    [House Hearing, 113 Congress]
    [From the U.S. Government Publishing Office]

      CHALLENGES IN RURAL AMERICA: INFRASTRUCTURE NEEDS AND ACCESS TO CARE

    =======================================================================

                                    HEARING

                                   before the

                         COMMITTEE ON VETERANS' AFFAIRS
                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED THIRTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                           THURSDAY, AUGUST 14, 2014

                                   __________

                               Serial No. 113-84

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

             Available via the World Wide Web: http://www.fdsys.gov

                                     ______

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    96-127                         WASHINGTON : 2015
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                         COMMITTEE ON VETERANS' AFFAIRS

                         JEFF MILLER, Florida, Chairman

    DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking
    GUS M. BILIRAKIS, Florida, Vice-         Minority Member
        Chairman                         CORRINE BROWN, Florida
    DAVID P. ROE, Tennessee              MARK TAKANO, California
    BILL FLORES, Texas                   JULIA BROWNLEY, California
    JEFF DENHAM, California              DINA TITUS, Nevada
    JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
    DAN BENISHEK, Michigan               RAUL RUIZ, California
    TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
    MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
    BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
    PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
    JACKIE WALORSKI, Indiana
    DAVID JOLLY, Florida
                           Jon Towers, Staff Director
                     Nancy Dolan, Democratic Staff Director

    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

                                  ----------

                           Thursday, August 14, 2014

                                                                       Page

    Challenges in Rural America: Infrastructure Needs and Access to
      Care...........................................................     1

                               OPENING STATEMENTS

    Jeff Miller, Chairman............................................     1
        Prepared Statement...........................................    50
    Gus Bilirakis, Vice Chairman.....................................     4
    Kristi Noem, Congresswomen From: South Dakota....................     5

                                   WITNESSES

    Bryan Brewer, President, Oglala Sioux Tribe......................     8
        Prepared Statement...........................................    52

    Tim Jurgens, Commander, American Legion Department of SD.........    10
        Prepared Statement...........................................    55

    Robert Nelson, Veteran...........................................    12
        Prepared Statement...........................................    73

    Amanda Campbell, Community Stakeholder...........................    14
        Prepared Statement...........................................    89

    Patrick Russell, Co-Chair, Hot Springs Safe the VA Committee.....    15
        Prepared Statement...........................................    98

    Larry Zimmerman, Secretary, Department of Veterans' Affairs,
      State of SD....................................................    17
        Prepared Statement...........................................   116

    Steven Julius M.D., Chief Medical Center and Acting Director,
      Veterans Integrated Service Network 23, VHA, U.S. Department of
      Veterans' Affairs..............................................    30
        Prepared Statement...........................................   116

        Accompanied by:
            Stephen DiStasio, Director, VA Black Hills Health Care
                System, Veterans Integrated Service Network 23, VHA,
                U.S. Department of Veterans' Affairs

      CHALLENGES IN RURAL AMERICA: INFRASTRUCTURE NEEDS AND ACCESS TO CARE

                                  ----------

                           Thursday, August 14, 2014

                Committee on Veterans' Affairs,
                         U.S. House of Representatives,
                                                       Washington, D.C.
        The committee met, pursuant to notice, at 10:05 a.m., at
    the Mueller Civic Center, 801 South 6th Street, Hot Springs
    South Dakota, Hon. Jeff Miller [chairman of the committee]
    presiding.
        Present:  Representatives Miller and Bilirakis.
        Also Present: Representatives Noem and Smith.

               OPENING STATEMENT OF CHAIRMAN JEFF MILLER

        The Chairman. The committee will come to order.
        Before I begin, I'd like to take care of one minor
    procedural detail. I ask unanimous consent that Congresswoman
    Kristi Noem and Congressman Smith be allowed to sit at the dais
    today and participate in the hearing. Without objection, so
    ordered.
        Good morning, everybody, and thank you for joining us this
    morning. I am Jeff Miller, Chairman of the House Committee on
    Veterans' Affairs. I come from the panhandle of Florida where
    thousands live like millions wish they could.
        The Chairman. I have never been to South Dakota. What a
    beautiful State. Thank you so much for your warm hospitality.
    It is a pleasure to be here with you today.
        I am joined by the vice chairman of the full committee,
    another Floridian, Congress Gus Bilirakis, from the 12th
    district of Florida and, of course, I have already said
    Congressman Adrian Smith from the 3rd district of Nebraska and
    your Congresswoman and my good friend, Kristi Noem, from right
    here in South Dakota.
        The Chairman. I think it is important that you know that
    Kristi is known in Washington as a leader, and this field
    hearing is being held today because Kristi asked us to come
    here and hold this field hearing. It is important to note that
    she has been involved in the issue in regard to your facility
    here in Hot Springs from the very beginning, and when it comes
    to veterans affairs issues, she is not shy about coming up to
    me on the floor and talking about the issues that affect her
    constituents here in South Dakota.
        Earlier this morning, I was able to have a tour of the Hot
    Springs campus so we could see the facility. Firsthand I will
    tell you this--I had not heard about this facility until Kristi
    brought it to my attention several months ago. The first thing
    I did was go to the Internet and start looking at photographs.
    The photographs do not do it justice. What a beautiful and
    wonderful historic facility.
        The Chairman. It is very clear that this community and that
    facility have a storied past, taking care of those that have
    worn the uniform of this Nation, and it is our hope that some
    way, somehow we will find a way to continue that storied
    history that is held within the walls of that magnificent
    structure.
        So, again, thanks to you all for being here today. Thank
    you again. Let me say this before we start. If you are able to
    stand, please stand, anybody who has worn the uniform and is a
    veteran of this country. If you cannot stand, just wave to us,
    but I would like to recognize the veterans in this audience
    today.
        The Chairman. Thank you very much for your service. Again,
    we are here today to ensure that you receive the quality health
    care in a timely fashion that you have earned by wearing the
    uniform of this country. I know the Black Hills Health Care
    System, which has campuses in Fort Meade and here in Hot
    Springs, has the same desire, and that is to provide you the
    quality health care that you expect and certainly you have
    earned.
        I just want to give a little background, if I can. In
    April, you know that the House Committee on Veterans' Affairs
    was able to break open, unfortunately, what is probably one of
    the largest crises that has ever happened within the Department
    of Veterans Affairs and maybe even the Federal Government. We
    found that VA employees were actually manipulating wait time
    schedules. Unfortunately, we have had veterans who have died
    because of those manipulations. And unfortunately, VA still has
    a long way to go to correct that wrong that was perpetrated on
    you.
        I have pledged to the new Secretary, Secretary McDonald,
    that our committee will, in fact, work as a partner with him in
    trying to help restore the trust in VA that you would want to
    have and you would expect to have. But I have also told him
    that we will not give them a honeymoon period, if you will,
    because our oversight continues, oversight of the second
    largest agency in the Federal Government, over 330,000
    employees and a budget of over $150 billion a year.
        I think that it is important to understand that the veteran
    is sacred, not the VA. And that is what I think you would want
    us as Members of the United States Congress both in the House
    and the Senate to feel as we have conducted a very aggressive
    schedule of oversight hearings in the House in particular. You
    may have caught us on Monday evenings for some late night
    hearings that started at about 7:30. Some went to 1 o'clock in
    the morning trying to get VA to come forward and be as
    transparent as they possibly could in trying to get to the
    bottom of this issue. We wanted them to explain to us some of
    the initiatives that they have undertaken to try to fix the
    backlog that exists out there not only when it comes to
    provision of health care but also the process of disability
    claims and the processing problems that exist there.
        VA will claim that they have cut the backlog in half. To be
    very honest with you, I do not trust those numbers. I would
    certainly expect that there are many of you that would feel the
    very same way. While they may have rushed some things out the
    door in an attempt to cut that number down, what they did was
    they actually adjudicated some incorrectly and they also sent
    you into the appeals process which, of course, comes off of
    their books and does not count as a backlog claim, but for you
    the veteran, it is certainly claimed.
        You know that the President signed last week a landmark
    piece of legislation that for the first time I think will
    change the way that VA provides health care. They continue to
    try to provide it the way that they did in the 1950's and the
    1960's, but things have changed. Certainly the younger veterans
    of today from Iraq and Afghanistan understand that health care
    is delivered differently. Those of you from wars and conflicts
    prior to that or even in peacetime understand things are
    delivered in a different way. We have got to meld them together
    if we possibly can.
        We reformed in a very small way a couple of things. Number
    one, we gave VA the ability to hold managers accountable. If
    they do not do the right thing, they should be able to be
    fired.
        The Chairman. There are very few people, up until the law
    was signed, that the Secretary could actually fire at will.
    Now, out of the 330,000, we actually have added another 450.
    That is a first step. Accountability is important.
        Transparency is important. VA needs to tell the truth.
    There is no reason that they should hide news, even when it is
    bad. They should bring that news forward so that each and every
    one of us understands what is going on at VA.
        I think thirdly what this bill did was give the ability to
    look from the bottom up within VA, a true look at how VA
    delivers the services and the benefits that you have earned and
    from an outside perspective, not from within VA. VA is very
    good at trying to analyze itself and then putting forth the
    best picture possible that they can. This will be done by an
    independent group or groups over the next 9 months.
        I will tell you this. Not one law that Congress creates
    will change the culture within VA. That has to be done within
    individuals. They cannot continue to have a culture of what I
    call corruption, what the White House calls corrosive. Same
    thing. They have to do the right thing in serving the veterans
    of this country.
        Here in Hot Springs, I know that you have been faced with
    an issue now for a number of years, and we are going to take
    testimony this morning as to what the community thinks, what
    the veterans think, and certainly we will hear from VA this
    morning as well. We have heard from VA about the significant
    issues that they have to contend with. But in a community like
    yours, I will say this, that it is important for the community
    to be involved, and to see this many people turn out today is a
    true blessing for this community and to see the signs in all
    the local businesses. I have got to say thank you to Kristi and
    her staff and the other members that are here today.
        I would also ask unanimous consent before we begin. Both
    Senators have asked that they have statements entered into the
    record. So without objection, that will be done.
        The Chairman. You have a Senator who is the chairman of the
    Appropriations Committee that could help you in this issue. You
    should talk to him about it. It is very important. I would
    think he should be here, if he could, if not today, certainly
    at another time to talk to you about this issue that is so
    important.
        With that said, I want to recognize the vice chairman of
    the full committee, Mr. Bilirakis, for his opening statement.

        [The prepared statement of Jeff Miller Appears in the
    Appendix]

            OPENING STATEMENT OF VICE CHAIRMAN GUS BILIRAKIS

        Mr. Bilirakis. Thank you, Mr. Chairman. And I will be very
    brief.
        But I do want to thank you, Mr. Chairman, because you are
    responsible for these reforms. The bill that passed this last
    month came out of our committee.
        And I will tell you this. You have an outstanding
    Congressperson in Kristi Noem. She is so very well respected on
    both sides of the aisle in Washington, DC. And she is fighting
    for you, particularly for our true American heroes, our
    veterans.
        So I do have a brief statement, Mr. Chairman.
        Thank you, Mr. Chairman, for holding this important field
    hearing to ensure that VA has the capacity to provide veterans
    quality health care in the VA Black Hills Health Care System.
        I would also like to thank all of the members of the
    community who gather here today to address the concerns and
    challenges that veterans in rural areas face so we can work
    towards improving these issues. I look forward to hearing from
    local veterans and stakeholders in the community on their
    views, opinions, and concerns on the current VA health care
    system and how we can better provide quality health care for
    our veterans. That is the bottom line.
        And you know, we are U.S. Representatives. We not only
    represent our district but the entire United States. So we will
    fight on your behalf.
        It is my understanding that many veterans must travel 100
    miles or so to your nearest VA hospital, and once you arrive,
    you are troubled to find that the hospital does not provide the
    services you need. I want to address these issues today so that
    we can find effective solutions to provide for each of our
    veterans' unique needs and improving a system that can benefit
    each one of our Nation's true American heroes. South Dakota has
    a longstanding history of health care and support for our
    veterans, with facilities provided for over 107 years. What
    beautiful facilities they are too. I was very impressed with
    the services you provide here. We must keep them here. With the
    expectation for both rural and highly rural veterans to
    increase, it is imperative that veterans continue to have
    access to these facilities and services.
        I remain hopeful that through our hearing here today we can
    find the right path forward that best suits the needs of our
    veterans and this community. I look forward to hearing the
    testimonies, and I thank you very much. What a beautiful place
    this is. Thanks for having us here today.
        I yield back.
        The Chairman. I now recognize your Congresswoman, Kristi
    Noem, for a brief opening statement as well. Kristi?

                 OPENING STATEMENT OF HON. KRISTI NOEM

        Ms. Noem. Well, thank you, Mr. Chairman. It is a good day.
    I am glad we are all here, and I am glad to see all of you here
    as well.
        I want to, first of all, thank the chairman for coming and
    for having this congressional hearing, Representative Bilirakis
    for coming and traveling so far as well, as well as
    Representative Smith who has constituents that are impacted by
    the proposed closure of this facility as well.
        Welcome to the veterans' town. Hot Springs has always been
    known in South Dakota as the veterans' town. The entire town
    wraps its arms around our veterans, cares for them, helps heal
    them. It is not just about buildings. It is not just about
    doctors and nurses. It is about coming to a place where
    everyone loves you, appreciates your service to this Nation,
    cares for you, and wants you to be healed and as well as you
    ever were at one point in your life.
        The Hot Springs VA Hospital has been slated for closure
    ever since the Department of Veterans Affairs announced a plan
    to realign the Black Hills Health Care System in 2011. For
    nearly 3 years, the tristate delegation has worked together and
    had a number of serious conversations and also serious
    reservations regarding that plan.
        I am very appreciative of your willingness to hear from the
    Hot Springs community, the veterans who are served from this
    hospital. We have some of them testifying today. Their
    perspective cannot be left out of this conversation.
        I have been very troubled by the VA's disregard of
    stakeholder grievances. I am also very concerned about the data
    that they have been using that has justified the hospital's
    closure, and I believe it is incorrect. I have seen
    overwhelming evidence of data discrepancies, including a very
    concerning cost-benefit analysis that was conducted last year.
    Additionally, there appears to be a systematic dismantling of
    services at the hospital.
        [Applause.]
        Ms. Noem. I believe that the true potential of this
    hospital has not been reached and that the services that our
    veterans deserve must return to Hot Springs immediately.
        [Applause.]
        Ms. Noem. Late last month, the VA released the findings of
    an audit that the VA conducted of the Black Hills Health Care
    System. I was very disappointed to see that the Black Hills
    Health Care System had considerably lower marks than other
    hospitals that were in the area and the national average. These
    numbers are unacceptable. I believe that the VA must address
    those numbers and those statistics by bringing services back to
    Hot Springs and ensuring that veterans are receiving the care
    that they deserve.
        I know that there are many other issues surrounding the Hot
    Springs VA, including the environmental impact statement
    process, the National Environmental Policy Act, or NEPA,
    compliance, costs for mothballing the facility, the restriction
    of access that Native American veterans would face if the Hot
    Springs facility were closed, and the potential for mental
    health treatment at the facility.
        I look forward to all of the witnesses and the wisdom and
    perspective that they will share with us throughout this
    committee hearing.
        I know in South Dakota that many veterans are satisfied
    with the care that they get because we have got good people
    here in South Dakota that grew up here helping to take care of
    them. We are very blessed to have them to care for those who
    have earned the distinction of being called a veteran. However,
    given recent reports of VA scandals and audit findings, I do
    not think it is appropriate to move forward with closing a
    facility that the veterans rely on.
        [Applause.]
        Ms. Noem. So ensuring that this facility is able to
    continue serving the men and women who have worn America's
    uniform is on my top priorities.
        I again thank Chairman Miller for holding this critical
    hearing as the community fights to restore the Hot Springs VA
    facility to full service so we can properly serve those
    veterans who have so honored us by serving us. Thank you.
        The Chairman. I now recognize Congressman Adrian Smith for
    his opening statement. Adrian.
        Mr. Smith. Thank you, Mr. Chairman. Thank you, Mr. Vice
    Chairman Bilirakis. Thank you to everyone who has shown up here
    today.
        I am grateful to have the opportunity to represent part of
    Nebraska in the United States House of Representatives and
    certainly representing more specifically the veterans who have
    so sacrificially served, as well as their families who have
    supported our veterans along the way as well.
        I want to thank our witnesses here. I appreciate the
    opportunity to work with you along this journey. It has been
    quite a journey, and I am grateful that we can interact so
    positively and hopefully bring about a positive result in
    standing behind I think not just the building, not just
    individuals one at a time, but perhaps that is the case too,
    but this community, this community of veterans. I have to think
    that the community--and when I say ``community,'' I actually
    kind of mean a three-State area, if you will, Mr. Chairman.
        In fact, how many are here today from Nebraska? Do you want
    to raise your hands?
        Mr. Smith. Very good.
        Maybe even some folks from Wyoming. Any folks from Wyoming
    as well? Okay. There we go.
        Mr. Smith. We know that there was an official announcement
    on December 12th, 2011 when the VA announced its plans to
    reduce the services at Hot Springs, moving all inpatient
    services to Rapid City. I immediately sent a letter to former
    Secretary Shinseki expressing disappointment and concern with
    the proposal. And, of course, we know that services have been
    changing in a less than positive fashion even prior to December
    of 2011. Specifically, I was concerned, following this
    announcement, it would jeopardize access to care of thousands
    of veterans, many of whom reside in the 3rd district of
    Nebraska.
        I have since sent or signed onto seven additional letters
    regarding this proposal. Reducing services at Hot Springs and
    requiring many rural veterans from Nebraska to drive upwards of
    6 hours round trip for care will cause many to not seek or
    delay seeking the services they need. It will put an
    unnecessary burden on their families who help transport and
    care for them. Rural veterans already find it increasingly
    difficult to access the care they require. Approximately 3.4
    million veterans, 41 percent of the total enrolled in the VA
    health care system, live in rural or highly rural areas of the
    country.
        I have appreciated the VA's cooperation with my and my
    colleagues' requests to hold additional meetings and delay any
    final decisions. And I appreciate former Secretary Shinseki
    agreeing to meet with the Save the VA Committee per our
    request.
        But I remain concerned that this is not enough and the VA
    has not fully and transparently addressed these concerns that
    we have expressed. Reducing services at Hot Springs will reduce
    services for our veterans who have already sacrificed so much.
    At a time when we are working so hard to improve access,
    increased transparency and accountability within the VA and
    improve the quality of care, this proposal simply does not make
    sense.
        Again, I appreciate the community support here today. I
    have to think that community support and accountability like
    this would prevent other problems in the VA that we have seen
    in other parts of our country.
        So, again, I want to thank Chairman Miller. Thank you for
    holding this hearing today and also everyone else who has
    worked so hard to preserve access to care here in Hot Springs,
    South Dakota. Thank you. I yield back.
        The Chairman. We are going to begin the hearing today with
    a group of witnesses that are already seated at the table, and
    in just a minute, I am going to recognize Kristi to introduce
    the witnesses at the table.
        But before, I would like to give you an idea of how a
    congressional hearing works. Each person will be given 5
    minutes for their opening statement. There is a little clock
    right in front of me. It has some lights on it. As long as that
    green light is on, you are good to go. When you get to the
    yellow light, some people say it is a minute. Some people say
    it is 30 seconds, but understand it is kind of time to wrap up.
    When it gets to red, that means, obviously, time is up. When it
    starts blinking, I have no idea what is going to happen.
        [Laughter.]
        The Chairman. Look, if it goes to red and it blinks a
    little bit and you have more to say, don't you worry about a
    thing. All right? We want to hear from you.
        Can I ask a favor? Do you mind if I take my coat off? Is
    that okay? All right. Guys, if you want to take your coats
    off----
        The Chairman. It is going to get hot.
        Kristi, you are recognized to introduce the folks that are
    here on our first panel. Thank you very much.
        Ms. Noem. Thank you, Mr. Chairman. I am very proud to have
    the witnesses here today seated at the first panel.
        First to testify will be President Bryan Brewer, who is
    President of the Oglala Sioux Tribe, who represents many
    veterans. And I appreciate his input throughout this entire
    process.
        We also have Commander Tim Jurgens here. He will be
    speaking on behalf of the American Legion, and we appreciate
    their leadership on this issue as well.
        Mr. Bob Nelson will be speaking as a veteran but also as an
    integral part of the Save the VA Committee. So I have always
    appreciated his candid conversations that he has had with me as
    well.
        Amanda Campbell will speak as well. She has been a very
    important part of the Save the VA Committee. She has worked
    through the EIS process and lends a lot of information and
    wisdom to that process, and we really appreciate her insight
    and ability of her to testify here today.
        Pat Russell will speak after Amanda. Pat has been a
    spokesperson for the Save the VA Committee, a very important
    one that has done a very fine job of coming to Washington, DC
    and articulating the concerns and the facts around the proposal
    that the VA has put forward and how the community feels and
    what their heart is on the issue.
        Last we have Larry Zimmerman who will be speaking as well.
    He is South Dakota's Secretary of Veterans Affairs, and if
    there are any veterans' issues going on in South Dakota,
    Larry's heart is there and he shows up and always gives us his
    perspective.
        So I would ask that all of you share your thoughts, your
    hearts, and your minds on this proposal and your perspective.
    It will be very beneficial to all of the members here today on
    the committee, and we certainly appreciate you being here.
        The Chairman. Thank you very much, Kristi.
        And again, all of your written comments will be entered
    into the record as is the custom of our committee. We are
    grateful that you would be here to testify today.
        Mr. President, President Brewer, you are recognized for
    your opening statement.

                       STATEMENT OF BRYAN BREWER

        Mr. Brewer. Good morning. [Speaking native language.] My
    name is [speaking native language.] My English name is Bryan
    Brewer, and I am President of the Oglala Sioux Tribe and I
    represent approximately 40,000 people on our reservation. Today
    I am also speaking for the Sicangu Nation of Rosebud and also
    the Cheyenne River Sioux Tribe.
        I am also a veteran. I served in Vietnam from--I was in the
    service from 1965 to 1969. I served three tours as a Navy
    Seabee. I am a combat veteran. And I am also a disabled
    American, and I use the facilities here at Hot Springs. I have
    been using the facilities here for over 15 years, and it is
    something that we all cherish our times when we come up here.
        I am aware of the recent concerns nationally regarding the
    VA health care system. You know, most of the health care that I
    needed--they all have been provided. Everything that I needed I
    could get here. There is a specific care that could not be
    handled here. I was sent to various other places, to Sturgis. I
    went to Omaha once and they flew me to Minneapolis one time. So
    the care is here. We need to utilize it.
        While it maybe seems isolated, it serves veterans beyond
    South Dakota and many from our sister Lakota tribes of the
    Cheyenne River and Rosebud. Over the years, I have met veterans
    from Wyoming, Montana, Nebraska, North Dakota, and sometimes
    beyond depending on what services they have come to receive. So
    this facility is crucial to the veterans in this entire region.
        One of my big concerns is that the numbers of the Lakota
    veterans--and I seen a letter that was sent to Senator Tim
    Johnson, and our numbers were not included in that, the Lakota
    veterans.
        As you are aware, there is a current memorandum of
    understanding between the VA and the Indian Health Service to
    encourage cooperation and resources between the two
    departments. While this partnership has been shown to work well
    for our sister tribes in other parts of the country, the
    preference for local American Indian veterans is to get their
    health care from the Hot Springs VA. Here we are consistent
    with our health care providers, quick responsiveness to our
    arising health issues, trust in confidentiality in our provider
    and patient exchanges, and for the most part, appointments are
    timely and prompt.
        As outlined in the 2010 report on IHS by former Senator
    Byron Dorgan, IHS in the Aberdeen area struggles and has a
    difficult time to meet the basic health needs of its patients.
    The VA recognizes that we as veterans have very unique health
    care needs and works hard to provide services to address those
    needs. For many reasons, IHS is an overwhelmed system and is
    not equipped to address the very precise and delicate nature
    and delivery of care that veterans require.
        One example of care veterans require is the treatment of
    post traumatic stress disorder. The PTSD treatment center here
    at the Hot Springs VA has the reputation of being one of the
    best treatment programs in the country. You know, we need to
    expand this.
        I appreciate the cultural competency and sensitivity of the
    staff and leadership here at the Hot Springs VA. It is one
    place I can come and I feel I am treated the same as my non-
    Indian counterparts. We are all treated with professionalism.
    We are all treated with dignity and respect. We are all treated
    as all American veterans.
        Over the years, I have seen many American Indians join the
    staff here. The Hot Springs VA supports and encourages the use
    of traditional Lakota practices. We are allowed to use a smudge
    with our medicines, sing our prayer songs, and are supported
    with our inipi, our sweat lodge ceremonies. These are conducted
    by local tribal members. The PTSD treatment program has
    components specifically tailored to the American Indian
    veterans. And I would like to thank Richard Galliani for all
    that he has done with our Lakota patients here.
        Culturally for the Lakota, the Hot Springs area has
    significance in regards to the healing properties and being a
    place to collect some of our traditional Lakota herbs and
    medicines. Located near Hot Springs, Wind Cave is a sacred site
    to us Lakota. It marks the place where we emerged from Mother
    Earth to the outside world. In a recent letter written to newly
    appointed Secretary Robert McDonald, delegates stated in that
    letter, ``For more than 100 years, veterans however been coming
    to Hot Springs to receive health care.'' We can appreciate this
    historical significance, as our ancestors have been coming to
    the Hot Springs area for thousands of years. For us Lakota, it
    makes sense that this area with is beauty and healing powers
    would be where a VA facility would be built.
        To date, there has never been a census of the veterans on
    our reservation. We estimate that there are over 3,500 Oglala
    Lakota veterans on our reservation. And we know that not all
    these veterans currently utilize the VA. Some are unaware of
    the services that they have a right to access. Locally we have
    partnered with the Disabled American Veterans and the American
    Legion to help inform and recruit veterans to use the VA. Our
    hope is by increasing the amount of veterans to the VA, revenue
    to the Hot Springs VA and overall area will also increase.
        In conclusion, the Hot Springs VA has a long history,
    strong cultural ties, and an undeniable commitment to veterans'
    health. As I sit here today, I think of all the veterans, the
    warriors, the heroes from our communities who passed through
    the walls of the Hot Springs VA. They came here for care, for
    healing, for camaraderie, and some came here for the final
    days. Closing the VA in Hot Springs not only changes the
    landscape of Hot Springs and western South Dakota, it robs
    veterans of the unique and specialized care that have received
    for decades and should receive for decades to come.
        I want to thank all of you. Mr. Miller, Chairman, I really
    want to thank you for coming to South Dakota. Mr. Bilirakis,
    Mr. Smith, and Kristi, I really want to thank you for making
    this all happen today. [Speaking in Native Language.]

        [The prepared statement of Mr. Brewer appears in the
    Appendix]

        The Chairman. Thank you very much, Mr. President.
        The Chairman. I wanted to say thank you in Lakota. I tried
    to look it up on my iPhone but I am not even going to try.
        [Laughter.]
        Mr. Brewer. Pilamiya.
        The Chairman. Thank you.
        Commander Jurgens, you are recognized for 5 minutes.

                        STATEMENT OF TIM JURGENS

        Mr. Jurgens. Thank you, Chairman Miller and members of the
    committee.
        Forty one veterans. That is the projected decline in
    veteran population between now and the year 2020 according to
    VA's own data. 41 veterans.
        With a market penetration 20 percent higher than the
    national average, the Black Hills VA medical service should be
    championed as a model of efficiency, not targeted for
    dismantling. It is clear that veterans in the Black Hills
    catchment area value the use of the VA. Reducing services and
    making VA treatment options more difficult to access violates
    the agreement our Federal Government has made with our Nation's
    veterans.
        Chairman Miller and members of the committee, on behalf of
    our National Commander, Dan Dellinger, and the 2.4 million
    members of the American Legion, thank you for holding this
    important hearing to help the VA and our Government understand
    how critically important it is to maintain the services we have
    here in Hot Springs and not degrade the services our veterans
    have relied on since 1909.
        Last week, the President signed the VA Health Care Access
    and Accountability Act into law. Our National Commander was
    present at the bill signing, and our national staff worked
    closely with your staff over the course of several months to
    ensure that the bill addressed the immediate needs of this
    country's veterans. As you know, that bill contains a provision
    that mandates VA to release veterans from VA-provided care and
    further burdens the Federal Government to absorb the additional
    expense of contracting that same care that the VA is incapable
    of providing in a timely manner.
        The proposed realignment transfers several services
    currently offered at Hot Springs to the Rapid City facility
    while relying on the Fall River civilian community facility for
    additional support at a contracted rate. While the American
    Legion opposes closing the Hot Springs hospital anyway, it was
    interesting and telling that after the VA announced this new
    proposed partnership, the American Legion met with the board of
    directors of the Fall River hospital, and as we have noted in
    our written testimony, no such agreement had been worked out
    and that as of March of this year, they have repeatedly asked
    VA for details regarding any proposed arrangement. But VA never
    responded.
        Realignment of Hot Springs services will disenfranchise
    more than 4,000 veterans. Rapid City is more than 60 miles one
    way from Hot Springs, which means that the vast majority of
    veterans who have services transferred from Hot Springs to
    Rapid City will immediately qualify for and be issued choice
    cards and leave the VA system.
        The American Legion spends tens of thousands of dollars
    annually conducting site visits to VA hospitals around the
    country. Our staff and members have hundreds of years of
    experience working with and for VA. Our members rely on us for
    accurate, meaningful, and timely information, which we
    painstakingly provide. As such, the American Legion has
    presented VA with a list of recommendations that we believe
    will best support our local veteran community and is in the
    best interest of VA.
        VA should not relocate and/or close medical services until
    a new facility is in place or in order to accommodate the
    health care needs of the veterans in Hot Springs catchment and/
    or surrounding areas.
        VA should maintain the same level of care and/or services
    and provide equal understanding of veterans' health care needs
    if contracted to non-VA medical facilities.
        If the VA medical center was to be closed, VA should plan
    to open a super CBOC to provide both primary and specialty care
    services.
        VA should keep the domiciliary on the Hot Springs campus to
    provide long-term extended care to meet veterans' long-term
    care needs.
        The VAMC should search opportunities to make use of the
    State Veterans Home in Hot Springs.
        Future plans should reflect necessary services that
    veterans in the Hot Springs catchment and surrounding areas
    need.
        And finally, without viewing a finalized contract with the
    local hospital in Hot Springs, the American Legion at this time
    cannot ensure reconfiguration of inpatient services will
    provide the same quality care that veterans are currently
    receiving at Hot Springs.
        Every day in America, 82 people take their own life. That
    is one every 17 and a half minutes. 26 percent of suicides are
    veterans. And yet, only 7 percent make up the population. The
    stakes could not be higher. Any degradation of services for
    veterans in this area, especially services associated with
    mental health, would be tantamount to reckless endangerment.
    The mental health of veterans is something the American Legion
    takes very seriously, and we adamantly oppose by resolution
    eliminating or reducing services to veterans in the Hot Springs
    area in any way.
        Thank you. Thank you, Mr. Chairman and the members of the
    committee.

        [The prepared statement of Mr. Jurgens appears in the
    Appendix]

        The Chairman. Thank you, Commander.
        Mr. Nelson, you are now recognized.

                       STATEMENT OF ROBERT NELSON

        Mr. Nelson. Chairman Miller, Vice Chairman Bilirakis,
    Congresswoman Noem, Congressman Smith, welcome and thank you
    for taking the time to come to Hot Springs to hear our concerns
    about the VA's proposed closure of the Hot Springs VA.
        My name is Bob Nelson. I served 4 years in the Navy and
    after my discharge in 1974, I began working at the Hot Springs
    VA Medical Center. After 36 years of serving America's
    veterans, I retired in December of 2012.
        Eighteen years ago, the VA merged two rural VA hospitals
    into the Black Hills Health Care System. That decision has
    eroded medical services and in many cases eliminated available
    services and, as a result, access to care for veterans wanting
    to use the Hot Springs VA. Some of these veterans travel 150
    miles one way from rural and highly rural America and from
    medically under-served areas in southwestern South Dakota,
    northwestern Nebraska, and eastern Wyoming.
        The VA insists the current domiciliary in Hot Springs and
    its associated substance abuse and PTS programs should be moved
    to Rapid City because Rapid City has the largest majority of
    veterans. In fiscal year 2010 and in fiscal year 2011, over 90
    percent of the domiciliary patients came from locations other
    than Rapid City.
        From 2008 through 2011, a total of 448 veterans were in a
    homeless shelter in Rapid City despite an average daily census
    in the Hot Springs domiciliary of only 76 veterans. A daily
    census that is 24 veterans under the authorized daily census
    for the domiciliary. The wait times to get into treatment
    programs in the domiciliary grew from 92 days in fiscal year
    2010 to 157 days in fiscal year 2011. If there is a wait time
    to get into the domiciliary, should it not be because the
    domiciliary is full?
        The cost to have veterans in that----
        Mr. Nelson. The cost to have veterans in that homeless
    shelter from 2008 through 2013 was $3.3 million.
        The VA has said publicly Hot Springs averages five hospital
    inpatients daily, which is insufficient to maintain staff
    proficiency over time and stresses recruitment and retention.
    The number is actually six inpatients, and the VA always
    neglects to mention the four nursing home care unit patients
    that are also on the same ward as the inpatients. The medical
    staff is not taking care of only five patients per day. They
    are taking care of 10 patients per day, twice the number the VA
    uses publicly.
        The VA's own internal audit of the Black Hills Health Care
    System found 14 percent of schedulers at the Black Hills Health
    Care System said they were instructed to change the waiting
    times after a veteran first requested an appointment.
        In December of 2011, the VA's announcement of the proposed
    Hot Springs closure was seen by many veterans as an attempt to
    marginalizes us. They had reduced us to green dots on a Power
    Point slide.
        In spite of these criticisms, veterans that are still able
    to use the Hot Springs hospital echo what other veterans across
    the country are saying. The quality of care they receive is
    excellent. The proposed closure of the Hot Springs VA, their
    access point to health care, is what angers them.
        The employees of the Hot Springs VA who work every day
    under difficult circumstances to provide care to America's
    veterans are victims of friendly fire, wounded by the very
    administrators entrusted to care for America's veterans.
        Chairman Miller, on behalf of the veterans who want to
    continue to use the Hot Springs VA, we need your committee's
    help. This has never been a proposal by the VA. The VA is
    moving forward with their plan. Without congressional
    intervention, the VA will likely close the Hot Springs
    hospital. Local management for 2 and a half years has
    repeatedly heard from the veterans that use the Hot Springs
    hospital, and the VA continues to turn a deaf ear to those
    veterans' concerns. Black Hills management is either unable or
    unwilling to stand up for the veterans they are charged to
    serve. Maybe they just do not know how.
        It is time to follow the lead of the national American
    Legion and call for a change in the current management of the
    Hot Springs VA. Veterans who want to continue to receive their
    care at Hot Springs and Hot Springs employees deserve better
    than an administration that has taken what was once a fully
    functional hospital and reduced it to little more than a
    transfer station to other hospitals.
        Mr. Nelson. Veterans who depend on Hot Springs VA for their
    care deserve administrators who understand the needs of rural
    veterans.
        And finally, Chairman Miller, Save the VA is asking you to
    support South Dakota's congressional delegation to have
    Secretary McDonald personally visit the Hot Springs VA. The
    first facility in the VA system to provide medical care for our
    country's veterans, Hot Springs is the granddaddy in the VA
    system, and we are proud to say also a national landmark.
        This concludes my oral testimony. Again, thank you for the
    opportunity to speak to you today. I will be happy to answer
    any questions you may have.

        [The prepared statement of Mr. Nelson appears in the
    Appendix]

        The Chairman. Thank you, Mr. Nelson.
        Ms. Campbell, you are recognized.

                      STATEMENT OF AMANDA CAMPBELL

        Ms. Campbell. Good morning and thank you. Welcome to Hot
    Springs and thank you for coming.
        We have said in the past that what has happened to the Hot
    Springs VA is a local example of a national problem. A toxic
    cocktail of four things has brought us to this current point:
    negligent management lacking integrity, poor and manipulated
    data, bad decisions based on that poor data, and agency
    inertia.
        We have recently seen a change in Washington, DC with the
    removal of Dr. Petzel and Secretary Shinseki.
        Ms. Campbell. In his final remarks, the Secretary said that
    the problems that this agency faced can be fixed. I believe
    that to be true 100 percent. We are hopeful and we are anxious
    to see how the new VA leadership in DC continues to heal this
    broken system.
        I ask you folks to hold onto your hats because I am going
    to say something that you probably never heard before. What has
    happened in DC in the last few months is exactly what needs to
    happen in the Black Hills.
        Ms. Campbell. We are calling for the immediate removal of
    the Black Hills VA Health Care System Director.
        Ms. Campbell. We are calling for the implementation of a
    leadership with national support for that leadership that does
    not reduce the National Environmental Policy Act to a
    predetermined process and an exercise in box-checking.
        We are calling for a leadership that does not violate the
    National Historic Preservation Act by neglecting to consult
    with the Advisory Council on Historic Preservation, the South
    Dakota State Historic Preservation Office, or the Tribal
    historic preservation officers.
        In 2010 and in 2011, the VA made the following statements.
        Number one, the Hot Springs facility is in poor physical
    condition.
        Number two, the Hot Springs facility has outlived its
    useful life.
        Number three, the Hot Springs facility is not ADA
    compliant.
        Number four, rehabilitating an old facility to meet
    historic preservation standards is too costly.
        And last but not least, quality care cannot be offered in
    the historic layout of the Hot Springs facility.
        We are calling for a leadership that does not decide to
    decommission a national historic landmark, a sacred site, and a
    national treasure with a legacy of care based on an uneducated
    and an unqualified opinion of two administrative staff and
    agency inertia. We are calling for a leadership that does not
    make those statements without first conducting a valid
    structural assessment, a feasibility study into the
    rehabilitation of that structure, and an adequate consultation
    with the required partners, and last but not least, a common
    sense discussion about what is best for rural veterans.
        I will tell you that a structural assessment was finally
    conducted by a qualified architectural firm with the
    experience. The words used to describe that facility were not
    poor. It was not unuseful. The words were excellent condition,
    very good condition, good condition, constructed of inexpensive
    and readily available materials, and no historic preservation
    premium should be anticipated.
        We are calling for a leadership that does not manipulate
    the interpretation of ADA regulations to insist on new costly
    construction versus economical rehabilitation of a facility
    that is already 100 percent ADA compliant and has been since
    the 1970's in areas where the patients receive care and reside.
        We are calling for a leadership that recognizes the
    outstanding level of care offered here because of that legacy
    of healing over the last 107 years and because of the
    nationally recognized care in that existing facility.
        We are calling for leadership that does not violate its own
    handbook and directive 7545 of the VA handbook.
        We are calling for leadership that does not instill fear of
    reprisal in hundreds of its employees.
        We are calling for leadership that does not employ a real
    estate firm to offer major repurposing options of a national
    historic landmark without even setting foot onto the campus.
    Mind you, this is the same firm that the VA OIG found to be off
    by $49 million regarding the consolidation of the Brecksville
    and the Wade Park facilities--$49 million annually.
        We are calling for a leadership that does not violate five
    executive orders with its intention to close, one of those
    being the removing of the access of Native Americans to sacred
    sites, another being the impact on low-income and minority
    populations, and yet another to consider the location of agency
    operations within historic districts.
        In closing, we have provided you with volumes of data that
    we cannot summarize in 5 minutes, but all of this data points
    towards a restoration of services here in Hot Springs. We are
    calling for a leadership that recognizes the legacy of healing,
    the potential, the advocate community, and rural and
    therapeutic setting, a healing environment, and bottom line,
    the desires and the needs of our veterans.
        Thank you.

        [The prepared statement of Ms. Campbell appears in the
    Appendix]

        The Chairman. Thank you, Ms. Campbell.
        Mr. Russell, you are recognized.

                      STATEMENT OF PATRICK RUSSELL

        Mr. Russell. Representative Miller, Representative
    Bilirakis, Representative Noem, Representative Smith, I am
    Patrick Russell, Army veteran, a medical technologist at the
    Hot Springs VA, President of the American Federation of
    Government Employees Local 1539, and co-chair of the Save the
    VA Committee in Hot Springs.
        On behalf of the Save the VA Committee, I would like to
    welcome you to Hot Springs, and we appreciate the opportunity
    to share our concerns about the proposal to close the Hot
    Springs VA Medical Center.
        There are many issues that need to be taken into
    consideration on this proposal, but I will limit my oral
    statements to the loss of services and personnel and the impact
    to the loyal employees and the veterans that we serve.
        Management of the Black Hills Health Care System has
    systematically been dismantling the Hot Springs VA since 1996.
    This was an observation made by Senator John Thune on January
    28, 2013 in a meeting with Secretary Shinseki, Senators Enzi,
    Barrasso, Johanns, Johnson, and Government Dennis Daugaard and
    Representative Noem. This systematic dismantling has caused
    undue hardships on the veterans and lowered the morale of the
    employees who have been bearing the brunt of a greater
    workload.
        Since 1996, we have seen the complete loss of surgery
    services to include orthopedic surgery, colonoscopy, and upper
    GI endoscopy, cataract surgery, and general surgery and
    anesthesia services. We have seen the loss of radiologists and
    fluoroscopy and other onsite radiologist-assisted procedures.
    We have lost our ICU unit. The emergency room is now downgraded
    to urgent care. We have lost our cardiac rehab clinic. We have
    lost the ability to ventilate patients in respiratory distress.
    We have lost the sleep lab. We have lost the pacemaker clinic,
    nuclear medicine, stress tests, a cardiology clinic, and a
    neurology clinic. The list continues to grow, and as these
    clinics and services are lost, our veterans are forced to
    travel longer distances for services they once received here.
    Many of the veterans we serve come from rural and highly rural
    areas where these services are not available in their local
    community hospitals and clinics.
        In March of 2004, in a hearing before the Senate Veterans
    Affairs Committee, the CARES Commission recommended that the
    Hot Springs VA Medical Center retain its current mission to
    provide acute in patient medical, domiciliary, and outpatient
    services. The commission did not concur with designating this
    facility as a critical access hospital.
        During the recent scoping meetings for the environmental
    impact statements, we heard from veterans in Pine Ridge, South
    Dakota; Chadron, Nebraska; Alliance, Nebraska; and Scottsbluff,
    Nebraska saying they now travel farther for their treatment,
    and they have all commented on the great quality of care they
    have received from the employees at the Hot Springs VA. Closing
    this facility will further reduce access into the VA system.
    The veterans we serve will be put into longer lines or perhaps
    waiting lists at VA medical centers where they will be
    referred.
        In the Black Hills proposal to close this facility, they
    state that they will absorb the 300 Hot Springs employees and
    nobody will lose a job. However, they go on to state that over
    a 5 to 10 year period, they will eliminate 300 positions
    throughout the system through attrition.t a time that the House
    Veterans' Affairs Committee is looking at access and waiting
    times, much of which is attributable to not having enough staff
    to handle the workload, Black Hills management wants to close
    an access point and reduce the staff. This will only make the
    issues worse. As a taxpayer, I feel my taxes will be wasted on
    building a domiciliary we already have. As a veteran receiving
    care at the Hot Springs VA, I have had to travel to Fort Meade
    to undergo procedures that were once available in Hot Springs.
        Veterans have paid for their care by service to their
    country. We should not have to beg to retain that care.
        Mr. Russell. But as a representative of the employees who
    work at the Hot Springs VA Medical Center, I see the pain and
    anguish as they are being pushed to their physical, mental, and
    emotional limits by a management that has cut their numbers and
    limited what they can do for the heroes that we serve every
    day.
        Mr. Russell. The VA's entire plan does not do justice to
    the veterans, the taxpayers, or the employees of the Hot
    Springs VA. What our veterans earned we deliver.
        This concludes my oral statement. I thank you for your time
    and willingness to hear our statements.

        [The prepared statement of Mr. Russell appears in the
    Appendix]

        The Chairman. Thank you, Mr. Russell.
        Secretary Zimmerman, you are recognized.

                      STATEMENT OF LARRY ZIMMERMAN

        Mr. Zimmerman. Thank you, sir. Good morning, Chairman
    Miller, Vice Chairman Bilirakis, Representative Noem, and our
    Representative from the State of Nebraska, and members of the
    committee. I am pleased to be here today to present our concern
    for the health care challenges faced by veterans in rural
    America.
        My name is Larry D. Zimmerman. I serve as Governor
    Daugaard's Secretary of the South Dakota Department of Veterans
    Affairs. Our department is the voice for South Dakota's 75,000
    veterans. I served active duty from 1973 to 1976 in the 4th
    Infantry Division at Ft. Carson, Colorado and served 29 years
    in the South Dakota National Guard, most recently serving as
    the State Command Sergeant Major. I had the distinct honor to
    complete a tour of duty in Afghanistan in support of Operation
    Enduring Freedom as the Operations Sergeant Major for the nine
    northern provinces in that country.
        South Dakota is fortunate to have three VA health care
    facilities in our State, 12 community-based outpatient clinics,
    and three vet centers. We are fortunate to have 66 county
    veterans service officers and seven tribal veterans service
    officers and over 20 service organizations that are committed
    to enhancing the lives of our veterans.
        In 1889, the Grand Army of the Republic secured territorial
    legislation to construct a veterans home. It is our
    understanding the Dakota Territory was the first of all
    territories to provide a home for their veterans. In 1907, the
    Battle Mountain Sanitarium opened its doors in Hot Springs to
    focus on short-term medical needs of veterans. All through over
    the years, both facilities have changed their names--although
    they have, the VA Black Hills Health Care System and the
    Michael J. Fitzmaurice State Veterans Home have worked together
    to provide care for the veterans for over 107 years.
        I give you some numbers that reflect the State veterans
    home use of the VA here in Hot Springs in the past year.
        Veterans health care is a critical issue and is important
    we honor the promise to take care of those individuals who
    secured and protected our freedoms. During a 1-year window, the
    Michael J. Fitzmaurice State Veterans Home transported our
    heroes to the VA health care facilities here in Hot Springs
    1,272 times for urgent care, eye care, dental care, dialysis,
    respiratory care, x-rays, urology, podiatry, and mental health
    care. In addition, during that same 1-year time frame, 40 of
    our heroes from the home were admitted to acute care at the VA
    Black Hills Health Care System here in Hot Springs, and 108
    times for higher level care they were transported to Rapid City
    via the VA. Additionally, thousands of veterans drive from
    other States, tribal lands, and many of South Dakota's most
    rural areas to receive that medical care here.
        Our heroes deserve the opportunity to enjoy the rest of
    their lives and being assured they will have access to quality
    health care. South Dakota has a strong legacy of taking care of
    our veterans, and we at Michael J. Fitzmaurice State Veterans
    Home will guarantee that our heroes' needs will be taken care
    of no matter what the decisions.
        In closing, I appreciate the support that your committee
    has given and to all the issues relating to veterans. I
    appreciate the invitation to present this information to you
    and will be pleased to answer any questions you may have.
        On a personal note, I just had knee replacement 7 weeks ago
    at our VA facilities in the Hills. The care and giving that
    those people from the VA gave me was outstanding.
        We do have issues. I totally understand that. We need our
    health care facilities. But I want everybody to please remember
    that the representatives and/or employees of these great VA
    facilities have a heart and a mind to take care of our heroes,
    and they do that with every ounce of their ability. They do
    take care of us. Change is not good sometimes. We want to
    represent the veterans of the State. I hope that you as a
    committee can understand the need and see the crowd that
    represents the veterans of this great State.
        Thank you for your time, Mr. Chairman.

        [The prepared statement of Mr. Zimmerman appears in the
    Appendix]

        The Chairman. Thank you very much to all of you for your
    testimony.
        Before I recognize Kristi for questions, I just want to
    make one quick comment. If there is one single employee that is
    singled out for reprisal for speaking the truth, I hope you
    will contact me directly because that is not acceptable. The
    men and women in this room fought for the ability for people in
    this country to speak their minds, even if their government
    disagrees with it, and if that happens, please let me know.
        And with that, Kristi, you are recognized for any
    questions.
        Ms. Noem. I wanted to start with Bob. I would like you to
    expand a little bit. The VA has continuously used demographic
    data to justify the closure of the VA facility. I would like
    you to expand on what the Save the VA Committee has done to
    refute some of the data that VA is currently using and how you
    arrived at some of the numbers that you did and how that is
    different than what you feel the VA system is using to justify
    closure of this facility here.
        Mr. Nelson. Thank you. After the VA made the announcement
    in 2011, we got together to try to figure out how we are going
    to make some sense of this. Pat is employed there. I am a
    former employee. There are a lot of folks that were saying this
    just does not make any sense. So through the Freedom of
    Information process, we started asking all kinds of data of the
    VA, the number of veterans that were on wait lists for
    domiciliary, just all the stuff that is in my written
    testimony. And time after time, the Freedom of Information
    requests confirmed what the employees were telling us, is that
    the numbers that the VA is putting out there are to put a spin
    on their proposal. It is my own personal belief that the VA did
    not expect to find themselves in this situation.
        In the summer of 2011, veterans and employees were starting
    to get a sense that something was happening up there that the
    VA was not telling us about. So it is when we approached South
    Dakota's congressional offices and started expressing the
    concerns that we need to have somebody look into this. And at
    the time, South Dakota's congressional offices got on board
    with us, as they have been from 2011, and they asked Secretary
    Shinseki to come to Hot Springs and talk about what was going
    on. He was not willing to do that. So we ended up in
    Washington.
        But consistently the VA, I think, has tried to defend a
    decision after they made it, and they have done a poor job of
    doing it because when they go back and they try to scramble and
    put a spin on what the true data is, they just cannot do it.
        Yesterday I gave to your staff, Chairman Miller, a little
    thumb drive that has all of the data that we have collected,
    the Freedom of Information Act requests. So I encourage you to
    interpret that data, have your staff and interpret it on your
    own. The resolutions that have come from the Native American
    tribes, just all the supporting documents. But what we have
    found is that consistently everybody that has used that
    facility disagrees with the presentation--the icing that the VA
    has put on their proposal. They did not expect to have to
    defend it.
        In so many other cases--New Orleans was a good example that
    we found. They just went through the process. Nobody called
    them on it. We called them on it, and they have been struggling
    for 2 and a half years to make sense of it.
        Ms. Noem. I wanted to follow up with President Brewer. I
    wanted you to speak a little bit about the veterans that we
    have currently living on Pine Ridge. And some of the
    suggestions by the VA have been that they could receive care
    through IHS. Now, you know and I know the challenges that IHS
    faces and how the contract dollars run out so early in the
    year. But I would like you to go into a little bit more detail
    about how that is not really feasible to transfer veteran care
    over to IHS services because of the lack of funds that are
    there.
        Mr. Brewer. You know, the people on the Pine Ridge
    reservation--they cannot meet the needs of our people. Our
    people are dying every day. They cannot afford to send them
    out. They cannot afford to pay their bills. They may transfer
    them out, and yet that person will be responsible for paying
    for their bills. And what happens to the people that are sent
    out? Their credit is ruined and everything else. IHS--they just
    cannot do it. They cannot meet the needs. They do not have the
    money. They do not have the facilities. Yet, now they are going
    to make an MOA to take on the 3,500 veterans just from Pine
    Ridge on. And with our special needs, they will never meet
    them.
        Kristi, it is not only Pine Ridge, but it is also the other
    reservations, Rosebud, Cheyenne Eagle Butte. The veterans are
    going to start dying because they are not going to get any
    services. They will not be able to do it.
        And one of the problems is that the VA does not pay its
    bills. So if they do send us someplace, we are going to have a
    difficult time there also.
        Ms. Noem. Thank you. I have run out of time. We will move
    on.
        The Chairman. Mr. Smith, I would like to recognize you for
    your questions.
        Mr. Smith. Thank you.
        Number one, I appreciate, again, your insight and certainly
    the remarks shared here today.
        Perhaps some of my questions are better suited for our next
    panel, but I do want to point out also that Senator Fischer and
    Senator Johanns have also worked on this issue from Nebraska.
        I am glad that the facility here does not know a State
    boundary. I say that as a Representative on another side of the
    State line. So I say thank you.
        But more specifically here, I guess, Mr. Nelson, as a
    former employee, looking at the big picture here, how do you
    feel like perhaps a bureaucracy in Washington, DC perhaps
    unintentionally--there is just a big disconnect there. I co-
    chair the Rural Veterans Caucus, this effort that we have in
    the House to focus on the needs that are unique to rural
    America, rural veterans most specifically. Certainly limiting
    the services in various facilities or closing or reducing,
    however anyone wants to call it--how much do you think might be
    an unintentional disconnect, nonetheless a disconnect, between
    the bureaucracy in Washington and what is really happening here
    in middle America?
        Mr. Nelson. I am not confident it is an intentional
    disconnect, other than at the cabinet level position, the
    Secretary's position. Dr. Petzel came from VISN 23. He came
    from Minneapolis, Sioux Falls, Sturgis, Hot Springs. He knows
    the situation out here. What frustrates us in this whole
    argument and one thing that we have tried to not focus on
    because it would seem to be pitting us against foreign aid, but
    the reality is we are--I say ``we''--it is tough to move away
    from 36 years of service out there.
        Fort Meade and Hot Springs are part of one system. But in
    this whole presentation, the VA continues talking about Rapid
    City and what needs to happen up there. And they should know
    their own system well enough to know that Fort Meade up around
    Rapid City and Hot Springs serve geographically different areas
    of veterans. The veterans that are in the Rapid City area did
    not historically come to Rapid City for the majority of their
    care. Prior to the CBOC being placed in Rapid City, they went
    up to Fort Meade. The veterans that come to Hot Springs have
    always come from the reservations. They have come from
    southwestern South Dakota. They have come from northwestern
    Nebraska, your area, your veterans. They have come from
    Wyoming.
        And in this whole proposal, the VA is willing to sacrifice
    those veterans who have traditionally used Hot Springs in my
    opinion. The VA is going to say we are not sacrificing them. We
    are going to provide them with CBOC's all over the place, and
    they can go to private health care. CBOC's are fine. CBOC's are
    necessary. For a veteran to travel 150 miles, if you can put a
    CBOC out there for an occasional visit, that is fine. But
    CBOC's are doctors' offices. They are open 9:00 to 5:00 Monday
    through Friday, excluding Government holidays. They should not
    be a feeder system into private health care.
        Mr. Smith. And perhaps not every day either. Right.
        Mr. Nelson. CBOC's should not be a feeder system into
    private health care. Veterans have unique medical conditions
    that they need to be taken care of that the private health care
    does not deal with on a daily basis. Folks within the VA system
    understand how to recognize those things that veterans present
    with.
        So I personally do not think in this particular case that
    there is a disconnect--there was a disconnect at the Washington
    bureaucracy level other than with Secretary Shinseki. I
    personally think Secretary Shinseki is an honorable man. I
    think he got lousy advice. His people failed him and they knew
    better.
        Mr. Smith. Thank you.
        And perhaps briefly before my time runs out, could you Bob
    or Pat elaborate on the capacity for Hot Springs to be a mental
    health care hub? We know that the needs of veterans are
    changing over time due to various impacts. But can you speak to
    that?
        Mr. Nelson. Pat, would you like to do that?
        Mr. Russell. I believe that Hot Springs has the capacity to
    take back many of the services that have been discontinued.
    They currently have lots of room in the domiciliary, and staff
    have even requested in the PTSD program that they create more
    cohorts so they can get more veterans through the PTSD program.
    Of course, with that, you are going to need staffing. Perhaps
    they need more room.
        But the problem that I have seen is that the VA, rather
    than creating administrative offices in the domiciliary and
    patient care areas--they should be leasing or buying the
    historical properties in Hot Springs per executive order
    several years ago that the President said the VA should be
    utilizing these properties. We have the Carnegie Library. We
    have several other buildings where they could be moving places
    like the call center and telehealth off of the hill, creating
    more rooms for exam rooms or patient care areas. We have the
    capacity. There is room up there if things were done right.
        I feel the biggest problem is in recruitment. We keep
    hearing from our current administration that nobody wants to
    live in Hot Springs and they cannot recruit people. All I know
    is that in 1995 this facility had five surgeons. We had two
    certified nurse anesthetists. We had a complete staff of
    doctors. There was no problem getting a professional to live in
    Hot Springs. But suddenly we hear on the news people from the
    VA saying that we cannot get anybody who wants to live in Hot
    Springs. I do not believe that. We have the capacity, and if
    things are done right, this could be a very viable medical
    center providing the care that our veterans earned.
        Mr. Smith. Thank you.
        The Chairman. Mr. Bilirakis.
        Mr. Bilirakis. Thank you, Mr. Chairman.
        I would like to hear from Mr. Nelson or Mr. Russell or
    anyone else who wants to comment on this particular question.
    We were visiting the dialysis unit at Hot Springs this morning,
    and again, the patients seemed to be very satisfied. I was very
    impressed with the unit. Where are these patients going to go
    if they do not have family? How are they going to travel to
    Rapid City or other locations? I mean, what is going to happen
    to these patients? Can you elaborate on that, sir? Why do we
    not start with Mr. Nelson?
        Mr. Nelson. I am not sure how many years ago, but the Hot
    Springs dialysis unit became the first dialysis unit within the
    VA system to be able to accept Medicare patients. They did that
    not to exclude veterans. And I do not know what the capacity is
    today, but for conversation purposes, let us say that they have
    a capacity of being able to do 20 patients a day, 20 dialysis
    patients a day. As long as the need for veterans are under that
    20, if there is extra capacity there, 15 veterans need
    dialysis, then the Hot Springs VA can provide care to five
    Medicare patients. Unique. It does not happen anywhere else in
    the country.
        So prior to that, those dialysis patients were traveling to
    Rapid City typically, and when you are on dialysis, one of the
    things that I experienced when I was up there is that people
    walk into dialysis or people that see patients walk into
    dialysis and walk out of dialysis think those people are not
    very sick. They walked in, they walked out. These people are on
    the fine edge. If they do not get their dialysis, they are in
    trouble quick. So they are not in good health. So to ask them
    to get on the road and travel somewhere else and spend 2 and a
    half to 3 hours in a dialysis treatment and then go back home
    when they are whipped anyway, it is a concern we have had all
    along. We talk about that. Dialysis--it is one of the proud
    things that Black Hills has hung onto.
        But I am not sure where they are going to go, and I do not
    know what all the resources are. Rapid City is the closest. I
    think if you would talk with Dr. Birch I believe is the
    consultant that comes down, I think he will tell you that there
    is not a lot of extra capacity in this area. And he has always
    appreciated coming down here. So it is a question that troubles
    us.
        Mr. Bilirakis. Mr. Russell, would you like to comment on
    that?
        Mr. Russell. I am thinking in the original proposal, they
    were talking about establishing a dialysis clinic adjacent to
    the Fall River Hospital. However, but nobody ever talked to the
    president of Fall River Hospital about it. I think another
    thing they mentioned was putting a dialysis unit up at the
    State home. I do not know if there have been further
    discussions on that. That is all talk.
        All I know is I do not think the veterans are being taken
    into consideration because the other alternative is them either
    traveling more often to get their dialysis or having to
    relocate to Rapid City or someplace that would have dialysis
    available. It serves a great need because the unused capacity
    is used for Medicare patients who are not veterans. So it is a
    good use of VA resources to help recoup some of the costs the
    VA is expending in maintaining that dialysis unit. I do know
    that the employees up there are very, very dedicated to what
    they do, serving not only the veterans but also the Medicare
    patients that they do see.
        Mr. Bilirakis. Thank you.
        I do not want to take too much time, but Mr. Brewer, can
    you elaborate? I understand that this is a very exceptional,
    special PTSD treatment center at Hot Springs, and I am very
    interested in this issue. What is so unique? Why do veterans
    travel across country to get to Hot Springs for treatment of
    PTSD? I want to know myself, but also tell me what is so unique
    about this and how can we bring even more veterans, expand the
    services here at Hot Springs with regard to PTSD? Thank you.
        Mr. Brewer. I have to say that I have not been through the
    program yet. Time has not allowed it. My physician has asked me
    to go to it, tried to get me into it, but I have not had the
    time yet.
        You know, people come from all over the country. I have
    heard of stories where guys have hitchhiked in here, veterans
    from back East, hitchhiked to Hot Springs, South Dakota hoping
    to get into the PTSD program here. It has that reputation of
    helping and healing people. You cannot cure anyone with PTSD.
    We know that, but they can give you things that will help you,
    things to do. And I cannot tell you what they do here, but they
    do a great job.
        And I think it would be nice to visit with some of the
    staff here because it needs to be expanded. I know there is a
    number of people that want to come through our program. This
    program here should be for our veterans nationwide to be able
    to travel to Hot Springs, South Dakota to get it because it is
    the best here in Hot Springs.
        Mr. Bilirakis. Thank you, Mr. Chairman. I yield back.
        The Chairman. Thank you very much.
        Mr. Nelson, in your testimony, you said overwhelmingly
    veterans have told Black Hills management that they want the
    Hot Springs VA to remain open. Tell me what the reaction has
    been to you and the veterans in this community from the
    management in regard to your pleas and the information that you
    have provided to them regarding keeping this facility open.
        Mr. Nelson. When I referred to veterans have overwhelmingly
    told them, that has been over the 2 and a half year span. When
    the VA first made the announcement, veterans were telling them
    no, do not do this. They would give their individual stories
    why that would not happen. That has been consistent from the
    original announcement in 2011 to today's meeting.
        You have seen the turnout that we get when we talk about
    closing the VA. And what we get from the VA are respectful
    smiles, nodding of the head, and then going about business as
    usual. They have done nothing to indicate to us that they have
    heard the veterans' pleas to keep this facility open. What they
    did was agree to enter into--Secretary Shinseki said, well, we
    will do an EIS process. But there is not anything about that
    process in the way it was presented that leads any of us to
    believe that there is not a predetermined decision here. What
    they are doing now they should have done 3 to 4 years ago. It
    should have been a question. The EIS process is about a Federal
    agency saying we think we have a problem here. Let us take a
    look at it and see if we are right and then let the public
    provide input and arrive at a conclusion. The VA never did
    that.
        As I have stated earlier, they made their decision and they
    will not honestly tell anybody what is behind that decision
    because I do not think they can defend it. They are going to
    tell you today that we have looked at the numbers and it makes
    sense to do this.
        I provide a lot of data in my written testimony. But I do
    not think we have gotten through to the VA. That is just
    another example of why you folks are out here. We are grabbing
    at straws, anything we can do to try to keep this facility
    here. I am not convinced the VA still gets it.
        The Chairman. Mr. Secretary, you had said in your testimony
    that there had been 1,272 different times that people had been
    transported from the State home. How many patients? Can you
    break it down to individuals?
        Mr. Zimmerman. Yes, sir. We have capacity for 135. We have
    52 skilled nursing care rooms and 48 residential. And that 52/
    48 is what we are building and putting in the new facility. I
    also have a larger residential capacity in one. But that is
    just that 135 resident and nursing care capacity. And we as a
    State veteran home have a level of care, and so when someone
    has a heart attack, they are brought to the VA, as the VA has
    levels of care that they have to go out of that facility maybe
    to the Rapid City regional hospital, and I mentioned some
    transports of that. But it is the 114 to 120 daily census
    capacity that does those visits, and that is daily appointments
    and/or high level of care needed, a patient fall or a nursing
    care resident in our dementia unit or something and bring him
    down. So the 1,272 is daily appointments and others.
        The Chairman. So if this facility were to close, where
    would those residents have to go?
        Mr. Zimmerman. I would have to yield to some of the Save VA
    Committee not to answer but in their answers they have given.
    It is kind of unsure. I mean, right now it would be the Hot
    Springs hospital which we take some of our residents' spouses
    to or Rapid City, minus there being a facility that we can
    transport them to here in town.
        The Chairman. Mr. Russell, you said in 1995 things were
    going very well in regard to the number of surgeons and people
    that were employed. Then all of a sudden, something happened.
    What happened?
        Mr. Russell. There was a shotgun wedding they call a
    merger, a consolidation of Fort Meade and Hot Springs. 1995 our
    center director was Daniel Marsh and Fort Meade was a separate
    facility. And for 2 years, they had been having discussions
    about collaboration between Hot Springs and Fort Meade about
    doing certain things to lower the costs, such as if you are
    going to order supplies, let us make it one big order instead
    of two separate smaller orders. What can we do to collaborate
    working with each other? After 2 years, they came out and
    announced the consolidation, the consolidation of Fort Meade
    and Hot Springs.
        And from that period on, it was not too long after that,
    the first thing we lost was our laundry services. We had a
    laundry that was doing not only the work for our facility but
    we were doing the laundry for Pine Ridge, Ellsworth Air Force
    Base, Sioux San Hospital up in Rapid City. We were contracting
    out the services in order to help recoup some of the costs for
    laundry. That was gone. That was closed up. Everything was
    moved up to Fort Meade.
        And shortly after that, our surgery department became
    ambulatory surgery only, no more inpatient surgery. And over
    the last several years, they have gradually eliminated surgeons
    and programs. And as of last April, the last surgeon to leave
    was the ophthalmologist who would do the eye surgery, cataract
    surgery. They would not renew his contract down here. They
    renewed his contract at Fort Meade, but not in Hot Springs.
    That was the last surgery we had in Hot Springs.
        So 1995, whether it is the cardiac rehab clinic, the
    radiologists, the pathologists, the histology lab, all these
    things have been taken out a brick at a time. They realized in
    1995 you cannot wreck that facility with a wrecking ball. If
    you cannot wreck it with a wrecking ball, you take out a brick
    at a time. Every program is a brick. Every employee is a brick.
    Pretty soon, the wall is so unstable, it crumbles. That is that
    they are doing by reducing the programs and services, hoping
    the wall crumbles and they can close it up.
        The Chairman. We will do a quick second round of questions
    if the members have them. Kristi, you are recognized.
        Ms. Noem. Pat, at any point in your conversations with the
    VA, did they indicate to you that they were considering what
    would be best for our veterans' health care needs?
        Mr. Russell. Using their logic, perhaps. But I do not think
    they are listening to the veterans themselves.
        Mr. Russell. The original announcement was made down here
    on December 12th, 2011, and that week there were meetings in
    Rapid City and Kyle, Pine Ridge, Chadron, Scottsbluff,
    Alliance, and overwhelmingly, from the very beginning, veterans
    were saying we do not want to go to the local community
    hospital. There was a veteran in Scottsbluff that stood up and
    said we will not go to that hospital because they will kill us
    there. I want to go to the Hot Springs VA.
        Mr. Russell. And on April 12th, 2012, Representative Noem,
    Senator Johnson, and Senator Thune were at the American Legion
    here in Hot Springs, standing room only. People were standing
    outside the doors on a Thursday morning for a 1-hour meeting.
    And they expressed their opinions. People talked. Veterans came
    to the mike, and not one of them advocated closing down our VA.
        And we have just completed the scoping meetings for the
    environmental impact statement, and I attended the ones in Pine
    Ridge, Chadron, Alliance, and Scottsbluff. Not one veteran
    advocated closing the VA. Every one of them said keep it open.
    We want our health care. We do not want to have to drive more.
        I do not think they are listening. It is we have made up
    our mind. We are not going to listen to the data. We have
    already made up our mind and that is what is very troubling to
    me is that they are not listening to the veterans. They are not
    listening to the taxpayers. And by God, I do not think they are
    listening to our Senators or our Representatives either because
    they feel----
        Mr. Russell. It appears that being a cabinet Department,
    they are above all of our congressional people that have been
    elected.
        Ms. Noem. Well, you are right. I came down here. The
    announcement was made in December. I came here first February
    4th, and I told you I would come back with the whole delegation
    and we did. We came back in April. After they continued down
    the process of continuing to follow through with closure of the
    facility, the delegation together sent a list of questions to
    the VA and asked them to answer these questions that we
    specifically were asking of them, cost-benefit analysis,
    consideration of care for veterans, the facility, the
    compliance with ADA requirements, a list of questions. It took
    them 134 days to answer our questions. 134 days. When we
    finally did get the answer, it was not a clear consensus with
    their data, what they were using, compared to what your data,
    what you were using. So I will say absolutely. It has been a
    very frustrating process.
        We did ask the Secretary to come here as well. He did not.
    When we did finally meet with him, I called his office many,
    many times. Never once received a return phone call from him. I
    could pick up the phone, call the Secretary of Agriculture, and
    he is on the phone 30 seconds later, but the Secretary of the
    VA--cannot get him to return a phone call. So I will tell you
    that has been my frustration through the process as well.
        But I want you to talk a little bit today so the committee
    has a full understanding of how they have treated the employees
    and especially, Pat, I want you to speak about how they offer
    openings for employment, how they offer temporary openings, not
    permanent placement, and then how long the openings exist. I
    was downtown this morning, had a man tell me that he believes
    one position was only open for 8 hours and closed again, and
    they said they could not find any applicants. Well, it was only
    open for 8 hours.
        So I would like you to speak to that because I think it
    shows some of the process where they justify not being able to
    find somebody to live in Hot Springs, how they conducted that
    led to the result of not getting people who could fill those
    positions.
        Mr. Russell. Thank you for asking that question because it
    is somewhat of a game they play. When they talk about not being
    able to recruit people to work in Hot Springs, they will open
    up a nursing position and they will open it up as a temporary
    job not to exceed 2 years. Not many people, especially if they
    have families, are going to relocate for a temporary position
    that may not be there in 2 years.
        The other example. We had a medical technology position
    that was open up in the laboratory. The announcement was open
    for 8 hours and closed. The vacancy is still there. It still
    has not been filled.
        They are creating new position descriptions of jobs. It is
    inconceivable. They have recently created four positions for
    medical technologists in the Black Hills Health Care System,
    but as a requirement for that job, you may be working at Fort
    Meade one day, you may be working at Hot Springs the following
    day. You do not know where you are going to work. The travel--I
    do not know whether that would be on company time or a company
    car, but part of that would be pulling call in Hot Springs. So
    if you have a person from Sturgis that accepted the job
    thinking they are working at Fort Meade and they say you are
    going to work now in Hot Springs and you are pulling call,
    where do you stay for call? They do not have anyplace for them
    to stay. They will have to rent a hotel room. So the
    requirements they are putting out for these jobs are totally
    unrealistic.
        And besides that, problems I see having employees driving
    back and forth between Fort Meade and Hot Springs. You are
    talking about an hour and a half one way, 3 hours for a total
    day. That is windshield time. You are not behind the bench. You
    are not producing results. What measurable workload have you
    done by commuting back and forth? It is a waste of taxpayer
    money. It is a waste of professional time.
        The jobs that are being eliminated--they are telling other
    employees just work harder--work smarter not harder. We have
    been hearing that since 1995, and that is why in my statement I
    said that the people are physically, mentally, and emotionally
    drained and exhausted because they have been working harder.
        The Chairman. Mr. Smith, any more questions?
        Mr. Smith. Yes.
        President Brewer, you mentioned briefly that the VA does
    not pay its bills. Could you elaborate on that?
        Mr. Brewer. I am very concerned that they do not. They do
    not pay their bills on time. And I am very concerned that if we
    are sent to a facility and that facility is aware--and they
    probably are--that the VA does not pay its bills in a timely
    manner, we are going to be put on the bottom of the list. We
    are not going to become a priority. So this is a big concern
    for us.
        Mr. Smith. You mentioned, I think, the population that you
    represent is about 41,000. How many veterans would you say are
    in that population?
        Mr. Brewer. On our reservation, we estimate we have over
    3,500 veterans alone in Pine Ridge. That is not counting
    Rosebud or Cheyenne Eagle Butte.
        Mr. Smith. Any rough estimate what those other reservations
    and tribes would----
        Mr. Brewer. Less than Pine Ridge. Pine Ridge is the
    largest. I do not have those figures with me.
        Mr. Smith. Thank you.
        Thank you, Mr. Chairman.
        The Chairman. Mr. Bilirakis.
        Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
        Just one question for Ms. Campbell. In your testimony, you
    state that the DoD conducted a study released in February of
    2013. The report supported the fact that rehabilitation of
    masonry buildings constructed prior to World War II is more
    cost-effective as opposed to new construction options. Are you
    aware of the costs to update the Hot Springs facility? And do
    they fall in line with this study's conclusions?
        Ms. Campbell. Bottom line--we do not know a bottom line
    figure mainly because the VA has neglected--despite the fact
    that they have moved forward with their planned decommission,
    they have not conducted a feasibility study to determine if,
    indeed, it is feasible to rehabilitate the facility. Based on
    past projections, based on past estimates, construction
    estimates and rehabilitation estimates, at the VA, the VA at
    Hot Springs specifically, I think we tossed around a number of
    right around $20 million to bring the facility into 100 percent
    full compliance and a variety of other issues and elements.
        The report about the masonry structures, about how easy
    those are to rehabilitate fall directly in line with reports
    from the National Trust for Historic Preservation, also from
    the Tenor report and a variety of others that say that it is 10
    times easier and significantly more cost-effective to
    rehabilitate historic structures, as directed by several
    Federal regulations, than it is for new construction.
        Another cost that we did not talk about that has not been
    considered is the cost of mothballing a national historic
    landmark. I believe--and this is data that has been rattling
    around in my mind for quite a while, but I believe we were
    looking at a figure of about $128 million over the course of
    several years it would require to abandon and mothball a
    national historic landmark. That would be money that would be
    mandatory and required in conjunction with new construction and
    staffing and filling those new buildings.
        Mr. Bilirakis. Thank you very much.
        Would anyone else on the panel----
        Mr. Bilirakis. Can you please elaborate on this issue?
    Thank you.
        Mr. Nelson. Yes. I would just like to add to what Amanda
    has said. The frustration with this whole thing--and she has
    referred to the Treanor report. The Treanor report shreds
    everything that the VA has said about what is not possible with
    that facility. As she alluded to earlier in one of her
    comments, the firm that the VA has based their numbers on never
    even stepped site on the VA here to make the assessment. That
    company used data that was provided to them by the VA.
        Thanks to Representative Noem, Senator Johnson, and Senator
    Thune pressing Secretary Shinseki about coming to Hot Springs.
    When he declined to do that, what he did is he said what I am
    going to do is I am going to instruct the VISN 23 in Black
    Hills to sit down with Save the VA folks, congressional staff,
    the veterans service officers--I talked a little bit about that
    in my written testimony--to figure out where do we disagree.
    And it became apparent very quickly that, again, the VA was
    working with their own data that I do not think they
    understood. So we pressed them to have a historic preservation
    specialist come in and assess that property. That is the result
    of the Treanor report.
        And what he talks about in there is that until the VA comes
    out with how they would redesign the buildings there, what they
    would want, what kind of medical facilities, it is very tough
    to come up with an estimate of what it is going to take to do
    it.
        So for us, it is just another example of if the VA was
    sincere in wanting to honestly look at this and see if they had
    made the right decision, they would not have resisted coming up
    with alternate plans. They should have gone back to an
    architect and said, okay, here is how we think it would look if
    we do not abandon the facility. Just another example of that is
    not the direction they want to go, so that is not what they are
    going to do. They want out of Hot Springs.
        Mr. Bilirakis. Thank you so much. Appreciate it.
        The Chairman. Thank you, Mr. Bilirakis.
        Mr. President, it has been said a couple of times that
    there is a zero number for veterans on Pine Ridge, that VA does
    not include those numbers. Could you explain to me if there are
    no veterans on Pine Ridge, why you just opened a veterans
    cemetery there in July?
        [Laughter and applause.]
        Mr. Brewer. We have a very beautiful cemetery now, and I
    would like to thank the Veterans Administration for that. I
    would like to invite all of you to come see it sometime. It is
    very beautiful.
        But, yes, a good question. And if they close up Hot
    Springs, we will probably be filling it up pretty fast too.
        [Applause.]
        The Chairman. Mr. President, Kristi will tell you that that
    was one of the places that I desperately wanted to visit while
    I was here, and unfortunately, time will not allow it. But
    after landing in Rapid City--and I am not going to stay in
    Rapid City anymore. I am going to come and spend the night in
    Hot Springs. All right?
        [Applause.]
        The Chairman. I love old hotels and look forward to coming
    back.
        But let me also say, Ms. Campbell, your $20 million number
    may be right, may not be right. We do not know. But it is the
    only number that we have to deal with. And I just would make
    this closing comment to you.
        We are spending $60 million to restore the dome on the
    United States Capitol Building. Now, it needs to be done. It
    really does. It needs to be done. But it is a historic
    landmark. And so is this facility.
        [Applause.]
        The Chairman. In the bill that was signed by the President
    last week that was passed jointly by the House and the Senate
    in the conference committee, we appropriated $5 billion, with a
    B, and within that $5 billion, there is an allocation for minor
    construction and also delayed care on facilities. So there is
    money that is now available for VA, should they choose to use
    it. The fact that they will say that there is no money does not
    hold water because it is available.
        I just want to say thank you. I wish we had a little more
    time for another round of questions, but we have a second round
    of panelists that have come here to speak today. I just want to
    say from the bottom of my heart thank you for fighting so hard
    to save not only the history of this town, but some of the
    history of the United States of America. We appreciate your
    fight. Thank you.
        [Applause.]
        The Chairman. And with that, we will excuse the first panel
    and say thank you very much for being here.
        We will call the second panel to come forward.
        And I want to ask a favor of everybody, if you would.
    Everybody in this room that wore the uniform of this country
    wore it to allow other people to speak, even when you may
    disagree with what they have to say. So I would beg your
    indulgence as to the two gentlemen that are here today speak.
    We are here to get information from them. We will continue to
    press for answers to questions that have not been answered. But
    again, I would ask that you treat them with the same respect
    that you treated the first panel because they are here
    representing the Department of Veterans Affairs.
        So, again, joining us from the Department is Dr. Steven
    Julius, Acting Network Director and Chief Medical Officer for
    Veterans Integrated Service Network 23. He is accompanied by
    Stephen DiStasio, Director of the VA Black Hills Health Care
    System. I appreciate them being here today.
        Dr. Julius, you are recognized for your opening statement.
    Thank you, sir.

                       STATEMENT OF STEVEN JULIUS

        Dr. Julius. Thank you, Chairman Miller. Good morning--or I
    guess in a couple minutes it is good afternoon--Chairman
    Miller, Congressman Bilirakis, Congressman Smith, and
    Congresswoman Noem. Thank you for the opportunity to discuss
    the VA Black Hills Health Care System's commitment to providing
    veterans high quality, patient-centered care and to address
    rural health care and access to care.
        I am accompanied today by Mr. Stephen DiStasio, Director of
    the VA Black Hills Health Care System.
        VA Black Hills provides primary and specialty medicine,
    extended care and rehabilitation services, surgical and mental
    health services, as well as residential rehabilitation
    treatment programs. VA Black Hills consists of two medical
    centers located at Hot Springs and Fort Meade, South Dakota,
    and VA-staffed community-based outpatient clinics located in
    Rapid City and Pine Ridge, South Dakota and Newcastle, Wyoming.
    In addition, six contract CBOC's are located in South Dakota
    and two are located in Nebraska.
        In fiscal year 2013, there were approximately 35,000 total
    veterans within the VA Black Hills service area. Of the
    approximately 35,000, approximately 21,000 were enrolled for
    health care services, and 19,207 of the enrolled unique
    veterans were served. This reflects an enrolled penetration
    rate of 60 percent in fiscal year 2013, one of the highest in
    VHA.
        The Hot Springs and Fort Meade campuses are particularly
    noteworthy as sites of historical significance. Hot Springs is
    the Battle Mountain Sanitarium National Historic Landmark with
    a proud history of caring for veterans extending back to the
    early 1900's. The Fort Meade cavalry post is known for its
    substantial military presence, extending back to the 1880's. We
    understand the significance of these sites and we appreciate
    the rich history they bring to the community.
        Maintaining and improving the aging buildings, ranging from
    40 to over 100 years old, significantly increases the cost of
    operation at both facilities. Existing operating rooms at both
    hospitals are reaching 40 years of age. The current residential
    rehabilitation treatment program building at Hot Springs is
    over 100 years old, and the structure is not compliant with the
    Architectural Barriers Act. For these and other reasons, VA
    Black Hills has the highest costs per unique patient of all
    VISN 23 facilities and one of the highest in all of VHA.
        VA Black Hills is committed to meeting veterans' needs in
    western South Dakota, Nebraska, Wyoming, and North Dakota. We
    have conducted a review of the services provided and the
    Department has determined that improvements and
    reconfigurations to VA Black Hills operations are needed to
    maintain the safety and quality of care it provides. We believe
    this will increase the scope of services available to veterans
    closer to their homes while being good stewards of public
    funds.
        VHA is concerned about its ability to preserve the quality
    and safety of care at Hot Springs, given that the volume of
    inpatient activity is so low. In these circumstances, it is
    difficult to recruit and retain skilled providers, as well as
    maintain their competencies. Surgical procedures at Hot Springs
    have been curtailed due to an inability to recruit and retain
    surgeons and anesthesia providers. In addition, all of the
    hospitalists and after-hours physicians are temporary staff
    hired on contract to fill staffing needs.
        The most significant changes proposed by the Department
    involve replacing the current medical center in Hot Springs
    with a new community-based outpatient clinic and relocating the
    residential rehabilitation treatment program to Rapid City,
    South Dakota. The overall goal of the reconfiguration is to
    realign services and resources to provide safe, high quality,
    accessible, and cost-effective care closer to where veterans
    live.
        To be transparent and make optimal decisions regarding
    veteran care, VA has openly shared access and quality data with
    stakeholders. VA Black Hills sites of care are insufficient to
    provide ready access to care to all veterans within the large,
    highly rural service area. The limited availability of
    specialists is also a barrier, requiring some veterans to
    travel to VA sites in Minneapolis or Omaha for needed specialty
    care. The recruitment and retention of physicians, nurses, and
    other health care providers has also been difficult with
    physician specialists particularly problematic.
        VA Black Hills has addressed these challenges by expanding
    the use of non-VA care to provide access to services locally
    and shorten waiting times. Major benefits for veterans and
    their families have been the reduction of travel to VA tertiary
    care sites and of out-of-pocket travel expenses, as well as the
    opportunity to be close to home and receiving medical care. VA
    Black Hills has also steadily increased the utilization of
    telehealth services. Through the end of fiscal year 2014's
    third quarter, over 1,100 clinical video telehealth encounters
    have been completed.
        In conclusion, the VA Black Hills Health Care System, in
    conjunction with health care providers throughout its service
    area, is committed to providing high quality care and services
    for our veterans. Our location in a highly rural landscape
    presents VA with some challenges, the most significant of which
    is the ability to recruit and retain highly skilled physicians
    and nurses. Despite these challenges, we continue to focus on
    improving veterans' access to care.
        We sincerely appreciate the opportunity today to appear
    before this distinguished panel to share with you the great
    service that the VA Black Hills Health Care System provides to
    our Nation's heroes every day.
        We are pleased to respond to any questions or comments you
    may have.

        [The prepared statement of Dr. Julius appears in the
    Appendix]

        The Chairman. Thank you very much, Doctor.
        Kristi, you are recognized for opening questions.
        Ms. Noem. You spoke specifically just now about the Hot
    Springs facility being the highest cost operating facility
    within VISN 23. Is that correct?
        Dr. Julius. That is correct.
        Ms. Noem. Can tell me how you evaluated that cost?
        Dr. Julius. Well, it has to do with the total cost per
    unique patient.
        Ms. Noem. Per patient. Okay. Just hold on there 1 second.
        So when you remove services, do you remove the ability to
    service patients? If you are offering less services at a
    facility, these patients then have to go to other facilities to
    get treatment if they needed service. Is that correct?
        Dr. Julius. That is correct.
        Ms. Noem. So after you have removed services the past
    several years, when did you evaluate the cost of running the
    facility and the number of patients that are served? What date
    did you run the cost of that?
        Dr. Julius. The high cost per patient for VA Black Hills as
    an entire system----
        Ms. Noem. Well, I am concerned specifically about how you
    evaluated that the Hot Springs facility was the highest cost
    operating facility within VISN 23.
        Dr. Julius. If I said that, that was incorrect. The VA
    Black Hills Health Care System----
        Ms. Noem. As a whole is the highest cost.
        Dr. Julius. As a whole.
        Ms. Noem. So you are not laying the blame on the Hot
    Springs facility, that this facility for some reason is the
    anchor that is dragging down the rest of the system?
        Dr. Julius. No. There are challenges in a highly rural
    environment for all VA healthcare. So Fort Meade shares some of
    that as well.
        Ms. Noem. Thank you for that clarification. That is what I
    was concerned about is that you were evaluating the cost based
    on per patient served at the facility, which I do not think is
    a fair assessment considering the services that have been
    removed from there. Obviously, patients are going to have to go
    get treated somewhere else, and it would obviously increase the
    cost per patient served.
        Other questions that I have for you is tell me why you do
    not offer permanent positions to employees at the Hot Springs
    facility. You said in your statement that you were offering
    temporary ones. Why do you not open it up for permanent
    positions?
        Dr. Julius. I am not aware of that. I would refer that to
    Mr. DiStasio. I am not aware that I mentioned in the
    statement----
        Ms. Noem. Well, you talked about people that were employed
    at Hot Springs and that there were some temporary positions
    that were employed at a certain time. It was in your statement.
    I could look it up for you too, if you do not remember.
        [Applause.]
        Ms. Noem But you talked about----
        Dr. Julius. No. I think----
        Ms. Noem [continuing]. Temporary positions. Tell me about
    your hiring processes. Maybe that would be--for over the last 5
    years your hiring processes.
        Dr. Julius. To answer your question specifically, we were
    talking about the after-hours physicians, locum tenens
    providers. VA Black Hills for a long time has been attempting
    to recruit permanent positions for those people, the
    hospitalists that we have in the hospital, the people who are
    there after hours. Due to an inability to do that, we have had
    to rely on what are called locum tenens physicians, or
    contracted physicians, temporary physicians, that are hired and
    come in for the weekend or for a week to cover the hospital.
        Ms. Noem. So tell me what your ideal hiring process would
    look like. How do you traditionally--if you were to fill
    positions, how long would the job position be open? How would
    you advertise? So that everybody is aware what the normal
    process is.
        Dr. Julius. Well, typically we would post an opening saying
    that we have an opening for a hospitalist, for a critical care
    physician, for a surgeon. We would publish it in various places
    in which doctors view that. It would be open. We would be
    asking for resumes. People would submit them. We would look at
    them. We would interview them if we felt it was appropriate and
    hire them as permanent staff. That would be the ideal goal, and
    that is what we have tried to do all along. That leads to a
    stable medical staff in which you can be assured of the quality
    of the care that you are getting rather than the situation
    where you have new doctors coming in all the time, which also
    may be qualified but you do not know.
        Ms. Noem. And you followed that process here in Hot Springs
    at this facility within the last several years. You have gone
    through that entire process you just laid out.
        Dr. Julius. As far as I know we have. I will defer to Mr.
    DiStasio if he knows differently.
        Ms. Noem. There is some discrepancy in that. We have had
    Save the VA Committee members that have come to us and told us
    it has been very different. So I would love to have you, Mr.
    DiStasio, talk a little bit about the hiring processes and tell
    me if you disagree with them. Do you disagree with them in what
    has happened here at Hot Springs in how vacant positions have
    been filled and if permanent positions have been offered?
        Mr. DiStasio. Just to add to Dr. Julius' comment about
    providers, he described very accurately what we call a
    continuous and open announcement for physicians, and that is
    across the entire system. And the fact that we are using locum
    tenens is a commitment to keep the services open.
        There are, indeed, within the system some positions that
    are advertised as permanent and some that are temporary. We
    make management decisions every day about how are we going to
    structure the workforce, where do we need in fact temporary
    help because we perhaps have an employee who is out for an
    extended illness, if you will.
        I did listen carefully, as there were some descriptions and
    I believe you used the example of 8 days or 8 hours. I
    encourage people to bring those to my personal attention, and
    if they bring it to yours, please share it with me. I would
    like to understand----
        Ms. Noem. Well, I heard it this morning and that is why I
    brought it to you today at the hearing.
        Mr. DiStasio. I cannot say that is true in my system. I
    would share that we have about 140 positions at any time in
    some sort of phase of recruitment. We share that with our union
    partners so that they see the same information. And it is a way
    of making a partnership because we are all responsible for
    recruiting.
        Ms. Noem. Has a permanent position been offered at this
    facility in the last 2 years?
        Mr. DiStasio. Yes, ma'am.
        Ms. Noem. All right. I am out of time. I will have more
    questions later.
        The Chairman. Mr. Smith.
        Mr. Smith. Thank you, Mr. Chairman.
        And to our panel, I realize you are probably messengers
    here today. I imagine you might find parts of your job
    frustrating. But we are at a position here that I know has
    frustrated many. Can you tell me, as briefly as you can, what
    kind of veteran input you gathered from affected veterans that
    would lead to the December 2012 decision?
        Dr. Julius. The input that we got was--it was not a
    decision. It was basically a proposal. Obviously,
    administrators within VA, hospital administrators we have are
    always looking at the future and need to do due diligence as
    far as planning, planning for changes as far as the
    demographics, planning for changes in availability of services,
    those things. And so as part of this ongoing process then, the
    initial suggested proposal came out in December of 2011.
        We were instructed by the Secretary at the time, after it
    had already been discussed with the Secretary, that we needed
    to and wanted to--and we did--held multiple town hall meetings
    which were discussed earlier by the earlier panel all over the
    area, starting in Hot Springs and going to Rapid City and going
    to various places. The purpose of those town hall meetings was
    to get the very thing that you are saying, to say this is what
    VA is thinking. These are the problems that we anticipate in
    the future that we are going to have in order to ensure that
    you have reliable healthcare. This is what we are proposing.
    This is what we have heard. We can see that people have to
    travel a long ways for care. Perhaps this is a better solution
    that we could purchase care.
        Anyway, we presented it. Steve and I went around to--and
    the network director, Jan Murphy, went around to all of these
    various town halls in the different States, presented the
    proposal and asked for feedback. And we got a lot of feedback,
    as people have mentioned before. Most of it was negative but
    not all of it.
        Mr. Smith. And I think you can appreciate the dynamics in
    play here today.
        Now, you mentioned that it is difficult to recruit medical
    professionals. I would say that is not unique to any town,
    large city in America. There are various challenges. I will not
    get into some of the other healthcare distractions we have at
    the Federal level these days. But I will say at least my sense
    of it is there has been a question about VA commitment to this
    facility for some years now, even prior to December 2012. And
    so was that taken into account in terms of evaluating the
    difficulty of recruiting various professionals, providers?
        Dr. Julius. I missed your question. The fact that there
    appeared to lack of support for----
        Mr. Smith. Lack of commitment to the facility by the VA in
    general. I mean, there is a list here of discontinued clinical
    services beginning in 1996. Now, was that ever taken into
    account in terms of--I do not want to get ahead of myself here.
    But I would think if there were a decision made by the VA that
    would outline the commitment that the VA would make to this
    facility, if that were definitively announced, would it not
    lead to perhaps a better position to recruiting professionals?
        Dr. Julius. Oh, I think absolutely.
        Dr. Julius. I would comment, yes, I think absolutely. I
    think the uncertainty and the lengthy uncertainty of the
    process that has gone on now for this many years without a
    decision has definitely adversely affected our ability to
    recruit to Hot Springs. If you are a young professional and
    realize that the situation that you are coming to might change
    in the future, you are going to be more reluctant. So I would
    agree.
        Mr. Smith. Now, in terms of reimbursement, we heard
    concerns about delayed reimbursement to non-VA facilities.
    Would you say that that is a concern?
        Dr. Julius. I am not aware that it is. I certainly trust
    what President Brewer was saying. We track that now. That has
    been a problem in VA that has been an irritant to the former
    Secretary about why VA does not pay its bills, and so we have
    been tracking payment for non-VA care. We want to get 90
    percent of it paid within 30 days. Black Hills Health Care
    System, the last time that I checked, was paying 89 and a
    certain percentage, so almost 90 percent within the required
    goal of 30 days.
        Mr. Smith. Let us talk about reimbursement--oh, my time has
    expired.
        The Chairman. We will come back.
        Mr. Bilirakis.
        Mr. Bilirakis. Thank you, Mr. Chairman.
        Dr. Julius, what are the current primary specialty and
    healthcare wait times for, let us say, mental healthcare as
    well, wait times for veterans within the VA Black Hills Health
    Care System service area? Currently.
        Dr. Julius. I would like to allow Mr. DiStasio to answer
    for his facility.
        Mr. DiStasio. Thank you for the question.
        For actual wait times--and this is to completion of
    appointment--in primary care in June, which is the last
    released data that we have, it is about 17 days for a new
    patient--excuse me--primary care patient. For an established
    primary care patient, it is about 3 days.
        Mr. Bilirakis. Can you say that again?
        Mr. DiStasio. I'd be glad to repeat that. Thank you.
        For a new primary care patient, it is about 17 days.
        The Chairman. Will the gentleman yield?
        Mr. Bilirakis. Yes.
        The Chairman. I heard this for the first time in Roswell,
    New Mexico last weekend that there is a new metric now that VA
    is using. It is called prospective primary care patient. Why
    did you change the measurement? All we want to know is how long
    does it take a patient to receive an appointment and get their
    primary care taken care of. After all of this stuff that hit
    the fan, somebody somewhere has come up with a new metric to
    measure by. Why?
        Wait, wait, wait, wait.
        The Chairman. And I promise you that it did not come from
    the Black Hills Health Care System. It came down from the
    mountain in Washington. Why?
        Mr. DiStasio. You know, in my experience as a healthcare
    leader, one of the things a bureaucracy can do is try to
    standardize the operational definitions of the data they use so
    that you can make, if you will, apples-to-apples comparisons
    between facilities.
        What I have in front of me is the objective data for the
    time it actually takes us to complete an appointment in primary
    care, specialty care, and mental health for new and established
    patients.
        The Chairman. All right. Established patients. What is that
    number? What is that number?
        Mr. DiStasio. The number for primary care is about 3 days.
        The Chairman. All right. Ladies and gentlemen, turn around
    and watch this. Anybody in here get your primary care
    appointment within 3 days?
        [Chorus of noes.]
        The Chairman. One hand. One hand. I just do not get it.
    Your numbers still do not add up. I yield back.
        Mr. Bilirakis. I will go ahead and take the next question
    in the second round. I will yield to Ms. Noem or the chairman.
        The Chairman. You are yielding to me.
        Mr. Bilirakis. Sounds good.
        The Chairman. All right. Thank you.
        Mr. Bilirakis. Since you are the chairman.
        The Chairman. Dr. Julius, Kristi asked about the
    discrepancy in cost of unique patients within the system. If
    you know that number for the system, certainly you know the
    number for Fort Meade and you know the number for Hot Springs.
    So what is the cost for a unique at Hot Springs and the number
    at Fort Meade?
        Dr. Julius. I am sorry, Mr. Chairman. I do not have that
    information with me. We will be glad to take that for the
    record. I do not have it broken out because it is an integrated
    healthcare system. Now, we can talk to our CFO, and I am sure
    we can come up with something close to what you are asking for.
    But the two systems do not operate entirely independently. So
    there are things that are shared costs and those things.
        The Chairman. This is not unique to this health system
    because when we asked Dr. Lynch in a hearing in Washington what
    it costs to see a patient at VA, they have no idea. None. It is
    beyond me. If you go into the private sector, I guarantee you
    every CFO or CEO will tell you to the penny what it costs to
    see a patient. And yet, you have known for quite some time that
    we were going to come and have this hearing and that one of the
    biggest questions was going to be how much it costs to see a
    patient at this facility. And you do not have the answer. So
    for the record, if you would, please get that number to us as
    soon as possible. When I say as soon as possible, a week is
    sufficient, not the 2 years.
        The Chairman. How much of the $35 million that is estimated
    to be spent on non-VA care in this region--I guess that is the
    number that you are talking about--will be allocated to the PC3
    program?
        Mr. DiStasio. Very little of those funds will go to PC3.
        The Chairman. And the reason is?
        Mr. DiStasio. Still a developing market. Our landscape here
    in the Black Hills is that the contractors or the providers
    that PC3 is approaching are the same ones, if you will, that we
    use already as part of our non-VA care network. So it is fair
    to say there is not a lot of competition in this market, and I
    am sure their conversations are ongoing about trying to
    establish a robust PC3 contract.
        The Chairman. So can you tell me how many? You said not
    much. But can you tell me how many authorizations have been
    issued through PC3? Close. It does not have to be exact.
        Mr. DiStasio. No. I would never estimate for you, but I am
    glad to come back with a better number in the near future.
        The Chairman. You did not give me any number.
        Mr. DiStasio. No number.
        The Chairman. Okay. I was going to say do not come back
    with a better one. Come back with a number.
        Mr. DiStasio. A number.
        The Chairman. The accuracy of the data that VA has used to
    support closing the Hot Springs campus has been called into
    question. You heard that this morning. Could you respond to
    some of those numbers and the criticism that you heard this
    morning? Because I think it is important. We heard them. We
    need to hear what your numbers are. So, Mr. DiStasio or Dr.
    Julius, either one.
        Mr. DiStasio. I think we always have an opportunity to
    check with each other when you have two parties that, if you
    will, have numbers that, if you will, differ. One of the things
    that is striking about the data we collect is that we have to
    make sure that we are both looking at the same site and the
    same currency date and the same operational definition for the
    numbers.
        I know there has been a lot of dialogue about the cost of
    renovation. When we in VA estimated what it would cost to
    rework the Dom, we had to make sure that we were fully
    compliant with various laws and access. We wanted to have a
    model of care that was better for our veterans. And we were
    required to show that those costs--what they extrapolated over
    30 years of operation. So our number was much beyond just the
    renovation portion of it, if you will.
        You know, I do agree with Save the VA's point, though. That
    is a grand old building. It is not going to blow down. It is
    not going to fall down. It is not going to flood. But in my
    estimation, it is not appropriate for healthcare services for
    the next generation of veterans. Thank you.
        The Chairman. Wait, wait, wait. Come on, everybody.
        What is it appropriately ready for?
        Mr. DiStasio. My largest concern about the Dom is, of
    course, the setting for our veterans, the privacy that they
    have or do not have, restroom access, those sorts of things.
        I think there could be some alternative uses for that
    building that would help bring better things for the community
    and VA. We are currently conducting an alternative use study,
    which gives us the ability to begin looking nationwide and
    seeing what opportunities could be available.
        I hope you are aware we received last week a proposal under
    the environmental impact statement process from an Iowa group
    that in fact prepared a rather lengthy prospectus on another
    possible use for some of those buildings at least.
        The Chairman. Ms. Noem?
        Ms. Noem. Dr. Julius, how many veterans do you say you
    service on Pine Ridge? Or how many veterans do you say are
    there that the VA actually counts?
        Dr. Julius. We have it and I am looking right now.
        The Chairman. Pause the clock for a minute while they are
    looking it up so Ms. Noem does not lose her time.
        Mr. DiStasio. So I have some data in front of me that was
    prepared in May of 2013 trying to get to the root of this. And
    we used a number of different sources. Let me just run through
    them very quickly.
        Ms. Noem. What do you use when you are evaluating whether
    to keep this facility open or not? I just want that number.
    What number do you say that you have on Pine Ridge that would
    use this facility?
        Mr. DiStasio. Our records show that we serve 1,370 Native
    Americans.
        Ms. Noem. 1,370.
        Mr. DiStasio. But there is a caveat. The Native American
    veterans are not required in our system to identify themselves
    as such. So there could be more.
        Ms. Noem. But I will tell you that I have been going
    through this for the last 2 and a half years with the Hot
    Springs community and with you, and the entire time the Pine
    Ridge reservation and the Oglala Tribe have told us that they
    believe they have 3,500 veterans. Tell me what you have done to
    try to reconcile the numbers so that you can identify the
    veterans that they have and reconcile the numbers and come to
    some kind of conclusion on how many veterans really are
    represented by that tribe.
        Mr. DiStasio. Thank you for the question.
        My personal effort has been to communicate with Chairman
    Brewer on a personal level and a letter to his office
    describing if you have more veterans, names, lists, whatever,
    we would gladly take a copy. We have also done that with our
    county veterans service officers and our tribal veterans
    service officers. We are also waiting to see what happens with
    Secretary Zimmerman's Reach All Veterans initiative, which I
    think will be an important part of----
        Ms. Noem. So have you come closer together in number? Have
    you reconciled after you wrote these letters? I know there was
    ongoing dialogue over the past 2 and a half years. Have you
    come closer together at agreement on how many veterans are
    actually served? What number are you currently using to
    evaluate how many are serviced by this facility?
        Mr. DiStasio. The 1,370 number is----
        Ms. Noem. You have not moved off your number at all.
        Mr. DiStasio. That is the best number we have to date.
        Ms. Noem. Does the sole responsibility of counting those
    veterans on Pine Ridge rest on them and not on you?
        Mr. DiStasio. It does not. We took another few steps and we
    went to the Census facts and then we went to the National
    Center for Veterans Analysis. They gave us a number of the vet
    population of about 2,435.
        Ms. Noem. So that might be a good number to use.
        Mr. DiStasio. It may be. Again, the caveat was these were
    for veterans who resided in the counties that encompassed the
    reservations and they include known non-Native American
    veterans. But if we use that range of 1,370 to 2,400, we hope
    we have got the best math possible at this moment.
        Ms. Noem. Did you do any kind of outreach to the tribe or
    go down there and try to register veterans? You did?
        Mr. DiStasio. We did.
        Ms. Noem. You had meetings down there and invited all the
    veterans to come in and get signed up for care through the VA
    facility?
        Mr. DiStasio. That is correct.
        Ms. Noem. How many veterans did you gain during that
    process? Because you are using the same number that you used 2
    and a half years ago. Are you saying a single veteran did not
    show up and say, hey, you were not counting me before?
        Mr. DiStasio. Well, I personally have been down there a few
    times each year over the last 5 or 6 years, and in my personal
    observations, we have enrolled one or two at each event. There
    could be others of similar numbers at other events, but I can
    capture that data for you and bring it back.
        Ms. Noem. That would be great.
        Dr. Julius, I would like you to speak to the recent audit.
    In late July, the VA released the results of their internal
    audit for all of the VISN's in the country. Out of the all the
    hospitals within VISN 23, Black Hills Health Care System had
    the worst results. Rapid City staff was instructed to not use
    the electronic wait list required by the VA for scheduling. The
    staff was also instructed to manipulate data throughout the
    Black Hills Health Care System. This is an audit that was done
    internally by the VA. I would like you to speak to that audit
    and tell me how those results impact you personally and what
    you are doing to change the delivery of healthcare to veterans
    in this area and how closing down the Hot Springs facility will
    help you better serve the veterans within your system.
        Dr. Julius. Congresswoman Noem, thank you for the question.
        Concerning the audit results, yes. I mean, this was
    obviously a crisis for VHA when the news from the Phoenix VA
    came out and the Secretary then tasked senior leadership to
    audit the scheduling practices at all of the 128 medical
    centers and all CBOC's more than 10,000 veterans. And I was a
    part of that group. I went to another VISN. I took part in
    these very audits.
        What I would say is obviously if we get any scheduler that
    says they felt that they were instructed to manipulate the
    data, that is unacceptable. And from the data, like I said, we
    tried to meet with maybe 10 schedulers. And so it is often
    difficult to tell. If one scheduler said that they were feeling
    they were encouraged to do that, we would put it down. And that
    would be a certain percentage that had answered yes to that
    question. I do not know how pervasive that is. But like I said,
    anytime any one of our scheduling people are feeling that they
    have been instructed, implied or
    overtly, to manipulate the scheduling package, that is
    unacceptable.
        As a result of that, then we have also been instructed--so
    me as the acting network director, Steve as a center director,
    we have been meeting regularly with the schedulers at all sites
    of care and having this very discussion and saying, you know,
    this is a crisis for VHA. We have been accused of losing our
    integrity. We have to earn our credibility back. We cannot earn
    it back if we are having stuff like this going on. And I
    realize these schedulers are the front line folks, but we as
    senior leaders need to be giving them the message that, no, you
    know, the wait times are the wait times. Whatever they are you
    are putting in. The desired date is what the veteran says. And
    we do not want anybody to feel that they are in any pressure to
    do something that they----
        Ms. Noem. So who has been fired?
        Dr. Julius. I am not sure we have anybody that needs to be
    fired for that within the VA Black Hills or VISN 23.
        Ms. Noem. So you do not trust what your schedulers have
    told you. That is the discrepancy that we have is this is an
    internal audit done by the VA, and your schedulers felt they
    were told to manipulate data, that they were instructed by
    staff to not use the electronic wait list. We had a discussion
    earlier here about your wait list, that the veterans largely in
    the room did not agree with the waiting times. So we do have a
    problem here in the Black Hills Health Care System, which our
    veterans are certainly paying the consequences. I want to know
    if there have been any actions taken within the healthcare
    system in the Black Hills in regards to this audit.
        Dr. Julius. Well, plenty of actions of what I just said. No
    personnel actions that I am aware of because, again, these were
    comments that we solicited from schedulers without attribution.
    We wanted them to be as candid as they could possibly be. It
    was also instructed we are not trying to get anybody in
    trouble. We want to know what is actually going on. And so in
    trying to create an environment of psychological safety, they
    answered candidly about the way that they felt things were
    going. Now we are going back and saying--I think in the data
    you have to interpret it again that not all schedulers said
    that.
        Ms. Noem. No. I agree. I do not believe every scheduler
    said that. But I would like to know what changes you are
    implementing. As a leader, as a manager, as a director of this
    healthcare system, I want to know how you personally are taking
    action to make sure this does not happen again and that our
    veterans are not having long wait times.
        Dr. Julius. Well, one of the first things I think that
    nationally they realized that contributed to this was our
    performance metric of--performance goal of getting people in
    within 14 days of their desired date. That was a good stretch
    goal. That was a good aspirational goal. That is something that
    we strive to do. All of us would like to have an appointment as
    near our desired date as possible. But I think when that goal
    was put into place, it was an unrealistic goal and we did not
    have the infrastructure as a system to actually meet that. But
    then it went from an aspirational goal into a performance
    measure where all of a sudden it was put into people's annual
    performance plans. And I think the unintended consequence of
    that is that was then viewed as a stringent, more serious
    thing. I am going to be judged whether my performance this year
    was satisfactory.
        And for whatever reason--like I said, I do not believe any
    of our senior leaders are telling schedulers to cheat, to
    change the data, but somewhere in the system, in mid-managers
    or somewhere, they were hearing the message or it was implied
    that we need to meet this metric, and they did the things that
    they should not have done.
        So the Secretary immediately ordered that any reference in
    anybody's performance plan to a 14-day metric be removed. They
    have all been removed. The other things that we have talked
    about is, like I said, that facility directors now will meet
    with schedulers at all sites of care every 30 days and have
    listening sessions to discuss what their life is like, what are
    they hearing, what are the barriers, what are their challenges.
    Then the VISN director is instructed to every 90 days visit
    every medical center and do the same thing, meet with the
    schedulers representing the VISN now and again reiterating our
    core values and that we do not want this behavior in VHA. We
    cannot have it. And like I said, we are rightfully accused of
    having lost our integrity, and we now need to spend time
    earning that back.
        The Chairman. Mr. Smith.
        Mr. Smith. Thank you.
        Let us discuss reimbursement levels if indeed it would come
    to the point where other entities outside the VA would be
    reimbursed for the care of veterans. Has that reimbursement
    schedule been established?
        Dr. Julius. On the new veterans' access act you mean?
        Mr. Smith. Well, on the premise that there would be
    veterans cared for outside the VA system, has a reimbursement
    level plan been established?
        Dr. Julius. I am obviously not an expert in the intricacies
    of the new law that was passed. It was my understanding that
    the reimbursement rate would be at Medicare rates, but if
    needed, higher rates could be negotiated locally if that were
    necessary to obtain care.
        Mr. Smith. Because we have veterans who would come from
    Scottsbluff, for example. We have veterans who would come from
    Gordon, who would come from Chadron, who would come from
    Alliance, among other places. So we have got critical access
    hospitals in some of these communities, not all of them, but
    critical access hospitals that have a level of reimbursement.
    Would that level of reimbursement be similar? Would it be the
    same? Could you guarantee that? Has there been any groundwork
    done to establish those reimbursement levels?
        Dr. Julius. To that specific question, I guess I cannot
    answer that. Steve, do you have any additional information?
        Mr. DiStasio. Thank you, Congressman Smith.
        We have had some preliminary discussions with them about
    their approachability about taking care of veterans. We are
    well aware of the reimbursement rates for critical access
    hospitals. But at this point in the process, it is really
    premature for us to enter into any contracts, but at the point
    that would be done, I think that conversation is possible, what
    will be the rate for what services that are provided.
        Mr. Smith. And I can appreciate that.
        And I actually misspoke earlier when I said December 2012.
    It is actually December 2011, as many in the room full well are
    familiar with that.
        Now, it would seem to me that as major of a decision as it
    would be--the proposal--and I hope that the VA will abandon its
    proposal to reduce its services in Hot Springs. And this is not
    about saving an historic building. I love old buildings. I love
    old architecture. And I think we have a very unique situation
    here, though, where we have got, yes, an historic location with
    a very unique mission, and I hope that we can combine those
    missions because I happen to think that if there is a will,
    there is a way to get this done. And I think it can be done
    without adding a greater burden on rural veterans who already
    travel a good ways to get to Hot Springs. It is even further,
    we know, to Rapid City or Fort Meade.
        So I think it is vital that we enter the decision with eyes
    wide open in terms of what reimbursement levels are. I struggle
    to think that the 3 years has not been enough time to
    investigate what reimbursement levels would be. We have heard
    that there are delays in payments. That has been a consistent
    concern within the VA over time. I am frustrated as someone who
    has voted to continually increase funding to the VA, and we
    hear about various situations throughout public policy where
    agencies are expected to do more with less, and yet, we have
    significantly increased the funding and again a few weeks ago.
    And I would hope that the funds could be utilized to maintain
    the mission and objective in Hot Springs.
        Thank you.
        The Chairman. Mr. Bilirakis.
        Mr. Bilirakis. Thank you. That applause was not for me.
        We have increased the funding by 40 percent in the last few
    years, and then we have given another $5 billion for additional
    healthcare providers.
        I am going to get back to the building for Dr. Julius. In
    your testimony, you state that the current residential
    rehabilitation treatment program--the building at Hot Springs
    is not compliant with the Architectural Barriers Act. Can you
    elaborate on which section of the act that the building is
    violating and how long has it been in violation?
        Dr. Julius. No. I am sorry I do not have the particulars as
    far as----
        [Laughter.]
        Dr. Julius [continuing]. What is involved with the
    Architectural Barriers Act. We had talked previously about the
    Americans with Disabilities Act, but I was informed by my
    highers-up in VACO that Federal buildings are not subject to
    that, but we are subject to the Architectural Barriers Act.
        Mr. Bilirakis. Excuse me, sir. I do not want to interrupt.
    But I do want to state that you are aware that there is a
    violation or a couple violations. This is what was stated by
    the VA. Are you not?
        Dr. Julius. That is my understanding, yes.
        Mr. Bilirakis. Now, have any of these violations--have any
    steps been taken to correct these violations, if there are
    violations?
        Dr. Julius. Well, again, without knowing exactly what was
    going on--I mean, certainly some things are. You know, the
    ramps that we talked about--typically they are too steep. And
    so we have made some corrections as you saw this morning. And
    elevators have been installed to mitigate some of the
    deficiencies of the building. But what specific parts of the
    act are in violation I cannot answer it accurately.
        Mr. Bilirakis. Mr. DiStasio, please.
        Mr. DiStasio. No, sir. I am unable to cite a specific
    chapter. But our folks in construction and facility management
    at VACO who have looked at the building and helped us clarify
    what standards we are required to meet by law consistently
    point out emergency exits and the angle of the ramps that you
    saw this morning.
        Mr. Bilirakis. Do you not think it would be more efficient,
    less costly to actually take care of any of these violations,
    bring them up to code, if there are any, than the
    reconfiguration plan proposed by the VA?
        Mr. DiStasio. I think this is a key point that needs
    ongoing discussion is which is the most viable cost, renovation
    or new construction. And of course, I am including operating
    costs over a number of years.
        We also have to look at something bigger than the Americans
    Barriers Act. We have to look at whether or not the veterans
    can have privacy, can they have a private bathroom versus a
    communal bathroom down the hall.
        Mr. Bilirakis. Well, the thing is that you guys are pleased
    with this building, are you not? Are you pleased with the
    services?
        Mr. Bilirakis. I mean, that is what should matter. In my
    opinion, Washington should not be making these decisions. Our
    veterans should be making these decisions.
        Well, thank you very much. I yield back. Thank you.
        The Chairman. If you would excuse me, sir. Thank you very
    much for your service. Thank you for your service.
        If you would, tell me exactly how stakeholder and
    congressional delegation feedback has been incorporated in your
    proposal.
        Mr. DiStasio. Through the initial hearing period that
    occurred in late 2011 and 2012, we took comments from almost
    3,000 people, as I recall, and we took it in emails and
    letters. We handed out comment cards. All of that was collected
    and then summarized.
        In our ongoing conversations with VA central office, we
    shared what we were hearing in terms of thematics. And it is
    accurate to say that the very largest majority of people were
    saying do not do this.
        Nonetheless, my concern has always been about conserving
    quality and safety of care. And so we have discussed very
    carefully with our VA leadership how do we balance these two
    things, if you will, a very heartfelt request from the
    veterans, do not take away this building, with the challenge of
    making sure that we do not harm a veteran.
        The Chairman. If I could, Doctor, this is a little off
    topic, but are you credentialed? Are you currently
    credentialed? Do you see patients within the VA system?
        Dr. Julius. Not currently, no.
        The Chairman. No.
        Dr. Julius. I did until 5 years ago, yes.
        The Chairman. I have a little bit of a problem with the way
    VA does this because when we had the backlog that erupted--
    actually it was back to April 9th, but there are physicians
    within the system that could not see patients. Are you paid for
    one job? Are you paid for more than one job in your current
    position?
        Dr. Julius. I assume I am paid for one job, being the Chief
    Medical Officer of the network.
        The Chairman. Well, certain pay scales are set. If you are
    a physician, then you get paid for being a doctor. You get paid
    for being Chief Medical Officer. You get paid for being the
    VISN Director. Can you explain----
        Dr. Julius. My salary is determined by the fact that I am a
    physician.
        The Chairman. Despite the fact that some of the most
    serious problems within South Dakota in regard to wait times
    were here, did either of you receive a bonus in the last
    several years?
        Dr. Julius. I received a performance award for last year's
    performance, yes.
        Mr. DiStasio. And I did also, the first time during my
    period as a Director for about 3 years now.
        The Chairman. Can you tell us how much it would cost,
    because I think there has to be some type of an idea, to bring
    the facility to the ADA compliance? How much money are we
    talking about?
        Mr. DiStasio. The financial analysis that was done included
    a significant focus on those costs. I did not bring that with
    me. Certainly the Members of Congress from this district have
    those figures, and of course, we are glad to provide them also
    as a question for the record.
        The Chairman. And also for the committee, if you would
    provide that for us as well. I think it is pretty important
    that we figure it out.
        I do not know if we have a failure to communicate.
        The Chairman. But let me ask you this. You talked about Hot
    Springs being a difficult place to recruit physicians to come
    to and live. Rapid City--a little easier?
        Mr. DiStasio. Yes, sir.
        The Chairman. How much easier is it to get a physician to
    go to Rapid City?
        Mr. DiStasio. We have no physician vacancies in our
    operations in Rapid City.
        The Chairman. Here is something that I am wondering because
    you pay veterans to travel from here, and you are talking about
    hundreds of veterans having to travel to Rapid City, but one
    doc, two docs, three docs. Why can they not live there and you
    pay them to travel down here?
        Mr. DiStasio. We do that already. Our specialists that come
    down here may be assigned to Fort Meade, may be in Rapid City.
    Some are assigned here. So they may often serve patients in
    both locations.
        I would offer to you that sometimes when we are in
    negotiation with a high value asset, a specialist, if you will,
    in medicine and we discuss with them that we would like them to
    travel to serve our patient population, that can be a
    disincentive to them.
        The Chairman. That is unfortunate because it calls into
    question whether they are working for the right reason. Are
    they working for a buck or are they working to serve America's
    heroes?
        [Applause.]
        The Chairman. And I would wonder if they are not willing to
    sacrifice, do we need them?
        [Applause.]
        The Chairman. I want to give Ms. Noem and Mr. Smith the
    opportunity to do another round of questions, if you have one,
    because we are scheduled to wrap up in about 11 minutes. So,
    Ms. Noem, you are recognized.
        Ms. Noem. You cannot remember what your original proposal
    of moving the facility to Rapid City was, how much that would
    cost moving care services to Rapid City, putting clinics in.
    What was your original proposal? What was the cost of that?
        Mr. DiStasio. It is never a good idea to try to recall off
    the top of your head----
        Ms. Noem. Well, the thing that is really unfortunate about
    the situation is that one of the biggest reasons you have used
    for closing down the Hot Springs facility has been cost and to
    the detriment of our veterans. So I would like to have a
    general conversation because the proposal has been around for
    years now. And it took a long time to get a cost analysis from
    the VA on what the investment would be to bring this facility
    up to what they would think would be something they could
    approve of, but you cannot remember that either. And so I do
    not need it to be down to the penny. Maybe just within $10
    million of where it was would be good because it is your
    proposals and it is your analysis.
        And the Save the VA Committee--not once--not once--during
    their testimony did they not have an answer that we asked them.
    They had every single answer for everything. They had their
    data. They had their numbers. They had their facts. They were
    prepared. Their heart and guts is invested in this thing. And
    you have sat here over and over today and said you do not know.
    You will have to get us the information. That is not
    acceptable.
        [Applause.]
        Ms. Noem. So at this point, I do not care if you are wrong.
    I really do not care if you are wrong. I want you to say
    something other than I will get that for you or I do not know.
        So what was your cost to get this facility up to where you
    would deem it--if that investment choice was made and what was
    your approximate cost for your original proposal of shutting
    down this facility and moving to the Rapid City area and Fort
    Meade?
        Mr. DiStasio. Congresswoman, I care about being accurate. I
    care about what is happening to veterans. I have those numbers.
    We have put them into the hands of your staff. We are glad to
    do that again.
        Ms. Noem. They did not realize they were responsible to
    bring your numbers. But we are getting them right now.
    Hopefully by the end of the hearing, we will have them.
        Mr. DiStasio. That is more than fair. I am always glad to
    continue this dialogue whether it is again in another hearing
    or perhaps in a visit in your office or mine. You deserve those
    answers. We will get them for you.
        Ms. Noem. Okay.
        Secretary Shinseki, when we had a meeting with him in
    Washington, DC and talked about his decision to move forward
    with the EIS process--he promised that there would be no more
    reduction in services at this facility while we went through
    that process. However, I have heard from many veterans in the
    area, the Save the VA Committee, that we have continued to lose
    services. And you will have to clarify for me if this is
    accurate or not. I believe one of them--it was a conversation
    that happened several months ago about checkups for pacemakers
    no longer being done here in Hot Springs, stress tests being
    moved to different facilities. And so is it true that services
    throughout this process, even though the Secretary of the VA
    told us in that meeting he would not degrade the services here
    any more--is it is true that it has continued to happen
    throughout the process?
        Mr. DiStasio. There are certainly episodic changes in
    services. And if I could address very simply the one about
    cardiac pacemakers. Our process in the past had been to have a
    primary care physician, if you will, oversee that program. The
    standard of care has exceeded that and it requires a
    cardiologist. We have no such person on staff. So we made a
    contract with a regional cardiology group. There really is only
    one in the Black Hills. And so we have been able to meet that
    standard of care which is more important to us than, if you
    will, not. That service is provided by those cardiologists at
    many locations in the Black Hills and then also remotely.
        Ms. Noem. So you are saying the standard of care changed
    and that is why that service can no longer be offered here at
    Hot Springs. Is that a standard of care that is set within the
    VA or within the American Medical Association? That standard of
    care--where did that come from?
        Mr. DiStasio. Those are generally set by the professional
    associations, for instance, cardiology. The American Medical
    Association certainly may sign onto that.
        Ms. Noem. And then the VA makes the decision whether they
    choose to adopt those standards of care?
        Mr. DiStasio. Generally speaking, we make every effort to
    meet the community standard of care, and in this case, that is
    how that is done here.
        Ms. Noem. I anticipated that when the Secretary told us he
    would not reduce services, he would do everything in his power
    to make sure that services were not reduced throughout this
    process. And that is what is disappointing about it is that I
    felt as though he should have made the investment to make sure
    we could deliver those services here and continue to see
    patients here while we went through the EIS process so it could
    be credible at the end of the day.
        Thank you. I am out of time.
        The Chairman. Mr. Smith.
        Mr. Smith. Just in the interest of time, I do want to
    respect the limits of time. But I would highly discourage using
    the information that you say is driving the decision that it is
    so difficult to recruit professionals because there is
    seemingly abundant data that there is an eager reduction in
    services, and it would be very difficult to recruit anyone to a
    facility that does not seem to have a commitment behind it.
        [Applause.]
        Mr. Smith. So I would humbly ask that you refrain from
    using many of these driving factors, seemingly driving factors
    in the decision because I just do not think it can be relevant
    and especially when perhaps any other facility, rural or urban,
    would be facing a similar challenge. So if you wish to respond,
    go ahead.
        Dr. Julius. Yes, thank you, Congressman.
        I totally agree. I totally agree that it is difficult to
    recruit when there is the uncertainty about what is going on. I
    think everybody has the same goal in mind, though, and that is
    that we are all trying to figure out how can we ensure that we
    are providing safe, quality, evidence-based care to our
    veterans. Standards of care change over time. We have noticed
    that in the surgical arena. We did a lot of surgeries in small
    hospitals in the past, and then there was a very famous bad
    example in VA in which we had terrible surgical outcomes as a
    result of that facility sort of overextending what the support
    the staff that they had to do that. That caused VA to reassess
    our surgical complexity models. All these things are
    continually evolving, and so it is not just a standard that
    just says, well, the way it was 20 years ago or 15 years ago or
    5 years ago is the way it is going to be 2 years from now.
        Mr. Smith. I fully understand the need for agility and
    flexibility and the ease of operation. But when there seems to
    be a self-fulfilling prophecy here, it is frustrating as a
    policymaker. It is frustrating as we do engage in how much
    money to spend--taxpayer dollars--to maintain the commitment
    that I think we can all agree we have to stand behind our
    veterans and their care.
        Dr. Julius. The reality is it is difficult to recruit and
    retain providers here. To your point--I grant that--the
    uncertainty of the situation exacerbates that.
        Mr. Smith. I think that is an understatement.
        But I yield back. Thank you.
        The Chairman. Mr. Bilirakis.
        Mr. Bilirakis. No further questions.
        The Chairman. Ms. Noem.
        Ms. Noem. Is it not true that you have justified the
    closing of this facility based on more veterans seeking
    services in Rapid City? I know that we have had conversations
    before, and I think, Mr. DiStasio, you and I have had that
    conversation before where you have said more and more veterans
    are choosing to go to Rapid City for their care and for their
    services.
        Mr. DiStasio. I would clarify that as the phenomenon we are
    seeing with distribution of the veterans. More and more of them
    live there. By nature of the kind of care they may need,
    regional health is our tertiary referral center. So they have
    to go to Rapid City. And then in addition, our specific effort
    to expand the spending of non-VA to save veterans from
    traveling to Minneapolis, Omaha, and so on has allowed them to
    seek care in Rapid City. And Congressman Smith also in
    Scottsbluff, Gordon, Alliance and so on.
        Ms. Noem. But as we lose services here, it obviously would
    cause more veterans to seek care in Rapid City as well. You
    would agree to that.
        Mr. DiStasio. Or some other local healthcare facility
    closer to their home.
        Ms. Noem. Can you elaborate--well, no. I am going to pass.
        Mr. Chairman, I am very concerned. As a representative of
    the VA, do you believe that you are carrying out the mission of
    the VA? What is the mission of the VA, and do you believe that
    you are carrying out that mission when the decision is being
    made to go forward with vacating the Hot Springs campus?
        Mr. DiStasio. There is no decision----
        Ms. Noem. Is there a mission of the VA?
        Mr. DiStasio. There is.
        Ms. Noem. What is that?
        Mr. DiStasio. To care for those who have borne the battle.
        There is no decision to close this campus. And in fact, the
    proposal is to certainly change our inpatient footprint but to
    maintain, as someone requested, a specialty community-based
    outpatient clinic to serve veterans here locally and then any
    that choose to travel to this location.
        Ms. Noem. You know, that reminds me. Have you had a
    conversation with the Fall River Hospital yet about caring for
    people in this area if this facility were to close?
        Mr. DiStasio. I met personally with the board of the
    hospital twice.
        Ms. Noem. What did they say to you? Do they have the
    capacity to----
        Mr. DiStasio. Their approach to the conversation was that
    essentially they did not want to have it at that time, that we
    would continue it at some later time.
        Ms. Noem. Okay. Continue on. I am sorry I interrupted you.
        Mr. DiStasio. Thank you. That was all.
        Ms. Noem. The last question I have then is when you are
    looking at evaluating a facility, whether for closure or to
    continue to operate it, what are the factors that you consider?
    I know cost is a factor. What else are the considerations? Is
    it desires of the veterans or the best service and care of the
    veterans? Is that one of the factors as well?
        Mr. DiStasio. First and foremost, it has been about
    delivery of care to the veterans. And it is focused almost
    entirely on quality and safety. Can we preserve that for our
    veterans? To be the leader of a healthcare organization or to
    be a physician or a nurse or a technician in a health care
    organization that might injure a veteran would just be a
    nightmare in our lives and certainly a nightmare for----
        Ms. Noem. Do you think that would happen here at Hot
    Springs?
        Mr. DiStasio. I am concerned that that could happen here.
        Ms. Noem. How could that happen here at Hot Springs?
        Mr. DiStasio. When you look at trying to recruit and retain
    people that have a full range of competencies, you have both
    the issue of them maintaining their competencies. Just as
    important for support staff is gaining the competency. So you
    might, in fact, have a nurse who does not have the depth of
    skill to recognize when a patient is getting in trouble and
    know when to notify a provider or to suggest that a transfer to
    a higher level of care be made.
        Ms. Noem. So you believe they are not treating enough
    patients to maintain the competency levels that they need to
    properly care for the veterans?
        Mr. DiStasio. That is part of the issue we are trying to
    deal with, yes.
        Ms. Noem. So could you tell me what consideration you gave
    to the Save the VA's proposal on the PTSD establishment of a
    center here in Hot Springs? And did it have potential, and did
    you consider using it as that kind of a facility as well?
        Mr. DiStasio. I did consider it. I still consider it. I
    think one of the very strong strengths of their proposal was
    also the veteran industry concept. I was a little surprised,
    though, that we have not heard much from Save the VA on either
    of those two proposals over about the last year, and I was
    expecting them to comment on it in the environmental impact
    statement process. They chose not to.
        Ms. Noem. Well, I think it might be because they have not
    gotten answers to their original questions. We are still
    arguing on----
        Ms. Noem. You have not been able to reconcile the data on
    number of veterans served in the area. You have not been able
    to reconcile the data on wait times. Then the audit came out
    which obviously showed we were not caring for our veterans in
    this healthcare system properly. So I think because they have
    never received clear answers from the VA on any of their
    original questions, why were they to put more work into a
    proposal they have already submitted to you that you have given
    them no feedback on and continue to push that when we still
    have all these unresolved issues? I do not fault them one bit
    for not bringing that up during this process because from the
    very beginning when they have been told something from the VA
    or from the Secretary, it has not been followed through on.
        With that, Mr. Chairman, I will yield back.
        The Chairman. Gentlemen, thank you very much for being part
    of the second panel. We appreciate you being here to answer our
    questions. We would ask that you continue to be open and
    transparent and listen to what the people in this community are
    saying. This is a very unique situation. We are not talking
    about a facility that was built 30 years ago. We are definitely
    talking about the heart of a community. I would not want to be
    on the watch when that heart quit beating. I think that the
    veterans here today are serious about trying to come up with
    solutions. We will do what we can.
        And I want the folks in the audience to understand too that
    VA is not perfect and the private sector is not perfect. There
    will always be errors that will be made by both. We will not be
    able to please everybody. Lord knows, we in the political arena
    understand that probably better than most. But we will try.
        We are here today at Kristi Noem's request to try to come
    to a resolution that is satisfactory to those that have borne
    the battle, their widows, and their orphans. That is the most
    important thing that we should all remember. As I said in my
    opening statement, the veteran is sacred. VA is not. We will
    continue to watch as these Members who have come here today and
    others within their delegation try to come to a resolution. I
    have got some ideas that I will share with Kristi offline when
    we get back in September.
        But, again, ladies and gentlemen, thank you for being here
    today. It has been an honor to be in Hot Springs. And next time
    I come, I will be spending the night here not in Rapid City.
        The Chairman. This hearing is adjourned.
        [Whereupon, at 1:06 p.m., the committee was adjourned.]

                                    APPENDIX

                  Prepared Statement of Jeff Miller, Chairman

        Good morning and thank you for joining us today.
        I am Jeff Miller, Chairman of the Committee on Veterans' Affairs
    for the United States House of Representatives and Congressman from the
    First District of Florida, where--as we like to say--thousands live
    like millions wish they could.
        I am joined today by Congressman Gus Bilirakis, Committee Vice
    Chairman from the Twelfth District of Florida; by Congressman Adrian
    Smith from the Third District of Nebraska; and, by your Congresswoman
    and my friend, Kristi Noem, from right here in South Dakota.
        Rep. Noem (Kristi) is known in Washington for her hard work,
    steadfast leadership, and strong voice--particularly where the needs of
    servicemembers and veterans in South Dakota and around the nation are
    concerned.
        Earlier this morning, she led us on a tour of the Hot Springs
    campus so that we could see first-hand the services that are provided
    and the impact closure of that facility would have on the hard-working
    employees who work there and the deserving veterans who receive care
    there.
        During that visit, it became even more apparent to me what an
    ardent and impassioned advocate she is for her fellow South Dakotans.
        This community has a long and storied history of coming together to
    care for its military and veteran populations and, looking out on this
    audience, it is clear that passion and enthusiasm has never been more
    alive.
        Thank you all for taking time out of your day to join us and for
    the work that you do to support and honor our nation's veterans.
        It is a honor to be in Hot Springs and I am grateful to Rep. Noem
    (Kristi) for inviting us here.
        Before I go any further, I would like to ask all of the veterans in
    our audience to please stand if you are able or raise your hand and be
    recognized?
        Thank you for your service.
        We are here today on your behalf to ensure that the care you
    receive is timely, convenient, accessible, and high-quality.
        The Department of Veterans Affairs (VA) Black Hills Health Care
    System--which has campuses in Fort Meade and Hot Springs--covers a
    service area of approximately one-hundred thousand (100,000) square
    miles across four states and has one of the highest enrolled veteran
    penetration rates in the country.
        As you all know, in April, a Committee investigation and
    whistleblower revelations exposed widespread corruption and systemic
    access delays and accountability failures across the VA healthcare
    system that left thousands of veterans--including some right here in
    your state--waiting for weeks, months, and even years for the health
    care they earned through honorable service to our nation.
        The Committee has conducted aggressive and historic oversight in
    the four months since the depth of VA's many deficiencies has come to
    light; VA senior leaders at all levels have resigned and been replaced;
    and, nationwide initiatives have been put undertaken.
        Just two weeks ago today, Congress passed a bipartisan Conference
    agreement that will improve accountability for VA employees; increase
    access to care for veterans facing lengthy waiting times for VA
    patients or residing far from the nearest VA facility; and pave the way
    for long-term reforms that will dramatically improve the Department for
    veterans today and for generations to come.
        However, no single law by itself will create the large scale
    cultural and structural reform that is truly needed in our nation's
    second largest bureaucracy or address all of numerous and varied issues
    our veterans and those who care for them experience every day.
        Here in Hot Springs you have faced your fair share of obstacles
    with the Department of Veterans Affairs.
        Recently, VA has told us that one significant factor impacting
    access to care for veterans is the lack of clinical and administrative
    space across the VA healthcare system.
        Yet, here in Hot Springs, VA has a historic campus that the
    Department claims it can no longer use. In a community such as yours
    open communication is vital, particularly when an agency is considering
    an action that could have a significant impact on the very livelihood
    of that community.
        I share your concerns about the quality of the data VA has provided
    to support the Department's proposal to close the Hot Springs campus
    while building new facilities and your frustration about the lack of
    transparency that seems to have characterized VA's response to your
    concerns.
        Unfortunately, data integrity issues and lack of transparency
    characterize much more than just VA's responses here.
        I am also concerned that VA's nationwide access audit found
    troubling scheduling practices were been in place in South Dakota,
    including instructions--against VA policy--to manipulate appointment
    waiting times.
        If VA leaders are so concerned about being unable to make the
    Department's access goals that they would resort to manipulating data,
    why is VA not making full use of its existing facilities--in this case,
    Hot Springs--to ensure access to care for veterans across South Dakota?
        I look forwarding to hearing from today's witnesses--local
    veterans, local stakeholders, and local VA officials--about what VA
    what actions have been taken and still need to be taken to improve
    access to care for veterans throughout the Black Hills and what need to
    be done to provide the highest level of care to those veterans who rely
    on services here in Hot Springs.
        As citizens and active community members, you are the true experts
    and I look forward to listening to your thoughts, ideas, and proposals.
        I thank you all once again for being here this morning.

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                     Prepared Statement of Larry Zimmerman

        Good morning Chairman Miller, Vice Chairman Bilirakis,
    Representative Noem, and members of the committee. I am pleased to be
    here today to present our concern with the healthcare challenges faced
    by veterans in rural America.
        My name is Larry D. Zimmerman and I serve as Governor Daugaard's
    Secretary of the South Dakota Department of Veterans Affairs. Our
    Department is the voice for South Dakota's 75,000 veterans. I served
    active duty Army from 1973-1976 in the 4th Infantry Division at Ft
    Carson, Colorado, and served 29 years in the South Dakota National
    Guard, most recently serving at the State Command Sergeant Major. I had
    the distinct honor to complete a tour of duty in Afghanistan in support
    of Operation Enduring Freed as the Operations SGM for the nine Northern
    provinces in that country.
        South Dakota is fortunate to have three VA healthcare facilities in
    our state, 12 community based outpatient clinics and three vet centers.
    We are fortunate to have 66 county veterans service officers and seven
    tribal veterans service officers and over 20 veterans service
    organizations that are committed to enhancing the lives of our
    veterans.
        In 1889 the Grand Army of the Republic secured territorial
    legislation to construct a veterans home. It's our understanding that
    Dakota Territory was the first of all territories to provide a home for
    their veterans. In 1907 the Battle Mountain Sanitarium opened its doors
    in Hot Springs to focus on short term medical needs of veterans.
    Although over the years, both facilities have changed names, the VA
    Black Hills Health Care System and the Michael J. Fitzmaurice State
    Veterans Home have worked together to provide care for our veterans for
    over 107 years.
        Veteran's healthcare is a critical issue and it is important that
    we honor the promise to take care of those individuals who secured and
    protected our freedoms. During a one-year window, Michael J.
    Fitzmaurice State Veterans Home transported our heroes to the VA
    healthcare facilities in Hot Springs 1,272 times for urgent care, eye-
    care, dental care, dialysis, respiratory care, x-rays, urology,
    podiatry, and mental healthcare. In addition, during that same one-year
    time frame, 40 heroes were admitted to acute care at the VABHHCS in Hot
    Springs and 108 were transported to Rapid City via the VA.
    Additionally, thousands of veterans drive from other states, tribal
    lands and many of South Dakota's most rural areas to receive medical
    care.
        Our heroes deserve the opportunity to enjoy the rest of their lives
    and be assured that they will have access to quality healthcare. South
    Dakota has a strong legacy of taking care of our veterans and we at the
    Michael J. Fitzmaurice State Veterans Home will guarantee that our
    heroes needs will be taken care of no matter what decisions are made
    of.
        In closing, I appreciate the support that your Committee has given
    us on all issues relating to veterans and I appreciate the invitation
    to present this information with you and I will be pleased to answer
    any questions you may have.

                    Prepared Statement of Dr. Steven Julius

        Good afternoon Chairman Miller and distinguished members of the
    panel. Thank you for the opportunity to discuss the VA Black Hills
    Health Care System's (VA BHHCS) commitment and accomplishments in
    providing Veterans accessible, high quality, patient-centered care and
    to specifically address rural healthcare and access to care in western
    South Dakota, northwestern Nebraska, eastern Wyoming, and a portion of
    southwestern North Dakota. I am accompanied today by Mr. Stephen
    DiStasio, Director of the VA BHHCS.

    VA Black Hills Health Care System Overview

        VA BHHCS provides primary and specialty medicine, extended care and
    rehabilitation services, surgical and other specialty care, and mental
    health services, as well as residential rehabilitation treatment
    programs. VA BHHCS is a part of Veterans Integrated Service Network
    (VISN) 23, the VA Midwest Health Care Network, which includes
    facilities in South Dakota, North Dakota, Nebraska, Iowa, Minnesota,
    and portions of neighboring states.
        VA BHHCS consists of two medical centers located at Hot Springs and
    Fort Meade, South Dakota (approximately 90 miles apart); and VA staffed
    Community-Based Outpatient Clinics (CBOC) located in Rapid City and
    Pine Ridge, South Dakota, and Newcastle, Wyoming. Contract CBOCs are
    located in Pierre, Winner, Mission, Eagle Butte, Isabel, and Faith,
    South Dakota, and Gordon and Scottsbluff, Nebraska. Compensated Work
    Therapy (CWT) programs are located in McLaughlin, Eagle Butte, and Pine
    Ridge, South Dakota, serving Veterans on the Standing Rock, Cheyenne
    River, and Pine Ridge Indian Reservations. In addition, Transitional
    Residences are located in Rapid City, Sturgis, Pine Ridge and Hot
    Springs, South Dakota. VA BHHCS also has collaborative relationships
    with the Vet Centers in Rapid City and Martin, South Dakota.
        The VA BHHCS--Fort Meade Campus is identified as a rural medical
    center and the VA BHHCS--Hot Springs Campus is recognized as a highly
    rural medical center. The VA BHHCS has a service area of approximately
    100,000 square miles covering parts of four states. The Hot Springs VA
    Medical Center is located in a community of approximately 3,900
    residents. The Fort Meade VA Medical Center is located in the community
    of Sturgis with approximately 6,300 total residents.
        In FY13, based on calculations by VA's National Center for Veterans
    Analysis and Statistics for Veteran Population, there were
    approximately 35,000 total Veterans within the VA BHHCS service area.
    Of the 35,000, approximately 21,000 were enrolled for healthcare
    services, and 19,207 of the enrolled unique Veterans were served. This
    reflects an enrolled penetration rate of almost 60 percent in FY13, one
    of the highest in VHA.
        There are approximately 1,033 dedicated VA staff members at the VA
    BHHCS who demonstrate their commitment to the care of Veterans every
    day. Often, employees travel to remote locations throughout the area to
    provide primary care, mental health, and other services to Veterans.
        VA BHHCS maintains 459,000 square feet and 77 acres of property at
    Hot Springs and 821,000 square feet and 220 acres at Fort Meade.
    Maintaining and improving the aging buildings at the Fort Meade and Hot
    Springs Medical Centers, ranging from 40 to over 100 years old,
    significantly increases the cost of operation at both facilities.

              Existing operating rooms at the Fort Meade and Hot
            Springs VA hospitals are reaching 40 years of age.
              The current Residential Rehabilitation Treatment
            Program (RRTP) building at Hot Springs is over 100 years old,
            and the structure is not compliant with the Architectural
            Barriers Act.
              The Hot Springs and Fort Meade campuses are both
            sites of historical significance. Hot Springs is the Battle
            Mountain Sanitarium National Historic Landmark, with a proud
            history of caring for Veterans extending back to the early
            1900s. The Fort Meade cavalry post is known for its significant
            military presence, extending back to the 1880s.

        VA BHHCS has the highest costs, per unique patient, of all VISN 23
    facilities and one of the highest unit costs in all of VHA. In addition
    to the factors previously mentioned, this cost derives from a number of
    operational and infrastructure variables, the ratio of staff to
    Veterans served, and utility and maintenance costs of extensive
    buildings/acreage.

    VA Black Hills' Proposal for Reconfiguration

        VA BHHCS is committed to providing safe, high-quality, and
    accessible healthcare to the Veterans in western South Dakota and areas
    of the bordering states of Nebraska, Wyoming, and North Dakota. We have
    conducted a review of the services provided in this region. The
    Department has determined that improvements and reconfigurations to VA
    BHHCS operations are needed to maintain the safety and quality of care
    it provides. We also believe this will increase the scope of services
    available to Veterans closer to their homes, while being good stewards
    of public funds.
        VHA is concerned about its ability to preserve the quality and
    safety of care at Hot Springs. The Hot Springs Inpatient Medicine Unit
    (1East) has maintained a cumulative Average Daily Census (ADC) of
    approximately 5 patients per day from FY 2010 to present. In these
    circumstances, it is difficult to recruit and retain skilled providers
    as well as maintain their competencies. As a result, surgical
    procedures at Hot Springs have been curtailed due to an inability to
    recruit and retain surgeons and anesthesia providers. In addition, all
    of the hospitalists and after-hours physicians are currently locum
    tenens providers, or temporary staff hired on contract to fill staffing
    needs.
        The most significant change proposed by VA BHHCS involves replacing
    the current medical center in Hot Springs with a new CBOC, and
    relocating the residential rehabilitation treatment program from Hot
    Springs to Rapid City, South Dakota. The overall goal of the
    reconfiguration is to realign services and resources, to provide safe,
    high quality, accessible, and cost-effective care, closer to where
    Veterans live.
        In 2011, VA BHHCS began holding stakeholder meetings with Veterans,
    Veteran advocates, congressional offices, employees, community and
    business leaders, and the general public. VA conducted these meetings
    to answer questions, address concerns, and seek feedback to the
    proposals. On October 10, 2012, the Network and Facility Director
    briefed VA's Secretary and his staff on the feedback received,
    alternative proposals received, and potential alternatives for
    consideration. At the invitation of South Dakota Senator Tim Johnson,
    the Secretary met with representatives from the community of Hot
    Springs, and staff from the offices of Senator John Thune and
    Congresswoman Kristi Noem, in Washington, DC on January 28, 2013. A
    follow-up meeting was held on May 6, 2013, with VA Central Office
    subject matter experts and community representatives to provide those
    representatives with a better understanding of the data VA used to
    develop and support the reconfiguration proposal.
        VA BHHCS initiated an Environmental Impact Statement (EIS) in early
    2014, to evaluate the impact of the proposed reconfiguration of care in
    the Black Hills service area. VA has contracted Labat Environmental,
    Inc. through the required federal contracting process to assist VA with
    conducting the EIS process, including scoping, consultation, public
    involvement, EIS preparation, and finalization. In June 2014, ten
    public scoping meetings were held during this process at locations in
    South Dakota, Nebraska, and Wyoming. Additional public meetings will be
    conducted as the process continues. The EIS process is expected to take
    approximately 10-18 months, with a current completion date targeted for
    late 2015. Once the EIS is complete, the VA Secretary can make a
    decision regarding the proposed reconfiguration.

    Focus on Access

        VA BHHCS leadership is committed to preserving access to healthcare
    services. To be transparent and make optimal decisions regarding
    Veteran care, VA has openly shared access and quality data with
    stakeholders. Access is a challenge for a variety of reasons. VA BHHCS
    sites of care are insufficient to provide ready access to care for all
    Veterans within the large, highly rural service area. The limited
    availability of specialists is also a barrier, requiring some Veterans
    to travel to VA sites in Minneapolis, Minnesota, or Omaha, Nebraska,
    for needed specialty care. The recruitment and retention of physicians,
    nurses, and other healthcare providers has also been difficult, with
    physician specialists in orthopedics, urology, psychiatry, internal
    medicine, and inpatient hospitalists particularly problematic.
        To address these challenges, VA BHHCS has expanded the use of non-
    VA care to provide access to services locally and shorten waiting
    times. This year, VA BHHCS is estimated to spend thirty-five million
    dollars for non-VA care, including inpatient, outpatient, and long-term
    care. A major benefit to Veterans has been the reduction of travel to
    VA tertiary care sites in Minneapolis, Minnesota, and Omaha, Nebraska;
    the reduction of out-of-pocket travel expenses for Veterans and their
    families; and the opportunity to be close to home when receiving
    medical care and services.
        In addition, VA BHHCS has steadily increased the utilization of
    telehealth services. Mental health, clinical pharmacy, cardiology,
    oncology, infectious disease, pulmonary, neurology, and other specialty
    services are provided to Veterans in Hot Springs via Clinical Video
    Telehealth. Through the end of FY 2014's third quarter, 1,153 Clinical
    Video Telehealth encounters have been completed.
        We are also working to improve communication with Veterans about
    appointment scheduling. VA BHHCS' efforts to bundle appointments for
    Veterans, ensure that appointment letters are accurate, and that the
    telephone reminder system is used, are helping to reduce the current 10
    percent no-show rate.
        The opening of a system-wide call center is providing Veterans the
    opportunity to get timely help with appointments, medication
    management, billing questions, and other matters. The center has been
    so successful that it now provides similar services for the Veterans
    served by the Fargo VA Healthcare System. In addition, other VA
    facilities have inquired about VA BHHCS providing call center support
    to their Veterans. Repeatedly, Veterans tell me how the call center
    makes it easier for them to conduct business with VA BHHCS.
        We consider an important part of access to be outreach to Veterans
    who may be unaware of the scope of services for which they might be
    eligible. VA BHHCS conducts numerous outreach events throughout our
    service area, with particular emphasis on the four Native American
    reservations, Cheyenne River, Pine Ridge, Rosebud, and Standing Rock.
    Special attention is also given to Veterans of Operation Enduring
    Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND).
    Due to the large geographic service area, VA collaborates with other
    military, Veteran, and community service providers, to ensure Veterans
    and their families receive the care they need. Specialty OEF/OIF/OND
    case managers are assigned to provide outreach to Veterans who live
    great distances from our main medical facilities, including those who
    are assigned to an outlying CBOC. Additionally, a Transition Patient
    Advocate works with the OEF/OIF/OND team assisting in an array of
    outreach efforts that facilitate integration of care for all
    generations of Veterans. Post deployment integrated care is available
    through the Patient Aligned Care Team Transition Clinic, a mobile team
    providing care at Fort Meade, Hot Springs, and the Rapid City Clinic.
    This team is staffed by a mid-level provider and a licensed practical
    nurse and is supported with a Medical Support Assistant for scheduling
    duties. As of this year, this clinic continues to serve the ongoing
    primary care needs of about 1,100 combat Veterans.
        As a result of the many actions taken to improve timely access to
    care:

              Ninety one percent of new and established Veteran
            patients receiving direct care from VA BHHCS get an appointment
            within 30 days.
              As of August 4, 2014, there are only four Veterans on
            the Electronic Wait List (EWL). The EWL count is the total
            number of all new patients (i.e., those who have not been seen
            in a specific clinic in the previous 24 months) for whom
            appointments cannot be scheduled in 90 days or less.
              As of August 2, 2014, there are no Veterans on the
            New Enrollee Appointment Request (NEAR) List. The NEAR List is
            the total number of newly-enrolled Veterans, who have asked for
            an appointment during the enrollment process for whom an
            appointment has not yet been scheduled.

    VA Department of Defense (DoD) Sharing Agreement

        The VA BHHCS' sharing program with DoD helps support a strong
    collaboration with VA and Ellsworth Air Force Base (AFB) leadership. VA
    continues to search for additional opportunities to share resources
    with DoD while improving cost effectiveness and efficiency in the
    provision of patient care. We are concentrating on the areas of
    radiology, dermatology, chronic pain management, and mental health. In
    2005, VA BHHCS and Ellsworth AFB successfully submitted a Joint
    Incentive Fund (JIF) proposal to purchase a Magnetic Resonance Imaging
    (MRI) system for VA and DoD to share. The agencies received $2 million
    from the JIF, to use for this purpose. In 2007, VA BHHCS and Ellsworth
    AFB successfully completed a JIF proposal for a Sleep Lab, and received
    $443,000 for this purpose. In June 2011, VA BHHCS, Ellsworth AFB, and
    VA Dakota's Regional Office initiated disability examinations for
    active duty service members, through the Integrated Disability
    Examination System. More recently VA BHHCS is providing some surgical
    care and inpatient mental health services for active-duty military
    members through a local sharing agreement with Ellsworth AFB.
        Projects in development include more robust provision of
    dermatology, pain management, physical therapy, and laboratory
    services. When a new Rapid City CBOC is opened, co-locating some VA and
    DoD services will provide improved access and services for Veterans,
    active-duty members, and their family members.

    VA Indian Health Services (IHS) Sharing Opportunities

        VA BHHCS has taken the leadership role in the VISN 23
    implementation of the national VA IHS Reimbursement Agreement, under
    which VA reimburses IHS for direct care services provided to eligible
    Native American Veterans in IHS facilities. VA BHHCS has developed
    strong relationships with the IHS and Tribal Health entities in Pine
    Ridge, Rosebud, Eagle Butte, and Rapid City, South Dakota, within the
    guidelines of the Reimbursement Agreement and is a leading VA facility
    in the amount of direct reimbursement to IHS facilities. A local
    sharing agreement with IHS supports non-Veteran Native American access
    to MRI services at Hot Springs. VA BHHCS also supports the direct
    referral of Native American Veterans seen in IHS facilities to VA
    specialty clinics, saving the Veteran an additional appointment with
    their primary care provider.
        Projects under consideration include the provision of mobile MRI/
    Computerized Tomography services to multiple IHS hospital sites, a
    jointly operated telehealth network for access to scarce medical
    specialists, and a potential fee-for-service arrangement for a Tribal
    Health-operated mobile clinic.

    Other Sharing Opportunities

        VA BHHCS enjoys positive relationships with other governmental
    agencies in the surrounding areas, and actively participates in the
    local community. VA BHHCS is the largest employer in both Sturgis and
    Hot Springs, South Dakota. VA BHHCS has strong relationships with the
    South Dakota State Veterans Home in Hot Springs; the Veterans Outreach
    Center in Rapid City, South Dakota; the Ellsworth AFB outside Rapid
    City, South Dakota; and the South Dakota and Nebraska Army National
    Guards. Through a lease agreement, the Fort Meade VA Medical Center
    campus hosts the South Dakota Army National Guard 196th Regiment, which
    serves as a nationwide training center for hundreds of National Guard
    leaders every year.
        In addition, VA BHHCS has a positive and mutually supportive
    relationship with the single non-profit hospital system in western
    South Dakota, the Regional Health System, and its affiliated healthcare
    centers.
        There have been preliminary discussions with multiple community
    hospitals in South Dakota, Nebraska, and Wyoming, about establishing
    sharing agreements to care for Veterans. To date no sharing agreements
    have been completed; pending the decision on the reconfiguration
    proposal.

    Conclusion

        VA BHHCS is committed to providing high-quality care and services
    for our Veterans. We continue to focus on improving Veterans' access to
    care. Our location in a highly rural landscape presents VA with some of
    the same challenges faced by other healthcare systems in highly rural
    areas. The most significant of these is the ability to recruit and
    retain highly-skilled physicians and nurses. Throughout our service
    area, the scarcity of primary care providers and hospitalists is acute.
        We sincerely appreciate the opportunity to appear before this
    distinguished panel to share with you the great work that the VA BHHCS
    provides to our Nation's heroes every day. We are pleased to respond to
    any questions or comments that you may have.

                                     [all]