[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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67-194 PDF                       WASHINGTON : 2011 

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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?

                              ----------                              


                         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.

                                 
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