[Senate Hearing 111-846]
[From the U.S. Government Publishing Office]



 
                                                        S. Hrg. 111-846

                     VA HEALTH CARE IN RURAL AREAS
=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             JUNE 16, 2010

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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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

                              ----------                              

                             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

                              ----------                              


                        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\
---------------------------------------------------------------------------
    \1\ L. Gamm, L. Hutchison, et al., eds. Rural Healthy People 2010: 
A Companion Document to Healthy People 2010, vol. 2, College Station, 
Texas: Texas A&M University System Health Science Center, School of 
Rural Public Health, Southwest Rural Health Research Center, 2003. 
www.mentalhealthcommission.gov/reports/FinalReport/downloads/
downloads.html
---------------------------------------------------------------------------
     Inadequate access to care, limited availability of skilled 
care providers, and stigma in seeking mental health care are 
particularly pronounced among residents of rural areas.\2\ The smaller, 
poorer, and more isolated a rural community is, the more difficult it 
is to ensure the availability of high quality health services.\3\
---------------------------------------------------------------------------
    \2\ President's New Freedom Commission on Mental Health, Achieving 
the Promise: Transforming Mental Health Care in America, July 2003
    \3\ Institute of Medicine, NIH, Committee on the Future of Rural 
Health Care, Quality through Collaboration: The Future of Rural Health, 
The National Academies Press, 2005.
---------------------------------------------------------------------------
     Nearly 22 percent of our elderly live in rural areas; 
rural elderly represent a larger proportion of the rural population 
than the urban population. As the elderly population grows, so do the 
demands on the acute care and long-term-care systems. In rural areas, 
some 7.3 million people need long-term-care services, accounting for 
one in five of those who need long-term care.\4\
---------------------------------------------------------------------------
    \4\ L. Gamm, L. Hutchison, et al., eds., Rural Healthy People 2010: 
A Companion Document to Healthy People 2010, vol. 3, College Station, 
Texas: Texas A&M University System, Health Science Center, School of 
Rural Public Health, Southwest Rural Health Research Center, 2003.

    Given these general conditions of scarcity of resources it is not 
surprising or unusual, with respect to those serving in the U.S. 
---------------------------------------------------------------------------
military and to veterans, that--

     There are disparities and differences in health status 
between rural and urban veterans. According to the VA's Health Services 
Research and Development office, comparisons between rural and urban 
veterans show that rural veterans ``have 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

                              ----------                              


       Prepared Statement of Walter G. Sampson, Vietnam Veteran, 
                        formerly of Noorvik, AK

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


                                  
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