[Senate Hearing 116-471]
[From the U.S. Government Publishing Office]
S. Hrg. 116-471
VA TELEHEALTH DURING AND BEYOND
COVID 19: CHALLENGES AND OPPORTUNITIES
IN RURAL AMERICA
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
JULY 29, 2020
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
45-201 PDF WASHINGTON : 2021
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COMMITTEE ON VETERANS' AFFAIRS
Jerry Moran, Kansas, Chairman
John Boozman, Arkansas Jon Tester, Montana, Ranking
Bill Cassidy, Louisiana Member
Mike Rounds, South Dakota Patty Murray, Washington
Thom Tillis, North Carolina Bernard Sanders, (I) Vermont
Dan Sullivan, Alaska Sherrod Brown, Ohio
Marsha Blackburn, Tennessee Richard Blumenthal, Connecticut
Kevin Cramer, North Dakota Mazie K. Hirono, Hawaii
Kelly Loeffler, Georgia Joe Manchin III, West Virginia
Kyrsten Sinema, Arizona
Caroline R. Canfield, Staff Director
Tony McClain, Democratic Staff Director
C O N T E N T S
----------
Wednesday, July 29, 2020
SENATORS
Page
Moran, Hon. Jerry, Chairman, U.S. Senator from Kansas............ 1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana...... 3
Manchin III, Hon. Joe, U.S. Senator from West Virginia........... 9
Boozman, Hon. John, U.S. Senator from Arkansas................... 11
Hirono, Hon. Mazie K. U.S. Senator from Hawaii................... 13
Cassidy, Hon. Bill, U.S. Senator from Louisiana.................. 16
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 18
Loeffler, Hon. Kelly, U.S. Senator from Georgia.................. 19
Sinema, Hon. Kyrsten, U.S. Senator from Arizona.................. 21
WITNESSES
Dr. Kameron Matthews, Assistant Under Secretary for Health for
Community Care, Veterans Health Administration; Accompanied by
Dr. Kevin Galpin, Executive Director of Telehealth Services,
Veterans Health Administration; Dr. Thomas Klobucar, Executive
Director, Office of Rural Health, Veterans Health
Administration; and Mr. Eddie Pool, Executive Director,
Solution Delivery, IT Operations and Services, Office of
Information and Technology, U.S. Department of Veterans Affairs 4
APPENDIX
Hon. Jerry Moran, Chairman, prepared statement................... 26
Dr. Kameron Matthews, prepared statement......................... 28
American Federation of Government Employees, AFL-CIO, prepared
statement...................................................... 35
Response to hearing questions submitted by:
Hon. Jon Tester................................................ 42
Hon. John Boozman.............................................. 56
Hon. Marsha Blackburn.......................................... 59
Hon. Mazie K. Hirono........................................... 62
Hon. Kyrsten Sinema............................................ 66
Telehealth Hearing Deliverables................................ 80
VA TELEHEALTH DURING AND BEYOND
COVID-19: CHALLENGES AND OPPORTUNITIES
IN RURAL AMERICA
----------
WEDNESDAY, JULY 29, 2020
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The committee met, pursuant to notice, at 2:03 p.m., in
room SD-G50, Dirksen Senate Office Building, Hon. Jerry Moran,
Chairman of the Committee, presiding.
Present: Senators Moran, Boozman, Cassidy, Rounds, Tillis,
Sullivan, Blackburn, Loeffler, Tester, Brown, Blumenthal,
Hirono, Manchin and Sinema.
OPENING STATEMENT OF CHAIRMAN MORAN
Chairman Moran. Good afternoon, everyone. The committee
will come to order.
We are here today in this hearing to discuss the Department
of Veterans Affairs' use of telehealth as a modality to deliver
care to veterans, especially those in parts of America that are
rural, highly rural, or Tribal lands.
For my entire time that I have been a Member of Congress, I
have been a proponent of telehealth as a way to deliver care to
veterans and, in fact, to all patients, particularly those in
Kansas, and especially those who live in rural areas. It has
great potential.
Currently, we see these capabilities being utilized for an
even greater share of veterans due to the pandemic of COVID-19.
COVID-19 has unexpectedly accelerated the process of
expanding the VA's use of telehealth. In recent years, the VA
had advanced its capabilities, but in the spring of this year,
as the country and the VA prepared for the anticipated spread
of the novel coronavirus, telehealth was often the only safe
option to provide care.
The consolidation of resources at VA medical centers,
postponing non-urgent in-person care, and restrictions placed
on referrals to Community Care fueled a more widespread use of
telemedicine.
As we continue to move toward a new normal, it is essential
that the VA optimize the use of telehealth delivery where it
works best, build on the lessons learned where it can be
enhanced, and recognize the limits of its utilization.
Telehealth has great promise, and the unexpected expansion
of telehealth has yielded great knowledge in the last few
months. There are many times where it is practical for a
veteran to see their provider through VA Video Connect or even
through just a conversation by phone. While this flexible and
time-saving modality can be great in many ways, we know
telehealth cannot entirely replace the need for face-to-face
medical appointments. This is true as it relates to access to
care in the community, and the VA must ensure the full
implementation of the MISSION Act to increase access to
Community Care is pursued.
The limitations of telehealth are also amplified for those
living in rural America or Indian Country. VA Video Connect
only works when you have a broadband connection at a certain
speed. In many parts of our country, that reliable broadband
service simply is not an option.
I am disappointed the VA chose not to participate in a
recent listening session led by this committee with key
stakeholders from across the medical community,
telecommunications industry, VSOs, and other Federal agencies.
As of 2019, rural veterans make up approximately one-third
of VHA enrollees and are, on the average, older than their
urban veteran peers, tend to experience higher degrees of
financial instability, and often live with a greater number of
complex medical health needs and co-morbidities.
Many veterans in rural America and Indian Country live
prohibitively far from VA facilities, which underscores both
the need for innovative solutions on how to reach them and the
importance of access to Community Care.
For rural and tribal veterans, the geographic barriers to
VA care often go hand-in-hand with poor or nonexistent
connectivity to broadband necessary for high-quality care via
telehealth. I applaud the VA's outside-the-box thinking with
regard to creative partnerships with the private sector and VSO
community and the distribution of wireless devices to isolated
veterans.
Additionally, I am interested in learning from our
witnesses today, the progress the Department has made on
forming agreements with telecommunications companies to provide
subsidized short-term internet access to rural veterans. This
was a provision I was proud to champion in the CARES Act in an
effort to better serve the mental health care needs of rural
veterans, especially during a time of social isolation during
COVID-19, and look forward to hearing the progress the VA has
made on this front.
It is also important to note, in addition to skyrocketing
numbers of telehealth appointments, the VA has also been called
on to fulfill its Fourth Mission across 46 States, including my
home State of Kansas, as well as the District of Columbia,
Puerto Rico, and the Navajo Nation.
As we look forward to both the near-term needs and long-
term goals, the VA should make certain that the innovation of
telehealth is utilized in the most efficient and appropriate
way.
I look forward to hearing from all of our witnesses today
on these challenges and opportunities and how we can work
together to best leverage this modality to address long-
standing access to care issues.
I understand that it has not been easy to adjust how the VA
delivers care, especially at the rapid pace the COVID-19
pandemic has required. I thank the VA for its work, and I thank
them for being here today.
I want to yield now to my colleague, Senator Tester, who
may be in the Indian Affairs Committee, where I am also
supposed to be.
Senator Tester?
OPENING STATEMENT OF SENATOR TESTER
Senator Tester. No. I have got a few minutes before either
one of us have to get there, but I want to thank you, Mr.
Chairman, for holding this hearing.
Chairman Moran. Jon, we need greater volume.
Senator Tester. Good God. That is always a problem, but I
will work on it.
I want to thank you, Mr. Chairman.
Chairman Moran. I am glad we raised the volume and allowed
you to say that. I have never asked you to speak louder to me
before.
Senator Tester. Can you hear me now? I feel like an
internet provider.
Chairman Moran. I can hear you now.
Senator Tester. You can hear me?
Chairman Moran. Yes.
Senator Tester. Good deal.
Well, I will say it for the third time. I want to thank
you, Mr. Chairman, and I also want to thank our witnesses for
being here today.
VA's recent efforts to expand telehealth options deserve a
lot of praise. The Department has prioritized the health and
well-being of its patients while working to keep its work force
safe, and for that, you need to be commended.
However, a 75 percent increase in daily telehealth
appointments as of May has not been without its challenges.
Today's hearing is going to offer us an opportunity to take
stock of where the VA is now and to discuss further steps that
can be made to improve the care provided to veterans.
I want to hear directly from the VA, the Nation's largest
integrated health care system, about the challenges that it is
facing and what it is doing to address them.
In Montana, many vets, especially those in highly rural
areas, are accustomed to virtual appointments, but we need to
remember that not all veterans have access to smart telephone
technology or reliable internet access. To address these
technological shortcomings, I know the VA has conducted nearly
6 million more telephone appointments with veterans compared to
the same period last year. What more can we be doing to make
these visits more valuable for the patients and the providers,
and how are providers coping with a change in practice? We need
to ensure that VA staff is supported and have the tools that
they need to adequately care for our vets.
We especially need management to work with employees in
good faith to hear what the folks on the ground think about
virtual or telephone care and what suggestions they have for
improvement. That effort by the VA leadership will pay off
greatly, particularly when the health care system is
experiencing increased demand and has a staff at risk of
burning out as the coronavirus pandemic continues to rate.
As VA begins to reopen certain service lines in some
facilities, it will be important to monitor the shift from
telehealth appointments to in-person appointments. Many
veterans may still feel uncomfortable seeing their providers
face-to-face and will want to continue to utilize telehealth
services. We need to make sure that that opportunity and the
resources for that ongoing care are available.
And as hotspots and surges move from one location to
another, VA's ability to expand and retract its telehealth
capabilities will be critical. Therefore, it will be important
to monitor whether the CARES Act funding is adequate to meet
ongoing telehealth demand or if the successor COVID packages
will need to include additional emergency funding to provide
these services to veterans, and we will need a good accounting
of where the appropriated funds are being spent in order to
make informed decisions on a path forward.
I want to again thank the Chairman, and I want to thank the
VA team for being here and being a part of this conversation. I
look forward to this hearing.
Chairman Moran. Senator Tester, thank you very much.
We are going to take a pause. So we will stand in recess
just for a moment while we fix one of our own technical
glitches so we can hear our witnesses who are appearing
virtually.
[Recess.]
Chairman Moran. So the committee will resume its work.
Thank you, Senator Tester, for your comments, and let me
now introduce the witnesses from the Department of Veterans
Affairs.
Dr. Kameron Matthews is the Assistant Under Secretary for
Health for Community Care, Veterans Health Administration. Dr.
Kevin Galpin is the executive director of Telehealth Services,
Office of Connected Care, Veterans Health Administration; Dr.
Thomas Klobucar, executive director, Office of Rural Health,
Veterans Health Administration; and Mr. Eddie Pool, the
executive director, Solutions Delivery, IT Operations and
Services, Office of Information and Technology, Department of
Veterans Affairs.
I thank you all for being here in person or virtually by
connectivity, and we are grateful for your presence.
Dr. Matthews, I understand you are speaking for the group
of VA witnesses today instead of individual Statements from
each of our witnesses. As such, you are now recognized for 5
minutes to delivery your testimony.
STATEMENT OF KAMERON MATTHEWS; ACCOMPANIED BY KEVIN GALPIN,
THOMAS KLOBUCAR AND EDDIE POOL
Dr. Matthews. Thank you so much, sir.
Good afternoon, Chairman Moran, Ranking Member Tester, and
distinguished members of the committee. I appreciate the
opportunity to discuss VA's telehealth activities during the
COVID-19 pandemic.
I am accompanied today by Dr. Kevin Galpin, Executive
Director of Telehealth Services in the Offices of Connected
Care; Dr. Thomas Klobucar, Executive Director of the Office of
Rural Health; and Mr. Eddie Pool, Executive Director, Office of
Information and Technology.
This is a transformational time in U.S. health care,
accelerated by the unprecedented challenge of the COVID-19
pandemic. VA is proud to be leading the response to COVID-19
beside our Federal partners. As a result of early proactive
planning and the unmatched dedication and resilience of the VA
work force, we are continuing to deliver excellence for the
more than 9 million veterans who entrust us with their care.
In addition, we consider it a privilege to be the backstop
to the Nation's health care system, serving veteran and
civilian Americans in 46 States and the District of Columbia
through our Fourth Mission, providing testing and supplies, and
deploying more than 1,000 personnel in support of community
facilities in areas of the Nation most severely affected by
COVID-19.
VA has been open throughout the pandemic for all in-person
care where clinical urgency rises above the risk of COVID-19,
and we are now expanding in-person services at more than 100
sites.
We are grateful for the opportunity today to discuss a key
area where VA's early and proactive commitment to innovation
and health care delivery is paying significant dividends for
those we serve; that is, telehealth. VA has long been
recognized as a national leader in telehealth, and together
with our strategic partners, we are rapidly advancing our
vision to leverage telehealth to enhance the accessibility,
capacity, quality, and experience of VA health care for
veterans, their family members, and their caregivers anywhere
in the country.
Continued expansion and deep integration of telehealth into
clinical and technical operations is an essential element of
our strategy. Telehealth can make it easy and enjoyable for
veterans to partner with VA in optimizing health, and it can
enhance the delivery of health care, enabling expert
consultation, facilitating remote management of acute and
chronic conditions, and enhancing coordination of care.
VA's early investment in virtual technologies, including
our patient portal, My HealtheVet, provided a solid foundation
for VA's agile and effective response to COVID-19. More than 60
percent of primary care and mental health providers had already
used video telehealth prior to the pandemic, and VA delivered
more than 2 million episodes of care through telehealth in
Fiscal Year 2019, with approximately a third of the veterans
served living in rural areas.
In a matter of weeks, at the beginning of this pandemic,
that solid foundation enabled us to increase video telehealth
delivery to veterans' homes by more than 1,000 percent. We have
delivered more than 9 million additional virtual care
interactions this year over last year, and the numbers continue
to grow.
Achieving this progress required strong cross-functional
partnerships. The Veterans Health Administration and the Office
of Information and Technology have worked closely at all levels
of the organization to address and stay ahead of the
anticipated increase in demand for virtual care. Our IT
colleagues strengthen and enhance the existing environment and
are continuously monitoring and optimizing its performance. New
and enhanced capabilities improve telehealth visit performance
and quality, and new scalable options expanded access, tripling
the concurrent use of capacity of VA's video telehealth
platform and enabling care delivery in a location of a
veteran's choosing, such as at home.
Importantly, amidst the collective stress of this time,
this capacity has allowed VA to provide over 1.5 million
telemental health visits to more than 400,000 veterans so far
this year. We want each veteran to know that VA is here for
them, that we will meet them where they are, and that we
believe in their resilience.
Expanded capacity has also advanced our other critical
operations, including the tele-Intensive Care Unit program,
which brings remote monitoring and consultation to augment care
teams at the bedside of critically ill patients, and
meaningfully, the benefits of added technical capacity are not
just clinical. This also enables personal connectedness for
veterans residing in community living centers or even
hospitalized to connect with loved ones.
VA has continued to work with Tribes and Indian Health
Service to develop standardized processes to ensure that
veterans who require care among the various health care systems
receive one coordinated approach in getting the services they
need in the environment they choose. VA is planning a Tribal
Consultation later this summer with the Tribes to deploy the
approved plan.
VA appreciates the continued support of Congress regarding
telehealth, including through the recent Coronavirus Aid Relief
and Economic Security Act, which provided the supplemental
funding needed for VA to invest in enhancing and expanding our
systems and technology.
Recent legislation such as the MISSION Act, which
authorized Anywhere to Anywhere telehealth, has also been
pivotal to that advancement.
VA is committed to providing excellence for each veteran in
our care, even and especially during these unprecedented times.
We will continue to lead the way forward, and we are grateful
for your continued support, as it is essential to provide care
for veterans and their families.
This concludes my testimony. My colleagues and I are
prepared to answer any questions that you may have.
Chairman Moran. Doctor, thank you very, very much, and
thank you to your colleagues for joining you.
I want to ask my question to Dr. Galpin, at least my
initial question.
Could you detail for the committee the amount of CARES Act
funding that has been spent to date on the total allocated for
VA telehealth services?
And in addition to that, I have been exploring with the VA
for several months now, the issue of the amount of money that
was allocated to the VA in the CARES Act, which gave the VA
authority to form agreements with telecommunication companies
to provide short-term complimentary internet services to rural
veterans, and generally, when I have those conversations--let
me get an answer to your first question, and then I will
follow-up with my second one related to that topic. So total
amount of money spent compared to what was allocated under the
CARES Act?
Dr. Galpin.
[inaudible]--providers during the pandemic. So far, since
March 1st and through July 15th, we have spent over $69 million
on COVID-related requirements, of which $57.8 million came from
the CARES Act funding.
We have used that to provide over 30,000 4G-connected iPads
to veterans. For providers, we have bought 12,000 iPads, 24,000
webcams, 22,000 headsets, 10,000 speakers. We have expanded our
help desk. That was a big challenge for us early on. It was
just the amount of calls we were getting to the help desk as we
expanded. We practically quadrupled the staff there.
We are funding some research to make sure we learn from
this event, and we are expanding our telecritical care program
with that funding as well. So, yes, that has been critical, but
the number, I think you are looking for is just over $57
million so far.
Chairman Moran. $57 million so far out of the amount that
was appropriated which was what?
Dr. Galpin. Ours was about $250 million. It included
teleradiology as well, and a large chunk of that was for the
telecritical expansion, which we are just about to undertake.
Chairman Moran. Thank you very much.
The second part of this question is, when I have raised
these topics before, I generally hear about iPads and Walmart.
What I have not found an answer to is, How did the VA utilize
that provision to create agreements with telecommunications
company to provide services to rural veterans?
Dr. Galpin. Yes, it is a great question. Fortunately, we
have an office, a Strategic Partnership Office, and we have
been working really for a while now to develop partnerships
with organizations, with internet service providers or cellular
providers to try and expand connectivity to veterans in rural
communities, wherever they may be.
In telehealth, we realized when we were trying launching
our Anywhere to Anywhere initiative that that was critical. We
could build these fantastic programs, but if a veteran cannot
receive it on the other end, it does not make a difference.
So we already have partnerships with T-Mobile, with Sprint
which is owned by T-Mobile, with Verizon, with SafeLink by
TracFone help support veterans. We are using VA Video Connect
to make data.
As you know, as you mentioned, we have partnerships with
Walmart, with veterans service organizations, and with Philips
to develop our ATLAS sites in rural communities where veterans
do not have internet access or therapeutic environment.
We have partnerships with Microsoft. Microsoft is helping
us outline the areas in the country using both our data and FCC
data when we have a population of veterans that do not have
access to internet, and then they are going to help us go and
identify additional partnerships to bring in Airband internet
into those areas and help with digital scaling.
Following the CARES Act, we did actually get some companies
from the committee who are interested in partnering with us. We
have met with those. A lot of them are interested in helping
out with the ATLAS program. I think that seems to be a real
strong concept that people want to support.
The other area, which is great, is helping us co-promote
the FCC Lifeline program. FCC Lifeline is a program a lot of
veterans qualify for. We think it may be underutilized in the
veteran population, and so we want to make sure veterans get
that benefit. It is a subsidy of $9.25 a month for their
internet or phone service, but if they are in Tribal or Native
land, they can get up to $34.25 a month.
So we are trying to reach out to more partnerships. In the
next couple weeks, we are going to be releasing an RFI, Request
for Information, to go out publicly to look for other companies
that want to partner with us. We feel there is probably more
people out there than we have been able to identify so far that
would like to help out the scenario.
I mean, it is amazing. Honestly, since we started the work
with the Partnership Office, many companies are just absolutely
ready to say yes when we talk about supporting veterans in the
digital divide. It is an issue that people recognize really
needs a broad coalition and a lot of support.
Chairman Moran. Thank you, Dr. Galpin.
Let me ask you. I assume that if I ask my staff to delve
deeper into the details of those partnerships, you and your
team would be cooperative in providing us that information.
Dr. Galpin. Yes. We would love to collaborate with you and
your team on this. Again, this is a big issue and very
important to us.
Chairman Moran. Thank you for your efforts and your
testimony.
Let me ask just a question that is worth more than the time
I have. But, Dr. Matthews, can you explain how expanded
telehealth services will impact access standards for community
care?
Dr. Matthews. Sure. This was----
Chairman Moran. Go ahead.
Dr. Matthews. Sorry.
Chairman Moran. You anticipated my question.
Dr. Matthews. Yes. This was actually a very early
conversation, actually, that I had with Dr. Galpin and others
in VA, how could--how should, actually, we approach the
eligibility standards.
Currently, telehealth, unfortunately, does not impact them,
and unfortunately, I mean, in the sense that it actually would
take some regulatory change, so we could not do really any
quick changes during the pandemic.
The idea is that telehealth is offered. If a veteran
accepts that care, it will, of course, be coordinated, but
otherwise it does not affect their eligibility. Eligibility is
only determined by face-to-face services at this point.
Chairman Moran. Thank you very much.
When you say at this point, you are suggesting there is a
change coming?
Dr. Matthews. There is always at least reconsideration. I
think you would expect us to continue to improve upon how we
provide access, and if telehealth--especially in specialty
services is available and especially with our quality of care
and when, of course, it is clinically appropriate. I think
there is always going to be consideration that perhaps
telehealth would be a major, meaning primary form of delivery.
It could never replace face-to-face 100 percent. That is in no
way the concept there, but perhaps initial consultation,
follow-up visits, and the like. So it would be actually as the
MISSION Act promotes more of an integrated platform with face-
to-face care in the community.
Chairman Moran. Thank you. Senator Manchin?
SENATOR JOE MANCHIN
Senator Manchin. Thank you, Mr. Chairman. I appreciate it
very much, and thank you, Doctor, for being here.
I have introduced the HOTSPOTS bill, which would expand our
Government's ability to purchase and distribute internet-
connected devices to libraries and low income in rural areas,
and I encourage my Senate colleagues really to look into this.
And, hopefully, we get this into the next package we are
working on right now for the COVID relief package.
So many rural areas, especially rural Appalachia, does not
have any connectivity whatsoever, but we have been able to
hotwire, basically, a wireline into all rural libraries. This
would allow--if a hotspot could be given to a veteran, they
would be able to connect for telehealth. Right now, they
cannot. All they are doing is audio health.
So my question, can you give me a sense of where all
these--you spent $38.9 million, I am understanding, from the
CARES Act on telehealth initiatives and equipment for both
veterans and providers. You all reported distributing more than
46,000 iPads to veterans and providers for accessing and
facilitating telehealth appointments and also reported an
additional 22,000 iPads are on order.
So my question would be, Can you give me a sense of where
all the devices are going? Are they all network-enabled? I want
to make sure that, hopefully, my State of West Virginia is
getting its fair share, and can you share a full report of
where they have been distributed?
Can anybody speak to that?
Dr. Galpin. I can speak to that. I do not have that data
with me, but we have--we can get that breakdown for you after
the hearing, if we can take that back for the record as to
where they are distributed.
Senator Manchin. Can you also determine where the VA
telehealth infrastructure resources are going and how you are
helping veterans with high-speed internet access? That is what
we are having problems with. There is no use to have an iPad if
you have no connectivity. So I hope you are looking at----
Dr. Galpin. Correct.
Senator Manchin [continuing]. the challenges that we have.
Whether it is rural West Virginia, rural Arkansas, rural North
Carolina, rural Kansas, wherever it may be, we have got
problems, and to get quickly to help these people, HOTSPOTS
would be the quickest way we can get them set up to something.
Dr. Galpin. Yes. Let me provide some feedback on that. I
think that was a question about what we are doing. So let me go
through the broader list because you are absolutely right. This
is a critical issue for us, and it is impossible for us to
deliver telehealth services where there is not internet
connectivity.
There was an FCC report that was released last year that
said 2.2 million veteran households do not have fixed or mobile
broadband internet.
Senator Manchin. First of all, if I can correct you on one
thing. We have proven the FCC maps are totally incorrect. They
are totally incorrect. That is why we are holding up some of
their money until they get the maps corrected. So I hope you
are not working off of their old maps because they have even
agreed they are incorrect.
Dr. Galpin. Well, I think irrespective of whether we are
looking at the maps, we recognize that this is a problem. I
mean, for the reason that you just described, when we talk to
our providers and get their satisfaction surveys back--we just
had one from one of our VISNs where they interviewed or got
feedback from 1,600 providers, and one of the biggest
challenges they face is the veteran not having the internet or
the equipment on their end. And that is, again, why we launched
an initiative to bridge the digital divide for veterans.
I can tell you it is something we cannot do alone. I mean,
this is a huge issue, and the VA is not going to solve it
alone. That is why we need cross-administration, collaboration
with Congress, public-private sectors. There is a tremendous
amount of work to do.
Senator Manchin. Well, I know you have all used solutions.
One of your solutions was offering veterans to use store for
telehealth options at places like Walmart, VFWs, American
Legion halls through the ATLAS technology. The idea is that
since a veteran does not have access to broadband at home,
their local Walmart, VFW, American Legion would have better
broadband.
While it sounds promising, you have only opened six ATLAS
sites in five States, and unfortunately----
Dr. Galpin. That is correct. So----
Senator Manchin. So what is the VA's plan to expand these
telehealth sites?
Dr. Galpin. So the ATLAS program, we think is very
promising. Again, that is a public-private partnership that we
have been working on.
What we have done--and going back to your library concept--
we have created a scheduling package, a scheduling system so
that we can identify if there is an ATLAS site near a veteran.
So we can set up libraries via a set of sites, Walmart sites.
Wherever we have a therapeutic environment, internet
connection, and veterans in that area, we can establish this.
Now, we were beginning to open these sites, and we had a
plan to get, I think, 11 prior to COVID. We did temporarily
shut them down due to infectious disease concerns. We are now
beginning to open them back up. The first one that opened was
in Eureka, Montana. The Walmart sites are expected to open up
by mid-August, and then we will continue on with the
progression.
But we agree. I mean, this is a huge issue. We need to get
the services out there, and there is a lot of veterans that
either do not have the connectivity in their home or the home
is not a therapeutic environment. And these type of ATLAS
locations that can be in their community, if not their home,
would serve both needs.
So this is a huge issue for us, and we are on the same
page, as we need to solve it.
Senator Manchin. Well, let me just say as a State with a
high percentage, one of the highest percentages of veterans,
and a very patriotic State like all of our States are, but West
Virginia has a very high percentage. If you want to try
something and see if it works, try West Virginia because if it
will work in our hills and mountains and valleys, it will work
anywhere.
Dr. Galpin. I appreciate that. Thank you.
Chairman Moran. Senator Manchin, thank you.
I recognize Senator Boozman.
SENATOR JOHN BOOZMAN
Senator Boozman. Thank you, Mr. Chairman, and thank you all
for being here with your testimony.
I want to give you a pat on the back. I believe in Central
Arkansas, the VA there, it is up 1,000 percent, and the
Veterans Health Care System of the Ozarks, I think it is up
approximately almost 4,400 percent in regard to their ability
to do telemedicine. So they truly are leading in the area, and
we appreciate your support as we go forward.
Senator Manchin was talking about the partnerships and
things. Dr. Galpin, in the areas where the partnerships exist,
even though there is not that many, are you seeing an increase
in veterans using VHA to receive their health care? Is it
working in the areas that are actually set up?
[No response.]
Senator Boozman. Maybe our technology is not working.
Chairman Moran. Dr. Galpin, are you there?
[No response.]
Chairman Moran. Dr. Matthews?
Senator Boozman. Yes.
Dr. Matthews. I unfortunately cannot speak to numbers.
Dr. Galpin. I do not know if anyone is having an issue, but
we have not heard the questions or any of the comments in the
last few minutes.
Mr. Klobucar. I have not either.
Chairman Moran. Can you hear now?
Mr. Klobucar. I have not heard this time.
Chairman Moran. Can you hear now?
Senator Boozman. It is the story of my life.
Dr. Galpin. Yes.
Mr. Klobucar. We got it now. We can hear now.
Senator Boozman. Okay. Good enough.
What I was saying was that, first of all, we have had a
tremendous increase in Arkansas. We are very proud of that.
They are doing a great job, and we just appreciate all that is
being done in that area.
Senator Manchin talked about the partnerships. We would
like to have more. In the areas, though, that we are actually
doing the partnerships, what are the results? Are we seeing a
significant increase in veterans using VHA as a result of that
to get their health care?
Dr. Galpin. I think I can address that, that question.
Senator Boozman. Yes.
Dr. Galpin. The partnerships for the past couple years have
been focused on getting more video telehealth services out to
veterans, and we had a strong program prior to this year. Last
year, we did over 2.6 million episodes of telehealth care to
over 900,000 veterans.
But what you have seen happen this year has been just
incredible growth with the pandemic. So already this year--and
as we all know, this year is not over yet--we have already done
3.6 million episodes of care to 1.2 million veterans. We have
seen our use of Video Connect into the home, which is our
platform that does deliver the video telehealth to the veteran.
We have seen that grow by about 2,000 encounters a day to over,
now touching, 32,000 encounters a day. It is over 1,000 percent
increase.
Fortunately, with the public-private partnerships, we have
been able to advertise. We have been able to purchase more
equipment. So we are seeing the growth out there. We are seeing
that veterans are adopting the technology.
We had some really nice feedback. The Veterans Experience
Office just interviewed several veterans, about 43 in hour-long
interviews. Overwhelmingly like telehealth, they prefer it over
telephone because it makes them feel more connected to their
providers and more comfortable with the visit.
So I think we are getting the word out there. The public-
private partnerships have been critical in helping us
communicate, to advertise, and again, getting the veterans some
of the services that they otherwise might struggle to get.
Senator Boozman. Right. So you are truly the industry
leader in the sense of doing telehealth and doing a great job.
Your numbers are way up.
I guess my next question--and you partly addressed it--but
do we have enough data? Do we have the metrics? Not just the--
you know, I like this on-the-phone type approach, but do we
have the metrics on telehealth services to know that the
quality of care and the outcomes of that care are better,
worse, or equivalent to traditional in-person care?
Dr. Galpin. Yes. There has been a good amount of research
on this. So when you look at an area that I think is really
important to us like telemental health, there is consistent
research that shows that the quality of the telemental health
visit is equivalent to care in person, and that crosses
populations in the studies from civilians to veterans.
We also have regular feedback from our veterans. So we do
veteran satisfaction surveys to see how their experience is,
and that is a little different than the outcome.
But, in general, particularly pre-COVID, we saw very high
satisfaction scores in telehealth: 96.9 percent in quality this
year prior to March 1st, 87.9 in overall satisfaction, 87.3 in
trust.
Now, we have seen some dips in some of those satisfaction
scores since COVID in the 3 to 5 percent range, but we had some
action to help out with that going forward that we are excited
about.
In addition, we just, at one of our VISNs, interviewed
providers and they asked about the quality there as well, and I
think it was about 77.4 of the providers that do telehealth
care was equivalent or better quality than delivering care in
person with masks, and 81 percent felt that the care was more
efficient or equal to delivering care in person with masks. And
that actually exceeded the efficiency, exceeded care via
telephone.
So there are a lot of people that have studied this in the
area--particularly in the area of mental health, and they do
see that it is equivalent to traditional in-person care.
Senator Boozman. Thank you, Dr. Galvin.
Thank you, Mr. Chairman.
Chairman Moran. Thank you, Senator Boozman.
Senator Hirono?
SENATOR MAZIE HIRONO
Senator Hirono. I was just listening to you, Dr. Galpin,
talking about surveying veterans. Have you surveyed any
veterans in Hawaii as to how they feel about telehealth?
Dr. Galpin. I am fairly positive we have. We distribute
surveys after our video visits. I do not have the breakdown
here, but we can provide a breakdown. I think it is by VISN
facility. So we can certainly get that information to you.
[Please see page 80 for response]
Senator Hirono. I would be curious to know, because I
remember when the veterans are first given the option of doing
remote telemedicine or some fashion of it. And I remember
talking with veterans, albeit this was maybe a decade ago, and
a number of them were quite resistant. And I think that what
you are seeing, what you are telling me is that more of them
are becoming used to this form of getting care, and that they
consider it to be good, if not adequate.
Dr. Galpin. Yes. Again, I will point to that Veterans
Experience Office survey. That the veterans they interviewed,
again, it was a small number, and I do not think that survey
included anyone in Hawaii, but there was an overwhelming
positive response to telehealth. Again, they preferred it over
telephone because it made them feel more connected to the
providers.
In general, I would say that this pandemic has been eye-
opening to people, I think providers and veterans alike. I
mean, we have had thousands of providers do this for the first
time, thousands--hundreds of thousands of veterans do it for
their first time, and I think people have recognized the value.
And they appreciate the type of services you can get through
the video modality.
Senator Hirono. So Senator Joni Ernst and I really pushed
for telehealth across State lines, so providers across State
lines could provide those services, and that this provision was
included in the MISSION Act.
This is for Dr. Matthews. In your testimony, you noted that
this authority to go across State lines to provide services is
pivotal for telehealth delivery for veterans.
So could you provide a little bit more detail on how this
kind of authority has extended access to health care, and is
there any particular type of health care that particularly
benefits from telehealth? And how many providers across State
lines have utilized this authority to provide services to
people outside of the State in which they practice? Dr.
Matthews?
Dr. Matthews. Sure. I will definitely need to defer the
majority of that question back to Dr. Galpin, but overall, just
to note within the Community Care program, we had at the onset
of the pandemic in similar timing with CMS, did extend
telehealth coverage within our Community Care episodes of care.
So while we are also organizing it at massive quantities within
the VA, it is available through our Community Care network as
well too, including urgent care.
But, Dr. Galpin, if you want to speak more about the
provider concerns?
Dr. Galpin. Yes, absolutely. And I will start out by just
saying that the MISSION Act was absolutely critical for
allowing us to move forward. That authority, which we call our
Anywhere to Anywhere authority, allows us to feel comfortable
delivering care on and off Federal property.
So when we look at VA Video Connect, irrespective of the
State laws, our providers are able to deliver care into a
veteran's home. So it allows us to make care more accessible.
It allows us to take the care that was being delivered in a
community outpatient clinic and do it at that Walmart site,
take it to the veteran's home, help them get health care in the
community.
The other big thing, though, and--oh, go ahead.
Senator Hirono. Well, I wanted to know. Do you have a sense
of how many providers are doing, providing this kind of care
across State lines?
Dr. Galpin. I do not have that number specifically.
Senator Hirono. Are there participants?
Dr. Galpin. I do not have that----
Senator Hirono. Do you know whether there are thousands? If
you have some idea? But if you do not, we move on because the
fact is that it has expanded, telehealth accessibility.
So for Dr. Matthews again--I am sorry.
Did you want to add something else before I go on to the
next question? If not, I am going to the next question.
One of the questions I have--I think I am running out of
time. So if you do not mind. Citizens of the Freely Associated
States--that would be the Republic of Marshall Islands,
Federated States of Micronesia, Republic of Palau--they serve
in the U.S. military, and do so and retire then like the U.S.
citizens, yet the VA cannot provide direct services to these
veterans because they are prohibited from doing so in foreign
nations, that this includes prohibition against providing
telehealth services.
So I would like to know. I mean, we need to do a statutory
change in order to enable at least telehealth services to be
provided to these citizens; is that correct? And have you----
Dr. Galpin. Yes.
Senator Hirono [continuing]. considered the feasibility of
making that statutory change so at least telehealth services
can be provided?
Dr. Galpin. So I can address that. So, yes, it would
require statutory change, starting with USC 1724. At present,
we are prohibited from providing care internationally, and that
is any type of care.
We have thousands of veterans who utilize the VA system,
who live internationally. They come to a State or to a
Territory to get care, but then they return home. And to those
veterans, we cannot provide the same type of service that we
provide to a veteran in a State. They have to come for care in
a State. So it would require----
Senator Hirono. Yes, I understand all that.
Dr. Galpin [continuing]. statutory change.
Senator Hirono. Would you support--would the VA support a
statutory change to enable this kind of service to be provided?
Dr. Galpin. I can tell you that we have certainly looked at
it. I really cannot get ahead of the Department's opinion on
it. So I think that is something we would have to take back and
have a broader discussion with our leadership on.
Senator Hirono. Please do that because I think it is what
we owe the citizens of these countries to provide them some
level of health care.
So one more question. I do not know what my time is, Mr.
Chairman.
Senator Boozman. [Presiding.] It is out.
Senator Hirono. Well, there you go.
Do you mind if I just ask one more short question, Mr.
Chairman?
Senator Boozman. One really short one. Thank you. Go ahead.
Senator Hirono. This is for Dr. Klobucar about connectivity
in Pacific Islands, and while that has improved, many
communities in the Pacific--while it has improved, many
communities--sorry--in the Pacific Islands still lack
sufficient connectivity for telehealth. What is the VA doing to
improve internet connectivity for extremely remote and rural
island locations like those in the Pacific Islands? Very
briefly, are you doing anything to address that concern?
Mr. Klobucar. Hi. I am hoping you can hear me.
As Dr. Galpin outlined before, we are seeking to work with
community partners to make an attempt to do that and also
investigating the possibility for local hotspots.
Senator Hirono. Uh-huh.
Mr. Klobucar. But that work is ongoing, and I do not know,
Dr. Galpin, if you can elaborate any more on that.
Dr. Galpin. I do not have too much to offer beyond what you
said.
I think the key is that this really needs a broad
leadership coalition. I do not think we can take this on and
get to where we need to be for veterans. I think we need to
collaborate with Congress, committee, across administration,
other Federal agencies to really reach the end zone on this
really critical issue.
So we would look forward to working with you all more on
this, again, to get to where we need to be.
Senator Hirono. Thank you very much.
Thanks, Mr. Chairman.
Senator Boozman. Thank you, Senator Hirono.
Senator Cassidy?
SENATOR BILL CASSIDY
Senator Cassidy. Thank you all.
Dr. Galpin, I am interested in the--we have spoken about
outcomes. An earlier question was about the outcomes of
telemental health, for example, versus those in person.
In some institutions, I know there has been a real problem
with missed appointments, and I am interested whether
compliance has actually improved or not. Is the reason for the
noncompliance formally because someone just could not get there
on time, but now they have taken care of that with telemental
health, or is it just that their life is too disorganized to
show up on time for anything? What have you all learned about
that?
Dr. Galpin. There is probably a good amount of studies on
that, that I cannot quite today, but that is something we could
find for you and bring back for the record.
I was just going to look up--because I know we did a study
for our tablet program, and let me just provide some of the
data here that I have in my notes. So tablet recipients
experienced an increase of 1.94; for psychotherapy encounters,
an increase of 1.05; medication management visits, an 18.5
percent increase; and their likelihood of receiving recommended
mental health care necessary or continued care in the 20.24
percent increase in their missed opportunity rate in a 6-month
period following the receipt of a tablet.
Senator Cassidy. I am sorry. So there is an increased
missed opportunity rate or a decreased missed opportunity rate?
Dr. Galpin. Decrease. I am sorry. I misquoted my own
reading here. Decrease, 20.24 percent decrease in their missed
opportunity rate in that 6-month period.
Senator Cassidy. Now, is there any----
Dr. Galpin. So, you know, again, their----
Senator Cassidy. It is pretty soon to tell, but I would be
curious. Clearly, veteran suicide has been a risk, and we have
had different strategies of how to reach people. The ability to
reach online might be something which would augment a telephone
hotline. Has there been any effort to look at that, or is it
too soon? But any kind of implications regarding that issue?
Dr. Galpin. Well, I think the one thing we can say is that
to help improve and decrease veteran suicide, we need to get
the care to the veteran, and so however the veteran wants to
get care, I think we need to provide as many options as
possible. So, you know, telehealth is a great option----
Senator Cassidy. I accept that. I am just wondering if this
is--if all--if all avenues of providing care are created equal,
and I think that is what we are trying to figure out here is
the--empirically, on some of our biggest public health issues,
suicide, for example, among veterans, is this something which
just sounds good, or is it really going to pan out? But it may
just be that it is too soon.
Let me ask you as well, and this may be for you or Dr.
Klobucar. We have obviously put a lot of money to expand the
telehealth mental--the infrastructure. My hope is that that
would decrease your unit cost of delivering care. It is a lot
cheaper to have somebody in an office looking at a computer
screen and going very efficiently one patient to the next than
having a big waiting room and having all the attendant costs of
clerks and aides, et cetera.
So is there any chance that this initial investment will
result in cost reduction opportunities after next fiscal year?
Mr. Klobucar. Hi. Yes. I cannot really speak to cost
reduction, although we can find out what that looks like and
get back with you with those data.
I think it is important to note and just to briefly refer
back to what you said earlier that there are a number of
programs that are Web-based programs that provide support for
veterans online that are suffering from depression and post-
traumatic stress disorder, and we have seen some significant
uptake in that area. These are relatively new programs that the
VA started in Fiscal Year 2019 or Fiscal Year 2018. So we
expect those to continue to grow, particularly as our younger
veterans grow older and our veteran population grows younger
over time.
So we are making a significant effort with several online
programs that we hope will have some advantage in helping those
veterans with post-traumatic stress disorder.
As far as the numbers and the data and the cost per unit, I
will definitely look into that for you and get back.
Senator Cassidy. Maybe one last question. Are there any
telehealth visits that are not appropriate? I am a physician.
So, immediately, I think of the physical exam. You are quite
limited what you can do for a physical exam, but are there any
visits in which--somebody told me they want to do orthodontia
by telehealth. How do you do orthodontia by telehealth?
So what is out there that we kind of learned, ``Oh, it is
better to have the people seen in person''?
Dr. Galpin. The way we approach that--and I would say that
every specialty could add a telehealth component now. Some
specialties can do more of the care through telehealth, so
telemental health. One of the reasons why it is so successful
is they can do the vast majority of their care by that route.
If you look at surgery, they can do pre-visit, post visit,
obviously not the surgery itself.
So it is less about that we find a specialty or type of
care that we cannot delivery through telehealth. It is more
about what portion of that care can we deliver through
telehealth.
Senator Cassidy. And let me ask you----
Dr. Galpin. So there is really no absolute----
Senator Cassidy [continuing]. one more question.
Dr. Galpin [continuing]. yes or no.
Senator Cassidy. Doctor, one more thing, I am a
gastroenterologist. I think I knew at one time, the VA required
somebody to drive in to be consented. Even if they lived 100
miles away, they would have to drive in, get consented, return
home, and then come back from the colonoscopy. It seemed very
impractical, as anyone who has taken a colonoscopy prep can
imagine.
So the question is, will VA regulations allow people to be
consented for a procedure like a colonoscopy remotely by a
telehealth visit as opposed to having to drive in?
Dr. Galpin. I believe the answer is yes to that, but I need
to check back and make sure I am being consistent with the
regulation. But, yes, I believe the answer is yes to that.
Senator Cassidy. Please let us know that.
[Please see page 81 for response]
Okay. Thank you.
I yield back. Thank you, Mr. Chairman.
Senator Boozman. Thank you.
Senator Blumenthal?
SENATOR RICHARD BLUMENTHAL
Senator Blumenthal. Thank you, Mr. Chairman.
We have a vote, which I understand has been called. So I am
going to try to be brief.
I know that the VA has provided some national statistics.
Specifically, the telehealth video visits have increased by
1,132 percent since February, rising from about 11,000 to
138,700 appointments per week between February and June 2020,
which is quite remarkable. Do you have statistics State by
State specifically for Connecticut?
Dr. Galpin. I do not have it with me for this hearing. I
believe we can get those State by State.
[Please see page 84 for response]
Senator Blumenthal. Yes.
Dr. Galpin. I believe we can.
Senator Blumenthal. That would be great.
Can you tell me--maybe you will have to get back to me
about this one too--how well Connecticut is doing, VA in
Connecticut is doing in terms of telehealth?
Dr. Galpin. Again, I do not have State-specific information
with us today.
Senator Blumenthal. Okay. Can you tell me what--I know that
you answered the question about generally the need to form a
coalition to get different groups together to bridge the
digital divide. My guess is it affects veterans not only in
rural areas, but throughout the country, because it affects our
general population throughout the country. It affects school
students, the homework gap.
I have been a major advocate of extending the Lifeline
program, funding it more adequately. Commerce Committees had
hearings on this issue.
Is the VA working with the FCC on this issue?
Dr. Galpin. Yes. The Lifeline program is actually something
that we are very excited about. We have talked to them. We have
had FCC representatives at our meeting.
One of the things we are going to be doing in the next
month is lodging a digital divide consult. So when a provider
identifies that a veteran does not have technology or internet
access, they can refer that veteran to a social worker.
And one of those tools a social worker will have in their
tool belt is the Lifeline program. They are going to do an
assessment, assuming the veteran is interested, to see whether
the veteran qualifies and then help them get connected to those
benefits. Again, it is $9.25 a month for veterans, and if you
are on Native land or Tribal land, it is $34.25.
We would be interested in discussing what you are
describing there as potentially an expansion of the benefits
for veterans. That is something we would love to collaborate on
and work together to discuss.
Senator Blumenthal. Do you have an estimate as to what
percentage of the veteran population lack connectivity? We hear
about telehealth, but does the VA have an estimate on the
percentage of its constituency?
Dr. Galpin. Yes. So we have the data that the FCC provided
last year in their report. In that report, they talked about
2.2 million veterans of the veteran population they had as 18
million not having access to fixed or mobile internet in their
home. About 15 percent of veteran households do not subscribe
to it, and there is about 364,000 veterans, about 0.2 percent
of the veteran population that live in an area where they
cannot get fixed or mobile broadband or fixed or mobile
internet at sufficient speeds.
So it is a large population out there, which is why it is a
big concern for us.
Senator Blumenthal. And just going back to the line of
questions that Senator Cassidy asked, specifically concerning
veteran suicide, does telehealth offer potential means of
reaching out, providing counseling that so far have not been
used as well as they should?
Dr. Galpin. Well, I think specifically telehealth is one of
the ways that we can make mental health care more accessible.
Again, it is a lot about can we get services out to the
veterans who need them in a way that they want to receive them.
For some veterans, taking time off work is challenging,
trying to find child care, to get to appointments, traveling
the long distances. So telehealth is one of the ways that we
can create quality visits where they can feel connected to
their provider, but we can do it in an accessible way so that
we are really lowering the activation energy threshold for a
veteran to seek help.
There is also value in the sense that some veterans, they
do not want to get care in their community. They might be
concerned about getting care from the mental health provider
that they are going to see in a store. This allows them to get
care at a distance in a therapeutic environment.
So I think it is a huge way that we can get mental health
care out to the veterans in a way that they want it. It does
not mean it is going to work for everyone. Some people will
prefer to come in, in person. Some people are going to prefer
telephone, but again, we want to make sure all veterans have
that option so they can get the care when they need it and they
want it.
Senator Blumenthal. Thank you. These topics are very, very
important. My time has expired. Thank you for having this
hearing, Mr. Chairman.
Senator Boozman. Thank you, Senator Blumenthal.
Senator Blackburn?
[No response.]
Senator Boozman. Senator Sinema?
[No response.]
Senator Boozman. We have got a vote going on. So we may
have people who have left and will come back.
Senator Loeffler?
SENATOR KELLY LOEFFLER
Senator Loeffler. Hi. Can you hear me?
Senator Boozman. Yes, perfectly.
Senator Loeffler. Wonderful. Thank you so much, and thank
you all for being here for this really important topic.
Obviously, the COVID-19 pandemic really demonstrated the
value of telehealth across the VA throughout so many areas in
the health care system and continues to, and it is vitally
important we continue to ensure that veterans regain access to
the full spectrum of in-person care. But, obviously, for now,
the demand for telehealth will continue to remain high, and
that is why it is imperative that residents, fellows, interns,
and other VA health care trainees are given the chance to
experience the needed ability to provide care via telehealth
during their supervised training instead of having to learn on
the job or in person.
And that is why I partnered with my Georgia colleague,
Representative Buddy Carter, to introduce the VA MISSION
Telehealth Clarification Act. It is a basic bill that allows
supervised training to utilize telehealth technology throughout
the delivery of care, and my version goes a step further by
providing additional clarity on the types of qualified VA
providers that can actually provide care through telehealth
under the law. So it helps expand the VHA's capacity to provide
much needed care through its existing work force. So I want to
thank Congressman Carter for his partnership on that.
My question really relates to, Dr. Galpin, if you could
comment on any of the steps that are being taken by VHA to
ensure that providers are trained to provide care, effective
care really, through telehealth as well as any limiting factors
that we need to be aware of as we start to integrate telehealth
more into our delivery of health care to our veterans to go
forward.
Dr. Galpin. I appreciate that question and certainly
appreciate the bill that has been proposed.
Regarding your question about how we are working with
providers to make them capable of doing telehealth, just to
provide some context, last year as part of our Anywhere to
Anywhere initiative, we set an objective that by the end of
this year, 2020--this is pre-COVID--that all of our primary
care clinicians and our mental health clinicians would be
capable of offering video to the home.
Last year, we got to about 60 percent, and now we are at
just about 90 percent in both categories. The goal is always to
have all of our ambulatory care providers capable of delivering
video to home by the end of the next year.
So what we are doing to that, we have national trainings
the providers are taking. We are purchasing equipment for them.
We are making sure their schedulers are capable of doing it,
and so solely--well, not solely anymore, but we are moving
toward, again, 100 percent capability there.
When you talk about some of the things that we need to do,
we still have a lot of work to do on enhancing the experience.
We want to make this as simple as possible for both veterans
and providers. So we are taking feedback from both groups and
making sure we are updating our processes, updating our
software to make sure it works for everyone.
Some of the challenges, I think, you mentioned, what is
hard, what needs to be done, this is an area where I think,
again, we need collaboration with Congress. We are still
navigating a very complex legal environment, despite the
MISSION Act. Even with the MISSION Act, Clarity Act, which
would be outstanding in letting us use all of our clinical
resources, all of our clinicians to participate in telehealth,
there is still a challenging combination of Federal and State
laws that limit us in providing comprehensive care to veterans
through the modality or are confusing to our providers and so
in some ways makes it challenging for them to participate in
certain types of care where they would otherwise like to.
So I appreciate the question. I hope that I answered it and
see if there is a followup.
Senator Loeffler. That is very helpful. Thank you, Doctor,
and obviously, we would be interested to learn about some of
the challenges as they relate to Federal laws that would limit
your ability to deliver care. So thanks so much for everything.
I yield my time.
Senator Moran. [Presiding.] If I understand where we are
at, at the moment, it is Senator Sinema. Senator Sinema?
SENATOR KYRSTEN SINEMA
Senator Sinema. Yes. Thank you, Mr. Chairman and Ranking
Member Tester, for holding this hearing. And thank you to all
of our witnesses for being here today.
Since the start of the pandemic, the CDC and health experts
have emphasized the need to social distance, wear face
coverings, and wash hands frequently to minimize the spread of
the disease. Our daily lives look very different now than they
did earlier this year.
Increased telework, distance learning, socializing, and
telehealth have become more commonplace, but for many, access
to broadband and devices still remains a challenge.
In Arizona, the VA health system covers a lot of rural
areas, and access to telehealth can be a major resource for so
many in these areas, but telehealth cannot work without access
to broadband.
In addition to being a cosponsor of the Access to Broadband
Act that was passed by the Commerce Committee a few months ago,
I have repeatedly highlighted the importance of expanding
broadband services, particularly during this pandemic.
So my first question is for Dr. Klobucar. According to the
Department of Commerce, 22 percent of American households do
not have access to the internet from home, and this issue
disproportionately affects Indian Country where 53 percent of
homes do not have access to broadband networks.
As VA expands telehealth services during the pandemic, what
is the VA learning about broadband needs in rural and Tribal
areas, and are barriers to access due to limitations of
broadband a lack of devices or other critical infrastructure
needs?
Mr. Klobucar. Thank you for that question, Senator Sinema.
I think as Dr. Galpin indicated before, this is an area
that is a constant challenge for us in VA, especially when we
talk about Tribal areas. We have expanded telehealth services
into some Tribal facilities across the country, but those
opportunities present themselves locally as local VA medical
centers look for solutions to deliver care to these Tribal
communities.
Again, as Dr. Galpin said, this is something we cannot do
alone. We do need the support of other agencies such as the
U.S. Department of Agriculture Rural Utilities Service, such as
the Federal Communications Commission, and others to try to
reach into these Tribal lands where internet, broadband access
is limited.
The President's Broadband Interagency Working Group that
formed about 2 and-a-half years ago was an attempt to address
some of those problems, and as a result, the NTIA has
established some Web resources for local internet providers to
help them access Federal funds, but certainly more is needed.
We are now with FEMA in Regions 1 and 2 to look for
solutions in the region, and they are bringing together
partnership with VA with USDA and with other national
organizations to try to address some of these burning issues.
This is an important issue for us, and it is something that we
have been working with partners to try to address for a number
of years. And we hope that the pandemic has made it
increasingly evident that more needs to be done.
Senator Sinema. Thank you.
Dr. Matthews, my office is hearing from veterans in Arizona
who have been seen via telehealth appointment, and they have
concerns that they did not get the same level of care they
would have gotten in person. How is the VA addressing these
concerns among veterans who might be hesitant or concerned
about the care they are receiving virtually, and what processes
do you have in place to collect feedback from veterans in these
appointments so we can improve the process?
Dr. Matthews. Thanks so much for that question. I will
definitely defer to Dr. Galpin about the different processes
the veterans can use to change their different platform.
We have instituted, even during this pandemic, a new
Veterans Experience Survey focused on care associated with
during this pandemic, and we are collecting that data now
regularly. That survey just started July 10th, and we are
getting information about their experience, both face-to-face
care and telehealth, what their preferences would be for next
visit and the like.
So we will continue to improve upon how veterans'
experiences are actually reflected. A lot of the questions even
get down to their technology concerns. Were they able to see
their provider clearly? Could they hear them clearly? Do they
feel that their privacy concerns were addressed?
So we are definitely taking the veteran experience into
account, but, Dr. Galpin, if you want to go into some of the
processes on how veterans can actually receive this care?
Dr. Galpin. Yes. This is a really important area for us.
Improving the veteran's experience, the family members, the
caregiver's experience, that is part of our vision for
telehealth in the VA.
We regularly collect--we have surveys that go out to
veterans post their telehealth visit. So we can see the data,
what the experience is. We can see that for providers as well,
and so this is something that we take very seriously.
We are working with the Veterans Experience Office now.
They were conducting interviews--I think I mentioned those
before--that overwhelmingly veterans like telehealth, and they
prefer it over a telephone. But we want to work with them to
really map out the entire experience. From the moment that
someone talks to them about telehealth and when someone is
offering them help with the equipment to ask them do they have
the right internet, would they want to do a test call, if
things do not work during the appointment, then obviously the
experience in the level of care is not going to be good.
So our goal is to keep working on these areas, enhancing
the processes, integrating the processes, and enhancing the
technology so that we do meet expectations, but ultimately, we
want this to be a choice for veterans.
We are in a really unusual time right now, but if this is a
modality that does not work for an individual veteran, we want
there to be an option for them to say, ``I want in-person care.
That works better for me,'' and that is really the right way to
treat the individual, allow them to make their health care
choices and to find their preferences.
Senator Sinema. Thank you.
Mr. Chairman, I have additional questions I will submit for
the record. Thank you. I yield back.
Senator Moran. Thank you, Senator Sinema.
I think Senator Tillis is returning for an additional
question, and I have a couple of additional questions. And then
we will be close to wrapping up.
Let me make certain--that Senator Sinema's question caught
my attention, and I want to make certain that the answer is
that a veteran who does not feel comfortable, does not want to
utilize telehealth is not in any way coerced to do so.
Dr. Matthews. Correct, sir.
Senator Moran. Thank you.
This would be Dr. Klobucar. Would you speak directly to the
challenges the Department faces in providing virtual care to
veterans in highly rural and frontier areas? What is the update
that you would have on the VA Video Connect for a rural Native
veteran project?
Mr. Klobucar. Yes, sir. The Office of Rural Health's
Veterans Rural health Resource Center in Salt Lake City has
established a VA Video Connect project, and the goals behind
this are to educate providers on delivering mental health care
to Tribal nations, culturally sensitive mental health care, and
also to deliver training for veterans who may wish to engage in
that care.
This is an ongoing program. We have trained dozens of
providers so far. It is a relatively new program, and it is
designed to enhance the VA Video Connect effort as we expand
out into more and more Tribal areas. There is ongoing expansion
planned for next year and the following years, and we are
seeing positive results already.
Senator Moran. Thank you.
Dr. Galpin, I want to understand about the ATLAS telehealth
pods. My understanding was they were closed at the start of the
pandemic, and do you have an update on when those pods might be
reopened?
Dr. Galpin. Yes. The one in Eureka, Montana, has opened.
The other ones, the Walmart sites, the plan is to open them in
mid-August, and then we have another VSO site that we
anticipate or we target for the end of September.
As you noted, they were closed down, and we were concerned
about infection risk. We have worked with infection control,
with Walmart, to make sure that we have new protocols in place.
They will maybe feel a little bit different. Hopefully, people
will feel safe going to them, and that we do want to then
reopen them and expand. But that is the timeline.
Senator Moran. Thank you.
This is not a filler question while we wait for Senator
Tillis question, but I always give--at least I always attempt
to give our witnesses an opportunity. Is there anything that
you would like to make certain that I and the Committee hears,
anything you would like to correct or wish that someone had
have asked you that you would now like to answer?
Dr. Matthews. Thank you for this opportunity, sir.
I think I just want to echo really what our executive in
charge, Dr. Stone, almost builds into his message. He builds a
video message every day during the pandemic. It is actually
something that has caused a great deal of just positive energy
throughout VHA, and one of his messages that is regularly
shared is just one of great gratitude for our VA staff.
What it took for the administration to really respond to
the pandemic, particularly in the March-April timeframe of
converting to a very acute responsive mode, that took a great
deal of energy. Even within my own office, the Office of
Community Care is administrative completely. We are nowhere
near the front line of actually taking care of patients.
My own deputy, three of my staff actually volunteer to go
to the front line to assist with emergency management, and that
is just one office. There were others as well.
So I would be remiss if I did not really recognize on the
record just unbelievable commitment of the VA staff during this
response.
Senator Moran. Doctor, you are right and appropriate to do
so, and I would be remiss if I did not agree with what you said
and express gratitude on behalf of this committee and members
of the U.S. Senate, but most importantly, our veterans for the
efforts that were made to care for them during this time, which
we wish would end sooner than it has. But we are grateful for
those, and many of them are veterans themselves helping other
veterans. So please express our gratitude for that
circumstance.
Let me see if we are going to conclude this meeting, and I
am ready to do so, unless you tell me otherwise. Done.
I thank our witnesses for being here, and thanks for
bringing us some education and enlightenment. We have
additional questions that would be submitted for the record. I
would ask that the VA respond to those as soon as possible. The
committee members should have those questions to the committee
within 5 days.
With that, our hearing is concluded.
[Whereupon, at 3:17 p.m., the committee was adjourned.]
APPENDIX
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