[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]
VETERANS HEALTH CARE IN MICHIGAN'S
UPPER PENINSULA: WHERE ARE WE?
=======================================================================
FIELD HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
__________
JUNE 20, 2011
FIELD HEARING HELD IN IRON MOUNTAIN, MI
__________
Serial No. 112-19
__________
Printed for the use of the Committee on Veterans' Affairs
----------
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
Vacancy
Vacancy
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON HEALTH
ANN MARIE BUERKLE, New York, Chairwoman
CLIFF STEARNS, Florida MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida
DAVID P. ROE, Tennessee SILVESTRE REYES, Texas
DAN BENISHEK, Michigan RUSS CARNAHAN, Missouri
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
June 20, 2011
Page
Veterans Health Care in Michigan's Upper Peninsula: Where Are We? 1
OPENING STATEMENTS
Chairwoman Ann Marie Buerkle..................................... 1
Prepared statement of Chairwoman Buerkle..................... 34
Hon. Dan Benishek................................................ 3
Prepared statement of Congressman Benishek................... 34
WITNESSES
U.S. Department of Veterans Affairs:
Mary Beth Skupien, Ph.D., National Director, Office of Rural
Health, Veterans Health Administration....................... 18
James W. Rice, MA, Director, Oscar G. Johnson Veterans Affairs
Medical Center, Iron Mountain, MI, Veterans Health
Administration............................................... 19
Prepared statement of Mr. Rice............................. 43
Dinesh Ranjan, M.D., Chief of Surgery, Oscar G. Johnson
Veterans Affairs Medical Center, Iron Mountain, MI, Veterans
Health Administration........................................ 21
Clifford Smith, M.D., Chief of Mental Health, Oscar G. Johnson
Veterans Affairs Medical Center, Iron Mountain, MI, Veterans
Health Administration........................................ 22
______
Dickinson County Office of Veterans' Affairs, Iron Mountain, MI,
Chuck Lantz, Director.......................................... 6
Prepared statement of Mr. Lantz.............................. 36
Military Order of the Purple Heart, Shirley A. Rentschler,
National Service Officer, Department of Michigan............... 8
Ms. Rentschler, Letter....................................... 42
Veterans of Foreign Wars of the United States:
Patrick D. Holcomb, Assistant State Service Officer,
Department of Michigan..................................... 10
Jack Pray, State Commander, Department of Michigan........... 11
VETERANS HEALTH CARE IN MICHIGAN'S
UPPER PENINSULA: WHERE ARE WE?
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MONDAY, JUNE 20, 2011
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., at
the Oscar G. Johnson Veterans Affairs Medical Center, 325 East
H Street, Iron Mountain, Michigan, Hon. Anne Marie Buerkle
[Chairwoman of the Subcommittee] presiding.
Present: Representatives Buerkle and Benishek.
OPENING STATEMENT OF CHAIRWOMAN BUERKLE
Ms. Buerkle. Good morning. It is such a pleasure to be
here. My name is Ann Marie Buerkle, and I represent New York's
25th Congressional District, and I'm Chairman of the
Subcommittee on Health for the House Veterans' Affairs
Committee.
It's wonderful to be here this morning, and I must say this
is my first time in the Upper Peninsula (UP). I was just
chatting with some folks in the back. I had a daughter who went
to the University of Michigan, and we spent a lot of time in
Ann Arbor; but this is beautiful. This is beautiful country,
and the people here are so nice and so welcoming. It is just a
great honor to be here.
I want to begin by thanking all of you for taking time out
of your busy schedules to be here this morning. This is a very
important hearing, and we're so delighted to have the
opportunity to hear from all of you.
I'm honored to serve on the Health Subcommittee and to have
your Congressman and my very good friend, Dan Benishek, serving
with me.
As you all know, Dan has practiced general surgery in the
Upper Peninsula since 1983. He has also worked part time at
this veterans' facility for the past 20 years. Dan is an
invaluable voice for veterans and brings a wealth of expertise
to our Committee. We are really fortunate on our Committee to
have health care professionals like him.
My background is in nursing and I worked for a hospital for
many years, and Dan is also in medicine. We also have another
physician, Dr. Roe from Tennessee. So we are very fortunate
from a health care perspective on our Committee.
Our oversight agenda this year has spanned a wide range of
topics from patient safety to caregiver's assistance, to
meeting the health care needs of the next generation of
veterans from Iraq and Afghanistan.
And throughout each of these discussions, Dan, myself and
the rest of the Committee have provided unique insight that
only one with health care background and insider knowledge can
bring.
The one thing that Dan always talks about is the
dedication, the commitment, and the very high level of care
that the staff here at this veterans facility provides. So, I
want to take this opportunity to commend all of you for your
service and for what you do for our veterans. We appreciate it
very much, and we thank you.
So I would like to take this opportunity with Dan here to
thank all of the employees here. It's good to know that
veterans are in good hands at this facility.
I, too, come from a rural district in central New York, so
I'm familiar with the topic that we're going to be talking
about today and the importance of reaching out and providing
access to care for our veterans. This is a very important topic
to me, as well as to Dan, and to all of our veterans who live
in rural areas.
Congress took a significant step in 2007 when it created a
new Office of Rural Health (ORH) in the U.S. Department of
Veterans' Affairs (VA). It was formed to address the unique
needs of veterans living in rural areas.
In 2009 and 2010, Congress provided this office with over
$500 million in additional funds to improve the delivery of
health care to rural veterans. That is why it's so very
disheartening to read an audit by the VA Office of the
Inspector General (OIG), which found that not only has the VA
not properly managed the use of these funds, but still
continues to lack even a process to assess the needs of
veterans in rural areas. I think we can all agree that time is
of the essence, and this is not acceptable.
At our hearing today, we will be taking a look at the
health care programs provided to local veterans throughout the
Iron Mountain VA Medical Center (VAMC), including the use of
telemedicine and other technologies.
We want to hear from our witnesses how, if at all, the
Office of Rural Health initiatives have improved services for
veterans in the Upper Peninsula.
Further, we want to know how VA is going to improve the
management of our precious resources, improve access to
services and really work towards the goal of increasing access
and quality care for rural veterans across our great country.
I think it's important to set the tone here, and I think
Congressman Benishek will agree with me. This isn't a witch
hunt; this is an effort for our Committee to reach out to
Veterans Affairs and work together to lay the groundwork to
make sure that our veterans in rural areas have access to good
quality care. That's the purpose of this hearing this morning
and we are looking forward to hearing from all of our witnesses
in that regard.
With that said, I now recognize your Congressman, my
colleague and good friend, Dr. Benishek, for his opening
statement.
[The prepared statement of Chairwoman Buerkle appears on
p. 34.]
OPENING STATEMENT OF HON. DAN BENISHEK
Mr. Benishek. Thank you. Good morning, everyone.
It's great to be back here in the UP. I want to thank all
the veterans and the veterans service organizations for coming
and giving their time today to provide testimony, as well as
the administrators who are providing insight on how this system
works here in the UP.
I want to thank the staff of the House Committee on
Veterans' Affairs for helping set this all up, bringing
Congress up here to the UP. I don't think I've ever seen
anything like this.
Ann Marie Buerkle was very modest in her comments. She
represents, as she said, New York's 25th District. She is a
graduate from St. Joseph Hospital School of Nursing, a
registered nurse. Then she returned to college and became an
attorney, worked as the Assistant New York State Attorney
General. It's been a pleasure working with her on the
Committee.
It's amazing the accomplishment of so many people that you
meet in Congress, how accomplished they are in their past
lives; and then they are willing to take their time away from
their lives to help serve our country. It's been a privilege
meeting her and many others like her. So I appreciate her
making the trip up here, and I surely value her leadership and
help with the Veterans' Affairs Committee.
You know, I worked here off and on part time for the last
20 years; and I want to be clear that I think that the staff
here at the Oscar G. Johnson Hospital is incredibly dedicated,
hardworking and a professional group of health care providers.
Their commitment to our veterans, their enthusiasm and their
expertise is above reproach. I'm proud to have worked alongside
them, and I want to take this opportunity to thank them all for
their service. Please join me in giving them a round of
applause.
[Applause.]
With that said, I wouldn't have dragged Congress all the
way up here, and I wouldn't have put Congresswoman Buerkle on a
plane to Iron Mountain for nothing. Like everything we do in
life, veteran care here in Iron Mountain can use improvement.
You know, at the start of the 112th Congress, I chose the
Veterans' Affairs Committee as one of my Committee assignments
so I could bring my experience working here at the VA to
Congress, and my experience on the Committee has been very
encouraging. When you bring a veterans issue to the Committee's
attention, they listen; and they work with us to try to find
solutions.
That's why we're here today, to get an honest assessment of
what needs to be improved within the VA health care system to
help our veterans in rural areas.
As I said, based on my experience, it's not because of lack
of effort or passion that the VA staff falls short of providing
the best care. They're frustrated, I think, by the VA Central
Administration. My observations, this frustration is caused by
a lack of autonomy in the local VA systems.
Veterans in rural areas face different challenges compared
to veterans elsewhere in accessing and receiving health care.
As Congresswoman Buerkle can attest, the needs of veterans in
this district differ from those in her district in New York or
Chairman Jeff Miller's district in Florida or Ranking Member
Bob Filner's in California. One size fits all top-down approach
will not address or anticipate every issue or road block to
veterans in rural areas. And they often create barriers that
waste work and resources in these settings, forcing rural VAs
to shift patients at huge costs and patient dissatisfaction.
One point from my personal experience here is that local VA
facilities, such as Oscar, lack discretion on how their funds
are spent. A facility's budget is divided into three
categories: Medical service, medical administration and medical
facilities.
Local facilities are not allowed to use funds from one
budget style to another. For example, you know, you have money
designated to rebuild a wing, you can't hire somebody on the
staff with that money. It's always very frustrating to me,
being here in Iron Mountain, when they're spending $3 million
on a wing here, and we didn't have $40,000 to hire an
organization. So that kind of disparity, it's frustrating.
And, you know, that's hopefully something that maybe we can
help with. That's one of the reasons for being here. Rural
facilities should have the ability to allocate funds, you know,
as they deem appropriate.
Another personal frustration I've had here working at the
VA was the high rate of hospital directors. I mean, I've been
here 20 years, and we've had ten directors. Every 2 years the
director turns over. That is very difficult to maintain a
continuity of care or an investment in the leadership of this
hospital.
So I think that's something I would like to have the
Veterans Affairs, the Director, Mr. Rice, address. I think that
short tenure provides little incentive to face the issues we
have here. I'm not sure of the cause. I mean, apparently it's
sort of been isolated to this hospital. It doesn't occur
everywhere, but I would like to have that addressed.
Before we turn to the panel, I just want to tell you that I
just appreciate the fact to be back here at the VA. When I was
here as a physician, I had a lot of fun in the operating room
playing my music. You know, I listened to a lot of Elvis on the
iPod. You know, I asked the patients what kind of music that
they preferred to listen to as they're about to go under
anesthesia; and I sort of miss that. I don't get to do that all
the time, the opportunity to play my own music.
So that's one of the things that I miss about coming here.
Sort of coming back here reminded me of that. I'm not able to
do that as much as when I worked here.
So with that, I would yield back to the Chair.
[The prepared statement of Congressman Benishek appears on
p. 34.]
Ms. Buerkle. Thank you very much.
Dolores, maybe we can talk to Chairman Miller about having
music piped into the Veterans' Affairs Committee.
We are going to start now with our first panel.
Doctor, would you please introduce our first panel?
And at this time, I would ask that we seat Panel No. 2 as
Panel No. 1.
Mr. Benishek. Thank you, Madam Chairman.
The first panel is a group of veterans service
organizations individuals.
We have Mr. Chuck Lantz. Mr. Lantz served in the Air Force
for 10 years and served in Operation Desert Storm, an operation
to provide comfort in the Middle East. He's been working with
the Dickinson County Office of Veterans' Affairs since 2009,
serving as its Director and Veterans Counselor.
Mr. Lantz has also served as the Veterans of Foreign Wars
(VFW) Post 3674 Commander and also received the VFW All-State
Commander Award in 2008. He's a member of the Sons of American
Legion, the VFW, the American Legion.
Additionally, he has served on the National POW MIA
Committee. Simply put, Mr. Lantz's service to our veterans has
been remarkable; and I want to personally thank him for his
dedication in improving the livelihood of our veterans.
Our second person on the panel is Shirley Rentschler. Do I
have that right?
Ms. Rentschler. Yes, you do.
Mr. Benishek. And she's been a veterans counselor for more
than 17 years with the Iron County Department of Veterans
Affairs and received accreditation as a Service Organization
Representative through the Department of Veterans Affairs.
In 2007, she was chosen as the UP National Service Officer
for the Military Order of the Purple Heart (MOPH) and currently
works out of this hospital.
Ms. Rentschler has held many memberships with the National
Association of County Veteran Service Officers, Michigan
Association of County Veterans Counselors, as well as with the
American Legion Auxiliary and Veterans of Foreign Wars. She was
also a member of the Auxiliary of the U.S. Marine Corps of the
Upper Peninsula.
I thank Ms. Rentschler for the service to our veterans and
for her participation in today's hearing.
Then we have Mr. Pray--Commander Jack Pray. Mr. Pray was
selected in June to be the VFW State Commander for the State of
Michigan. He served in the Navy for 22 years, serving in
Vietnam. He's been a member of the VFW for the past 35 years. I
would like to thank Mr. Pray for his service to our veterans as
well.
In addition, we have Mr. Holcomb, who is the Assistant
State Service Officer for the VFW under Mr. Pray's direction.
Mr. Pray, could you give a brief bio of Mr. Holcomb? I'm not
familiar with him.
Mr. Pray. He's a Navy veteran, electronics technician and
served all 20 years in the Navy and currently works as the
State Assistant Service Officer, filing claims for veterans of
any service with the coalition that we have developed in
Michigan.
Mr. Benishek. Thank you very much for coming in and taking
your time today.
With that introduction, I will yield back to the
Chairwoman, Mrs. Buerkle.
Ms. Buerkle. Thank you, Dr. Benishek.
We will begin by asking each one of our witnesses this
morning to give their opening statements. Generally, we limit
it to 5 minutes, so if you could keep it within that timeframe,
that would be helpful. Then we will have more time to ask
questions.
Mr. Lantz, if you would like to begin.
STATEMENTS OF CHUCK LANTZ, DIRECTOR, DICKINSON COUNTY OFFICE OF
VETERANS' AFFAIRS, IRON MOUNTAIN, MI; SHIRLEY A. RENTSCHLER,
NATIONAL SERVICE OFFICER, DEPARTMENT OF MICHIGAN, MILITARY
ORDER OF THE PURPLE HEART; PATRICK D. HOLCOMB, ASSISTANT STATE
SERVICE OFFICER, DEPARTMENT OF MICHIGAN, VETERANS OF FOREIGN
WARS OF THE UNITED STATES; AND JACK PRAY, STATE COMMANDER,
DEPARTMENT OF MICHIGAN, VETERANS OF FOREIGN WARS OF THE UNITED
STATES
STATEMENT OF CHUCK LANTZ
Mr. Lantz. Congressman, Congresswoman and guests, I would
like to thank you for the invitation allowing me to testify
today on the big issues of our veterans.
I would like to start out with the subject at hand, which
is rural veterans health care.
I think Oscar D. Johnson VA Medical Center and Veterans
Integrated Services Network (VISN) 12 has taken many steps for
us to extend access to the veterans in the Upper Peninsula,
which is one of the most rural areas of Michigan, if not the
Nation.
By building many CBOCs, community-based outpatient clinics,
in and around the Upper Peninsula and Northern Wisconsin, it
allows the veterans to have veterans' health care closer to
their community.
However, there are still several issues in regards to the
health care of the rural veteran. Number one being
transportation. There's many issues with transporting veterans
to and from their health care visits.
Yes, we do have volunteer systems out there with AV vans
and so forth, but we still have issues where they cannot get to
their health care visit.
I'll give you one example today. I do have a 100-percent
service-connected veteran today that had to be in Milwaukee for
her Social Security disability hearing. I have a volunteer
today that took her to Milwaukee for that disability hearing.
Yes, it's outside the VA system, but she's still a 100-percent
service-connected veteran, still trying to get her Social
Security benefit. That needs to be implemented to help those
veterans get to these visits so they can better their life.
Better access to mental health caregivers for the veterans
having issues with traumatic brain injury (TBI) and post-
traumatic stress disorder (PTSD), as well as substance abuse.
Implement a coalition with community agencies so they don't
have to travel so far to get substance abuse programs for
inpatient care.
Better access--the Veterans Affairs has grown by leaps and
bounds, but need to keep thinking outside the box to keep
growing and caring for our Nation's veterans. There's still
many veterans that cannot get VA health care due to the income
threshold, unless they have been injured while serving or
receiving a service-connected injury.
Many of these veterans served voluntarily and need to be
cared for as a veteran. Even if they are put in a priority
group that requires a co-pay, at least our Nation's veterans
would be cared for regardless of their income status.
That being said, I would like to discuss the issue of the
underrepresented veteran. Most of the State of Michigan--most
of all in the State of Michigan, of the 69 counties in Michigan
with CVSOs, which is County Veterans Service Officers, only 37
provide full-time veterans benefit counseling.
Thirty-two counties have part-time veterans' benefit
counseling; 14 counties without CVSOs. The veteran population
of those 14 counties is 66,525 veterans. They have no veteran
representation, other than the veterans service officers (VSOs)
that are traveling to those counties.
The veteran cannot establish the benefits alone. The
veteran needs an advocate to assist them in the application
process of Veterans Benefits Administration (VBA) benefits, as
well as the Veterans Health Administration (VHA) health care.
The veteran also needs the advocacies to assist them in
gaining those benefits and keeping them in place. It is a
consistent struggle for the veteran.
I would like to just point out two counties in Michigan.
One being Dickinson County, with a full-time CVSO, as well as
childhood VSOs.
Veteran population, 2,671, with a total expenditure of
$30,643,000. Of that, $7,830,000 was for compensation and
pension, and that being liquid income comes directly back into
the rural community.
Now take Antrim County with a part-time CVSO. Veteran
population, 2,673, two more veterans than Dickinson County.
Their total VA expenditure is $7,109,000. Of that, $4,339,000
was compensation and pension.
So you can see the difference we as CVSOs make advocating
for the veteran benefit.
Michigan has changed the grant funding to VSOs; and now
with those changes, the number of VSOs had to be reduced. That
brings more travel for those VSOs; and that time they are
traveling, they're not meeting with the veteran, which is a
disservice to our veterans.
Also, with that reduction, no more services were added or
changed to take up for the veteran they can no longer reach in
a timely manner.
I'm advocating that the State of Michigan and/or the Nation
mandate that there be a service officer in each county and each
State.
The process, Michigan--The process of the VA benefits is so
cumbersome that the veterans cannot accomplish these tasks on
their own. They need an advocate to accomplish their struggles
with the system.
Why is it that we as a Nation send our soldiers to war with
no questions asked, and yet once they come home with injuries,
they have to prove without a shadow of a doubt that that injury
was due to their military service. If they do not have any
injuries, they have to prove that they are under a certain
income threshold to get health care.
Changes need to be made to cover our Nation's veterans, all
of them.
The Office of Veterans Affairs serving Dickinson County has
a motto: If we send them, we must mend them.
Thank you for allowing me to express the needs of our
Nation's veterans and the need for all the veterans' advocates
to assist them.
This is a very important job in our Nation, and funding
laws need to be established and changed so that our Nation--the
Nation and State have the VSOs and the CVSOs to take care of
our true American heroes.
For my last comment, I would like to say and challenge
Congress to establish CVSOs in each and every county in
Michigan and the Nation. Thank you.
[The prepared statement of Mr. Lantz appears on p. 36.]
Ms. Buerkle. Thank you, Mr. Lantz.
Ms. Rentschler.
STATEMENT OF SHIRLEY A. RENTSCHLER
Ms. Rentschler. I would like to thank you for the
invitation to participate in this field hearing.
I believe that the Iron Mountain VA Medical Center is one
of the finest facilities serving the veterans of Michigan's
Upper Michigan and Northern Wisconsin. Over the past couple of
decades that I've been coming through here, I have seen a
growth of the veterans' care at this facility, with many
veterans saying they feel like they've been treated like
royalty.
On some issues that we would like to talk about, the
delivery of the health care to rural veterans has been a great
addition to the home health care. The home health care and the
specialty clinics, especially women's veterans' programs here
in health care; and I would like to see--I personally or my
veterans would like to see maybe a dermatologist and more hours
for our chiropractor here at this facility.
Regarding the recruitment retention of medical personnel,
we have some very caring medical personnel at this facility;
and I think it's very important when we're recruiting
physicians, that they also be fully trained in VA law regarding
pension and service-connected disabilities and what is needed
when documentation is concerned.
I understand that sometimes when you recruit in a small
remote area like Iron Mountain, it is difficult; but we would
like to see longevity of our VA providers.
Sometimes the veterans get very frustrated because their
providers are changed often.
Most of our Iron Mountain providers here have compassion
for our veterans in treating them and listening to their
concerns, but we also have a few that do belittle them and are
disrespectful; and we understand that we would like to have the
providers understand the physical and mental demands of being
in the service and understand that.
To our veterans, their conditions are real. And at times
the providers will even ask, just making a comment like, ``Are
you just here for money?'' And that's just not right. It's not
acceptable.
In regards to our compensation exams, they have greatly
improved in this facility; and they are done with efficiency
and thoroughness with respect to the veterans in most of the
cases.
In mental health, we have a longer waiting time to get
appointments for the World War II or Korean or Vietnam
veterans, because we are putting the Operation Enduring
Freedom/Operation Iraqi Freedom (OEF/OIF) veterans first, which
is right; but we would really like to see that time shorten up
so that all of our veterans having mental issues can be seen on
a timely basis.
In regards to mental health, I would also like to see more
counselors at the Vet Center. We have a Vet Center in Escanaba,
and we would like to see more counselors; and we would like to
see the VA recognize that Center more on issues with their
claims, you know, that they accept what's written by the
veterans' counselors at the Vet Center.
Telehealth Programs: Our veterans would like to see more of
this type of service, as it would ease up their VA appointment
times here and maybe allow the VA providers more time on a one-
on-one with the veteran here to discuss their problems, instead
of being more like a number and they're in and out. We would
like to see more one-on-one time with that.
The Community Partnerships: More of this partnering would
be more cost efficient and effective to help our veterans with
the different resources available in our own communities. I
would encourage this type of partnership.
You know, like if we have veterans in Iron River and they
can't come here, that maybe they could partner with the Iron
River Hospital or Northstar, I believe it's called.
I would like to make a few comments on fee basis, such as
maybe chemotherapy, physical therapy and maybe chiropractic
care.
We have some in the UP. We have a lot of veterans that are
driving distances; and if they're coming up here for physical
therapy, it doesn't make sense because, you know, driving all
those miles kind of undoes what they're doing at the
chiropractor. I would like to see that maybe on a fee basis out
there more, and I would like to see more outreach treatment for
them.
Just on another note, service officers work with veterans
every day, of course; but they're dependent also on their
surviving spouses. On occasion when a veteran passes away, the
physicians need to be more conscious of what their disabilities
might be, that they're listed on the death certificate, you
know, so that veteran can get what's due her, like the payment
for her claim.
And I also would like to see maybe more educating of
physicians in our communities, especially when it comes to
service-connection disabilities. You know, the documentation
that the veteran is telling the doctor or the provider that,
you know, his left ankle hurts or something.
I mean, we need that more documented, I think, at this time
in support of the claim.
And we need--when we have forms--sometimes I deal with
diabetic forms. We send it to the provider. We just ask that it
be more thorough.
Oh, on hearing aids, I would like to know why it takes so
long in Iron Mountain to get hearing aids for our veterans.
Some of them are 8 months out.
I would like to thank you for allowing me to participate in
this.
[The letter of Ms. Rentschler appears on p. 42.]
Ms. Buerkle. Thank you very much.
Mr. Holcomb.
STATEMENT OF PATRICK HOLCOMB
Mr. Holcomb. Thank you to the Congressional staff, and
thank you to the staff of Iron Mountain for allowing us to
speak.
Iron Mountain VA Hospital takes very good care and very
personal care to the veterans here, but there is some
significant issues we would like to discuss.
Continuity of care. Myself, personally, I have used the VA
facility for 6 years. Since I retired, I'm working on my fifth
doctor--primary care doctor.
Increasing access to clinics, such as the chiropractic.
Chiropractic care is a 3-month wait. And then if you live in
Marquette, like myself, you must drive an hour and a half to
get to the chiropractic care and go through the care and then
drive the hour and one-half back, which null and voids the care
that you just received.
Access to compensation pension exams. I personally have a
veteran who lives here in Iron Mountain, who is being sent to
Marquette for an exam instead of being seen here in Iron
Mountain. He has an 8 a.m. appointment, so he must leave here
by 5 a.m. or stay overnight, and there is no overnight
facilities in Marquette. There is no transportation from Iron
Mountain to Marquette for a veteran for care, so his wife must
drive them; and there is no additional anything for the spouse
to drive a veteran that can't drive because of his service-
connected disabilities.
Most all staff here at Iron Mountain are very good, very
personal. There are issues with a couple of doctors. One doctor
in particular, I will read what one of my veterans wrote up for
me.
``In closing, the doctor stated he was just another gray-
haired old man that he had to deal with, and he would hope to
forget him within a day or two.''
That is not how we are supposed to be treating our national
veterans. I believe that care should be--and respect should be
granted to our veterans. That is not very respectful.
Audiology, like Ms. Rentschler said, is a significant wait,
even for a service-connected veteran, anywhere from 4 to 8
months to get a set of hearing aids. They are allowing some fee
basis out, but it still comes back to the hospital here; and it
is still a significant wait for veterans trying to hear what
the doctor is saying to them.
Clarification--or notification of compensation pension
exams, letters are being sent out but not being received by the
veterans. The veteran that was sent a letter June 9th still has
not received notification of his compensation pension exam
through the 27th of June. So then when he misses his exam, he
is denied service-connection because he didn't show up because
he was never notified. Hopefully we can see what we can do
about better notification to the veterans on their exams.
Again, I would like to thank the Iron Mountain staff. They
are a very good staff for the most part, and they do treat most
of the veterans--most all of them treat the veterans with
respect, but there are some issues with them.
Thank you.
Ms. Buerkle. Thank you, Mr. Holcomb.
Mr. Pray.
STATEMENT OF JACK PRAY
Mr. Pray. Congressional Chairman, Congressman, Congress
Lady, thank you very much for the opportunity to speak.
Naturally, as a veteran service organization, our primary
goal is to see that all veterans receive VA assistance in
filing claims, reducing backlog of claims, compensation where
service-connection is proven beyond a shadow of a doubt, which
leads me to the subject of PTSD.
PTSD and TBI are two of our major disabling functions here,
especially in this current conflict; and we have to take better
care of our veterans and really need more qualified physicians
that are able to deal with the ramifications of PTSD.
A lot of symptoms are embedded and not understood. Some of
the tests that they use to determine whether a veteran has PTSD
or not sometimes are considered to be unfair and often are--
basically, they're told a stigma of their imagination, which it
may be. But the veteran with PTSD has every right to the health
care and should be offered and allotted the maximum flexibility
in claiming a disability.
That's about it for me. Thank you very much.
Ms. Buerkle. Thank you very much, Mr. Pray.
Mr. Grimes. Madam Chairman, I am not on your agenda, nor am
I part of your panel, but my name is Harold Grimes. I'm the
Past National Commander of Uniformed Services Disabled
Retirees, and I would like to reiterate with all of these
ladies and gentlemen have said about this facility. I believe
that this facility takes the best care they can of every
veteran that comes through the door.
I drive from Green Bay, Wisconsin, every 3 months to come
up here for care. I'm a 100-percent disabled veteran, veteran
of Korea, Vietnam and all of the brush fires in between:
Berlin, Cuba and a few others.
I work very, very closely with veterans across this
country, and I get a very good cross section of what's
happening in New York State, New Jersey, Wisconsin, Georgia and
the rest of this country and veterans with their needs.
I know of a need at this hospital that is not being
addressed as far as I am aware, and that is that you have a
dental clinic here that the staffing has been understaffed now
for 2\1/2\ years because of the added influx of veterans into
the system.
The service has been pushed out 6 to 8 months because there
is not adequate staff. I have been coming to this facility for
over 15 years. This staff takes care of me every time I come
here. I don't care what the need is.
I would also like to speak to just a little bit about other
issues that pertain to veterans, not only in the Iron Mountain
area, but veterans that come from Wisconsin into the Iron
Mountain VA hospital.
Ms. Buerkle. Sir----
Mr. Grimes. Yes.
Ms. Buerkle [continuing]. I apologize, but we have a format
here.
Mr. Grimes. Okay.
Ms. Buerkle. And I'm sure we will sit with you afterwards.
Dr. Benishek's staff will hear all those concerns----
Mr. Grimes. Thank you.
Ms. Buerkle [continuing]. Because they are very important
to us. Thank you very much.
I'm going to begin my round of questioning, and then I will
yield to Dr. Benishek.
I want to begin by asking all of you. In 2007, there was a
recognized need that, we were not reaching all of the veterans
in the rural area.
So Congress recognized that need, and then in 2009 and 2010
allocated a specific amount of money, over $500 million to the
VA to make that outreach to the veterans in the rural areas, to
improve their access, and quality of care.
So I want to ask all of you, during that time since 2009,
2010, have you seen any changes or any improvement from where
you sit with regards to access to veterans in the rural areas?
Mr. Lantz. I started my CVSO position in 2009. From July of
2009 to the present, access has become expanded by about 100
percent, I would say.
Ms. Rentschler. I would agree. We have a lot of veterans,
like you said, in the rural area; and they really like the home
health care. They like the idea that someone can come to their
home, check, you know, with them on their conditions or help
them with any administrative things that they may need or
referrals; and the counseling has improved, and they really do
like that.
Ms. Buerkle. Mr. Lantz, you mentioned 100 percent. What
does that mean? So every veteran in a rural area now has access
to health care?
Mr. Lantz. No, just the veterans that were covered already
probably received 100 percent more care and more accessibility
to the care.
Ms. Buerkle. Thank you. Mr. Holcomb.
Mr. Lantz. Yes, there has been a significant increase in
rural care. They have opened up an additional CBOC, and they
have provided more mental health out in the CBOCs instead of
just here at the hospital. So it has definitely increased the
mental health in the rural areas in the combined outreach
clinics.
There has been more, but there's still--the Upper Peninsula
is still a vast and open area, trying to find local areas to
establish the CBOCs, and a lot of the people drive at least an
hour to get to one.
Ms. Buerkle. Thank you. Mr. Pray.
Mr. Pray. Yes, and I agree that the availability has
increased.
We do have a problem with our service officers being on the
road as much as they are to file claims. And with that issue,
we can have a coalition where we combine the Purple Heart, the
Marine Corps League, the VFW, the Disabled American Veterans;
and we split a grant system to pay for our VSO's travel.
So that's kind of limited. If the funds were more readily
available, I think it would get more help out to more veterans.
Ms. Buerkle. Thank you.
One of the charges given to the Department of Veterans
Affairs with this rural outreach program was to assess the
needs of rural veterans, because in order to treat them, we
need to know what their needs are, where they are located, and
how we can access them?
To your knowledge, have you been asked or any other
veterans service organizations been asked or been a part of
assessing the needs of rural veterans? Have you been included
in that discussion?
Mr. Lantz. Personally, I have not.
Ms. Rentschler. Nor have I.
Mr. Holcomb. Nor have I.
Mr. Pray. No, I have not.
Ms. Buerkle. If you could sit here today in an ideal
world--and I would like each one of you to comment on this,
what is the most pressing need for rural veterans, and how can
we address that need?
We will start with Mr. Lantz.
Mr. Lantz. One of the biggest issues, I think, is travel,
transportation. They have to travel way too far to get to a
clinic.
Ms. Buerkle. And how would you want that need addressed? In
this perfect world, what's the answer to that?
Mr. Lantz. Either fee base it out to the local community
hospitals or provide a grant system to provide transportation
or more transportation opportunities to get them to their
appointments.
Ms. Buerkle. Thank you.
Ms. Rentschler.
Ms. Rentschler. I would say that transportation is the big
issue. I would also say that we need more community
partnership, you know, maybe in a fee basis area.
I would like to see more--maybe even another Vet Center if
we could or more counselors at that Vet Center because PTSD and
some mental health issues are very, very huge here.
Ms. Buerkle. Thank you.
Mr. Holcomb.
Mr. Holcomb. Transportation and the fact that there are
several DAV transportation buses or vans that travel to bring
people here to Iron Mountain; but if you are on oxygen or in a
wheelchair, you don't have access to them. You are not allowed
to ride in the vans.
So if you have a veteran that is in a wheelchair or is on
oxygen, he still has no availability.
Again, fee-based to their local community so they can, you
know, be seen right there or to provide better access in
transportation with wheelchair accessibility.
Ms. Buerkle. Thank you.
Mr. Pray.
Mr. Pray. Yes, I would agree with the other witnesses that
transportation is the main thing. Fee-based availability would
be a good answer, too.
Also, the availability of veterans health care facilities
in areas that have a large concentration of veterans.
Ms. Buerkle. Thank you. At this time I will yield to Dr.
Benishek.
Mr. Benishek. Thank you, Madam Chairman.
Mr. Lantz, as County Veteran Service Officer, you're here
in Dickinson County. Are you aware of the situation in some of
the other counties up here, like Gogebic County--that's
Ironwood. That's a long way from here. I kind of wonder, those
veterans over there, do they have an officer in Gogebic County,
too?
Mr. Lantz. Yeah, very minimal and very part time.
I actually provided in my package of my testimony all the
counties in the State for you to take a look at as far as
comparison, what counties have part time and full time.
Mr. Benishek. I mean, I know that Antrim was quite an
example you testified to earlier.
Mr. Lantz. Correct.
Mr. Benishek. What concerns me is that those people, those
veterans that live in Gogebic County, they don't have access to
someone to help them get their benefits?
Mr. Lantz. Not on a full-time basis. We have VSOs that are
traveling to them. However, all that travel time, they're not
seeing the veteran.
Mr. Benishek. Ms. Rentschler, do you have an opinion on
that?
Ms. Rentschler. I know the county counselor in Gogebic
County, and he is full time, his name is John Frellow; and he's
doing a good job with the Gogebic County veterans. However,
when we have to travel there, we are traveling 2 hours and more
sometimes to see veterans.
Mr. Benishek. Well, it just concerns me that the people in
the outlying areas are not getting access to--you know, maybe
there are veterans out there that don't have access to the
system.
Ms. Rentschler. Mr. Frellow is here today, and he is a
full-time service officer in Gogebic.
Mr. Benishek. No, I just picked that out as an example.
Ms. Rentschler. Oh.
Mr. Benishek. You know, I'm just trying to get an idea of
how many veterans out there are having difficulty in getting
into the system. Do you have any idea?
Mr. Holcomb. There's a lot of them out there that have
trouble getting to a Veteran Service Office. I, myself, travel
to here, Iron Mountain, Escanaba twice a month, Menominee,
Manistique, Houghton and Ontonagon, as well as being in
Marquette usually 3 days a week.
So I do a lot of traveling to get out to as much of the
outlying areas as possible.
Mr. Benishek. Is there a coordination system with the VA
here in Iron Mountain to figure how you can do all of that?
Mr. Holcomb. Not within the VA but within the coalition I
do.
Ms. Rentschler. Can I interrupt?
Mr. Benishek. Sure.
Ms. Rentschler. If we go out to rural areas and we know
that a veteran has never been seen in this facility or CBOC, we
promptly get them in. We help them fill out the application,
and then we hand carry them back here to this facility. So we
do provide that service.
Mr. Benishek. I guess one question I had about this
compensation pension exam, what was the story? Do you know why
they were not doing the exam here, Mr. Holcomb, or what that
was about? That seems kind of odd.
Mr. Holcomb. They have less doctors here to do health exams
than they do in Marquette. So to get within their timeframe, to
get a compensation pension exam done, they send them up to
Marquette. They send people from Wisconsin up to Marquette for
an exam.
Mr. Benishek. All right. Then the audiologist, has that
been a long-time problem, or is that something new?
Mr. Holcomb. It's a long time. There's only one audiologist
here, and they've tried to hire a couple more; and they don't
stay very long.
Ms. Rentschler. They will fee base out to maybe Laurie
Sario or Laurie LaFleur in Florence, if they're not service-
connected. At least that's the story we're getting.
But if they're service-connected, you know, it still takes
a long time for them to get the fitting for the hearing aid and
then get the hearing aid back to the client. So it's--we're
having an issue with that right now.
Mr. Benishek. All right. If there's one thing that I want
you to comment--there's one thing, the best thing that we can
do from this hearing to improve the situation for veterans here
and in the Upper Peninsula and Northern Wisconsin, what is the
one thing you would like to see, the most important thing. Mr.
Lantz.
Mr. Holcomb. I would like to see that it's given a better
opportunity for that veteran, regardless of income threshold,
to be provided care. If he's a veteran, we need to take care of
him.
Ms. Rentschler. I guess I would like to see the veterans
coming in at a faster pace maybe and more providers, if we
could, to come here or even CBOCs. Another CBOC way up in the
rural--way up in Houghton Hancock right now or Houghton. Maybe
we should have another CBOC in there or something.
Mr. Benishek. Mr. Holcomb.
Mr. Holcomb. I would like to see more continuity of doctors
and the--what you were saying. More continuity of doctors, I
guess.
Ms. Buerkle. Very good. Mr. Pray.
Mr. Pray. I think it would have to be the availability of
transportation to the existing health care facilities, finances
to pay travel pay or overnight stays necessary to get these
people in to the appointments that they need to go to.
And a lot of it has to do with the armed services
themselves, the uniformed services, the education of veterans
leaving service as to what services are available. I had no
idea. Many of them go to Veteran Service Officers after they
leave the service and have no idea what they're entitled to or
what their services are. So we need to better educate those
people.
Mr. Benishek. We've heard that comment before.
Mr. Pray. I'm sure you have.
Mr. Lantz. I would like to reiterate one last comment on
that. The VA actually provide partnership--more partnerships,
like Shirley said earlier, more partnerships within the
community for the PTSD and TBI, the substance abuse programs.
We have many, many OIF and OEF veterans that come home with
PTSD and TBI issues that get involved in substance abuse, get
into the court system, need that counseling and struggle to get
it.
So if the VA was to do a community partnership where there
are substance abuse programs in the community already, they can
actually fee base that out or partner with them.
Mr. Benishek. Thank you very much.
Madam Chairman.
Ms. Buerkle. Thank you, Dr. Benishek.
Because Mr. Lantz just raised the issue, we had a hearing
last week in full Committee about mental health for our
veterans with PTSD and traumatic brain injury. We actually had
a veteran testify that he received his services in a different
organization outside of the VA because he didn't have success
in the VA facility.
So this is on everyone's radar screen and really the
presumption is--and Dr. Benishek and I talked about this last
night--for anyone who has been involved in an engagement, the
presumption should be they're coming home with issues that need
to be dealt with.
My concern, as we sit here today, is that there are
veterans in the Upper Peninsula who may not even know what
services are available to them. How are we going to get to
them?
So, I look forward to having our next panel here. We will
have the opportunity to ask some questions.
On behalf of Dr. Benishek, myself and the Veterans' Affairs
Committee, thank you all very much for coming here today and
for sharing your testimony with us. Thank you.
We will seat Panel No. 2 now.
Welcome and good morning, everyone. Thank you for being
here this morning.
I'm going to ask Dr. Benishek to make the introductions for
us.
Mr. Benishek. Good morning, everyone.
Well, first we have Dr. Clifford Smith, the Chief of Mental
Health Service at the Oscar D. Johnson VAMC. He's a board
certified clinical neuropsychologist by specialty.
And prior to joining the VA in 2008, Dr. Smith served as an
Associate Professor of Psychological Science at Rush Medical
University, 2001 to 2008.
Dr. Smith's leadership has been pivotal in the significant
growth of the VA in the Iron Mountain Mental Health Service and
the implementation of mental health services throughout the
VAMC area.
Then we have Dr. Dinesh Ranjan. Dr. Ranjan and I have been
colleagues here at the VA for a number of years, and he's the
Chief of Surgery and the Director of the ICU in this system
since 2009.
Prior to that, he was the Chief of Transplant Surgery at
the University of Kentucky, where he was also a Professor of
Surgery.
Dr. Ranjan received his medical education in India, did his
residency training at William Beaumont Hospital in Detroit, St.
Agnes Hospital and the University of Miami and the University
of Nebraska.
He received board certifications in general surgery and
surgical critical care.
In addition to giving numerous presentations and appearing
in peer review literature, Dr. Ranjan is currently the
President of the International College of Surgeons, Chair of
the Transplant Critical Care Task Force and the Chair of the
Rural Surgery Advisory Board for the Veterans Health
Administration.
Welcome, Dr. Ranjan.
Mr. Rice, he's a native of Iron River, as am I; and he was
appointed as the Medical Staff Director at the Oscar D. Johnson
Medical Center in just May of 2011. And prior to assuming this
position, Mr. Rice was the Quality Management Officer for the
Veterans In Partnership Network of VISN 11, where he was
responsible for the development, oversight, coordination and
leadership of all quality and performance programs throughout
the VISN.
In addition, Mr. Rice served as the Acting Medical
Director--Medical Center Director at the Aleda E. Lutz VA
Medical Center in Saginaw.
He began his VA career as a Safety Manager at the VA
Medical Center in downstate Allen Park, where I actually worked
myself.
He's held positions of increasing responsibility at the VA
Medical Center in Detroit, at the Veterans In Partnership
Network, VISN 11, in Ann Arbor.
Mr. Rice is a 2008 graduate of the 113th Interagency
Institute for Federal Health Care Executives and Health Care
Leadership Institute for Executive Career Field members. He's
also a member of the American College of Health Care
Executives. Welcome, Mr. Rice.
Dr. Mary Beth Skupien--Am I saying that right?
Dr. Skupien. Correct.
Mr. Benishek. She's the Director of the Office of Rural
Health for the Veterans Health Administration. She's the
Managing Director of the Rural Health Office of the Department
of Veterans Affairs.
She's been responsible for providing leadership for
improved access and quality of care for rural and highly rural
veterans. This is done by developing evidenced-based policies
and innovative practices to support the unique needs of
veterans residing in remote areas.
She's got 28 years of experience in previous Federal
service, including leadership and management for the Indian
Health Service, has achieved success through innovative
leadership and knowledge of health care administration at all
levels.
She's--you've got many, many accolades here.
She's educated at Johns Hopkins University, School of
Public Health, PhD., MS, from the University of Michigan,
College of Nursing; BSN from Lake Superior State.
She's a member of the Sault Ste. Marie Tribe of the
Chippewa Indians, with her hometown in Newberry. So she's
working in DC now, but she started in Newberry, right here in
the north, so it's really a pleasure to have you testifying
with us here today, Dr. Skupien.
Dr. Skupien. Thank you.
Mr. Benishek. You're welcome.
Ms. Buerkle. Thank you very much.
At this time I would ask each one of our panelists to begin
with an opening statement.
Dr. Skupien, if you could begin.
STATEMENTS OF MARY BETH SKUPIEN, PH.D., NATIONAL DIRECTOR,
OFFICE OF RURAL HEALTH, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; JAMES W. RICE, MA, DIRECTOR,
OSCAR G. JOHNSON VETERANS AFFAIRS MEDICAL CENTER, IRON
MOUNTAIN, MI, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS; DINESH RANJAN, M.D., CHIEF OF SURGERY,
OSCAR G. JOHNSON VETERANS AFFAIRS MEDICAL CENTER, IRON
MOUNTAIN, MI, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS; AND CLIFFORD SMITH, M.D., CHIEF OF MENTAL
HEALTH, OSCAR G. JOHNSON VETERANS AFFAIRS MEDICAL CENTER, IRON
MOUNTAIN, MI, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS
STATEMENT OF MARY BETH SKUPIEN, PH.D.
Dr. Skupien. Good morning, Madam Chairwoman and Members of
the Committee. Thank you for inviting us today to discuss the
accessibility and quality of health care for veterans who
reside in the Upper Peninsula of Michigan.
I am Dr. Mary Beth Skupien, National Director for the
Department of Veterans Affairs, Office of Rural Health. I am a
native of the Upper Peninsula, and it is a honor to be here
today and to serve the rural and highly rural veterans here and
across the country.
My testimony today will provide overview of the Office of
Rural Health, discuss the services and outreach we are
performing for veterans in rural and highly rural areas and
discuss the improvements we are making in the Office of Rural
Health.
Mr. Rice stated in his opening written testimony that rural
veterans face many, many challenges when it comes to health
care; and VA is committed to enhancing the care of rural
veterans.
The many successful rural health project outcomes and
positive impacts for the veterans as a result of the ORH
funding for the Iron Mountain catchment area is a model for
other rural VA communities. The Iron Mountain VAMC has been
able to measure and demonstrate the positive impact with the
rural veterans as a result of the ORH funding.
VA's National Office of Rural Health provides support and
funding to ensure veterans living in rural and highly rural
areas have access to care and the services they need. Its
mission is to improve access and quality of care of enrolled
rural and highly rural veterans by developing evidenced-based
policies and innovative practices to support their unique
needs.
The Office of Rural Health has invested resources to
implement projects across the country. Over $500 million was
dedicated to these projects in FY 2009 and 2010, and we have
dedicated another $250 million in FY 2011.
These funds supported national and local initiatives in
expanding telehealth, home-based primary care, mental health,
education and training, rural community-based outpatient
clinics and outreach clinics, rural hiring initiatives, VISN-
specific initiatives, community outreach, transportation
programs and other efforts.
In FY 2011, VA is using ORH funding to expand national
telehealth programs, implement Project ARCH, access received
close to home and sustain teleradiology services, home-based
primary care and support a wide range of initiatives mentioned
above.
In FY 2010, VA's Office of Inspector General reviewed ORH
and made six recommendations to improve accountability and use
of resources. We have concurred with all six recommendations,
and the Office of Rural Health has accomplished work to address
five of the six recommendations.
ORH has hired nine staff in the past 10 months, including a
Director and a Deputy, who have collectively over 60 years of
rural health experience.
In FY 2010, the Office of Rural Health realigned the
Veteran Health Resource Centers under leadership of myself. ORH
is working to complete an updated strategic plan, project
tracking system and functional evaluation before the end of
2011.
ORH project monitoring is ongoing, utilizing data
collection and aggregation mechanisms, and the work has
continued to improve the processes through the development of a
Web-based project monitoring system.
Reassessment of the rural health initiatives will be
completed by August of 2011, utilizing these assessments and
geographic needs assessments for all business, as well as
performance and measure of accomplishments and analysis of
compliance with the Office of Rural Health, VHA and VA
priorities and strategic objectives.
Thank you again for this opportunity to discuss the work of
the Office of Rural Health and what we are doing to improve
access and quality for veterans living in the Upper Peninsula
of Michigan and throughout the Nation.
My colleagues and I look forward to answering your
questions.
Ms. Buerkle. Thank you, Dr. Skupien.
Mr. Rice.
STATEMENT OF JAMES W. RICE
Mr. Rice. Good morning, Madam Chairwoman and Members of the
Committee. Thank you for inviting us here today to discuss the
accessibility and quality of health care for veterans residing
in the Upper Peninsula of Michigan.
I'm accompanied today by Ms.--I'm sorry, Dr. Mary Beth
Skupien, National Director for VA's Office of Rural Health; Dr.
Dinesh Ranjan, Chief of Surgery at the Iron Mountain VA Medical
Center; and Dr. Clifford Smith, Chief of Mental Health at Iron
Mountain VA Medical Center.
I would like to address some of the specific efforts we
have taken to improve access to quality health care in the
Upper Peninsula, including our recruitment retention efforts of
qualified health professionals and specialty care programs for
veterans.
My colleagues, Dr. Smith and Dr. Ranjan, will discuss other
aspects of our work, including our mental health programs and
our VA partnerships.
Given our presence in the Upper Peninsula and Northern
Wisconsin, much of what we do can mean considerable help.
For the second straight year, we are participating in the
Rural Health Professional institute funded by VA's Office of
Rural Health, which provides clinicians an opportunity to
enhance their skills, with the capacity for delivering health
care to veterans in rural and highly rural locations.
We are currently supporting rural health projects through
funding from VA's Office of Rural Health, as well as through
local resources.
Iron Mountain VA Medical Center has received approximately
$7.7 million over the past 3 years to implement and sustain
rural health programs.
An example of a project supported by ORH includes expanded
telehealth capabilities to include the provision of specialty
services to veterans in rural and highly rural areas. We made
significant investments in our telehealth programs and have
seen remarkable growth in terms of veterans utilizing these
services.
In year 2010, we provided specialty care through telehealth
to 1,631 veterans, and we expect to increase that number to
more than 2,500 this fiscal year. This program has seen a 400
percent increase since 2008.
We have also supported the enhanced rural access network
for growth enhancement for the program, which is designed to
expand the intensive case management services for veterans with
serious mental illnesses and outreach services to homeless
veterans.
We've also expanded primary and specialty care services,
and we established a home-based primary care program in fiscal
year 2008, with an additional location offering services in
fiscal year 2009.
Using ORH funding, we opened the Manistique outreach clinic
in August of 2009, and rural health funds were used to expand
the Hancock clinic.
This year ORH funding has enabled Iron Mountain VA Medical
Center to implement on-site cataract surgery, interventional
pain management and Ears, Nose and Throat (ENT) clinics.
In addition to these efforts, we are supporting several
initiatives to increase outreach, awareness and services in
rural and highly rural areas.
The Iron Mountain VA Medical Center helped pioneer the
Veterans Directed Home Care initiative, which allows veterans
to choose friends and neighbors to assist them with their
activities of daily living and to be paid for these services.
We've also expanded suicide prevention teams for increased
outreach and coordination of high risk services.
Transportation and lodging are challenges unique to the
vast rural and highly rural areas we serve.
The Iron Mountain VA Medical Center spent $1.9 million in
fiscal year 2008, growing to $2.4 million in fiscal year 2009
and $3.4 million in fiscal year 2010 for beneficiary travel
between facilities, as well as to and from appointments.
In addition, we lodged over 1,800 veterans and their
caregivers this past year.
The Iron Mountain VA Medical Center has actively recruited
and retained staff, while at the same time improving our
relationships with community health providers in the Upper
Peninsula and Northern Wisconsin to broaden the continuum of
care available to the veterans we serve.
Thank you again for the opportunity to discuss the work VA
is doing to improve access of quality care for veterans in the
Upper Peninsula of Michigan. I am proud of the work the
employees at the Iron Mountain VA Medical Center and CBOC do
every day to deliver the best health care possible to American
veterans.
My colleagues and I look forward to answering your
questions.
[The prepared statement of Mr. Rice appears on p. 43.]
Ms. Buerkle. Thank you, Mr. Rice.
Dr. Ranjan.
STATEMENT OF DINESH RANJAN, M.D.
Dr. Ranjan. Good morning, Madam Chairwoman and Dr.
Benishek. I appreciate the opportunity to be able to
participate in today's hearing. I bring a fresh perspective to
this, having recently come from a super-specialty practice in a
large university setting to basic general surgery practice in a
rural setting within this VA facility. I have enjoyed the
rewards and challenges of rural practice.
The VA system of health care daily offers many advantages,
including a regulated system driven by protocols and policies,
a highly functional electronic health record, and the ability
to deliver care without the pressures of a fee-for-service
model.
That rural health care faces entirely different challenges
when compared to metropolitan urban areas has been recognized
and discussed in scientific literature and other forums.
The Surgery Program at Iron Mountain has benefited from
VA's Office of Rural Health, and we have used ORH funds to
establish a cataract surgery program, opened up an ENT clinic
and provide much needed support to the interventional pain
management service.
Our surgical program has also managed to significantly
improve the backlog and waiting time in almost all of our
surgical clinics.
I recognize and appreciate the extent of this hearing in
identifying areas where we face challenges and see
opportunities.
I know that you have a lot of experience with the VA system
and Iron Mountain and that you understand the issues specific
to rural health care.
Some examples of these challenges include continuing
education and academic support, the lack of clinical research
opportunities, recruitment and retention of qualified
providers, competition with non-VA facilities in the area,
support from other VA facilities in the area, transportation of
veterans to and from appointments, and logistical support to
maintain effective the operations.
I would like to offer a few thoughts on delivery of care to
rural settings.
These recommendations are my own, from the perspective of a
rural surgeon with input from my surgical team, and do not
necessarily reflect the views of the Department.
Additionally, I must note that these comments are
independent of my position as the Chair of Rural Surgery
Advisory Board. Given the well-recognized uniqueness and
challenges faced by rural health care, I believe that some
local flexibility and autonomy should be allowed within a
standardized system, both in clinical and administrative
situations.
A rural VA facility should be allowed to provide services
as similar to comparable private facilities with tailored
outcomes, if maintained within an acceptable range. The
clinical practice should always be evidence-based.
There should be a structured mechanism for educational and
academic fulfillment in the rural VA facilities. A mechanism
should be developed for facilitating non-basic science research
at rural VA facilities to ease participation in clinical trials
and perform retrospective and prospective clinical analyses.
Considering that a rural VA is more likely to depend on
purchased care, we need a well-defined protocol and clear
expectations concerning financial, clinical and geographic
variables.
Transportation of veterans from their own community to Iron
Mountain and from Iron Mountain to other more advanced
facilities should be further facilitated.
While recruitment and retention problems in rural areas
have been well publicized, a better understanding of the
reasons that may be specific to Iron Mountain and our community
may provide a solution to ameliorate this problem.
The funding mechanism and compartmentalization of funding
as it pertains to rural VA's should be reviewed to incentivize
entrepreneurship and reward performance.
We should reexamine the necessity for standards that are
separate from nationally-accepted benchmarks, such as The Joint
Commission, Centers for Disease Control and Prevention (CDC)
and Health Insurance Portability and Accountability Act
(HIPAA).
Finally, in terms of support systems, such as information
technology, contracting and human resources should be relocated
and administered from within the rural VA facility.
This concludes my prepared remarks. Thank you again for the
opportunity to participate in today's hearing.
Ms. Buerkle. Thank you very much.
Dr. Smith.
STATEMENT OF CLIFFORD SMITH, M.D.
Dr. Smith. Good morning, Madam Chairwoman. Thank you for
the invitation to discuss the accessibility and quality of
mental health care for veterans residing in the Upper Peninsula
of Michigan.
My testimony today will highlight the services and outreach
mental health staff members are performing for veterans in the
rural and highly rural areas in the Upper Peninsula.
Specific area of focus will be on improvements to the
delivery of rural mental health care, recruitment and retention
of mental health personnel, the scope and impact of telemental
health programs; and our collaboration and partnerships with
our community providers.
Mental health care is a critical component to overall
health, and we understand the importance of ensuring veterans
can access this care. With this, we have added 45 mental health
providers over the last 5 years, which has improved the ability
of veterans to seek appointments and receive the evidence-based
treatments they need.
Mental health staff members are available for outpatient
psychotherapy at every CBOC. Telepsychiatry services are
provided at Sault Ste. Marie, Manistique, Menominee,
Rhinelander, Ironwood and here in Iron Mountain.
In fiscal year 2010 and 2011, we added additional
outpatient services, including the Veterans' Recovery Health
Advisory Council, the Veterans' Justice Outreach Program, the
Health Promotion and Disease Prevention Program, Peer Support
Programs, the HUD Short-Term Contract Housing, and the Aging
and Homeless Programs.
In fiscal year 2010, we provided mental health care to
approximately 3,000 veterans through 31,000 encounters, more
than a two-fold increase from our services in fiscal year 2006.
The Iron Mountain VA Medical Center Behavioral Health
Service has grown tremendously over the past 5 years.
Recruitment has historically--historically, recruitment of
qualified psychologists and psychiatrists has been a challenge.
Our current staff of 14 psychologists is the largest single
group practicing in the Upper Peninsula of Michigan.
We could use recruitment and retention funds to offset
costs of moving to rural regions, and we are currently using
the Student Loan Repayment Program and the Education Debt
Reduction Program as additional incentives for recruitment.
The economic downturn at issue has resulted in significant
mental health cuts to State-funded programs. With the
decreasing community mental health services available in the
Upper Peninsula of Michigan, utilizing ORH funding, we
established an Enhanced Range Team in Manistique to serve
veterans in the Eastern Upper Peninsula, whose mental health
needs cannot be met by typical outpatient psychotherapy and
psychiatry.
The E-Range Program has made a significant impact on
quality of life, medical and mental health of our rural
veterans living with serious mental illness.
Iron Mountain has been one of the Nation's leaders in
implementing telemental health services. Currently, we employ
three psychiatrists who are physically located at another VA
Medical Center or a non-VA facility and who provide
telepsychiatric services to the Iron Mountain VA and the CBOCs.
Additionally, our onsite psychiatrists provide
telepsychiatric services to our CBOCs on a regular and as-
needed basis.
Since fiscal year 2010, we have successfully operated a
Telepsychiatry Substance Abuse Addiction Clinic in
collaboration with the Madison VA.
To build on this program, we are currently in the process
of hiring our own part-time teledivisional psychiatrist, who
will be able to provide additional services to both Iron
Mountain and the CBOCs.
Again, thank you for this opportunity to discuss these
important programs.
Ms. Buerkle. Thank you very much, and thank you to all of
our panelists for your testimony this morning.
I'm going to give myself some time for questions and then
will yield to Dr. Benishek.
Dr. Skupien, I wanted to talk to you, first of all, because
one of the deficiencies in the report had to do with reaching
out to rural veterans and trying to assess their needs.
Congress recognized this need back since 2007, so it's been
awhile.
What have you done to correct that? How are you reaching
out? How are you assessing the needs of the veterans?
Dr. Skupien. There's a number of things that we implemented
just within the last 10 months since my arrival. We are doing a
geographic and health-needs assessments across all areas.
Geographic needs assessments were due in May in my office,
and the health needs assessments will be done the end of June.
That's the first thing.
Ms. Buerkle. Could I interrupt?
Dr. Skupien. Sure.
Ms. Buerkle. When you say ``geographical assessments,'' to
whom? How are those divided up?
Dr. Skupien. Those are divided up by VISN, and what they're
looking at are gaps in services. We look at drive times, we
look at the amount of time that the veteran has to spend
getting to a facility. So we're looking at access issues.
In addition, the health needs assessment, they look at
every aspect of the veteran, what their needs are in relation
to their health care.
We look at the partners, who look at facilities available
and other resources that are available in the community. That's
one thing that happened this year.
Another thing that happened is we really did a robust roll-
out of the ORH Web site and the communication system. We
published newsletters, we published success stories on our Web
site. We have about 3,000 people that got sent to.
In addition, what we're trying to do to assess needs is
we're trying to have focus groups in the community of all the
veterans and have them reported out by VISN to our office.
We've also been able to--in order to meet the needs, we're
looking at, based on these needs assessment, what are the
actual needs of the veterans in tailoring our priorities for
funding for FY 2012 for the projects that we fund?
So we've done a number of activities this year.
Ms. Buerkle. One of my concerns is, and you've heard it
from our first panel, because I asked each one of them, has
your organization been reached out to in order to get needs
assessments from the folks who are on the ground at the front
lines, and they all said ``no.''
So I'm wondering, are you reaching out to local veteran
groups in each of these rural communities so that you can get a
true understanding? There's one thing to talk to this level;
but I think if we're really going to assess needs of veterans,
you've got to talk to the veterans service organizations.
Dr. Skupien. I know that we have VISN rural consultants in
each VISN, and what they're doing, they're doing the needs
assessment, and it varies in VISN.
But many of them have conducted focus groups. They address
the needs identified by the veterans. So there's a variety of
ways we're doing that, but I understand that there's still a
need to really talk to the veterans.
I can say every time I come out on a visit, and I've only
been here for 11 months, I make visits to the rural communities
with the veterans, I go to the centers that we're funding and
talk with the veterans.
So we are really making an effort to really hear what the
veterans' needs are.
Ms. Buerkle. Thank you.
One of the other issues we heard in that first panel was
transportation, and some of you have alluded to it today in
your testimony as well.
Now they mentioned ``fee-based.'' Is there any fee-based
transportation, anything in progress with regards to that?
And, Mr. Rice, in your testimony, you talked about the
costs in 2009, 2010, 2011, the cost of transportation. Maybe
you could first clarify that for me. That sounded like a lot of
money for transportation, if that's what I was hearing.
Mr. Rice. That's been for travel, so that's paying the
veteran to come from their home to the nearest CBOC or the
campus of care. That just takes care of that cost. But we also
have an additional cost where we have a bus that we send down
to Milwaukee twice a week to take veterans to specialty care.
I would like to add, one of the programs we just submitted
a grant for 2 weeks ago is to start our own transportation
program here. I will be putting in a grant to purchase two
buses that would hold 19 to 22 veterans.
It would have four staff. We would have a driver on each
bus and an LPN; and then we would have five travel routes, so
we would hit 19 different cities across the Upper Peninsula and
try to bring the veterans here for their care. So we have that,
and we are working on that because we recognize that as a need,
too.
I would just like to thank the Disabled American Veterans
(DAV). They have seven buses and over 146 drivers, so they
support the VA Center. Without them, we couldn't do it.
Ms. Buerkle. Excellent. One of the issues that was brought
up this morning was oxygen and wheelchair access. Would they be
allowed on these buses?
Mr. Rice. On the buses that we're looking at, yes.
Ms. Buerkle. Okay.
Mr. Rice. Those buses go to Milwaukee. We would also allow
the caregiver to go as well.
Ms. Buerkle. Okay. Now, it appears to me from the testimony
I heard this morning that Iron Mountain seems to have a very
good outreach program that is in tune with the needs of rural
veterans.
Is the Department of Veterans Affairs using this paradigm
and what this hospital is doing for best practices and
recommending some of what they're doing here to other veteran
hospitals who may not have such a high level of care?
Dr. Skupien. Yes, we are, and that's not all. We are using
our Web site and our newsletters. To get those evidence-based
successful programs out, we're using the vignettes.
One of the things that Iron Mountain has done very well,
and has been an issue for some other areas, is that they've
really been able to demonstrate measures in the number of
veterans served, the impact for this community; and that is a
model for the Office of Rural Health for any projects that get
funded forward that we can track.
Ms. Buerkle. Thank you.
Dr. Smith, as I mentioned, we had a hearing last week
regarding the mental health needs of our veterans and helping
them transition out of active duty to veteran status and then
making sure they are aware of what services are available.
In your opinion, are we doing a good enough job? Should
more be done to reach out to the veterans? Is there a stigma
attached to receiving mental health care.
Dr. Smith. Certainly.
Ms. Buerkle. Can you speak to that and make some
recommendations for us so that we can reach out to veterans and
avoid the substance abuse and this downward spiral that many of
them are encountering?
Dr. Smith. Thank you for the opportunity. I would certainly
agree there's--as noted previously, there's difficulty with
their transition coming out of their service into the VA
system. Often they are told in service they're not eligible for
services that they really are, and so they never knock on the
VA's door.
So again, those DoD/VA collaborations are critical. I know
our staff, mental health staff, OEF, OIF and Operation New Dawn
(OND) staff make a commitment to visit the demobilization
meetings and others throughout the facility, throughout our
catchment area. The mental health staff makes an effort to get
out to the colleges and the universities, speaking to college
students, trying to get in the door to address some of that
stigma.
There's often the issues of the adjustment difficulties
coming out of a very structured military service into a very
unstructured civilian life. Many of our veterans have
difficulty during that transition time, and they may be afraid
they have PTSD; or they may have some other serious mental
illness, when it's really part of that transition.
So opportunities to--where we can normalize the difficult
transition may help head off some of those difficult areas.
Ms. Buerkle. Here in the Upper Peninsula, though, you have
almost a double whammy if you have a veteran who is in a remote
area and then he's having these feelings. How do you recommend
we access those veterans? Because really the burden should be
on VA to reach out and to understand. The presumption being
that most of these young men and women coming home may very
well have some issues, a whole range of issues.
Dr. Smith. I agree.
Ms. Buerkle. But that should be the presumption.
So my concern is they go back home, and how are we reaching
them? Because the burden should be on VA.
Dr. Smith. I believe our catchment area is a good model of
what it is to live a remote life, where many of our veterans
live 2 hours away from even a CBOC.
And if you're up by Lake Superior or down by Lake Michigan,
you live by one of nature's greatest snow factors. And when you
have 300 inches of snow a year, it's difficult to get into a
clinic.
So that those continued opportunities, supporting the VSO,
supporting the mental health staff that are able to go out into
the community are critical.
There is, as a manager, the staffing difficulties of
safety. What that means, we send a single person out 2 miles--
or 2 hours away, what does that mean for that staff?
So logistically, it's not a simple solution of just jumping
in the car and driving. There may not be cell phone coverage
where many of our veterans live. They may not have a land line
at their home. So you have lots of things to consider to get to
these very remote areas.
To get there costs money; and often in the VA, we have
performance monitors. So we are, say, called to be--to use E-85
is a good solution.
While in the Upper Peninsula of Michigan, we have three E-
85 gas stations. So in order to work with the VA in that
performance measure, we may have to drive extra miles to go get
our E-85.
So everything comes at a trade-off. We can get out there,
but it's also going to cost us increased miles and things like
that.
Ms. Buerkle. Thank you. I yield to Dr. Benishek for any
questions.
Mr. Benishek. Thank you, Madam Chairwoman.
You kind of got me distracted there with the E-85. Are you
required to use E-85, is that what you're telling me?
Dr. Smith. We are not required. We are encouraged to use
E-85.
Mr. Benishek. Well, we will get off that. That will
probably be a subject for the hearings in Washington.
But, Dr. Smith, my focus of this meeting is to try to make
it better for veterans here; and the fact--Because we have said
so much of the centralized control in the VA, that there's
little room for innovation or change at the local level.
So, for example, in their mental health services, are there
any programs that you are required to do or mandated to do in
your department that because of our rural area, it's difficult
to do those, the manual things that may be required to do?
Dr. Smith. Certainly. The VA has the Uniformed Services
Package, which outlines the required mental health services for
every VA. Many of those may be a challenge for rural facilities
in that, you know, we're 4 hours from our sister VA in
Milwaukee. We use their residential system, we use their
domiciliary (DOM), we use their substance use disorder (SUD)-
treatment program, we will use their acute psychiatric
facility.
So if I have to hospitalize a veteran living from Sault
Ste. Marie, that's a heck of a long drive from the Sault down
to Milwaukee. And if Milwaukee is full, we may have to use even
a further VA.
So we can provide the services, but they're often at a
challenge and a cost.
Mr. Benishek. Was it your idea, if you had input to that,
would you be able to find an easier way of doing it and then
use that?
Dr. Smith. Well, there I would have to be a VISN/Program
Project. I'm also charged to be fiscally responsible to the VA.
And, you know, say, do we build a psychiatric facility
here? That's not very cost smart, because for the amount of use
that we would have, it would be so cost intensive to hire the
psychiatric staff, to maintain it at full capacity, an
appropriate capacity, we wouldn't have full utilization.
So there's the balance that we just cannot do some things
because we may need it this month, but next month we may not
need it. So then what do you do with the staff and the program
during that time?
So we find our balance with utilizing both VISN 11 and VISN
12 facilities.
Mr. Benishek. Thank you very much.
Some of the VSO guys have the same sort of theme to their
answers and, you know, the continuity of doctors was an issue.
Well, Mr. Rice is sort of in a spot here, because you've only
been here 2 weeks; and that's one of my problems with the
system, is that the director turnover has been so rapid.
Having been from Iron River, I know you bought a house, I'm
hoping that this means we will maybe have a director that will
last a little bit longer with your presence here. But that's
something that I want to monitor going forward, because I think
the stability of the hospital is so much better.
Can you just address that? If not, then perhaps another
gentleman could comment as well as to the continuity. Why is it
a problem that while I've been coming here, I've seen six
different doctors?
Mr. Rice. Yeah, I would agree. Since I'm new, I will defer
to Dr. Ranjan.
But I think in the past 2 years, leadership here has made a
commitment to providers. We spent almost $2 million in
retention and recruitment bonuses. I know that we have a great
doctor in Dr. Ranjan in the Upper Peninsula, and I think this
year so far we spent over a million dollars to date. So I think
that's the way we're trying to recruit top-notch physicians to
the Upper Peninsula.
Mr. Benishek. Dr. Ranjan, are there any particular problems
with retention of physicians and other important staff to the
hospital that you may be able to address?
Dr. Ranjan. Well, as Mr. Rice pointed out, there is--We had
seen turnover, and we are taking steps to provide resources.
But for a professional--from a professional perspective,
it's important to have an environment where they feel
professionally challenged, to meet their educational and
professional needs. So that becomes difficult in this facility,
especially in a rural facility where the practice may be
restricted, so----
Mr. Benishek. What about the facility? I mean, I practiced
in Dickinson County. We have doctors over there like crazy.
What makes this so difficult?
Dr. Ranjan. Well, the policy and procedures sometimes
dictate what you can or cannot do. And, therefore, across the
street you might have been able to do certain things, we are
not allowed to do here.
There may be--and then there are other educational and
academic requirement that are needed, and the qualified
physician must have that. Being in a rural setting, it is more
difficult to get that. Being in private settings, you may have
less effort to get that in.
Mr. Benishek. Like CME's (continuing medical education) and
stuff like that?
Dr. Ranjan. CME. Clinical research out, you know, and go to
meetings during the daytime and things like that.
Mr. Benishek. Well, you have a localized peer review of
your mortality rate here, right?
Dr. Ranjan. Right. We have our own peer review in almost
every department, and then we do have a level peer review; but
that is different--that's different from what I'm talking
about.
Mr. Benishek. Dr. Smith, do you have any comments about the
continuity of care issue from your Department?
Dr. Smith. In mental health, it's been spectacular. I've
lost very few staff over the 3 years that I've been here. The
things that have had an impact on my staff generally have been
out of our control and focus on the economy.
Mr. Benishek. What do you mean by ``out of your control?''
Dr. Smith. There's a huge housing downturn right now. And
many of my staff have--they're not from the area, so they all
move here. Many staff have left a home, moved here, and that
home has never sold. So after 2 years, they've had to return
back home because they cannot sell their house.
Mr. Benishek. I see.
Dr. Smith. There's been several instances where that has
been the reason staff have left.
But as a core, I've got a great core of mental health staff
that are here for the long-term.
Mr. Benishek. Dr. Skupien, I have a question about the
local Office of Rural Health.
Dr. Skupien. Uh-huh.
Mr. Benishek. My understanding is that it's been up for 3
or 4 years here now, with this trouble with having a director--
you haven't had a full-time director there.
Dr. Skupien. The national level?
Mr. Benishek. No, no, no, at the local level here. Is that
right, or is that not right?
Dr. Skupien. I will let Jim answer that, because that's----
Mr. Benishek. Jim doesn't know, I don't think, because he
just got here.
Dr. Skupien. Well----
Mr. Benishek. I thought there was a problem with there not
being a director, or is that at the national level?
Dr. Skupien. The national level.
Mr. Benishek. That was the national level?
Dr. Skupien. Yes.
Mr. Benishek. Is there a lot of coordination between the
Office of Rural Health and the hospital here?
Dr. Skupien. There is.
Mr. Benishek. Who do you talk to? Who is in charge of the
Office of Rural Health? Is that somebody here in the building?
Dr. Skupien. The Office of Rural Health is coordinated in a
number of ways. We have a VISN consultant who works almost
daily with Jim and his staff and his leads for rural health.
They're in constant communication.
They actually--the local staff develops the projects and
the outcomes and measures, and then we monitor it very
carefully. Sometimes it's weekly, sometimes it's monthly.
Mr. Benishek. Who do you talk to here at the VA? Would it
be Mr. Rice's office? Is there anybody in the Mental Health
Department or the Surgery Department that you coordinate with?
Dr. Skupien. I would talk to the VISN consultant.
Mr. Benishek. Where is he at?
Dr. Skupien. He is in Chicago, and then I would work
directly with Jim Rice. If I have a specific issue, I would
work directly with him.
Mr. Benishek. I just want to be sure that this coordination
between what you're doing, what the people at the VA are doing,
do you feel that that's going on?
Dr. Skupien. I do feel that. There's a very bottom-up
process, especially now where the needs are identified by the
local communities. What we do is set priorities.
For example, we have six ORH priorities at the VACO-HQ
level, but then we have the local communities here in Iron
Mountain, for example, determining what their needs are and
setting projects up.
Mr. Benishek. So, Dr. Smith, have you had input then into
the Office of Rural Health's ability to provide mental health
care that may help you then with your services?
Dr. Smith. They certainly help with my services. My
interactions with the Office of Rural Health would be when they
put out an opportunity for new funding, I put in my
applications.
Mr. Benishek. I see. So it's more of a funding issue?
Dr. Smith. For me.
Ms. Buerkle. So they're strictly mostly funding when the
Office of Rural Health gets involved?
Dr. Skupien. Primarily, but also now because of the
measurements that now come, we have assigned liaisons from our
office to deal with each of the project coordinators on a
quarterly or monthly basis, depending on need.
Mr. Benishek. Do you provide funding for somebody like a
county-based VSO? Is that within your purview?
Because, I mean, one of the issues that came up in the
previous panel was that some of the counties don't have, you
know, permanent VSO staff, depending on State funding or county
funding.
Would that be within the realm? It seems to me that it
would be perfectly within the realm of your agency to provide
funding for somebody like that.
Dr. Skupien. At this point, it would have to be--we don't
have the mechanism in place. However, there are some models.
Like if Iron Mountain decided that they wanted a project funded
for transportation, if they had a mechanism for getting that
funding or a joint venture, we would consider that as long as
everything was above aboard and we were able to do that. So
yes, that is a potential.
Mr. Benishek. Well, it's just that, you know, with the
partnership--you know, the different community organizations
and stuff, it seems to me with this of transporting people with
so many issues is really a problem. You know, with the
distances involved and like a mental health person having to
come to Iron Mountain for a mental health session, you know,
three times a week is pretty arduous.
So I'm just wondering if there's funding available in your
department to help for them to go to a regional outlet? Because
I'm not sure that this is happening enough.
Dr. Skupien. I can tell you a couple of things. One is that
ORH funded 86 vans--transportation vans, and those were
projects submitted by the local communities.
And also, as I noted in my opening statement, we fund a lot
of telehealth; and that seems to have worked very well in rural
communities where we're using telehealth or mental health
services for every type of specialty care.
Mr. Benishek. Dr. Smith, how does this mental health work
then? Do you put a computer in somebody's house then and you
have a consultation over the Web or what?
Dr. Smith. Currently, my process is all veterans go to a
facility, so either Iron Mountain or one of the CBOCs. My
psychiatrist may be set up with a computer--a teleconferencing
computer, either at another VA facility, where we are using one
of their rooms, or out of a non-VA facility, out of a private
office.
And in VISN 20, they are currently piloting programs with
veterans and their own computer and their own Web setup from
their private homes. I have not implemented or moved towards
that at this point.
Mr. Benishek. That makes a lot more sense, doesn't it?
Dr. Smith. Clinically, it may or may not. If I were to
implement that, I would want a case manager in that home,
because from a mental health standpoint, what happens if
there's a problem?
Mr. Benishek. Right.
Dr. Smith. So if it's just the veteran and there's a power
outage and the line goes dead, you know, that may have been at
a critical moment.
Mr. Benishek. Yeah.
Dr. Smith. So I certainly use lots of ``tele'' out into the
facilities. My E-range team will provide transportation, will
pick up a veteran in their home and bring them to the CBOC for
that telepsychiatry session.
Mr. Benishek. Thank you. How are we with our time
situation?
Is there anything else that we should be addressing? Is
there something that the Committee can do for you, Dr. Smith,
that would be the biggest, best thing that we can do to help
your service move forward? This is your opportunity to help the
people upstairs.
Dr. Smith. Well, I think I could probably--you know, I
would think about that both as an administrator, as the leader
of my department, in my staff meetings and then as a clinician
for the veterans' needs.
I think the challenge for my staff is--Often comes down to
getting Washington to understand that we cover a pretty big
area, and a lot of the expectations for performance are a
challenge when the veteran lives 4 hours away.
And, you know, if a veteran is discharged from Milwaukee
yesterday and now they're back home, you know, 3 hours away, is
it respectful to that veteran to mandate that they come back to
the Medical Center to have their 24-hour follow-up appointment?
Now there's the challenge.
Now we want to get them in. That's good continuity of care,
but then we also have to understand that veteran may have just
been on a very long bus to get home.
As a clinician, the challenge is, you know, certainly
providing good care in the community. We are provided the same
level of funding to hire as a facility in Chicago.
Yet for me to hire, that person is going to have to move
say to Hancock, which is a very remote area. It costs more
money than if you lived in Chicago and you could just recruit
from your pool.
Here in Iron Mountain, I have one community psychiatrist
who does not work for the VA. He works for me part time. That's
all I have to recruit from. It's not like a community pool.
So we have to pull people up. I think, as the
administrator, that's the frustrating part is when I get the
call from someone in Central Office asking me, you know,
``What's the local cab company?'' What is the local cab
company? You know, that's the challenge.
Mr. Benishek. Dr. Ranjan, is there anything else we can do
as far as your perspective is concerned?
Dr. Ranjan. From my perspective, I think we are growing,
and so some of what we have already touched on is quite
relevant.
If I could point one thing out, I would say probably the
uniqueness of the rural practice. That is different from urban
practice and providing mechanism for some growth in autonomy
and flexibility to the out patient's need and our veterans.
Mr. Benishek. Mr. Rice, do you have any comment on that?
Mr. Rice. No, just your continued support.
Mr. Benishek. You know, that's been my impression coming
from here going to Washington, is the fact that it's been so
frustrating to me, like I pointed out before with these funding
cycles, it doesn't leave any room for innovation on a
director's part to have your different funding cycles.
If you had an option of taking some of that money and maybe
you didn't spend it all, maybe it's kind of left over for the
next year to spend it in an area where you're able to innovate
a little bit, I mean, to provide an extra nurse or an extra
case worker if you didn't need to have that, you know, $3
million wing or--you know, those 50 extra computers.
You know what I mean? Or vice versa, if you needed the
money. I think that that's important. I think that addresses
Dr. Ranjan's concern.
You know, our needs up here are so different than the needs
in Chicago. And for the rules to be the same, you know, for
both hospitals is just not realistic.
To have the local guy, which hasn't been here but for 2
years, to realize better than, you know, the VISN Director or
the people in Washington; that there was room for variability
amongst the hospitals. They don't have to be exactly the same
throughout the country.
And your testimony here and the testimony of the VSO
people, I think verified my opinion in that regard.
So that's going to be my goal going back to Washington as I
report to the full Committee these hearing results--we're not
wasting money, we're trying to make the situation better, to
allow flexibility within the VA to address concerns, not only
for your system, but maybe urban centers might have an idea
that might suit them better than the average setting.
So I appreciate your coming forward today and doing your
best to inform us what's happening, and I want to thank you all
very much.
With that, I will yield back to Chairwoman Buerkle.
Ms. Buerkle. Thank you very much. And I echo Dr. Benishek's
appreciation. Thank you, all of you, for being here this
morning for your testimony.
It's been an honor and a pleasure to be here and to conduct
this hearing in Iron Mountain.
Before we conclude, though, I would ask all of the veterans
in this room as well as upstairs in the two overflow rooms to
please stand up. Let us express our appreciation to you for
your service.
[Applause.]
Ms. Buerkle. Thank you.
Yesterday the Secretary of Defense, Robert Gates, was
giving one of his exit interviews, and he mentioned about the
military that one of the hardest parts for him leaving his
position was the fact that he was leaving a group of men and
women who are capable and dedicated and extraordinary. And I
think we need to recognize that those capable, dedicated,
extraordinary people become veterans; and that's the population
we serve.
So we want to be sure to let you know how much we
appreciate your service to this country. The United States of
America is the greatest Nation in the history of mankind, and
it is because of our military, our men and women who so
honorably served this Nation.
Thank you for your service.
At this time, I ask unanimous consent that all Members have
5 legislative days to revise and extend their remarks,
including extraneous materials. Without objection, so ordered.
Ms. Buerkle. At this time, this hearing will be adjourned.
Thank you.
[Whereupon, at 11:54 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Ann Marie Buerkle,
Chairwoman, Subcommittee on Health
Good morning. It is a pleasure for me to be here in beautiful Iron
Mountain, Michigan. This is my very first time in the Upper Peninsula
(U.P.) and I am so very grateful to you for allowing me to join you
this morning despite my questionable ``troll'' status.
In all seriousness, I want to thank each of you for taking the time
out of your busy lives to spend the morning with us.
I am honored to serve as the Chairwoman of the House Veterans
Affairs Subcommittee on Health and to have your Congressman, and my
friend, Dr. Dan Benishek, serving on the Committee with me. As I am
sure you know, Dan has practiced as a general surgeon in the U.P. since
1983. He has also worked part-time at this VA facility for the past 20
years. Dan is an invaluable voice for veterans and brings a wealth of
expertise to our Committee to help guide our efforts to improve VA care
for veterans residing here in Iron Mountain and across the country.
Our oversight agenda this year has spanned a wide range of topics--
from patient safety to caregiver benefits to the health needs of our
newest generation of veterans from Iraq and Afghanistan--and throughout
each of those discussions, Dan has provided a unique insight that only
one with his ``insider'' knowledge can bring.
One thing he is always sure to stress about his time at the Oscar
G. Johnson VA Medical Center is the high caliber of employees who
dedicate themselves day in and day out to providing Michigan veterans
with quality care and services.
I know he has the utmost confidence in the men and women who work
at this facility and it is a comfort to us both to know that veterans
are in such good hands up here in Iron Mountain.
To all of the VA employees joining us this afternoon--thank you for
all you do each day to care for those who have so honorably served our
Nation.
Coming from a rural district myself in Central New York, I am
familiar with the struggles veterans living in rural communities, like
yourselves, face in accessing the care and benefits you earned.
Congress took a significant step in 2007 when it created a new
Office of Rural Health within the Department of Veterans Affairs (VA)
to address the unique needs of veterans living in rural areas. In 2009
and 2010, Congress provided this office with over $500 million in
additional dedicated funds to improve the delivery of health care to
rural veterans. That is why it is so very disheartening to read a
recent audit by the VA Office of the Inspector General (IG) which found
that not only has the VA not properly managed the use of these funds,
but still continues to lack even a process to assess the needs of
veterans in rural areas. I think we can all agree that this is
unacceptable.
At our hearing today, we will be taking a look at the health care
programs provided to local veterans through the Iron Mountain VA
Medical Center, including the use of telemedicine and other
technologies. And, I want to hear from our witnesses how, if at all,
the Office of Rural Health initiatives have improved services for
veterans in the U.P. Further, moving forward, I want to know how VA is
going to improve the management of our precious resources to meet the
goal of increasing access and quality of care for rural veterans across
our great country.
With that said, I now recognize your Congressman and my colleague
and friend, Dr. Dan Benishek, for an opening statement.
Prepared Statement of Hon. Dan Benishek
Thank you, Chairman Buerkle. Good morning, everyone. It's good to
be home. I would like to thank all the veterans and their guests who
are in attendance. I would like to thank our local Veteran Service
Officers who have given their time today to participate in this
hearing, as well as the VA administrators who will provide us insight
on how to improve health care for our veterans. Additionally, I want to
thank the staff of the House Committee on Veterans' Affairs for their
hard work bringing Congress all the way up here to Michigan's U.P.
I would also like to introduce the Chairman of the Veterans
Subcommittee on Health, Congresswoman Anne Marie Buerkle. Congresswoman
Buerkle represents the people of New York State's 25th Congressional
District. She graduated from St. Joseph's Hospital School of Nursing as
a Registered Nurse and went to work in New York City's Columbia
Presbyterian Hospital. In 1991, she returned to college, this time to
earn her law degree, and worked as an Assistant New York State Attorney
General representing the State of New York on behalf of Upstate Medical
University. It has been a pleasure working with Congresswoman Buerkle
on the Committee thus far. I greatly appreciate her making the trip up
here and I value her contributions to the Veterans Committee and her
leadership.
Ladies and gentlemen, I worked at this hospital for 20 years, and
let me be clear: the staff at the Oscar G. Johnson Hospital is an
incredibly dedicated, hardworking, and professional group of health
care providers. Their commitment to our veterans, their enthusiasm, and
their expertise are beyond reproach. I am proud to have worked
alongside these men and women, and I want to take this opportunity to
thank them for their service. Please join me in applauding these men
and women.
With that said, I wouldn't have dragged Congress all the way up to
the U.P., and I wouldn't have put Congresswoman Buerkle, an admittedly
fearful flyer, on a propeller plane from Detroit to Iron Mountain for
nothing. Like everything we do in life, veteran health care in Northern
Michigan needs improvement.
At the start of the 112th Congress, I chose the Veterans' Affairs
as my committee assignment so that I could bring my experience working
in the VA health care system to Congress. So far, my experience on the
Committee has been very encouraging. When you bring a veterans' issue
to the Committee's attention, they listen, and work with you to find
ways to remedy problems. And that is what we are here to do today: to
get an honest assessment of what needs to be improved within the VA
health care system to help our veterans in rural areas. As I stated,
based on my experience, it is not for lack of effort or passion that VA
health care providers fall short in providing quality service to our
veterans, rather, on occasion, despite their best efforts, they are
frustrated by the VA's central administration. From my observations,
this frustration is caused in part by a lack of autonomy among VA
health care facilities in rural areas.
Veterans in rural areas face different challenges compared to
veterans elsewhere to accessing and receiving quality health care. As
Congresswoman Buerkle can attest, the needs of veterans in this
district differ from those in her district in New York, or Chairman
Jeff Miller's district in Florida, or Ranking Member Bob Filner's in
California. A one-size fits all, top-down approach will not address or
anticipate every issue or roadblock to veterans in rural areas, and
often they create barriers that waste work and resources in these
settings, forcing rural VAs to shift patients at huge costs and patient
dissatisfaction. One point from my personal experience that might help
illustrate this point is that leadership at local VA facilities such as
this hospital lack discretion on how their funds are spent; a
facility's budget is divided into 3 categories: medical service,
medical administration and medical facilities. Local facilities are not
allowed to use funds from one budget ``silo'' for other necessities;
for example, a hospital cannot use money designated for facility
repairs to hire more staff, even if the repairs are unnecessary and the
hospital is understaffed. It seems to me that rural facilities should
have the ability to allocate funds as they deem appropriate.
Another personal frustration I had working in the VA system was the
high turnover rate of hospital directors at this facility. During my
time here, I worked with no fewer than 10 directors, a new one for
every 2 years. Two years is simply not enough time to understand the
unique challenges of a VA facility in a rural area, and such a short
tenure provides little incentive to face these challenges and improve
them. I'm not sure the cause for such a high turnover rate, but if a
hospital such as this one hopes to improve their quality and access to
health care, it needs stable leadership. In addition to his prepared
testimony, I would request that Director James Rice speak to these
issues.
Before we turn to the panel, I would like to share a short personal
story that I believe highlights the many great doctor-patient
relationships you see at this hospital.
And with that, I yield back the Chair.
Prepared Statement of Chuck Lantz, Director, Dickinson
County Office of Veterans' Affairs, Iron Mountain, MI
Congressman, Congresswoman, and guests, I would like to thank you
for the invitation and allowing me to testify today on this big issue
of our Veterans today. I would like to start out with the subject at
hand which is Rural Veterans health care. I think Oscar G. Johnson VA
Medical Center and VISN 12 has taken many steps forward to extend
access to the Veterans in the upper peninsula which is one of the most
rural areas of Michigan if not the Nation. By building many CBOCs
(community based outpatient clinics) in and around the Upper Peninsula
and northern Wisconsin, it allows the Veteran to have Veterans health
care closer to their community. However, there are still several issues
in regard to the health care of the rural Veterans, 1. Transportation,
2. Better access to mental health caregivers for the veterans having
issues with PTSD and TBI, and the related health issues that come with
that, 3. Better access to substance abuse programs due to the PTSD
issues. Veterans Affairs has grown by leaps and bounds but needs to
keep thinking outside the box to keep growing and caring for our
Nation's Veterans. There are still many Veterans that cannot get VA
health care due to the income threshold laws unless they have been
injured while serving and receiving a service-connected injury. Many of
these Veterans served voluntarily and need to be cared for as a
Veteran. Even if they are put in a priority group that requires co-
pays, at least our Nation's Veterans would be cared for regardless of
their income status.
Next I would like to discuss the issue of the underrepresented
Veteran, most of all in the State of Michigan. Of the 69 counties in
Michigan with CVSOs (County Veterans Service Officers) only 37 provide
full time VB counseling, 32 counties have part time VB Counseling, 14
Counties without CVSOs. The Veteran population of 66,525 has no Veteran
representation in those 14 Counties. The Veteran cannot establish their
benefits alone, the veteran needs an advocate to assist them in the
application process of VBA benefits as well as VHA benefits. The
Veteran also needs that advocacy to assist them in gaining the benefits
and keeping them in place; it is a constant struggle for the Veteran. I
would like to just point out a comparison of 2 Counties in Michigan,
one being Dickinson County with a fulltime CVSO, Veteran population of
2,671 with a total VA expenditure of $30,643,000.00 and of that
$7,830,000.00 was compensation and pension, and that being liquid
income comes directly back into the local Dickinson County community.
Now take Antrim County with a part time CVSO. Veteran population 2,673
(2 Veterans more than Dickinson County), their total VA expenditure of
$7,109,000.00 and of that $4,339,000.00 was compensation and pension.
So you can see the difference we as CVSOs make advocating for the
Veterans Benefits. Michigan has changed the grant funding to VSOs
(Veterans Service Officers) and now with those changes, the number of
VSOs had to be reduced. That brings more travel for the VSOs, and the
time they are traveling they are not meeting with the Veteran which is
a disservice to our Veterans. Also, with that reduction, no more
services were added or changed to take up for the Veteran they can no
longer reach in a timely manner. I am advocating that the State of
Michigan and/or the Nation mandate there be Service officers in each
county of each State. The process of the VA Benefits is so cumbersome
that the Veterans cannot accomplish these tasks on their own; they need
an advocate to accomplish their struggles with the system. Why is it
that we as a Nation send our soldier to war with no questions asked and
yet once they come home with injuries they have to prove without a
shadow of a doubt that injury was due to their military service and if
they do not have any injuries they have to prove they are under a
certain income threshold to get health care. Changes need to be made to
cover our Nation's Veterans, ALL OF THEM.
Office of Veterans Affairs (serving Dickinson County) has a motto:
IF THEY SEND THEM WE MUST MEND THEM. Thank you for allowing me to
express the needs of our Nation's Veterans and the need for all the
Veteran advocates to assist them. This is a very important job in our
Nation and funding and laws need to be established and changed so that
our Nation and State has the VSOs and CVSOs to take care of our true
American heroes. For my last comment I would like to say and challenge
Congress to establish CVSOs in each and every county of Michigan and
the Nation.
Thank you.
__________
Counties' Commitment
To assist veterans and their dependents in obtaining any
and all Federal, State, and local veterans benefits to which they are
entitled.
This service is best provided through a local veterans
office where the veterans' programs and assistance are consolidated
into an easily accessible ``one-stop shopping'' location.
Enabling Legislation
Public Act 214 of 1899 (MCL 35.21-35.27)
An Act to provide relief outside of the soldiers'
home for honorably discharged indigent soldiers, sailors,
Marines, nurses and members of women's auxiliaries and the
indigent wives, widows and minor children of such . . . .
Public Act 235 of 1911 (MCL 35.801-35.804)
An Act to provide for the payment and reimbursement
by counties, in certain cases upon application therefor, of
expenses incurred in the burial of bodies of honorably
discharged members of the armed forces of the United States and
their spouses . . . .
Public Act 9 of 1946 (MCL35.601-35.610)
An Act to create the Michigan veterans' trust fund,
and to define who shall be eligible to receive assistance
therefrom; to provide for the disbursement . . . .
Public Act 192 of 1953 CMCL-35.621-35.624)
An Act to create a County Department of Veterans
Affairs in certain counties, and to prescribe its powers and
duties; and to transfer the powers and duties of the Soldiers
Relief Commission in such counties. . . .
Board of Commissioners Resolution/Letter of Agreement
Other Enabling Legislation
Public Act 156 of 1851 (MCL 46.12b)
Excerpt from the Act to create County Boards of
Commissioners regarding ``Local councils of veterans affairs;
appropriation by board of supervisors for operation.''
Public Act 77 of 1945 (MCL 35.11)
An Act to provide for local councils of veterans'
affairs; and to authorize appropriations by counties, cities,
villages and townships.
Public Act 139 of 1973 (MCL 45.554)
An Act to provide forms of county government; to
provide for county managers and county executives and to
prescribe their powers and duties;
Trained and accredited county counselors . . . .
Initiate, develop and prosecute claims for Federal,
State and local veterans benefits.
Assist veterans to enroll in the USDVA medical care
system.
Administer the county veterans burial allowance
program and assist with other death benefits for veterans'
survivors.
Utilize and coordinate emergency assistance from the
Michigan Veterans Trust Fund and County Veterans Relief.
Refer veterans and their families to other
appropriate programs.
May host part-time service from related veterans
agencies and other community services.
Network
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
CVSO--County Veterans Service Office NVSO--National Veterans
Service Organization
MDMVA--Michigan Department of USDVA--U.S. Department of
Military & Veterans Veterans Affairs
MVTF--Michigan Veterans Trust Fund VBA--Veterans Benefits
Administration
MHV--Michigan Homes for Veterans VHA--Veterans Health
Administration
MDOL--Michigan Department of Labor NCA--National Cemetery
Administration
Of the 69 Counties with CVSO
37 provide full time VB Counseling
Alpena Isabella
Barry Jackson
Berrien Kalamazoo
Branch Kent
Calhoun Lapeer
Cheboygan Leelanau
Chippewaw Lenawee
Clare Livingston
Clinton Macomb
Dickenson Midland
Eaton Monroe
Genesee Oakland
Gladwin Ogemaw
Gogebic Sanilac
Grand Traverse St. Clair
Hillsdale Tuscola
Huron Washtenaw
Ingham Wayne
32 have part-time VB Counseling
Alcona Mackinaw
Allegan Manistee
Alger Mecosta
Antrim Menominee
Baraga Montomrency
Benzi Newaygo
Cass Ontanogan
Charlevoix Otsego
Delta Ottawa
Emmet Presque Isle
Gratiot Roscommon
Houghton Schoolcraft
Ionia Shiawassee
Iosco St. Joseph
Iron Van Buren
Kalkaska
14 Counties without CVSO
1 Arenac1 Missaukee Missaukee
< Arenac
Bay Montcalm
Crawford Muskegon
Lake Oceana
Luce Osceola
Marquette Oscoda
Mason Saginaw
Veterans Represented by CVSOs
Counties with Full time Offices:
532,650 veterans plus their families
Counties with Part time offices
104,795 veterans plus their families
Counties without CVSOs
66,525 veterans plus their families
* * * * 703,970-VA estimated Michigan veteran population for 2010,
which represents a decrease of 100,041 since 2006.* * * *
Commitment to Maintain CVSO Training
State of Michigan
$50,000 Training Appropriation (revoked 4/12/07)
Counties
Registration/Conference Costs
VBC salary/leave time
Host training conferences
Individual
Personal time
Miscellaneous expenses
Accreditation & CEU Training
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Approximate 65 Veterans Benefits Counselors attend the
Spring Training Conference each year.
Training conferences provide:
USDVA accreditation training and/or continuing
education unite training
Reference materials
Opportunities to network collaborate and cooperate
with other County Counselors, USDVA and MDMVA staff and
Veterans Service Officers.
Benefits/Outcome
For the Veteran/families
Financial
Service-connected Compensation
Non-service-connected disability pension
Dependency and Indemnity Compensation
Death pension
USDVA and County Burial Benefits
State and County Emergency Financial Relief
Health
USDVA Medical Centers
Community Based Outpatient Clinics
Vet Centers
Education
Various USDVA Veterans and Dependents
Education benefits
-Vocational Rehabilitation
-MI Children of Veterans Tuition Grant
Quality of Life
National Cemetery Burial
Military Records
Michigan Veterans Homes
Benefit to Michigan Veterans
For the Community, County, State
Economy
USDVATotalFY 2010ExpendituresforMl-$2.4Billion
Compensation and Pension-$1.1Billion
State/Local monetary/non-monetary benefits
Health
USDVA Medical Care (5 VA Medica1Center (16 CBOCS)
Vet Centers
Quality of Life
Federal Non-monetary Benefits
Government Marker, U.S. Flag, Military Records
National Cemeteries
Fort Custer
Great Lakes National Cemetery
State Veterans Homes
MACVC Challenge to you:
. . . is to help us accomplish our mission which is to provide
consistent and professional veterans services through out every county
in our great State of Michigan
Glossary
DoD ESGR--Dept of Defense--Employment Support Guard & Reserves
GLNCAC--Great Lakes National Cemetery Advisory Council
JVC--Joint Veterans Council
MAC--Michigan Association of Counties
MDMVA--Michigan Department of Military and Veterans Affairs
MDOL--Michigan Department of Labor
MHV--Michigan Homes for Veterans
MVTF--Michigan Veterans Trust Fund
NACVSO--National Association of Veterans Service Officers
NCA--National Cemetery Administration
NVSO--National Veterans Service Organization
TAP--Transitional Assistance Program
USDVA--U.S. Department of Veterans Affairs
VBA--Veterans Benefits Administration
VHA--Veterans Health Administration
VISN 11 & 12--Veterans Integrated Services Network
& MAC--& Management Assistance Committee
FY 2009 GEOGRAPHIC DISTRIBUTION OF VA EXPENDITURES (GDX)
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Iron Mountain, MI
June 16, 2011
The Honorable Congressman Dan Benishek
500 South Stephenson--Suite 500
Iron Mountain, MI 49801
RE: Veterans Affairs Field Hearing
Thank you for your invitation to participate in your Veterans
Affairs Field Hearing on Monday, June 20, 2011 at the Iron Mountain VA
Medical Center. I believe that our Iron Mountain (Oscar G. Johnson) VA
Medical Center is one of the finest facilities serving the veterans of
Michigan's Upper Peninsula and Northern Wisconsin. Over the past couple
of decades, I have seen the growth of veterans' care at our VA Medical
Center with many veterans saying they feel like they are being treated
like royalty.
Regarding the issues addressed in the House letter of June 8, 2011,
I offer the following comments:
Delivery of health care to rural veterans . . . has
been great with the addition of the home health care, specialty
clinics, women veterans' programs. I would like to see a
dermatologist and more hours for our chiropractor.
Recruitment and retention of medical personnel
including leadership . . . we have some very caring medical
personnel at our facility and I think it's important that when
recruiting physicians, that they also be fully trained in VA
law regarding pension and service-connection disabilities and
what is needed when documentation is concerned. I understand
that sometimes recruiting to a small remote area like Iron
Mountain is difficult, but would like to see longevity of
providers. Sometimes, the veterans get frustrated because their
providers are changed often. Most of our VAMC providers have
compassion for our veterans when treating them and listening to
their concerns, but we also have a few that do belittle them,
are disrespectful, not understanding the physical and mental
demands of being in the service. To our veterans, their
conditions are real. At times, their providers would even ask
'are you just looking for some more money?' This is
unacceptable. In regards to most compensation exams, they have
greatly improved, are done with efficiency and thoroughness
with respect to the veterans.
Mental Health . . . longer wait time to get
appointments especially for WW-I1, Korean and Vietnam veterans
because OEF/OIF veterans have preference at this time. Would
like to see more providers or outreach facilities as well more
counselors at the Vets Center in Escanaba as well.
Telehealth programs . . . Our veterans would like to
see more of this type of service as it would ease up VAMC's
appointment slots and workload to allow the VAMC providers more
time with individuals to discuss their medical problems and
concerns. This would also be more cost effective for the
veterans.
Community partnerships . . . More of this partnering
would be more cost efficient and effective, and to help our
veterans with the different resources available in their own
communities; I would encourage more of this type of
programming.
I would also like to make a couple of comments regarding . . .
Fee Basis . . . such as chemotherapy, physical
therapy and chiropractic care. In the U.P. of Michigan, it is
sometimes impossible for the veteran to drive to Iron Mountain
for chemo treatment especially when he or she is taking
numerous medications. The same thing for physical therapy as
the long drive into Iron Mountain is sometimes an aggravation
of their condition. I would like to see more outreach for these
types of treatments to ease the pain for the veterans.
VA and/or VAMC forms . . . Service Officers work with
veterans, of course, but also with their dependents and/or
surviving spouse. On occasion, when a veteran passes away, the
physicians should be more conscious about all the veteran's
conditions when they fill out the death certificate as it could
result in a grant or denial for spousal benefits. This would
also be a good subject for educating our physicians in our
community partnerships. At times, it is also necessary to have
the VAMC provider fill out forms that would support the
veteran's claim and we would request thoroughness for each form
to eliminate another request.
Thank you for allowing me to participate in this hearing for the
House Committee on Veterans' Affairs Subcommittee on Health.
Respectfully,
Shirley A. Rentschler
National Service Officer
Military Order of the Purple Heart
Department of Michigan
Prepared Statement of James W. Rice, MA, Director, Oscar G. Johnson,
Veterans Affairs Medical Center, Iron Mountain, MI, Veterans
Health Administration, U.S. Department of Veterans Affairs
Good Morning, Madam Chairwoman and Members of the Committee. Thank
you for inviting us here today to discuss the accessibility and quality
of health care for Veterans residing in the Upper Peninsula of
Michigan. I am accompanied today by Dr. Mary Beth Skupien, National
Director for the Department of Veterans Affairs (VA) Office of Rural
Health, Dinesh Ranjan, M.D., Chief of Surgery at the Oscar G. Johnson
(Iron Mountain) VA Medical Center (VAMC), and Clifford Smith, M.D.,
Chief of Mental Health at the Iron Mountain VAMC.
My testimony today will describe the work done at the Iron Mountain
VAMC, and then review the services and outreach we provide to Veterans
in the rural and highly rural areas here in the Upper Peninsula.
Specific areas of focus will be improvement in mental health and rural
health care, recruitment and retention of medical personnel, the scope
and impact of telehealth programs, and our collaboration and
partnerships with community providers.
About Iron Mountain VAMC
The Iron Mountain VAMC provided care and services to almost 20,000
Veterans in fiscal year (FY) 2010 with an operating budget of $106.9
million and more than 580 employees. The facility oversees community-
based outpatient clinics (CBOC) in Michigan (Ironwood, Hancock,
Marquette, Sault Ste. Marie and Menominee) and Wisconsin (Rhinelander)
that serve 15 counties in Michigan and 10 counties in Wisconsin. It
also operates a rural outreach clinic in Manistique, Michigan. The Iron
Mountain VAMC has the largest geographic patient service area east of
the Mississippi River, home to approximately 53,000 Veterans, 23,863 of
whom are enrolled in VA's health care system.
The Iron Mountain VAMC is a primary and secondary level care
facility with 13 medical/surgical beds and four intensive care unit
(ICU) beds. Its Community Living Center has 40 beds. The Iron Mountain
VAMC provides limited emergency and acute inpatient care in a
geographically rural area, and collaborates with larger health care
facilities in Veterans Integrated Service Network (VISN) 12 to provide
higher level emergency and specialty services. It employs state-of-the-
art telehealth technologies and is a leader in the delivery of health
care to rural Veterans. The Iron Mountain VAMC provides ambulatory and
acute primary and secondary health care, as well as surgery,
psychiatry, physical medicine and rehabilitation, neurology,
ophthalmology, ear/nose/throat (ENT), podiatry, orthopedics, oncology,
dentistry, geriatrics, and extended care.
In FY 2011 to date, the Iron Mountain VAMC is providing more than
99.7 percent of patients' primary care appointments within 14 days of
their desired date, exceeding the VA benchmark. At all of our
facilities, more than 99.5 percent of patients seeking a specialty care
appointment are scheduled within 14 days of their desired date. Our
patients are satisfied with the quality of care they receive as
evidenced by the Medical Center's patient experience data, which
exceeds the VA's national score for both inpatient and outpatient care.
More than 82 percent of our Veterans would recommend Iron Mountain to
their friends and family.
We have made great strides in the quality of care we provide by
reducing readmission rates for patients with heart failure, developing
better screening and surveillance processes for colo-rectal cancer,
improving the timeliness of placing patients discharged from acute care
into the Community Living Center, developing Patient Aligned Care Teams
(PACT), and expanding teleretinal services and care. This year, we are
making further enhancements to our telehealth services and their
availability at our CBOCs; we currently support telemedicine programs
for Pulmonary, Rheumatology, Endocrine, Cardiology, Prosthetics,
Diabetes, Infectious Disease, Weight Management Program (i.e., MOVE!),
Healthy Heart, Behavioral Health, Teleretinal Imaging Program and
Telepathology.
Improvement to the Delivery of Rural Health Care
Rural Americans, including rural Veterans, face many challenges
when it comes to health care, and VA is committed to enhancing the care
rural Veterans receive. Given our presence in the Upper Peninsula, much
of what we do can be considered rural health care. For the second
straight year, we are participating in the Rural Health Professional
Institute, which provides clinicians an opportunity to enhance their
skills and capacity for delivering health care to Veterans from rural
and highly rural locations. We are currently supporting rural health
projects through funding from VA's Office of Rural Health (ORH), as
well as through local resources.
ORH Funded Projects
VA's national ORH provides support and funding to ensure Veterans
living in rural and highly rural areas have access to the care and
services they need. Its mission is to improve access and quality of
care for enrolled rural and highly rural Veterans by developing
evidence-based policies and innovative practices to support their
unique needs. ORH has invested resources to implement projects across
the country. Over $500 million was dedicated to these projects in FY
2009 and 2010, and another $250 million in FY 2011. These funds
supported national and local initiatives in expanding telehealth, home-
based primary care, mental health care, education and training, rural
CBOCs, rural hiring initiatives, a rural fee-basis pilot, VISN-specific
initiatives, community outreach, transportation programs, and other
efforts. In FY 2011, VA is using ORH funding to further expand national
telehealth programs, implement our Project Access Received Closer to
Home (ARCH), sustain teleradiology services, and support a range of
VISN initiatives.
In FY 2009 and 2010, VISN 12 received approximately $15 million to
support projects serving Veterans in rural and highly rural areas. Iron
Mountain received approximately $7.4 million dollars over the past 3
years to implement and sustain rural health programs. Examples of
projects supported by ORH in the Iron Mountain region include expanded
telehealth capabilities to include the provision of specialty services
to Veterans in rural and highly rural areas; the Enhanced Rural Access
Network for Growth Enhancement (E-RANGE) Program, which is designed to
expand intensive case management services for Veterans with serious
mental illness and outreach services for homeless Veterans; expanded
primary and specialty care services; panic alarm installation; and
home-based primary care with the Lac Vieux Tribe to address issues of
access and quality of care for some of our most medically complex
Veterans. Using ORH funding, the Manistique outreach clinic was opened
in August 2009 to improve access for Veterans residing in the eastern
Upper Peninsula. In the first full operational year, the clinic
provided 2,042 patient care encounters. This fiscal year, the clinic
already has provided 2,320 encounters to 470 Veterans. Rural health
funds were also used to expand the Hancock CBOC. The 1,550 square foot
expansion has enhanced patient flow, improved Veteran privacy, and
facilitated a 19 percent increase in telehealth visits.
This fiscal year, ORH funding enabled Iron Mountain VAMC to
implement on site cataract surgery, interventional pain management, and
ENT clinics. To date, we have completed 20 cataract procedures, 658
pain management procedures, and 460 ENT encounters.
Locally Funded Projects
In addition to these efforts, we are supporting several initiatives
to increase outreach, awareness and services in rural and highly rural
areas. Iron Mountain VAMC helped pioneer the Veterans Directed Home
Care Initiative, which allows Veterans to choose friends and neighbors
to assist them with their activities of daily living and to be paid for
their services. There are currently 31 Veterans receiving care through
this program. We also expanded our Suicide Prevention Team for
increased outreach and coordination of high risk services.
Transportation and lodging are challenges unique to the vast rural
and highly rural areas we serve. Iron Mountain VAMC spent $1.9 million
in FY 2008, growing to $2.4 million in FY 2009, and $3.4 million in FY
2010 for beneficiary travel between facilities, as well as to and from
appointments. We lodged over 1,800 Veterans and their caregivers this
past year to provide treatment without undue travel hardship. Our 35
passenger bus transports Veterans two times weekly to the Milwaukee
VAMC for specialty care appointments, and our partners at Disabled
American Veterans operate a shuttle program that logs more than 360,000
miles annually bringing over 5,200 Veterans to and from the main
facility in Iron Mountain VAMC for appointments.
We have specific outreach efforts for Veterans of Operation
Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/
OIF/OND). We send letters and place phone calls to recently discharged
servicemembers, conduct site visits to demobilization sites, and attend
job fairs, Yellow Ribbon Events, local Universities, Post-Deployment
Health Reassessments and Welcome Home Events. We reach out to members
of the National Guard and Reserve Units and assess all newly enrolled
OEF/OIF/OND Veterans for community resource needs and care management.
In addition, Veterans are referred into our program and to our
Caregiver Support Coordinator as needed. Iron Mountain VAMC has more
than 1,800 unique OEF/OIF/OND patients.
Recruitment and Retention of Medical Personnel
We understand the importance of offering proper incentives to
ensure we have quality health care providers capable of delivering care
to Veterans in rural areas. Nationally, there are several new
incentives and training programs designed to provide our medical
residents and other health professions trainees with educational
opportunities in rural areas through collaboration with our academic
affiliates. The Iron Mountain VAMC maintains active affiliations with
Bay de Noc College for licensed practical nurses (LPN), registered
nurses (RN), and phlebotomy students; with Northern Michigan University
for RN, nurse practitioners, and social work students; with Northeast
Wisconsin Technical College for RN; with Central Michigan University
for physician assistants; with Michigan State University for social
work students; and with Northeastern Wisconsin Technical College for
phlebotomy students.
The Iron Mountain VAMC has actively recruited and retained staff
while simultaneously improving relationships with community health care
providers in the Upper Peninsula and Northern Wisconsin to broaden the
continuum of care available to the Veterans we serve. In a rural,
sparsely populated area, few facilities are able to offer the full
range of services normally available in larger metropolitan areas.
Strong collaborations with multiple health care providers, both public
and private, are essential in meeting the needs of patients. Iron
Mountain has grown from 499 staff employed in FY 2008 to 572 staff at
the end of FY 2010, an increase of 73 positions and almost 15 percent.
Of that increase, 67 of those positions are in direct patient care.
Recruitment and retention incentives for clinical providers of over $2
million in 2010 and over $1 million in 2011 affords the Iron Mountain
VAMC the opportunity to procure top notch clinical staff in multiple
areas including but not limited to general surgery, internal medicine,
emergency medicine, and primary care. The staffing increase accompanied
a 31 percent increase in outpatient visits from FY 2008 through FY
2010, and an overall increase of 6 percent in unique Veterans served.
During this same period, the Iron Mountain VAMC treated 54 percent more
OEF/OIF/OND Veterans.
Telehealth Programs
We have made significant investments in our telehealth programs and
have seen remarkable growth in terms of Veterans utilizing these
services. Telehealth uses information and telecommunication
technologies to provide health care and increased access to care. It
refers broadly to any encounter that involves the use of information
and telecommunications technologies to deliver services in situations
in which patient and health care provider are separated by geographical
distance. VISN 12 was the first Network in VA to implement diagnostic
telepathology, and it has been used between the Iron Mountain and
Milwaukee VA Medical Centers since 1996, allowing the Iron Mountain
VAMC access to multiple pathologists.
Expanded telehealth services have brought specialty expertise to
Veterans in the Upper Peninsula. In FY 2010, we provided specialty care
through telehealth to 1,631 Veterans and we expect to increase that
number to more than 2,500 Veterans in FY 2011. This program has seen a
400 percent increase since 2008. More than half of these Veterans will
only have to travel to the nearest CBOC to receive this specialty care.
Work is progressing on the development of additional clinics including
audiology, speech, spinal cord injury, and anesthesiology for pre-
surgical clearance of Veterans receiving surgical procedures in
Milwaukee, and a nephrology clinic that is scheduled to begin June 27,
2011. Current projections are that there will be more than 6,800
encounters completed in these programs in FY 2011, exceeding the FY
2011 target by 96 percent.
We initiated a teleretinal imaging program at the beginning of FY
2011. This program is focused on providing timely and convenient
evaluation of retinal degeneration related to diabetes. Through May
2011, 109 patients had retinal images taken and forwarded to
specialists at the Madison VAMC for evaluation.
Delivery of Mental Health Care
Mental health care is a critical component to overall health, and
we understand the importance of ensuring Veterans can access this care.
We have added 45 mental health providers over the last 5 years, which
has improved the ability of Veterans to seek appointments and receive
the evidence-based treatments they need. Mental Health staff (social
worker and psychologist) is available for outpatient psychotherapy at
every CBOC but Ironwood where a social worker is available.
Telepsychiatry services are provided to Sault Ste. Marie, Manistique,
Menominee, Rhinelander, Ironwood, and Iron Mountain. New FY 2010 and FY
2011 outpatient services include a Veterans Consumer Board, E-RANGE,
Veterans Justice Outreach, Health Promotion/Disease Prevention, Peer
Support Programming, and Homeless Programs (Housing and Urban
Development-VA Supportive Housing, Short-Term Contract Housing, and
Aging and Homelessness Program). In FY 2010, we provided mental health
care to 3,217 Veterans through 31,000 encounters. This is more than
twice as many Veterans as received care from Iron Mountain VAMC mental
health programs in FY 2006.
VA ensures that treatment of mental health conditions includes
attention to the benefits as well as the risks of the full range of
effective interventions, with emphasis on all relevant, evidence-based
modalities, including psychopharmacological care, psychotherapy, peer
support, vocational rehabilitation, and crisis intervention. VA is
focused on providing patient-centered, effective care by ensuring that
when there is evidence for the effectiveness of a number of different
treatment strategies, the choice of treatment should be based on the
Veteran's values and preferences, in conjunction with the clinical
judgment of the provider. We have integrated mental health care
delivery into the primary care setting to improve access and reduce the
stigma that some perceive in seeking mental health care. The two
exposure-based psychotherapies for which evidence has found an
especially strong support for treatment of post-traumatic stress
disorder (PTSD) are cognitive processing therapy (CPT) and prolonged
exposure (PE). VA has trained more than 3,400 clinicians nationwide in
the use of these treatments. Currently, we have certified seven
clinicians and we are in the process of certifying 12 additional
clinicians at the Iron Mountain VAMC in these treatments. Additional VA
endorsed evidenced-based psychotherapies include Acceptance and
Commitment Therapy (ACT), Social Skills Training, Cognitive-Behavioral
Therapy-Depression (CBT-D), Cognitive-Behavioral Therapy-Insomnia (CBT-
I), and Motivational Interviewing. We have 12 additional providers
either certified or in process of completing these certifications.
Recruitment and Retention of Mental Health Professionals
The Iron Mountain VAMC Behavioral Health Service has grown
tremendously over the last 5 years. Historically, recruitment of
qualified psychologists has been a challenge. Our current staff of 14
psychologists is the largest single group in the Upper Peninsula of
Michigan. Due to the rural setting, most staff recruited to the
Department moved to the area from some distance. The poor housing
market has adversely impacted many qualified providers' ability to sell
a home and move to the area. Recruitment and retention funding has been
used to offset costs of moving to a rural region, which has increased
our ability to bring on and keep qualified providers. Additional
efforts at retention include utilization of the Student Loan Repayment
Program for psychologists, but recruitment of qualified onsite
psychiatry remains a challenge.
ORH Funded Mental Health Programs
With decreasing community mental health services available in the
Upper Peninsula of Michigan, the E-RANGE team was established in
Manistique to serve Veterans with seriously mental illness (SMI) in the
Eastern Upper Peninsula (Marquette and Escanaba to the West, Sault Ste.
Marie to the East). With one full-time social worker, one part-time
social worker, one RN, and one peer support specialist, the E-RANGE
team serves Veterans with mental health needs that cannot be met by
typical outpatient psychotherapy and psychiatry. While stationed away
from the Iron Mountain VAMC, the staff members utilize CBOCs community
agencies (as available) for primary care and mental health (psychiatry)
services. Assisting with medical and mental health care, social skills
training, and recovery programming, the E-RANGE program has made a
significant impact in the quality of life and medical health of our
rural Veterans living with serious mental illness. For example,
significant improvements in medical (e.g., improved glucose control),
social (e.g., stabilized housing and community involvement), and mental
health (e.g., medication compliance and significant reduction in
psychiatric hospitalizations) have been attained. ORH funding has been
utilized to expand CBOC space in anticipation of adding additional E-
RANGE teams as funding is available. Current challenges include
significant driving distances (7,500-8,000 miles per month), decreasing
community-based resources, limited recovery and recreational activities
available in rural regions, limited support from community hospitals,
and maximized enrollment.
ORH funding is being used to provide biofeedback training and
machines to each CBOC and the Iron Mountain VAMC. Biofeedback devices
and stand-alone computers for data processing have been issued to each
site, and the psychologists have completed the initial certification
training. The trained psychologists continue to meet as a team for
biofeedback program development. The addition of biofeedback to our
Behavioral Health Service offers increased treatment options for
Veterans living with anxiety, chronic pain, and hypertension, as well
as many other medical and mental health conditions.
Telemental Health Program
Iron Mountain has been one of the Nation's leaders in
implementation of telemental health services. Currently, we employ two
full-time psychiatrists and one part-time psychiatrist who are
physically located at other VA and non-VA facilities and provide
telepsychiatric services to the Medical Center and CBOCs. Our two full-
time onsite psychiatrists and one part-time onsite psychiatrist
provides telepsychiatric services to our CBOCs on a regular and as-
needed basis. Since FY 2010, we have successfully operated a
telepsychiatry substance abuse/addiction clinic with Madison VAMC. We
are in process of hiring a part-time addiction psychiatrist, who will
provide teleaddiction services to the Iron Mountain VAMC and CBOCs. In
2008, we averaged approximately 75 unique telepsychiatry appointments
per month; currently, we are averaging 650 unique telepsychiatry
appointments a month. Additional teleservices provided by Behavioral
Health staff include: emergency clinic coverage, PTSD groups, gender-
specific psychotherapy, evidence-based psychotherapies, and staff
training and education. Current challenges include scheduling,
coordinating care, supporting staff, managing cases, and balancing
between the critical need for onsite services and demand for increased
teleservices.
Escanaba Vet Center
Vet Centers are another venue through which VA provides Veterans
with necessary counseling and support. Vet Centers provide community
outreach, professional readjustment counseling for war-related
readjustment problems, and case management referrals for combat
Veterans. Vet Centers also provide bereavement counseling for families
of servicemembers who died while on Active Duty. In the Upper
Peninsula, VA operates the Escanaba Vet Center, and in FY 2010,
provided readjustment counseling services to 390 Veterans and their
families (3,071 encounters). Mobile Vet Centers provide outreach and
direct readjustment counseling at active military, Reserve, and
National Guard demobilization activities. Since beginning operation in
2009, the Escanaba Mobile Vet Center has completed 50 outreach events.
The Iron Mountain VAMC Behavioral Health Service provides face-to-face
and telesupervision to Vet Center staff. Teleconferencing is available
at the Vet Center for clinical (psychiatry) and administrative
(supervision) needs. Additionally, Iron Mountain VAMC has initiated
peer support programming in collaboration with Vet Center staff to
develop a Co-Occurring Recovery Program located at the Escanaba Vet
Center.
Home-Based Primary Care
Not all Veterans are able to routinely travel to see their primary
care provider at the Iron Mountain VAMC or the nearest CBOC. In FY
2008, the Iron Mountain VAMC started a Home-Based Primary Care program,
and we added an additional location in FY 2009 in Watersmeet, Michigan.
These programs take primary care to the patient's home, expanding
access to care and benefits, and providing health education to this
unique Veteran population. The two programs have made tremendous
progress since they opened and have served more than 200 Veterans. The
Veterans served by these programs have seen a 16.9 percent reduction in
inpatient admissions and a 76.3 percent reduction in inpatient bed days
of care. There are currently 74 Veterans enrolled in the Home-Based
Primary Care program. Through May 2011, 118 Veterans have received care
through this program. This is more than three and a half times the
number that were cared for in 2008 when the program started.
Partnerships with Community Providers
We provide exceptional care in the VA system, but understand there
are times when a Veteran needs services that are not available in our
facilities. As a result, we maintain robust partnerships with a range
of community providers to ensure Veterans receive the care they have
earned. These partnerships include collaborations with other
governmental organizations, as well as with the private sector. We also
utilize community providers in the private sector to deliver care to
Veterans in the community.
Iron Mountain remains committed to providing the care Veterans
deserve not only from our main facility and related CBOCs but also by
purchasing care from Upper Peninsula and Northern Wisconsin facilities
and providers. We purchased over $12 million worth of care in FY 2008,
$18 million in FY 2010, and we are on pace to purchase $16 million
worth of care this fiscal year. Currently, we have six fee basis
providers from within the community to supplement care in areas such as
ophthalmology, orthopedics, general surgery, podiatry, and behavioral
health.
As previously mentioned, Iron Mountain has a passenger bus that
travels to the Milwaukee VAMC two times a week. The bus is used to
carry enrolled Veterans and their caregivers to specialty care
appointments. It has the capacity to carry 35 passengers, and the
average number of travelers per trip is 25. We have an ambulance
contract with a local ambulance company that is utilized to transfer
and pick up patients to and from other facilities as needed for care.
We also have a contract with a local company to provide transportation
services for those enrolled Veterans that do not require an ambulance
to be used to transport them.
We coordinate with all VISN facilities to transfer patients who
need services and care we cannot provide. If VISN facilities are not
available, we utilize Dickinson County Health care System in Iron
Mountain; Bellin, St. Vincent, Aurora Bay Care and St. Mary's in Green
Bay, Wisconsin; and Marquette General Hospital in Marquette, Michigan.
For Behavioral Health issues we utilize Milwaukee VAMC, Tomah VAMC,
Madison VAMC, Battle Creek VAMC, and at times Marquette General
Hospital and War Memorial Hospital in Sault Ste. Marie, Michigan.
For pharmacy coverage after hours, we utilize the pharmacy staff at
the Milwaukee VA to review all orders. Pharmacy is staffed at the Iron
Mountain VAMC from 7 am until 10 pm.
We recently accepted a bid from Dickinson County Health care System
to dock our magnetic resonance imaging unit at their campus until the
construction of the second floor of our outpatient department is
completed. We began using our MRI at that location earlier this month.
We have purchased care agreements in place with local hospitals for
each CBOC to complete mammograms and any urgent diagnostic tests. In
Iron Mountain, we utilize Dickinson County Health care System and the
local Marquette General outpatient clinic for mammograms, the Veteran
decides where they prefer to go. We have a telehealth contract to
provide services to read x-rays, computed tomography images,
ultrasounds, and other radiological studies on off-tours and weekends.
Using ORH funds, the Home- and Community-Based Care program was
significantly expanded. We purchased services from approximately 50
home health agencies and other community providers in our service area
to provide care to our enrolled Veterans. The program went from serving
111 unique Veterans in FY 2008, to 418 in FY 2009, and 456 in FY 2010.
This initiative targets Veterans who are most at risk for institutional
long-term care and helps them function as independently as possible in
the comfort of their own homes. When necessary, we collaborate with 10
local community nursing homes and one adult day care to provide
services for Veterans that permit them to be close to family and
friends.
Conclusion
Thank you again for the opportunity to discuss the work VA is doing
to improve access and quality care for Veterans in the Upper Peninsula
of Michigan. I am proud of the work the employees at the Iron Mountain
VAMC and its CBOCs do every day to deliver the best health care
possible to America's Veterans. My colleagues and I look forward to
answering your questions.