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Witness Testimony of Mr. Barry Hagge, Vietnam Veterans of America, National Secretary

Good morning, Chairman Michaud, Ranking Member Miller, and members of this subcommittee.  Thank you for giving Vietnam Veterans of America (VVA) the opportunity to offer our comments on several veterans’ health-related bills up for discussion here today.

All of these bills, with the possible exception of H.R. 1853, are extremely important.  With a few reservations, they are worthy of your consideration and our support.

The topic of accessibility to VA medical services for veterans who live in rural areas has been percolating of late.  We believe that H.R. 2005, the “Rural Veterans Health Care Improvement Act of 2007,” offers pragmatic solutions to address the problems of access to health care experienced by too many rural veterans.  The bill would increase travel reimbursement for veterans who travel to VHA facilities to the rates paid to federal employees.  The current reimbursement rate was established decades ago and does not adequately compensate for the costs of gasoline, “wear and tear” on the vehicle or increased insurance that might be necessary in order to travel to distant medical centers.  In the same vein, the grant program for rural veterans’ service organizations to develop transportation programs could be an innovative way to strengthen community resources that may already assist with veterans’ travel needs. 

The establishment of centers of excellence for rural health research, education, and clinical activities, another component of this bill, should fill a gap in VA health care and should lead to innovation in long-distance medical and telehealth care.  These centers have brought the synergies of clinical, educational and research experts to bear in one site.  Such centers have allowed VA to make significant contributions to the fields of geriatric medicine and mental illness.  It would require demonstrations of rural treatment models.  Demonstrations on treating rural veteran populations would be extremely useful in assessing effective ways to offer health care to individuals who are generally poorer, more likely to be chronically ill, and almost, by definition, more likely to have challenges in access to regular health care. 

And establishing partnerships – with the Indian Health Service and with the Department of Health and Human Services – also should add to greater cooperation and collaboration in meeting the needs of rural veterans. 

We would caution, however, that we would not like to see these demonstration projects exploring more opportunities to do widespread contracting out of veterans’ health care services.  Demonstration models should be assessed according to a number of outcomes such as quality of care, cost, and patient satisfaction and the results reported to Congress.

H.R. 1448, the “VA Hospital Quality Report Card Act of 2007,” is a quality control measure that would help with accountability and issues regarding follow-up care and timely visits.  It would require the VA to provide grades for its medical centers on measures such as effectiveness, safety, timeliness, efficiency, patient-“centeredness,” and equity.  Health-care quality researchers have long thrived trying to objectively define some of these measures. 

As members of this subcommittee are aware, the VA has a number of performance measures it regularly assesses in order to reward its medical center     and network directors, among others.  Some of these outcomes, such as immunizations for flu, foot care and eye care for diabetics, set the “benchmark” for care in the community.  In addition to these internal performance measures, VHA voluntarily submits to Joint Commission on Accreditation of Healthcare Organization, Commission on Accreditation of Rehabilitation Facilities, and managed care quality  review standards.   

VVA understands the importance of quality measurement; there is an expression with which we agree:  “What’s measured, matters.”  We also agree that VA officials should be held to the highest degree of accountability, and whatever measures are available to allow this to better occur we wholeheartedly endorse.  However, before enacting this clearly well-intended legislation, which could require significant retooling of quality measurement systems in the VA, the committee should hold a hearing to identify gaps and deficiencies in current performance and quality measurement systems.  It would also be useful to understand how report cards would be used and reported to improve VHA processes and performance rewards.   Would poor grades be dealt with by changes in management?  By withholding bonuses to senior executives?  With more funding?  How would good grades be rewarded?   Such questions should be addressed before requiring a significant new quality measurement program to be installed.

H.R. 1853, the “Jose Medina Veterans Affairs Police Training Act,” would require VA police to receive training in interacting with patients and visitors with severe mental illness.  Most VA police are in daily contact with veterans with mental illness, often dealing with stressful situations that are liable to exacerbate symptoms.  Sensitivity training in confronting any individuals in crisis could potentially assist officers in peacefully de-escalating or defusing volatile situations, thus avoiding the use of force.   

VVA does not have a position on H.R. 1925, which would establish a Gulf Coast Veterans Integrated Service Network.

H.R. 2172, the “Amputee Veteran Assistance Act,” would require that all VA orthotic-prosthetic laboratories, clinics, and prosthesists are certified by either the American Board for Certification in Orthotics and Prosthetics or the Board of Orthotics and Prosthetic Certification.  We endorse this bill because, very simply, as more and more catastrophically wounded veterans are returning home minus arms and legs, it is incumbent on us to ensure that they are receiving quality prosthetics and orthotics.

The VA already has the authority to contract with community mental health providers; however, under the strain of thousands of returning troops in need of mental health services, the VA is struggling to implement provisions of its mental health strategic plan, including providing “round-the-clock” access to care.  The funding authorized in H.R. 2173 for the provision of mental health care from community providers -- $50 million – would greatly assist the VA in filling the programmatic gaps it recognized in both its strategic plan and in its budget submission for FY 2008.

Community mental health providers should be selected based on quality of care indicators such as compliance with standards for either the facility or its clinical personnel (what credentials/training are required for the clinical personnel?)  Standards for community providers should be no less rigorous than those required for similar VA facilities.  And the VA must provide vigorous oversight of the care these community facilities provide veterans.

We should also note that mental health providers across the country are eager to assist returning veterans in dealing with their demons.  Passage of 2173 should help give them the opportunity.

VVA endorses H.R. 2192, which would establish an Office of the Ombudsman within the Department of Veterans Affairs.  Although most of the duties of an ombudsman are the responsibility of program managers and assistant secretaries, veterans and their families who are sometimes frustrated by bureaucratic runarounds or non-answers often encountered at VA medical centers or regional offices will have a champion – if H.R. 2192 is enacted and sufficiently funded.

VVA very much supports H.R. 2219, the “Veterans Suicide Prevention Hotline Act of 2007,” which would authorize and fund the establishment of a national toll-free suicide prevention hotline.  As many of those in this room are aware, up to one-third of the thousands of veterans of the fighting in Iraq and Afghanistan have screened positive for mental illness.  As more of these veterans return home from ongoing deployments in Southwest Asia, the acute symptoms of these illnesses, including post-traumatic stress disorder, depression and anxiety, are likely to manifest resulting in more preventable losses of life. 

In a report published last month (May 10, 2007), the VA’s Office of Inspector General recommended that VA provide such a hotline (VA OIG Report No. 06-03706-126).  The VA’s response indicated that the Veterans Health Administration’s Office of Mental Health Services was developing a hotline that would be rolled out November 30, 2007 and fully implemented by January 30, 2008.  Enacting this legislation will better ensure that the VA meets these goals.

The provision should assure that contracted services for the hotline call for a minimum percent of vets hired – including veterans who have recently returned from deployments abroad – over and above the 3 percent required for government contracts.

VVA supports, too, H.R. 2378, the “Services to Prevent Veterans Homelessness Act.”  If veterans at risk of becoming homeless can be identified and assisted before they are turned out of their apartment, if they can be given the modest assistance they need to maintain their independence, if they have access to the supportive services they need to maintain their dignity, it is entirely possible that hundreds will be saved from having to live with no permanent address, and no roof over their head.

That some 200,000 military veterans, including growing numbers of men and women who served in Iraq and on the “Global War of Terror” are homeless is a national scandal.  It should shock you into action.  And indeed, Congress has responded, but often with too little in the way of resources that can make a real difference.

VVA supports the provisions in H.R. 2623 that would prohibit the collection of co-payments for all hospice care furnished by the VA.  Hospice care is a service that allows individuals with terminal illness to reject extraordinary measures for prolonging life and, instead, accept “comfort care.”  The last year of life is known to be far more expensive than those that precede it.  It is unfortunate, then, to penalize veterans and their families by charging co-payments for hospice care when those same veterans might have elected to receive, free-of-charge, acute, in-patient care that was far more expensive and ultimately fruitless.  The VA should be encouraging its patients to prepare living wills and advanced directives that specify their choices for end-of-life care and educate veterans with terminal illness about hospice.  Relieving veterans of co-payments for hospice care seems one means to better ensure that they are able to choose hospice for their end-of-life care. 

Members of this subcommittee, VVA welcomes your comments and your questions.