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Hon. Michael J. Kussman, M.D., MS, MACP

Hon. Michael J. Kussman, M.D., MS, MACP, Veterans Health Administration, Under Secretary for Health, U.S. Department of Veterans Affairs


Mr. Chairman and members of the Committee, thank you for this opportunity to discuss how Veterans Affairs (VA) is addressing medical care costs for the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) population.  Today, my testimony will focus on how VA continues to enhance its programs and projects its annual budget in order to meet the needs of this newest generation of veterans. 

Since the onset of combat operations in Iraq and Afghanistan, VA has demonstrated flexibility in its ability to create new services and to adapt resource allocations to meet the unique medical need of returning OEF/OIF veterans.  We continue to have confidence in our planning and budgeting processes and we are committed to utilizing all necessary resources to provide timely and quality health care to all our veterans.   

VA has grown from four Traumatic Brain Injury Centers into an entire Polytrauma System of Care, expanded its Readjustment Counseling Services by establishing new Vet Centers across the country and enhanced our mental health system to more robustly address Post Traumatic Stress Disorder (PTSD) and suicide, among other mental health issues.   Mr. Chairman, we would like to thank this Committee for its continued support in our efforts to provide the best health care for all veterans.   

Planning and Utilization

Since 2002 thru the end of the 3rd quarter of fiscal year (FY) 2007, 751,273 OEF/OIF veterans who left active duty have become eligible for VA health care.  Thirty-five percent (263,909) of the total separated OEF/OIF veterans have come to VA to obtain VA health care.  We follow and analyze trends and other data to ensure that VA is ready and able to meet future demands for medical care, particularly for our OEF/OIF veterans. 

Polytrauma System of Care

Prior to FY 2002, Traumatic Brain Injury (TBI) Lead Centers provided acute medical and rehabilitation care to veterans suffering from severe TBI and one or more other major traumatic injuries such as amputation of a limb(s), or blindness. Due to the unique and severe injuries caused by improvised explosive devices, VHA created the Polytrauma System of Care that provides a continuum of care when these heroes are able to move from acute care to less intensive levels of care.  The networks provide three levels of care from acute to less intensive outpatient care.  These less intrusive care levels are provided at facilities through out the 21 Veteran Integrated Network Systems (VISNs).  To give this Committee a sense of the magnitude of severe injuries in the OEF/OIF population, there have been 681 patients with amputations, and 110 patients with spinal cord injuries.  VA has accepted 436 transfers from Military Treatment Facilities to the polytrauma centers. 

This system of care consists of four regional Polytrauma Rehabilitation Centers (PRC) and provides acute intensive medical and rehabilitation care for complex and severe polytraumatic injuries.  The Secretary of Veterans Affairs recently announced the decision to locate a fifth Polytrauma Center in San Antonio, TX.  The PRCs serve as hubs for acute medical and rehabilitation care, research, and education related to polytrauma and TBI. 

Transition Patient Advocates

VHA developed new programs to provide additional transition assistance and case management for OEF/OIF veterans.  In 2007, VA hired 100 Transition Patient Advocates (TPAs).  TPAs serve as veteran advocates when severely injured veterans transition to VA from a Military Treatment Facility.  The TPA works closely with the VA Social Work Liaison to ensure a smooth health care transition.   These specialized case managers are located in VA medical centers and the number assigned to a specific VAMC is based on the number of OEF/OIF veterans treated by the medical center.  Annually, VA distributes approximately $19 million among the Veteran Integrated Service Networks to cover TPA salaries.  

Vet Centers

Vet Centers serve veterans and their families by providing professional readjustment counseling.  Currently, there are 209 VA Vet Centers located in all 50 states, the District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands.  The Vet Centers operate in the community outside of larger medical facilities.  With the onset of the hostilities in Afghanistan and Iraq, the Vet Centers stepped up to actively outreach and extend services to the OEF/OIF veterans.  From early FY 2003 through the end of the third quarter FY 2007, the Vet Centers provided services to 183,530 veterans and clinical services to 58,504 veterans.  During the same time period, more than 1,570 family members have been referred to the Vet Centers for bereavement counseling.

From 2001 through 2003, the Vet Center program operated with a total of 206 Vet Centers and 943 total staff nationwide.  The program’s annual operation budget was flat except for annual cost of living increases.  However, investments in Vet Centers became a higher priority in 2003.  Starting in 2003, the Vet Centers recruited the first 50 of a total of 100 Global War On Terror (GWOT) veteran outreach specialists to conduct a focused outreach campaign to their fellow veterans returning from OEF/OIF.  The second 50 GWOT outreach specialists were hired in 2005.  The associated recruitment cost for the 100 GWOT veterans was approximately $5 million.  Also in 2005, the Readjustment Counseling Service (RSC) established a new 4-person Vet Center in Nashville, TN at a recurring cost of approximately $350,000.  In 2006, RCS established two new 4-person Vet Centers in Atlanta, GA and Phoenix, AZ, and augmented the staff of 11 existing Vet Centers by one position each.  This initiative added 19 permanent positions to the Vet Center program with a cost of approximately $1.5 million. 

Today, the Vet Center program is undergoing the largest expansion since the early days of the program’s founding.  The planned expansion complements the efforts of the Vet Center outreach initiative by ensuring sufficient staff resources are available to provide the professional readjustment services needed by the new veterans as they return home.  In February 2007, VA announced plans to increase the number of Vet Centers from 209 to 232, and to augment the staff at 61 existing Vet Centers.   The expansions, started in 2007 and planned for completion in 2008, will increase the Vet Center program’s annual recurring budget by approximately $14 million.

In May 2007, VA announced that it planned to add yet an additional 100 new staff positions to the Vet Center program in FY 2008.  VHA has also targeted an additional 100 positions for FY 2009, which will further augment the Vet Centers’ ability to address the readjustment needs of combat veterans and their families.  These staff augmentations will result in an annual recurring increase of approximately $8.3 million.  Collectively, starting from the first 50 GWOT veterans in 2004, the Vet Center program will realize a total of 473 new positions by the end of 2009, or a 50 percent increase over pre-2004 staffing levels.    

Mental Health

Of the OEF/OIF veterans who sought care from VA, about 38 percent have received at least a preliminary diagnosis of a mental health condition, and 18 percent have received a preliminary diagnosis for PTSD, making it the most common, but by no means, the only mental health condition related to the stress of deployment.  To meet the specific mental health needs of these returning veterans, VHA has developed new and enhanced existing mental health programs and services.  For example, veterans with a serious mental illness are seen in specialized programs, such as mental health intensive case management, day centers, work programs and psychosocial rehabilitation.  General and psychogeriatric mental health services are also being integrated into primary care clinics. 

VA continues to promote the recruitment and retention of mental health professionals.  At the local level, opportunities have been developed for VA facilities to engage in local advertising and recruitment activities and to cover interview-related costs, relocation expenses, and provide limited hiring bonuses for exceptional applicants.  VA employs full and part time psychiatrists and psychologists who work in collaboration with social workers, mental health nurses, counselors, rehabilitation specialists, and other clinicians to provide a full continuum of care for mental health services for veterans.   

The cost of mental health services and programs specifically dedicated for OEF/OIF veterans was $2.4 million in FY 2005, $11.7 million in FY 2006, and $19.0 million in FY 2007.  Most returning veterans receive mental health services in programs serving veterans of all eras.  At present, OEF/OIF veterans represent approximately 10 percent of all veterans with a mental health diagnosis, and, therefore the costs of their mental health care can be estimated at 10 percent of VHA’s $3 billion of expenditures in this area.

Mr. Chairman, this concludes my statement.  I am pleased to respond to any questions you or the members may have. 

Thank you.