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The U.S Department of Veterans Affairs Fiscal Year 2008 Health Budget.












FEBRUARY 14, 2007

Printed for the use of the Committee on Veterans' Affairs

SERIAL No. 110-2





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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
JEFF MILLER, Florida, Ranking
HENRY E. BROWN, JR., South Carolina

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



February 14, 2007

The U.S. Department of Veterans Affairs Fiscal Year 2008 Health Budget


Chairman Michael H. Michaud,
    Prepared  Statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member
    Prepared Statement of Congressman Miller
Hon. Henry E. Brown, Jr., prepared statement of
Hon. John T. Salazar, prepared statement of


U.S. Department of Veterans Affairs, Michael J. Kussman, MD, MS, MACP, Acting Under Secretary for Health, Veterans Health Administration
    Prepared Statement of Dr. Kussman

American Psychiatric Association, Joseph T. English, M.D., Member, Board of Trustees, Chairman of Psychiatry, St. Vincent's Catholic Medical Centers of New York, Professor and Chairman of Psychiatry, New York Medical College, and Commissioner, Joint Commission on Accreditation of Healthcare Organizations
    Prepared Statement of Dr. English

Friends of VA Medical Care and Health Research (FOVA), Gary Ewart, Director, Government Relations, American Thoracic Society
    Prepared Statement of Mr. Ewart

 Iraq and Afghanistan Veterans of America, Patrick Campbell, Legislative Director
   Prepared Statement of Mr. Campbell


American Federation of Government Employees, statement
American Legion, Shannon Middelton, statement
American Veterans (AMVETS), David G. Greineder, statement
Brown, Hon. Corrine, a Representative in Congress from the State of Florida, statement
Paralyzed Veterans of America, statement
Stearns, Hon. Cliff, a Representative in Congress from the State of Florida, statement
Vietnam Veterans of America, John Rowan, Patricia Bessigano, and Thomas J. Berger, joint statement


Post-Hearing Questions and Responses for the Record:

Written questions for the record submitted to the VA follow.

Hon. Michael H. Michaud, Chairman, Subcommittee on Health to Dr. Michael Kussman, Acting Undersecretary of Health, Veterans Health Administration, letter dated March 7, 2007
Hon. Jeff Miller, Ranking Republican Member, Subcommittee on Health to Dr. Michael Kussman, Acting Undersecretary of Health, Veterans Health Administration, letter dated February 28, 2007
Hon. Henry E. Brown, Jr., attachment to Hon. Jeff Miller letter to Dr. Michael Kussman, dated February 28, 2007


Thursday, February 14, 2007
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 2:00 p.m., in Room 334, Cannon House Office Building, Hon. Michael H. Michaud [Chairman of the Subcommittee] presiding.

Present:  Representatives Michaud, Snyder, Salazar, Miller, and Brown of South Carolina.


Mr. MICHAUD.  We will begin this hearing.  First of all this afternoon we would like to thank everyone for braving the little dusting of snow that we received last night and this morning to come here today.  This is a very important issue.

This will be the first of many hearings in the 110th Congress for the Veterans' Affairs Health Subcommittee.  I would like to welcome my Ranking Member, Congressman Jeff Miller of Florida, and say that I look forward to working with you in a bipartisan manner as we deal with Veterans Affairs issues over the next couple of years.  We have a lot on our plate, and I know that by working together, we will be able to accomplish a great deal this year.

I would also like to welcome our first panel of witnesses; Dr. Michael Kussman, who is the acting Undersecretary of Health.  He is accompanied by Joel Kupersmith, who is the Chief Research and Development Officer, as well as Dr. Katz, who is the Deputy Chief PCS Officer for Mental Health, and Mr. Paul Kearns, who is the Chief Financial Officer.

The Veterans Health Administration is responsible for the health and well-being of our nation's veterans.  There are no other agencies in government that will affect our veterans more than this agency.  We have an aging veterans population.  We also have a new generation entering the system, with unique needs like mental health, traumatic brain injury, and others from service in Iraq and Afghanistan.

We are here today to learn if this budget can meet all these needs.  The request is an increase of six percent over the last year's funding.  We have heard from the Independent Budget group and from other veterans service organizations that more money is needed for veterans.  This request includes increases in fees, and copayments as well.  It also includes a cut in medical and prosthetic research that we will have to address.

That being said, I believe that this request is a good starting point for us, and I think we can move forward to create a budget that we all can consider a success.  And let me be clear.  I do not measure success by the dollars spent or dollars saved; I measure the success in the number of veterans receiving the highest possible quality care in a timely manner.  We look forward to hearing your testimony today, and having a frank discussion about meeting the needs of our veterans. 

[The statement of Chairman Michaud appears in the appendix.]

Mr. MICHAUD.  And with that, I would like to turn to Ranking Member Miller, if you have an opening statement.


Mr. MILLER.  Thank you very much, Mr. Chairman.  I have an opening statement that I would like to submit for the record.  It is lengthy, but I do want to bring a couple things to the Committee's attention.

First, congratulations on becoming the Chairman of the Subcommittee.  I know that we will work together in a true form of bipartisanship.  The only thing that would sound better would be if it was Chairman Miller.


We have already begun the dialogue, and I look forward to many good working times with you.

Today we are on the floor debating a very important resolution, for those that support it and those that oppose it, but we also meet today to discuss some very important issues here that we need to talk about.  I am pleased to say that the Administration proposes this year a record $36.6 billion for VA healthcare for fiscal year 2008.  This is the largest amount that any administration has ever requested, and it is a six percent increase over the request for fiscal year 2007. 

Last year, this Committee uncovered weaknesses in the process that VA was using to develop its healthcare budget.  This year's budget submission doesn't assume savings from management efficiencies that the U.S. Government Accountability Office (GAO)  recently reported, did not materialize last year. 

The Administration requests $3 billion for mental health service, including $360 million to continue implementation of mental health initiatives that began in 2005 to address deficiencies and gaps in services.  While this amount is substantial, last September, GAO reported that the VA had not used all its mental health funds that were allocated in 2005.  I believe, as I am sure the Chairman does, that we must have a better handle on how much, and in what way the VA is spending its resources to meet the emerging demand for mental health services, especially post-traumatic stress disorder (PTSD).

VA must plan for and fund those programs that have been identified as particularly relevant to the needs and requirements of our soldiers.

Three years ago, the  Capital Asset Realignment for Enhanced Services (CARES) commission identified, and if I may, a point of personal privilege in my statement, the Florida Panhandle as underserved for inpatient care.  In fact, it is the only market in VISN 16 without a medical center.  The absence of a VA inpatient facility continues to be one of the biggest concerns to the over 100,000 veterans who live in my congressional district.  Currently, many of these veterans have to travel to Mississippi for inpatient care.  Bringing a full-service facility to the first district is something that we have been looking at for a long time, and I look forward to working with the Department in support of VA's overall capital construction program to address the issue of providing timely access to inpatient healthcare for veterans living in and around Okaloosa County, in the center of my district.

In conclusion, I too want to say thank you to the witnesses for appearing today on such a blustery day outside, and I look forward to your testimony.  I ask that my statement be included in the record, and yield back the balance of my time.

[The statement of Congressman Miller appears in the appendix.]

Mr. MICHAUD.  Thank you.  Without objection.  Dr. Snyder, do you have an opening statement? 

Mr. SNYDER.  No, I do not.  Just a comment about whether it is truly blustery, or just plain cold.


Mr. MICHAUD.  Thank you very much.  So we will begin, Dr. Kussman.


Dr. KUSSMAN.  Well, thank you, Mr. Chairman, and Ranking Member, and Dr. Snyder, good afternoon.  I have submitted a written statement for the record.  Sir, you did a very good job of introducing the panel so I won't go through that again.

Mr. Chairman, let me begin by telling you how proud I am to be leading the Veterans Health Administration today.  I firmly believe that if you are a veteran, you have a much better chance to receive the care you need in an expeditious and thorough manner from the VHA than any other healthcare system in the nation, or perhaps the world.

I am not the only one who says that.  In 2006, American Customer Satisfaction Index found that customer satisfaction with our system was higher than the private sector for the seventh consecutive year.  Last year, Harvard University recognized the VHA's computerized patient records system by awarding us with their prestigious Innovations in American Government award.  We recently received an award from the American Council for Technology, along with the Department of Defense, for our innovative ability to securely exchange real-time medical records between our two departments.  We are the best around, and we are working to be better.

My written testimony discusses the details of the President's budget for veterans healthcare.  Our total budget is more than 83 percent higher than the funding available to VHA for healthcare at the beginning of the Bush administration.  There are some who have said that our department is or will soon be overwhelmed by the number of returning veterans we are seeing from Operation Iraqi Freedom, and Operation Enduring Freedom.  That is not correct.  In 2008, we expect to treat about 263,000 veterans of the Global War on Terror. 

This is only a small fraction of the 5.8 million patients we expect to treat overall in 2008.  With the resources we have requested for medical care in 2008, our department will be able to continue to ensure that servicemembers transitioning from active duty status to civilian life is as smooth and seamless as possible, and to continue our exceptional performance in providing access for all veterans to VA healthcare.  We expect to meet our goals at 96 percent of our primary care appointments, and 95 percent of our specialty care appointments will be scheduled in 30 days of the date or patient want them to be scheduled.

Another area in which VA's readiness has been questioned is in the area of mental health.  The President's budget request includes nearly $3 billion to improve access to VA mental health services throughout the nation.  These funds will help ensure that we provide standardized and equitable access throughout the nation to a full continuum of care for veterans with mental health disorders.  Much has been made recently of the incidence of PTSD among OIF-OEF veterans.  Thus far, approximately 39,000 veterans have received provisional diagnoses of PTSD in our hospitals and vet centers.

But most veterans with mental health issues do not have PTSD.  They have easily treatable problems related to their readjustment to civilian society after serving in combat.  Mislabeling readjustment issues as PTSD may keep some veterans from seeking care, and paints a misleading picture of the likely effects of combat service.  VA has the capacity to treat those veterans with PTSD, and those with readjustment disorders, and we will augment that capacity if needed.

Suicide among veterans is another issue that has recently been in the news.  VA recognizes that any veteran suicide is a tragedy, and we are committed to address the needs of veterans who may be at risk of taking their own lives.  VA mental health professionals work with community providers and agencies to ensure that veterans in need are referred for care.

Our vet centers, open to combat veterans from all wars, provide outreach to returning veterans, and encourage them to seek help if they are having difficulties in readjusting to society.  By April, every VA hospitals will be funded for a designated suicide prevention coordinator.  They will work to identify veterans who have previously attempted suicide, and enhance their care.  We are increasing the availability of 24-hour mental healthcare, and we will soon hold a Suicide Prevention Awareness Day, to remind all VA employees of their responsibility to help prevent veteran suicide, and to increase their awareness of possible warning signs that might indicate a veteran is considering taking his or her own life.

Our budget includes funding for the expansion of our services to severely injured servicemembers from Iraq and Afghanistan. Our four polytrauma centers have already been expanded to encompass additional specialties to treat patients with multiple complex injuries.  Their efforts in turn are augmented by 21 polytrauma network sites and clinic support teams around the country, bringing state-of-the-art treatment closer to the injured veterans' homes.

The budget also includes funding to continue construction of a new medical center in Orlando and completes funding for our Las Vegas hospital, provides funds to build new facilities in Pittsburgh, in Denver, and a spinal cord injury Center in Syracuse, and an outpatient clinic in Lee County, Florida.

Altogether, our fiscal year 2000 construction request will bring the nation's investment in improving our infrastructure, since the CARES report was issued, to $3.7 billion. 

Mr. Chairman, the President's requested funding level will allow VHA to continue to improve the world-class care we provide to veterans, especially those who need us the most; the OIF-OEF veterans, those with service-connected disabilities, those with lower incomes, and those with special care needs.  I am proud to present it to you today.

This concludes my presentation.  Thank you.

[The statement of Dr. Kussman appears in the appendix.]

Mr. MICHAUD.  Thank you very much, Dr. Kussman.

In your budget, again this year, you have requested increased pharmaceutical copayments from $8 to $15 for certain veterans.  In comparison to previous years, when you have advocated an increase in pharmaceutical copayments, the revenues received would be treated as mandatory dollars instead of discretionary dollars.  How many veterans do you estimate would leave the VA in fiscal year 2008 as a result of the enactment of the copayments?  Second, is what discussion led you to decide in this budget cycle submission to deem these fees mandatory revenues instead of discretionary revenues?  And last—and you can submit to the Subcommittee—if you could detail for the Subcommittee, categories built upon earnings; the enrollment fees and co-pays.  Could you break out how many veterans are affected in those different categories? 

Dr. KUSSMAN.  Yes, Mr. Chairman, thank you for the question.  There are three policy issues in this budget.  One is co-pays, as you had mentioned, and those are tiered.  That is a new thing, that has never been done before.  And then the second is the pharmacy co-pay, and there is a third one that we can discuss as well.

It is important to remember that these policies only affect people who don't have any service-connected disabilities.  It wouldn't affect anybody who is one through six.  It just focuses on the sevens and eights.  And obviously, the difference between seven and eight is how much money you make.  So, it starts at $50,000, and goes up to $100,000, I believe.  And so, the issue was one of an equity issue that we have discussed in the past.  As you know, people like myself and others who spent 25 or 30 years in service to our country, when we retire, if we tend to use TRICARE, have to pay enrollment fees that are in the same ballpark of figures that we are talking about.  And so the feeling was that somebody who didn't have any service connection and was using our system, it would not be unreasonable to expect some nominal co-pay of $250 a year, $21 a month, it think it is, if you make $50,000 and tier it up to $100,000.

So that was the thought processes behind it.  But in the past, as you know, those initiatives are part and parcel of our budget.  And we know that this is not a popular thing, and we know that when we have come to Congress, each time it has been not approved with that, and then that we were confronted with a deficit in the budget that had to be made up.  In this case, our budget as requested is separate from this, and we believe that this was a fair way to look at it so veterans in general, and the budget, didn't get deficit.

Mr. MICHAUD.  And would you provide for the Subcommittee how many veterans are affected in each of the tiers?  Because you came up with a dollar figure, so if you can provide that to the Subcommittee?  How many veterans will be affected by this proposal, do you think, be dropped in all this? 

Dr. KUSSMAN.  Totally, if you look at uniques, not enrollees, but the people who are actually using our system—as you know, a lot of people enroll with us and then don't actually use the system, effectively at all.  They keep it as a hip pocket, because obviously they are using some other healthcare system for their needs.

Of the 5.5 million or 5.8 million that we expect to see in 2008, I believe that the total number would be 111,000, of people who might choose to not use the system.

Now, we have done some review of the types of patients who are sevens and eights, and particularly eights, who might not use the system.  And 89 percent of them have another type of insurance.  So those are the numbers that we looked at.

Mr. MICHAUD.  The enrollment fees do not start until 2009? 

Dr. KUSSMAN.  Yes.  We don't think we could have the infrastructure ready and everything to start collecting that until October of 2009.

Mr. MICHAUD.  Okay, so this number is predicated on 2009? 

Dr. KUSSMAN.  Yes.

Mr. MICHAUD.  The long-term care issue; the average daily census level in nursing home care is 11,000.  As you know, Congress passed legislation back in the 106th Congress, that would mandate it be maintained at 13,391.  Does the VA plan on submitting another budget?  How are you going to meet that obligation of the 13,391?  Do you plan on not meeting it? 

Dr. KUSSMAN.  Sir, as you know, we have gone back and said that that was related to the Millennium Bill, that was established in 1998, I believe, that set where we were in 1998.  And we believe that the types of care for long-term care have dramatically changed, emphasizing noninstitutional care.  And for us to try to maintain 13,391 would not be effective use of our resources.  More and more of our veterans want to be treated near where they live. 

And as you know, we have basically four ways of delivering care.  One is in our bricks and mortar.  One is in community-based nursing homes.  And the third is in State homes.  And the fourth one, which is really the most rapidly growing one, at really 124 percent increase from 1998 to 2008, is noninstitutional care, to assist people in staying home and things like that, where they really want to be.

And so we believe that we are increasing the total census of patients that are being provided for us.  It is up 30 percent from 1998.  But we also believe that we are putting them in the right place.

Mr. MICHAUD.  And if you had all the slots available?  If you had the over 13,000 slots, would you be able to fill them today? 

Mr. MICHAUD.  With the types of patients that we are emphasizing, people who have priority one, special needs, indigent, and others; we believe that we are providing that service for the people in the full spectrum of the beds that are in those four categories.

Mr. MICHAUD.  So if the beds were available, would you be able to fill them? 

Dr. KUSSMAN.  If we put those beds open in our own facilities, they would be adequately utilized, and that is what you are asking me, to go from 11,000 to 13,391?  We don't believe that those beds would be appropriately utilized for the needs of our veterans.

Mr. MICHAUD.  Congressman Miller? 

Mr. MILLER.  Back to the co-pay, do you anticipate any increase in co-pays for fiscal year 2008 based on the medical consumer price index?  I know we had one last year, do we anticipate one this year? 

Dr. KUSSMAN.  I think it would be overcome.  I mean, we are going from eight to 15.

Mr. MILLER.  You can strike that, that is not going to happen.  I am talking about your annual review—it was seven dollars and then went to eight.  Do you anticipate it going up?

Dr. KUSSMAN.  I understand the question.  No, because it is not part of the budget.  We are not counting on any change from any of this, eight to 15, or anything else, because the budget stands for itself.  We believe we will be able to provide the services with the budget as submitted.

Mr. MILLER.  The 2006 GAO report on VA's budget formulation revealed that VA had underestimated the cost of serving veterans returning from Iraq and Afghanistan in fiscal year 2006 in part because VA was not able to obtain sufficient data needed to identify these veterans from DoD.  I have three questions, if I can give you all three of those, or I can give them to you one at a time.

To what extent has VA improved the projections on demand for care for returning OIF and OEF veterans?

The second question is, what challenges does VA continue to face in getting the data from DoD to identify these veterans?  Is there a continued problem there?

Lastly, does your budgeting process include the projection of the future long-term cost for treating OIF and OEF veterans? Example, mental health and rehabilitation? 

Dr. KUSSMAN.  We believe that, as you mentioned, our original projection was lower than it turned out to be.  In 2006, there were actually 155,000 OIF-OEF veterans who came in.  We have learned from that.  Our actuarial model is being perfected.  The OIF-OEF people are new to the actuarial model, and so we have learned.  We project that in this year, in fiscal year 2007, the total number of OIF patients will be 209,000, 54,000 more than we saw in 2006.

I can tell you that we monitor this on a monthly basis now, and that it is tracking quite closely, so we won't be surprised at the end of the year with a sudden influx or number that we weren't aware of.  We have projected another 54,000 or 2008.  A lot of this, as you know, will be driven by what happens in the war itself, and how many people are deployed, or not deployed.

We put money against these types of veterans.  In 2006, there were $405 million directed directly to the 155,000.  In 2008, it is $752 million against the 263.  That is an increase of dollars at 86 percent, with what we project a 70 percent increase in individuals.  So we are watching that very carefully, to be sure that we have an accurate assessment of the total number of new OIF-OEF that are coming in.

As far as the second question, about getting info, we work very closely, and these numbers are coming readily to us, and we have a very good working relationship with DoD.

As far as long-term care, as I mentioned, as far as mental health and things, there is still a small number of patients in the 5.8 million that we expect to see that most of the patients with mental health issues are what we hope will be short-term, not long-term issues, related to severe mental illness.  Most of the people have readjustment reactions related to normal reactions to abnormal situations.  But we will continue to monitor that, and put money against it as we need, for both that and any other kind of rehabilitation services.

Mr. MILLER.  I will hold my questions, and let some of the other members ask.

Mr. MICHAUD.  Dr. Snyder? 

Mr. SNYDER.  Thank you, Mr. Chairman.

I have two lines of questions I wanted to ask about, and I'm sure, Dr. KUSSMAN., you can predict the first one, that is this research issue that I get discouraged about.  With this administration, it seems like this issue never goes away.  Secretary Gates was unaware, and said he was going to personally look into it, because it concerned him after we called it to his attention.  But in the defense budget, the President's budget has a basic research cut of nine percent, and an applied research cut of 18 percent.  And that is, when you look at what the inflation rate may be for that kind of technological inflation rate, which I expect is a point or two higher than normal inflation rate would be in real dollars, even more than that.  It just makes no sense as we are looking ahead to the military of the future, what our edge is, that we would be doing that.

And we had this discussion when you were sitting at the table the other day with Secretary Nicholson.  I just want to reiterate, I do not understand why at this time in our Nation's history, when you are dealing with an influx of injured veterans and veterans with a variety of different diagnoses in great numbers, we are not looking to perhaps dramatically increasing the amount of dollars coming out of your budget for medical research.

I understand everything that you all say about, "we are going to leverage those dollars." Well, I will accept the argument, okay?  You put in more of your dollars, you can leverage even more dollars.  The American people expect us to do this kind of research, to help our veterans, particularly our new veterans, but also our older veterans, with the kinds of illnesses they face, and the kinds of injuries they face, and rehabilitation they face.

Are you all intending to revisit this number, which has essentially been flatlined for the past four years, in terms of the contribution coming from veterans' healthcare budget to medical research?

Dr. KUSSMAN.  As you know, sir, we believe that there is a 3.7 percent increase in the research budget this year, that includes both money from appropriated dollars, other government agencies, and the industry.  With that, we have readjustment how we spent that money, and projected that we are moving from a 48 percent to 59 percent of that total amount of money is geared toward issues related to OIF-OEF, such as TBI, PTSD, other mental health things, amputations, and things of that sort.

Mr. SNYDER.  But my question was, why would you not want to increase your Federal dollar share, your VA Federal dollar share of research, so that you could leverage even more dollars at this point in our nation's history?

I mean, the answer is you don't have a good answer.  I mean, if I was sitting there I wouldn't have a good answer either.  My guess is that you all probably advocated to do that and you got shot down, so maybe we will just leave it at that.  But I think it is really hard to understand.  But it is also consistent with what either the Administration or OMB has done to research budgets for the last several years.  And I don't understand.  I think it is very shortsighted.  So maybe I will just leave it at that.

I wanted to ask about the interface between DoD and VA.  And I want to ask you the same question I asked Dr. Winkenwerder yesterday, but I won't tell you his answers until I hear your answers.  And it is not like it is a trick question—

Dr. KUSSMAN.  Thank you.

Mr. SNYDER.  Yeah, that is right.  My question was, you know, he was bragging on you all, and feeling like the two of you, between DoD and between military healthcare and the VA, that there has been progress in terms of seamlessness and some other joint—for want of a better word, "joint-ness."

I asked him yesterday at our hearing, before the Military Personnel Subcommittee, what were the things on his list of things that he would like to see better between DoD and VA, or things that he is working on, or would like to work on?  Tick off four or five things on your list of things that you think that you all ought to be working on, or that you want to see progress made on.

Dr. KUSSMAN.  Thank you for the question.  It is a very interesting one, and I hope I don't give an answer that is a diametrically different one than—

Mr. SNYDER.  Well, if you do it just means instead of four items to work on, we will have eight items to work on, which is okay, too.

Dr. KUSSMAN.  You know, I am retired military, and both on a personal and professional level, we have unprecedented cooperation with DoD and VA.  We have put VA benefits counselors and social workers in 10 major transition points in the military health system.  We have military active-duty people in our four major level one trauma centers.  So we are working very closely.

As far as the things that we need to improve on, as you know, we just announced recently the initiative to work together to get a single inpatient electronic health record, and I am very excited about that.  And we will see hopefully some dramatic results of that in the not-too-distant future.

One of the other things that we have been challenged with, and really in an unprecedented way, is working together to case-manage people who have multiple venues of care.  The people who are leaving DoD, I am talking about the segment that have been significantly injured getting medically retired.  They have options to use their TRICARE benefit, they can use the military health system, or they can come to the VA.  And sometimes they use all three of them.  And that has been a challenge, to be able to keep track of what is going on, as well as, you know, in an unprecedented way, the active-duty people, many of them are staying on active duty. 

But also, when they come to us, frequently they are still on active duty.  We are not waiting for them to go through their PEB process.  And so they frequently go back and forth; to VA facility, then they go back to a military facility, and come to us.  And working together to make sure that nothing falls through the cracks, from a clinical perspective, on what we are doing.

So those are the things that I would really want to emphasize in our partnering.

Mr. SNYDER.  I will give you my summary of what Dr. Winkenwerder had as his four things, and you may want to pull the transcript, or you all have ongoing discussions with him anyway, and maybe just have you respond to them.

Number one on his list was the electronic health record, that the work that needs to be done.  He specifically mentioned the inpatient, and the challenges that will be there.  This second one, he thought there needed to be improved screening in follow-up on traumatic brain injury, in terms of following people after they get back, and have been around trauma, but maybe not in such a way that they realize that they have been hurt.

And his third one was mental health issues.  Again, transition.  He said his experience is that people, when they get back, they may be so eager to get home they are just not as candid as maybe they think they ought to be, or want to be, and the transition following those folks.  They may get a clean bill of health from them, but by the time they get to you, they have some issues.  And he thought that there could be work done there.

And his fourth one was joint procurement issues, joint market access.  He thought you all could work together closely in terms of buying stuff.

That is my amateurish summary of the four things he said.  Do you have any response to or thoughts on any of those? 

Dr. KUSSMAN.  Yes, I would agree with those.  I was looking at the things that are going on on a daily basis. 

TBI is obviously an important thing.  Every war has its sentinel things that you look at.  TBI is one of those.  I think what we are learning is that it is more complicated than anybody thought, in a way that we all know what to do, and the VA has been a world leader in taking care of TBI.  We all know what happens when somebody has a gunshot wound to the head, or significant TBI.  The challenge is undiagnosed or minor TBI.  And we are working particularly with the Army and the Navy, to look at ways of screening people for minor TBI. 

I mean, no one really knows what happens if you—whatever your full capability was, if—and it is related to boxing and playing football.  You know, football players, they get concussions repeatedly, really are in the same category of things.  And together, we are developing a screen that we will provide for everybody when they come back.  We have a screen now, when somebody comes to us, who was in OIF-OEF, when they come—it could be for anything.  When they go see their primary care provider, a drop-down menu alerts them and they have to ask certain questions related to PTSD.  We are going to provide that same drop-down menu for TBI to ask the questions. 

As you know, there is no single test to determine about—there is no x-ray or one blood test that you can do.  The issue is to be sure that we do what we can, and help people maximize whatever capacity they have.  So we are working together very aggressively on that. 

Joint procurement are things that we have always been working—we need to more aggressively do that, have joint purchases, leverage our buying capacity.

Mental health is one that we have talked about a great deal.  As you know, along that spectrum, whether it is a readjustment or PTSD, there are a lot of resources in-country, to try to talk with people as they develop it. 

But when they come back, as you know, particularly with the National Guard and Reserve, the American soldier is very smart.  They know what to answer and what not to answer, and that if, you know, if you say "yes" to anything that is said to you, you are going to have to stay around for a couple more days versus being able to go home, they say "no." And it is not only that they want to go home but, you know, as you alluded to, is that sometimes people with adjustment reactions or PTSD don't know they have a problem that early on, and they transition back because they are euphoric about coming back, and many of us have experienced that same thing; you come back and you just want to go home.

And that is why we have initiated, with DoD, the Post-deployment Health Risk Assessment, that is focused on the National Guard and Reserve—and they do it on active duty, but that is not a group that we are involved in—that takes place 90 to 180 days later, to ask those questions again.  We have been quite successful in that outreach.  For the VA, we have hired 100 Global War on Terrorism counselors.  Almost all of them are OIF-OEF veterans that worked with our vet centers.  They go out to all the armories and things, going out and making sure that—asking questions.  We work very closely with the State.

So the outreach program to try to get people to understand, and make it easy for them to come in and get help—as you know, in our country there is a stigma related to that, and people generally don't want to come.  And what we need to do is make it easy for them and nonthreatening to come in, so we can assess.

It is clear that if you have symptoms related to PTSD, if you can get at it early and treat it, you can attenuate, if not eliminate, the long-term complications.  So we are very aggressive about outreach.  Sorry to be so long-winded.

Mr. SNYDER.  One final question, and I guess no answer is fine with me if that is what you would like to do.  Secretary Nicholson was talking prospectively about the electronic health record that you have—now, I go back to my VA training days, when we would have two-volume charts of handwritten notes, and they would be literally several inches thick, and how are you going to make a conversion over to an electronic health record?

My question is, is there anything inherently different in the VA system in the transfer over to the electronic health record for inpatients, from the private sector?  You know, a community hospital would also have a thick written record.  Is there anything inherently different in making that transition to an electronic health record for inpatients? 

Dr. KUSSMAN.  Sir, do you mean nationally?

Mr. SNYDER.  [Nods head affirmatively.]

Dr. KUSSMAN.  We believe it is a state-of-the-art system.  It has one weakness with it; it is MUMPS-based rather than Java-based, Web-based, and we are in the process of re-engineering that.  That will make it more easily compatible with what I believe Secretary Leavitt and the country is moving to, to make them be able to communicate more easily.

Mr. MICHAUD.  Thank you, and we will be having a separate hearing on TBI and mental health issues.

Congressman Brown? 

Mr. BROWN OF SOUTH CAROLINA.  Thank you, Mr. Chairman, and thank you, Mr. Under Secretary, for being here today.  I know we had the Secretary come the other day, and brief us on some items; I want to commend you for your cooperation between between the DoD And the VA on trying to make some things happen.  In my district, we have an outpatient clinic which is a combination DoD and VA.  And we also are trying to do some things to even further that combination of sharing of research, and sharing cost, and sharing patient load.

And we have been working with the Medical University of South Carolina to try to get some joint efforts moving towards, you know, better service for our veterans.  And I noticed, as we passed the construction bill last year we added some $36.8 million in there for planning at Charleston.  And I noticed in this budget that you have before us today, that nothing was included to continue that planning.  And I was just curious, exactly where we are on that particular issue?

Dr. KUSSMAN.  Thank you.  As you know, it was an authorization.  There was no appropriation with the dollars, and we are certainly still—we hope not too much longer—in our Continuing Resolution.

But as you know, we are aggressively working with the University of South Carolina in Charleston.  We have always had a great relationship with them and, as you know, with partnering and staffs interchange.

The director of the veterans hospital is working with the medical school now, finishing up a very elaborate memorandum of agreement.  What we intend to do is buy equipment, sophisticated—particularly radiologic equipment, that we don't believe that either one should alone as neither one would have the number of patients to fully utilize it.  It will be on the campus of the University because of space issues with the VA.  But we will pay for the equipment, and we will get the services of the specialists that are at the University, and they will be able to keep track of quid pro quo, get free services, if you will, from the University, at the same time as buying in a partnership.

So we believe there is a lot of movement to that.  The specific relationship, building a new hospital, is still under negotiation, as you know.

Mr. BROWN OF SOUTH CAROLINA.  And I appreciate you bringing that to our attention.  I know that 95 percent of those doctors actually come from the Medical University, and I am grateful for that cancer research equipment, treatment equipment that is going to be shared.  But the Medical University, of course, is under a construction program now.  It would seem like to me that the ideal time to continue further cooperation would be for the VA to explore the possibility of replacing the old VA with more current facilities.  And if we don't move, I guess, within the construction time frame, then this could be difficult to utilize the space available at that site.  And as we speak, the VA hospital is in a flood zone, and we would be at certainly the same risk as New Orleans was back when Katrina hit if, in fact, we had a class three or four hurricane come in to Charleston.

Dr. KUSSMAN.  Yes, Sir, I understand.

Mr. BROWN OF SOUTH CAROLINA.  And one further question if I might, Mr. Chairman.

We have had some of our returning veterans develop ALS.  And I was just trying to find out in the budget how much dollars were going to be directed towards ALS research?

Dr. KUSSMAN.  I will have to ask Dr. Kupersmith, but as you know, we have made ALS a service-connected issue.  The number is 6.8 million.

Mr. BROWN OF SOUTH CAROLINA.  6.8 million.

Mr. Chairman, if I might, if you could maybe arrange to have, like, a public hearing on ALS, to give our veterans and opportunity to be heard?  Because they tell me, and I will just read this for further clarification. 

It says that, "I recently learned of a number of cases in my district of veterans who have developed ALS, where VA has denied their claims because their service was not within the presumptive time frame of August the second, 1990 through August the 31st, 1991."

Is that correct? 

Dr. KUSSMAN.  I am sorry, I cannot answer that.  We have to ask the Veterans Benefits Administration, so we can be happy to take that question for the record, and get back to you.

Mr. BROWN OF SOUTH CAROLINA.  Okay, I appreciate it.  Thank you.

Thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you, Mr. Brown.  We definitely will work with you on that, as well.

Congressman Salazar? 

Mr. SALAZAR.  Well, thank you, Mr. Chairman, and thank you, Mr. Secretary, for coming and joining us today.

I have great concerns about the President's budget and his proposal to cut dollars for prosthetic research.  Could you address that a little bit?  I know that there are great new, exciting advances that have been made in myoelectric prosthetic limbs.  And you know, I was at Walter Reed Hospital a couple weeks, Monday, and the greatest concern I have is that we have a brand-new generation of veterans that are basically left without arms and legs.  I had the opportunity to meet with several from Colorado.  I think it is critically important that we continue to develop that research, and to provide better prosthetics for returning men and women from Iraq and Afghanistan.

And secondly, I would also like to ask you about the CBOC facilities.  I know that there are certain requirements that you have to meet before a CBOC can be constructed.  I know that out in Craig, Colorado, we have been working on trying to put one together there because veterans have to travel over five hours of mountainous terrain to get to any kind of primary healthcare physician.

Is there any way that we could waive some of those provisions, or some of those requirements, to be able to do that?  Or is there a way that we would be able to contract with private industry, or private healthcare to address the needs of these veterans? 

Dr. KUSSMAN.  If I could, sir, I will try to answer the second one first.

Mr. SALAZAR.  Okay.

Dr. KUSSMAN.  And then if I can remember what the first one was—no, I can remember it.


Dr. KUSSMAN.  Rural health is a very important issue to us, as you know.  And we are going to establish an office of rural health, to look at some of the questions that you ask.  There are challenges, obviously, with people who live in—I want to say "inaccessible," but I mean rural areas.  It is not just with healthcare and the VA.  It is healthcare in general that they have challenges with.  And they also have trouble getting phone service, and cable TV, and all kinds of things that are challenges with living there.

You are right.  We do have criteria that are established under the CARES process, to look at CBOCs, the number of veterans that are living in a place, the type of veterans in there, the needs of the veterans.  We try to adhere to that as much as possible, obviously, so that we can be consistent with what we are doing.  We are always willing to look at unique issues and see what we can do.  This particular issue, because we are going to set up this office, that would be something that the office could certainly look at.

As far as the rehabilitation and prosthetics research, as I mentioned, we are redirecting a sizable amount of our research, 48 percent to 59 percent, related to OIF-OEF and prosthetics research.  Prosthetics and rehabilitation research has gone from 55 to 63 and a half million, from 2006 to 2008; that our prosthetic budget, totally, is $1.3 billion.  Now, that prosthetic budget encompasses a lot more than limb prosthetics; it is the whole gamut of things.  But as you may or may not know, the number of amputees that have been suffered in this conflict—now, we are not talking about toes and fingers.  It is a limb loss, the number of servicemembers that have suffered an amputation is under 600.  And not that that is not 600 more than I would like, but it is not an overwhelming number that both together DoD and VA can approach.  So we believe that we are monitoring these people very closely, providing them all services they need.  Cost is not an issue with them.  We will provide them anything they need.

Mr. SALAZAR.  Thank you, sir.  I yield back.

Mr. MICHAUD.  Thank you, Congressman Salazar.

To follow up on the CBOC question that Congressman Salazar posed, and Congressman Miller; how many CBOCs will be open in fiscal year 2007?  And how many will be open in fiscal year 2008? 

Dr. KUSSMAN. Twenty-four have been announced for 2007.  Did you ask about 2008? 

Mr. MICHAUD.  Yes.

Dr. KUSSMAN.  Yes.  There is a projection of up to 29 for 2008. That hasn't been totally decided on, but that is a fair guesstimate of where we are.

Mr. MICHAUD.  Okay.  And out of which appropriation account are these new CBOCs located? 

Dr. KUSSMAN.  That question came up, as you know, and it comes out of the VISN VERA dollars.  The VISNs started, locally determined where they think a CBOC should be, meeting all the criteria.  It does come up to the central office for review, not for distribution of dollars, but for review to make sure that everybody is following the same rules that we have standardization and consistency about what we are doing.

Mr. MICHAUD.  Okay.  And where does the VISN get their money? 

Dr. KUSSMAN.  It comes out of the VERA distribution of medical dollars, that we take our $36 billion in budget, and we distribute it through the VISNs, and they are tasked to initiate CBOCs if they think it is appropriate, at the local level.

Mr. MICHAUD.  So it comes out of medical care dollars? 

Dr. KUSSMAN.  Yes, sir.

Mr. MICHAUD.  You know, the concern I have with that is if you actually require the VISN to request a CBOC in order for them to move forward, even though the CARES process says that there is a need there, unless the the VISN asks for a business plan, then it doesn't move forward, and it is like a catch-22.  If you don't have the money, you are not going to ask for a business plan, and therefore you are not going to get it, and therefore there is a lack of service, particularly in the rural areas.  And it goes right back to some of the issues that we have talked about before on mental health issues, and a lot of other issues.  I know the VA is doing all it can with PTSD and other issues, but the need is not being taken care of.

I was reading an article this morning, and I will quote.  It says, "I am not going to take shots at the administration or the Democrats.  It is just a problem that needs to be fixed.  It is an American problem." End of quote.  That was from Larry Provost, an Army reservist who was given two months' wait for an appointment to address his PTSD problem.

And you know, Larry is not the only one.  I am reading the articles where suicide has occurred because the service is not there.  My concern, particularly when you look at the CARES process, in rural areas is to make sure that we have adequate service for our veterans.  And we look at the mental health area, former Congressman Lane Evans and myself, when we asked the GAO to look at the mental health dollars, to help initiate the mental health initiative; when it came back, it pretty much showed that the VA did not use all the money that it was allocated.  Some of the money they did use they couldn't figure out where it was used.  So I guess my next question is, does the department plan on using all the money in the mental health area that has been allocated for fiscal year 2008?  As well as the $306 million in 2007?  Are you going to be utilizing all that money? 

Dr. KUSSMAN.  Yes, sir.  The intent is obviously to use that money.  Let me address the GAO's report.  And we are not refuting that.  The problem was that between a Continuing Resolution and our challenge to hire people, we did not spend all the money.  We didn't lose the money, it was carried over to the next year.  We are working very hard to track, and be sure that we put a performance measure in place to monitor that on a monthly basis of how that mental health money is being used.  So we are very aggressive on trying to—but we don't want to waste it either.  We want to be sure that it is appropriately spent to increase services for the veterans.

As far as waiting times go, obviously there can be all kinds of anecdotal situations.  We provide 39 million appointments a year.  37 million of them are done within 30 days of the request of the patient, 95 percent.  So we want to make it 100 percent.  We are going to work hard to do that.  But all told, I think we are providing pretty good service for people when they need it.

Mr. MICHAUD.  But do you agree that that service could be improved? 

Dr. KUSSMAN.  It can always be improved, sir.

Mr. MICHAUD.  Good answer.  Just a couple more quick questions.

Dealing with priority eight veterans.  When the Secretary was here the other day, in order to include the remainder of priority eight veterans, he said it would cost $1.7 billion.  The Independent Budget came up with a much lower number, $366 million.  Out of that $1.7 billion, did the Secretary forget or not calculate the effect of the fees and the copayments?  Is that the difference between the Independent Budget's numbers versus the Secretary's?

Dr. KUSSMAN.  The Secretary never forgets anything, sir.  I believe that it is in there, in the $1.7 billion, but we will get back to you on that.  Over 10 years, it is $33 billion projected that it would cost if we open back up to priority eights.

Mr. MICHAUD.  What? 

Dr. KUSSMAN.  Over 10 years, and we opened it to—the cost would be $33.3 billion.

Mr. MICHAUD.  But for the priority eights that will be utilizing the system, they will also have to pay copayments.

Dr. KUSSMAN.  Right.

Mr. MICHAUD.  Now, out of that number, the $1.7 billion, have you backed out all of the copayments? 

Dr. KUSSMAN.  I think that they have, but we will need to get back to you on that, because I don't want to give you the wrong answer.

Mr. MICHAUD.  Okay, great.  Congressman Miller? 

Mr. MILLER.  I will go ahead and pass, I know we have another panel.

Mr. MICHAUD.  Congressman Brown?


Mr. MICHAUD.  Once again, I want to thank the panel for coming over this afternoon.  I really appreciate it and look forward to working with you, and look forward to doing whatever we can to improve how we give services to our veterans.  So thank you very much.

Dr. KUSSMAN.  Thank you, Mr. Chairman.

Mr. MICHAUD.  I would ask the next panel if they would come up, please.

I would like to welcome the second panel.  The second panel includes Dr. Joseph English, who is a Board of Trustee member of the American Psychiatric Association; Gary Ewart, who is the Director of Government Relations for the American Thoracic Society, on behalf of the Friends of the VA Medical Care and Health Research; and we have Patrick Campbell, who is Legislative Director of the Iraq and Afghanistan Veterans of America.  So I would like to welcome all three of you gentlemen, and we will start off with Dr. English.



Dr. ENGLISH.  Mr. Chairman, I appreciate that, and it is a pleasure to address you and members of the Committee.  I also serve as Chairman of Psychiatry at St. Vincent's Catholic Medical Centers of New York, and Professor and Chairman of Psychiatry at New York Medical College.

My department is affiliated with two VA medical cen