[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
REALIZING QUALITY RURAL CARE THROUGH APPROPRIATE STAFFING AND IMPROVED
CHOICE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, SEPTEMBER 1, 2015
__________
Serial No. 114-35
__________
Printed for the use of the Committee on Veterans' Affairs
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Available via the World Wide Web: http://www.fdsys.gov
_________
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
GUS M. BILIRAKIS, Florida JULIA BROWNLEY, California,
DAVID P. ROE, Tennessee Ranking Member
TIM HUELSKAMP, Kansas MARK TAKANO, California
MIKE COFFMAN, Colorado RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana BETO O'ROURKE, Texas
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
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Tuesday, September 1, 2015
Page
Realizing Quality Rural Care Through Appropriate Staffing and
Improved Choice................................................ 1
OPENING STATEMENT
Dan Benishek, Chairman........................................... 1
Prepared Statement........................................... 29
Julia Brownley, Ranking Member................................... 2
WITNESSES
Aaron A. Payment MPA, Chairperson, Sault Ste. Marie Tribe of
Chippewa Indians............................................... 3
Prepared Statement........................................... 31
Anthony Harrington, Veteran Sault Ste. Marie, Michigan........... 5
Prepared Statement........................................... 32
David W. Pearce, Commander, Post 3676, Veterans of Foreign Wars
of the United States........................................... 7
Prepared Statement........................................... 33
Don Howard, Commander, American Legion Post 3.................... 8
Jacqueline Haske, Chippewa County Veteran Service Officer........ 9
Prepared Statement........................................... 34
Gina Capra, Director, Office of Rural Health, VHA, U.S.
Department of Veterans Affairs................................. 16
Prepared Statement........................................... 34
Accompanied by:
James Rice, Acting Network Director, Veterans Integrated
Service Network 12, VHA, U.S. Department of Veterans
Affairs
And
Gail McNutt M.D., Chief of Staff, Oscar G. Johnson VAMC,
Iron Mountain MI, Veterans Integrated Service Network
12, VHA, U.S. Department of Veterans Affairs
STATEMENT FOR THE RECORD
American Federation of Government Employees, Iron Mountain Local. 38
American Osteopathic Association................................. 40
REALIZING QUALITY RURAL CARE THROUGH APPROPRIATE STAFFING AND IMPROVED
CHOICE
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Tuesday, September 1, 2015
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The subcommittee met, pursuant to notice, at 10:05 a.m., in
National Guard Armory, 1170 East Portage Avenue, Sault Ste.
Marie, Michigan, Hon. Dan Benishek [chairman of the
subcommittee] presiding.
Present: Representatives Benishek and Brownley.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Dr. Benishek. As you know, I am Dr. Dan Benishek, and it
has been my honor to be both your congressman and the chairman
of the Subcommittee on Health for the Committee on Veterans'
Affairs of the United States House of Representatives.
Before I was elected to Congress, I was privileged to serve
for 20 years as a physician at the Oscar G. Johnson VA Medical
Center at Iron Mountain, overseeing the VA community-based
outpatient clinic here in Sault Ste. Marie. During my time
there, veteran patients would tell me every day about the
challenges and the frustrations that they faced when attempting
to get care through the VA, the VA which is, by the way, the
government's second largest bureaucracy, with a budget and
staff that trails only the Department of Defense in size.
Let me be clear: our veterans fought for our freedom; they
shouldn't have to fight government bureaucrats too.
The subcommittee members and our staff work hard every day
to break down the barriers between the VA bureaucracy and the
veterans that this bureaucracy should be serving here in the UP
and across the country.
I am joined here today by Congresswoman Julia Brownley, the
ranking member of the Subcommittee on Health, and a
representative from the 26th District in California, just north
of Los Angeles. Needless to say, she has traveled quite a
distance to be here today with us, and we are grateful for her
willingness to join us in Sault Ste. Marie this morning and for
being such a strong and effective voice on the subcommittee.
Thank you very much.
[The prepared statement of Chairman Dan Benishek appears in
the Appendix]
OPENING STATEMENT OF JULIA BROWNLEY
Ms. Brownley. Thank you.
[Applause.]
Dr. Benishek. The purpose of today's hearing is to make
sure that the care that you and your fellow veterans receive in
the Eastern UP is timely, accessible, and high quality.
Unfortunately, we all know that at times the VA has failed to
meet those measures, and in doing so has fallen short of
providing the treatment that our veterans have earned and
deserve.
An example of how the VA has fallen short here in Sault
Ste. Marie can be seen in the VA's inability for the past two
years to recruit a physician to staff the VA community-based
outpatient clinic here. The veterans that I have spoken to,
some of whom you will be hearing from this morning, are
understandably concerned about the lack of a physician at this
facility and the impact that the VA's failed recruitment
efforts have had on the quality of care at the clinic. I share
those concerns; and today, we are going to get some answers.
During this morning's hearing we will discuss efforts that
the VA has taken in this community and around the country to
ensure that rural clinics like the one here in Sault Ste. Marie
are properly staffed and that rural veterans are able to access
care in the community or through tribal health centers where VA
funding is unable to provide the care that our veterans need
and when our veterans would prefer to receive care elsewhere.
We will hear testimony from the VA, from local tribal
leaders and local veterans whose input, expertise and advice
are critical to the work that we do in Washington. I am
grateful to all our witnesses for being here and look forward
to their testimony.
Before that, I will take a moment to recognize the men and
women that we are here today to serve. Will the veterans in our
audience right now please stand, if you are able, or raise your
hand and be recognized?
[Applause.]
Dr. Benishek. Thank you so much for serving our country and
for being with us here this morning.
I would like to take a moment to recognize and thank the
Armory staff for allowing us to use their facility this morning
and for their assistance in setting up for the hearing. Thank
you for that.
[Applause.]
Dr. Benishek. With that, I would like to recognize Ranking
Member Brownley for any opening statement she may have.
Ms. Brownley.
Ms. Brownley. Thank you, Mr. Chairman. I appreciate that.
And thank you for calling this hearing today. I am always
pleased to visit Michigan, particularly at this time of the
year. So, thank you for that. Thank you for the invitation.
And thank you all for being here. This is an important
hearing and issue, access to quality healthcare in rural areas.
The veterans who choose to reside in rural areas face big
challenges in accessing appropriate healthcare. Rural veterans
are older, typically older, sicker than their urban
counterparts. They experience primary and specialist shortages,
hospitals closing due to financial instability, inadequate
broadband coverage, and geographic distance barriers.
In my district in California, we have rural areas as well,
bordered by small towns. Veterans in these areas continue to
have problems getting appropriate healthcare. So I think I am
familiar with some of the issues certainly here in Michigan.
I am pleased by what I have heard about the VA's telehealth
program. I think by all accounts the VA is leading the way, and
I think telehealth can play an important role, particularly in
rural areas, but it is not the only solution to the problem.
There is much more that we have to do.
So, I am extremely pleased to be here. It is a tremendous
honor for me to serve on the VA Committee in Washington, DC. My
brother was 20 years in the Navy, a pilot in the Navy. My dad
was a Marine. I had two uncles, one in the U.S. Army and one in
the Coast Guard. So at least I understand what the impacts are
on veterans and veterans' families. This was the committee that
I wanted to serve on when I arrived in Washington, and I am
extremely, extremely honored to be on this committee and to be
able to serve veterans, not only in my home district but across
the country.
So thank you all very, very much for your service and your
continued service. It is greatly, greatly appreciated. Thank
you.
Dr. Benishek. Thank you, Ms. Brownley.
We are going to begin today's hearing with our first panel
of witnesses who are already seated at the table here. As this
is a formal hearing, this is a real congressional hearing just
like we have in Washington. It is not a town hall. We have
invited witnesses to the table to speak, although I look
forward to speaking with other audience members after the
hearing is concluded.
Before I introduce our panelists, I need to remind all of
today's witnesses to be mindful of the 5-minute time limit on
your oral testimony, and then a question-and-answer period will
follow. The light here is green, and then it turns yellow when
there is a minute left, and then it turns red when your 5-
minutes is up. We try to do that even in Washington, especially
for Members of Congress, just to make sure we get through all
the testimony and have plenty of time for questions and
answers. Thanks in advance for your consideration.
With us on the first panel this morning is Chairperson
Aaron Payment, Sault Ste. Marie Tribe of Chippewa Indians;
Anthony Harrington, a veteran who lives right here in Sault
Ste. Marie; David Pearce, an Army veteran and Commander of VFW
Post 3676; Don Howard, Director and Commander of American
Legion Post 3; and Jacqueline Haske, the Chippewa County
Veteran Service Officer.
I am grateful to each of you for doing this, for your
willingness to be here and to speak candidly about the issues
of importance to our veterans and our community. I am honored
to have you all here with us this morning.
The Chairman. Payment, you are recognized for 5 minutes.
STATEMENT OF AARON A. PAYMENT
Mr. Payment. [Speaking native language.] My name is Aaron
Payment, and I am the chairperson of the Sault Ste. Marie Tribe
of Chippewa Indians, the largest tribe east of the Mississippi.
I want to thank you both for bringing this hearing to Sault
Ste. Marie. I also want to recognize one of our council members
who is a veteran who is with us here in the audience, Denny
McKelvey, Vince McKelvey, who is our treasurer. He is very
critical of the VA, and so I am here to represent some of those
criticisms and some members that I saw yesterday that gave me
some input.
While 1.4 percent of the U.S. population is American
Indian, the military population that is represented from our
people is 1.7 percent. So we represent more than our population
in military service.
I commend the Department of Veterans Affairs' efforts to
ensure that community-based outpatient clinics in rural areas
are properly staffed and rural veterans are able to access care
in the community where appropriate and necessary. However,
additional changes are critically needed.
The current system creates multiple barriers to treatment
for our Native veterans living in rural areas. In the Eastern
Upper Peninsula of Michigan, my tribe has partnered with the
American Legion to provide two additional service officers in
Michigan's 1st Congressional District. This effort extends
outreach activities to veterans who utilize our health
facilities across the UP. We provide space and offset costs
associated with additional service officers. Additionally, we
are establishing baseline data collection aimed at more
accurately reflecting the number of American Indian veterans
across the UP.
In 2010, our health division worked with the Iron Mountain
VA to establish an agreement with the tribe's optical
department in Manistique. Under this agreement, the tribe is
able to provide optical services to tribal and non-tribal
veterans alike.
The Sioux Tribe has also established a VA workgroup to
access additional services for our veterans; partnered with a
veteran's service organization, again the American Legion, to
provide benefits and service officers at tribal clinic sites to
assist with issues and questions about navigating the VA
bureaucracy; worked to identify tribal veterans as they visit
our clinics in order to plan services for them; worked to
incorporate both behavioral health and traditional medicine
programs to develop veteran-specific services to include PTSD
and emotional trauma; planned awareness outreach to get out the
word on tribal and VA services including tribal elder meetings,
the tribal newspaper, our website and video tag line
information; and worked with the Iron Mountain VA to establish
an MOA with the tribe for full reimbursement for providing
clinical services to tribal veterans eligible for VA services.
Our recommendations.
Freedom of choice. Our veterans should be free to choose
their care based on where they can secure the highest quality
services. Veterans who choose to utilize tribal health centers
and our providers as their primary care sites are not able to
access their VA benefits. Currently, the VA Choice Card does
not list tribal clinics as reimbursable entities for providing
the care as a referral from the VA.
MOAs should be entered into immediately. We recommend that
the tribal healthcare programs be reimbursed for both direct
service and referred care when veterans find tribal health
programs more accessible and more accommodating to their needs.
I urge Congress to instruct the VA to set up a process that
allows reimbursement for eligible services provided by tribes.
We would love to be part of that solution, including our
transportation.
My tribe has identified a lack of consistent and reliable
transportation to access many services that directly impact
quality of life, including health, education, and employment.
Available transportation across the Upper Peninsula is only
provided at night. You have to leave at 12:30 a.m. to get there
at 8:00 a.m., and that is not very good for them having a
clinic visit the next day.
We recommend that the VA reimburse tribal governments
providing Native veterans transportation to primary and
specialty clinics and follow-up care. Most American Indian
veterans live in remote areas of the United States, and the
cost of transportation to and from veterans' healthcare
facilities causes substantial hardship on these veterans
seeking care.
Throughout the history of the United States, Native
Americans have fought greatly and sacrificed for this country.
This proud tradition continues to this day with 24,000 active-
duty American Indians. The 2010 U.S. Census identified at least
152,000 Native American men and women who have served this
country in the Armed Forces. All veterans, including our Indian
warriors, gave their best. Some gave all. In turn, they deserve
our best, the best this country can offer.
Again, we stand ready to be part of the solution. Thank
you.
[The prepared statement of Aaron A. Payment appears in the
Appendix]
Dr. Benishek. Thank you.
Mr. Harrington, you are recognized for 5 minutes.
STATEMENT OF ANTHONY HARRINGTON
Mr. Harrington. Chairman Benishek, Ranking Member Brownley,
thank you for giving me the chance to testify today. I am a
disabled veteran and I live here in Sault Ste. Marie.
As you both know, there is a VA clinic here. The clinic has
been here for many years, but more than two years ago the
attending physician retired. In the interim, part-time doctors
have been trying to pick up the slack, and a nurse practitioner
has been brought in to replace the retired physician.
I truly and deeply believe that our veterans should be
entitled to proper healthcare. This specific VA clinic serves
the entire Eastern Upper Peninsula. They are a very busy
facility with many patients from across the region. I found out
that just in Chippewa County alone, there are over 3,000
veterans, just in this county alone. The facility is having
trouble keeping up with the number of patients, and its quality
of care is suffering as well. The nurse practitioner, although
very good at her job, can only do so much within the guidelines
of her job description and abilities.
Currently as it stands, the nurse practitioner can only see
a maximum of six patients a day--if that has changed, I don't
know--and is limited as far as what she is allowed to diagnose
and treat. The facility is in desperate need of a full-time
attending physician as well as the current nurse practitioner
to adequately care for the entire region and its patients.
Recently they hired a physician's assistant here. While
that is a good step, it is really not a replacement for a full-
time doctor. And the people from Iron Mountain at the last
meeting said that their hands were tied, they couldn't hire
anybody else, they couldn't hire a doctor. They were only
allowed through the VA a nurse practitioner. Then they turn
around now and they hired this physician's assistant, but they
can't get a doctor.
I just want to know why they were able to bring a PA if it
wasn't possible for them to bring a doctor. I have been told by
Iron Mountain VA officials that they were only authorized to
hire a nurse practitioner, and then all of a sudden the PA
shows up. That doesn't make sense to me.
Prior to the hiring of the nurse practitioner I was seeing
a doctor by the name of Lisa Vanhevel at the Bay Mills Indian
Clinic. The reason I turned to the Indian clinic instead of the
VA clinic was due to the lack of an attending physician at the
facility. While under Dr. Vanhevel's care we talked quite
extensively about the need of a full-time doctor at the VA
clinic. She told me that her contract with Bay Mills was coming
to an end and made her intentions clear that she was interested
in interviewing for the position at the VA clinic.
Upon following the proper channels she was then granted an
interview at the VA clinic in Iron Mountain, Michigan. Sometime
later I happened to run into Dr. Vanhevel at Wal-Mart and she
informed me that her interview went well and she was offered a
position at the Sault Clinic, as well as the Iron Mountain
clinic. She stated that she was only offered two days a week
through our facility or a full-time position in Iron Mountain.
She explained that she had to decline both positions because
she didn't want to move to Iron Mountain or commute 295 miles
away for work. She also didn't want to take a position for only
two days a week.
Dr. Benishek, Ms. Brownley, I am sure you can sympathize
with her. Who in their right mind would want to take a position
for two days a week following a contract where they had a full-
time position? This was very concerning to me considering the
dire need for a full-time attending physician here.
In addition, Dr. Benishek's staff has told me that prior to
the hiring of the PA, Benishek's office was told by the VA that
they were going to try to hire a doctor. However, despite what
Benishek's office was told, we have seen no evidence that an ad
was ever placed on usajobs.com, or that any ads were placed in
UP newspapers. I would like to know what exactly was done to
try to get a doctor here.
I am glad that Congress is finally investigating this
issue. I have yet to have someone explain to me why it is that
the veterans in this area are not entitled to a VA facility
with a full-time doctor and quality healthcare.
Thank you again for having me here today. I truly hope that
you will take the time to look into this matter and serve
justice to our vets as we have selflessly served you and this
country. It is my hope that you will confer with the new
director of the VA and that you can come to an agreement to
resolve this.
Thank you very much.
[The prepared statement of Anthony Harrington appears in
the Appendix]
Dr. Benishek. Thank you very much for your testimony.
Commander Pearce, you are now recognized for 5 minutes.
STATEMENT OF DAVID W. PEARCE
Mr. Pearce. Congressman Benishek, Congresswoman Brownley,
committee staff, and fellow panelists, thank you for the
opportunity to appear before you today on behalf of the members
of Veterans of Foreign Wars Post 3676 and approximately 58,000
Upper Peninsula of Michigan veterans, one of this great state's
most valuable resources. I feel qualified to provide input,
within my scope, as I am a retired service member, disabled
veteran that uses the VA healthcare system and the commander of
the Welsh-McKenna VFW post here in the Sault. I served this
great nation of ours for over 20 years as an active duty
soldier in the United States Army. I was also born and raised
in the Eastern Upper Peninsula and returned home to Sault Ste.
Marie upon the completion of my military career.
First, I would like to commend the Veterans Administration
for recognizing a problem in the care of our veterans that live
in rural areas. Speaking from my personal experience with the
VA healthcare system, I believe the VA is moving in the right
direction. There is still much more room for improvement.
Improvements have been gained in the last several years
with my access to care. When I started to use the VA healthcare
system, it was not uncommon to drive all the way to the Iron
Mountain VA hospital for an appointment or test. The Oscar G.
Johnson VA Medical Center in Iron Mountain, Michigan is the
closest facility. Some of those appointments were a simple 15-
to 20-minute doctor visit that would require a four-hour drive
one way, or an entire day off work. Most recently, the VA has
scheduled appointments for me at the local hospital or sent me
an authorization to seek care locally. I am satisfied with the
improved choice options; however, there are bugs to be worked
out.
One is with billing. As a retired service member, I also
use Tricare for medical insurance. Several times when I
received care locally, my healthcare insurance was billed and
not the VA. The response time is very slow when trying to get
the medical bills routed in the right direction.
I also feel that local access to healthcare for our aging
veterans should be a priority. I am still relatively young. It
is not as much of a burden for me as it is for some of our
older veterans to receive care. In our community here in the
Sault, there are several assisted-living facilities and nursing
homes with elderly veterans that do not have the physical
capability to travel great distances to receive care from the
VA. Improved choice could help with that issue.
I would like to comment that for me personally, the My
HealtheVet website is a great asset to access care, re-fill
prescriptions, and communicate with the local community-based
outpatient clinic through secure messaging. That was a great
idea for those of us who are computer literate. However, it is
not such a great choice for those that are not familiar with
using a computer or do not have access. Many of our older
veterans do not use a computer.
Another issue with improved choice that should be addressed
is the lack of specialized care and women veterans' healthcare
access in a rural environment. I am not sure how to address
these topics specifically, but they definitely need to be
looked into and more options for care need to be available for
all veterans.
Appropriate staffing is a concern. Soon after my retirement
from active duty I started using the VA community-based
outpatient clinic located in Kincheloe, Michigan. The clinic
was relocated to Sault Ste. Marie a few years later. I
personally think the staff at the Sault Ste. Marie CBOC is
absolutely wonderful. I interact with the staff at the local
clinic several times every month for my own appointments. They
are always helpful and friendly. The only concern I have is
there is not a permanently assigned medical doctor at the
clinic. The physician's assistant does a great job, but I feel
there should be a full-time M.D. assigned to the clinic also.
When the doctor that was assigned to the clinic retired,
the position was filled several times temporarily until the
physician's assistant was hired. That created a lack of
continuity in care. I feel due to this lack of continuity,
mistakes were made and treatment was not appropriate.
During that time I also had an appointment with a physician
located in Iron Mountain through video chat. I felt that
appointment was very impersonal and not effective at all. On
another occasion, I drove to Iron Mountain for a video
conference with a doctor located in Milwaukee and some online
testing. That, I feel, could have been accomplished at the
clinic in Sault Ste. Marie. Now put yourself in a World War II
veteran's shoes. Imagine how overwhelming and confusing the
video conference could be to them.
Again, it is a great honor to have the opportunity to
participate in this valuable discussion regarding the care of
our veterans. This concludes my testimony. I am prepared to
take any questions. Thank you.
[The prepared statement of David W. Pearce appears in the
Appendix]
Dr. Benishek. Thank you very much, Commander Pearce.
Commander Howard, you are recognized for 5 minutes.
STATEMENT OF DON HOWARD
Mr. Howard. Actually, it is Don Howard, Chairman of the
Veterans Affairs American Legion, State of Michigan. Thank you
for having me today.
Aaron Payment stole my--I paid for it, he copied it. It was
funny, we were standing out there talking and were exactly
saying.
Over a year ago, I had the opportunity to come up and visit
with Aaron's staff--Bonnie Kaufa, Tony Abramson, Mark Willis,
and Tom Tefnel--and we learned when I came up the first time,
first meeting with them, that their staff was not aware of the
fact that many of their veterans were entitled to pensions, aid
and attendance benefits, disability and such. So we took it on
to start training their nurses. Since then it has really,
really picked up.
Since then we moved our service offices into their clinics,
which has proven to be a major asset and it is really, really
going strong.
What we have learned in the State of Maine, the State of
Washington, the VA uses MOUs with the tribal health systems,
IHS I believe. Am I correct? The IHS systems. And again, the
Sioux Tribe has volunteered to see every veteran, every
veteran, whether it be Indian or not. They are willing to work
with Iron Mountain.
We have tried for the last year-and-a-half to work with
Iron Mountain. They are dragging their feet, non-cooperative.
We don't know where to go from here. I did have a discussion
with Danny Pummill, the Under Secretary of the VA in
Washington, DC., and his staff indicated that that is the
direction. I met him actually in Washington, DC. His father
actually lives south or just north of Escanaba, the VA
Secretary.
What we would like to see is have you guys encourage a
roundtable with all concerned--the tribes, the seven tribes in
the UP, Iron Mountain, Danny Pummill's staff out of Washington,
DC, and yourselves to oversee it, just like the UAW and Ford
Motor Company negotiations. We could hold this right here in
Manistique, plenty of room, and if it takes 4 to 40 hours, get
this fixed, make the UP the model for the rest of the state.
These veterans deserve better up here.
My family is from Singleton. I spend my summers up here. I
live south of Detroit now. I think this can be done. I know we
have the willingness between the tribes, and that is all we
need is some help from you, both of you and the VA, and to
bring this and put this together and work it out.
That is all I have to say. Thank you.
[The prepared statement of Don Howard appears in the
Appendix]
Dr. Benishek. Thank you, Mr. Howard.
Is it Ms. Haske or Haske.
Ms. Haske. It is Haske.
Ms. Haske, you are recognized for 5 minutes.
Ms. Haske. I would like to decline at this time. I am too
scared.
Dr. Benishek. You don't have to be scared. Just tell us any
issue that you are having with the VA.
STATEMENT OF JACQUELINE HASKE
Ms. Haske. I am Jacqueline Haske, the Chippewa County
Veterans Affairs Officer. Mine is piggybacking on everybody
else.
My main concern is having a doctor in the community. One of
the issues we have is if a veteran comes to the community as a
new veteran, they are unable to be seen by a doctor if they
have the Choice Card because several of the doctors are not
receiving new patients at this time. So our concern is not just
because of the need for a doctor in the area, but the doctors
with the Choice Card are refusing, and that is all.
[The prepared statement of Jacqueline Haske appears in the
Appendix]
Dr. Benishek. Is there anything else you would like to tell
us?
Ms. Haske. No, sir.
Dr. Benishek. All right. That was just fine.
In that case, I will recognize myself for 5 minutes to ask
a few questions.
Chairperson Payment, tell me about this Memorandum of
Understanding to get the tribal healthcare to be provided
through the VA. Has the VA talked to you? Have there been any
negotiations with them? Where are you at with that?
Mr. Payment. Well, first let me say what the young lady
said was very impactful even though it was few words, because
that is another issue. The Choice Card alone doesn't get it
done. You have to have doctors who are willing to see you. We
do have doctors who will see Medicaid patients or welfare
patients, and in this case it is kind of sickening to me that
they wouldn't see a veteran who has the ability to pay for the
care.
So we stand ready to be able to see veterans in our clinic,
and we also pledge that--sometimes it is hard to get into our
clinics too, but if we come to an agreement with an MOA, we
would be willing to designate a physician that would primarily
see veterans and then can do overflow for others.
Dr. Benishek. Why don't they have that agreement already?
What is the story?
Mr. Payment. I think we have. We do have it with dental. So
we have seen that the model can work. I think the bureaucracy
and the weight of the bureaucracy and the fear of dismantling
the existing bureaucracy is probably a threat.
So I would say what Congress should do is you should direct
them. You should give them a timeline, and we can work it out.
I like the idea of 4 hours or 40 hours to iron it out. We have
proven we can do it. We do it with our dental services right
now. And we have clinics in Manistique, and I think they would
probably be willing to extend their services as well.
So I think if you order it and you give them a timeline by
which they have to do it, it will get done.
Dr. Benishek. How long have you been in negotiations with
them? A year-and-a-half?
Mr. Payment. Yes, about a year-and-a-half.
Dr. Benishek. Mr. Pearce, you mentioned the fact that the
billing is a problem sometimes if you see somebody outside the
VA. Can you elaborate on that a little bit more?
Mr. Pearce. Congressman, I think that is primarily issues
due to hospital billing, not necessarily the VA. I will get co-
pays that I end up with because they bill Tricare instead of
the VA. A lot of times it doesn't matter if I actually take the
consent form with me and turn it in at the hospital. For some
reason it gets billed to my primary health insurance instead of
the VA.
Dr. Benishek. Are there any problems that you are aware of
with your record when you go to an off-site facility, any of
you or Ms. Haske? Do you know of a situation where a patient's
record of the care they had received outside the VA, is that
getting back to the VA so they are keeping track of what care
you had and where?
Mr. Pearce. Yes, it does, Congressman. You have to make
sure that happens. I do personally take care of that myself to
make sure it gets in my VA record also.
Dr. Benishek. Ms. Haske, are you familiar with any problems
in that regard?
Ms. Haske. With the records?
Dr. Benishek. The records, making sure that the veteran has
a continuous record of his care outside. Is that happening that
you are aware of?
Ms. Haske. Yes.
Dr. Benishek. All right. Great.
Our second panel of VA witnesses are going to testify that
the VA provides patient-centered care to approximately 15,000
of the 30,000 veterans that reside in the Upper Peninsula. Do
any of you want to comment? Do you think that the VA is
providing patient-centered care in the Upper Peninsula? Anyone
want to comment on that?
Mr. Howard, do you have any comment on that?
Mr. Howard. I really don't.
Dr. Benishek. Do any of you know if it is because----
Mr. Howard. From input from one of my veterans, he faced
the same issue with having to travel across the Upper Peninsula
to get to a visit and then leaving that visit, coming back to
the Sault, and then getting a phone call once he gets back
that, oh, we have an opening for you tomorrow. It seems like
that should be able to be addressed while you are there so he
didn't have to drive three hours and then drive all the way
back, and then drive all the way back. That is not patient
centered. That is getting weighted down by the weight of
bureaucracy and not taking a moment to do continuity of care
and say, okay, what is next for this patient. That didn't
happen. So I would say that is not patient centered.
Dr. Benishek. No, I can definitely agree with you there.
And frankly, that kind of stuff happens all the time, where
patients have to drive, here in the Sault, a good four hours,
and just that drive, as many of you have related, eight hours
to get there and back for a 20-minute appointment, does seem a
little bit on the ridiculous side.
I already have followed up on many of the issues that you
have brought up here today with the VA panel that is coming up
next, so I really appreciate bringing up all this stuff, and I
am going to yield to Ms. Brownley for her 5 minutes of
questioning. We may have another round of questions as well.
Ms. Brownley.
Ms. Brownley. Thank you very much. My staff helped me to
prepare some questions for you, and the first question was what
is the number-one barrier in terms of receiving access to VA
healthcare? And it sounds to me--tell me if I am wrong--that it
is access to a physician, a medical doctor. Would everybody
agree that that is probably the number-one barrier?
So I guess the question that I would ask is if the Choice
program was working perfectly, which it is not, and we are well
aware of that, but if it was working perfectly, are there
doctors in your communities, primary physicians and specialty
care physicians in the community that you could access? Because
sometimes that is a problem outside of the VA in rural areas.
The doctors aren't there either. So I am just curious to know
whether you have a sense within your own communities whether
the doctors are there.
Mr. Howard. Well, the Sioux tribes, all their clinics are
pretty much centrally located throughout the UP, and access to
their clinics are a reasonable distance. To give you an
example, there is a gentleman out here, sitting right behind me
out here, that drives from here to Escanaba. We have patients
that are on oxygen. Well, they are not allowed to ride that bus
because the oxygen is dangerous. So they have to find other
means to get all the way over to Iron Mountain for a C&P exam
because Iron Mountain says we have no doctors that are
qualified on the outside to do C&P exams. This individual may
have cancer, diabetes, whatever, and he has to find his own
way. In many cases these people haven't been working, so they
don't have the funds to get there.
Why we cannot train doctors from the tribes to do C&P exams
to keep these people from traveling across icy roads 300 miles
I think is insane, absolutely insane. Plus, we are paying 56
cents a mile. We are wasting Federal tax dollars when we can do
it locally. It just doesn't make sense. We have everybody on
board to work together. We need the help to push the VA ahead.
Thank you.
Ms. Brownley. That is very good. Well, I would just like to
comment that particularly the Choice program, the new program
provided by the VA, the Choice program was designed for areas
particularly like the areas here, and we have got to figure out
how to make that work. I know in my own district I had--I don't
know who the provider is here. In my district for the Choice
program, the health plan is TriWest. I don't know what it is
in--it is Health Net in Michigan.
So I had the TriWest folks come out to my district to meet
both with veterans to help them understand the program because
it hasn't been very clear, and we made amendments back in
Washington that have passed to make the Choice program work
better. But the main barrier, at least in my district, is there
are no doctors to access through the Choice program because the
doctors have to be part of--what's the program?--Health Net.
The doctors have to be part of Health Net.
So we had a meeting in our district, and I tried to invite
all the healthcare providers in our region to help them to
understand how the program works to try to recruit more doctors
into the program.
But I will just make the comment that we have to make
sure--I mean, this is the perfect place to ensure this Choice
program is working, because it was designed for you and for the
veterans across this region because you are so rural and have
less access to healthcare than veterans do in other parts of
the country. So somehow we have to figure that out and we have
to provide more providers that are in the program and simplify
it so that veterans know that they have access to local
doctors, and with Choice, a doctor cannot provide--I can't
remember who talked about the doctors not being available in
the Choice program, but the doctors have to be part of the
program, and the VA has to approve that appointment before the
veteran can utilize it.
But I think the biggest barrier for the Choice program to
work is actually having the providers in the program to do
that. So we have to figure that one out.
Dr. Benishek. Thank you, Ms. Brownley.
Ms. Brownley. I yield back.
Dr. Benishek. I am going to ask a few more questions while
we have you here, because once we get the VA up there, then I
am not going to have the opportunity to do that.
I just want to mention, Mr. Pearce, you talked about this
telehealth appointment not being very effective or being very
personal. So I would like you to expand on that a little bit,
because the comments that I have heard about the telehealth
from the VA and from some other people have been positive. So
can you kind of relate more about your experience with that?
Mr. Pearce. Yes, Congressman. I believe it is impersonal
because I am more of a face-to-face type of person. I don't
like talking to a camera, basically. You can see the picture of
the person on the camera, but you don't see body language, you
don't see--I am not a real well-versed person, so I rely on
other senses in a personal setting.
Dr. Benishek. Did you relay those sentiments to the staff?
Mr. Pearce. Yes, I did.
Dr. Benishek. And did they appreciate your input?
Mr. Pearce. Oh, yes. They definitely appreciated my input.
Dr. Benishek. But is there any way to improve that? Was it
a really small picture? Was--you didn't understand the person?
I am just trying to----
Mr. Pearce. There wasn't a language barrier or anything,
but I just felt it was impersonal, talking to a camera instead
of an actual person.
Dr. Benishek. Mr. Harrington, do you have a thought on
that?
Mr. Harrington. Well, I have done this before at the VA. It
was not personal. Somebody said on the camera or screen, you
don't get a rapport going like you can with a doctor.
Eventually you go see the doctor and they understand your
health because you can relate that to them and they know you.
But to talk to somebody that is on a camera, it is like ``Hi,
how are you?'' I mean, it would be like talking on the
telephone here in Washington. You are here now, I can look at
you, you understand where I am coming from, I understand what
you are trying to do.
So to me, it is just not a personal thing. I like to be in
front of a doctor and talk to a doctor. If I have an ache or a
pain, I can explain it to the doctor and then go from there.
But how do you do that with somebody who is 300 miles away?
Dr. Benishek. Chairperson Payment, I understand your tribe
is making an effort to collect more accurate information about
the number of American Indian veterans that live in the Eastern
UP. Do you have that data that you can share with our office to
help us identify those veterans? We are trying to make sure we
have accurate numbers as well. Can you elaborate on that a
little bit?
Mr. Payment. We have a commitment to our veterans because
it is a continuation of our rural society, and for a number of
years we have been reaching out. We have our veterans wall over
at our ceremonial grounds. But the challenge that we found out
was we don't have any registry of who our veterans are. We
don't have that as part of the membership. We have reached out
through communications in our newspapers with them, but because
of various reasons and because of different times when people
have served, people aren't always willing to volunteer that
information.
So now what we are doing is we have a dedicated person who
works with our veterans. We are doing a little bit now. I think
we should be doing a lot more. So we are identifying our
veterans when they come in so we can record that so we can then
try to bring access to them. We have done a census. Our last
census we collected aggregated data without names. So we don't
have the names of them, but we do have numbers of how many
veterans that we have.
But we need to do more of that. We need to find a way to
make them feel comfortable with identifying themselves as
veterans. We have some veterans who are very good at that
because they are trying to reach out and advocate for other
veterans. But we do have some still who don't bring that to the
forefront. So we need to do whatever we can to bring the
services to them rather than wait for them to come to us,
because already when they are rejected by either the VA or
whatever services, that is just salt in the wound. So we need
to find a different way to reach out to them.
Dr. Benishek. Is there anything else that any of you would
like to say to me now while you have the opportunity?
Mr. Harrington.
Mr. Harrington. Yes, sir. To give you an example of the
waste, I went to the doctor that was in the Sault district for
a little while, and they wanted to reevaluate my ears. I go all
the way to Iron Mountain. I did the whole hearing test,
everything. I come back home and I didn't hear anything because
it was for a compensation thing.
A month later I get a call, ``You have to come back to Iron
Mountain.'' I said what for? ``You have to have this hearing
test done all over again.'' I said why? I just had it done.
``Well, this doctor has to do it, okay?'' So I drive all the
way to Iron Mountain. That doctor did the exact same test that
I had done. And while I was in there, one of my hearing aids
was not working right. So I asked the doctor, I said could you
possibly adjust this? ``Oh, I can't do that.'' Well, is there
somebody else? ``No, they are not here. You have to make an
appointment to come back up here to get your hearing aid
adjustment.''
[Laughter.]
Mr. Harrington. So I finally was able to send it to them,
and they thought they fixed it, and it still isn't fully fixed.
So that is just a waste, a waste of time.
And one more point. I went up to this VA clinic and I
talked to the lady at the front desk, and I was trying to get
some information, not personal information, just trying to get
some information about how many vets were registered there. She
acted like she was appalled that I was trying to get a doctor.
``We don't have room for a doctor. We have a nurse
practitioner, and now we are getting a physician's assistant.''
I said, well, you had room for a doctor before. She said
everything is fine, we are not having any problems.
I left there, went to have a coffee where vets go, and I
run into--I have the guy's name. I won't mention it, but I do
have it. This man waited five weeks for an appointment here so
he could go in there and they could refer him to the clinic of
the Sioux Tribe to get x-rays--five weeks. This just happened,
and I have his name here.
I also have Dr. Vanhevel's contact information if you would
like me to share that with you folks. She is the doctor who
actually interviewed with them. They say it wasn't an
interview, and I still can't believe that a person would drive
295 miles just to have a chat, and she was honest.
Dr. Benishek. Thank you, Mr. Harrington.
I am going to yield to my friend here, Ms. Brownley from
California, once again.
Ms. Brownley. Thank you, Mr. Chairman.
I just wanted to ask very quickly, for the CBOCs, the
community health clinics that you have here, are they VA-run or
are they subcontracted out? They are all VA-run? Okay, very
good. I know in my district it is subcontracted out, and that
presents another big problem, because if you go up to the front
desk of my CBOC, they can't answer questions related to the VA
because they are subcontracted out. That becomes a very
frustrating element.
Mr. Howard. In Manistique, Michigan, they have a CBOC, and
some of the veterans refer to it as a band-aid clinic. They go
in there for chest colds or whatever. That is what Iron
Mountain--chest x-rays. Four miles down is a brand new Sioux
Tribe facility--eyeglasses, hearing aids, dental, x-rays. You
name it, they do it right there. Instead of sending them 4
miles, we are going to send them 170 miles.
Ms. Brownley. That is crazy.
Mr. Howard. It is insane. When these people are going out
of their way saying we are going to help you, you are kicking
the can down the road. They are afraid that they may take some
of their work away and maybe their VA will have to lay off a
few people. Exactly. That is a problem. But is it fair to send
a veteran 170 miles across the ice? No. A major problem.
Ms. Brownley. And I would just say that--and I don't know
if anyone can handle this question, but to try to understand in
terms of hiring doctors, is the VA not hiring the doctors
because the physician hasn't been approved, or are they trying
to hire doctors and can't find the doctors to fill the
positions but will wait for the next----
Mr. Howard. The reason they aren't hiring the doctors, the
point here in the UP is the traffic.
Ms. Brownley. Right. No, no, no, I get your point
completely, and I think the whole MOU and trying to figure that
out, it certainly sounds--based on what I am hearing, it sounds
like that is the right path to travel to resolve a lot of these
issues. I think probably the Choice program and an MOU and
putting it all together would really go a long ways in terms of
access to quality healthcare and not having to travel for it.
Mr. Howard. Please keep this in mind: 4 hours or 40 hours,
we don't care.
Ms. Brownley. Yes, I hear you. I hear you on that.
And I just wanted to comment on the telehealth that I
understand in terms of both of you saying it is an impersonal
experience, and I hear that a lot from veterans as well. I
think we have to continue to keep working on that. I do think
if you are in a CBOC and, as you said, it is a band-aid clinic,
but at least if you can have the nurse practitioner or whoever
is there sitting with you, if you approve of that, because you
would have to approve that, but sitting with you, because the
reason you are going to telehealth is typically because you
need to talk to another specialist of some sort and those
services aren't provided, to figure out a way in which we could
make it a more personal experience.
I know in my district, telehealth works for some people.
Some people like that. And I have found, I have heard from at
least my veterans, particularly around mental health, that they
like the telehealth process because they can do it in the
privacy of their own homes, they don't have to go to a clinic.
Sometimes people are embarrassed about reaching out for mental
health services, so they don't have to be seen within their
community, it can be very private.
So I do think that telehealth is a pathway here. It is not
a panacea or the ultimate solution, and I think it works for
some and it doesn't work for others. And we have got to be
able--the VA has to be nimble enough to be able to utilize it
and make it happen. But ultimately, we are not doing a good job
unless the client, the patient, the veteran is satisfied with
their healthcare.
So, thank you, Mr. Chairman.
Dr. Benishek. Thank you, Ms. Brownley.
Well, thank you for being part of our hearing this morning.
You are excused.
We are going to ask the second panel to come up and give
their testimony.
We certainly appreciate your participation.
[Pause.]
Dr. Benishek. We will welcome our second and final panel of
witnesses to the table. Joining us this morning from the
Department of Veterans Affairs is Gina Capra, the Director of
the Office of Rural Health. Ms. Capra is accompanied by James
Rice, the Acting Director for VISN 12 and the Director of Iron
Mountain VA; and by Dr. Gail McNutt, who is the Chief of Staff
of the Oscar G. Johnson VA Medical Center in Iron Mountain.
Thank you all for being here this morning.
Ms. Capra, you can proceed with your testimony when you are
ready. You are recognized for 5 minutes.
STATEMENTS OF GINA CAPRA, DIRECTOR, OFFICE OF RURAL HEALTH,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY JAMES RICE, ACTING NETWORK DIRECTOR,
VETERANS INTEGRATED SERVICE NETWORK 12, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND GAIL
MCNUTT, M.D., CHIEF OF STAFF, OSCAR G. JOHNSON VAMC, IRON
MOUNTAIN, MI, VETERANS INTEGRATED SERVICE NETWORK 12, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF GINA CAPRA
Ms. Capra. Thank you, sir. Good morning, Chairman Benishek
and Ranking Member Brownley. Thank you for the opportunity to
be here at the National Guard Armory in Sault Ste. Marie to
discuss rural health and staffing concerns. I am accompanied
today by Mr. James Rice, Acting Network Director for Veterans
Integrated Service Network 12; and Dr. Gail McNutt, Chief of
Staff for the Iron Mountain VA Medical Center. Dr. McNutt is
also the co-chairperson of the National Patient Aligned Care
Consultant Team.
Individuals living in rural areas have traditionally been
underserved with regard to healthcare access. The reasons for
this are multiple, but they stem from long travel distances to
reach healthcare facilities; lack of health insurance; and an
inadequate number of healthcare providers, particularly
specialists working in rural areas.
Currently, 3 million rural veterans are enrolled in the VA
healthcare system. They account for approximately one-third of
all VA enrolled users.
The Veterans Health Administration's Office of Rural Health
envisions an America where veterans thrive in rural
communities. Our mission is to improve the health and well-
being of rural veterans by increasing access to care and
services. We accomplish this mission through collaborations
with other VA program offices, Federal and state partners, and
local communities.
Accessible and quality healthcare for rural veterans is
possible through a combination of VA community-based clinic
expansion, increased partnership with rural community
providers, the use of telemedicine and health information
technology, and new efforts to recruit and retain healthcare
providers to rural areas.
At VA, we are continuously working to increase access to
care for rural veterans through innovative programs. Here are
several examples.
A mental health case management program called the Extended
Rural Access Network for Growth Enhancement or E-RANGE program
provides severely mentally ill veterans with intensive support
services to improve their quality of life. It increases
independent community living, and it connects veterans with
available local resources for support and care. The Iron
Mountain VA Medical Center has successfully implemented and
sustained this program.
Another example is the Rural Veterans Transportation
Program which supplies vehicles and drivers that transport
veterans to and from their VA medical appointments. This
program saves veterans personal driving time and reduces missed
appointments. The Iron Mountain VA Medical Center is a
successful participant of this program as well.
A final example highlights the importance of health
information exchange and its intent to increase care
coordination between veterans, their VA providers, and the
community providers who care for them. This effort is
facilitated by a cadre of rural health community coordinators
and increases the utilization of the virtual lifetime
electronic record, also known as VLER. These coordinators work
to ensure that each veteran's community provider is among the
trusted partners with whom VA will share health information.
Again, the Iron Mountain VA Medical Center is a current
participant in this program.
In the area of workforce recruitment and staffing, VHA is
expanding efforts and strategies to fill vacancies for
positions that are critical to our mission. VHA's Workforce
Management and Consulting Office, in collaboration with the
Office of Rural Health, is working to determine where and what
types of providers are in short supply at rural healthcare
facilities; to explore and promote the use of VA financial
incentives and other innovative solutions to recruit providers
to rural VA facilities; to determine best practices in rural
provider recruitment and retention; and to develop, expand, and
support clinical training opportunities for rural healthcare
practitioners so we can retain them in rural areas.
In addition, VHA employs a national advertising campaign
aimed at recruiting clinicians for rural patients. This
recruitment is possible through VHA's partnership with the
National Rural Recruitment and Retention Network, or RRRNet. As
a result, VHA has access to a robust database of candidates
interested in serving veterans in VA's rural sites of care.
In conclusion, VA is committed to providing high-quality,
safe and accessible care for our veterans. We continue to focus
on improving veterans' access to care. While rural locations
present unique access challenges, VA's rural health programs
are robust and will continue to serve veterans in rural areas.
We sincerely appreciate the assistance we have received
from your committee in particular and Congress as a whole, our
partners at the local veterans' service organizations, Native
American tribes, and key non-profit stakeholder groups. We
would not be able to provide the necessary care to our rural
veterans without the support and dedication of our partners.
Mr. Chairman, this concludes my testimony. My colleagues
and I are prepared to answer any questions you or Congresswoman
Brownley may have. Thank you.
[The prepared statement of Gina Capra appears in the
Appendix]
Dr. Benishek. Thank you, Ms. Capra.
Frankly, I am a little disappointed with your testimony. I
mean, it sounds like you are doing everything just wonderful
from that testimony. But as you heard from the first panel,
there are a lot of problems. What you have heard here today is
only an example of what is going on I think, across the
country. You said all great stuff there in your testimony, but
let's talk about some of the things that are actually going on.
One of the things I want to start out with is could you
provide my office with the recruitment documentation of the
recruitment efforts that have occurred to fill the position of
a physician here in Sault Ste. Marie? Could you provide that to
us in maybe the next 30 days?
Ms. Capra. Yes. I would also like to ask Dr. McNutt or Mr.
Rice if they could address that situation as well.
Dr. Benishek. Can you say yes to that question?
Ms. Capra. Yes.
Dr. Benishek. Great.
So what is the story, Mr. Rice or Dr. McNutt? Do you know
what the story is here? We have heard some contradictory things
here. I think we are trying to get a physician here, and yet we
don't have one. And then some people testified that they are
not trying to get a physician here, or only a part-time. So I
don't know what the real story is. What has been going on, and
when are we going to get a doctor here?
Mr. Rice. Okay. So Dr. Solomon retired in 2013 and we
started our recruitment for a full-time physician. The job was
advertised multiple times on usajobs, however, if a physician
approached us, we can hire them without the job being
advertised. So one of the things I did, I sent an email message
to the CEO War Memorial to see if he could help us in our
recruitment efforts, and all that he could provide at that time
was mid-levels. So then I reached out and got a listing of all
the providers in Chippewa County and I personally sent them a
note asking if they were interested in coming over to the VA. I
had one physician who was thinking about shutting down his
practice, but it would be two to three years.
The number of times the position has been advertised in the
newspaper was 25 times prior to us hiring the NP and 19 times
since. We made the decision, or I made the decision as the
Director that after recruiting for the position for over a
year, it was in the best interest of our veterans to hire a
mid-level, so I take full responsibility for that. We felt a
clinic with a provider was better than not having a provider at
all.
The panel size at the clinic was 1,187. A full-time
provider who could handle 1,200 patients--mid-level, 900.
During that time we were approached by an NP from the Battle
Creek VA. They grew up in the UP and wanted to relocate. So we
hired that individual, and then she ended up retiring, and then
just this past month we hired an additional PA. So we can cover
a panel of about 1,500 patients.
One of the things, I know not everybody is satisfied with
telehealth, but telehealth is the way we conduct for patients
that are more complex, back to the medical center where they
direct care from a physician.
Dr. McNutt can add to that.
Dr. McNutt. Congressman Benishek, I would like to add two
things, actually. The first is in reference to the physician
that was brought up during the first panel. I personally worked
hand in hand with HR to recruit for all of our CBOCs at Iron
Mountain. The day that that physician's name was handed to me
as somebody who might potentially be interested, I was on the
phone to her that night.
She indeed did interview with me twice. She was offered a
full-time position and declined.
Dr. Benishek. I understand that that was here in the Sault.
Dr. McNutt. Yes. I offered her either the Sault or Iron
Mountain.
Dr. Benishek. Oh, I see.
Dr. McNutt. And she declined the position.
I agree with Mr. Rice's testimony that we often advertise a
position----
Dr. Benishek. Is there a particular problem with physician
recruitment? I mean, what is the basic problem, Mr. Rice? Is it
they are not accepting the salary, or it is just hard to get
somebody up here? I mean, you have the same problem at Iron
Mountain too, as I understand it.
Mr. Rice. Right now, the first time since I have been the
Director at Iron Mountain, we are practically fully staffed and
we have three provider vacancies. We are really trying to focus
on recruiting physicians who like the rural environment, the
lifestyle. We have made a concentrated effort to approach it
that way, do more home grown approach. I don't think it has
been a thorny issue. I think we have been able to meet most
every demand from a physician that we recently hired, like the
anesthesiologist, podiatrist, some psychiatrists. We have been
able to meet their financial demands.
Dr. McNutt. Congressman Benishek, I think you probably
recognize this is not just a VA issue. Congresswoman Brownley
brought up there is a dearth of physicians to hire. We quite
often get no replies from physicians when we are recruiting.
Dr. Benishek. All right. Thanks.
I will yield now 5 minutes to my colleague.
Ms. Brownley. Thank you, Mr. Chairman.
So I think it was Mr. Harrington who testified earlier who
talked about a promise to hire a doctor, but then a nurse
practitioner or a physician assistant was hired in lieu of
that. So I am just trying to get to the bottom of whether that
was what was really, truly assigned by the VA, that we were
going to hire a nurse practitioner and not a doctor, or it was
because you could not hire a doctor is the reason for that?
Mr. Rice. Yes, that is correct. We try to staff with
physicians.
Ms. Brownley. Okay. Very, very good.
So I guess just a broad question to all of you. I notice
that a couple of you are wearing your ``We Care, I Care'' VA
buttons. Those buttons are symbolic of something, and in my
mind what it is symbolic of is the VA's commitment, certainly
the Secretary of the VA, his commitment to make sure that the
VA is working in a way to satisfy all veterans across our
country, every single one.
I had the opportunity to visit with a few veterans here
today who assured me that they are getting absolutely great
care. They are extremely satisfied with their care. But we all
know that we still have more work to do to make sure that we
are providing high-quality care for all of our veterans and
that we want the VA to be nimble enough and flexible enough so
that we are what we call back in Washington veteran-centric--it
is a veteran-centric VA, that our purpose in life is to serve
veterans and to make sure that veterans have great
satisfaction, in our case in healthcare delivery.
So having said that, based on what you have heard today
from our veterans, and we want to listen to our veterans and
learn from our veterans and hopefully create programs around
some of their issues and concerns, I guess I would just ask the
question, what is your take-away from this morning's testimony
from the veterans here?
Ms. Capra. Thank you, Congresswoman Brownley. What speaks
to me most is the implementation of the Choice program and
those significant challenges that we have implementing that
successfully, not just here in Sault Ste. Marie but, as I have
made my way around to other rural parts of the country, I do
hear the same concerns over and over about community providers
either not knowing about the opportunity to be part of the
Veterans Choice program or not being willing to participate for
a variety of reasons, whether it is reimbursement or they are a
little concerned about what the experience will be like to work
with the VA.
So I think while the Veterans Choice program presents a
great opportunity to bring care closer to home through
community providers, if the community providers aren't there or
aren't willing to participate, that diminishes the intent of
it.
I would say here in Michigan, I was fortunate on July 15th
to do a training to the Michigan Primary Care Association to
inform the Federally-qualified health centers of the
opportunity. We did this along with Health Net, the third-party
administrator implementing in Michigan, and thus far we have 19
Federally-qualified health center sites signed up in Michigan.
We have a long road to go to continue with that.
We are doing some national provider outreach efforts with
the National Rural Health Association and the National
Association of Community Health Centers to try to reach those
community providers, and many of them are already seeing
veterans or veterans and their families. So we would like to
bring them in, but there are challenges associated with that. I
heard that today.
Ms. Brownley. And what about the MOU that everyone was
talking about in terms of trying to integrate services here
with the tribes and the capacities that they have for
healthcare delivery?
Ms. Capra. My office has been talking--we talk very
regularly with the Indian Health Service. We actually did a
recent training to encourage tribal health programs to sign up
as Choice providers, and that is distinct and different from
the Memorandum of Understanding, which allows tribal health
programs to get reimbursed for the care they provide to Native
veterans. So we would like to see both of those mechanisms
activated more fully.
I understand here in Michigan that there are two tribes who
have signed the reimbursement agreement and are getting
reimbursed for the services they provide. We would love to see
that grow and can offer technical assistance on that. But those
are two distinct and very specific ways to get involved.
Ms. Brownley. Thank you. I yield back.
Dr. Benishek. I have a few more questions, a follow-up on
that.
Mr. Rice, have you been working with the Sioux Tribe? That
was one of the main points of Mr. Payment's testimony, that
they have been unable to secure a relationship with the VA to
allow their clinics. What is going on there?
Mr. Rice. So, a little history. We first started out with
Waters. Waters signed up, and we have an agreement with them,
as well as they are signing up to be a Choice provider. Then we
moved on to Hannahville. Hannahville doesn't have the capacity
to be a Choice provider, but they want to be reimbursed. So we
are finalizing an agreement with them.
Dr. Benishek. What was the deal there? They have a
different reimbursement plan? Is that what you are saying?
Mr. Rice. No, like Gina said, Ms. Capra, to sign them up as
either a Choice provider or an agreement to take care of Native
American veterans.
Dr. Benishek. Do they have to be a part of this Health Net
in order to be a Choice provider? Is that basically the----
Ms. Capra. Yes.
Dr. Benishek. Okay. So if they don't want to be a part of
this Health Net, then they cannot be a Choice provider.
Mr. Rice. Correct.
Dr. Benishek. But they can still do care within the VA
outside the Choice program, right?
Mr. Rice. Yes. The can get an authorization----
Dr. Benishek. Where are we here with the Sioux?
Mr. Rice. So we met with their representative actually
since 2014, and we are working with CBO to get the agreement
finalized so they can be reimbursed for the time they take care
of Native Americans. We are encouraging them to sign up to be a
Choice provider, but that is their choice, and they would have
to work with Health Net. We try to provide them information so
they can make that next step.
Dr. Benishek. They are not Choice providers at this time?
Mr. Rice. No, they are not yet. But we do have a successful
agreement over in Manistique where they take care of our
optometry patients in the Manistique area. So we have been
successful with the Sioux Tribe with setting up an agreement.
Dr. Benishek. What about this Memorandum of Understanding
for their tribal members? What is the problem there? That is
separate from the Choice, right?
Mr. Rice. Correct, and that is to reimburse for--we are
trying to set up these agreements so we can provide
reimbursement any time they take care of a Native American
veteran. I think the MOUs want to focus on taking care of all
veterans at their clinic, and that is why we are encouraging to
go the Choice route, because then we can reimburse through
Choice.
Dr. Benishek. I see. So what about just a fee-for-service
or another thing outside the Choice program?
Mr. Rice. Prior to the Choice program, we did have Waters,
for example, the health clinic in Waters sign up, and they
could be reimbursed for care in the community or the old NBCC
program as a fee provider. We can't direct patients--so if we
wanted to have all our patients go to that clinic, we would
have to have a contract, and the contract would have to go out
for bid. So we thought it was quicker if we had them sign up as
a Choice provider or a fee provider, because then they are
already signed up.
Dr. Benishek. It seems like this has been going on for a
while.
Mr. Rice. Actually, we have had three meetings over here,
educational sessions with all the tribal clinics, the Lower
Peninsula and the Upper Peninsula and VISN 11. We meet once a
year to try to provide education. So, yes, we have been
discussing this----
Dr. Benishek. Some of the issues from Mr. Payment is that
they are willing and eager to make this happen. I don't know
where the problem is, but I would think there is real
opportunity to find a local provider who is willing to be a
provider in the community. So I am just trying to facilitate
that by having this hearing here today.
One of the other things that was brought up was the
transportation issue and that there is difficulty providing
rural transportation. Can you address that a little bit as
well?
Mr. Rice. Yes.
Dr. Benishek. Ms. Capra talked about nationwide providing
transportation, it is already happening, but there still seem
to be some problems. Can you update us on what is going on as
far as you are concerned?
Mr. Rice. For VTS, we do have a local program. The routes
are based on Iron Mountain. We go 60 to 90 miles from Iron
Mountain. The transportation from the Sault to Iron Mountain,
as previously mentioned, is by vans. There are some
restrictions because they cannot take patients who are on
oxygen, so that does create a challenge. But with the recent
Choice program now, the services provided at the Sault, we have
been authorizing care in the community so the veterans don't
have to travel over to Iron Mountain, and that is improving
every day. We have work to do, but that is our goal, to provide
the care here, to get it closer to home for our veterans.
Dr. Benishek. Apparently, since 2009, there has been $14
million that has gone from the Office of Rural Health to the
Iron Mountain VA Medical Center. Can you tell me how that $14
million has been spent?
Mr. Rice. Sure. We have been real fortunate, actually. It
has allowed us to start programs this past year. For example,
this is the first time we are offering PT at one of our
outpatient clinics through a rural health grant. We were able
to remodel some space at the Rhinelander clinic in Wisconsin,
hire a physical therapist, as well as a PTA. That has allowed
us to establish three E-RANGE teams across the UP, one in
Manistique, one in Hancock, and one in Rhinelander. It has
enabled us to start some surgeon programs back at the main
campus.
So we have been real lucky that this program exists. We
were able to bring services that we wouldn't have been able to
bring to our community otherwise.
Dr. Benishek. Ms. Brownley.
Ms. Brownley. Thank you, Mr. Chairman.
I am just going to go back to the Choice program for a
minute. I know it has been confusing. It has been confusing I
think across the country, and as everyone knows here, there are
several community-based programs that the VA has, the Choice
being the third of a family of programs. They are all run
differently. Their reimbursement rates are different, et
cetera. I, for one, feel like we should combine all of those
programs into one and have one reimbursement program and
simplify it, but we are not there yet.
But on the Choice program, it has been my experience, at
least in my own community, that once doctors begin to
understand, the local doctors, once they understand how the
program operates and they understand that the reimbursement
rate is the Medicare rate, that they are more willing to
actually want to be a part of that program, but it does take
time. As you are doing recruitment for physicians to work
within the VA, that same effort has to be established to make
sure that the doctors in our communities are aware of the
program, and in this case getting them connected with Health
Net.
I would hope that Health Net is helping you in this
process, but I think we have made some changes and adjustments.
I know one of the issues that I worked on was the continuity of
care issue because under the Choice program, if you had cancer
and needed treatment, the continuity of care was only--I think
it was 60 days or something, and who wants to be treated for
cancer and at the end of 60 days say you have to now go to a
different doctor?
So that has been fixed in the Choice program. So there have
been--I think we have made some improvements.
I wanted to ask, and probably this question is not under
any of your jurisdictions necessarily, but how do we make Iron
Mountain more flexible to veterans who have to travel there for
their services? I mean, I heard several in their testimony say
that they went to Iron Mountain for X service, did the
traveling all day to get there, all the way home, and then get
a call the next day saying you need to come back because we
need to make that adjustment on your hearing aid, or we didn't
do this test.
How can we make the Iron Mountain folks more flexible so
that when our veterans travel there, if they need a hearing aid
adjustment, they need to get their eyes checked, and they need
a chest x-ray, that that can all be managed in one day as
opposed to three separate trips? How do we make that happen?
Ms. Capra. I would just say nationally, Congresswoman
Brownley, that this is an issue across the board for rural
veterans traveling into facilities. I have been to facilities
where they accommodate the veteran and his or her family
overnight if it is going to require that sort of long day. That
is really not a reasonable request to make of a veteran.
I think also the earlier conversation around technology. If
some veterans are uncomfortable with telehealth or a phone-
based call with a nurse, then for them that is not the right
fit. But we really try to use technology in a way to bridge
that distance so they don't have to go as far for certain
services.
I will ask Mr. Rice to comment on Iron Mountain.
Mr. Rice. I would just say the same, that what we are
trying to do is really educate our clerks that every time they
make an appointment, that they really discuss with the veteran
any future appointments.
But one of the goals, as I said for the medical center this
year, is prior to any veteran leaving the clinic, for example
if they need a specialty clinic, that they have that
appointment before they leave the medical center so we can be
more veteran-centric.
One of the things we also spend a lot of time on, I have a
slide that I use when I go out and do the town halls, really
that we want our staff to recognize that our main goal is to
make sure veterans get the care at the right time and at the
right place, and sometimes that right place isn't Iron Mountain
VA, it is here in the community.
So it is really changing the mindset of how we approach
care to our veterans, that it is okay if we give care in the
community, changing the mindset. Everybody always thought it
had to be behind our four walls, but really we have to put the
veteran first and make sure we address his or her needs.
Ms. Brownley. Thank you.
I yield back.
Dr. Benishek. I have a few more questions.
In following up with what Ms. Brownley was asking, the
gentleman testified about coming and then going back three
days, having to go back for more----
Mr. Rice. That is unacceptable.
Dr. Benishek. Really, is there some inquiry to the patient
prior to his arrival saying what are the issues you are going
to be talking to us about, is there anything else we can take
care of while you are at Iron Mountain that day? Do they have
that type of discussion with the patient prior to their showing
up? Because I haven't heard that.
Mr. Rice. They are supposed to. We try to do it. Because of
when Phoenix occurred, what we do now is leadership. Myself,
Dr. McNutt, we meet with our clerks every Friday and we go over
the hot topics and scheduling. We discuss this topic a lot
because some of the complaints I hear from the veterans when
they call me directly is the same that we heard today, that I
had an appointment today and they made me come all the way
back. So really educating our schedulers to make sure they have
that discussion with the veterans so we understand what their
future appointments are so we can try to batch them all on the
same day.
Dr. Benishek. It just seems to me that knowing that he is
going to go for a hearing evaluation, that the tech should be
there that same day so that those kind of issues can be dealt
with. The travel time is just horrible.
Mr. Rice. We did have some positive comments about
telehealth, but we do have over 37 clinical telehealth programs
now, and one of those programs, for example, is we have tele-
audiology where we can actually fit the hearing aid via tele to
prevent veterans from traveling far distances to get
adjustments to their hearing aids, and that is a new program we
started last year.
Dr. Benishek. I wanted to ask another question about the
medical record because I have heard also in other testimony
that when people get outside care in the community, their
medical record is not updated at the VA maybe in a timely
fashion.
Does that kind of communication happen electronically? Does
the patient in the community have access to the patient's
records in the VA? I mean, when I was taking care of some
patients at Iron Mountain, I was able to get into the VA's
computer record in my office. It was sort of an ordeal to get
in, but we always had that. Is that a routine now? Does the
patient seen in the community have access to the patient's
record?
Mr. Rice. Iron Mountain is one of 13 pilot sites across the
country where we are sharing records electronically with the
private sector hospital. Where we have been successful so far
is with the state home. In Marquette, any time they have a new
admission, we share the records electronically. Then we are
also working with Dickinson, Marquette General, and I think St.
Francis. It is in the early stages, but our goal is that
relatively soon we will be able to share records.
Ms. Capra. And I would add, under the Choice program
currently, although it is still very clunky, there is the
transfer of information between VA and the referred community
provider. That is a part of the process in order for the
provider to get paid on the community side.
Dr. Benishek. I think one more question and follow-up on a
previous line of testimony. I can't remember if you actually
said--are you going to continue to try to get a physician here
in Sault Ste. Marie, or is that pretty much by the wayside? We
went through the numbers game there for a minute. I don't know
if you did that because you are not going to recruit a
physician anymore? I am just trying to get what is the final
answer because that is the main question that people have. They
want a physician at this facility, and I don't think you
answered the question.
Mr. Rice. Currently right now we are not recruiting for a
physician, but one of the things we have been real successful
this past year--like, for example, Marquette, with some changes
that went on with Marquette General, that we have encouraged
all physicians, if they are interested in working for us, we
have been able to work out arrangements where we can take on
additional providers, be it via tele or other means of
providing care.
Dr. Benishek. And you have been unable to recruit somebody
to the Sault Ste. Marie facility to provide part-time physician
coverage? Is that correct?
Mr. Rice. Since 2013 we haven't had any.
Dr. McNutt. We have not had a single applicant other than
the one we discussed earlier.
Dr. Benishek. Well, you are no longer recruiting for the
job at this point in time.
Dr. McNutt. I wouldn't say that. I encourage, and I am sure
that you being part of this medical community you know this,
that we often talk among ourselves, and my cell phone is out
everywhere. I encourage anyone who is interested to call me
personally. I keep an ongoing file of anyone who might have
interest in working for us. So I would say that as a leadership
group, Mr. Rice has been very receptive to increasing FTE when
we have a qualified candidate.
Dr. Benishek. How much is the scope of care limited by not
having a physician here on site?
Dr. McNutt. I would comment on two things there,
Congressman Benishek. Number one is that we provide guarantees,
and our NPs and PAs are highly qualified for what they do. They
also have instant access to a physician. They all have a
collaborating physician. One of our very useful pieces of
technology is instant messaging. While sitting in an exam room,
one of those providers can instant message the chief of primary
care, me, their collaborator, saying they have a clinical
question.
Dr. Benishek. Does that occur here?
Dr. McNutt. It occurs all the time, not just in Sault Ste.
Marie but all of our CBOCs. They also all have my cell phone,
and they will text me saying can you give me a quick phone,
which we do. The chief of primary care and I, since this is a
small community, are extremely receptive to mentoring and
serving as the M.D. when they need one.
Ms. Brownley. So what is an example of when they need one?
What does that mean?
Dr. McNutt. So, for example, when you are hiring a new
provider, let's say you hire an NP for a site, and they will
start out with a limited number of patients while they learn to
use the computer system and try to understand our record. So
they may send me an instant message saying I have a patient
here who has a question about a referral. Where do I send this
patient? How do I enter this consult? Or they may send me a
question saying do you know who the pulmonologist is in
Milwaukee? Questions that are usually related to systems,
though on occasion they do ask a medical question also. But
they have almost literally instant access to a physician.
Ms. Brownley. But it is more logistical than it is----
Dr. McNutt. It has been more logistical than it has been
medical. Our NPs and PAs are extremely well trained for the
majority of chronic care that they deliver.
Ms. Brownley. I was just going to follow up to say I think
I suggested that if you have a nurse practitioner who is seeing
a patient and the patient needs more than he or she can provide
in terms of setting up a telehealth meeting, a consult with the
doctor, with the nurse practitioner, with the patient all
together, is that possible to happen, or is it----
Dr. McNutt. For all of our mid-level providers--NPs, PAs--
they always have the option if they feel the patient's medical
situation is too complex for them to provide for care, they
always have the option of referring that patient to an M.D.
Ms. Brownley. I totally get that. They can refer them to an
M.D., and then they go and travel into Iron Mountain. I am
trying to find other solutions to limit the amount of
traveling. In some sense we have to get the VA thinking in
terms of people that have to travel the farthest need to be
handled with kid gloves. It is just so much easier when you are
close by, but these patients have issues just like everybody
else, and then they have the trauma, if you will, of having to
do the traveling and the frustration that goes with setting
that up and having to experience going, coming back, and then
getting a call saying I need you to come back again, like it is
just right around the corner.
Dr. McNutt. We do provide primary care. We have two
physicians who provide primary care by tele. As he commented,
not everyone is fond of tele, but we have many patients who
come in and they do like telehealth. I do have the option to
assign patients to a tele-practice where the primary care
doctor is not located here but is the assigned physician of
record for a patient.
Ms. Brownley. Right. But if the patient has a relationship
with the nurse practitioner, all I am asking is, is it possible
for a doctor to be, via telehealth, and the nurse practitioner,
and the patient all be together?
Dr. McNutt. Yes, it is possible.
Ms. Brownley. Thank you.
Ms. Capra. Congresswoman Brownley, I would just add that
nationally we are seeing that rural communities, not just VA
service to communities, face this issue of a lack of
physicians. So the mid-level team that Dr. McNutt described is
so common. I talk frequently with my counterparts at the
Department of Health and Human Services, their rural health
office, and they are equally challenged by this issue of how to
support rural communities so that individuals don't have to
travel hours and hours to see specialists.
One of the things that is very unique, I have found, in the
VA is the home-based primary care program. It is a limited
program. It is something the Office of Rural Health has funded
to a limited degree, but it allows the team to go to a
veteran's home, those that are eligible, and I think that is
really a fantastic model. It is resource intensive, but it
really gets to the veteran where he or she is. So I think that
is a place where the VA does a little better, actually, than
those of us that get our care outside of the VA.
Dr. Benishek. Well, while I have you here and while we have
the time, I just want to touch again on this transportation
issue. You mentioned that the DAV is providing the
transportation. How is that really working? Because Mr. Payment
was saying it doesn't seem to be working that well from his
perspective. I know that we have a problem with capacity
because the volunteers are paging and it is not maybe as
reliable a system as it once was.
Can you talk about that? Is there another option for
veterans here? Are you willing to work with Mr. Payment to try
to----
Dr. McNutt. Yes, we can do that.
Dr. Benishek. Can you move a little more in his direction?
Mr. Rice. The DAV driver from the Sault I think is very,
very----
Dr. Benishek. I don't know the specifics, but I know this
has been a problem in the past.
Mr. Rice. In the past year we have driven 1,000 miles for
the VA. We transported almost 2,700 veterans who were served by
the DAV. But I would be willing to discuss with him those
issues. Recently I worked with some veteran groups, but not--we
try to get to the Hancock clinic, to our main campus. So we
would be willing to sit down and talk about that.
Dr. Benishek. Do you have any more questions, Ms. Brownley?
Ms. Brownley. No.
Dr. Benishek. I know that we haven't answered all the
questions that came up from our veteran panel, but I appreciate
you coming in here today with Mr. Rice and Dr. McNutt, Ms.
Capra. Thank you.
I still think there are a lot of concerns about our rural
veterans. Some of the things have been addressed, the traveling
back and forth, back and forth three times in the same week,
that sort of thing. These are problems that really need to be
solved, and I think better communication with the veteran prior
to the visit. I think you mentioned that it is very important
to be sure the veterans are informed as to the options and
having more options available when they go to Iron Mountain so
they don't face too many trips.
I know that we probably aren't trying to solve every
problem at the rural VA, but I hope that maybe some people here
who have a relationship with the providers here in the Sault
will continue to improve going forward. I didn't want to say
myself, having worked at the VA, I worked with Mr. Rice. He is
a keeper, and that means a lot. He is not somebody that is
coming through the VA every two years and moving on to his next
site. He is committed to being at Iron Mountain. So there is a
lot of improvement there, and I know that he is working
sincerely.
My frustration, frankly, is with upper management, making
sure that he has the tools he needs to provide the care that we
need in Michigan. I am happy to see that he came here.
Ms. Capra, like I said, I was a little disappointed in your
standard testimony, how you are doing things, but the specifics
matter here, and making sure that Mr. Rice has the tools that
he needs to provide care. Somebody on the first panel said his
hands are tied. I would like to see a physician here in the
Sault. I know that people here in the Sault want to see that,
and I continue to encourage the VA to hire a physician here in
the Sault, and I am going to continue to work on those efforts.
So if you don't have any further questions, I want to thank
you for being here today, and I will hereby adjourn the
hearing. Thank you very much.
[Whereupon, at 11:40 a.m., the subcommittee was adjourned.]
APPENDIX
Prepared Statement of Chairman Dan Benishek M.D.
The Subcommittee will come to order.
Good morning and thank you all for joining us today.
As you may know, I am Dr. Dan Benishek and it is my honor to be
both your Congressman and the Chairman of the Subcommittee on Health
for the Committee on Veterans' Affairs of the United States House of
Representatives.
Before I was elected to Congress, I was privileged to serve for
twenty-years as a physician at the Oscar G. Johnson VA Medical Center
in Iron Mountain, which oversees the VA community based outpatient
clinic here in Sault Ste. Marie.
During my time there, veteran patients would tell me every day
about the challenges and the frustrations they faced when attempting to
get care through VA--the VA which is, by the way, our government's
second largest bureaucracy with a budget and staff that trails only the
Department of Defense in size.
Let me be clear: Our veterans fought for our freedom--they
shouldn't have to fight government bureaucrats too.
And the Subcommittee Members and our staff work hard every day to
break down the barriers between the VA bureaucracy and the veterans
that this bureaucracy should be serving here in the U.P. and across the
country.
I am joined here today by Congresswoman Julia Brownley, the Ranking
Member of the Subcommittee on Health and the Representative from the
26th District of California, just north of Los Angeles.
Needless to say, she has traveled quite a distance to be here with
us today and I am grateful to her for her willingness to join me in
Sault Ste. Marie this morning and for being such a strong and effective
voice on the Subcommittee.
The purpose of today's hearing is to make sure that the care and
services that you and your fellow veterans receive in the Eastern U.P.
is timely, accessible, and high-quality.
Unfortunately, we all know that--at times--VA has failed to meet
those measures and, in doing so, has fallen far short of providing the
treatment that our veterans earned and deserve.
An example of how VA has fallen short here in Sault Ste. Marie can
be seen in VA's inability for the past two years to recruit a physician
to staff the VA community-based outpatient clinic here.
The veterans that I have spoken to--some of whom you will be
hearing from this morning--are understandably concerned about the lack
of a physician at this facility and the impact that VA's failed
recruitment efforts have had on the quality of the care at the clinic.
I share those concerns and, today, I want answers.
During this morning's hearing, we will discuss efforts that VA has
taken in this community and around the country to ensure that rural
clinics like the one here in Sault Ste. Marie are properly staffed and
that rural veterans are able to access care in the community or through
tribal health centers where VA is unable to provide the care that our
veterans need or when our veterans would prefer to receive care
elsewhere.
We will hear testimony from VA and from local tribal leaders and
veterans, whose input, expertise, and advice is critical to the work
that we do in Washington.
I am grateful to all of our witnesses for being here and I look
forward to their testimony.
Before that, however, I would like to take a moment to recognize
the men and women that we are here today to serve.
Would the veterans in our audience right now please stand--if you
are able--or raise your hand and be recognized?
Thank you so much for your service to our country and for being
here with us this morning.
I would also like to take a moment to recognize and thank the
Armory staff for allowing us to use their facility this morning and for
their assistance in helping us to prepare and set up for this hearing
today.
Thank you very much.
With that, I now recognize Ranking Member Brownley (Julia) for any
opening statement she may have.
Thank you.
We will begin today's hearing with our first panel of witnesses,
who are already seated at the witness table.
As this is a formal hearing and not a town hall, only invited
witnesses will be able to speak though I do look forward to greeting
and speaking with our audience members more informally after the
hearing has concluded.
Before I introduce our panelists, I want to gently remind all of
today's witnesses to please be mindful of the five-minute time-limit
for your oral testimony and the question-and-answer period that will
follow.
The light that has been placed in front of me and in front of you
will change from green to yellow when there is one minute left and from
yellow to red when time has expired.
We are going to try to stay as closely within the five-minute time-
limit as possible so that we can be sure that everyone has a chance to
be heard in a timely manner.
Thank you in advance for your consideration.
With us on our first panel this morning is Chairperson Aaron
Payment of the Sault Ste. Marie Tribe of Chippewa Indians; Anthony
Harrington, a veteran who lives right here in Sault Ste. Marie,
Michigan; David W. Pearce, an Army veteran and the Commander of the VFW
Post 3676; and, Don Howard, a veteran and Commander of the American
Legion Post 3.
I am so grateful to each of you for your willingness to be here
this morning and to speak candidly about issues of such importance to
our veterans and our community.
I am honored to have you here.
We will begin with you, Chairperson Payment.
You are now recognized for five minutes.
Thank you.
Mr. Harrington, you are now recognized for five minutes.
Thank you.
Commander Pearce, you are now recognized for five minutes.
Thank you.
Commander Howard, you are now recognized for five minutes.
Thank you.
I will now yield myself five minutes for questions.
If there are no further questions, the panel is now excused.
Thank you all very much.
I now welcome our second and final panel to the witness table.
Joining us from the Department of Veterans Affairs is Gina Capra,
the Director of the Office of Rural Health.
Ms. Capra is accompanied by James Rice, the Acting Network Director
for Veterans Integrated Service Network 12, and by Dr. Gail McNutt, the
Chief of Staff of the Oscar G. Johnson VA Medical Center in Iron
Mountain, Michigan.
Thank you all for being here.
Ms. Capra, please proceed with your testimony.
You are recognized for five minutes.
Thank you.
I will now yield myself five minutes for questions.
If there are no further questions, the panel is now excused.
Once again, I thank all of our witnesses and audience members for
joining in today's conversation.
It has been a pleasure for me to spend the morning here with all of
you.
With that, I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks and include
extraneous material.
Without objection, so ordered.
This hearing is now adjourned.
Prepared Statement of Aaron Payment
My name is Aaron Payment, and I am the chairperson of the Sault
Ste. Marie Tribe of Chippewa Indians. As a member and leader of the
tribe, I am speaking on behalf of the tribe. As always, my tribe and I
want to work in partnership with you.
Throughout the history of the United States, Native Americans have
fought bravely and sacrificed for this country. This proud tradition
continues today with 24,000 active duty American Indian service
members.
The 2010 U.S. Census identified over 152,000 Native men and women
who have served this country in its, Armed Forces. While the U.S.
population recorded nearly 1.4 percent American Indian, the military
population was 1.7 percent Native, making it the highest per-capita
commitment of any ethnic population to defend the United States.
I commend the Department of Veterans Affairs' efforts to ensure
that community-based outpatient clinics in rural areas are properly
staffed and rural veterans are able to access care in the community,
where appropriate and necessary. However, additional changes are
critically needed to meet the needs of American Indian veterans. The
current system creates multiple barriers to treatment for American
Indian veterans living in rural areas, which is where most reside.
In the Eastern Upper Peninsula of Michigan, where there exists a
shortage of service officers and service office open hours, Sault Tribe
has partnered with the American Legion to provide two additional
service officers in congressional District 1. These added service
officers provide outreach activities to veterans who utilize Sault
Tribe's Indian Health facilities across the EUP. The tribe provides the
space to offset costs associated with the additional service officers.
Additionally, the tribe has begun baseline data collection efforts
aimed at more accurately reflecting the number of American Indian
veterans across the U.P.
Veterans' Services Within the Sault Ste. Marie Tribe of Chippewa
Indians Health Division
In 2010, the Health Division worked with the Iron Mountain VA to
establish an agreement with the tribe's optical department in
Manistique. Under this agreement, the tribe is able to provide optical
services to tribal and non-tribal veterans.
The tribe has also:
Established a VA workgroup to access additional
services for its tribal veterans.
Partnered with a veteran's service organization,
American Legion, to provide benefits. Service officers at
tribal clinic sites to assist veterans with issues and
questions about navigating the VA bureaucracy.
Worked to identify tribal veterans as they come into
tribal clinics as also being a veteran in order to plan
services.
Worked to incorporate both behavioral health and
traditional medicine programs to develop veteran specific
services to include PTSD, emotional trauma, etc.
Planned awareness outreach to get out the word on
tribal and VA services including tribal elders meetings, tribal
newspaper, website and video tag line information.
Worked with the Iron Mountain VA to establish a
Memorandum of Agreement with the tribe for full reimbursement
for providing clinical services to tribal veterans eligible for
VA services.
Challenges to Choice
Veterans who choose to utilize their Tribal Health centers and
tribal providers as their primary care sites do not use their VA
benefits. The VA cannot reimburse Sault Tribe until there is an MOA in
place. The VA Choice Card Program does not list tribal clinics as
reimbursable entities for providing the care as a referral from the VA.
The tribe would need to become PC3 and Choice Provider under Health
Net. The tribe is awaiting contact information from the VA about these
programs.
If veterans are unable to get an appointment at the Iron Mountain
VA in 30 days, they can receive a Choice Care card and referral. They
would then need to see if they could be seen at War Memorial Hospital
(Sault Ste. Marie, Mich.), which is the preferred referral location in
this area. Lastly, if WMH could not see veterans in 30 days, they would
need to go back to the VA to receive another referral to use the Choice
Card at Sault Tribe's health center, and then the tribe would be
reimbursed.
The frustration for tribal veterans is to drive three to five hours
to Iron Mountain and not receive an appointment resolving their issue,
then receive referral to clinics in Wisconsin rather than Michigan,
thus making the travel time even longer for follow-up and specialty
care appointments.
Barriers to access care involve transportation to and from Iron
Mountain because of distance and frequency. Community-based outpatient
clinics are staffed with mid-level providers, not physicians, so
veterans using CBOCs are not able to obtain the primary evaluations
necessary to access their VA benefits.
Recommendations
Freedom of choice. American Indian veterans should be
free to choose their care based on where they can secure the
highest quality health services. Veterans who choose to utilize
tribal health centers and tribal providers as their primary
care sites are not able to access their VA benefits. Currently,
the VA Choice Card program does not list tribal clinics as
reimbursable entities for providing the care as a referral from
the VA.
Reimbursement to tribes. Tribal healthcare programs
should be reimbursed for both direct service and referred care
when Veterans find tribal health programs more accessible or
more accommodating to their needs. I urge Congress to require
the VA set up a process that allows reimbursement for eligible
services provided by Tribes, including tribes such as the Sault
Ste. Marie Tribe of Chippewa Indians, which is a self-
governance tribe.
Improve public transportation. The tribe has
identified a lack of consistent and reliable transportation to
access many services that directly impact quality of life,
including health, education and employment. The 2015 Sault
Tribe Transit Implementation Plan showed transportation for
making trips across the Upper Peninsula is provided only at
night (12:15 a.m.-8:35 a.m.), which is of limited use for
medical trips. The tribe also found a lack of evening and
weekend service, another barrier limiting members' ability to
access critical health services.
Reimbursement to tribes. The Department of Veterans
Affairs should reimburse tribal governments providing Native
veterans transportation to primary and specialty clinics, and
follow-up care. Most American Indian veterans live in remote
areas of the United States and the cost for transportation to
and from Veterans healthcare facilities cause substantial
hardships on these veterans seeking service.
I am available to answer any questions you might have. Thank you.
Prepared Statement of Anthony Harrington
Chairman Benishek, Ranking Member Brownley, thank you for giving me
the chance to testify today.
I am a disabled veteran and I live here in Sault Ste. Marie.
As you both know, there is a VA clinic here. The clinic has been
here for many years but more than 2 years ago the attending physician
retired. In the interim, part-time doctors have been trying to pick up
the slack, and a Nurse Practitioner has been brought in to replace the
retired physician.
I truly and deeply believe that our veterans should be entitled to
proper healthcare. This specific VA clinic serves the entire Eastern
Upper Peninsula. They are a very busy facility with many patients from
across the region. The facility is having trouble keeping up with the
number of patients and its quality of care is suffering as well. The
NP, although very good at her job, can only do so much within the
guidelines of her job description and abilities.
Currently, as it stands the NP can only see a maximum of six
patients a day and is limited as far as what she is allowed to diagnose
and treat. The facility is in desperate need of a full-time attending
physician as well as the current NP to adequately care of the entire
region and its patients.
Recently they hired a Physician's Assistant here. While that's a
good first step, it's really not a replacement for a full time doctor.
I just want to know why they were able to bring a PA if it wasn't
possible for them to bring a doctor? I have been told by Iron Mountain
VA officials that they were only authorized to hire a nurse practioner,
and then all of a sudden the PA shows up. That doesn't make sense to
me.
Prior to the hiring of the NP I was seeing a doctor by the name of
Lisa Vanhevel at the Bay Mills Indian Clinic. The reason I turned to
the Indian clinic instead of the VA clinic was due to the lack of an
attending physician at the facility. While under Dr. Vanhevel's care we
talked quite extensively about the need of a full time doctor at the VA
clinic. She told me that her contract with Bay Mills was coming to an
end and made her intentions clear that she was interested in
interviewing for the position at the VA clinic.
Upon following the proper channels she was then granted an
interview at the VA clinic in Iron Mountain, Michigan. Sometime later I
happened to run into Dr. Vanhevel at Wal-Mart and she informed me that
her interview went well and she was offered a position at the Sault
Clinic as well as the Iron Mountain clinic. She stated that she was
only offered two days a week through our facility or a full time
position in Iron Mountain. She explained that she had to decline both
positions because she didn't want to move to Iron Mountain or commute
295 miles away for work. She also didn't want to take a position for
only two days a week.
Dr. Benishek, Ms. Brownley, I'm sure you can sympathize with her.
Who in their right mind would want to take a position for 2 days a week
following a contract where they had a full time position? This was very
concerning to me considering the dire need for a full time attending
physician here.
In addition, Dr. Benishek's staff has told me that prior to the
hiring of the PA, Benishek's office was told by the VA that they were
going to try to hire a doctor. However, despite what Benishek's office
was told, we've seen no evidence that an ad was ever placed on
usajobs.com, or that any ads were placed in UP newspapers. I'd like to
know what exactly was done to try to get a doctor here.
I'm glad that Congress is finally investigating this issue. I have
yet to have someone explain to me why it is that the veterans in this
area are not entitled to a VA facility with a full time doctor and
quality healthcare.
Thank you again for having me here today. I truly hope that you
will take the time to look into this matter and serve justice to our
vets as we have selflessly served you and this country. It is my hope
that you will confer with the new director of the VA and that you can
come to an agreement to resolve this.
I'm happy to answer any questions you may have.
Thank you.
Prepared Statement of David W. Pearce
Congressman Benishek, Committee Members, Committee Staff, and
Fellow Panelists,
Thank you for the opportunity to appear before you today on behalf
of the members of Veterans of Foreign Wars Post 3676 and approximately
58,000 Upper Peninsula of Michigan Veterans--one of this great state's
most valuable resources. I feel qualified to provide some input, within
my scope, as I am a retired service-member, disabled veteran that uses
the VA healthcare system and the Commander of the Welsh-McKenna VFW
post here in the Sault. I served this great nation of ours for over 20
years as an Active Duty Soldier in the United States Army. I was also
born and raised here in the Eastern Upper Peninsula and returned home
to Sault Sainte Marie upon the completion of my military career.
First, I would like to commend the Veteran's Administration for
recognizing a problem in the care of our Veterans that live in rural
areas. Speaking from my personal experience with the VA healthcare
system, I believe the VA is moving in the right direction, there is
still much more room for improvement. Improvements have been gained in
the last several years with my access to care. When I started to use
the VA healthcare system, it was not uncommon to drive all the way to
the Iron Mountain VA hospital for an appointment or test. The Oscar G.
Johnson VA Medical Center in Iron Mountain, Michigan is the closest
facility. Some of those appointments were a simple 15 to 20 minute
doctor visit that would require a 4 hour drive, one way, and an entire
day off work. More recently, the VA has scheduled appointments for me
at the local hospital or sent me an authorization to seek care locally.
I am satisfied with the improved choice options; however there are bugs
to be worked out. One is with billing. As a retired service member, I
also use Tricare for medical insurance. Several times when I received
care locally, my healthcare insurance was billed and not the VA. The
response time is very slow when trying to get the medical bills routed
in the right direction.
I also feel that local access to healthcare for our aging veteran's
should be a priority. I'm still relatively young. It is not as much of
a burden for me as it is for some of our older veterans to receive
care. In our community here in the Sault, there are several assisted
living facilities and nursing homes with elderly veterans that do not
have the physical capability to travel great distances to receive care
from the VA. Improved choice could help with that issue. I would also
like to comment that for me personally, the MyHealtheVet website is a
great asset to access care, re-fill prescriptions, and communicate with
the local Community Based Outpatient Clinic thru secure messaging. That
was a great idea for those of us that are computer literate. However,
it is not such a great choice for those that are not familiar with
using a computer or do not have access. Many of our older Veterans do
not use a computer. Another issue with improved choice that should be
addressed is the lack of specialized care and Women Veterans'
healthcare access in our rural environment. I'm not sure how to address
these topics specifically, but they definitely need to be looked into
and more options for care need to be available for all Veterans.
Appropriate staffing is a concern. Soon after my retirement from
active duty I started using the VA Community Based Outpatient Clinic
located in Kincheloe, Michigan. The clinic was relocated to Sault
Sainte Marie a few years later. I personally think the staff at the SSM
CBOC is absolutely wonderful. I interact with the staff at the local
clinic several times every month for my own appointments. They are
always helpful and friendly. The only concern I have is there is not a
permanently assigned Medical Doctor at the clinic. The Physician's
Assistant does a great job, but I feel there should be a full time MD
assigned to the clinic also. When the Doctor that was assigned to the
clinic retired the position was filled several times temporarily until
the Physician's Assistant was hired. This created a lack of continuity
in care. I feel due to this lack of continuity, mistakes were made and
treatment was not appropriate. During that time I also had an
appointment with a physician located in Iron Mountain thru video chat.
I felt that appointment was very impersonal and not effective at all.
On another occasion, I drove to Iron Mountain for a video conference
with a Doctor located in Milwaukee and some on-line testing. That, I
feel, could have been accomplished at the clinic in Sault Sainte Marie.
Now put yourself in a World War II Veterans shoes. Imagine how
overwhelming and confusing the video conference could be to them.
Again, it is a great honor to have the opportunity to participate
in this valuable discussion regarding the care of our Veterans. This
concludes my testimony. I am prepared to take any questions you or the
committee members may have regarding my personal experiences with
Appropriate Staffing and Improved Choice. Thank you.
Pursuant to Rule X12(g)(4) of the House of Representatives, I have
not received any federal grants in Fiscal Year 2015, nor have I
received any federal grants in the two previous Fiscal Years.
I have not received payments or contracts from any foreign
governments in the current year or preceding two calendar years.
Prepared Statement of Jacqueline A Haske
Chippewa County Department of Veterans Affairs, 319 Court St, 3rd
Floor, Sault Ste. Marie, MI 49783, (906) 635-6370/Fax (906) 635-6867,
[email protected].
September 15, 2016
To whom it may concern,
My name is Jacqueline A Haske. I am with the Chippewa County
Department of Veteran Affairs Office. My office is designed to assist
and support Veterans. File claims with the VA, apply for assistance
with the Michigan Veterans Trust Fund, and seek further resources in
the community and more. My concern is with the growing population of
veterans in the Eastern Upper Peninsula, is the ability to provide
healthcare to the veterans. We have been told about receiving a Doctor
at the War Memorial VA Clinic and still have not received one. Several
veterans have expressed their concern about getting a Doctor at this
local facility.
Jacqueline A Haske, Veterans' Counselor
Prepared Statement of Ms. Gina Capra
Good morning, Chairman Benishek and Ranking Member Brownley. Thank
you for the opportunity to discuss staffing and rural health concerns
nationally and in the state of Michigan. I am accompanied today by Mr.
James Rice, Acting Veterans Integrated Service Network (VISN) 12
Network Director and Dr. Gail McNutt, Chief of Staff Iron Mountain
Veterans Affairs (VA) Medical Center and Co-Chairperson of the National
Patient Aligned Care Team (PACT) Consultant Team.
Overview
The employees of VISN 11 proudly provide patient-centered care to
approximately 399,825 Veterans living in portions of Michigan, Ohio,
Indiana, and Illinois. Of the nearly 400,000 Veterans being treated,
82,798 are classified as living in either rural or highly-rural areas.
VISN 11 consists of 32 Community-Based Outpatient Clinics (CBOC) and 7
healthcare systems with main campuses located in: Ann Arbor, Battle
Creek, Detroit, and Saginaw in Michigan; Indianapolis and Ft. Wayne in
Indiana, and Danville, Illinois. For fiscal year (FY) 2015, VISN 11 is
operating on a budget exceeding $2.2 billion providing our Nation's
heroes with high-quality care through traditional and innovative
methods. VISN 11 also has a collaborative relationship with Vet Centers
located throughout the catchment area.
VISN 12 provides patient-centered care to approximately 15,000 of
the 30,000 Veterans residing in Michigan's Upper Peninsula. These
services are provided primarily through the Oscar G. Johnson VA Medical
Center (OGJVAMC) in Iron Mountain, Michigan. The medical center
operates six CBOCs in Michigan (Ironwood, Hancock, Marquette,
Menominee, Manistique, and Sault Ste. Marie) and one in Rhinelander,
Wisconsin.
OGJVAMC is a complexity level III care facility with 17 medical/
surgical beds. It also has a Community Living Center with 40 beds.
OGJVAMC provides urgent care and acute inpatient care in a
geographically rural area and collaborates with larger healthcare
facilities in VISN 12 and community facilities to provide higher level
emergency and specialty services. It employs state-of-the-art
telehealth technologies and is a leader in the delivery of healthcare
to rural Veterans.
The facility has 686 employees and an FY 2015 operating budget of
$126 million. This includes $26 million for care provided by community
providers. In FY 2014, there were 12,477 Veterans authorized to receive
care in the community. Since the passage of the Veterans Access,
Choice, and Accountability Act of 2014 (Choice), OGJVAMC has authorized
over 4,226 Veterans to receive care for those waiting greater than 30
days, primarily for psychiatry, optometry, and physical therapy
appointments. In addition, OGJVAMC serves 2,484 Veterans that live
greater than 40 miles away and are eligible for Choice; however, only
450 of these Veterans have elected to use their Choice option.
OGJVAMC ranks 18/140 in overall efficiency and 15/140 in clinical
efficiency according to the latest efficiency analysis by the Office of
Productivity, Efficiency, and Staffing. For each VA medical center,
clinical and administrative cost efficiency is measured by using
stochastic frontier analysis (SFA). SFA is a well-validated approach in
assessing operational efficiency with quality of care taken into
account. Additionally, the medical center has done well on national
level employee surveys. For example on the Federal Employee Viewpoint
Survey, the medical center had a greater percentage of positive
responses to the summary satisfaction questions than VA, the Veterans
Health Administration (VHA), and VISN 12. The Employee Engagement score
for the facility was also higher than VA, VHA, and VISN 12. In fact,
the facility's score of 66.5 was higher than the Government-wide score
of 63. On the All Employee Survey Best Places to Work Index 2014
results, the facility ranked 27 out of 142 facilities--in the top 20
percent. On the 2014 Integrated Ethics Staff Survey, the facility's
overall rating as an ethical organization was the 8th highest in the
country for all VAMCs.
OGJVAMC patients are satisfied with the quality of care they
receive as evidenced by the medical center's patient experience data,
which exceeds the VA's national score for both inpatient and outpatient
care. As evidenced, over 80 percent of Veterans would recommend OGJVAMC
to their friends and family. Facility leadership holds regular staff
meetings with all schedulers, to include CBOCs, and the Director
personally conducted mandated clinic observation interviews with all
schedulers including CBOCs. The facility monitors access with internal
stakeholders by reviewing and addressing data from the VHA Support
Service Center (VSSC), New Patient Wait Times Exception Summary Report,
and Access Glide Path data. To quickly identify opportunities to
improve Veteran access, the Director reviews data during the daily
morning report, such as the New Enrollee Appointment Request (NEAR),
the Electronic Wait List, the Provider Workload, the local access data
list, and the number of new patients seen in Urgent Care Clinic with no
primary care provider assigned.
Expanded mental health programs include the following: Operation
Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/
OND) case outreach, Enhanced Rural Access Network for Growth
Enhancement (E-RANGE) program for rural Veterans diagnosed with serious
mental illness, Mental Health Intensive Case Management (MHICM),
Posttraumatic Stress Disorder (PTSD) Clinical Care, Home-Based Primary
Care (HBPC) psychology services, Compensated Work Therapy (CWT),
recovery-based programs, suicide prevention, outpatient substance abuse
programs, evidenced-based therapies, VA Caregiver Support, and the
Homeless Veterans Program including Veterans Justice Outreach.
VA Rural Healthcare Program--State of Michigan
There are approximately 660,800 Veterans in the state of Michigan,
of which an estimated 230,000 (35 percent) are enrolled in the VA
healthcare system. Additionally, 207,000 or 31 percent of all Michigan
Veterans live in rural areas. Forty-one percent or approximately 95,000
of enrolled Veterans live in rural areas.
In addition to funding allocated to VISN 11 through the Veterans
Equitable Resource Allocation (VERA) system for Veterans' healthcare,
in FY 2014, VISNs 11 and 12, together, received $8 million from the
Office of Rural Health (ORH) to support 21 projects and programs to
increase access to care for Michigan's rural Veterans. The programs
specific to Michigan include a Mobile Prosthetics Van, which brings
prosthetic services typically found only at the main campus to the
CBOCs; clinical training opportunities for providers in rural
locations; enhanced rural access to mental healthcare services;
Veterans transportation programs in the Upper and Lower Peninsulas;
telehealth; and Home-Based Primary Care.
Increasing access to VA-provided care for Tribal Veterans is
addressed with a VA ORH-funded project for Battle Creek VAMC. This
project supports a Native American Indian Veteran that has been trained
as the Tribal Veteran Outreach Worker (TVOW). The focus of this project
is to bring access to mental health services at the Battle Creek VAMC
by utilizing telehealth technology. The project has also provided a
liaison for Tribal Veterans that has assisted them within navigating VA
for all their healthcare needs. The TVOW has served as the VA
representative to several Tribal Events related to the collaborative
relationship building that has occurred. These include Pow Wows, the
Potowattomi Gathering in 2014, Tribal Veteran Council meetings, and
Tribal Veterans Days events to name a few.
VA continues to seek opportunities to expand our care via
telehealth technology. VHA is in the early stages of developing a
collaborative effort with community providers to be able to exchange
health information, and OGJVAMC is one of the 14 pilot sites. We now
have the capability to provide CVT in the home, which will improve
access to care for rural Veterans and mitigate the need for travel to a
VHA site of care. Additional mental health services via telehealth to
Veterans at the Patriot House in Gaylord in 2014 are also being
established.
Since October 1, 2009, OGJVAMC has received approximately $14.2
million dollars from ORH to implement and sustain programs. Recent
grants include sustainment for the E-RANGE program, an outpatient
mental health program that provides intensive, supportive services to
Veterans living in rural areas who have a primary mental health
diagnosis that is classified as severe, our Veteran Transportation
Service, implementation of Physical Therapy at the Rhinelander CBOC,
and a VA-Coordinated Transitional Care (C-TRAC) Program.
Recruitment & Staffing
Nationally, VHA employs an aggressive marketing and advertising
campaign aimed at patient care providers for rural locations through
its partnership with the National Rural Recruitment & Retention Network
(3RNet), a national network of non-profit organizations devoted to
healthcare recruitment and retention for underserved and rural
locations. Through this partnership, VHA has access to a robust
database of candidates especially interested in its rural vacancies.
National recruiters routinely post VHA practice opportunities on
3RNet's career page. In addition, 3RNet annually dedicates the month of
November to Veteran healthcare awareness by making VHA its featured
employer for the month.
VHA also strives to relocate physicians from urban areas to rural
VAMCs and outpatient clinics. The increase in the rural Veteran
population calls for a strong recruitment, marketing, and advertising
campaign that directs qualified prospects to rural VA centers
struggling to open their doors. The rural relocation marketing campaign
targets urban physicians in transit during their daily commutes with a
compelling recruitment marketing and advertising campaign to persuade
them to explore options for relocation to the nearest rural VAMC. This
extensive campaign targets geographic regions and specialties with the
highest need, online, and in a wide range of professional healthcare
publications.
In addition to internal robust recruitment efforts by facility
level human resources offices, VISN 11 partners with VHA's Workforce
Management and Consulting (WMC) Office for increased recruitment and
staffing support. The National Recruitment Program (NRP), a sub-
division within WMC's Healthcare Recruitment and Retention Office,
provides a centralized in-house team of skilled professional recruiters
employing private sector best practices to fill the agency's most
critical clinical and executive positions. The national recruiters, all
of whom are Veterans, collaborate with executives, clinical leaders,
and local human resources departments in the development of
comprehensive, client-centered recruitment strategies that address both
current and future critical needs. In FY 2014, the NRP recruited 25
clinical providers for VISN 11 vacancies of which 16 were for hospitals
and clinics in Michigan. For FY 2015, to date 11 of the 15 Medical
Officers recruited by the NRP currently provide care to Veterans at
Michigan VAMCs and outpatient clinics. As of July 31, 2015, VISN 11 has
921 physicians onboard and 136 active recruitments for physicians. In
addition, WMC, ORH, other VA partners, and non-VA Federal partners are
collaboratively exploring to:
Determine where and what types of providers are in
short supply at rural healthcare facilities providing care for
rural Veterans;
Solicit the voice of Veterans to better understand
rural Veterans' preferences and decisions regarding healthcare
providers;
Determine best practices in rural provider recruitment
and retention;
Explore and promote the use of VA financial incentives
and other innovative solutions to recruit providers to rural VA
facilities;
Develop and/or expand and support clinical training
opportunities for rural health practitioners providing care to
rural Veterans to help retain them in rural areas;
Promote and support rural health educational and rural
health clinical training experiences for medical residents,
nursing, and other health professions students to help recruit
future healthcare providers to rural practice; and
Expand opportunities for training rural primary care
providers in specialty areas that address the unique medical
needs of rural Veteran demographic groups.
OGJVAMC has actively recruited and retained staff while
simultaneously improving relationships with community healthcare
providers in the Upper Peninsula of Michigan and Northern Wisconsin to
broaden the continuum of care available to Veterans. In a rural,
sparsely populated area, few facilities are able to offer the full
range of services normally available in larger metropolitan areas.
Strong collaborations with multiple healthcare providers, both public
and private, are essential in meeting the needs of patients. OGJVAMC
has grown from 604 Full Time Employees (FTE) in FY 2012 to 648 FTE at
the end of June 2015, an increase of 44 positions.
OGJVAMC's proactive recruitment of providers is ongoing. Since
2014, the facility has filled the following critical positions: Chief
of Surgery, Chief of Behavioral Health, Associate Chiefs of Staff for
Geriatrics and Primary Care, Chief of Medicine, and Chief of Staff.
Furthermore, OGJVAMC recruited and hired an Anesthesiologist/Pain
Medicine, Podiatrist, Certified Registered Nurse Anesthetist, and an
Optometrist in FY 2015. In addition, since FY 2014, the facility has
hired eight primary care providers and is fully staffed at all
locations. To enhance CBOC services, mid-level providers are utilized
to supplement primary care vacancies. Since April 2014, the on-board
total of critical clinical care positions (physicians, physician
assistants, nurse practitioners, nurses, and other select critical
occupations) has increased by 20--representing an 8 percent increase.
The medical center increased interim staffing to fill short term
vacancies and mitigate disruption to scheduled appointments. To address
short-term primary care and mental health vacancies, telemedicine
clinics were expanded to provide interim coverage.
Rural Provider Education
In FY 2012, ORH and the Office of Academic Affiliations (OAA)
launched a collaborative three-year workforce program called the Rural
Health Education and Training Initiative (RHTI) to increase healthcare
workforce recruitment to rural areas. Seven sites in Maine, New York,
Virginia, Nebraska, North Carolina, Alabama, and the Pacific Islands
were awarded $250,000 per year for three years. By the end of FY 2014,
690 trainees in 23 separate medical, dental, and mental health
disciplines had been trained at rural VA sites of care.
Telehealth
In FY 2014, more than 717,000 Veterans (12 percent of Veterans
receiving VHA care) accessed VA care through Telehealth during more
than 2.1 million encounters.
Forty-five percent (45 percent) of these Veterans lived in rural
areas, and may otherwise have had limited access to VA healthcare. The
number of Veterans receiving care via VA's Telehealth Services grew
approximately 18 percent in FY 2014.
Veterans in Michigan are served primarily by two VISNs. VISN 11
includes medical centers providing telehealth services in and around
Ann Arbor, Battle Creek, Detroit and Saginaw, MI. Veterans in
Michigan's Upper Peninsula use telehealth to access services from VISN
12's Iron Mountain, MI, VAMC and its affiliated VA CBOCs in Marquette,
Menominee, Hancock, Ironwood, Manistique and Sault Ste. Marie, MI.
In FY 2015, Year to Date, more than 25,700 Veterans accessed VA
care through Telehealth during more than 60,600 episodes in VISN 11.
During this same period in VISN 12, about 23,000 Veterans accessed VA
care through Telehealth during more than 109,900 encounters. Fifty-four
percent of the VISN 11 Veterans as well as 54 percent of VISN 12
Veterans lived in rural areas.
In FY 2014, within VISNs 11 and 12, 16,230 Veterans in Michigan
accessed VA care during 32,971 clinic-based telehealth encounters. More
than two-thirds of these Veterans (22,024) lived in rural Michigan. The
types of care Michigan Veterans were accessing through telehealth
included the following: mental health, the MOVE! program, primary care,
diabetes, Cardiology, Dermatology, and other services. Currently in
August 2015, approximately 2,560 Veterans in Michigan are enrolled in
VHA's Home Telehealth service to help them manage chronic conditions
such as diabetes, chronic obstructive pulmonary disease, and congestive
heart failure.
Conclusion
In conclusion, VA is committed to providing high-quality, safe, and
accessible care for our Veterans and will continue to focus on
improving Veterans' access to care. While the location presents unique
challenges with regard to distance, culture, and constrained healthcare
markets, VA's rural health programs are robust, and we will continue to
strive to serve Veterans in rural areas.
Mr. Chairman, this concludes my testimony. My colleagues and I are
prepared to answer any questions you, Ranking Member Brownley, or other
members of the Committee may have.
Statement for the Record by Benjamin Balkum, President, AFGE Local 2280
Oscar G. Johnson VA Medical Center Iron Mountain, Michigan, the
American Federation of Government Employees, AFL-CIO Before the Health
Subcommittee of the Committee On Veterans' Affairs United States House
of Representatives Realizing Quality Rural Care Through Appropriate
Staffing and Improved Choice
September 1, 2015,
Chairman Benishek, Ranking Member Brownley and Members of the
Subcommittee:
Thank you for the opportunity to provide a statement on behalf of
Local 2280 of the American Federation of Government Employees, AFL-CIO
and its National Veterans Affairs Council (AFGE).
AFGE represents over 220,000 employees of the Department of
Veterans Affairs (VA). AFGE Local 2280 represents all the healthcare
professionals and support personnel at the Oscar G. Johnson VA Medical
Center, including the Sault Ste. Marie CBOC, other outpatient
facilities and our community living center.
I have served as Local President of Local 2280 for almost 30 years
and I have worked at the Iron Mountain VA since 1984. As a Vietnam-era
combat veteran, I also receive healthcare services from the VA.
At our facility, management practices have adversely impacted
staffing levels, recruitment and retention of healthcare personnel, and
most important, the ability of veterans in this very rural area to
access quality, timely care.
My statement focuses on the following problem areas:
Cuts in critical healthcare services;
Hostile and unreasonable work environment;
Adverse impact of ``firing'' bills on recruitment,
retention and accountability.
Cumbersome hiring processes
Cuts in Critical Services
2Over the past year, management at Oscar G. Johnson VA Medical
Center has downgraded its emergency room (ER) into an urgent care
facility so it no longer provides 24-hour emergency care. As a result,
the facility is unable to accept ambulances, veterans with chest pains
or veterans presenting other acute conditions. Management also recently
closed our intensive care unit (ICU); we are now unable to perform
general surgeries or intubate patients. If a patient codes, he or she
must be sent to a very small community hospital or to a full capacity
VA facility that is over 100 miles away in Green Bay.
Millions of taxpayer dollars were spent to build a state of the art
surgery suite in 2014. As soon as the doors opened earlier this year,
management lowered the complexity of our surgery program to a basic
ambulatory standard of care, requiring veterans to travel great
distances to other VA medical centers for all general surgeries and
emergency surgeries. This brand new surgical suite is now being used
only for ``lumps and bumps'' surgery that could just as easily be
performed on an outpatient basis.
Just prior to the opening of the new surgical suite, we were
finally able to recruit and competitively pay an anesthesiologist to
come to Iron Mountain. As a result of these cutbacks, the VA has had to
pay for him to receive additional credentials in acupuncture in order
to supervise our pain clinic instead.
These cutbacks in essential medical services are life threatening
to veterans with serious medical conditions. They also put veterans at
risk by devastating the medical center's ability to recruit and retain
surgeons, hospitalists and other clinicians who will no longer be able
to maintain their skills and credentials if they stay at Iron Mountain.
Iron Mountain's cutbacks are very drastic but not unique. A spring
2015 AFGE survey of our locals at VA medical centers found that 62% of
respondents reported similar cutbacks at their facilities, especially
closings of ERs, ICUs and inpatient beds.
Hostile and Unreasonable Work Environment
A number of providers have already left Iron Mountain for positions
in the private sector due to our facility's toxic workplace and
difficult working conditions. Because of increased turnover rates, many
veterans at Iron Mountain never see the same doctor twice for clinic
care. Chronic turnover is also significantly undermining the
effectiveness of our PACT teams; many PACT team clinicians are being
reassigned to fill vacancies in the CBOCs. We recently lost three
highly qualified physicians (two emergency doctors and a long time
hospitalist.)
The dedicated healthcare personnel represented by Local 2280 are
very concerned that the closing of our ICU and downgrading of our
Emergency Department and surgical unit are seriously impacting the
services to veterans who reside throughout the rural areas of the Upper
Peninsula, Northern Lower Peninsula, and North Eastern Wisconsin.
Attrition is also worsening because of management's overreach into
providers' clinical decisions and because of their use of sham peer
reviews and other performance evaluations to intimidate and harass
providers. False allegations of poor performance can irreparably damage
a VA provider's future employment opportunities both within and outside
the VA.
Varying panel sizes and double booking (in direct violation of VA
policy) have forced Iron Mountain providers to work long extended hours
on a regular basis without additional pay or time off. Initially, our
physicians were promised an hour of administrative time every day to
enable them to promptly respond to hundreds of daily computer alerts,
review lab results and follow up on care provided by other VA and non-
VA providers. However, due to constant overbooking by management,
providers were not actually able to use these one-hour daily slots to
handle their other major responsibilities. Management's quick fix was
to block off four hours one day a week instead, but even that limited
set aside time continues to be swallowed up by enormous panel sizes,
walk-ins and unassigned patients.
Adverse Impact of ``Firing'' Bills on Recruitment, Retention and
Accountability
The counterproductive and fear-driven work environment at Iron
Mountain is deteriorating further in the face of legislative proposals
such as H.R. 1994 that assault basic workplace rights. At-will
employment is simply not an accountability tool. Taking away our
physicians' rights to defend their professional reputation and
positions prior to termination is not a path to accountability either.
We must ask ourselves: How many VA healthcare professionals will come
forward to Congress or will even want to work at the VA if they know
they can be fired on the spot or falsely accused of poor patient care
without recourse?
That is why AFGE Local 2280 urges lawmakers to support the true
accountability fixes in H.R. 2999. This bill preserves due process--
which is critical for protecting the front line employees who are the
VA's most valuable watchdog against mismanagement--while addressing
workplace safety, improper management-contractor relationships and
abuse of paid administrative leave. If we truly want bureaucrats out of
the examining room and the operating room, we cannot give VA managers
more power to interfere with patient care through whistleblower
retaliation, anti-veteran animus, nepotism, politics and other
prohibited personnel practices.
To further increase accountability and the voice of the front-line
provider, AFGE Local 2280 urges passage of H.R. 2193 to restore equal
collective bargaining rights to the ``full Title 38'' VA providers--VA
physicians, dentists, registered nurses, physician assistants,
optometrists, chiropractors and podiatrists--who have been unfairly
singled out and silenced by current VA Title 38 policy. It hurts VA
accountability and recruitment to deny a VA physician the basic
bargaining rights afforded to a DoD physician or to every Hybrid Title
38 VA healthcare employee. This unfair VA practice is another example
of nonmedical personnel (managers and human resources) interfering with
clinical decisions.
Finally, to improve recruitment and retention, AFGE Local 2280
urges reintroduction of legislation to make sure every veteran working
as a VA Title 38 healthcare professional has equal veterans' preference
rights. An unintended loophole in the Veterans Employment Opportunities
Act allows VA hiring officials to pass over veterans with preference
points to hire non-veterans for Title 38 healthcare positions. Former
combat medics and corpsmen will not want to bring their valuable
experience to the VA instead of DoD or the private sector if they
cannot enforce their veterans' preference rights at the VA.
Cumbersome Hiring Processes
I would like to close by focusing on hiring instead of firing. The
providers represented by AFGE offer the following suggestions for
strengthening the VA healthcare workforce and we urge the Subcommittee
to conduct VA provider roundtables on Capitol Hill and in the field to
further explore these and other reforms to the hiring process:
Establish a more formal and permanent applicant pool
that can be quickly accessed when vacancies occur (and even
earlier when providers give notice that they are leaving).
Shorten the credentialing process by requiring less
information and reducing duplication by reducing requests for
older information already collected by state medical boards.
Eliminate the requirement that VA providers
transferring within the VA healthcare system repeat the full
credentialing process.
Conduct oversight to curb ``bait and switch''
practices by human resources personnel who fail to deliver on
promises made to new hires. healthcare professionals regularly
share this type of information with colleagues who are
considering VA employment.
Conduct oversight to ensure that job openings are
always posted and posted in a timely manner (e.g. 48 hours).
This will greatly assist in recruitment and also curb ``off the
grid'' hiring that bypasses job postings and has resulted in a
growing problem of cronyism where hiring and promotion is based
on who you know rather than skills and experience.
I want to thank the Subcommittee for the opportunity to share AFGE
Local 2280's views on these critical issues. Over the past 30 years, I
have personally witnessed the transformation of the VA healthcare
system into a national leader in patient care, research and training
and the nation's most exemplary provider of veteran-centric medical and
behavioral healthcare.
I am extremely proud of the care that our employees deliver and
that I personally receive at the Iron Mountain VA. We should not let
the rhetoric of privatizers and opponents of employee rights obscure
the truth that this is a healthcare system very much worth saving and
fixing and that veterans consistently prefer to receive their care
inside the VA. But we must stop starving Iron Mountain and other
medical centers of the very clinicians who consistently receive high
marks from veterans. The critical ingredients for improved access to
rural healthcare for Oscar G. Johnson Medical Center veterans are a
professional, supportive work environment, an end to politically driven
assaults on due process and the restoration of critical surgical, ER
and ICU services. Thank you.
Benjamin F. Balkum.
American Osteopathic Association
Chairman Benishek, Ranking Member Brownley, and members of the
Committee
On behalf of the American Osteopathic Association (AOA) and the
more than 110,000 osteopathic physicians and osteopathic medical
students we represent, including more than 7,500 in Michigan, thank you
for your continued focus on efforts to improve choice and access to
healthcare for our nation's veterans, especially for those in rural
areas. I appreciate the opportunity to provide the perspective of the
osteopathic medical profession as the committee examines ways to ensure
the delivery of high-quality care for rural veterans, and to reiterate
our commitment to working with you to address the health needs of all
veterans.
The AOA strongly supports the mission of the U.S. Department of
Veterans Affairs (VA) and the Veterans Health Administration (VHA) in
delivering care tailored to those who have served our country. There is
little doubt the VA is uniquely positioned to address the comprehensive
health needs of its veteran population, as well as the specific areas
of traumatic brain injury, post-traumatic stress disorder, prosthetics,
and other injuries and conditions associated with the battlefield. The
philosophy and practice of osteopathic medicine is grounded in a
``whole person'' approach to care, which aligns well with the diverse
needs of the veteran population.
We also believe that community care providers serve an important
role in this mission--not only to help relieve some of the existing
strain upon VA personnel and resources, but also to improve access to
high-quality care for veterans living in rural areas. Osteopathic
physicians in particular tend to practice in rural and underserved
communities, and more than sixty percent of our members enter primary
care fields. Guided by a patient-centered, holistic approach to care,
osteopathic physicians are well-equipped to help meet the healthcare
needs of veterans, whether in the VA or in the communities in which
they reside.
The Veterans Choice Program (VCP) is an essential tool in achieving
our shared goal of improving veterans' access to care. While
implementation of the VCP has not been without challenges, the AOA
appreciates the Committee's efforts to identify these issues and work
with the VA to effect positive changes. We are encouraged by successful
recent legislative efforts, spearheaded by the House Committee on
Veterans' Affairs, which will streamline existing VA community care
programs under a unified ``Veterans Choice Program,'' ensuring that the
system will be easier to navigate for veterans and healthcare providers
alike.
We must also continue our efforts to ensure that a highly-skilled
physician workforce is trained and ready to meet the needs of veterans
with complex health conditions, as well as the specific health needs of
new generations of veterans who will be entering the VA system. The AOA
strongly supports efforts to increase graduate medical education (GME)
residency positions, such as the 1,500 new positions created under the
Veterans Access, Choice, and Accountability Act (``Choice Act,'' P.L.
113-146). Especially as the majority of these new residencies are in
primary care fields, we believe this is a critically important step
toward ensuring an adequate supply of physicians to care for these
deserving patients. Further, as a majority of physicians tend to
practice where they complete their residencies, the value of a robust
graduate medical education system with sufficient rural training track
opportunities cannot be understated.
The AOA looks forward to today's discussion, and we are eager to
work together with Committee members, the VA, and veterans to ensure
that those who have served our country receive the care they have
earned and deserve through a system that is equipped and responsive to
their needs. Thank you for the opportunity to share the perspective of
the osteopathic medical profession, and for your continued attention to
the healthcare needs of rural veterans.