Joint Hearing of the Committee on Homeland Security and Governmental Affairs of the U.S. Senate and the Committee on Veterans’ Affairs of the U.S. House of Representatives at 1:00 p.m. CDT.
Submission For The Record of Wounded Warrior Project
On behalf of BVA, thank you for this opportunity to provide testimony today on the current legislation before the Subcommittee on Health. Chairman Benishek, Ranking Member Brownley, and members of the House Committee, thank you for the bringing these bills before the committee. The Blinded Veterans Association (BVA) is the only congressionally chartered Veterans Service Organization exclusively dedicated to serving the needs of our Nation’s blinded veterans and their families; BVA has served blinded veterans for over 68 years.
BENEFICIARY TRAVEL FOR BLINDED VETERANS: HR 1284
We appreciate the ranking member Congresswoman Brownley for introducing H.R. 1284 and we would point out that last week the Senate VA Committee held hearing on the companion bill S 633 introduced by Senator Tester that was broadly supported by the witnesses. This legislation would assist disabled spinal cord injured (SCI) and blinded or visually impaired veterans who are currently ineligible for Beneficiary travel benefits. This bill would assist mostly low- income and catastrophically disabled veterans by removing the travel financial burdens to access vital care that improve independence and quality of life. Veterans who must currently shoulder this hardship, which often involves airfare, can be discouraged by these costs to travel to a Blind Rehabilitation Center (BRC) or Spinal Cord Injury (SCI) VA medical center for either inpatient or residential bed stay while receiving training. The average age of blinded veterans attending a BRC is 67 because of the high prevalence of degenerative eye diseases in this age group.
It makes little sense to have developed, over the past decades, outstanding blind rehabilitation programs at 13 Blind Centers known for very high quality inpatient specialized services, only to tell low income, non-service connected disabled blinded veterans that they must pay their own travel expenses to access the training they need. To put this dilemma in perspective, a large number of our constituents are living at or below the poverty line while the VA Means threshold for travel assistance sets $14,340 as the income mark for eligibility to receive Means tested travel benefits. VA utilization data revealed that one in three veterans enrolled in VA health care was defined as either a rural resident or a highly rural resident. The data also indicate that blinded veterans in rural regions have significant financial barriers to traveling without utilization of public transportation.
To elaborate on the challenges of travel without this financial assistance analysis confirmed that rural veterans are a slightly older and a more economically disadvantaged population than their urban counterparts. Twenty-seven percent of rural and highly rural veterans were between 55 and 64. Similarly, approximately 25 percent of all enrolled veterans fell into this age group. In FY 2007, rural veterans had a median household income of $19,632, 4 percent lower than the household income of urban veterans ($20,400) . The median income of highly rural veterans showed a larger gap at $18,528, adding significant barriers to paying for air travel or other public transportation to enter a BRC or SCI rehabilitation program. More than 70 percent of highly rural veterans must drive more than four hours to receive tertiary care from VA. Private blind outpatient agency services such as Lighthouse for Blind are all located in large urban cities and usually established as outpatient training sites, again barrier for rural veterans traveling long distances every day to get training verses VA rehabilitation centers.
Consider the following facts:
• In a study of new applications for recent vision loss rehabilitation services, 7 percent had current major depression and 26.9 percent met the criteria for subthreshold depression.
• Vision loss is a leading cause of falls in the elderly. One study found that visual field loss was associated with a six-fold risk of falls.
• While only 4.3 percent of the 65 and older population lives in nursing homes, that number rises to 6 percent of those who are visually impaired, and 40 percent of those who are blind and Medicaid direct costs of $11 Billion per year.
• Individuals who are visually impaired are less likely to be employed-44 percent are employed compared to 85 percent of adults with normal vision in working population age 19-64.
If blinded or spinal cord injured veterans are not able to obtain the rehabilitation center training to learn to function at home independently because of travel cost barriers, the alternative—institutional care in nursing homes--may be far more expensive. The average private room charge for nursing home care was $212 daily ($77,380 annually), and for a semi-private room it was $191 ($69,715 annually), according to a MetLife 2008 Survey. Even assisted living center charges of $3,031 per month ($36,372) rose another 2 percent in 2008. BVA would point to these more costly alternatives in describing the advantages of VA Beneficiary Care so that veterans can remain in their homes, functioning safely and independently, and with the rehabilitation training needed to re-enter the workforce. For FY 2014 VA has proposed spending $7,637 Billion in Nursing Home Care program.
We caution that private agencies for the blind are located in large urban cities in New York City, Chicago, Seattle, Orlando, or Boston, so the travel barriers would preclude utilization of those sites. VA Centers offer the full specialized nursing, physical therapy, audiology, pharmacy, radiology or laboratory support services that are necessary for the clinical care. BVA requests that private agencies demonstrate peer reviewed quality outcome measurements that VHA Blind Rehabilitative Service have and they must be accredited by either the National Accreditation Council for Agencies Serving the Blind and Visually Handicapped (NAC) or the Commission on Accreditation of Rehabilitation Facilities (CARF). Blind Instructors should be certified by the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP).
13 Inpatient Blind Rehabilitation Centers (BRCs)
For those members here today we would encourage you to visit one of the 13 VA BRC’s and to visit VA SCI locations to better understand the coordinated care being provided at these hub and spoke locations. The BRCs provide the most intense and in-depth rehabilitation to severely disabled blind veterans and servicemembers returning from OIF and OEF. Comprehensive, individualized blind rehabilitation services are provided in an inpatient VA Medical Center environment by a multidisciplinary team of rehabilitation specialists. The management of chronic medical conditions is addressed as part of the training regimen as well. Blind Rehabilitation Specialists guide the individual through a rehabilitation process that leads to adjustment to blindness, new skill development in living skills, orientation and mobility, manual skills, and use of prescribed adaptive technology devices and Computer Access Training (CAT) learning the use of this specialized technology and reorganization of the person’s life to enhance their independence. All BRC’s use same training approach to maximize the team approach to the needs of each blind veteran. These new skills and attitudes foster new abilities to contribute to family and community life and allow individuals to often regain employment.
BVA supports the change in Beneficiary Travel being proposed in HR 1284 and in our discussions with VA Veterans Travel Program office found support for this legislation that would improve access to rehabilitation care and services for this severely disabled population. Recently VHA however testified before SVAC on S 633 and stated the language currently in this bill was restrictive, and it should include other disabilities like PTSD or TBI veterans. HR 1284 addresses catastrophically disabled veterans going to very specialized rehabilitation centers, and VA operates more than 300 community-based PTSD Vet Center sites, has more than 50 mobile VA centers, and dozens of TBI centers and we would hesitate having the committee broadening this language trying to include many other conditions that are often treated at the 153 VA medical centers.
H.R. 288 CHAMPVA Children’s Eligibility Act: BVA fully supports this bill to amend Title 38 USC, to increase the maximum age for children eligible for medical care under the CHAMPVA program that would allow same coverage mandated in other current federal programs. Dependent children who currently turn age 23 have loss of insurance coverage under CHAMPVA and have difficulty finding and being able to afford health insurance. We believe to change this to age 26 is consistent with other mandated coverage for other insurance plans. Often college students or those new graduates who face difficult employment challenges are unable to afford their own health insurance and being covered by CHAMPVA would provide them protection from being uninsured.
Urotrauma Task Force HR 984:
Soldiers who now survive on front line at highest percentages ever however now suffer much more grievous injuries. Bulletproof Kevlar vests protect soldiers’ central chest and abdomen, but not their limbs, groin and genitals, and this bill highlight the need for more resources for better care for genito-urinary (GU) wounds. Because there's little research for urologists in the military to draw upon in diagnosing and the surgical initial management and reconstruction of treating these complex cases, plus the social stigma about discussing genitor-urinary problems, this serious life altering injury has received far less attention over past eight years than other combat blast injuries. Most urologists in training and private practices rarely treat civilian patients with these kinds of severe genito-urinary trauma now seen in the military field hospitals or large military trauma centers caused by IED’s blasts during dismounted combat patrols.
The Veterans Affairs Office of Public Health tracks veterans who have left active duty in Iraq and Afghanistan and have sought medical treatment in the VA system. From July 2002 through June 2009, 12.5 percent of the 508,000 veterans who sought treatment were diagnosed with diseases or disorders of the genitourinary system, but the report doesn't specify how many of those diagnoses are related to combat injuries and still doesn’t report specific GU trauma which we point out highlights growing need for joint DOD-VA urological trauma clinical registry for these specific injuries similar to those existing for TBI, amputees, and for vision and hearing.
Again we stress one big challenge is that in the civilian medical world, there is not a high incidence of these kinds of blast urotrauma injuries so development of best practices to treat these kinds of battlefield genitourinary system injuries from this Task Force are urgently needed and DOD and VA must find improved reconstructive approaches for them. Genitor-urinary system mutilation can cause incontinence, infertility, impotence, recurrent infections in these young service members, plus they have emotional and psychological consequences of depression, and psycho-social isolation, and are at higher rates suicide risk in this young mostly male population. It is imperative, therefore, management of this complex pattern of GU injury requires attention paid towards surgical reconstruction and psychological health of these urological injuries with adequate deployment peer reviewed genitor-urinary trauma research funding.
GENITOURINARY (GU) RECONSTRUCTION
GU interventions must be performed in multiple stages starting at front line field surgical sites. If extensive soft tissue is lost, finding adequate tissue to cover these wounds, debridement, immediate wound management, then later in evacuation chain when is best time to perform reconstruction is more challenging. Individuals with Dismounted Combat Battle Injury (DCBI) and genital injury will often require a protracted inpatient/outpatient stay. It is best if these injuries are managed by the same surgical team over time rather than transferring care elsewhere. Because of this, provisions must be made to have adequate staffing, housing, administrative, and medical support at Role V facilities to provide protracted care for these individuals. Currently, there are a limited number of providers (civilian and military) who perform phallic reconstruction surgery—thus indicating the need to train more military urologists and plastic surgeons in these techniques.
GENITAL LOSS AND HORMONAL CONCERNS
While GU injuries present complex surgical and behavioral health challenges, other medical issues must be addressed. Low testosterone levels have been reported after trauma, serum testosterone levels are significantly reduced. Therefore testicular loss will only complicate further hormone deprivation. The role of hormone replacement to promote soft tissue and nervous tissue healing has not yet been determined. It is also unknown when the optimal timing for replacement should begin. Given the long-term needs of hormonal replacement and monitoring, systems should be established to provide life-long care by medical specialists in this area. BVA strongly supports passage of this bill by the HVAC and HASC.
H.R. 241 “Timely Access to Health Care Act”
BVA supports the recommendations made in the Veteran Service Organizations Independent Budget (VSOIB) FY 2014 section on the problems of access to care and waiting times. VHA managers plan budget priorities, measure organizational and individual medical center directors’ performance, and determine whether strategic goals are met, in part by reviewing data on waiting times and lists. However, they cannot manage and improve what they cannot measure. Unreliable data compromise meaningful analyses for decision making on the timeliness of access and trends in demand for health care services, treatments, and providers.
The OIG reports of 2005, 2007, and 2012 reiterate the continuing weaknesses causing VA’s failure to meet its own access standards. Based on the reports by the OIG and Booz Allen Hamilton137 on the weaknesses in the Department’s outpatient scheduling process, the VHA needs to improve data systems that record and manage waiting lists for primary care, and improve the availability of some clinical programs to minimize unnecessary delays in scheduling specialty health care.
BVA appreciates that the committee has investigated the long standing problems over waiting times for clinic appointments and has heard previously in other recent hearings on March 13 about the finding of GAO “Waiting For Care; Examining Patient Wait Times at VA” the testimony by the Director, Health Care Government Accountability Office, Debra Draper provided recommendations. GAO outlined problems found in examining wait times at various VA clinics that despite attempts to solve the problem “VHA report times are unreliable and there was inconsistent implementation of certain elements of VHA’s scheduling policy.” BVA supports the intent of HR 241 to address this problem.
DRAFT “Veterans Integrated Mental Health Care Act of 2013”:
The problems of mental health care access and wait times in this area are ongoing concern to BVA and the other veteran service organizations as suicides have increased despite numerous programs by both DOD and VA that have been established in the past few years and growing numbers of veterans are being diagnosed with variety of mental health disorders we feel more must be done. The number of Veterans receiving specialized mental health treatment from VA has risen each year, from 927,052 in fiscal year (FY) 2006 to more than 1.3 million in FY 2012 . One major reason for this increase is VA’s proactive screening of all Veterans to identify those who may have symptoms of depression, Post Traumatic Stress Disorder (PTSD), problem use of alcohol or who have experienced military sexual trauma (MST).
BVA applauds efforts made by VA and the DOD to improve the safety, consistency, and effectiveness of mental health care programs for servicemembers and veterans. We also appreciate that Congress is continuing to provide increased funding in pursuit of a comprehensive package of services to meet the mental health needs of veterans, in particular veterans with wartime service and post-deployment readjustment needs.
While the VSOs are pleased with VA’s progress in implementing its Mental Health Strategic Plan, and veterans who are able to get care from the 300 Vet Centers are very satisfied, we still have concerns that these goals may be frustrated unless proper oversight is provided and VA enforces its own mechanisms to ensure its policies at the top are reflected as results on the ground in VA facilities. As members here know VA announcement from the Secretary of Veterans Affairs Eric K. Shinseki the department would add approximately 1,600 mental health clinicians – to include nurses, psychiatrists, psychologists, and social workers as well as nearly 300 support staff to its existing workforce of 20,590 mental health staff as part of an ongoing review of mental health operations.
While VA has increased the total numbers of full time psychiatrists in 2006 from 1,836 to FY 2012 up to 2,586, and the number of psychologists 1,788 from FY 2006 up to 4,200 in FY 2012, and VA also has 3,498 clinical social workers, and 645 nurse practitioners full time assigned to mental health clinics with additional 244 advanced practice nurses. Still as everyone knows here the wait times grow and so does the OIF OEF enrollment numbers. DOD and VA both continue struggling to hire the same pool of mental health providers and each agency will probably continue to fail to meet the growing demands. We must find alternatives to provide care.
Chairman Miller draft “Veterans Integrated Mental Health Care Act of 2013” would provide mechanisms for medical centers to coordinate necessary clinical services through care-coordination contracts. BVA supports the draft version of this and stresses that ensuring that any veteran that obtains care has their medical records sent to the VA is vital. The VA should exchange clinical best practice guidelines with outside providers on management.
Chairman Benishek and Ranking member Brownley, BVA again expresses its support for these proposed changes to VHA programs listed above being considered here today. BVA appreciates the opportunity to provide this testimony today and be glad to answer any questions now.
DISCLOSURE OF FEDERAL GRANTS OR CONTRACTS
The Blinded Veterans Association (BVA) does not currently receive any money from a federal contract or grant. During the past two years, BVA has not entered into any federal contracts or grants for any federal services or governmental programs.
BVA is a 501c (3) congressionally chartered, nonprofit membership organization.
MICHAEL J. O’ROURKE
Assistant Director BVA Government Relations
Michael J. O’Rourke, a native of Minneapolis, Minnesota, became Assistant Director, Veterans Health Policy, and VFW National Veterans Service in March 2001 to 2010. In this role he made frequent site visits to most Department of Veterans Affairs medical centers. Michael began his employment with the Veterans of Foreign Wars Washington Office in 1999 as a Claims Consultant where he has represented veterans before the Department of Veterans Affairs. He has served as a Post Service Officer and Department Service Officer in Rhode Island and served on various VA and DOD committees.
Michael’s military career began in1968. Upon entering in the United Sates Marine Corps, and after Marine Corps Recruit training in San Diego California, he received Advance Infantry training in Regiment at Camp Pendleton, California. His first operational assignment took him to the Third Marine Division DaNang, Republic of Vietnam. Michael’s transition to the United States Navy took place at the Naval Station in San Diego, California. He then went on forward deployment on the U.S.S. WORDEN (DLG-18) from Yokosuka, Japan. Michael then served at the Naval Hospital San Diego, California, and U. S. Naval Hospital Taipei, Taiwan. After a move back to the United States, he served at the Underwater Demolition School San Diego, California. With his next tour of Independent Duty he served on the U.S.S BRONSTEIN (FF-1037). He was commissioned after attending the Naval School of Health Sciences Physician Assistant Program, where he received his Bachelor’s Degree from George Washington University. He next reported to the Naval Hospital Long Beach, California and served in the Emergency Medical Department, and then on to the USS Carl Vinson. His last assignment was to the Naval Hospital Newport, Rhode Island as Physician Assistant/Administration Officer before his Navy retirement. He was hired June 2010 as Assistant Director Government Relations BVA.