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Witness Testimony of Richard F. Weidman, Vietnam Veterans of America, Executive Director for Policy and Government Affairs

Good morning, Mr. Chairman, Ranking Member Brown-Waite, and distinguished members of the Subcommittee on Health.  Vietnam Veterans of America (VVA) appreciates the opportunity to testify before you on the eight bills under consideration by the Subcommittee. I hope our comments and insights will prove of value to you.

HR 2790, Amends title 38, United States Code, to establish the position of Director of Physician Assistant Services within the office of the Under Secretary of Veterans Affairs for Health.  Physician assistants are an extremely valuable resource for veterans who use the VA health care system.  To ensure that they are properly educated and trained, and that they are appropriately utilized in the programs and initiatives of the Veterans Health Administration, should be facilitated with the establishment of such a position.  Veterans will be well served if the directorship is filled with a physician assistant with uncommon vision and competence.

For too long the Veterans Health Administration (VHA) has essentially been allowed to thwart the clear intent of the Congress, and reuse to properly utilize Physicians Assistants in the mix of vitally needed health care practitioners at VHA.  It is worth noting that the VA is the largest single federal employer of Physician Assistants (PAs) with the exception of the military, with approximately 1,574 full time PA FTEE positions. The VA has utilized PAs since 1969, when the profession first started. However, since the Veterans Benefits and Health Care Improvement Act of 2000 (P.L. 106-419) directed that the Under Secretary of Health appoint a PA Advisor to his office, VHA has continued to assign this duty as a part time field FTEE,  as collateral administrative duties to their clinical duties. VVA has requested for the past six years that this be a full time FTEE within VHA for six years. Most other veterans’ service organizations have made similar requests.

All such requests have been ignored, and generally met with what can frankly only be characterized as condescending disdain if indeed not outright derision. VVA points out that this is just one of many instances where the VA ignores the clear will of the Congress, and even “black letter law” directing them to do something, such as complete the National Vietnam Veterans Longitudinal Study (NVVLS).

This is the fourth Under Secretary of Health who has refused to establish this important FTEE as full time. This is the case despite numerous requests from members of Congress, the VSOs, and professional PA associations. The current Undersecretary has maintains this position as part time, field based position with a very limited travel budget, and no discernible access to policy making. During the time that the current part time PA Advisor was authorized the number of PAs have grown from 1,195 to approximately 1,600 today. Despite the growth a 34% increase, this important clinical representative, has not been appointed to any of the major health care VA strategic planning committees, has been ignored in the entire planning on Seamless Transition, Poly Trauma Centers, Traumatic Brain Injury planning and staffing, and has not been allowed to participate in Rural Health Care or been utilized for emergency disaster planning.

This is despite the facts that 36% of all VA employed PAs are veterans or currently serve in the National Guard or military reserves. These veterans who are also PAs could bring vital experiences with highly dangerous situations to new initiatives for improving veterans’ health care access. Particularly in disaster response planning and execution.  

PAs in the VA health care system were vital primary care providers for millions of veteran encounters in each of he past few years, and PAs work in ambulatory care clinics, emergency medicine, and in 22 other medical and surgical subspecialties.  VVA believes that PAs are a vital part of VA health care delivery. The PA Director must be included in VA Headquarters Patient Care Services, be full time FTEE in Washington D.C. This needs to be just the first step toward the VHA changing the corporate culture that does not value Pas on a par with Nurse Practitioners. We urge Congress to enact H.R. 2790 and fund this FTEE within the VHA budget for FY 2009 and to ensure the position is in Washington DC.

Frankly, what VVA believes the Congress and the VA should do in addition to prompt enactment and implementation of this bill regarding Physician Assistants is: 1) Take steps to dramatically change what is often a hostile work environment for PAs in the VHA; and, 2) Ensue that the scope of practice of PAs in the VA is at least as extensive as it is in the Armed Services; and, 3) Create a scholarship program for returning Navy Corpsmen (and women) and Army Medics to become Pas in the VA system, with active recruiting of the separating and demobilizing Medics, and with partnering agreements with affiliated institutions. The seasoned expertise of these returning Corpsmen (women) and Medics could be vital in the future to assist VA to deliver more effective and efficient services, especially in rural areas.

VVA strongly supports the bill as written.

HR 3458, Direct the Secretary of Veterans Affairs to carry out a pilot program on the provision of traumatic brain injury care in rural areas.
While the goal of this bill, which calls for a pilot program, is laudable, we believe that the best treatment for TBI is to be had in the VA’s Polytrauma Centers of Excellence.  Additional treatment “back home” ought to be done by clinicians who can communicate with their counterparts at these Polytrauma Centers.

Frankly, we need to change the current paradigm of service for TBI and other profoundly wounded veterans. While there were many problems with the VA care received by seriously wounded veterans during Vietnam, when you were in the VA hospital you were literally IN the VA hospital. That is no longer the case, as most of the health care at VA is delivered on an outpatient basis, even to those who cannot drive because of TBI or other wounds. The current model, which came out during a recent symposium with Prosthetics, depends on an intact nuclear family with a spouse (or parent) who can take the veteran to the many medical appointments he or she may have in a given week.

However, it is not always the case that there is an intact nuclear family and a stable home situation near to the needed medical services needed by that particular veteran to help shoulder this travel expense and burden with the new veteran. The “freeze” and rule at VA nursing homes and domiciliary facilities leave them unable to adequately respond to this need. Perhaps there is need for low cost veterans housing units that are near VA Medical Centers or even constructed on their grounds if there is adequate land may be part of the answer. At a hearing before the House Committee on Financial Services last month there appeared to be some interest in such cooperative models by the Honorable Maxine Waters, a former member of this distinguished panel, in crafting legislation that would create such housing. Perhaps now is the time to move quickly on the possibility of such a new paradigm that would assist new veterans with TBI or other problems, but would also solve similar transport problems of other deserving veterans who are dependent on the ongoing treatment modalities at a VHA facility.

We would caution about the use of outside providers of care for this increasingly common wound of war.  While it does make sense to contract with non-VA clinicians in areas where no VA medical center or outpatient clinic is convenient for a patient, that outside provider must be certified as able to care for those with this unique wound.  We do not believe that such clinicians are going to be easy to find. Further, as VA has shown with the mishandling of the inaptly named “Project HERO” the VHA must be watched like a hawk to keep them from distorting a good idea that makes sense.

Having noted all of the above, VVA still favors enactment of this bill to create such a pilot program, but urge that you amend the bill to require frequent substantive input by the VSOs, frequent reporting to this Committee, and other accountability mechanisms to keep this good idea on track toward something that will strengthen the matrix of services for these deserving veterans.

HR 3819, Veterans Emergency Care Fairness Act of 2007 amend title 38, United States Code, and requires the Secretary of Veterans Affairs to reimburse veterans receiving emergency treatment in non-Department of Veterans Affairs facilities for such treatment until such veterans are transferred to Department facilities, and for other purposes.  VVA strongly believes that veterans who receive emergency treatment in non-VA facilities until they can be transferred to a VA facility should be reimbursed for their out-of-pocket expenses. This should not be the onerous, often ugly, and lengthy process that it often is today, and which usually results in the veteran being stuck with the bill for this emergency care.  If they are not among the 1.8 million veterans who do not have health insurance, the VA should be able to – and does – bill their insurance carrier, which is right and proper.

VVA supports the bill as written.

HR 4053, the Mental Health Improvements Act of 2007, to improve the treatment and services provided by the Department of Veterans Affairs to veterans with post-traumatic stress disorder and substance use disorders, and for other purposes is one of the most important bills for your consideration.  As more and more troops, some disturbed, others shattered by their wartime experiences come home, and it is patently and painfully obvious that neither the Department of Defense nor the VA have enough medical professionals on staff to meet their needs. The British Medical Journal released a study led by DOD researchers this past Tuesday that says that at least 1 in 9 returnees have problems with PTSD. Earlier DOD studies fount a higher rate.

VVA has been pointing out the deficiencies in the number of mental health professionals at the Veterans Health Administration (VHA) for almost ten years, and while there has been quite a bit of progress in the level of staffing in the past two years, they are still not where they should be, particularly in as to the substance abuse staff. Further most VAMC need more full time mental health professionals as team members on the primary care teams (as distinct from the mental health clinic or the PTSD teams). We still hear often about veterans referred to the mental health clinic or the PTSD team at a VA hospital, only to be referred back to the primary health care team because the mental health diagnosis is not their primary diagnosis, and the mental health clinic does not have the resources to properly serve them.

DOD must be taken to task for having discharged some 28,000 service members for “personality disorders” which allegedly pre-existed their entrance into the U.S. military.  To send them off to war, and then to cut them loose because of some phantom “preexisting condition,” is damnable. It violates the covenant made with these men and women when they pledged life and limb in defense of the Constitution of the United States.  They need the help of health care professionals, not the disapprobation of their superiors and the termination of their enlistment and all the mental baggage that goes along with it. Further, the military has done really very little on their pledge to change the corporate culture that punishes those who admit to problems with PTSD symptoms to one that gets those soldiers (and their families) much needed help.

VVA went to see Assistant Secretary of Defense for Health about three weeks before the war started to urge they do a better pre-deployment health assessment, including a mental health work-up. We also urged that they move to be ready for significant PTSD problems, and that they set up non-punitive modalities whereby war fighters could get help without effectively ending the their military career. Dr. Winkenwerder essentially was dismissive of all we had to say, and stated that they saw no need to change any of their policies. Unfortunately, we were prescient of what was to come, and the deplorable situation that still exists today. As we are all aware, DOD’s mistakes and non-performance becomes the problem of the VA as soon as the service member is no longer on active duty.

This bill needs to dovetail with mental health initiatives taken by the VA to ensure that there is no duplication of effort.  More importantly, its provisions must have the funding needed to be effective.  Anything less is unacceptable.

VVA requests that you modify the provision that mandates the Special Committee on PTSD to require that this Committee meet in public, at least to the VSOs and other key stakeholders. Our preference would be to require that they have consumer representatives meet with the committee regularly as well. The current Undersecretary refuses to allow VSOs even to attend the Special Committee on PTSD meeting, and continues to conduct their business in secrecy. When asked why his response has been that they need to be able say things they might not say in public. VVA’s response has been and is that then they perhaps should not be saying something that cannot stand the light of day.

In this same vein, VVA urges the Committee to require that the Advisory Committee on (Serious) Mental Illness be public in the sense that the constituent representatives and the VSOs be allowed to attend the entire meeting, even if they are participants in the discussion for only a portion of the multi-day meeting. This Committee began to conduct much of their business in secrecy during the reign of Dr. Jonathan Perlin after he summarily fired the most senior and respected members of that body in what is still known in VHA as the “Friday Night Massacre.” We ask that the Congress require this committee return to the way of business that is in keeping with an open and democratic government.

With the modifications noted, VVA favors passage of this bill.

HR 4107, the Women Veterans Health Care Improvement Act amends title 38, United States Code, to expand and improve health care services available to women veterans, especially those serving in Operation Iraqi Freedom and Operation Enduring Freedom, from the Department of Veterans Affairs, and for other purposes should go a long way toward enhancing the health care services offered to – and needed by – women veterans.  Women now constitute 16-18 percent of our Armed Forces.  They are being killed and maimed in record numbers.  It is vital for the VA to gear up to meet their needs now and over the coming decades.

Beginning a long-term study of the health status of women who served in Afghanistan and Iraq should be an invaluable tool in enabling the VA to assess current needs and anticipate future health care needs.  And make no mistake:  the PTSD that affects women is not a carbon copy of that which takes over the psyche of their male counterparts.  There are other psychological ramifications that we are only now beginning to comprehend.

One would hope that VAMC directors, seeing a spike in the numbers of women veterans seeking health care, would gear up to meet their needs.  They should not have to be prodded by legislation.  Several years ago, Sanford Garfunkel, who then was the director of the VAMC in Manhattan, saw an influx of veterans with HIV and full-blown AIDS.  He secured the funding, necessary approvals, and established the first ward for veterans with these then-fatal conditions.  We know there are bright and committed medical center directors today who react to the needs of their patients; we would hope that passage of this bill would be of significant assistance to them.

At minimum every VA Medial Center facility should have a full time women veterans coordinator who sits on the policy making council for the hospital, and in the larger cities there should be a full free standing women’s clinic, such as is found at Washington, D.C. VAMC.

HR 4146, Amends title 38, United States Code, to clarify the availability of emergency medical care for veterans in non-Department of Veterans Affairs medical facilities. This just seems to make a lot of sense.  Amending Section 1725(f)(1)(C) of title 38 by adding “ . . . with the determination of whether the veteran can be so transferred to be based both on the condition of the veteran and on the availability of a bed in a Department facility that is no geographically inaccessible to the veteran” just makes sense.  One has only to wonder why such a provision needs to be added into law.

VVA supports the bill as written

HR 4204,The Veterans Suicide Study Act directs the Secretary of Veterans Affairs to conduct a study on suicides among veterans is based on two unfortunate realities, recognized by Congress:  That suicide among veterans is a serious problem; and that there is a lack of information on the number of veterans who commit suicide each year.

Anecdotally, suicide by active-duty troops and recently separated troops seems to be surging.  DOD has tended to minimize the numbers, tracking only those on active duty who take their lives.  No one, however, is tracking veterans who, months or years after they have reentered the civilian world, are overcome by war-induced demons.

We doubt very much if truly accurate numbers can ever be arrived at.  But the VA – and DOD – really do need to try harder and not sniff that the suicide of someone six months removed from Iraq can not be attributed to his/her service over there.

HR 4231, the Rural Veterans Health Care Access Act of 2007, directs the Secretary of Veterans Affairs to carry out a pilot program to provide mental health services to certain veterans of Operation Enduring Freedom and Operation Iraqi Freedom.  VVA believes that this bill needs some careful treading.  While it is of the utmost importance that mental health problems be dealt with forcefully and in a timely manner, handing out vouchers for mental health services to veterans who reside in rural America is not necessarily the way to go – unless there is close communication with case managers and primary care clinicians at VA clinics and medical centers.

Our concern is that outsourcing a lot of this care can only lead to future difficulties if not carefully and closely monitored.  And, to be quite frank, we can envision scenarios in which VA managers, rather than hiring the psychologists and psychiatrists they need, rather than ensuring that the Vet Centers are adequately staffed, outsource mental health to the detriment of veterans and their families.  This must be guarded against.

VA VET Center staffing and Suicide Prevention - VVA is very concerned that the VA Vet Centers, operated by the Readjustment Advisory Service, have not received additional staffing that is vitally needed. The War Supplemental Appropriations bill enacted early last March contained $17 Million to hire an additional 250 full time mental health practitioners at the VA Vet Centers. These funds were not released to the RCS until mid-August, when it was too late to even get those staff on board before the end of the Fiscal Year, much less fully spend the money on additional personnel. So they bought a new computer system.

If the Congress wants to do something about the first line of defense against suicide, then forcing the VHA to increase the staffing of the VA Vet Centers is the single most effective action you can take, as well as the most cost effective and cost efficient step you can take. The Vet Centers are essentially the forward Aid stations to go out and get the wounded and get them into the medical services and treatment matrix. The Vet Centers see veterans of every generation who initially would not go anywhere near the VA Medical Center with a mental health or PTSD problem, for a variety of societal reason.

VVA thanks the subcommittee for permitting us to present our views on these vital issues here today. I will be happy to answer any questions.