Mr. Chairman and Members of the Subcommittee:

Thank you for inviting the Disabled American Veterans (DAV) to testify at this legislative hearing of the Committee on Veterans’ Affairs Subcommittee on Health.  DAV is an organization of 1.3 million service-disabled veterans, and devotes its energies to rebuilding the lives of disabled veterans and their families. 

You have requested testimony today on two bills primarily focused on health care services for injured military servicemembers and veterans, and personnel issues affecting health care employees of the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA).  We appreciate the opportunity to provide our views on these measures to the Subcommittee.

H.R. 3051—the Heroes at Home Act of 2007

In general, this bill seeks to improve the diagnosis and treatment of traumatic brain injury (TBI) and raise awareness about post-traumatic stress disorder (PTSD) among current military servicemembers and veterans; provide support to families of severely injured veterans; and, expand tele-health and tele-mental health programs of the Department of Defense (DoD) and VA. 

Section 2 of the bill would require VA, in collaboration with the Secretary of Defense, to develop a program of training and certification of family caregivers and other personal care attendants of veterans and still-active members of the armed forces with TBI, at every VA medical center.  The curricula developed would incorporate the standards and protocols of national brain injury care specialist organizations and, to the degree possible, would require use of, and would expand the curricula developed under, the John Warner National Defense Authorization Act for Fiscal Year 2007 (Public Law 109-364).  Certification received by family caregivers or others would qualify them to be compensated for personal care services rendered to the injured veteran or servicemember.  Training would be provided at no cost to the veteran or caregiver, but would be borne by VA or reimbursed through TRICARE. 

Section 3 of the bill would require VA to conduct comprehensive outreach to enhance awareness among veterans and the general public about the symptoms of PTSD and TBI and the services provided by the VA.  It would further require VA to make information available to non-VA practitioners on best practices in treatment of TBI and PTSD.  

Section 4 of the bill addresses tele-health and tele-mental health services of DoD and VA, and would require the Secretaries to jointly establish a demonstration program to assess the feasibility of using tele-health technologies to evaluate cognitive functioning among servicemembers who have sustained head trauma.  In addition, the bill would require an assessment of tele-health tools to obtain information regarding the nature and symptoms of brain injury, the use of technology to rehabilitate those with TBI, and the usefulness of applying such technology to dissemination of educational material to veterans and servicemembers.  The funds for the demonstration would be drawn from the DoD-VA Health Care Sharing Incentive Fund and the results of the demonstration would be reported in the Administration’s joint report to Congress on sharing initiatives between the two Departments.  Another study the bill would require is an ongoing review of tele-health and tele-mental health services, to include the number of servicemembers and veterans who have used such services and the extent to which the National Guard and Reserve components of the armed forces use them, in addition to identifying improvements for such programs.  The report would also require best practices of civilian mental health providers assisting veterans and former servicemembers and demonstrate the feasibility and advisability of partnering with civilian mental health facilities to provide tele-health and tele-mental health programs.

While modern protective gear and battlefield medicine have greatly improved from previous conflicts, the intensity of poly-trauma injuries, including TBI, presents great challenges to DoD and VA in meeting servicemembers and veterans acute, rehabilitative and long-term care health needs.  As you well understand, Mr. Chairman, the most severe of these injuries may require a lifetime of care.  The family members of military poly-trauma casualties typically appear at the bedside of their loved one and remain with them throughout their acute treatment and extensive rehabilitative periods.  A survey conducted on behalf of the President’s Commission on Care for America’s Returning Wounded Warriors (Commission) found that “…33 percent of active duty, 22 percent of reserve component, and 37 percent of retired/separated servicemembers [who were injured] report that a family member or close friend relocated for extended periods of time to be with them while they were in the hospital.”[1]

Family members of severely injured veterans often shoulder a great and lifelong burden as home and institutional caregivers, giving up or severely restricting their own employment and educational advancement and negatively impacting social interactions that are taken for granted in the normal course of life.  The Commission’s survey also found that “21 percent of active duty, 15 percent of reserve component, and 24 percent of retired/separated service members [who were injured] say friends or family gave up a job to be with them or act as their caregiver.”[2]  Not surprisingly, family caregivers often suffer severe financial and personal hardships as a consequence of providing care to a severely disabled veteran.  Yet, in their absence, an even greater burden of direct care would fall on DoD and VA, at significantly higher financial cost to the government and a reduced quality of life for severely wounded war veterans.

DAV testified before the Senate Committee on Veterans’ Affairs earlier this year in support of S. 2921, a bill that would require VA to develop a pilot program to train and certify family caregivers of traumatically brain injured veterans.  We are very enthusiastic about bolstering the financial support for these vulnerable families and believe that this is also an idea that will improve the quality of care our veterans receive.  We agree with the intent of H.R. 3051 that this common-sense program could be started without being a pilot—since family caregivers of severely injured veterans are already shouldering a great deal of the care these veterans receive.  This program would allow these family members to have up-to-date and consistent training and to receive compensation that recognizes their services and will better ensure the stability of the family at an extremely difficult and vulnerable time.  The needs of these veterans and their families are urgent.  However, we believe that initially, the training and certification process may need to be limited to sites that have these capabilities in place—most likely in the poly-trauma centers and other units within the Defense and Veterans Brain Injury Network.  We ask the Subcommittee to consider this aspect of the bill and modify it accordingly to ensure the training provided is of high quality and focused on the particular needs of these families.

Similar to the provision for a training and certification program in S. 2921, Section 2 of the Heroes at Home Act would address veterans with traumatic brain injuries but would also be beneficial for other catastrophically injured veterans with long-term personal assistance needs, such as veterans with spinal cord injuries or severe physical trauma without brain injury.  Indeed, an educational proposal to assist family caregivers of all veterans with catastrophic injuries who would be taking on personal assistance duties was originally recommended by the Commission on Care for America’s Returning Wounded Warriors.  If successful, we would like to see this provision related to training caregivers expanded to other catastrophically disabled veterans requiring caregiver assistance.

Section 3 of H.R. 3051 would require that VA conduct outreach activities targeted at increasing recognition of symptoms and public awareness that resources are available within VA to treat traumatic brain injury and PTSD.  Veterans may not be the first to recognize the changes in their own behavior consequent to their exposure to concussive and traumatic events.  Indeed, even with the high rates of prevalence expected for both TBI and PTSD, some veterans will not recognize their own symptoms until weeks or months after repatriation, if ever.[3]  Often, a family member notices changes in a veteran’s behavior and mood; thus, informing the general public is also an important element of this bill.  DAV believes that there must be a systematic means of educating veterans and their families about these problems and how to find support.  We acknowledge that some veterans are receiving care for war-related disabilities outside of the VA and military systems, so we appreciate the requirement in the bill that VA would disseminate best practices on both mild-to-moderate TBI and PTSD to non-VA providers.

Mr. Chairman, DAV also supports, but with some concern, Section 4 of this bill to improve and expand tele-health and tele-mental health in VA and DoD.  DAV certainly agrees that it is a challenge for VA and DoD to place resources everywhere veterans want and need to receive care.  Tele-medicine has played a vital role in filling gaps in care in a number of communities—particularly in rural and frontier communities that lack access to a full continuum of care, and in some cases even basic health care services.  We support efforts to assess new web-based diagnostic tools for the prevalent cognitive conditions that are emerging among our returning veterans.  However, this section also contains a provision that would require VA and DoD to study ways that civilian providers might be used to enhance tele-health services offered to injured veterans and servicemembers.  DAV has long held the position that contracting for health care outside VA should be attempted judiciously so as not to undermine VA’s high-quality and specialized health and rehabilitative programs, and only when community-based care is coordinated and of high quality.  Thus, we ask the Subcommittee to carefully consider the results of the required study in this bill before advancing any legislative mandate for VA or DoD to significantly expand tele-medicine into the private sector.  Any such expansion should include coordination through the VA Office of Rural Health and would also need to be attended by new resources outside VA’s Medical Care appropriation to garner full DAV support.

While we support this bill, we would ask the Subcommittee to also consider the needs of veterans with less severe traumatic brain injuries.  Mild-to-moderate brain injuries are prevalent among the Iraq and Afghanistan deployments—possibly as many as 320,000 veterans may be affected, yet of those reporting a probable TBI, 57 percent had not been evaluated by a clinician for that injury according to the recent RAND report.  Key findings of the study also noted that about half of those who need treatment for PTSD, depression or probable TBI seek care for those conditions, and only slightly more than half who receive treatment get minimally adequate care.[4]  The DoD and VA must be at the forefront of efforts to improve the diagnosis, treatment, management and surveillance of all brain injuries to ensure high-quality and consistent care is obtained for all servicemembers and veterans who suffer from concussive blasts in Iraq and Afghanistan.  This bill would acknowledge the enormous debt the nation owes, not only to injured veterans, but to their family caregivers, whose lives may be forever altered.  However, we ask the Subcommittee to also consider expanding this measure to include the broader slate of initiatives DAV supports for family caregivers.  DAV supports legislation to provide comprehensive supportive services, including financial support, health and homemaker services, respite, education and training and other necessary relief to immediate family member caregivers of veterans severely injured, wounded or ill from military service. 

With these cautionary notes, DAV believes the ideas in the bill are worthy and if implemented carefully, could provide relief and support for sick and disabled veterans, particularly those with invisible wounds of war, including TBI and PTSD, and would provide welcome relief to family caregivers of the severely disabled.  With exceptions noted, most of the proposals are consistent with recommendations of the Fiscal Year 2009 Independent Budget. Thus, DAV supports this bill and urges the Subcommittee to work toward its enactment.

H.R. 6153—Veterans' Medical Personnel Recruitment and Retention Act of 2008

Along with our partners in the Independent Budget, DAV has called for improvements in VA policies and procedures used to recruit and retain highly qualified VA clinical staff.  Also for the past several years our organizations have expressed concerns that VA needs new authority to achieve and sustain this goal, to be competitive with private sector providers and become a preferred employer of physicians, nurses, dentists and other personnel needed to care for enrolled veterans.  With increasing numbers of veterans turning to VA for their health care and—particularly at a time of ongoing military engagements in Iraq and Afghanistan—VA needs the best and the brightest to meet the increasingly complex medical needs of an aging veteran population, veterans severely disabled during wartime service, and enrollees suffering from chronic disease.  This bill, aimed at providing meaningful financial and professional incentives to encourage VA clinicians to pursue full careers in the VA health care system appears to be timely and appropriate given all of the challenges VA faces to maintain its effectiveness as a provider of comprehensive health care services. 

Section 2 of the bill would provide authority to the Secretary of Veterans Affairs to establish additional “hybrid title 38-title 5” occupations (32 such occupations have been established by previous acts of Congress in section 7401, title 38, United States Code, including psychologist, physician assistant, licensed vocational or practical nurse, social worker, and numerous technical health fields).  Under this section, the Secretary would be required to report any such reclassification of VA occupations to the Office of Management and Budget (OMB) and to both House and Senate Committees on Veterans’ Affairs.  This section would also add “nurse assistant” as a specific new occupational class in this hybrid category.  Section 2 would clarify probationary periods and appointment policies for full-time and part-time registered nurses.  The section also would authorize VA on a case-by-case basis to reemploy federal annuitants with temporary appointments in selective health care occupational fields under sections 7401 and 7403, title 38, United State Code, without offsetting their retirement annuities for which they would remain eligible under title 5, United States Code.  This section would provide VA additional authority to raise compensation of personnel employed in the immediate Office of the Under Secretary for Health; provide VA pharmacist executives eligibility for special incentive pay; and provide clarification on compensation policy for VA physicians, including comparability pay adjustments and market pay provisions in chapter 74, title 38, United States Code.  Finally, it would provide additional policy clarifications on nurse compensation caps, special compensation for nurse executives; locality salary systems for VA nurses; part-time nurse compensation rules; weekend premium rules, as well as clarified direction on the use and disclosures of wage surveys in nurse locality compensation determinations.

Section 3 of the bill would add a new section 7459, title 38, United States Code, to specify VA policy on VA’s use of overtime by VA nurses, in effect reversing VA’s practice of requiring “mandatory overtime,” and extending specific protections to VA registered nurses, licensed practical or vocational nurses, nursing assistants (and other nursing positions designated by the Secretary for purposes of these protections), under the Civil Rights Act of 1964, from discrimination or any adverse action based on their refusal to work required overtime.  Under this section, the VA Secretary would be provided an emergency exigency power in certain circumstances to require a nurse to work overtime, but the section defines the term “emergency” within narrow grounds.  Section 3 also clarifies language on weekend duty and other alternative work schedules for VA nurses, and would provide a number of associated technical and conforming amendments.

Section 4 of the bill would reinstate the former Health Professionals Educational Assistance Scholarship Program, an authority that expired in 1998, and would extend its coverage to employees appointed under paragraphs (1) and (3) of section 7401, title 38, United States Code.  It would add “retention” as an additional purpose of VA’s Education Debt Reduction Program, and would increase the amounts of assistance to eligible VA employees.  The section also would establish a loan repayment program targeted to VA clinical research personnel who come from disadvantaged backgrounds.

Mr. Chairman, while DAV has no national resolution adopted by our membership that addresses these specific matters, The Independent Budget for Fiscal Year 2009, sponsored by DAV, Veterans of Foreign Wars of the United States (VFW), American Veterans (AMVETS) and Paralyzed Veterans of America (PVA), conveys a series of recommendations that are fully consistent with this bill.  Therefore, DAV would have no objection to its enactment.

Mr. Chairman and members of the Subcommittee, as you may know, our DAV advocacy campaign, Stand Up For Veterans, is well underway.  Its purpose is to generate greater public awareness and support for strengthening federal policies to provide greater health care assistance to veterans disabled in the ongoing wars in Iraq and Afghanistan, as well as to sick and disabled veterans from prior eras and conflicts.  In this effort, our campaign has focused on TBI, post-deployment mental health challenges (including PTSD), women veterans’ health, family caregiver support, and reforms in budgeting that will bring sufficient, timely and predictable funding to VA health care.  DAV has been pleased by Congressional responsiveness to many of the proposals emanating from our campaign that we have shared and discussed with members of this Subcommittee and others in Congress.  We appreciate that responsiveness and encourage the Congress to complete a significant package of veterans’ health legislation before adjournment. 

Mr. Chairman, this concludes my statement on these two bills, and I would be happy to answer questions on these issues from you or other Members of the Subcommittee.

SUPPLEMENTAL STATEMENT

H.R. 6629, the Veterans Health Equity Act of 2008

This measure would seek to ensure availability of at least one full-service hospital of the Department of Veterans Affairs (VA) Veterans Health Administration (VHA), or comparable services through contract, in each of the 48 contiguous States. 

Congresswoman Shea-Porter provided an opening statement for the Subcommittee at the September 9th hearing explaining the reasons for the introduction of this measure (H.R. 6629).  Ms. Shea-Porter noted that New Hampshire was the only State that did not have access to a VA full-service medical center and that the most ill veterans in her state routinely had to drive or be transported to Boston for more comprehensive health care services.  She stated that she was particularly concerned that the sickest and generally very elderly veterans with complex and chronic health problems were subjected to having to first report to the VA’s Manchester facility—which could be up to a three hour drive—and then having to continue on for another hour to get to the Boston VA Medical Center (VAMC) or other VA provider sites.  Finally, the Congresswoman noted that it may not be fiscally responsible, given the veterans’ population in her state, to have VA provide a full continuum of hospital services and that contracting for such services may be the best option.  Her main concern was that sick and disabled veterans in New Hampshire are having to make unnecessarily long trips to Boston area VAMCs to get the care they need for complex health conditions. 

Convenient access to comprehensive VA health care services remains a problem for many of our nation’s sick and disabled veterans.  While VA must contract or use fee basis to provide care to some veterans, it maintains high quality care and cost effectiveness by providing health services within the system.  According to VA, the Manchester VAMC of New Hampshire provides urgent care, mental health and primary care services, ambulatory surgery, a variety of specialized clinical services, hospital based home care and inpatient long-term care.  In addition, community-based outpatient clinics (CBOCs) are located in Somersworth, Tilton, Portsmouth and Conway. 

In light of the escalating costs of health care in the private sector, to its credit, VA has done a remarkable job of providing high quality care and holding down costs by effectively managing in-house health programs and services for veterans.  However, outside care coordination is poorly managed by VA.  When it must send veterans outside the system for care, those veterans lose the many safeguards built into the VA system through its patient safety program, evidence-based medicine, electronic health records, and bar code medication administration program (BCMA).  The proposal in H.R. 6629 to use broad-based contracting for necessary hospital services in the New Hampshire area concerns us because these unique internal VA features noted above culminate in the highest quality care available, public or private.  Loss of these safeguards, which are generally not available in private sector systems, equate to diminished oversight and coordination of care, and, ultimately, may result in lower quality of care for those who deserve it most.  However, we agree that VA must ensure that the distance veterans travel, as well as other hardships they face, be considered in VA’s policies in determining the appropriate locations and settings for providing VA health care services. 

In general, current law places limits on VA’s ability to contract for private health care services in instances in which VA facilities are incapable of providing necessary care to a veteran; when VA facilities are geographically inaccessible to a veteran for necessary care; when medical emergency prevents a veteran from receiving care in a VA facility; to complete an episode of VA care; and for certain specialty examinations to assist VA in adjudicating disability claims.  VA also has authority to contract to obtain the services of scarce medical specialists in VA facilities.  Beyond these limits, there is no general authority in the law to support broad-based contracting for the care of populations of veterans, whether rural or urban. 

DAV believes that VA contract care for eligible veterans should be used judiciously and only in these authorized circumstances so as not to endanger VA facilities’ ability to maintain a full range of specialized inpatient and outpatient services for all enrolled veterans.  VA must maintain a “critical mass” of capital, human, and technical resources to promote effective, high-quality care for veterans, especially those with complex health problems, such as blindness, amputations, spinal cord injury, or chronic mental health problems.  Putting additional budget pressures on this specialized system of services without making specific appropriations available for new VA health care programs only exacerbates the problems currently encountered. 

Nevertheless, after considerable deliberation, and in good faith to be responsive to those who have come forward with legislative proposals such as H.R. 6629, to offer alternatives to VA health care, we have asked VA to consider developing a series of tailored demonstration projects and pilot programs to provide VA-coordinated care (or VA-coordinated care through local, state, or other federal agencies) in a selected group of communities that are experiencing access challenges, and to provide to the Committees on Veterans’ Affairs reports of the results of those programs, including relative costs, quality, satisfaction, degree of access improvements, and other appropriate variables, compared to similar measurements of a like group of veterans in VA health care.  To the greatest extent practicable, VA should coordinate these demonstration pilots with interested health professions’ academic affiliates.  We suggest the principles of our recommendations from the “Contract Care Coordination” section of the FY 2009 Independent Budget be used to guide VA’s approaches in this effort.  Also, any such demonstration pilot projects should be funded outside the Veterans Equitable Resource Allocation (VERA) system, and their expenditures should be monitored in comparison with VA’s historic costs for care.  

Veterans service organization representatives from the local areas involved, and other experts need a seat at the table to help VA consider important program and policy decisions, such as those described here, that would have positive effects on veterans who live in these areas.  VA must work to improve access for veterans that are challenged by long commutes and other obstacles in getting reasonable access to a full continuum of health care services at VA facilities and explore practical solutions when developing policies in determining the appropriate location and setting for providing VA health care services. 

As a final note, we believe VA must fully support the right of all enrolled veterans to have reasonable access to health care and we insist that funding for alternative care approaches and outreach be specifically appropriated for this purpose, and not be the cause of reductions in highly specialized VA medical programs within the health care system. 

[1]The President’s Commission on Care for America’s Returning Wounded Warriors.  Final Report: Serve, Support, Simplify.  July 2007: 9. 

[2] Ibid.

[3] Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery.  Ed’s:  Tanielian, T;  Jaycox, L.  RAND Center for Military Health Policy Research: 2008

[4] Ibid.