41,000 Veteran patients to remain living
independently in their own homes. These programs are particularly
applicable for the management of chronic disease and non-institutional
care. Forty (40) percent of home telehealth patients are in rural and
remote locations. Using funding in FY 2009, VA increased the delivery
of care via home telehealth to Veteran patients in rural and remote
locations by 19 percent and is seeking to achieve a further increase of
20 percent in FY 2010.
VA continues to optimize its Polytrauma Telehealth Network to
facilitate provider-to-provider and provider-to-family coordination, as
well as consultation from Polytrauma Rehabilitation Centers and Network
Sites to other providers and facilities. Currently, about 30 to 40
videoconference calls are made monthly across the Network Sites to VA
and DOD facilities. New Polytrauma Telehealth Network initiatives in
development include home buddy systems to maintain contact with
patients with mild Traumatic Brain Injury (TBI) or amputation, and
remote delivery of speech therapy services to Veterans in rural areas.
VA is undertaking a range of initiatives to expand access to
telehealth services in rural and highly rural areas. These initiatives
focus on the clinical, technological and business processes that are
the foundation for the safe, effective and cost-effective
implementation of telehealth in VA to support Veteran care. For
example, VA is working to formalize the clinical processes necessary to
use telehealth to support the 41,096 Veterans with amputations
receiving care from VA. Telehealth enhances access to care in rural
areas as close to Veterans' homes and local communities as possible, if
the Veteran wishes to use the services. We are also working to
implement CVT services to make specialist care more widely available,
including in rural areas. VA recently completed the necessary work to
implement its Managing Overweight and/or Obesity for Veterans
Everywhere (MOVE!) program within CCHT programs. This development will
expand the reach of this successful and groundbreaking program for
weight management to Veterans in rural and highly rural areas. We have
also completed a program for supporting Veterans with substance abuse
issues via home telehealth available during FY 2009.
new model of care--moving forward
One key element of VA's strategy for improving services for
Veterans in rural and highly rural areas is a new model of care. VA is
undertaking the most significant change in its model of care delivery
since the rapid expansion of CBOCs began in the 1990s. In many ways,
this new approach is a continuation of the same strategy VA has always
pursued: bringing care closer to Veterans and making care more
accessible.
To support this effort, VA has joined the Patient-Centered Primary
Care Collaborative, a national coalition of other public and private
sector members to improve primary care. We are redesigning our systems
around the needs of our patients, improving care coordination and
virtual access through enhanced secure messaging, social networking,
telehealth, and telephone access. An essential component of this
approach is transforming our primary care programs to increase our
focus on health promotion, disease prevention, and chronic disease
management through multidisciplinary teams. These changes will focus on
improving the experience patients and their families have when seeking
care from VA. We will benchmark with private sector organizations such
as Kaiser-Permanente. We intend to seek patient input to help guide
this transformation.
The President's FY 2011 budget submission describes this model in
greater detail. The VA Tele-health and Home Care Model initiative will
use technology to remove barriers to Veterans and increase access to VA
services. This initiative will enable VA to become a national leader in
transforming primary care services to a medical home model of health
care delivery that improves patient satisfaction, clinical quality,
safety and efficiencies. VA Tele-health and Home Care Model will
develop a new generation of communication tools (i.e. social
networking, micro-blogging, text messaging, and self management groups)
that can be used to disseminate and collect information related to
health, benefits and other VA services.
The Veteran-Centered Care Model will improve health outcomes and
the care experience for Veterans and their families. The model will
standardize health care policies, practices and infrastructure to
consistently prioritize Veterans' health care over any other factor
without increasing cost or adversely affecting the quality of care. VA
looks forward to working with Congress to ensure these plans become a
reality for Veterans of all eras across the country.
public law 110-387, section 403 pilot program
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 Pub. L.
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 re-configured 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 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 exception'' and the mileage standard.
visn 19 initiatives
VA's Rocky Mountain Network (VISN 19) actively works to enhance the
delivery of health care to Veterans in rural and highly rural areas in
the Rocky Mountain region. VA understands that Veterans and others who
reside in VISN 19's rural and frontier areas face a number of
challenges associated with obtaining health care, such as geography,
weather, and terrain. VISN 19 is pursuing a range of initiatives to
share the expertise and experience of the entire VA system with these
Veterans.
For example, VISN 19 is supporting four projects made possible by
VA's Office of Rural Health (ORH) that harness technology to improve
access and quality. VISN 19 received $7.3 million from ORH to develop
10 Primary Care Telehealth Outreach Clinics that will serve more than
7,000 Veterans in Glenwood Springs and Salida, Colorado; Hamilton and
Plentywood, Montana; Idaho Falls, Idaho; Moab and Price, Utah; and
Evanston, Rawlins and Worland, Wyoming. All of these clinics will be
established by the end of 2010. VISN 19 also received $2.8 million to
develop an innovative virtual Intensive Care Unit (ICU) and Rapid
Response Team monitoring system with video conferencing; the virtual
ICU is operational and successfully maintaining access to critical care
services in Fort Harrison, MT, Grand Junction, CO, and Cheyenne, WY.
VISN 19 received another $3.8 million to establish a VISN Telehealth
Care Shared Resource System to provide expanded specialty care
conferencing and consultation for care providers and Veterans in rural
areas. Some of the disciplines or conditions included are
endocrinology, Traumatic Brain Injury (TBI), cognitive impairment
services, pain management, dementia, Post Traumatic Stress Disorder
(PTSD), dermatology, rehabilitation and wound care, cardiology, and
pre- and post-surgery care. This project is also exploring the
feasibility of expanding services to non-VA telehealth networks.
Finally, VISN 19 received $1.7 million to provide innovative education
and wellness strategies to Veterans in rural areas using primarily
telehealth modalities. The program will deliver intensive case
management and education to Veterans with high-risk conditions, such as
TBI, PTSD, depression, obesity, heart failure, diabetes, pulmonary
disease, and substance use disorders.
VISN 19 also utilizes rural outreach clinics to offer services on a
part-time basis, usually a few days a week, in rural and highly rural
areas where there is not sufficient demand for full-time services or it
is otherwise not feasible to establish a full-time CBOC. There are
currently six designated outreach clinics in VISN 19: Havre, MT;
Burlington, CO; Craig, CO; Elko, NV; Afton, WY; and Logan, UT which
were recently approved and funded.
With regard to specialty care for our Veterans, the VA Rocky
Mountain Network received four grants totaling $1.4 million to support
non-institutional care for Veterans. These resources have helped us
expand the home-based primary care and medical foster home programs to
more Veterans in the region, preserving their independence while
providing them the safe and effective care they need. VISN 19 is also
home to the Mental Health Care Intensive Care Management-Rural Access
Network for Growth Enhancement (MHICM-RANGE) Initiative, which has
added mental health staff to CBOCs and increased the use of tele-mental
health services. Similarly, VISN 19 has conducted outreach and
developed relationships with the Indian Health Service, as well as
other agencies and academic institutions committed to serving rural
areas.
Other efforts specific to Montana include:
A $6.7 million contract for construction of a 24 bed
inpatient mental health facility at the VA Montana Healthcare System.
This expansion will provide Veterans residential rehabilitation in
substance abuse and PTSD in Montana. Currently, Montana Veterans
needing these longer stay programs are required to travel to VA
facilities in North Dakota, Wyoming, or Idaho.
A pair of grants totaling $707,172 to partner with a
private company, Billings Clinic, to pilot Programs of All-Inclusive
Care for the Elderly (PACE) services for Montana Veterans in
Yellowstone County and Livingston, Montana. PACE provides community-
based care and services to frail, elderly individuals as an alternative
to institutional nursing home placement, and provides all health care
and related services to participants over time and across all delivery
settings. VA Montana plans to serve 15 Veterans through the PACE
program.
A part of the grant previously mentioned for a Home-Based
Primary Care Team to provide the maximum of in-home care to rural and
frontier Montana Veterans with complex medical conditions. The Team
provides assistance to caregivers supporting concerns with housing and
financial issues, and helps improve home safety and fall prevention,
which maximizes the independence of the Veterans. VA Montana plans to
serve 25-30 patients in the HBPC program.
An $818,506 rural health eye care project in the Missoula
and Bozeman Montana CBOCs. Each site will utilize Tele-retinal
Equipment to connect providers at the site with locations throughout
the VA Montana HCS. In addition, VA Montana proposes to rent surgical
space as needed, along with support staff for a VA ophthalmologist to
perform eye surgeries (cataract removal) in Bozeman, MT at a local
contract surgical site. This site will provide support to VA locations
in Eastern Montana including Billings, Miles City, Glasgow, Glendive,
Lewistown, Havre, as well as Western Montana in Missoula, Kalispell,
Cut Bank and Hamilton. We expect services will be available at the
Missoula and Bozeman CBOCs by the end of August 2010.
visn 20 initiatives
Much is happening in VISN 20 to support Veterans in rural areas,
particularly in Alaska. The Alaska VA Healthcare System (Alaska VA) has
recently opened, or will soon open, three clinics: the Mat-Su CBOC in
Wasilla opened in April 2009; the Homer Outreach Clinic, opened in
December 2009; and the Juneau Outreach clinic, which is currently
operating part-time in temporary space in the U.S. Coast Guard Clinic,
Juneau Federal Building, and will be moved to a permanent space later
this fall after renovations on the first floor of the Federal building
are complete.
In the area of telehealth, VISN 20 has implemented a tele-
dermatology consultation system using store-and-forward technology and
a consistent, defined curriculum of basic training and continuing
education for primary care providers. This program has been implemented
in Anchorage and has expanded to the clinics in Fairbanks and Kenai
during FY 2010. The Kenai CBOC recently received funding to obtain
tele-retinal imaging equipment and has begun offering this service,
which particularly benefits Veterans with diabetes. VISN 20 also has
adopted care coordination home telehealth (CCHT) programs; in Alaska,
220 Veterans have enrolled. Twenty-seven (27) percent of the enrollees
live in highly rural areas, 20 percent live in rural areas, and 53
percent live in urban areas. The Alaska VA has been a leader in the
rollout of this technology, and CCHT has been adopted by the Alaska
Federal Health Care Partnership. It is being offered to other Federal
beneficiaries, to include clinics of the Alaska Native Tribal Health
Consortium, as a result of VA collaboration.
During FY 2009, the Alaska VA successfully recruited a psychiatric
nurse practitioner to support a tele-mental health clinic in Kenai,
operating 3 to 5 days per month. As of May 31, 2010, 62 unique patients
are being seen through this clinic, with an increase of 4 to 6 Veterans
per month. In addition, a Social Work Mental Health Clinic for intake
and ongoing therapy will begin at the Kenai CBOC during June, and a
pain management group will begin at the Kenai CBOC in July 2010. At the
end of March 2010, the Alaska VA neuro-psychologist started a TBI
screening clinic via videoconference with the Fairbanks VA CBOC. Tele-
mental health services are also offered to the Yukon-Kuskokwim Health
Corporation (YKHC) in Bethel, AK, as they identify a need or forward a
request. The Alaska VA has visited both YKHC and Maniilaq Health
Corporation in Kotzebue to educate local health care providers about
its tele-mental health resources. A January 2010 presentation to the
Alaska Federal Health Care Partnership Telehealth and Technology
Committee resulted in positive contacts with staff from the Alaska
Native Tribal Health Consortium, Bristol Bay Area Health Corporation,
and Maniilaq Health Care Corporation. This venue holds promise for
spreading the message about tele-mental health resources at the Alaska
VA. VA staff will continue to attend these quarterly meetings.
The Alaska VA is conducting a project focusing on collaborations
with existing Alaska Native Tribal Health Corporation (ANTHC)
facilities and federally-supported Community Health Centers (CHC) to
provide primary care and mental health services to Alaska's Veterans.
This project began in August 2009, with its goal to maximize existing
VA authorities to enhance access to primary and mental health care for
rural Veterans through purchased care provided by ANTHC and the CHCs.
The project includes the Bethel census area; Bristol Bay Borough,
Dillingham Census Area, Nome Census Area, Northwest Arctic Borough,
Wade Hampton Census Area, and the city of Cordova. Under the project,
Veterans may be authorized three primary care visits and two mental
health visits within a 6 month period. If the Veteran requires
additional visits, the Veteran or health care provider may contact VA
to request additional care as needed. VA sent letters to 548 enrolled
Veterans in the pilot areas inviting them to participate, and through
May 2010, approximately 20 percent (N=110) have enrolled and 17 have
requested and been granted authorizations for care (14 for primary care
and 3 for mental health care).
Another initiative underway in Alaska involved VA hiring a full-
time employee, a Rural Veteran Liaison, to be a local community-based
contact for VA questions on health care and benefits. In June 2009, the
Alaska VA hired a Bethel-based liaison to perform outreach to the
Yukon-Kuskokwim area. There are two other outreach programs the Alaska
VA is supporting: the Tribal Veteran Representative (TVR) Program,
which uses local community volunteers to assist VA in reaching out to
Alaska Native Veterans; and an Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF) program focused on the newest generation of
Veterans. The TVR Program identifies Alaska Native Veterans recognized
or appointed by an Alaska Native health organization, tribal
government, tribal council, or other tribal entity to act as a liaison
with local VA staff. The representative is a volunteer, unless paid by
the Alaska Native entity. VA provides collaborative training for the
TVRs on VA health care and benefits programs. Four training sessions
have been completed, two in Anchorage, one in Juneau, and one in
Ketchikan. As of April 2010, 16 people have completed TVR training.
The Alaska VA has made special efforts to reach out to Alaska
Native Tribal Health Consortium organizations upon the first major
deployment of the Alaska National Guard in support of OEF/OIF. A multi-
disciplinary group of VA staff traveled to rural areas to educate
Veterans and the community about PTSD, TBI, and suicide awareness and
prevention. In addition to the educational aspect of these sessions, VA
staff and Alaska Native Tribal Health System staff focused on providing
a pathway of care for each system to work together to ensure returning
Servicemembers and other Veterans living in rural areas could
seamlessly access their Alaska Native health benefits as well as access
their benefits through the VA health care system. The presentations on
the pathway of care focused on the VA enrollment, eligibility, and fee
authorization process to assist Veterans in accessing VA health care
and how to bill for reimbursement from VA should their health
corporation seek authorization to provide services to Veterans. Packets
of information with contact names and phone numbers were given to each
participant, and information tables were staffed in community settings
such as post offices, grocery stores, and other areas to raise
awareness in the general community.
Finally, the Alaska VA has a signed a memorandum of understanding
with the State of Alaska Department of Military and Veterans Affairs
that outlines a partnership to work together to meet the needs of
returning soldiers. OEF/OIF staff members regularly attend Post-
Deployment Health Re-Assessment (PDHRA) events. In addition, the Alaska
VA actively participates in pre- and post-deployment events for active
duty Servicemembers. The National Guard's ``Yellow Ribbon'' events
deliver information about VA benefits to Servicemembers and their
families. The Rural Veteran Liaison and OEF/OIF staff members have
accompanied these liaisons on a number of trips to rural Alaska to
provide information about various VA programs and benefits.
conclusion
VA continues to work to improve the quality and access of services
for this important population. Thank you again for the opportunity to
discuss VA's programs for Veterans in rural and highly rural areas.
Again, this is a priority for the Secretary, and VA is bringing to bear
all of its resources to ensure that every Veteran can access the care
he or she earned through their service in uniform. This concludes my
prepared statement. My staff and I look forward to answering your
questions.
______
Response to Post-Hearing Questions Submitted by Hon. Patty Murray to
U.S. Department of Veterans Affairs
Question 1. Dr. Jesse, I have been working with the VA to open new
contract clinics in three underserved communities in my home state,
Omak, Republic and Colville, so that local veterans can have easier
access to VA-provided care. I have also been working with the VA to
open a virtual clinic in Port Angeles. It is critical for veterans in
these communities that we get these up and running as soon as possible.
Where are we with efforts to expand care in Omak, Republic
and Colville as well as with the virtual clinic in Port Angeles?
Response. Status of Contract Clinics--Republic, Colville and Omak,
Washington: Contracts for each site have been awarded and T1 lines have
been ordered (which require a minimum of 30 days for implementation).
Background investigation, fingerprinting and credentialing information
has been sent to each site to complete and return to Spokane for
verification (which should require 4-6 weeks for processing). It is
projected that the three sites will start seeing patients mid-to-late
August 2010 The contracts are with local providers to improve access to
Primary Care (including preventive medical services) for rural
Veterans. We are projecting the patient volume yearly for Republic will
be between 78-130 Veterans, for Colville between 388-646 Veterans and
for Tonasket between 139-232 Veterans. (Although Omak was the
anticipated location within Okanogan County, the contract was awarded
to a provider in Tonasket). The contractors will provide continuous
delivery and management of primary and preventive care only. Mental
health examinations are included in the contracts, although
consultation and treatment services will be provided by VA. Referrals
for specialty care, extensive diagnostic work-ups and non-emergency
hospitalization will be made to the nearest VA medical centers.
Status of Port Angeles: VA Puget Sound Health Care System (VAPSHCS)
staff is utilizing facilities at the virtual clinic in Olympic Medical
Center in Port Angeles and at the Lower Elwha Tribal Health Clinic,
part of the Lower Elwha Klallam Nation, to help meet the health care
needs of Veterans living in the region. This partnership brings VA
health care closer to Veterans in Jefferson, Clallam and Grays Harbor
Counties in Washington State. As of May 31, 2010, there are 1,134
patients enrolled in the Port Angeles Clinic. In FY 2009, the clinic
had 6,937 patient appointments. Veterans are assigned to one of three
health care providers (1.0 MD, 1.6 Nurse Practitioners). The clinic has
a full complement of support staff consisting of three health
technicians, one medical support assistant and two registered nurses.
In addition, the clinic staff includes one home based health nurse, one
social worker and one mental health nurse practitioner. The clinic
provides laboratory drawing services and can arrange for radiology
services, if needed, through purchased care in the local community. The
lease with Olympic Medical Center expires September 30, 2011. With the
opening this month of the South Sound Community Based Outpatient Clinic
(CBOC) in Chehalis, Washington, the priority focus is now on developing
a formal CBOC request for the Olympic Peninsula. This will include
updating the Veteran demographics in that region and recommending the
optimal location.
How is the VA addressing needs for veterans in highly
rural areas where care is needed and there is limited access to
services?
Response. Department of Veterans Affairs (VA) recognizes the
importance of providing effective, high quality and accessible care to
all eligible Veterans in rural and highly rural areas and is
accomplishing this goal through mobile medical units (MMUs), telehealth
services, Community Based Outpatient Clinics (CBOCs), outreach clinics,
and community collaborations. An MMU has been operational out of the
Spokane Washington VAMC since 1992. In addition, at the beginning of FY
2009, 4 MMUs became operational including one in Washington State
located at the Puget Sound Healthcare System.
The Veterans Health Administration (VHA) has three national
telehealth programs--Care Coordination Home Telehealth (CCHT), Clinical
Video Telehealth (CVT), and Care Coordination Store and Forward
Telehealth (CCSF). In FY 2009, VA's telehealth programs provided care
to over 100,000 Veterans in rural and highly rural areas and increased
the delivery of telehealth services to rural Veterans by 41 percent
from FY 2008. With the additional funding provided by VHA's ORH
telehealth initiatives, the number of telehealth services provided to
Veterans in rural and highly rural areas is projected to increase by
more than 20 percent in FY 2010 (FY 2010 actual data will be available
in November 2010). Veterans Integrated Service Network (VISN) 20
network-wide (Washington State) initiatives include Teledermatology.
CBOCs and Outreach Clinics also play an important role in providing
accessible care to highly rural Veterans. In FY 2010, ORH funded fifty-
one CBOCs in counties identified as being 100 percent rural. This
includes the Chehalis, Washington CBOC that became operational in
May 2010. Thirty-nine Home Based Primary Care Teams have also been
activated, including one at the Walla Walla, Washington VA Medical
Center.
VA also recognizes the importance of partnering with local provider
organizations as a means of extending VA's reach and improving access
to care for highly rural Veterans. Referred to locally as community
partnership contracts, three were recently awarded to providers in
Tonasket, Republic and Colville for primary care.
I have heard stories of veterans traveling a couple of
hours for routine care including dental appointments. How does the VA
determine when to provide care on a fee-basis instead of forcing the
veteran to drive long distances for basic care?
Response. Enrolled Veterans are eligible to receive the full range
of health care services included in the medical benefits package
codified at 38 CFR Sec. 17.38. When VA facilities determine that they
cannot furnish economical hospital care or medical services because of
geographic inaccessibility or they are not capable of furnishing care
or services required, VA may utilize the authority in U.S.C. 1703
(often described as ``fee basis'' care) to purchase these services from
a community provider. Other authority, such as the authority to enter
into sharing agreements pursuant to 38 U.S.C. 8153, is utilized for
Veterans who do not meet the statutory eligibility requirement of 38
U.S.C. 1703. Clinical status of the patient and availability of the
services both factor into the decision. Local VA Medical Center
providers determine the most appropriate care and location of services.
It is important to note that VA provides a Beneficiary Travel benefit
for those qualifying Veterans who are required to travel to their
appointments. This benefit currently provides mileage reimbursement of
41.5 cents per mile to eligible Veterans. VA also works with Veteran
Service Organizations and other transportation resources to assist
Veterans traveling to appointments at VA facilities.
Question 2. Dr. Jesse, recently the VA proposed to adopt the
Medicare payment method for all non-VA inpatient and outpatient health
care services in the absence of contracts between these providers and
the VA. I am concerned about the impact this potential change might
have on certain services like laboratory services and dialysis
providers. While I agree with the VA that we need to be fiscally
prudent, I feel that a change this large should be phased in to ensure
a smooth transition process. I am also concerned the first areas to be
impacted would be rural and underserved areas where alternate care
options are not available.
What is the status of the pending rule to reduce
reimbursement of providers to the Medicare rate?
Response. The Department of Veterans Affairs (VA) published 2900-
AN37, Payment for Inpatient and Outpatient Health Care Professional
Services at Non-Departmental Facilities and Other Medical Charges
Associated with Non-VA Outpatient Care, as a proposed rule on
February 18, 2010 (75 FR 7218). VA received numerous public comments
and has prepared a final rule, currently under legal review. Once the
Secretary approves the final rule, it will be sent to the Office of
Management and Budget (OMB) for their review under Executive Order
12866 (Regulatory Planning and Review). After OMB's review, which can
take up to 90 days, VA will publish the final rule in the Federal
Register.
One of the services impacted by this proposed rule is
dialysis. For veterans with End Stage Renal Disease who live in rural
or under-served areas, what preparations are being made to mitigate the
closure of clinics in some of the most rural areas in VISN 20 and other
rural areas in the country?
Response. VA is carefully reviewing all of the comments we received
on this proposed rule. Several comments indicated the proposed
regulation would have a significant impact on small dialysis providers.
We anticipate addressing this concern in the final rule, and we will
work closely with Veterans requiring dialysis treatment to ensure they
receive services as close to home as possible.
Question 3. Dr. Jesse, Recently the VA announced the Surgical
Complexity Initiative, which organized VA hospitals, based on their
capabilities, to provide three levels of surgeries: complex,
intermediate and standard. As part of this reorganization, the Spokane
VA Medical Center was found to be performing some ``intermediate''
level surgeries although it is a ``standard'' surgery facility. Under
the new initiative, it may only perform surgeries of ``standard''
complexity. Now the Spokane VA provides services to rural veterans
across Northeastern Washington, who would struggle to access services
provided by the VA in Seattle or Portland. I am concerned that this
surgery downgrade may lead to veterans postponing elective procedures
because they are unable to travel long distances for care. I would also
like to know how the VA determines whether to refer patients to local
providers on a fee basis or to send them to VA facilities.
Response. VA is the first hospital system to conduct a
comprehensive review to determine what level of inpatient surgeries may
be performed in each of its 112 surgery programs. After an expert work
group's review of surgical standards, VA conducted on-site studies of
each of its hospitals between June 2009 and March 2010. As a result, VA
has assigned each of its medical centers an inpatient ``surgical
complexity'' level--complex, intermediate or standard. While aimed at
ensuring patient safety and high-quality care for all Veterans, the
initiative affected only a very small number of surgical procedures.
Each of VA's 21 hospital networks developed a surgical strategic plan
to ensure that Veterans receive needed care while facilities strengthen
quality, safety and service.
How does the VA plan to address this at facilities like
Spokane that work with a largely rural population and where alternate
medical care options may not be available?
Response. Each of the 21 Veterans Integrated Service Networks
(VISN) has a policy in place for the transfer of appropriate care and
delivery of medical services when not available at any given facility.
Furthermore, each VA medical center has a policy for the transfer of
care either into the community or to the most closely located VA
facility depending on circumstances at the time of presentation,
including the severity and complexity of the Veteran's disease and the
requirement for urgent or emergent care.
During the interim period of the Surgery Complexity
Initiative , how are VA doctors preserving their expertise if they are
no longer able to practice certain procedures at their facilities?
Response. In 2009, the surgeons at the 13 VHA Surgical Programs
designated to be Standard performed 25,111 surgical procedures of which
347 have been determined to be ``intermediate'' and no longer able to
be scheduled per VHA Directive 2010-018, Facility Infrastructure
Requirements to Perform Standard, Intermediate, or Complex Surgical
Procedures. Therefore, the Operative Complexity Initiative will have
little overall impact on the ongoing practice of the individual
surgeons currently on staff at these facilities.
What limitations is the VA taking into consideration along
with health concerns when determining whether to provide care in the
local community on a fee-basis or sending the veteran on to another
facility?
Response. Each VA medical center has a policy for the transfer of
care either into the community or to the most closely located VA
facility depending on circumstances at the time of presentation,
including the severity and complexity of the Veteran's disease and the
requirement for urgent or emergent care.
______
Response to Post-Hearing Questions Submitted by Hon. Mark Begich to
U.S. Department of Veterans Affairs
Question 1. As for Behavioral Health, do you think the staffing is
adequate to provide the proper level of care for our rural veterans,
explain how you are providing Behavioral Health care for rural
veterans.
Response. The parameters of required mental health care for
Veterans, including rural Veterans, are specified in the Office of
Mental Health Services (OMHS) ``Uniform Mental Health Services in VA
medical centers and Clinics'', Handbook 1160.01. In rural areas, mental
health services are primarily delivered through VHA's community based
outpatient clinics (CBOCs) and, as required or needed, through VHA
medical centers, via fee and contracts with community providers, and
tele-mental health services.
Basic principles of care for Veterans in rural areas include the
following:
(1) Ambulatory Mental Health Care: Facilities must offer options
for needed mental health services to Veterans living in rural areas
even when medical centers or clinics offering relevant services are
geographically inaccessible. When necessary, this can include the
provision of tele-mental health services with secure access near the
Veteran's home, or sharing arrangements, contracts, or non-VA fee basis
care to the extent that the Veteran is eligible from appropriate
community-based providers, as available.
(2) Residential Care: Each Veteran receiving VA health care
services must have timely access to Mental Health Residential and
Rehabilitation Treatment Programs (MH RRTPs) as medically necessary to
meet the Veteran's mental health needs.
MH RRTPs provide specialized, intensive treatment and
rehabilitation services to Veterans who require them in a therapeutic
environment. Veterans living in rural areas need to be referred to
these programs when they are medically necessary to treat the Veteran's
mental health condition.
(3) Veterans with Serious Mental Illness: VISNs and facilities have
been provided guidance to implement Mental Health Intensive Case
Management--Rural Access Network Growth Enhancement (MHICM-RANGE)
programs for Veterans who need them in smaller facilities, especially
in more rural areas. MHICM is a program of intensive services for
Veterans with serious mental illness with teams that have collaborative
linkages with other VA mental health professionals and with experienced
full-time staff.
Ongoing initiatives that further enhance access to mental health
services include the following:
(1) Vet Center/Readjustment Counseling. An effort that is
complementary to rural mental health services are Vet Centers/
Readjustment Counseling Services (RCS). RCS's Mobile Vet Center program
is a major initiative for extending the geographic reach of outreach
and counseling services to Veterans particularly Operation Enduring
Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans and their families.
(2) Rural Pilots. Public Law (PL) 110-387, Sec. 107 directed VA to
conduct a pilot program to evaluate the utility of providing OEF/OIF
Veterans with peer outreach, peer support, readjustment counseling
services, and mental health services in collaboration with contracted
community mental health providers. We anticipate that the pilot
projects will begin provision of services in three VISNs by October 1,
2010.
(3) MHICM-RANGE expansion. An expansion of the MHICM-RANGE program
has been supported by the VA's Office of Rural Health. This initiative
adds mental health staff to CBOCs, enhances tele-mental health services
and uses referral to community mental health services and other
providers to increase access to mental health care in rural areas.
(4) My HealtheVet Program. OMHS has partnered with the My
HealtheVet Program office and Office of Information and Technology to
develop online resources designed to complement traditional mental
health services and to expand access to these services to Veterans in
rural areas.
VA is committed to adequate staffing to provide the proper level of
care to Veterans residing in rural areas. There are many challenges to
recruitment and retention of staff, most notably: (1) availability of
qualified mental health care professionals in small rural communities
is often limited; and (2) at times, in rural areas as in other places,
VA salaries are not competitive to attract mental health personnel. VA
has addressed these challenges by continuing to expand access to tele-
mental health services, use of fee-basis contract arrangements with
community providers, and education and training of community providers
in rural areas about Veterans issues.
Question 2. Telehealth and Telemedicine, including home telehealth
systems are becoming more acceptable to administer care to veterans.
What are your plans to expand telehealth, and have you surveyed
Veterans on how they are utilizing it and if they feel it is working
for them? What are the major challenges with telehealth in rural
Alaska?
Response. VA plans to expand both the numbers of patients receiving
care via telehealth and the scope of these services. Examples of
telehealth services that VA is developing include teleaudiology,
telepathology, dementia care, spinal cord injury, post-amputation care
and pain management.
The Veteran patient experience with telehealth is a critical
component of developing these services and for ongoing refinement and
improvement. Veteran patients show satisfaction levels between 86
percent and 90 percent with telehealth services routinely provided by
VA.
The challenges encountered with developing telehealth services in
Alaska are comparable to those that exist elsewhere, but they are
magnified by geographic, distance, climatic and economic circumstances
that are unique to Alaska and its Veteran population. These challenges
include the buy-in of clinicians and resolving the clinical, technology
and management challenges necessary to implement and then sustain
services.
Question 3. Recently a White Paper on the Alaska VA Health
Administration's use of Special Authority for Fee-Basis Care was
provided to this Committee dated June 7, 2010, which discusses U.S.C.
1703 (a)(5), tell me how this is working for Alaska?
Response. This authority expands access to both outpatient and
inpatient care from non-VA providers for Alaska Veterans where such
care will ``obviate the need for hospital admission''. Its use in
Alaska allows Veterans to be pre-authorized for outpatient care if the
care is not available at an Alaska VA facility.
Question 4. How many veterans utilized this authority and where did
you send them for treatment?
Response. The Alaska VA Healthcare System (AVAHS) provided care to
15,170 Veterans in fiscal year 2009. Of these, 8,959 Veterans received
a combination of VA and non-VA care. Approximately 58 percent of care
was delivered within the Municipality of Anchorage. The rest was
distributed across the remainder of the State: 19.7 percent of non-VA
care was delivered in Fairbanks; 8.6 percent in the Kenai/Soldotna
area; 3.1 percent in Juneau; 3.6 percent in the Palmer/Wasilla area;
2.4 percent in Homer; and 1 percent in Kodiak. The remaining 3.6
percent was delivered in communities across the state with
concentrations of less than one percent of the State's population.
Question 5. What was the total number of patient care visits in
2009 that were sent for care to places other than the VA facilities in
Alaska? Of that number, how many were sent to ``Non-VA Preferred
Providers'' within Alaska?
Response. During fiscal year 2009, 596 unique Veteran patients (3.9
percent of all users) generated 719 outpatient visits and 217 inpatient
admissions in VA facilities in the contiguous 48 states. A total of
1,471 inpatient periods of care were authorized across the State of
Alaska in fiscal year 2009. During fiscal year 2010 to date, 1,140
inpatient periods of care have been authorized. Approximately 26,580
authorizations of non-VA care were provided in fiscal year 2009.
Considering each authorization averaged three visits, there were
approximately 79,000 visits for non-VA care in Alaska. Unlike a Health
Maintenance Organization (HMO) or other private insurance plans, VA
does not have ``preferred providers.''
Question 6. With respect to Pre-Approval and emergency care, could
you explain ramifications of ``prudent layman's criteria for clinical
review'' as described in the White Paper?
Response. The ``prudent layperson standard'' is used by Alaska as a
clinical assessment of the urgent nature of the episode of care (a
prudent layperson would have reasonably expected a delay in seeking
care would have been hazardous to life or health). Application of this
standard for assessing an episode of care assists in assuring that
consistent clinical standards are utilized across all programs.
Assessing the emergent nature of the care is required for VA to approve
these cases. By using an industry standard criteria, such as prudent
layperson, the Alaska facility assures standardization in their
decisionmaking process and consistency with emergency care
determinations across all VA authorities for emergency non-VA care (38
U.S.C. 1725 and 1728). This standard also assures the decision is based
on what a ``prudent layperson'' would determine to be an emergency,
affording Veterans the most expansive of standards in making decisions
on payment for non-VA health care.
Question 7. Again with respect to Pre-Approval as discussed in the
White Paper of June 7, 2010 and referring to U.S.C. 1703 (a)(5), is it
reasonable to assume that a fully qualified eligible veteran that is
transported to a Non-VA facility for care under emergency conditions
should expect that the charges incurred from such treatment would be
covered by the VA?
Response. For enrolled Veterans, it is reasonable for a Veteran to
expect that each episode of emergent care will be paid for by VA if
these clinical standards are met. This does not apply to the costs of
travel, which are governed by other authorities and eligibility is not
limited to the prudent layperson standard.
Question 8. Many folks that we talk to that are sent outside are
confused and irritated that it would appear that the exact same care is
available in Alaska. I know that the overriding issue may be resources
and the VA can mitigate the costs better by treating the veterans in
government facilities but when do we take the veteran into
consideration and start doing what is best for them. Sending them
outside to Washington or Oregon for their treatment they could receive
in Alaska is stressful for the Vet and their families. Explain why they
get sent out and if this Special Authority could be utilized more in
state.
Response. The Alaska VA has maximized its Special Authority within
the intent of Federal regulations. The AVAHS follows regulatory
guidance for providing care to Veterans in Alaska as directed in 38 CFR
Sec. 17.93 (Eligibility for Outpatient Services) and 38 CFR Sec. 17.53
(Limitations on Use of Public or Private Hospitals). Following this
guidance, AVAHS maximizes the use of internal resources for care when
available. Accordingly, when required services can be provided within a
clinically appropriate timeframe by a VA facility in the Lower 48,
Veterans are referred to that facility since 38 CFR 17.52 directs that
non-VA ``* * * care within Alaska be consistent with the incidence of
the provision of medical services for Veterans treated within the 48
contiguous States''. When services are not available internally, local
Federal partners are utilized. If local Federal partners are not
available, contract facilities are a third choice. Non-VA care is
provided when Federal or contract services are not available based on
demand or urgency of request.
Senator Tester. Thank you, Dr. Jesse. I appreciate your
testimony.
Correct me if I am wrong, Glen. You are going to be here,
available for questions, is that correct?
Mr. Grippen. Yes, sir.
Senator Tester. OK. And I will make sure to at least have
one or two for you.
We will have 5-minute rounds. The order of questioning will
be Senator Murray, followed by Senator Johanns, Senator Begich,
and I will go last. Senator Murray?
Senator Murray. Thank you very much, Mr. Chairman, and to
all of you for your testimony today.
Dr. Jesse, I have been working with the VA, as you know, to
open new contract clinics in three of our underserved
communities in my State, Omak, Republic, and Colville, so that
those local veterans can get easier access. I have also been
working with the VA to open a virtual clinic in Port Angeles
that is really critical for that community, as well, and I
wanted to ask you this morning, where are we with those efforts
to expand care in Omak, Republic, and Colville, as well as the
virtual clinic in Port Angeles?
Dr. Jesse. I can't give you the exact details, but I do
know that all of those are moving forward, but we can get back
to you on the record for their exact status.
Senator Murray. If you could do that for me, those veterans
are waiting to hear----
Dr. Jesse. Absolutely----
Senator Murray [continued]. And we certainly are, as well.
Do you have a timeframe when you can get back to me on that?
Dr. Jesse. As soon as possible. We can get that in the next
couple of weeks, I am certain.
Senator Murray. In the next couple of weeks. OK. I would
appreciate that a lot. Thank you.
Dr. Jesse. Sure.
[The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to
Robert Jesse, M.D., Acting Principal Deputy Under Secretary for Health,
U.S. Department of Veterans Affairs
Context of Inquiry: During the June 16, 2010 Senate Veterans'
Affairs Committee hearing on rural health, Senator Murray requested an
update on the status of the Port Angeles, WA, virtual clinic.
Response. VA Puget Sound Health Care System staff are utilizing
facilities at the Olympic Medical Center in Port Angeles and at the
Lower Elwha Tribal Health Clinic, part of the Lower Elwha Klallam
Nation, to help meet the health care needs of Veterans living in the
region. This partnership brings VA health care closer to Veterans in
Jefferson, Clallam and Grays Harbor Counties in Washington State. As of
May 31, 2010, there were 1,134 patients enrolled in the Port Angeles
Clinic. In FY 2009, the clinic had 6937 patient appointments. The
Veterans are assigned to one of three health care providers (1.0 MD,
1.6 Nurse Practitioners). The clinic has a full complement of support
staff consisting of three Health Technicians, one Medical Support
Assistant and two Registered Nurses. In addition, the clinic staff
includes one Home Based Health Nurse, one Social Worker and one Mental
Health Nurse Practitioner. The clinic provides laboratory drawing
services and can arrange for radiology services, if needed, through
purchased care in the local community. The lease with Olympic Medical
Center expires September 30, 2011. With the opening this month of the
South Sound Community Based Outpatient Clinic (CBOC) in Chehalis,
Washington, the priority focus is now on developing a formal CBOC
request for the Olympic Peninsula. This will include updating the
Veteran demographics in that region and recommending the optimal
location for a clinic site.
Senator Murray. I have heard stories of veterans, as I said
in my opening remarks, traveling for hours for routine care,
and I hear a lot about dental appointments, as well, for folks.
Can you tell us how the VA determines when to provide care on a
fee basis instead of forcing the veteran to drive long
distances?
Dr. Jesse. There are, I think, a couple issues that need to
be discussed in the context of that. First of all, the most
important thing for us is that the veteran can get the best
care in a way that is most convenient for them. That being
said, that generally means as close to home as possible.
Sometimes, that care, when it is complex, is not available in
the local areas.
A good example would be--and we have had some of this
discussion, I think, from the last meeting in regards to cancer
care--that patients might need to be sent down to Seattle to
get that care when, in fact, some of that care might be
available in Anchorage; and we are actually now looking to
build the kind of contracts we can to get that care in
Anchorage so they would have to travel less far, when
appropriate. We do know that some of the veterans would prefer
to travel down to Seattle, and if that is the case, we would
accommodate that. And in certain cases----
Senator Murray. So is this on a case-by-case basis or are
there guidelines? Are there rules, or just----
Dr. Jesse. Well, it is--it has been, I think, case by case.
We are in the process of establishing contracts so that we can
have those services available so that they don't have to
travel.
Senator Murray. So there aren't any----
Dr. Jesse. But we don't have all the----
Senator Murray [continuing]. Specific guidelines when you
go to fee basis versus making somebody travel?
Dr. Jesse. Not that I am aware of.
Senator Murray. It is case by case determined. Should there
be guidelines?
Dr. Jesse. Well, I think where the guidelines would come
into play would be having the availability of those services
through contracts or through other mechanisms locally. We have
historically not been as good about that as we should have
been. We relied on the patients having to come to our centers,
traveling many miles, like Montanan's going down to Denver,
which would be a good 400 miles, just like to travel down to
the lower 48. And I think one of the real initiatives----
Senator Murray. It takes that long in some places from my
State to get----
Dr. Jesse. Yes. And so I think one of the major important
initiatives of the Office of Rural Health is to really
determine--to move that away from being case by case and to
develop the policy and the opportunity to deliver that care as
close to the home as possible.
Senator Murray. All right. I wanted to ask you, as well,
the VA recently proposed to adopt the Medicare payment method
for all non-VA inpatient and outpatient health care services in
the absence of contracts between providers and the VA. I am
really concerned about the impact of that potential change on
services like laboratory or dialysis providers, especially
dialysis providers. We have heard a lot of concern about that.
We all know we have got to be fiscally prudent, but a
change this large I think ought to be phased in so we can have
a smooth transition process. I am also very concerned about the
impact on rural and undeserved areas. So can you share with
this Committee the status of that pending rule?
Dr. Jesse. Certainly. I think there are actually two issues
here: one being fiscally responsible; but more important than
that is access, and we need to ensure not only access today,
but access 5 years from now to the needed services so that we
weigh both concerns.
Specifically related to dialysis, this has been a huge
financial burden on the VA. It is not that we have been paying
a little bit more than Medicare. We have been paying sometimes
400 percent of Medicare and it has had a huge financial impact,
which, as you know, takes away from the ability to provide
other services. So the VA, in moving toward that Medicare, our
proposal is to phase it in over 4 years----
Senator Murray. Four years?
Dr. Jesse [continuing]. Which is historically what, I
think, the Department of Defense did when they have made
changes along these lines in TRICARE, but also what Medicare
has done when they have made major changes like this.
Senator Murray. OK.
Dr. Jesse. Four years, I think, should be sufficient time
to----
Senator Murray. Well, I would like my staff to follow up
with you----
Dr. Jesse. Sure.
Senator Murray [continuing]. Because we are very concerned,
especially about the dialysis and how we can mitigate some of
the closure of the clinics in some of our rural areas.
Dr. Jesse. And the VA also is, as I mentioned--access is
important and there is a lot of effort going on to improve the
VA's ability to deliver dialysis services.
Senator Murray. OK. I appreciate it. Thank you very much.
Thank you, Mr. Chairman.
[The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to
Robert Jesse, M.D., Acting Principal Deputy Under Secretary for Health,
U.S. Department of Veterans Affairs
Context of Inquiry: During the June 16, 2010 Senate Veterans'
Affairs Committee hearing on rural health, Senator Murray requested an
update on the status of VA's proposed adoption of the Medicare
Prospective Payment Systems (PPS) and fee schedules for dialysis care.
She would like a timeline for the proposed regulation's implementation
and the phased transition to the Medicare PPS.
Response. VA published proposed rule, 2900-AN37, in the Federal
Register on February 18, 2010, with the public comment period ending
April 19, 2010. This proposed rule would amend current payment
regulation, 38 CFR Sec. 17.56, to allow for the use of Medicare
Prospective Payment Systems (PPSs) and Fee Schedules in the
reimbursement of inpatient and outpatient health care professional
services at non-VA facilities and other medical charges associated with
non-VA outpatient care. VA received 18 public comments related to the
proposed rule. VA has addressed the public comments and is in the
process of circulating the Final Rule for internal VA concurrence. Once
internal VA concurrence is complete the Final Rule will be subject OMB
review. The publication date for the Final Rule is expected to be fall
of 2010.
Senator Tester. Senator Johanns?
Senator Johanns. Thank you, Mr. Chairman.
Dr. Jesse, let me continue, if I could, with questions for
you.
Dr. Jesse. Sure.
Senator Johanns. I haven't been to a hearing on these
issues yet where the promise of telehealth/telemedicine wasn't
emphasized, and I, as a former Governor, certainly promoted it,
also recognizing this as a way of trying to get medical
services into rural areas. I think we would all agree it would
be great to have a cardiologist and a psychiatrist and an
oncologist in every area of our States. It is just not going to
be possible. We know that. They are hard to recruit, even to
larger cities, much less a very rural area.
One of the things that you say in your testimony is that
you believe that telehealth has reduced hospital admissions.
That conjures up the notion that maybe it saves some money. Do
you have any measurement at all at your fingertips that can
demonstrate to us that our investment in telehealth is, in
fact, paying off by whatever measure you might use? Talk about
that and walk me through how I can be convinced that, in fact,
our continued emphasis on this effort is working, resulting in
better care or fewer hospital admissions or whatever.
Dr. Jesse. Certainly. As a cardiologist, I appreciate your
recognition of----
[Laughter.]
Dr. Jesse [continuing]. Of how difficult it is to get the
services, and particularly in the area I practice, which is
acute cardiac care, where things are very time dependent. There
are very real challenges that occur in getting very urgent and
timely care to these patients.
There are three forms of telehealth that we are looking at.
First, tele-consultation, which would get cardiology expertise,
say, to a primary care provider in a remote area, hence, the
connection of medical services.
The second is storing forward, which is what we do with the
tele-retinal imaging, for instance. So rather than people
having to travel distance just to get an eye exam, the
diabetics where we do this annually, and a good 25 percent of
our patients are diabetics, we can do that. We can put that
technology into primary care offices. It goes into the medical
record. It is then read remotely by experts and we can codify
this and follow it over years.
And then the other is the home telehealth. Again, I will
use my background as a cardiologist and point out we have been
actually doing this since the mid-1980s with the home
monitoring of pacemakers and implanted devices. So it is not
new; and, in fact, in that example, 2 years ago or 3 years ago,
there was a large number of recalls of pacemakers and
implantable devices. By having the home monitoring process in
place, we estimated we saved 25,000 clinic visits across this
country.
So just to see the travel costs, the staff time, the
patients' time, especially where they have to travel and be
seen in clinics, it is a tremendous savings that adds up in
that case.
In the broader sense, yes, we can easily quantitate that we
reduce admissions because we can intervene on things early, and
that is the rough block of money. I think the heart of this
question, though, is as we move from a health care model that
is inherently episodic--people come to us when there is a
problem--to one that is driven by wellness, prevention, and
risk mitigation in the long sense; it is having that
connectiveness between the patient and the health care system
in order to manage that, which I think will be the real payoff
in the long run.
We don't have those numbers right now, but if you look at
the cost of managing just hospitalizations alone and managing
patients with chronic diseases, if that can be better managed
through telehealth to prevent those admissions, and more so
avoid the secondary or bad outcomes from those diseases, that
is where the true cost savings comes in.
So the simple answer is we can give you hard numbers about
prevented admissions. The 20-year plan is at this point, I
think, a good model, but is not hard and proven.
Senator Johanns. This is something that the VA is really
going to have to help us with, because we are putting money out
there. I think we are testing a lot of different approaches
here. We hear testimony, though, that, gosh, maybe this isn't
doing all it needs to be doing or we need to do more. Somehow,
some way, we have got to figure out how to measure this. We
have got to be able to figure out that this strategy works
very, very well with telehealth, maybe another one doesn't, and
be honest about that so we can focus our spending in an
appropriate way, because, again, I would love to say that we
are going to have specialists throughout every rural area in
America. There aren't that many. And so we have got to somehow
figure out what is working and what is not working.
Mr. Ahrens, I think you offered a thought here about
whether telehealth was getting the job done. I am out of time
now, but if you could take just a minute and offer your
thoughts in reaction to what Dr. Jesse has said. Are you as
excited about telehealth maybe as you once were, or are there--
are we making the progress you want to see?
Mr. Ahrens. Senator, let me answer it this way. I think we
are making progress, but we ought to measure it. And some of
the money that you put out could be used for measurement
studies. Does it save money? I am convinced it does, but you
have got to have the metrics out there which show that it does.
You need outcome measurements, and I think it would be well
worthwhile for the Office of Rural Health to do one of those
studies to show you. And we need to expand it; there is no
question about it. You can't deliver health care to everybody
in rural America without using it.
Senator Johanns. Yes. Adrian, you mentioned this in your
testimony. Is there anything you want to offer as I wrap up
here?
Mr. Atizado. Yes, Senator. I think that there is sufficient
study that shows telemedicine does save money, primarily on the
preventive medicine side. The other anecdotal evidence shows
the use of specialized consultants does help, as well. You have
to understand that when you go to especially the frontier areas
of our Nation, there is no safety net. I mean, you have got one
primary care doctor doing everything.
Senator Johanns. Yes.
Mr. Atizado. They are on call 24/7. They can't take a
vacation. So when they have these technologies, in fact--there
is, I think, an article in the AARP Bulletin magazine about
this where the physician actually had a telemedicine hook-up
videoconference with a cardiologist who could listen to the
vital signs and breathing sounds of a patient who had a chronic
condition. That saved that patient having to drive 7-8 hours
with a chronic condition to the nearest town or city that has
the services that they need.
So, I mean, the evidence seems logical that it would save
money. It is just a matter of proving it. The whole idea of
saving admissions and lowering the cost of health care is, VA
parlance, they are a business. I mean, they are a health care
provider, so they have to talk in this sense. But as far as
users of VA health care, it seems apparent to us that it is
something that VA should do.
I must note, if I could have a few more seconds, the FDA,
FCC, and HRSA have set aside funding not only to build
broadband infrastructure to the rural communities, but certain
initiatives are devoted to telemedicine in rural areas. I think
with the advent of new technology, which is moving rapidly as
we speak, for telemedicine, a lot of policymakers and a lot of
industry experts are actually looking at VA and their research
into whether or not they are going to invest in telehealth and
telemedicine.
So I think it is crucial, as Mr. Ahrens said, that VA, in
fact, document not only health outcomes, not only cost savings,
but health status and the ability for telemedicine to deal with
the workforce shortage that everybody is facing now.
Senator Johanns. Thank you, everybody.
Senator Tester. Senator Begich?
Senator Begich. Thank you very much, Mr. Chairman.
If I can, Dr. Jesse, let me add follow-up questions in
regards to telemedicine, but also on utilization by other
facilities that are non-VA regarding the contracts that you are
trying to work out.
You had made the comment you were trying to expand these
contracts, and you used Anchorage as an example. You are
working through it. Can you elaborate a little bit more? What
does that mean? Why I ask this is because, to be very frank
with you, I have heard that on a regular basis. This is one
thing that we have: for a huge opportunity for medical
facilities, and Indian Health Care Service is a great example,
because of the way we manage them up there, but huge facilities
both in Anchorage and Fairbanks that, I think, are
underutilized.
So, help me understand. When you say you are working out a
process or you are working through contracts, tell me what that
means and what kind of time table.
Dr. Jesse. OK. So I think Mr. Schoenhard could probably
speak to that better, since he is involved in the details of
that, but----
Senator Begich. OK. He is behind you and smiling, so that
is----
Dr. Jesse. Is it the Providence Health----
Mr. Schoenhard. Yes.
Dr. Jesse. So it is the Providence Health System----
Senator Begich. If you want to reserve some of your answer,
you can, and----
Dr. Jesse. Since you have asked for it, it is the
Providence Health System in Anchorage that they are in the
process of developing or negotiating to cover at least the
cancer care.
Senator Begich. Let me ask you, if I can, and I will hold
more detail until the next panel, but let me ask you, can you
or do you keep data on, in any State, utilization of non-VA
facilities by VA recipients, or do you have data points? If I
said to you, what is the percentage in Montana or Nebraska or
Alaska that take advantage of them based on proximity and other
reasons, do you have such answers--what kind of services they
receive?
Dr. Jesse. Yes. So this is complex, because there are a
couple terminologies that we need to be clear about. One is,
what is called fee care? Fee care by the strict definition
means we don't provide the service and we authorize the veteran
to go and get it.
Senator Begich. Right.
Dr. Jesse. And we pay that bill. That is a small component
of what is in broadly more encompassing non-VA care, which
would include both fee care but also care that is through
contract, through community providers, care that is delivered
through contract or other agreements, if you will, through our
academic affiliates.
And the other is what we don't have a handle on, because we
don't really pay for it, which is care that the veteran
themselves----
Senator Begich. Right, get on their own.
Dr. Jesse [continuing]. Chooses to get on the outside,
because many of them also do have secondary insurance and/or in
addition to Medicare. That dual care is a particular challenge
to us, not from the financial side, but from the managing care
side.
So we have the ability to track fee care, obviously. We
have a lot of contract care that is--the ability to roll it up
is a little less robust because some of it is--it rolls in
rather than being just a flat rate that we are paying out on an
annual basis. But we can tell you what that is with at least
some level of precision, I am sure.
Senator Begich. Is that something that you can provide to
us----
Dr. Jesse. I believe so, yet without making a promise, I
will go back and tell you what granular we can provide to you.
Senator Begich. Excellent. And again, as you say, there is
fee and there is contract and----
Dr. Jesse. Right. There is a host of vehicles by which we--
--
Senator Begich. The more defined data you can provide, the
better off----
Dr. Jesse. Sure.
Senator Begich. I would be very interested in that.
Dr. Jesse. OK.
[The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Mark Begich to
Robert Jesse, M.D., Acting Principal Deputy Under Secretary for Health,
U.S. Department of Veterans Affairs
Context of Inquiry: During the June 16, 2010 Senate Veterans'
Affairs Committee hearing on rural health, Senator Begich requested
that VHA provide his office with information on the utilization of fee-
basis care for all 50 states. The Senator would like this information
broken down by the percentage of overall VHA care (by state) that is
delivered through fee-basis and the amount spent (by state) on fee-
basis care.
Response. Non-VA purchased care data (fee-basis) is collected
nationally for processing payments through the Financial Management
System (FMS). This data can be associated or grouped with a state
through two different methods (both attached).
Method 1: The data is grouped by the Provider State. This is the
state identified by the Provider for billing purposes and is not always
the actual, physical location where care was received. For example,
larger providers will use centralized billing centers which may be
located in a different state from where care was provided. We estimate
that 80% of the addresses in the Provider file are the same physical
location where the care took place. The other 20% of addresses in the
Provider file include centralized or offsite billing centers.
Method 2: The data is grouped by the Veteran's Home of Record
State. This state is identified by matching the Social Security Number
(SSN) in the payment files to the SSN record in the VHA enrollment
file. The VHA enrollment file contains the primary mailing address for
all enrolled Veterans. When the payment data is associated with this
state grouping, it is directly associated with the state where the
Veteran primarily resides. With this grouping, there will also be some
instances where Veterans receive care in states other than their state
of primary residence (e.g. where major cities are located near state
borders).
Senator Begich. There has been some good testimony on
telehealth. In Alaska, we use it a great deal, not only from a
VA perspective, but our travel consortium, which is our Indian
Health Services, which is a huge piece of the puzzle. How we
move through delivering health care in areas where even a van--
I know, Mr. Ahrens, you talked about increasing the vans--but,
we can't even get a van there, let alone a plane, depending on
weather.
There was a comment earlier about where the Office of Rural
Health Care is located. Do you think elevating that to a higher
level will get some more recognition of the data that needs to
be collected, the need to understand it better and deliver it
better, or is the location--you were concerned about where it
was located and kind of the system where the office is. Mr.
Ahrens, I didn't hear you make a comment on that. Do you have
any comment in regards to that?
Mr. Ahrens. The Office of Rural Health in the VA?
Senator Begich. Yes.
Mr. Ahrens. I think the higher the elevation you can give
it, the better off we are. We are slowly getting it staffed.
There have been a lot of staff changes. I think it has got the
attention of the Secretary and we ought to keep it right at the
highest level we can, because it is very important.
Senator Begich. Do you think where it is located now, that
the telehealth issues--I mean, I agree with you, if you don't
have the data, it is irrelevant. I mean, you can spend a lot of
time talking about how important it is. We see it in real life
in Alaska. But do you think that has any relationship to doing
some of that hard data collection that is necessary, or is it
just two separate issues that need to be addressed? In other
words, data collection is its own issue, and then moving this
office up higher.
Mr. Ahrens. Well, again, keep the office as high as you
can. This data collection is very important. We don't even know
where veterans are, and we need to know their utilization of
services, if that is what you are asking me. We have to have
certain data in order to proceed. If you are running a
business, how are you going to pursue that if you don't know
where your customers are?
Senator Begich. Right.
Mr. Ahrens. So we have to continue to get that. We can't
even make some decisions with our committee because we don't
know where they are, what disease entity they might have, and
what services should be placed in those areas. If we knew a
little more of that, we would be better off. So the Office of
Rural Health ought to get on that and get it done.
Senator Begich. My time has expired. The report you sent up
to the Secretary, do you anticipate that to be available to us?
At what point do you think?
Mr. Atizado. As I said, it is under the Secretary's
scrutiny. If I could release it to you today, I would, but I
can't. It is a public document. It should be available to you.
Senator Begich. Great. Thank you very much, Mr. Chairman.
Senator Tester. Thank you, Senator Begich.
Jim, Senator Murray had asked Dr. Jesse about fee basis and
who goes where and about the fact that there were no guidelines
for that. Has the Veterans Rural Health Advisory Committee
taken that up at all? Is that something that is within your
purview? Has it been part of the conversation?
Mr. Ahrens. There has been a lot of discussion about fee-
based, and I think it is the consensus of the committee that,
especially in rural areas, there ought to be more of it. Now,
what is coming up in this discussion is, can you provide the
same quality of care in the private sector that the VA thinks
they provide. So I think you can do that, but then we have got
to overcome that barrier.
So it makes a lot of sense to me to use fee-based in areas
where they are very remote, like Scobey, MT, or someplace like
that.
Senator Tester. I get you. It seems a bit odd, as far as if
we take individual by individual and not have guidelines. I
mean, I appreciate your honesty, Dr. Jesse. Jim, does that seem
odd to you? You have been in the business for a long time.
Mr. Ahrens. Well, I think I would establish protocols so
they can be part of the business, and if they can't be met,
they shouldn't be.
Senator Tester. All right. Dr. Jesse, a quick question. It
does deal with rural veterans' health care along the area of
dialysis. Has the VA looked at home dialysis?
Dr. Jesse. Yes. Actually, we had a long discussion about
this the other day. I think, if I remember the number
correctly, it is about 7 percent of our veterans now get home
dialysis. There are two ways to do this. One is through a
conventional hemodialysis type of machine. The other, which is
where most of the home dialysis is done, is through peritoneal
dialysis. It is doable. It doesn't even require sending
somebody into the home; patients and their families can be
trained to do it----
Senator Tester. Is it cost effective?
Dr. Jesse [continuing]. And it is one of the options that
we are looking at to improve it's distribution. It is an area
that even outside of the VA has struggled to really catch on.
Senator Tester. Is it cost effective?
Dr. Jesse. Well, we think it is at least cost neutral.
Senator Tester. OK, that is good. I think you have to take
into account everybody----
Dr. Jesse. So those are exactly the two questions the
Secretary asked me the other day when we were meeting about
this. We think that this is an opportunity, but it has
struggled to catch on and we are not sure why.
Senator Tester. Well, I think it is an incredible
opportunity. It might be lack of knowledge. Let us move on.
Mr. Ahrens, I know for a fact, and you talked about it in
your testimony as one of the recommendations, that we need to
work more with IHS and VA; then you even took it a step
further, VA and other health care facilities. Every time we
have approached this, it has become somewhat of a turf issue.
So could you talk a little bit more about what we could do to
encourage IHS and VA to work together, because it is an
incredible opportunity for saving some money and offering
better health care.
Mr. Ahrens. I would be happy to. I think it has to start at
the top. You have to have the head of the Indian Health Service
and the head of the VA make it a priority. In my opinion, over
the years, even working in the private sector, it hasn't been
that high a priority. Once you do that, everything falls into
place. But you have got to do that and you also have to have
each State collaborate at the local level, where you can get
the various Indian Health Service organizations and tribes
together to sit down and start talking. It is a long, long
process, but you have got to start it because we are wasting
money by having these two systems.
Senator Tester. Any ideas on what we can do as far as
recruiting and retaining health care folks in rural areas, what
the VA could do better?
Mr. Ahrens. Well, I think most of the VA training
facilities are located in major metropolitan areas, and somehow
you have got to get practitioners to have some type of a
residency or training program in rural areas. You know, we do
this in Montana on the private side, where people stay in
Montana. If they can serve their residency in Montana, you have
got a pretty good retention rate. That is not happening to the
full extent that it should, in my opinion. So you have got to
do that.
Senator Tester. OK. That is our priority with me, to try to
get them back in the system. It is something I hear more about
than any other single issue as I have town hall meetings.
We have spoken in the past about opportunities with
prescription drugs for Priority 8s. Could you just talk to me a
little bit about how it might work?
Mr. Ahrens. Well, I am not sure exactly how it will work
mechanically, but I think if you are enrolled and you are a
veteran, you ought to be able to avail yourself of the
services. So get these people enrolled in some fashion and let
them use the drug benefit. I think it would be a wonderful
opportunity.
Senator Tester. OK.
Mr. Ahrens. Mechanically, I don't know how to do it. I
leave it up to my friend, Dr. Jesse, to put it together.
Senator Tester. All right. Do you have any ideas on that,
Dr. Jesse? Is that something you would support, or is there
something else that you think the VA could do for Priority 8
veterans?
Dr. Jesse. The Secretary has begun with, I think,
authorization through Congress to actually open things back up
to Priority 8s. It is being done in a fashion that would meter
them in, because if we opened it up all at once, it would be
overwhelming----
Senator Tester. How about just with respect to prescription
drugs?
Dr. Jesse. In respect to prescription drugs, there are a
couple of challenges there.
Senator Tester. OK.
Dr. Jesse. One is that we don't have the authority right
now--I hope I am saying this correctly--to accept prescriptions
from outside providers, so that, in fact, VA has to process
that prescription. For many pharmaceuticals, the basics for
hypertension and diabetic care and things, that is really not
an issue. But there are some cardiac drugs that require
monitoring and the like, where there is a lot of responsibility
on the provider when we can't ensure that it raises some other
issues. From a purely technical perspective, whether we could
just open up, we will have to get back to you on that. I don't
have the----
Senator Tester. Could you, please? That would be good, if
you could get back to us. If you need Congressional
authorization, that would be something. I think it really could
be a win for Priority 8 folks.
Dr. Jesse. I will take that back to the Secretary.
[The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Jon Tester to
Robert Jesse, M.D., Acting Principal Deputy Under Secretary for Health,
U.S. Department of Veterans Affairs
Context of Inquiry: During the June 16, 2010 Senate Veterans'
Affairs Committee hearing on rural health, Senator Tester asked VHA to
evaluate the feasibility of providing pharmacy benefits to Priority 8
Veterans prior to their enrollment/eligibility for other VA care. In
his recent travels through Montana, the Senator noted that his
constituents seem most concerned about having access to safe,
affordable, prescription drugs. Although full VA health care access for
all Priority 8 Veterans is not feasible in the near term, the Senator
asked if a prescription-only benefit for these Priority 8 Veterans
would be a ``bridge'' to fill the gap until full Priority 8 enrollment
can resume.
Response. It is true that providing access for all Priority 8
Veterans is not feasible in the near term. VA would like to acknowledge
that while a stand-alone prescription benefit may seem attractive as an
interim measure, there have been lessons learned by VA regarding the
management of a drug formulary, the overall cost of providing a
prescription benefit, infrastructure requirements, and potential
patient risks from fragmented care. VA is committed to offering
enrollment to greater numbers of beneficiaries based on available
resources without sacrificing timely access or quality medical care for
those Veterans already enrolled in VA's health care system.
Several years ago, VA gained experience through offering a stand-
alone prescription benefit, the Transitional Pharmacy Benefit (TPB).
This program was designed to ease the out-of-pocket costs for
prescription drugs. Under this program, VA filled prescriptions from
non-VA (private) physicians for patients waiting more than 30 days for
their initial VA medical appointment.
For a limited time in 2004 and 2005, VA was authorized to fill
prescriptions from non-VA (private) physicians until a VHA physician
could examine the Veteran and determine a course of treatment. This
program was made available in VA prior to the enactment of the Medicare
prescription drug benefit which now offers a variety of choices to
Medicare eligible Veterans that wish to select a stand-alone
prescription benefit. The TPB program was offered to 44,322 eligible
Veterans and 17,931 (40%) participated.
The TPB program demonstrated that its administrative costs were
extremely high and the current infrastructure (i.e., software and
business processes) is not designed to support this type of benefit.
Through TPB, it was more costly to provide prescription coverage as a
stand-alone benefit than to provide prescriptions through VA's
comprehensive healthcare benefit. VA lacked software support to
appropriately manage a stand-alone prescription benefit and lacked
access to each patient's non-VA medical record, where important
clinical information is maintained to properly evaluate the
appropriateness of a medication.
Unique to VA's TPB experience was the comparison of formulary and
non-formulary drug use. Forty-two percent of all TPB prescriptions
received were for drugs not listed on the TPB Formulary. VA was able to
reduce the percentage of non-formulary drugs dispensed to 27%, but this
modest reduction was very labor intensive and costly. This stands in
sharp contrast to VA's overall non-formulary dispensing rate of
approximately 6%.
VA is concerned that a stand-alone drug benefit would induce demand
by attracting a significant proportion of the non-enrolled population,
thereby increasing costs for Veterans' healthcare. Depending on the
eligibility criteria for a stand-alone drug benefit, it could also
induce demand for enrollment.
VA believes that coordination of care by one provider is the
cornerstone of high-quality health care. Without up-to-date information
such as a detailed medical history, a complete medication use summary,
and other pertinent clinical information that can only be provided by a
single, primary care provider, there is risk that a course of treatment
for an individual patient, based on incomplete or inaccurate
information could lead to significant negative outcomes. Specifically
from a quality of care perspective, practicing pharmacy in a
fragmented, non-integrated manner, as is the norm in most of the U.S.
health care system, is conducive to greater medication misadventures.
VA has much experience to demonstrate that providing pharmaceuticals as
an integrated part of VA's healthcare benefit is effective and
efficient from both a qualitative and quantitative perspective.
From an economic perspective, dispensing prescriptions prescribed
by non-VA doctors would dramatically increase VA's outlays. Indeed,
VA's current outlays for pharmaceuticals are below those of most
managed care organizations in the US. VA has the infrastructure in
place to develop and promulgate drug treatment guidelines and an
effective National Formulary process. We strongly believe that the
quality of care provided by a comprehensive Primary Care approach,
integrated with a well-managed National Formulary process, is vastly
superior to the fragmented, pharmaceutical delivery model that many
Americans access today.
VA does not support plans to offer a stand-alone prescription
benefit and is committed to working with Congress toward developing
policy and a healthcare delivery system which builds on the strength of
an integrated approach as opposed to the fragmented delivery of
healthcare so common in United States.
Senator Tester. Glen, I promised you a question. I am going
to give it to you, and then we have got to go to a vote at
10:45, so we will recess and come back with Senator Begich's
panel.
We have got more female veterans coming into the VA system
every year. One of the services that is lacking in Montana--
this is a Montana-specific question--is mammography screening,
particularly in Helena. Is that something that we could really
take a look at? Is it something that we could do? We need more
than just equipment. We need more than space. Is it something
that is on the radar screen as the female veteran population
grows?
Mr. Grippen. Senator Tester, first of all, thank you for
all your support, working together closely with us. Certainly,
women veterans are one of our highest priorities. We are taking
a close look at our programs in women's health and we will make
sure mammography and cervical prevention care are two key
pieces of that, and we will take a closer look and provide
information to you about where we are planning to go in that
direction.
Senator Tester. I would appreciate that a lot, Glen; and
once again, thank you for your service.
I am sorry I didn't get a question for you, Mr. Putnam or
Mr. Atizado. I really appreciate everybody's testimony today. I
appreciate your commitment to veterans across this country.
With that, we will recess until Senator Begich gets back to
reconvene.
[Recess.]
Senator Begich [presiding]. The meeting will come back to
order. Thank you all very much; I appreciate your patience. We
had a little issue on the floor and some of us were having to
have some negotiations while we were trying to vote and leave
to get back here. So thank you very much for your time.
I am going to make my comments very brief and just go right
into the testimony, but I do want to say, as I said in my
earlier comments, there is no more rural State than Alaska in
the sense of delivery of services and how you can get from one
point to the next. As I was just describing to Mr. Ahrens, who
has a friend in Kodiak. I had to explain to him that I was just
in Kodiak and could not leave for almost a full day because the
weather conditions would not let me out of there, and I can
only imagine the struggle when people need medical services.
As folks know from Alaska, with almost 76,000-77,000 folks
that are veterans or registered veterans, we have one of the
highest percent per capita, so we have a huge demand for
veterans' services in Alaska. At the same time, as I mentioned,
it is very difficult to move around and get access to the
services they need.
Today, this is the second panel that we have in front of us
and I thank you all for being patient while we move through the
process of voting on the floor and attempting to run Committee
meetings at the same time.
We are joined today, and I appreciate the Alaskans that are
here, Brigadier General Deborah McManus is the Assistant
Adjunct General for Alaska, Commander of the Alaska Air and
National Guard, and Alaska State Women Veterans Coordinator.
She is accompanied by Verdie Bowen, who has traveled with us
many places around the State. I thank you, Verdie, for being
here. He is Director of the Office of Veterans Affairs for
Alaska Department of Military and Veterans Affairs.
Dan Winkelman is the Vice President and General Counsel for
the Yukon-Kuskokwim Health Corporation. Dan, thank you for
being here.
Finally, Robert Jesse, M.D., gets a round two. You have
survived round one, which is a good sign, so welcome again to
this panel.
And also, Bill Schoenhard, Deputy Under Secretary for
Health for Operations and Management at VA. Thank you for your
visit to Alaska and getting a sense of what Alaska is about.
You lucked out because the weather was pretty good. It was very
good. So you will be our representative to explain to all the
folks in D.C., when we say it is warm and not humid, you
actually know what we are talking about now. Again, thank you
for being here.
What I would like to do, General McManus, is start with you
and have you to give your testimony. You each have about 5
minutes. The clock in front of you will signal. If you exceed
that, the floor will release below you. Just kidding.
[Laughter.]
So, General?
STATEMENT OF BRIGADIER GENERAL DEBORAH McMANUS, ASSISTANT
ADJUTANT GENERAL--AIR, JOINT FORCES HEADQUARTERS--ALASKA, AND
COMMANDER, ALASKA NATIONAL GUARD; ACCOMPANIED BY VERDIE BOWEN,
DIRECTOR, OFFICE OF VETERANS AFFAIRS, ALASKA DEPARTMENT OF
MILITARY AND VETERANS AFFAIRS
General McManus. Thank you, Senator Begich. It is my
privilege and honor to be able to be here today and to appear
in front of the Committee Members and to be able to address our
rural health care issues in reaching out to our veterans.
I would like to draw your attention to the map of Alaska.
As you can see, Alaska is the largest State, it is one-fifth
the size of the continental United States, and has five times
the coastline. Over 5 percent of Alaskans speak one of the 22
indigenous languages.
We look at the 2000 Census and how they distinguish between
urban areas, urban clusters, and rural areas. We only have two
locations that are urban areas and that is Anchorage and
Fairbanks, with Anchorage being the largest. Over 250,000 folks
live there from the Census Bureau. Then we have Fairbanks with
over 50,000. So, that is about 300,000 of Alaskans that live in
urban areas.
Then they have urbanized clusters, and these are defined as
those densely populated areas that have over 2,500 people, and
in Alaska, the 348 localities, 17 of them are identified as
clusters. I would like to point out that only about 11 of those
clusters do not even reside on the Anchorage road system, as
you can see the road system there. There is less than 5,000
paved miles reported by the Department of Transportation.
Then we have those non-urbanized areas which the term is
typically referred to as rural. I would like to use the term
``remote'' when we address Alaska because those are off the
road system. You can reach them by air, and that is on a good
day and it is weather-dependent, seasonal-dependent, with a lot
of communication barriers. Some of our villages, they may not
even have phone access and do not have Internet access. They
have a subsistence lifestyle, so they may not have regular
stores in which you can go to shop for goods.
You can see out of those that are not one of the two
urbanized area clusters, that leaves about 350,000 Alaskans.
The veteran population, as the good Senator said, is the
largest per capita in the country. So the veteran population is
dispersed similarly.
There are some projects. The VA, they are active in that
area. Of course, Anchorage, our largest area, they have a large
outpatient clinic. They just opened a new one in May which is
attached to the Elmendorf Military Treatment Facility. It is a
wonderful facility, very large and very welcoming to women
veterans and also to families. Our younger veterans like to
bring their families in to serve with them.
The CBOCs up at Fairbanks, Wasilla, Kenai, the more
populated areas, off the road system, they have also opened
some outreach clinics. In Homer, they use the Kenai CBOC staff
to staff that on Mondays and they provide outreach services to
those veterans in that area. Also, in Juneau we expect an
outreach clinic to be opened in the fall. In Juneau, they have
a population of about 3,000 veterans and it is designed to
reach veterans along the inter-island ferry system, which is
excellent.
Also, we have talked about the Rural Health Care Pilot
Areas. There are seven of those areas and they are also on this
map. The rural population resides typically around the coast
and the inland areas around the river system.
What we have found to be most successful is our Yellow
Ribbon Reconnecting Veterans Outreach Program. This was a
program initiated by the Alaska National Guard, which we did
receive a Federal grant of $500,000. The goal is to reach out
to the IA recognized villages and the incorporated cities and
towns. It is a year program which will be expiring in July, and
we only have, like, 30 more locations; and we are visiting
locations today.
So what has been very successful is to go out there and
ask, where are our veterans? Then they want to know how do they
know they are a veteran, so we explain that. We take out the
paperwork and we help them fill out their paperwork. Many of
them have said that, oh, yes, we have received those packages
from the Veterans Administration in the mail. We just don't
know what to do with it and we don't know what it means. Even
if we were to fill out this paperwork, what does it mean for
us? So that has been very instrumental, to help them complete
that paperwork.
Members of this team understand that if a veteran reaches
30 percent disability, that enables them to receive travel
benefits to travel to one of these VA health care locations.
And we work with them on that initial health exam through funds
within the Alaska National Guard and other creative ways. We
reach out to NGO's, veteran organizations that will help fund
some of our rural veterans to come into those locations for
care. We also let them know that they are eligible for military
gravestones, and they are eligible for military funeral honors.
ANG also talked to some of the National Guard retirees that may
not have filled out the paperwork for their benefits, and to
our ATG members to help them fill out applications.
So, that has been a very successful effort and we would
like to be able to continue that, but it will take another
grant. We got a lot out of that $500,000 grant because we have
folks that are really dedicated, part of the community and want
to reach out to these folks.
[The prepared statement of General McManus follows:]
Prepared Statement of Brig. Gen. Deborah C. McManus, Deputy Adjutant
General--Air, Joint Forces and Commander, Alaska Air National Guard
I am truly honored I was invited to testify before the Senate
Veterans' Affairs Committee.
My first experience managing the complex issues regarding our
Alaska National Guard (AKNG) members in remote Alaska was in 2006 when
we were faced with mobilizing 600 soldiers in October for Operation
Iraqi Freedom (OIF). This was the largest AKNG deployment since WWII.
At that time, I was the Director of Manpower and Personnel for the
AKNG. We were faced with providing services to over 100 soldiers and
their families from 26 remote Alaskan native villages throughout
western Alaska. These soldiers were ready and anxious to serve in
combat. They grew up as hunters with proven survivor skills. The 297th
Regimental Crest worn by this Infantry Battalion displayed a Tlingit
motto, Uyh Yek that translates to ``Be on Watch. Ready to fire.'' The
challenge was preparing their remote communities and families for their
15-month absence. Ms Jan Myers, the Family Readiness leader was
instrumental in this process. Before the deployment, we conducted a
workshop in the village hub of Bethel. The AKNG sponsored the travel of
soldiers and their families to ensure maximum participation. Among the
entities represented were the Association of Village Council
Presidents, faith leaders, Indian Health Services, state legislatures,
TriWest, and local government. Issues included maintaining the
subsistence lifestyle while many of the healthy males deployed,
continuing use of Indian Health Services (IHS) ILO remote TRICARE since
civilian practitioners were practically non-existent, and communication
with families during the deployment since some did not even have phones
or spoke English.
The next challenge became preparing for their return and ensuring
access to veteran benefits in the remote native villages. In
August 2007, only two months before the return of our rural veterans, a
historic MOU was signed between the Alaska Veterans Affairs (VA)
Healthcare and Benefits Administrations (VHA/VBA) and the Alaska
Department of Military and Veterans Affairs (DMVA) to ensure access to
the full spectrum of Veteran benefits with an emphasis on healthcare.
Key goals included:
Seamless Delivery of Healthcare Services to Rural Veterans
Home Station Reunion and Reintegration Workshop for
Returning GWOT Veterans to include Post Deployment Health Reassessments
(PDHRA)
Multidisciplinary Mobile Outreach Teams
The MOU was based are two primary assumptions: 1) Statistics
reflected that up to 30-35% of returning Veterans will seek at least
one psychological health visit within the first year after returning
home. Such unresolved emotional disturbances as a result of a Veteran's
combat experience could be extremely detrimental to a small, remote
Alaskan community; and 2) Due to lack of access to a VA facility for
healthcare, rural Alaska Native Veterans will probably utilize the
Alaska Tribal Health System.
The following initiatives were identified. Today, there is
continuing progress.
Telemedicine and teleradiology capability at 235 sites
around the State and a multi-year home telehealth monitoring project
through Alaska Native Tribal Healthcare Consortium (ANTHC).
A VA Tribal Veterans Representative Program to train
tribal representatives on VA policy, procedures, eligibility, and
rules.
A VA education program for the Alaska Tribal Health
Organizations on VA eligibility and clinical information regarding Post
Traumatic Stress Disorder and other Veteran readjustment issues.
Vet Centers participation in outreach services.
Coordination of access to care through flexible case
management services that recognize the individual and family needs of
veterans. These services or ``pathways of care'' would become a link of
services that connect rural Alaska with Anchorage and Anchorage with
Puget Sound.
Work with state and Federal agencies, civic organizations,
and faith-based agencies to ensure a wide variety of benefits for
Alaska Veterans. All agencies will identify key individuals and commit
resources to address/work issues.
DMVA will conduct Post Deployment Health Reassessments
(PDHRAs) on-site vice a telephone or web-based format.
The Post Deployment Health Reassessments (PDHRAs) were vital in
providing VA services to veterans returning from OIF living in remote
western Alaska. We made it mandatory for these assessments to be
conducted in-person in Anchorage to ensure access to a multi-
disciplinary support team that included representatives from NGB, VHA,
VBA, Vet Centers, TriWest, and Family Readiness. Since the soldiers
were in an official status, their travel was sponsored by the AKNG. Our
goal was to generate referrals to the maximum extent possible so the
costs of further diagnosis and treatment at the Anchorage MTF were
absorbed by the military. Typically, the seven permissible appointments
were adequate to address those medical issues that presented themselves
upon return from the deployment.
However, mental health problems may have a delayed onset or
veterans delay seeking treatment. Reports on our OEF/OIF veterans
document substantial mental health distress and adjustment difficulties
among military personnel returning from combat operations in Iraq and
Afghanistan. They are discovering problems with depression, Post
Traumatic Stress Disorder, and alcohol misuse are common particularly
among National Guard and Army Reserve soldiers. Screening efforts to
identify mental health concerns in the months following return from
combat suggest that up to 42% of National Guard and Army Reserve troops
require mental health treatment, but that relatively few actually get
care (<10%). Many redeployed soldiers express concerns about
interpersonal conflict (14-21%), highlighting the potential impact of
war on the well-being of family members, as well as friends and
employers. Why? The Reserves typically return to the civilian community
and do not have the same access to military support networks. To better
assist returning reserve veterans, many support programs have been
developed. Typically, the AKNG has had to modify such programs to
ensure outreach to the remote areas of Alaska.
In May 2005, the National Guard's Transition Assistance Advisor
(TAA) Program was initiated to assist Servicemembers in accessing
Veterans Affairs benefits and healthcare services to include obtaining
entitlements through the TRICARE Military Health System and access to
community resources. Mirta Yvonne Adams, the TAA for the AKNG brought 8
years TriWest experience to the position in addition to her countless
years as a voluntary military spouse in Family Readiness groups. Mirta
uses the AKNG integrated support network to better ensure seamless
delivery for our Servicemembers. This network includes the following
services: education, Employer Support of the Guard and Reserve (ESGR),
Military Funeral Honors, Yellow Ribbon Program, Military Family and
Life Consultants, Survivor Outreach Services, Military One Source,
Family Readiness, Chaplain, Director of Psychological Health, and
Family Programs.
In 2008, the National Defense Authorization Act required the
Secretary of Defense to establish a national combat veteran
reintegration program to provide National Guard and Reserve members and
their families with sufficient information, services, referrals, and
proactive outreach opportunities throughout the deployment cycle.
Although the AKNG had already established a well-functioning
reintegration program, the four full-time resources associated with the
Yellow Ribbon program were a welcome addition. However, once again,
funding for travel throughout remote Alaska was inadequate.
Providing veteran services throughout Alaska is extremely
challenging. Alaska is #1 per capita of veterans in the Nation, making
up about 17% of the state's population as compared to the national
average of about 11%. The 2000 Census recorded our population to be
650,000 (now is 686,300) with only two urbanized areas and 17
urbanized clusters. Out of 348 census localities, 52% have less than
250 people. Of the roughly 77,000 vets in the state, approximately 20%
live in ``remote'' Alaska. I personally define remote as areas
inaccessible by the road system with very small populations with very
limited healthcare typically through an Indian Health Services (ISH)
health aide.
In the first ever effort to personally connect with Alaska veterans
in remote areas, the AKNG has funded a one-year temporary Yellow Ribbon
Reconnecting Veterans Outreach Program at $500K to visit every BIA
recognized village and incorporated city, visiting approximately 250
locations. The objectives are to locate and assist every veteran to
apply for benefits they have earned from either the National Guard or
the Veterans Administration, to assist families of deceased veterans
apply for Veterans Headstones and Honor Guard Military Memorial
Service, and to assist completing Alaska Territorial Guard
applications. This team understands a veteran is eligible for
government sponsored transportation to a VA medical facility upon
receiving a disability rating of 30%, thus, they work diligently with
veterans to complete the required paperwork. Village administrators
have indicated a willingness to learn more about veteran benefits and
the forms as well as ways to access the system. A report will be
published in the October to November 2010 timeframe. Although this is
the first program to have a significant impact in obtaining benefits
for our remote Alaskan veterans, it will be expiring soon.
The Team Leader, Ms. Alice Barr, M.Ed., LPC, LMHC, has shared
tentative insights as listed below. In summary, the primary barriers to
receiving benefits are communication (use of indigenous languages and
reliance on the spoken word), obtaining ID cards, understanding/
completing paperwork, and access to healthcare.
Negative reactivity to Federal entities and their
subordinates who may not understand or have the patience to deal with
remote challenges such as language, finances, travel issues, and the
accompanying emotional problems.
The high cost of traveling to urban areas to seek medical
care due to agency financial inability to ``travel'' the veteran in for
care.
The team has also encountered issues with those veterans
who are not able to finance a trip into the nearest ID card facility.
These members are having issues with their TRICARE entitlement, as they
do not have a valid military ID.
Education, home loan guarantee and SGLI/VGLI questions
have also been a hit with these visits.
Evidence of post war trauma in veterans who served in the
Vietnam Conflict, Korean Conflict, Aleutian Campaign and OEF/OIF.
Vietnam Vets are finally applying for benefits after years
of personal neglect and who now find themselves riddled with the after
affects of their service and accompanying Agent Orange complications
while residing outside medical service areas.
This team has encountered many female veterans--primarily
National Guard, Navy, Air Force, and Army. Typically, the female
veterans were afraid to report issues of gender discrimination, sexual
harassment or assault due to their awareness that they would be
stigmatized in the service and that their situations could in fact
become worse. Many choose to serve their time and get out rather than
make appropriate reports.
Often, female veterans who did not think they deserved any
benefits. They wanted to make sure that all the male veterans were in
line first. Some of the female Veterans had injuries they kept quiet
for so long a time and were now suffering very severe arthritis
problems.
Male and female veterans experience sexual trauma in their
early lives. For some this impacts the way they experience and handle
trauma as adults. For the Alaskan veterans this impact is doubled due
to the lack of counseling services in their local areas.
AKNG retirees and those within two years of their 60th
birthday do not understand the how to apply for retirement benefits,
the importance of the SBP, and converting from SGLI to VGLI to continue
life insurance.
Extreme dental problems secondary to remote living and
lack of dental care.
Economic problems stemming from the expense of remote
living as well as lives as hunters and trappers in an effort to escape
modern living.
The Alaska VA has fully partnered with the AKNG in seeking
innovative solutions to serve our rural veterans. Recognizing the large
number of AKNG OIF veterans in remote western Alaska, they established
a Rural Veterans Liaison position in the Bethel ``hub'' last year. The
liaison, Irene Washington, was perfect for the position. She had joined
the active duty Army in 1979, transferred to the AKNG where she retired
in 2005 and started working with the VA. Her military background and
Yupik language enabled her to assist the regional veterans in
understanding and obtaining the veteran benefits they had earned. Many
had previously been receiving VA documentation in the mail and had
never responded due to lack of understanding.
In July 2009, a one-year VA pilot program went into effect to allow
non-native veterans in remote Alaska to be provided healthcare through
the Native Health Care network with VA reimbursement. This program
involved seven remote census areas (Bethel, Dillingham, NW Arctic
Borough, Cordova, Bristol Bay Borough, Nome, and West Hampton. Often,
the Indian Health Services is the only provider in remote Alaskan
locations. A report is anticipated within a few months after the
program's completion.
Additionally, the VA is extending medical facilities/services
within the Great State of Alaska. A VA Outreach Clinic was opened in
Homer in December 2009 using Kenai CBOC staff to provide services one
day/week. Out of 582 veterans who live in this area, 328 are provided
care through this clinic. A new VA Outreach Clinic in Juneau will open
this fall with anticipation of eventually reaching veterans along the
inter-island ferry system.
I also have the privilege to serve as the Alaska State Women
Veterans' Coordinator. As we know, women veterans are one of the
fastest growing segments of the veteran population. Today, women
comprise 7% of the veteran population which is expected to be doubled
in five years as a result of OEF and OIF. Within Alaska, the female
population is actually 10%. Of the 8,250 women veterans within Alaska,
approximately 16% are located in remote Alaska. In this position, I
work closely with the Alaska VA's Women Veteran Program Manager (WVPM).
In 2008, VAs were funded for the WVPM to be a full-time position.
In November 2009, the AKNG sponsored the first Alaska State Women
Veterans Outreach Campaign at several locations on the more populated
``road system''. At that time, VA statistics revealed only 3,000 or 36%
of Alaska female veterans were enrolled with VA and only 1200 were
using VHA services.
Like their male counterparts, many women veterans feel frustrated
and disappointed by the complex bureaucracy of the Veterans Affairs
health system. And, they are more reluctant to seek out the help of the
Veterans Administration and utilize the benefits they've earned,
possibly because of a lack of knowledge of their eligibility. This is
especially acute when a veteran has suffered Military Sexual Trauma
(MST). Once they finally gain the courage, they often feel victimized
again when subjected to the cumbersome, impersonal process. I have a
friend Andrea who was raped twice in 1987 while in the active duty Army
and never reported it for fear of retribution. She retired from the Air
Force Reserve in 2005 with 24 years of service. After attending the
November 2009 Alaska Women Veterans Outreach Campaign, she finally
sought help and was diagnosed as PTSD. When applying for compensation,
she received a medical opinion that her PTSD most likely began due to
abuse in childhood and adolescence and exacerbated by the two rapes.
However, she characterizes her childhood as normal. Although she had
not received her ``rating'', she still felt victimized all over again.
Nationally, we must simplify the application process for MST victims.
The Alaska VA has expanded women veteran services significantly
over the past few years. Services now include:
Full-time Women Veterans Program Manager
The Women Veterans Health Strategic Health Care Group
sponsors a special campaign each month and the Alaska VA Healthcare
System has been using the materials to promote the attention to women
Veterans; monthly campaigns: August--Domestic abuse, September--Flu
Prevention, October--Breast Health, November--Stop Smoking, December--
Mental Health Awareness, February--Healthy Heart, March--Homelessness.
For these campaigns, posters are printed and distributed to service
areas, Vet Centers and CBOCs. Poster displays are created for some of
these in the lobby of the main Anchorage VA Outpatient Clinic.
Provide written materials: Tri-fold describing services
available to women veterans and a booklet with greater detail about
services available to women Veterans.
Conduct a monthly Environment of Care Assessment to ensure
an environment in which women feel welcomed, safe and cared for.
An active Women Veterans Advisory Committee composed of VA
healthcare staff, Veterans Benefits staff, Vet Center, active duty
military, OEF/OIF staff, Military Sexual Trauma staff, women Veterans
Health Provider, and Women Veterans Program Manager, representatives
from the 3MDG, and State Veterans Affairs Women's Coordinator that meet
monthly.
September 11, 2010--First annual Women Veterans Retreat to
include keynote speakers, educational events, lunch, and a closing
ceremony.
Two Primary Care Providers (PCP) from the Anchorage VA
Outpatient Clinic and one PCP from the Fairbanks VA Community Based
Outpatient Clinic (CBOC) attended the VA sponsored Women Veterans
Primary Health Care Mini-Residency in Seattle to improve their
proficiency in women's health care. More VA sponsored Women Veterans
Mini-Residencies are planned for FY 2010 where PCPs from the Alaska VA
will be able to participate.
The Women's Health Clinic at the Alaska VA expanded
services to treat women with abnormal pap smear results rather than
referral to non-VA providers.
At the new VA clinic location in Anchorage which opened
May 10, 2010, women veterans are able to come to the Comprehensive Care
Clinic where they may receive Primary Care and Women's Health Care from
one PCP as well as evaluation and treatment by Social and Behavioral
Health providers in an integrated clinic setting.
Women's Comprehensive Health Care Implementation Plan (W-
CHIP) has moved ahead with PCPs at the Anchorage VA Outpatient Clinic,
the Fairbanks VA CBOC, Kenai VA CBOC, Mat-SU VA CBOC and the VA
Domiciliary for Homeless Veterans. Each of these locations has PCPs who
are trained, interested and credentialed to provide comprehensive
Primary Care and Women's Health care to their patients.
Basic benefits available to women include but are not
limited to:
- Comprehensive Women's Health Exams
- Mammograms
- Contraception Counseling
- Bone Density Testing
- Maternity Benefits
- Gynecology Surgery
- Menopause Diagnosis
- Mental and Addiction Treatment
- Military Sexual Trauma Counseling
I sincerely appreciate this opportunity to testify before the
Committee. It is such a privilege and honor to serve our country and
the state of Alaska.
______
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
Brig. Gen. Deborah C. McManus, Assistant Adjutant General-Air, Alaska
Question 1. As the Alaska State Women Veterans' Coordinator, I know
that you have been working on ensuring that women veterans receive the
access to care; I have heard that they are not offered the same level
of information about benefits, what do you see as the problem and
solutions?
Response. Like their male counterparts, some feel frustrated and
disappointed by the complex bureaucracy of the Veterans Affairs health
system. And, women veterans are more reluctant to seek out the help of
the Veterans Administration and utilize the benefits they've earned,
possibly because of a lack of knowledge of their eligibility. This is
especially acute when a female veteran has suffered Military Sexual
Trauma (MST). They often remain embarrassed, alienated, and ashamed.
The military is trying to reduce the stigma of seeking help for MST
through increased awareness, education and guaranteeing confidentiality
to victims reporting such crimes. To help our Alaska women veterans
understand they are veterans too, the AKNG sponsored the first Alaska
State Women Veterans Outreach Campaign in November 2009 at four
locations on the more populated ``road system''. Since then, enrollment
has increased by 300 and those using VHA services increased by 400. We
must continue these efforts at all levels.
Question 2. What are some of the problems with female veterans
enrolling, with on 36% of Alaska female veterans enrolled and only 1200
using VHA services?
Response. Please refer to answer to Question 1.
Question 3. The Yellow Ribbon Reconnecting Veterans Outreach
program to reach out to 250 locations in rural Alaska to locate and
assist every veteran to apply for benefits. This program will be
expiring soon, would you give this Committee a quick summary of the
results.
Response. In the first ever effort to personally connect with
Alaska veterans in remote areas, the AKNG has funded a one-year
temporary Yellow Ribbon Reconnecting Veterans Outreach Program at $500K
to visit every BIA recognized village and incorporated city,
approximately 250 locations. The objectives are to locate and assist
every veteran to apply for benefits they have earned from either the
National Guard or the Veterans Administration, to assist families of
deceased veterans apply for Veterans Headstones and Honor Guard
Military Memorial Service, and to assist completing Alaska Territorial
Guard applications. This team understands a veteran is eligible for
government sponsored transportation to a VA medical facility upon
receiving a disability rating of >30%, thus, they work diligently with
veterans to complete the required paperwork. Village administrators
have indicated a willingness to learn more about veteran benefits and
the forms as well as ways to access the system. A report will be
published in the October to November 2010 timeframe. Although this is
the first program to have a significant impact in obtaining benefits
for our remote Alaskan veterans, it will be expiring soon.
The Team Leader, Ms Alice Barr, M.Ed., LPC, LMHC, has shared
tentative insights as listed below. In summary, the primary barriers to
receiving benefits are communication (use of indigenous languages and
reliance on the spoken word), obtaining ID cards, understanding/
completing paperwork, and access to healthcare.
Negative reactivity to Federal entities and their
subordinates who may not understand or have the patience to deal with
remote challenges such as language, finances, travel issues, and the
accompanying emotional problems.
The high cost of traveling to urban areas to seek medical
care due to agency financial inability to ``travel'' the veteran in for
care.
The team has also encountered issues with those veterans
who are not able to finance a trip into the nearest ID card facility.
These members are having issues with their TRICARE entitlement, as they
do not have a valid military ID.
Education, home loan guarantee and SGLI/VGLI questions
have also been a hit with these visits.
Evidence of post war trauma in veterans who served in the
Vietnam Conflict, Korean Conflict, Aleutian Campaign and OEF/OIF.
Vietnam Vets are finally applying for benefits after years
of personal neglect and who now find themselves riddled with the after
affects of their service and accompanying Agent Orange complications
while residing outside medical service areas.
This team has encountered many female veterans--primarily
National Guard, Navy, Air Force, and Army. Typically, the female
veterans were afraid to report issues of gender discrimination, sexual
harassment or assault due to their awareness that they would be
stigmatized in the service and that their situations could in fact
become worse. Many choose to serve their time and get out rather than
make appropriate reports.
Often, female veterans who did not think they deserved any
benefits. They wanted to make sure that all the male veterans were in
line first. Some of the female Veterans had injuries they kept quiet
for so long a time and were now suffering very severe arthritis
problems.
Male and female veterans experience sexual trauma in their
early lives. For some this impacts the way they experience and handle
trauma as adults. For the Alaskan veterans this impact is doubled due
to the lack of counseling services in their local areas.
AKNG retirees and those within two years of their 60th
birthday do not understand the how to apply for retirement benefits,
the importance of the SBP, and converting from SGLI to VGLI to continue
life insurance.
Extreme dental problems secondary to remote living and
lack of dental care.
Economic problems stemming from the expense of remote
living as well as lives as hunters and trappers in an effort to escape
modern living.
Question 4. Can you give me an example of how an IHS beneficiary
living in a small village whose spouse is a member of the National
Guard deployed would access care? How about a non-beneficiary?
Response. My experience is the IHS beneficiaries continue using the
IHS. Although they are automatically enrolled in TRICARE Prime Remote
(TPR) when their spouse deploys, there are simply no civilian or
TRICARE network providers in these areas. It is typical for non-
beneficiaries to also access the IHS since their policy is to provide
care to anyone requesting their services with the expectation of
reimbursement. There are simply no other healthcare options in remote
Alaska.
Question 5. In your experience, what have you witnessed as
challenges for rural veterans?
Response. The biggest challenge for our rural veterans is access to
VA medical services. However, before one can be granted access, you
must complete the bureaucratic paperwork. The Yellow Ribbon
Reconnecting Veterans Outreach Program discovered many veterans had
received VA ``packages'' but did not understand the entitlements or the
paperwork. This outreach program provides that one-on-one assistance
along with training community liaisons. Once a veteran is determined
30% disabled, they become entitled to travel benefits. Communication is
often a barrier in remote Alaska--both language and technological. To
help overcome such cultural barriers, while recognizing the large
number of AKNG OIF veterans in remote western Alaska, VA established a
Rural Veterans Liaison position in the Bethel ``hub'' last year. The
liaison, Irene Washington, was perfect for the position. She had joined
the active duty Army in 1979, transferred to the AKNG where she retired
in 2005 and started working with the VA. Her military background and
Yupik language enabled her to assist the regional veterans in
understanding and obtaining the veteran benefits they had earned. Such
outreach programs are the result of innovative problem solving among
multiple governmental and non-governmental agencies and organizations.
We must ensure a continuous funding source for innovative outreach
programs.
Question 6. As for transition from the Guard to the VA system, how
does that work for someone living in a rural area?
Response. In May 2005, the National Guard's Transition Assistance
Advisor (TAA) Program was initiated to assist Servicemembers in
accessing Veterans Affairs benefits and healthcare services. Within the
AKNG, all members separating from the Guard are required to process
through this program to understand their entitlements and complete the
necessary paperwork. We even sponsor travel for our remote veterans to
receive their initial VA exam.
______
Response to Post-Hearing Questions Submitted by Hon. Mark Begich to
Brig. Gen. Deborah C. McManus, Assistant Adjutant General-Air, Alaska
Question 1. In your testimony you reference the MOU between the
Alaska VHA/VBA and the Alaska Department of Military and Veterans
Affairs, would you explain how that works and if you feel it has been
beneficial to veterans?
Response. This historic August 2007 MOU was to ensure access to the
full spectrum of Veteran benefits with an emphasis on healthcare for
the 100+ soldiers returning to 26 remote Alaskan native villages
throughout western Alaska upon their return from OIF. Key goals
included: Seamless Delivery of Healthcare Services to Rural Veteran,
Home Station Reunion and Reintegration Workshop for Returning GWOT
Veterans to include Post Deployment Health Reassessments (PDHRA), and
Multidisciplinary Mobile Outreach Teams
The MOU was based are two primary assumptions: 1) Statistics
reflected that up to 30-35% of returning Veterans will seek at least
one psychological health visit within the first year after returning
home. Such unresolved emotional disturbances as a result of a Veteran's
combat experience could be extremely detrimental to a small, remote
Alaskan community; and 2) Due to lack of access to a VA facility for
healthcare, rural Alaska Native Veterans will probably utilize the
Alaska Tribal Health System.
The following initiatives were identified. Today, it's still a work
in-progress.
Telemedicine and teleradiology capability at 235 sites
around the State and a multi-year home telehealth monitoring project
through Alaska Native Tribal Healthcare Consortium (ANTHC).
A VA Tribal Veterans Representative Program to train
tribal representatives on VA policy, procedures, eligibility, and
rules.
A VA education program for the Alaska Tribal Health
Organizations on VA eligibility and clinical information regarding Post
Traumatic Stress Disorder and other Veteran readjustment issues.
Vet Centers participation in outreach services.
Coordination of access to care through flexible case
management services that recognize the individual and family needs of
veterans. These services or ``pathways of care'' would become a link of
services that connect rural Alaska with Anchorage and Anchorage with
Puget Sound.
Work with state and Federal agencies, civic organizations,
and faith-based agencies to ensure a wide variety of benefits for
Alaska Veterans. All agencies will identify key individuals and commit
resources to address/work issues.
DMVA will conduct Post Deployment Health Reassessments
(PDHRAs) on-site vice a telephone or web-based format.
Senator Begich. Thank you very much, General.
General McManus. You are welcome.
Senator Begich. Verdie, were you going to speak, or did you
have----
Mr. Bowen. If you want me to speak, sir, I am more than----
Senator Begich. I wasn't sure if you had testimony you
wanted to give.
Mr. Bowen. Well, I can provide testimony. I had not had
time to write one and present one to you.
Senator Begich. Let me hold you there, then, and I will
probably have some questions for you.
Mr. Bowen. Thank you, sir.
Senator Begich. Dan?
STATEMENT OF DAN WINKELMAN, VICE PRESIDENT FOR ADMINISTRATION
AND GENERAL COUNSEL, YUKON-KUSKOKWIM HEALTH CORPORATION, ALASKA
Mr. Winkelman. Good morning, Mr. Chairman. The Yukon-
Kuskokwim Health Corporation has been contracting with the
Indian Health Service to provide health care services for over
20 years. Today, in remote Western Alaska, we provide
comprehensive health care to 28,000 people, largely Yupik
Eskimos across a roadless area the size of the State of Oregon,
where the average per capita income in our region is about
$15,000 on an annual basis.
Our unemployment rate in our villages is over 20 percent.
Gas in our main hub city of Bethel is $5.34 per gallon. In our
villages, it is $6 to $8 a gallon, about the same price we pay
for a gallon of milk. Many homes in our region are without
piped water and sewer, and over 6,000 homes in rural Alaska do
not have safe drinking water.
When considering the high energy, food, and personnel costs
against an IHS appropriation that does not allow for mandatory
medical inflation increase, providing health care to our 58
tribes on a daily basis is an extraordinary challenge,
especially when you consider the enormous health disparities in
our region.
For example, Alaska Natives' leading cause of death is
cancer. The Alaska Native cancer mortality rate is
approximately about 26 percent higher than U.S. Caucasians.
While cancer mortality for the rest of Americans is decreasing,
it is dramatically increasing for Alaska Natives. Particularly
disturbing is our region's high suicide rates. Unfortunately,
our age-adjusted suicide rate for teens, 15 to 19-year-olds, is
17 times the national average.
This is the environment where many Alaska Native veterans
were born and raised and then return to after serving our great
country. For Alaska Native American Indian veterans who serve
at the highest rate per capita of any U.S. race, to lack access
upon their return from duty to culturally appropriate and
quality health care services by the Veterans Administration is
a shame.
In Alaska, highly rural veterans must break through several
barriers in order to receive care. There are almost no VA
facilities in rural Alaska. The existing IHS and tribal
facilities managed by Tribal Health Organizations like YKHC are
underfunded, according to the IHS, by approximately 50 percent.
Last, the Alaska VA Health System's Rural Health Pilot Project
is not statewide and needs dramatic improvement.
I have three recommendations. The first is to establish a
VA clinical encounter rate for the IHS and tribal facilities.
Instead of building new VA health care infrastructure in rural
Alaska, the VA should increase its collaboration with Tribal
Health Organizations and use the existing Alaska Tribal Health
System infrastructure that already exists for rural veterans'
care. The Alaska Tribal Health System provides quality
services. We are nationally recognized and we are fully
accredited by the Joint Commission. However, due to the IHS's
chronic underfunding, it is important that the VA reimburse
tribal facilities that provide care to veterans and their
eligible family members.
The creation of a VA clinical encounter rate to reimburse
IHS and tribally-operated facilities should include multiple
types of services, such as primary, emergent, behavioral
health, and telemedicine services. Non-native veterans should
also be able to access these services through this encounter
rate, as well, since in rural Alaska these facilities are the
only ones available.
My second recommendation is that in the alternative of
establishing a VA clinical encounter rate for IHS and tribal
facilities, the Committee should review, redesign with tribal
input, and redeploy the Statewide Alaska Rural Health Care
Pilot Project. The Committee should review how the pilot was
developed, the extent of tribal participation in the pilot's
design prior to deployment, and its scope of services offered
versus the actual need, whether the pilot was effectively
communicated to our highly rural veterans and tribal partners,
its billing processes, and the number of veterans who, quote,
``opted in'' and utilized services.
As for the pilot itself, it could have been designed and
deployed more effectively. Instead, it seemed to be an
afterthought. For example, although care is rendered in tribal
facilities, veterans must first self-enroll with a different
agency, the VA. We have no control over that enrollment
process. This process is called opt in. Why are veterans
required to fill out additional paperwork in order to
participate in the pilot when they should already be deemed
eligible by virtue of their service record? Our veterans
deserve better than having to research how they and their
eligible family members can opt in for health care services.
After all, our veterans opted in when they signed over their
lives to serve our country.
Another opportunity for improvement is to do away with
limiting the scope of health care services a veteran may
utilize within a 6-month time period. I do not know anyone, as
I am sure you don't either, who can plan ahead of time when to
have their illnesses take place, especially in a 6-month
timeframe. To require our highly rural veterans to jump through
additional barriers to receive only limited services is
bureaucratic and ineffective to improve access to care.
My third recommendation is to monitor appropriations to the
Office of Rural Health Care to ensure that all rural and highly
rural veterans are adequately served. According to a June 3,
2009, letter by Senator Murkowski to VA Secretary Shinseki,
Alaska's rural or highly rural veterans were initially going to
receive zero dollars of last year's historic $250 million
appropriation to the Office of Rural Health. Senator Murkowski
wrote, quote, ``I first learned of this project on Friday, May
22, after I expressed concern that none of the $215 million in
Office of Rural Health Projects announced that week would have
any significant effect on Alaska's access problems.''
Obviously, we have received the pilot since then, and, Mr.
Chairman, I see I have run out of time. May I have a few more
seconds just to wrap up?
Senator Begich. Wrap it up very quickly.
Mr. Winkelman. Thank you. But it is unacceptable for
America's most remote rural veterans living in remote bush
Alaska to be forgotten by the VA and the ORH, whose mission is
to ensure highly rural veterans have access to quality health
care resources, especially with such an historic appropriation.
In conclusion, any rural or highly rural veteran should be
able to go to any IHS or tribal facility and receive the care
they need from that facility and that facility should be fully
reimbursed by the VA for providing such services. In your own
words, Senator Begich, I think it was last year you said it is
all Federal monies, regardless of which Federal agency is
providing that care, the IHS or the VA.
And last, I would like to give an example. For a veteran
that is living in one of our areas, the reality is that if you
are seeking behavioral health care services, it might mean
waking up in the early morning hours to leave your home, let us
say along the Bering Sea Coast in the Village of Kotlik via a
small single-engine plane and flying a half-an-hour to the next
village, which is Emmonak, which is near the mouth of the Yukon
River, transferring to another small plane, flying another hour
and a half to Bethel, and then transferring to a regional
airliner to fly the last 400 air miles to Anchorage, all for an
appointment the following day. That is a big deal.
Those are some major barriers, and those are the types of
situations that we need to improve on, and Congress is entirely
in power to solve those problems. Thank you, Mr. Chairman.
[The prepared statement of Mr. Winkelman follows:]
Prepared Statement of Dan Winkelman, Vice President, Administration &
General Counsel, Yukon-Kuskokwim Health Corporation, Bethel, Alaska
Good morning, Mr. Chairman and Members of the Committee:
i. introduction
The Yukon-Kuskokwim Health Corporation (YKHC) has been contracting
with the Indian Health Service (IHS) to provide health care services
for over twenty years. Today in remote Western Alaska we provide
comprehensive health care to 28,000 people, largely Yupik Eskimo across
a roadless area the size of Oregon, where the average per capita income
is $15,000. Our unemployment rate in our villages is over 20%. Gas in
our main hub city of Bethel is $5.34 per gallon, and in our villages it
is $6-8 per gallon, the same price we pay for a gallon of milk. Many
homes in our region are without piped water and sewer and over 6,000
homes in rural Alaska do not have safe drinking water. When considering
the high energy, food and personnel costs against an IHS appropriation
that does not allow for mandatory medical inflation costs, providing
health care for our 58 tribes is a daily and extraordinary challenge.
Especially, when considering the enormous health disparities our
region faces. For example, Alaska Natives' leading cause of death is
cancer. The Alaska Native cancer mortality rate is approximately 26%
higher than U.S. Caucasians. While cancer mortality for the rest of
Americans is decreasing, it is increasing dramatically for Alaska
Natives. Particularly disturbing is our region's high suicide rates.
Our age-adjusted suicide rate for 15-19 year olds is 17 times the
national average.
This is the environment where many Alaska Native veterans were born
and raised and then return to after serving our great Country. For
Alaska Native/American Indian veterans, who serve at the highest per
capita rate of any U.S. race, to lack access upon their return from
duty to culturally appropriate and quality health care services by the
Veterans Administration (VA) is a shame.
In Alaska, highly rural veterans must break through several
barriers in order to receive care. There are almost no VA facilities in
rural Alaska. The existing IHS and tribal facilities, managed by tribal
health organizations like YKHC, are underfunded according to the IHS by
approximately 50%. Last, the Alaska VA Health System's, ``Rural Health
Pilot Project'' is not statewide and needs improvement.
ii. recommendations
I have three recommendations.
1. Establish a VA Clinical Encounter Rate for IHS and Tribal
Facilities.
Instead of building new VA health care infrastructure in rural
Alaska, the VA should increase its collaboration with tribal health
organizations and use the existing Alaska Tribal Health System
infrastructure for rural veterans care.
The Alaska Tribal Health System provides quality services and our
facilities are nationally accredited by the Joint Commission. However,
due to the IHS's chronic underfunding, it is important that the VA
reimburse tribal facilities that provide care to veterans and their
families.
A VA clinical encounter rate is needed. The creation of a VA
clinical encounter rate to reimburse IHS and tribally operated
facilities should include multiple types of services, such as primary,
emergent, behavioral health and telemedicine. Non-native veterans
should also be able to access care through this encounter rate since
tribal facilities are often the only provider available in rural
Alaska.
2. In the Alternative of Establishing a VA Clinical Encounter Rate for
IHS and Tribal Facilities, the Committee Should Review,
Redesign with Tribal Input and Redeploy Statewide the Alaska
Rural Health Pilot Project.
I ask the Committee to review, redesign with tribal input and
redeploy statewide the Alaska Rural Health Pilot Project. The Committee
should review how the Pilot was developed, the extent of tribal
participation in the Pilot's design prior to deployment, its scope of
services offered versus actual need, whether the Pilot was effectively
communicated to highly rural veterans and tribal partners, its billing
process and the number of veterans who ``opted-in'' and utilized
services.
The Pilot could have been designed and deployed more effectively,
instead it seemed to be an after-thought. For example, although care is
rendered in tribal facilities, veterans must first self-enroll with a
different agency, the VA. This process is called ``opt-in''. Why are
veterans required to fill out additional paperwork in order to
participate in the Pilot when they should already be deemed eligible by
virtue of their service record? Our veterans deserve better than having
to research how they and their family members can ``opt-in'' for health
care services. After all, our veterans ``opted-in'' when they signed
over their lives to serve our Country.
Another opportunity for improvement is to do away with limiting the
scope of health care services a veteran may utilize within a six-month
period. I do not know anyone who can plan ahead of time when to have
their illnesses take place, let alone in a six-month time period. To
require our highly rural veterans to jump through additional barriers
to receive limited health care services is bureaucratic and ineffective
to improve access to care.
3. Monitor Appropriations to the Office of Rural Health to Ensure All
Rural and Highly Rural Veterans are Adequately Served.
According to a June 3, 2009 letter by Senator Murkowski to VA
Secretary Shinseki, Alaska's highly rural veterans were initially going
to receive zero dollars of last year's historic $215 million
appropriation to the Office of Rural Health (ORH). Senator Murkowski
wrote:
I first learned of this project on Friday May 22 after I
expressed concern that none of $215 million in Office of Rural
Health projects announced that week would have any significant
effect on Alaska's access problems.
It is unacceptable for America's most remote rural veterans living
in roadless Bush Alaska to be forgotten by the VA and the ORH whose
mission is to ensure highly rural veterans have adequate access to
quality health care resources, especially with such an historic
appropriation.
iii. conclusion
Any rural or highly rural veteran should be able to go to any IHS
or tribal facility and receive the care they need and that facility
should be fully reimbursed by the VA for providing service. In the
words of Senator Begich, ``it's all Federal monies'' regardless of
which Federal agency provides the care, the VA or the IHS.
Unfortunately, since last year's appropriation of $215 million in
Office of Rural Health projects, little has changed for Alaska's highly
rural veterans. Hopefully Chairman Akaka's recent landmark legislation,
the Caregivers and Veterans Omnibus Health Services Act will be able to
address some of these concerns.
Ultimately, for tribal organizations like YKHC, being able to
systematically improve access to quality services for our highly rural
veterans is more than a priority, access can dramatically improve the
lives of our veterans and their families.
The reality for a highly rural veteran seeking behavioral health
services is that it might mean waking in the early morning hours to
leave their home in the coastal community of Kotlik via a small single-
engine plane and flying a half-hour to Emmonak located near the mouth
of the Yukon River. Transferring to another small plane and flying
another hour and a half to Bethel. Then transferring to a regional
airline to fly the last 400 air miles to Anchorage that evening. The
round-trip ticket cost alone is currently over $1,000. All to make an
appointment the following day at a VA facility in Anchorage. Whew!
Instead, improving access could mean the veteran not having to
leave their community at all. That same veteran could wake-up and walk
from his or her house to YKHC's Kotlik Village Clinic, and receive
quality telepsychiatric care via high-definition video. It is obviously
far more efficient and less costly for the VA to use existing IHS and
tribal facilities for serving rural and highly rural veterans.
Ultimately, it is simply the ability for a highly rural veteran to
receive quality care closer to home and it is a matter entirely within
Congress's power to address!
Thank you for the opportunity and honor to address your Committee
today.
Senator Begich. Thank you, Dan. Let me move to Dr.
Schoenhard. Thank you very much again for visiting Alaska.
Thank you for being here today. I will turn to you.
STATEMENT OF WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR
HEALTH, OPERATIONS AND MANAGEMENT, U.S. DEPARTMENT OF VETERANS
AFFAIRS
Mr. Schoenhard. Sir, I do not have any testimony to give
but am happy to answer any questions.
Senator Begich. Very good. Verdie, that gives you a few
minutes if you want to say any additional comments before I
start going through a series of questions.
STATEMENT OF VERDIE BOWEN, DIRECTOR, OFFICE OF VETERANS
AFFAIRS, ALASKA DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
Mr. Bowen. Thank you, sir, and thank you very much for
inviting me to this Committee.
I believe that in Alaska, we have come a long way. We still
have a long way to go to provide health care to our rural
veterans. As I travel throughout the State I see different
issues, and a lot of them really deal with something that Dan
just touched on and it deals with the reality of travel time it
takes to get from one place to another to another in order to
get adequate health care. Sometimes, if the veteran could just
stop by the local Native Health Office for a simple blood test
instead of spending 2 days or 3 days to get to Anchorage to do
the same thing, it would be a wonderful thing for them.
As I was in Ketchikan a couple of weeks ago, some of those
guys were spending 3 days just to come up for simple blood
tests and X-rays that could have been done at their local
hospital. I think there are probably better ways that we could
utilize our money and this is a good point that we should be
able to take care of. I think through partnerships with Indian
Health Service and other local hospitals throughout the State,
we will be able to treat every single veteran that we have.
Several things that have been touched on, and this is the
last thing I will say, is that we have a hard time getting most
of our veterans to register within the VA system. I have heard
several times today talk about getting everyone registered. I
am not really sure what the answer is. The Yellow Ribbon Team
by the end of this month will have hit every populated center
in the State of Alaska, which is well over 300. In that effort,
we were only able to sign-up 2,000 additional veterans within
the VA Health Care System.
I think that more will come as we move along, but if you
look at the State of Alaska's Permanent Fund Dividend Form that
is filled out each year by all Alaskans so that they can
receive those royalty funds, only 700 have checked the box
saying that they are veterans. So I am not quite sure what the
answer is to get them to register besides going out and doing
one-on-one visits with each and every one of them, which is
what we have pursued.
The one request I do have for this Committee is that the
Yellow Ribbon Team in our National Guard goes out and treats
all veterans. It doesn't matter what war, whether they are
National Guard, whether they are--lately, they have been
reaching out to a lot of Vietnam-era veterans. They are working
on a budget of about $500,000 for their travel expenses
currently, and between the State of Alaska and them, we have
partnershipped in order to reach all of these communities, and
those funds will be up in October. It would be very nice if we
can continue on and do follow-up visits next year because we
might be able to take that 2,000 to 77,000. That should be all
of our goal.
Thank you.
Senator Begich. Very good. Thank you very much.
I am going to follow up on that regarding people signing
up. I know, General, with your work with women veterans, the
coordination that you are doing there, even within women
veterans, there is a small--I want to say it is about one-third
of them signed up or taking advantage. Can you elaborate a
little bit of what you think, and maybe following up on Mr.
Bowen's comments regarding how difficult it is to register
them. I know it is a concern for me. I know it is a concern for
Senator Murray. What are you finding specifically in the area
with women veterans? Give me a little bit of thought on that
please.
General McManus. Well, when we look at our female women
veteran population, a lot of them are from the older wars and I
think there is a cultural issue there in which many of them
were in subordinate roles or support roles and their service
was not as greatly appreciated when they returned to the
States.
Also, a lot of them experienced military sexual trauma,
whether it is rape, sexual assault, or harassment. So there was
a fear of seeking help through the system, so a lot of them
just faded away. However, I think it is different with our
current OEF/OIF veterans, that there are mechanisms so that
they can report the trauma and receive help.
A lot of times, women do not recognize that they are
veterans, as women have traditionally been in a caregiver role.
So I think there is a cultural issue, and there is an education
issue. When we had the women veterans outreach campaign in
November 2009, last year, we did see an increase in enrollment
and use of services. Three hundred women additionally enrolled
and 400 were seeking services. So I think a routine education
system that lets women know they are vets, too, they have
earned these rights and these are their benefits--a lot of them
have female-specific health care needs. So now they understand
the VA facilities can provide services in those areas, as well.
Senator Begich. Very good. Let me move over to this side to
either one of you who would answer, is there more that the VA
can do? An example was just given how the outreach was done to
increase the amount of women who recognize that they have
benefits available to them but may not be taking them for a
variety of reasons just described. Do you have any thoughts on
that? Dr. Jesse?
Dr. Jesse. A couple. I think the issues that have been
brought up are really important. We have historically on the
health care side measured access by wait times to clinic
visits, wait times----
Senator Begich. How many came through? And how long they
waited?
Dr. Jesse. How long they waited. And all that is irrelevant
if they don't know that they are entitled to services; they
can't access those services; they can't get to us; or we are
not connected to them in one way or another. Particularly as we
move to our new models of care, if you will, where we are not
talking about episodic access as a driving function but
actually connectivity, that front-end engagement becomes
absolutely crucial.
So we have an awful lot of effort going on trying to
understand this now. Why don't people declare themselves as
veterans on forms? Why can we repeatedly send people
information and they just don't act upon it? Our assumption is,
well, we sent it to you. You should have acted on it. And the
simple answer is, people should probably be enrolled when they
swear into the military and make that very--we talk about
seamless transition and there is a lot of discussion going on
between VA and the Department of Defense as to how do we best
affect that. I can only say that, again, this is one of the
Secretary's top priorities and he understands these issues
probably better than any of our leadership in prior years.
So we are trying to understand this. We are trying to make
it easier. But there are complex issues here.
In terms of the women's issues, this gets, again, really
interesting, because historically, we measure what we do in
health care statistically. We look at all of these
statistically. But whenever we look at women's health issues,
the numbers aren't big enough to make sense of the statistics.
What we have really learned from this is we have to treat each
individual as a man of one and really try and understand how we
can manage their health care needs in a much more specific
manner.
So the VA over the past several years has done a lot. Every
VA facility now has Women's Health Coordinators. We do have an
Office for Women's Health Issues that is very proactive in
trying to develop these. The issues of military sexual trauma
are extremely complex. Just to see them coming forward, I
think, is happening because the discussion is coming out into
the open. Again, we are willing to accept any help, any advice.
We see these as very important issues and are trying to deal
with them.
Senator Begich. So obviously, if the General has some
ideas, she will be able to share them with you and you will--
that is good. I will leave that to you two going forward.
Let me kind of narrow in on one subject and that is the
Rural Health Project. Mr. Winkelman laid out some concerns, and
I know you have heard from me more than once on this issue. I
think you had three suggestions, but I want to take it a little
broader, and maybe if, Dr. Schoenhard, you could respond to
this, and that is--I may be a little bold here. The effort and
idea is good. I don't think anyone disagrees with that. The
implementation is the struggle. And it sounds like, based on
the testimony, there might have been some linkages in the front
end that might not have been put together as well and now we
are trying to kind of patch it as we move along.
I am wondering if it is better to kind of freeze-frame on
it for a second and say, OK, let us sit down with our rural
health care providers who have been in the business for years
and have figured out how to deliver to the most remote areas in
the world; learn how to restart it rather than, I think, what
is happening. The sense I get, and I may be wrong about this,
but I hear from so many different people that it is almost like
we are trying to patch a little issue here and patch a little
issue when really maybe we should just freeze-frame it, stop,
step back. What is the right approach? Bring some of the people
who have been in the field and ask, what should we do
differently?
Just the fact that you have to go get opt-in through
another type of system before you are really in, you know, I
can only tell you from my experience, and Dan has much more
experience around this, for rural individuals who lived in
rural Alaska most of their lives, that is just another piece of
paper they are not going to respond to. They are just--I don't
want to say give up, but they do less.
Is that too bold or--I am just trying to--it seems like
every time I talk about this issue, it is always like almost
starting, then not, then moving, then not. So give me your
thoughts on that.
Mr. Schoenhard. Yes, Senator. I think the numbers on the
rural pilot really speak for themselves. We obviously are
struggling with getting veterans to sign up for this program.
At this point, only 21 percent in the pilot have signed up, and
of that, very few have asked for primary care authorizations
for mental health consultations. So I think the numbers speak
for themselves. We need to improve.
We have hired a company to do a focus group to understand
better why we haven't had more success in enrolling veterans,
but I welcome what Mr. Winkelman and Mr. Bowen have shared
today. We need to sit down and understand together, because IHS
has assets on the ground. They are in the communities. They
understand well what is needed there, much better than anyone
else that would be in a distant location, whether they are with
VA or anywhere else. We should collaborate; and I think your
suggestion that we freeze-frame--we were talking a little bit
during the recess----
Senator Begich. That was strategically done. You know that,
don't you?
Mr. Schoenhard. Yes, sir. [Laughter.]
We had a good conversation and I would certainly welcome
undertaking the discussion of the three recommendations that
were shared to see how we can better serve and better get
veterans engaged with IHS in these locations.
Senator Begich. The consultant that you are using, do you
know if the list of folks they are consulting with or getting
input from include some of the delivery systems within the
consortium, the Native Health Care Consortium? Do you know if
that is part of the list of who they are kind of--not just
veterans, I assume they are talking to veterans in their focus
groups, but also the current providers of other health care--do
you know if they are doing that?
Mr. Schoenhard. I do not know. My impression is that it is
primarily veterans that we have not reached, but I think,
hearing what we have heard today, we should reach out and
certainly have them also talk to the providers.
Senator Begich. I appreciate that.
Second, is that consultant responsive to you, or who are
they----
Mr. Schoenhard. To the VA.
Senator Begich. OK, to the VA organization. So there is one
or two below you that kind of manage that in some form?
Mr. Schoenhard. Yes, sir.
Senator Begich. I would ask this, and I don't know if you
can commit to this. I believe in these kind of Committee
meetings we can make all kinds of speeches or we can get some
work done and I would like to get work done. Is there a way
that you would be willing to commit your level, some of the
folks you just heard some testimony from, to say, we are going
to sit down in the next month or two and kind of do the freeze-
frame, make sure the consultant is actually touching bases with
the right people to hear that input, and then maybe just
restart the program. Would you be willing to say, we will
commit to this in an aggressive way? Because I think the
concept is--I mean, you heard a little bit earlier, I think
everyone wants to see this work.
Mr. Schoenhard. Right.
Senator Begich. And the delivery capacity is huge. But it
seems like we are just--something is missing in the mix. I
guess in our State, which you have heard me say before, if you
can do it in Alaska, you can do it anywhere. If you can deliver
services to the most remote areas in the world in Alaska, the
rest of the country will be a piece of cake.
Do you feel that is a commitment you could give now, or do
you need to have a conversation back with the VA and more of an
administrative discussion before you commit to sit down within
a very short period? Maybe it is a month or two, say, we are
going to engage at this different level with the consultant and
some of the stakeholders, which we would obviously be happy to
provide you with some of those names. Any thought from there?
Mr. Schoenhard. Sir, I would not hesitate to make that
commitment. I think we should do that.
Mr. Schoenhard. Excellent. Dan, if I can swing back over to
you and to the General, are you prepared, if there is a time
table set up to put the resources on the table to have that
discussion, to work through some practical implementations?
First, to Mr. Winkelman.
Mr. Winkelman. Yes. You bet, Senator. There is already
precedent for this. There was a Memorandum of Understanding
that was signed way back in February 2003 between the VA, HHS,
and IHS that said they would collaborate together on how to
provide better access and how to develop better processes and
systems of care for both of their constituents. So there is an
agreement already there. I would suggest that it be used; and
that there be a high-level meeting to show that there is a
commitment with IHS at the table, VA at the table, and then
also the Tribal Health Organizations which have the compact and
contracts that run the health care in Alaska between us and the
Indian Health Service.
Senator Begich. General, any comment from you on that?
General McManus. Yes, sir. We also did a MOU in 2007
working with the VA to prepare for the returning 100 soldiers
that were coming out of rural Alaska, 26 villages. In that,
some of the assumptions were that these folks would continue to
access care through the Indian Health Services available in
their villages. So some of the initiatives surrounded good
collaboration between VA Health Care Services and the Alaska
Native Tribal Health Care Consortium, such as providing
telehealth services and educating the health aides at the
villages to identify some of these illnesses associated with
deployments and serving in combat, such as PTSD, and how to
best serve them.
Senator Begich. Dr. Jesse, did you have a comment? I wasn't
sure if you----
Dr. Jesse. Yes, a couple of things. First is that the VA is
committed to working with IHS. I know that there is a refresh
of the 2003 MOU in process. I can't tell you exactly where that
is right now. We have the new Director of the Office of Rural
Health coming on board actually on July 6, who is at an SES
level but comes to us with 20-some years of experience in IHS,
which I think will be----
Senator Begich. That will be great.
Dr. Jesse [continuing]. Extraordinary for developing and
strengthening those relationships. So we are extremely excited
about that.
Just one other comment about what Mr. Schoenhard mentioned.
He said the numbers speak for themselves. You know, if you look
at why we do pilots, it is because we want to be sure we do
things right. When we set up the rural pilot in Bethel, there
were some boundaries around the extent of services that could
be accessed. I wasn't privy to that, but my sense is that it
was done because we didn't want to overwhelm a system. Well, we
have, in fact, underwhelmed the system. You know, we sent
letters out to 548 people. We enrolled 20 percent, and only ten
have asked for things. Clearly, we haven't done something
right, and your comment that there are issues here that,
clearly, we don't understand, and to step back, to have a
stand-down and--I mean, I don't say stop the program.
Senator Begich. Correct.
Dr. Jesse. That was----
Senator Begich. That is why I suggest a kind of freeze-
frame.
Dr. Jesse [continuing]. But we need to revisit what is
going on here and try and get a better understanding about why
people aren't jumping at the service and what we need to do to
open this up. We would commit to doing that.
Senator Begich. Excellent. I will say this, and I
appreciate that, because I know when you do these programs,
sometimes you want to just keep going down the path, but this
is a moment, I think, where we can make a shift, reexamine it,
and probably have a much more successful program. Actually, the
fact that you have MOUs tells me that paper is good, but action
is better. So it sounds like we have plenty of MOUs. Now, how
do we collaborate?
Again, I think why we selected this panel the way we did
was specific, because I knew the diversity that was going to be
here was going to be just right to have this discussion. It is
an important program. Again, if we can be successful in Alaska,
I really, truly believe we can do this all across the country
in other more remote rural areas that are having a difficult
time receiving services.
Let me end with a couple of other quick questions and a
couple more comments here with respect to the new facilities
that Alaska is getting--again, this is specific for the VA--the
one in Anchorage, which again, Dr. Schoenhard, thank you for
being there. That is a great new facility that I think is going
to have a great impact to our veterans, no question about it.
Again, this is very parochial, but can you give me any update
on the Juneau facility? That has always been kind of in the
churn and it seems like it gets pushed back, and I am just
wondering, how are you doing on that one? If you don't know,
you can provide that for the record.
Mr. Schoenhard. If I can check and get that back to you on
the record, sir, just to be sure, but we are currently open
part-time. We anticipate moving to permanent space by the
summer of 2010, and the summer of 2010 is very close, so let me
get more specific----
Senator Begich. I was going to say, we are in it.
[Laughter.]
Mr. Schoenhard. Yes. So let me get back with the specific
opening there.
[The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Mark Begich to
William Schoenhard, Deputy Under Secretary for Health for Operations
and Management, U.S. Department of Veterans Affairs
Context of Inquiry: During the June 16, 2010 Senate Veterans'
Affairs Committee hearing on rural health, Senator Begich requested an
update on the status of the Juneau, AK, VA clinic.
Response. Space is currently being renovated on the first floor in
the Juneau Federal Building to house the Juneau VA Outreach Clinic. The
square footage of the clinic will be 3,566 square feet. There have been
delays due to unforeseen asbestos abatement requirements in the space
allocated for the clinic. The projected construction contract
completion date is August 31, 2010. Furniture and equipment delivery
and installation is scheduled for mid-September, and an early October
clinic opening date is anticipated.
The Alaska VA Healthcare System continues to operate a one day per
month clinic with staff from the Anchorage VA Outpatient Clinic
traveling to Juneau to see patients in the US Coast Guard clinic, also
located within the Federal Building. This will continue until the
permanent VA clinic is operational in October.
The outreach clinic will support an annual appointment volume of
2,640 which equates to approximately 1,000 patients. If demand exceeds
that number, the clinic space will allow for expanded staffing. Primary
Care and Mental Health Care will be the services provided within the
outreach clinic.
The clinic nurse manager has been hired and is on-board. Selections
have been made for a psychiatrist, medical support assistant, health
technician, and social worker. We are currently recruiting for a
licensed practical nurse and a primary care physician.
Please see the file below for the clinic's preliminary floor plan.
Senator Begich. OK. That would be great.
Dan, if I can ask you one general question, you have heard
the discussion about the capacity. Does the Health Care
Consortium have--I think I know the answer to this, but I want
to just feel comfortable in saying it--if there is a kind of
freeze-frame and it gets altered in the sense of a new idea of
how to improve rural health care, does the consortium have the
capacity in the areas from the small villages on up to meet
probably what you might perceive as the need of the veterans?
Mr. Winkelman. Yes, we do. We have over 200 village clinics
out in the remotest of the remote areas, which is oftentimes
what we call home.
Senator Begich. That is right.
Mr. Winkelman. You know, some people like to say it is in
the middle of nowhere. I like to say, well, that is my home.
[Laughter.]
But we have that infrastructure in place and we also have
subregional clinics. Many of our Tribal Health Organizations
throughout the State of Alaska really have a three- or four-
level tier plan of care, and it starts out in our villages with
emergent primary care happening in the clinics with our
community health aide practitioners.
Then, if a higher level of care or referral is needed, it
usually goes to some sort of subregional clinic. I know for
YKHC, we have five of those and we staff those with mid-level
providers. They are usually physician assistants or nurse
practitioners. We also have master's level behavioral health
clinicians that work with our hospital, as well, and we have
care teams around that. We also have dental health aide
therapists there, who are essentially mid-level within the
dental structure. And we also have community health aide
practitioners with lab and X-ray capabilities, digital X-ray.
Then anyone who needs an additional level of care are often
referred to our hospital, and those are all regional hospitals,
as you know and have visited.
Then the fourth level of care is the Alaska Native Tribal
Health Consortium in Anchorage, which runs, in conjunction with
South Central Foundation, the Alaska Native Medical Center.
So we have multiple levels of care, an infrastructure that
is already in place. We are willing and waiting to give all our
veterans, whether they are rural or native or non-native, to
open our doors. Our doors are always open. It is just
essentially, for a non-native veteran an issue of payment. With
the rural native veteran, they are going to be able to come to
us and have their payment taken care of by us, so it is not
really an issue.
Senator Begich. If I can interrupt you, that was actually a
question we had back in Anchorage, and you have just answered
it, I think. One concern that we had was when a non-native
veteran entering a facility that is Indian Health Service-
funded through the consortium, that someone who is a non-native
veteran, as long as there is a payment stream----
Mr. Winkelman. Yes.
Senator Begich [continuing]. That handles them, you can
take care of them.
Mr. Winkelman. Yes, Mr. Chairman. Our doors in Alaska are
open to anyone, regardless of race or whoever they are. But
what is really important for non-native veterans who are in
highly rural areas in Alaska is that for the first time, they
have a reason to go and use our services because there is
payment provided by the VA through this pilot program. Now, in
areas such as in Southeast Alaska and other areas in Alaska
where the pilot is not available, or if they are not opted-in
and signed-up and received their preauthorization, they are not
going to be able to do that. But if we can deal with those
barriers with a meeting and talk about processes, I think we
will be able to see our enrollments go up.
Senator Begich. Very good. Now, my last general question is
about telemedicine. Would you say your system is a fairly good
system, a robust system? How would you measure it?
Mr. Winkelman. I would say our system is probably the best
in the United States. We are again, in the remotest of the
remote areas. I know our Federal partnership, they have various
measures--I don't have them in front of me today, but the
AFHCAN Partnership, who are in charge of telemedicine, have
various measurements that demonstrate how effective it is and
how it can be used.
For instance, we have radiologists that are down in Ohio.
Someone can go get a reading in the Village of Kotlik or in
another village along the mouth of the Yukon River, and through
telemedicine we can get them read in less than a day. It will
go from there all the way down to Bethel, then it will go from
Bethel to Ohio and then back. So we have really quick
turnaround times using that sort of digital process which we
are really proud of. But I think our utilization rates could be
higher. That is something that we need to focus on, especially
at YKHC. That is something that we are working on right now.
Senator Begich. Very good. Let me end there and just say
again, thank you, first to the whole panel. Thank you to the
two folks from the VA for your willingness to kind of take this
to a higher level, at least in this initial stage of
discussion. Like I said, Dr. Jesse, it is not to stop the
program, it is to freeze-frame it for a moment to kind of do a
little reanalysis, especially while you have a consultant
online, which is a very valuable asset. You are spending
resources there. You have some Alaskan experience here that is
anxious to advise in any capacity they can, and your acceptance
to acknowledge that, I think is great. So I just want to say
thank you for your willingness to do that.
Thank you to the Alaskans who have traveled a great
distance. Sorry for the humidity. That is an adjustment you
will have to make, and I know you are anxious to get back on
the plane to get back to home, no matter how small the village
may be. Again, thank you all for being here today and
testifying in front of the Committee.
That ends the Committee hearing for the day. It is
adjourned.
[Whereupon, at 11:59 a.m., the Committee was adjourned.]
A P P E N D I X
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Prepared Statement of Walter G. Sampson, Vietnam Veteran,
formerly of Noorvik, AK
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]