[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
______
U.S. GOVERNMENT PUBLISHING OFFICE
96-127 WASHINGTON : 2015
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
Washington, DC 20402-0001
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]