Chairman Michaud and members of the Subcommittee, on behalf of Paralyzed Veterans of America (PVA), I would like to thank you for the opportunity to present PVA’s views on how the Department of Veterans Affairs (VA) is caring for the severely injured Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans.  The challenges the VA has faced in delivering care to OEF/OIF veterans have been unique as this generation of service members has experienced new and different actions in combat, such as the wide-spread use of improvised explosive devices (IED).  And yet, the delivery of specialized health care is something that the VA has greatly improved upon over the years and has established itself as a world leader.

The wars in Afghanistan and Iraq have now continued for an extended period of time.  The number of casualties and new veterans being created has had a significant impact on the VA.  PVA appreciates the Subcommittee’s continued efforts to sufficiently fund the care for this growing number of veterans.  VA has done a great many things to provide for the care of our newest generation of veterans.  The open enrollment of OEF/OIF veterans into the VA health care system for up to five years after these service members leave the service, creation of multiple polytrauma centers to address the complex and severe disabilities that some service members are experiencing as a result of their service, the expansion of mental health programs as well as programs targeted at women veterans, and other efforts to ensure the proper care of these men and women demonstrates VA’s willingness to go the extra distance to provide timely and sufficient care.

It is important to emphasize that specialized services are part of the core mission and responsibility of the VA.  For a long time, this has included spinal cord injury care, blind rehabilitation, treatment for mental health conditions—including post-traumatic stress disorder (PTSD)—and similar conditions.  Today, traumatic brain injury (TBI) and polytrauma injuries are new areas that the VA has had to focus its attention on as part of their specialized care programs.

Specialized services were initially developed to care for the unique health care needs of veterans.  The VA’s specialized services are incomparable resources that often cannot be duplicated in the private sector.  With this in mind, we believe that the VA must be given the opportunity to show what it is capable of doing in addressing TBI and polytrauma conditions for this newest generation of veterans. 

The provision of specialized services is vital to maintaining a viable VA health care system.  Specialized services are part of the primary mission of the VA.  The erosion of these services would lead to the degradation of the larger VA health care mission.  With growing pressure to allow veterans to seek care outside of the VA, the VA faces the possibility that the critical mass of patients needed to keep all services viable could significantly decline.  All of the primary care support services are critical to the broader specialized care program provided to veterans with spinal cord injury.  If primary care services decline, then specialized care is also diminished. 

As such, we are pleased to see that the VA has applied the spinal cord injury care model to treatment for polytrauma and TBI.  PVA believes that the hub-and-spoke model used in the VA’s spinal cord injury service serves as an excellent model for how this network of polytrauma centers can be used.  Second level treatment centers (spokes) refer spinal cord injured veterans directly to one of the 23 spinal cord injury centers (hubs) when a broader range of specialized care is needed.   

Treatment of polytrauma and TBI can function in the same fashion.  The new level two polytrauma centers (spokes) being established will better assist VA to raise awareness of the complex medical issues that severely injured service members and veterans are facing.  These increased access points will also allow VA to develop a system-wide screening tool for clinicians to use to assess TBI patients.  When more comprehensive treatment is needed, a veteran can be referred to the level one polytrauma center that serves as the hub.  Unfortunately, the ability of VA to provide this critical care has been called into question.  PVA recognizes that the VA’s ability to provide the highest quality TBI care is still in its development stages; however, it continues to meet these veterans’ needs while continuing to expand its capabilities.       

While VA has gone to great lengths to provide appropriate care for OEF/OIF veterans, there have been several recent media reports indicating problems with proper identification and treatment of service members suffering from TBI.  This has occurred despite increased attention to the problem.  Those with significant cases of TBI are being identified and well cared for.  It is those with less severe cases of TBI that seem to be falling through the health care cracks.  In most cases, this is not VA’s fault.  Instead, the identification and treatment by Department of Defense (DOD) personnel on the scene or at the initial care sites are not making this identification.  This is leading to a lack of continued care when those veterans who may suffer from mild to moderate, but undiagnosed, TBI injuries leave the service and seek care at VA facilities.  We expect VA will continue to work closely with DOD to ensure TBI care is provided to all veterans who have suffered this often debilitating injury.

But for PVA, there is an ongoing problem that has not received a similar level of appropriate media coverage.  Some active duty soldiers with a new Spinal Cord Injury/Dysfunction (SCI/D) are being transferred directly to civilian hospitals in the community and bypassing the VA health care system.  This is particularly true of newly injured service members who incur their spinal cord injury in places other than the combat theaters of Iraq and Afghanistan.  This violates a Memorandum of Agreement between VA and DOD that was effective January 1, 2007 requiring that “Care management services will be provided by the Military Medical Support Office (MMSO), the appropriate Military Treatment Facility (MTF) and the admitting VAMC as a joint collaboration” and that “whenever possible the VA health care facility closest to the active duty member’s home of record… should be contacted first.”  In addition, it requires that “To ensure optimal care, active duty patients are to go directly to a VA medical facility without passing through a transit military hospital,” clearly indicating the critical nature of rapidly integrating these veterans into an SCI health care system.

This is not happening.  For example, service members who have experienced a spinal cord injury while serving in Afghanistan and Iraq are being transferred to Sheppard Spinal Center, a private facility, in Atlanta when VA facilities are available in Augusta.  When we raised our concerns with the VA regarding Augusta in a site visit report, the VA responded by conducting an information meeting at Sheppard to present information and increase referrals.  However, reactionary measures such as this should not be the standard for addressing these types of concerns. 

Of additional concern to PVA, it was reported that some of these newly injured soldiers receiving treatment in private facilities are being discharged to community nursing homes after a period of time in these private rehabilitation facilities.  In fact, some of these men and women have received sub-optimal rehabilitation and some are being discharged without proper equipment.  PVA is greatly concerned with this type of process and treatment.  There is a serious need to reinforce compliance by DOD regarding the Memorandum of Agreement toward the treatment of soldiers with new SCI/D at VA SCI centers. 

Ensuring that these men and women gain quick access to VA care in spinal cord injury centers is critically important because it begins what will become a lifelong treatment process.  SCI/D care in the VA is unique from private care for spinal cord injury rehabilitation because of the care coordination that the veteran receives for the remainder of his or her life.  Care coordination begins as soon as a new injury enters the VA SCI service.  Failure to transfer new injuries into the VA only serves to deny these men and women the world-class specialized care the VA will provide.  While we understand that local VA medical centers and DOD facilities are taking actions to improve this process, we ask that the Subcommittee work with your colleagues of the House Committee on Armed Services to ensure our SCI/D veterans are getting the complete, proper and appropriate care for their sacrifices.

VA has historically been the best provider of care for our injured veterans.  They are familiar with the wounds of war and the physiological and psychological conditions that accompany them.  It is unacceptable that DOD might move its disabled warriors to sub-standard care and we can only believe that this is because some individuals within the DOD health care system do not understand the complexities of SCI/D care and the multitude of conditions that require attention for veterans with spinal cord injuries.

PVA also remains concerned that the VA must maintain its capacity for the provision of SCI/D care as mandated by P.L. 104-262, the “Veterans Health Care Eligibility Reform Act of 1996.”  This law required the VA to maintain its capacity to provide for the special treatment and rehabilitative needs of veterans with spinal cord injury, blindness, amputations, and mental illness.  The baseline of capacity for spinal cord injury was established based on the number of staffed beds and the number of full-time equivalent employees assigned to provide care on the date of enactment of the law.

Ultimately, we cannot emphasize enough that any reduction in staffed beds can have a direct negative impact on the newest generation of veterans as well as veterans of previous generations.  Unfortunately, the single biggest accountability measure—an annual capacity reporting requirement—expired in April 2004.  This allows the VA to make changes to its SCI/D capacity in a less than transparent manner.  In accordance with the recommendations of The Independent Budget for FY 2011, PVA calls on this Subcommittee to approve legislation to reinstate this vitally important reporting requirement. 

Additionally, the SCI/D programs of the VA face a common challenge with the larger health care system—a shortage of qualified nurse staffing.  As a result, VA is experiencing delays in admissions and bed reductions at its SCI centers.  In order to meet this challenge head on, some SCI centers in the VA have offered recruitment and retention bonuses to enhance their nurse staffs.  Unfortunately, this is not a uniform national policy and these actions are subject to the budget decisions of local VA medical center and Veterans Integrated Service Network (VISN) directors.  In accordance with recommendations of The Independent Budget, we believe it is time for the Veterans Health Administration (VHA) to centralize policies and funding for systemwide recruitment and retention of SCI nurse staffing.  Additionally, we believe Congress should establish a specialty pay provision for nurses working in the SCI service, and should consider extending similar provisions to the other VA specialized services.

PVA appreciates the emphasis this Subcommittee has placed on reviewing the care being provided to the most severely disabled service members and veterans returning from OEF/OIF.  It cannot be overstated that the VA is the best option for these men and women when it comes to provision of specialized services.  And yet, we have only touched on a small segment of this population—SCI/D veterans—in our testimony today.  There are many more severely injured service members and veterans who are dealing with TBI, vision impairment, amputations, and serious mental illness.  We would encourage the Subcommittee to review The Independent Budget for FY 2011.  This comprehensive policy document includes significant discussion about the challenges of providing care to this generation of war-wounded veterans, as well as the individual issues with the different segments of specialized services. 

PVA would like to thank the Subcommittee once again for allowing us to provide testimony on these important health care issues facing OEF/OIF veterans, as well as other severely disabled veterans.  We certainly appreciate the continued attention this Subcommittee has placed on these issues.  I would be happy to answer any questions that you might have.  Thank you.