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Testimony Presented by Thomas H. Miller Executive Director Blinded
Veterans Association (BVA) U.S. House of Representatives Committee on Veteran’s Affairs Subcommittee on Health Hearing on H.R. 2792 Thursday,
September 6, 2001 Mr.
Chairman and members of this distinguished subcommittee, on behalf of
the Blinded Veterans Association (BVA), I want to express our
appreciation for your invitation to present our views on H.R.2792 The
Disabled Veterans Service Dog and Health Care Act of 2001, currently
pending before the subcommittee.
I want to commend you, Mr. Chairman, for introducing this
important legislation. We
in BVA feel especially qualified to comment on the importance of the
role of service dogs in assisting severely disabled veterans.
Service dogs help veterans in coping with their disabilities
and achieving successful reintegration into their communities.
Section 2 of H.R.2792 would amend section 1714 authorizing the
Secretary of the Department of Veterans Affairs (VA) to provide
service dogs to disabled veterans with spinal cord injury or disease
or other chronic impairments that result in limited mobility as well
as service dogs for the hearing impaired.
We are especially pleased that this bill makes all veterans
enrolled in VA Health Care eligible for these dogs.
In our view, eligibility for prosthetics services based on
enrollment was one of the fundamental elements of the Eligibility
Reform Act that contributed significantly to the transformation of the
VA Health Care system. The
removal of complex and unnecessary eligibility criteria for the
provision of vital prosthetics services has substantially improved
access for disabled veterans to needed services.
As I mentioned above, Mr. Chairman, BVA feels especially
qualified to comment on this provision of your bill because VA has
possessed the authority to provide guide dogs to blinded veterans for
many years. The value of
guide dogs for enabling people who are severely visually impaired or
blind to overcome the problems associated with safe and independent
mobility has been well documented and widely accepted by the general
public. Guide dogs are
permitted access everywhere, affording visually impaired individuals
the opportunity for full participation in their communities.
Despite the fact that guide dogs afford the fastest, safest,
and most efficient means of travel for people who are blind, a very
small percentage of people who are blind use guide dogs.
The use of a guide dog is a personal decision, which is
influenced by many factors. The
utilization of guide dogs by blinded veterans reflects the general
blind population, which is less than four percent.
Consequently, the impact on VA is minimal.
This is especially true in that the guide dog schools do not
charge a fee for the dogs, and generally will pay for the
transportation to and from the school.
As you may know, VA Blind Rehabilitation Service (BRS) only
trains blinded veterans in the use of the long cane for safe and
independent travel. Whether
a veteran chooses to apply for a guide dog is a very personal
decision. Long cane
travel is quite stressful, as you might imagine, requiring intense
concentration and skill. Some
blinded veterans never develop enough confidence in the skills with
the cane and turn to a guide dog.
The guide dog enables the person to travel more quickly,
safely, and efficiently than when using a cane.
The choice therefore between the cane and a guide dog depends
primarily on the individuals independent travel needs, confidence, and
comfort level when using the long cane BVA
believes a very similar experience will result from providing VA the
authority to provide service dogs to certain disabled veterans.
The service dogs, while not as common and widely accepted as
the guide dog, clearly provide the same kinds of benefits. Mr. Chairman, the most difficult aspect of accepting and
adjusting to a disability is coping with the loss of independence.
Becoming dependent on others to perform basic activities of
daily living, which are normally taken for granted, is the single most
difficult aspect of disability to cope with.
Restoring ones independence is essential to rehabilitation and
fundamental to this process is the integration of prosthetic devices,
sensory aids, appliances, and now service dogs.
It has been clearly demonstrated that using service dogs
enhance the quality of life characterized by restored self-esteem,
confidence, and worth. Concurrently,
the utilization of the service dog substantially reduces dependence on
paid personal care assistants. Without
question, Mr. Chairman, the VA should be authorized to provide service
dogs to those disabled veterans who have a demonstrated need and can
benefit from the use of a service dog.
Similar to guide dogs, we would not expect that a substantial
percentage of disabled veterans would require or benefit from a
service dog. Regulations
should be specific as to under what conditions a service dog is
necessary. Guide dogs and
service dogs alike are not intended to be companions, pets, or attack
dogs. SECTION
3 BVA
strongly supports Section 3 of this bill, which requires VA to
maintain its capacity to provide specialized treatment and
rehabilitation for disabled veterans.
This requirement was originally established with the adoption
of the eligibility reform Act of 1996.
This act not only required VA to maintain such capacity, it
also required VA to submit a report to congress annually known as the
Capacity Report (CR). The
ERA only required VA to maintain national capacity in the
Special-Disabilities Programs. Sec.
3 of H.R. 2792 requires not only maintenance of National but Network
Capacity as well. We
believe this is essential to assuring disabled veterans equitable
access to these vital services. The
importance of this requirement is exemplified by a situation that
occurred more than two years ago.
One VAMC hosting a blind Rehabilitation Center (BRC)
arbitrarily closed fifteen beds dedicated to the delivery of
comprehensive residential blind rehabilitation. They also eliminated the professional positions dedicated to
provide that service. In
an effort however, to comply with ERA, another fifteen-bed BRC was
established in another Network. While
strong arguments can be made for the need for the new BRC, the loss of
the fifteen beds at the original VAMC has only resulted in longer
waiting lists and times for admission.
Consequently, blinded veterans are either being denied or at
the very least delayed access to essential specialized rehabilitative
services. The
Special-Disabilities Programs are regional in nature, making it
extremely important to maintain a national balance affording equity of
access for disabled veterans. While
BVA supports this provision in H.R. 2792, we have several concerns
regarding its depth and scope. Specifically,
the method utilized to measure capacity is problematic. We believe it is not enough to only measure number of
veterans treated and the dollars spent.
Certain Special-Disabilities programs such as blind
rehabilitation and spinal cord injury/disease are carried out in
residential settings. Therefore,
they require a certain number of beds dedicated to the provision of
these very specialized services along with a specific number of
Full-Time Employee Equivalent (FTEE) professionally educated and
trained to deliver these services.
It follows, therefore, if these beds and essential FTEE are not
counted, preserved, and protected, VA certainly cannot maintain its
capacity. There
are those who would argue that the Special-Disabilities Programs
should mirror the shift from inpatient service delivery to outpatient
settings. In our view,
the need for acute care provided on an inpatient basis will always
exist as will the need for inpatient residential rehabilitative
service for severely disabled veterans.
The comprehensive benefits realized in the inpatient programs
cannot be duplicated on an ambulatory basis.
There is no question, in some instances, outpatient services
may be indicated and appropriate, but this does not negate the need
for the residential training programs. It is imperative, therefore, that beds and FTEE be integral
elements of any methodology for measuring capacity.
VA will argue they have treated more blinded veterans than ever
before and spent more dollars providing this treatment.
This is the basic argument employed against counting beds and
FTEE. The fundamental
flaw with this argument in our view is the increases in numbers of
blinded veterans receiving treatment in the BRC’s is due primarily
to substantially reduced lengths of stays.
Limiting the programs enables VA to pump an increasing number
of blinded veterans through the program, inflating the numbers treated
and reducing the cost per blinded veteran.
We are deeply concerned that quality of care is being
compromised to achieve artificially high numbers.
Some BRC’s have gone so far as to introduce shortened
programs (1 or 2 weeks) in an effort to inflate the numbers treated as
well as game the Veterans Equitable Resource Allocation (VERA) model.
Under VERA, blinded veterans who are admitted to a BRC and
spend at least one night qualify their host Network for reimbursement
at the high or complex rate. Mr.
Chairman, these short programs are not residential blind
rehabilitation, and only serve to improperly utilize beds dedicated
for the comprehensive program. The
CR clearly has been a numbers game.
It does not address quality issues and accountability.
Therefore, we strongly believe that maintenance of capacity
must be included as a performance measure in the facility and Network
Directors Performance contracts.
They have vigorously resisted this in the past, insisting that
they only be required to monitor these programs.
Monitoring is not the same as measure and they must be held
accountable. We strongly
encourage the inclusion in H.R. 2792 such requirements. BVA
is also deeply concerned that the outpatient programs currently in
operation in VA Blind Rehabilitation Service (BRS) be included in the
maintenance of capacity requirement.
Specifically, I am referring to the Visual Impairment Service
Team (VIST) Coordinators and the Blind Rehabilitation Outpatient
Specialist (BROS) positions. The
VIST Coordinators are the case managers responsible for assuring the
delivery of comprehensive service to all blinded veterans in their
respective areas. They
serve as the access point for blinded veterans into the system and for
referral to the BRC’s. The
BROS are the professionals charged with providing blind rehabilitation
services to blinded veterans unable to attend the BRC program. Both positions are very vulnerable in the de-centralized
management environment employed by the Veterans Health Administration
(VHA). When vacancies
occur, field managers either attempt to eliminate, or drastically
alter the position descriptions, usually assigning collateral duties.
This latter tactic prevents those professionals from meeting
the demand for care and specialized rehabilitative services. Additionally, local management frequently attempts to fill
these crucial positions with unqualified individuals. Therefore, we believe very strongly the full-time VIST
coordinators and BROS must be counted if capacity is to be maintained. BVA
also firmly supports the requirement that VA continue providing the CR
to Congress for the next three fiscal years.
Although BVA has complained that data used for the CR’s
provided over the past several years has been flawed, we fervently
believe, without the reporting requirement, the Special-Disabilities
Programs would have possibly been damaged beyond repair.
We believe it imperative that the focus on these specialized
programs must be continued. Mr.
Chairman, on a personal note, I have had the honor of chairing the
Federal Advisory Committee on Prosthetics and Special-Disabilities
Programs for the past several years and I know first hand that our
committee has failed to agree with VA’s assertion that they have
been maintaining capacity. Each year of the CR, we have reported the data utilized has
been flawed, highlighting the limitations of VHA Information
Management systems. Clearly
uniform national standards for coding and costing must be implemented
if valid and reliable data is to be generated for reporting purposes.
The Advisory Committee, in its most recent meeting held at the
end of May, strongly recommended the continuation of the CR reporting
requirement and will certainly appreciate your efforts to that end. SECTION
4 BVA
supports Section 4 of this bill that would implement the Department of
Housing & Urban Development (HUD) low-income index for
establishing thresholds for veteran’s health care eligibility means
tests. We believe this is
a more equitable method for conducting means testing of veterans and
allows for variability in cost of living in certain areas of the
country. Veterans
burdened by a substantially higher cost of living associated with
certain areas, should not be penalized, and required to utilize their
limited resources to pay for care from VA.
We appreciate your inclusion of this provision in the bill. SECTION
5 Mr.
Chairman, BVA is deeply concerned by this section of the legislation.
We opposed this provision in the last session of Congress and
feel compelled to do the same this time.
Converting VA into a payer for veteran’s health care rather
than a provider is disturbing at the very least.
The provision seems to be a cost avoidance measure and
certainly not in the best interest of disabled veterans. BVA
is painfully aware of the financial constraints under which VA must
operate its health care system, but question the wisdom of turning
veterans over to non-VA providers which would insist that veterans
rely on their own insurance or Medicare.
Proper management of veteran’s care utilizing this model
seems problematic at best. This
provision requires that all payments by VA for deductibles, co-pays
etc. must be made from the Medical Care Cost fund (MCCF) at the local
level. As you know, these
are receipts collected from third party payers and retained at the
local facility. Although
these funds are used to offset the cost of providing care to certain
Non Service-Connected (NSC) veterans, or for the care provided for
treatment of NSC conditions, it is also available to enhance the
overall capacity to provide service at any given facility for all
veterans including those with Service Connected (SC) disabilities.
Therefore, the proposed pilot projects contemplated under this
provision would avoid costs by providing care in non-VA facilities.
Potentially, this could result in reduced capacity and quality
of care of SC disabled veterans.
Fundamental to maintaining quality is maintaining a sufficient
workload at facilities, assuring professional opportunities for
learning, education, and the acquisition and maintenance of skills and
expertise necessary for the provision of high quality services.
This is particularly important in specialty areas. VA cannot
provide specialized services without the availability of the full
array of medical and ancillary services necessary to support the
Special-Disabilities Programs. We
are also very concerned this approach to service delivery sets a
precedent that can be perceived as the first step towards vouchering
out all VA health care. We
also believe this approach would not be in the best interest of
disabled veterans. VA
possesses a long history of experience, expertise, and knowledge in
providing specialized health care and rehabilitative services rarely
available in the community. The
drive to reduce the cost associated with the delivery of VA health
care should not result in disabled veterans being forced out of the
system especially designed to address their unique and special needs. SECTION
6 Mr.
Chairman, BVA also has reservations to Section 6 of this bill. Requiring all contract or fee basis treatment to be provided
through managed care programs raises serious concerns.
Managed care programs do not offer all the specialized services
that might be required by disabled veterans nor make appropriate
referrals to VA providers who do indeed possess this expertise.
Again, is cost avoidance warranted at the risk of disabled
veterans not receiving essential service in a timely manner? SECTION
7 BVA
supports this provision. The
families of severely disabled veterans who have suffered for years, or
are burdened by catastrophic illness or disease, deserve all the
bereavement counseling assistance VA can provide.
Typically, family members are the primary care givers and, in
many cases, devote much of their adult lives caring for veterans.
Without this devoted care, the burden would fall to VA.
Clearly, VA should provide counseling to support and assist
these devoted Americans in coping with their loss. SECTION
8 BVA
supports this provision of H.R. 2792. CONCLUSION Again, Mr. Chairman, BVA appreciates the opportunity to appear this afternoon to share our comments on H.R. 2792 and commend you and the subcommittee for introducing this important legislation. As always, I would be pleased to respond to any questions you or other members might have. Back to Witness List |