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Witness Testimony of Joy J. Ilem, Disabled American Veterans, Assistant National Legislative Director

Mr. Chairman and other Members of the Subcommittee:

Thank you for inviting the Disabled American Veterans (DAV) to testify at this legislative hearing of the 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 eight bills primarily focused on health care services for veterans under the jurisdiction of the Veterans Health Administration (VHA), Department of Veterans Affairs (VA). This statement submitted for the record relates our positions on the proposals before you today. Our comments are expressed in numerical sequence of the bills.

H.R. 2790—To amend title 38, United States Code, to establish the position of the Director of Physician Assistant Services within the Office of the Under Secretary of Veterans Affairs for Health
The VA is the largest single federal employer of Physician Assistants (PA), with approximately 1,600 full-time equivalent employee (FTEE) PA positions.  In the VA health care system PAs are essential primary care providers for millions of veteran outpatient and inpatient encounters and work in ambulatory care clinics, emergency medicine, and 22 other VA medical and surgical subspecialties. 

The passage of the Veterans Benefits and Health Care Improvement Act of 2000 (P.L. 106-419) directed the VA Under Secretary for Health to appoint a PA Advisor to that office.  Since that time VHA has assigned this duty to a PA as a part time, field-based collateral position, in addition to their local clinical care duties. However, this important clinical representative has not been appointed to VHA’s major health care strategic planning committees or been fully integrated into VHA policy and planning management and health care planning activities.  Additionally, the PA Advisor has not participated in establishing priorities or policies for the new Office of Rural Health Care, or been utilized for emergency management planning, even though 36 percent of all VA PAs are veterans or currently serve in the military reserves or Guard forces. These experiences and perspectives of VA’s PA workforce could bring vital information to a number of new initiatives for improving veterans health care, including services for our newest generation of war veterans returning from Operations Iraqi and Enduring Freedom (OIF/OEF). 

The Independent Budget veterans service organizations, including DAV, believe that PA’s are a critical component of VA health care delivery and urge that the Subcommittee report this bill that would legislatively mandate the Advisor position as a full time Director of Physician Assistant Services within the office of the Under Secretary for Health in Washington, D.C. 

H.R. 3458—To direct the Secretary of Veterans Affairs to carry out a pilot program on the provision of traumatic brain injury care in rural areas
This bill would require the VA to establish a five-State pilot program of VA case-managed traumatic brain injury (TBI) care in rural States, and would provide various protections to ensure rural veterans with TBI received sufficient care from competent, trained providers, whether in VA facilities or those with which VA contracted to provide necessary specialized services.  VA would be required to assign a case manager to each TBI patient with a determination of an appropriate ratio of patients to each case manager.

The bill would require the pilot program be conducted in consultation with the VA Office of Rural Health established under Public Law 109-461. The bill would also require VA to distribute best practice information on the treatment of TBI to the VA facilities and private providers that would participate in this pilot program. 

DAV has no objection to this bill since it is consistent with recommendations of the Independent Budget.

H.R. 3819—Veterans Emergency Care Fairness Act of 2007
This bill would amend the two existing authorities, sections 1725 and 1728 of title 38, United States Code, that determine the circumstances in which the Secretary may pay for expenses incurred in connection with an eligible veteran’s authorized emergency treatment in a non-VA facility. 

Under current law VA is authorized to pay for non-VA emergency treatment for a veteran’s service-connected disability, a non-service connected disability aggravating a service connected condition, any condition of veteran who is rated permanently and totally disabled, or a veteran enrolled in VA vocational rehabilitation.  However, expenses incurred after the period of medical emergency ends but before the veteran can be transferred to a VA or another Federal facility may not be reimbursed. 

If enacted, this measure would require the Secretary of Veterans Affairs to reimburse a veteran for emergency treatment provided in a non-VA facility until such veteran is transferred to VA.  In addition to applying the prudent layperson definition of “emergency treatment” under both sections, the bill intends to reverse the current VA practice of denying payment for emergency care provided to a veteran by a private facility for any period beyond the moment at which VA determines the veteran can be safely transferred.  Specifically, it would amend the definition of reimbursable emergency treatment to include the time when VA or another Federal facility does not agree to accept a stabilized veteran who is ready for transfer from a non-VA facility, provided the non-VA provider has made reasonable attempts (with documentation) to effect such a transfer. 

The DAV supports the intent of this bill which is in accordance with the mandate from our membership and consistent with the recommendations of the Independent Budget to improve
reimbursement policies for non-VA emergency health care services for enrolled veterans. 

H.R. 4053—Mental Health Improvements Act of 2007
This measure would establish new program requirements and new emphases on existing programs for treatment of post-traumatic stress disorder (PTSD) and substance use disorder—with special regard for the treatment of veterans who suffer from co-morbid associations of these disorders. 

Title I—Sections 102-104 of the bill would require VA to offer a complete package of continuous services for substance use disorders, including counseling; intensive outpatient care; relapse prevention services; aftercare; opiate substitution and other pharmaceutical therapies and treatments; detoxification and stabilization services; and other services the Secretary deemed necessary, at all VA medical centers and community-based outpatient clinics (unless specifically exempted.)  The measure would require that treatment be provided concurrently for such disorders by a team of providers with appropriate expertise.  This section guides allocation funding to facilities for these new programs, as well as how facilities would apply for such funding.  Sections 105 and 106 would require establishment of not less than six new National
Centers of Excellence on Post-Traumatic Stress Disorder and Substance Use Disorder, that provide comprehensive inpatient treatment and recovery services for veterans newly diagnosed with both PTSD and a substance use disorder.  The bill would require the Secretary to establish a process of referral to step-down rehabilitation programs at other VA locations from a center of excellence, and to conduct a review and report on all of VA’s residential mental health care facilities, with guidance on required data elements in the report. 

Title II—Section 201 of the measure seeks to make mental health accessibility enhancements. This provision would require the establishment of a pilot program of peer outreach, peer support, readjustment counseling and other mental health services for OIF/OEF veterans who reside in rural areas and do not have adequate access through VA.  Services would be provided using community mental health centers (CMHC) (grantee organizations of the Substance Abuse and Mental Health Services Administration, Department of Health and Human Services), and facilities of the Indian Health Service, through cooperative agreements or contracts.  This pilot program would be carried out in a minimum of two Veterans Integrated Service Networks (VISNs) for a three year period.  Provisions would require the Secretary to carry out a training program for contracted mental health personnel and peer counselors charged to provide these services to OIF/OEF veterans.  All contractors would be required to comply with applicable protocols of the Department and provide, on an annual basis, specified clinical and demographic information including the number of veterans served. 

Title III—Section 301 of the bill would establish a new, targeted research program in comorbid
PTSD and substance use disorders, and would authorize $2 million annually to carry out this program, through VA’s National Center for PTSD.  Title IV—Sections 401 and 402 of the measure seek to clarify authority for VA to provide mental health services to families of veterans coping with readjustment issues.  The bill would establish a ten-site pilot program for providing specialized transition assistance in Vet Centers to veterans and their families, and would authorize $3 million to be used for this purpose.  Finally, provisions included in the measure would require a number of reports on these new authorities. 

Current research highlights that OIF/OEF combat veterans are at higher risk for PTSD and other mental health problems, including substance use disorder, as a result of their military experiences.  Mr. Chairman, like you, we are concerned that over the past decadeVA has drastically reduced its substance abuse treatment and related rehabilitation services, and has made little progress in restoring them—even in the face of increased demand from veterans returning from these current conflicts.  There are multiple indications that PTSD and readjustment issues, in conjunction with the misuse of substances will continue to be a significant problem for our newest generation of combat veterans; therefore, we need to adapt new programs and services to meet their unique needs.  We are especially pleased with the provisions pertaining to mental health services for family members.  The families of these veterans are suffering too, and are the core support for veterans struggling to rehabilitate and overcome readjustment issues related to their military service.  We hope at the same time that previous generations of veterans and their families could also benefit from these newly proposed programs and services. 

Although DAV has no approved resolution from our membership calling for a joint treatment program for PTSD and substance use disorders, we believe the overall goals of the bill are in accord with providing high quality, comprehensive health care services to sick and disabled veterans.  Additionally, the bill is consistent with recommendations in the forthcoming Independent Budget for fiscal year 2009.  Thus, with only one exception, stated below, we believe these are very timely provisions, and we fully support them. 

Our concern relates to Title II Section 201 of the bill.  We support the peer counseling concept it would authorize, but we continue to have concerns about contracting with non-VA providers to provide specialized PTSD treatment. 

Although DAV believes that VA contract care is an essential tool in providing timely access to quality medical care, we feel strongly that VA should use this authority judiciously.  Current law limits the use of VA purchased care to specific instances so as not to endanger the VA’s ability to maintain a full range of specialized services for enrolled veterans and to promote effective, high quality care for veterans, especially those disabled in military service and those with highly complex health problems such as blindness, amputations, spinal cord injury or chronic mental health conditions.  A major concern is that in most cases where VA authorizes care to veterans by contract providers VA has not established a systematic approach to monitor that care, or consider any alternatives to its high cost, has not analyzed patient care outcomes, or even established patient satisfaction measures.  For several years, the Independent Budget has recommended VA make major improvements in its contract and fee-basis programs, but VA has yet to make any improvement. 

DAV wants to ensure that all veterans receiving care from VA or through its fee basis or contract programs are treated in accordance with VA’s standards.  In its 2001 report, “Crossing the Quality Chasm:  A New Health Care System for the 21st Century,” the Institute of Medicine (IOM) put forward six aims that now underpin the standard of care for U.S. providers.  The IOM aims are that health care will be safe (avoiding errors and injury), effective (based on the best scientific knowledge), patient-centered (respectful of, and responsive to patient preferences, needs and values), timely (reduced waiting time and harmful delay), efficient (avoiding waste), and equitable (unvarying, based on race, ethnicity, gender, geography, or socioeconomic status).  VA embraces the IOM aims and therefore should manage rural veterans’ health care issues in a way that addresses all of the aims collectively. 

VA also lacks an integrated approach to address the unique health care challenges of rural veterans, including OEF/OIF veterans living in rural areas.  To remedy the gaps, VA should identify an effective and creative approach to make health care—including mental health care—available to our newest generation of wartime veterans irrespective of their locations of residence.  VA should develop performance measures and quality standards to assess the care that is provided through contract or fee-basis arrangements.  DAV believes that reform in rural, remote and frontier VA care can be achieved with the same overarching principles that have accompanied the transformation of the Veterans Health Administration (VHA) over the past decade.  Necessary actions to achieve this reform would include:

• Issuance of clear VHA policy that local facilities and Networks, through their mental health leadership, are responsible for creating a VHA-sponsored system that provides a stipulated array of services reasonably accessible to as many rural veterans, including OEF/OIF veterans as possible who need these services.
• Provision of direct services wherever VHA has a large enough concentration of veterans needing such services, and has an existing VHA site of care.  This would require VA to upgrade access to marital counseling and develop brief interventions for substance abuse—services that VHA does not make easily accessible in even some of its largest facilities.
• Contracting for care where there is not a large enough concentration of veterans needing readjustment counseling services, after local and Network leadership assess the availability and quality of alternative service providers (e.g. Vet Centers, State veterans services), including the availability and quality of services which could be purchased in the community, and assuring that a full array of services is made readily available.
• Oversight by Congress of this policy, with evidence that it is coordinated with the VHA Office of Mental Health Services and the newly established Office of Rural Health. 

Mr. Chairman, VA has received significant new funds targeted to providing better access to mental health services to all enrolled veterans.  VA has developed a national Mental Health Strategic Plan to deploy several new mental health programs, ramp-up existing specialized mental health services and hire new staff.  VA should rapidly deploy those plans then determine the degree of unmet need in rural areas.  In that connection, in Public Law 109-461, sections 212 and 213, Congress mandated VA to take specific steps to develop innovative and successful programs to improve care and services for veterans who reside in rural areas; assess its fee-basis health care programs; and, develop a plan by September 30, 2007 to improve access and quality of care, including measures for meeting the mental health needs of veterans residing in rural areas.  VA was also required by that Act to report to Congress not later than March 30, 2007 on the VA community based outpatient clinics (CBOC) and other access points identified by the Capital Asset Realignment for Enhanced Services (CARES) May 2004 decision document, and to coordinate that report through the Office of Rural Health.  Finally, VA must conduct an extensive outreach program to OIF/OEF veterans who reside in rural communities in order to enroll those veterans in VA health care during the existing two-year enrollment period after their release from active duty.  In carrying out the program the Secretary is required to work with State agencies, community health centers, and rural health clinics, to increase awareness of veterans and their families about the availability of health care services provided by VA. 

Again, we recognize and appreciate the emphasis placed on peer counseling, outreach and ensuring that non-VA providers are properly trained and compliant with VA standards, and coordination with VA’s Office of Rural Health in this provision.  As a community everyone is very concerned about rural veterans access to health care—including mental health and readjustment services, especially for our newest generation of OEF/OIF veterans.  We ask the Subcommittee to request the above noted reports from the Office of Rural Health to see what progress VA has made in addressing the needs of rural veterans.  This information will provide essential information on how to best develop a comprehensive solution and meet the health care and mental health needs of this population. 

H.R. 4107—Women Veterans Health Care Improvement Act
Mr. Chairman, women veterans are a small but dramatically growing segment of the veteran population.  The current number of women serving in active military service and its reserve and Guard components has never been larger and this phenomenon predicts that the percentage of future women veterans who will enroll in VA health care and use other VA benefits will continue to grow proportionately.  Also, women are serving today in military occupational specialties that take them into combat theaters and expose them to some of the harshest environments imaginable, including service in the military police, artillery, medic and corpsman, truck driver, fixed and rotary wing aircraft pilots and crew, and other hazardous duty assignments.  VA must prepare to receive a significant new population of women veterans in future years, who will present needs that VA has likely not seen before in this population. 

Title I, sections 101-103 of the bill would authorize and mandate longitudinal studies by VA in coordination with the Department of Defense (DoD) to evaluate the needs of women who are currently serving, and women veterans who have completed service, in OIF/OEF.  Also, VA would be required to study and report existing barriers that impede or prevent women from accessing health care and other services from VA.  Thirdly, this title would require VA to make an assessment of its existing health care programs for women veterans and report those findings to the Congress. 

Title II, sections 201 and 202 would make improvements in VA’s ability to assess and treat women who have experienced military sexual trauma (MST), and would mandate the use of evidence-based treatment practices and methods in caring for women veterans who suffer from post traumatic stress disorder (PTSD) related to MST and/or combat exposure.  The Secretary would be required to ensure appropriate training of primary care providers in screening and recognizing symptoms of sexual trauma and procedures for prompt referral and require qualified MST therapists for counseling.  Under this authority the Secretary would also be required to provide Congress an annual report on the number of primary care and mental health professionals who received the required training, the number of full-time employees providing treatment for MST in each VA facility, and the number of women veterans who had received counseling, care and services associated with MST.

Section 203 and 204 would require a study on the adequacy of care and counseling for women veterans in VA’s existing Readjustment Counseling Service, through its Vet Center programs, and would authorize a pilot program of child care reimbursement for certain women veterans to ensure they are able to avail themselves of VA’s existing mental health and other specialized health care programs.  Section 205 would establish a pilot program of counseling in retreat settings for recently discharged women veterans who could benefit from VA establishing off-site counseling to aid them in their repatriation with family and community after serving in war zones and other hazardous military duty deployments.

Mr. Chairman, this comprehensive legislative proposal is fully consistent with a series of recommendations that have been made in recent years by VA researchers, experts in women’s health, VA’s Advisory Committee on Women Veterans, the Independent Budget, and DAV.  Therefore, we support this measure and urge the Subcommittee to recommend its enactment. 

H.R. 4146—To amend title 38, United States Code, to clarify the availability of emergency medical care for veterans in non-Department of Veterans Affairs medical facilities
Although less comprehensive, this bill is intended to achieve the same purpose as H.R. 3819, discussed above, to provide equity of reimbursement to veterans who receive emergency health care services through private providers under VA eligibility.  DAV holds similar views on both bills, and therefore, supports the merit of this bill.  While supporting the intent, we believe this bill may not offer a complete remedy to the conditions which prompted its introduction.  Therefore, we recommend the Subcommittee defer action on this bill and instead favorably report H.R. 3819. 

H.R. 4204—Veterans Suicide Study Act
This bill would require VA, in coordination with DoD, State public health offices and veterans agencies, and veterans service organizations, to conduct a study and report to Congress the number of veteran suicides that have occurred since 1997.  Given DAV’s testimony on this topic at the full Committee’s hearing on December 12, 2007, we support the need for a study of suicide in the veteran population; however, DAV recommends the language of the bill be amended to include other relevant measures that could help reduce veterans’ suicides, specifically—information about risk factors—including age and gender, combat service and co-morbid medical and behavioral health conditions. 

VA should also invest in translational research on how to improve clinical techniques to prevent suicidal behaviors.  Another area VA should address is the impact on families (including parents) after a veteran or military servicemember commits suicide and what these families may need in terms of continued mental health counseling and care, or other VA or DoD services.  Currently neither VA nor DoD knows very much about impact on these families post-suicide, and to our knowledge no rigorous studies have been undertaken. 

Most importantly, suicidal behavior can be controlled and monitored with readily available access to quality psychiatric care for those who may be at risk because of a variety of mental health conditions.  Mental health professionals and suicidologists are well informed about techniques and treatments that can reduce suicidal behavior (most often a prelude to suicide attempts), including attentive primary health care and mental health screening, good psychological health care, early intervention in substance misuse or abuse, addressing of relationship and interpersonal problems, reduction in risk-taking behavior, crisis intervention, protective hospitalization, etc. 

While DAV supports the need for data on suicide in the veteran population and appreciates the intent of this measure, we hope the Subcommittee will consider making amendments to this bill to address some of these additional needs. 

H.R. 4231—Rural Veterans Health Care Access Act of 2007
This bill would establish a five-year mental health services pilot program in seven specific Veterans Integrated Service Networks (VISNs), in which veterans in need of mental health services, but who reside at least 30 miles from a VA medical facility that employs a full-time mental health professional, would be issued vouchers by VA to receive private mental health services at VA expense.  Vouchers would expire six months after issuance but could be renewed for an additional six months on request of a veteran, if deemed appropriate by the Secretary of Veterans Affairs.  VA would be required to maintain a list of participating private providers, including family counseling providers and a contractor’s participation would hinge on agreement to accept VA’s vouchers as payment in full.  While the program would expire five years after commencing, the Secretary would be required to recommend whether the program should be extended or expanded at the time.

We have a number of concerns about this bill.  The Independent Budget is clearly on record as opposed to vouchering, privatization and other initiatives that could endanger VA’s capabilities and lack contract care coordination aspects that we see as essential to the delivery of high quality care for veterans and the long-term maintenance of veterans’ health services. 

Sick and disabled veterans need a strong and vibrant VA system, one that offers specialized services for the kinds of serious injuries and chronic illnesses endemic to that population.    Congress has historically agreed with this premise and in consequence authorized VA to build and sustain its specialized programs in spinal cord injury, blindness, prosthetics and sensory aids, amputation care and rehabilitation, and, importantly in this instance, care for the seriously mentally ill and other disabled war veterans with mental health readjustment issues including PTSD.  We are sympathetic to the plight of veterans residing in remote and rural regions, but we believe the type of vouchering program envisioned by this bill lacks the essential component of VA-managed care coordination.  We believe VA’s Offices of Mental Health Services and Rural Health should identify unmet needs in mental health within the rural veteran population, then fashion programs or solutions to meet those needs.  As stated previously in this testimony, Congress has provided VA resources to hire thousands of new mental health providers, and VA has informed us that over 3,500 have in fact been hired to date.  These new employees, and a multiplicity of new VA mental health programs, and the mandate to the Office of Rural Health should create greater access to mental health services for rural veterans.  We ask the Subcommittee to provide oversight and to request from VA its strategic plan to outreach and provide services to OIF/OEF veterans and other veterans living in rural areas. 

We also call to your attention that under the bill, the decision on whether an eligible veteran would be in need of mental health counseling would be made by a “certified mental health professional” with no requirement that VA make or confirm that determination.  We believe access to care and its quality, quantity and safety, should be closely controlled and monitored by VA.  We are also concerned about the intent of the provision in section 3, subsection b(4) of the bill, that states an eligible veteran would need to “reside[] at least 30 miles from a medical facility of the Department of Veterans Affairs that employs a full-time mental health professional” (emphasis added).  We interpret this provision to mean that if a veteran lives within 30 miles of a VA medical facility, and that clinic or medical center only has a part-time mental health professional, or more than 30 miles from a VA facility with a full-time mental health professional, the veteran would be eligible to seek care through the proposed voucher system without regard to whether that VA facility were able to provide an appointment in a timely manner.  If a qualified VA provider is unable to provide the service a veteran needs, VA should make a determination that veteran’s need for care dictates the use of a contract provider.  In any case, we believe VA should identify an appropriate contract provider and make a prompt referral.  However, we believe, to ensure a veteran has access to VA’s full range of services, VA should always remain that veteran’s care manager. 

Mr. Chairman, DAV appreciates the opportunity to provide this written statement for the record and present our views on these bills.  I will be pleased to respond to any questions you or other
Subcommittee Members may have.