Joseph E. Wafford
Chairman Michaud and other Members of the Subcommittee—
Thank you for requesting the testimony of the Disabled American Veterans (DAV), Department of Maine, at today’s field hearing of the Subcommittee. DAV is a national veterans service organization of 1.3 million members, and is dedicated to rebuilding the lives of disabled veterans and their families.
The topics before the Subcommittee—women, rural and special needs veterans—are of acute interest to DAV in Maine and nationwide. Maine, with an adult population of 970,000, is home to 155,000 veterans, who constitute 16 percent of our adult population, among the highest proportion of veterans in any State. Also, with so many members of the National Guard and Reserve forces fighting the wars in Iraq and Afghanistan, including the Maine National Guard, and with nearly half of those serving coming from rural, remote and frontier areas, access to Department of Veterans Affairs (VA) health care and other VA services in rural areas is perhaps VA’s most pressing challenge today, and is an exceedingly important issue in this State. Within that set of challenges, we are encouraging VA to do a better job of addressing the needs of women veterans, who are playing such an important role in these war deployments, and because of that exposure, are suffering a degree of disability and combat-related illnesses that we have never seen before in American military expeditions. In that regard, we urge the Subcommittee to swiftly consider and approve a bill, H.R. 4107, the Women Veterans Health Care Improvement Act, offered by Representatives Herseth Sandlin and Brown-Waite, two Members of your Committee. We are seeing a large number of rural veterans, both men and women, coming home from these wars with severe injuries and illnesses. Therefore, we are very pleased that the Subcommittee is turning its attention to these issues, and urge that you maintain that strong focus.
As you know, VA operates a major regional medical center in Togus, near Augusta. Opened in 1866, the Togus facility was the first national home for disabled volunteer soldiers. Today, Maine’s only VA medical center plays a major role in the community and State, providing medical, surgical, psychiatric and nursing home care. It is also a significant employer in the Augusta community.
VA also operates community-based outpatient clinics (CBOC) in Bangor, Calais, Caribou, Rumford and Saco, and there is a part-time outpatient clinic in Lincoln. Also the VA’s Readjustment Counseling Service has established “Vet Centers” in Bangor, Lewiston, Caribou, Portland and Springvale, and VA provides a mental health clinic in Portland. Given the vast distances, severe weather and geographical barriers of our beautiful State, coordination of health care and patient referrals for subspecialty services are major, continuing challenges, both within the VA and in the State’s private sector as well. In an effort to provide more effective health care to Maine’s veterans, the Togus Center operates a home tele-health program that currently aids 116 veterans, and uses VA’s video “Help Buddy” system to monitor the health status of outpatient veterans who live at a distance from the Medical Center.
Mr. Chairman, as you know, VA had planned to open a CBOC in Dover Foxcroft, but those plans were shelved due to an insufficient veteran population base to support a full time VA clinic. DAV believes that area still needs VA’s attention, and we highly recommend that Togus provide a “satellite van” or a portable physician office to serve veterans in that area. Once veterans in the Dover Foxcroft area become aware that VA has established a health care presence for them, even on a part time basis, this may help justify a full time clinic later on in that community. We would appreciate the Subcommittee’s making that recommendation to the VA.
According to VA, in 2006 (latest information available), inpatient admissions to VA health care facilities in Maine totaled 1,696, while outpatient visits reached 325,718. Also, 17,474 veterans 65 years of age and older received health care from VA in 2006. VA makes a wide range of geriatric, rehabilitation and extended care services available and offers expanded programs to meet the growing needs of this elderly population. The Togus VA Medical Center offers elderly veterans geriatric primary care, geriatric and gero-psychiatric consultations, geriatric evaluation, nursing home and dementia care, as well as palliative and respite care.
Mr. Chairman, in Maine, more than 1,400 active duty service members and veterans of the Global War on Terror have sought VA health care. Many veterans from the conflicts in Iraq and Afghanistan have visited Vet Centers. These community-based Vet Centers serve as an important resource for veterans who, once home, often seek out fellow veterans for advice to help them transition back to civilian life.
The State of Maine operates six state veterans homes supported by VA subsidies. They are located in Augusta (120-bed skilled care and 30-bed residential care); Bangor (120-bed skilled care); Caribou (40-bed skilled care and 30-bed residential care); Scarborough (120-bed skilled care and 30-bed residential care); South Paris (62-bed skilled care and 30-bed residential care) and Machias (30-bed residential care). We are very fortunate in Maine to have these homes available to the State’s war veterans as a continuing source of care and comfort in their elderly period. One difficulty, however, that concerns us is that our State Homes do not provide a rehabilitation or convalescence capability. Given our elderly veteran population’s needs, the State Homes could offer veterans a great new service if they embraced a rehabilitation/convalescence mission in partnership with the Togus Medical Center. Many veterans in inpatient care at the Togus VA Center live in Bangor, Caribou and other communities at great distance from Togus. Following surgery or other invasive care in Togus, if they had a local residential provider available to help them with rehabilitation, these veterans could be placed closer to home. The State Homes are available but do not offer rehabilitation, so often these veterans are admitted to community nursing homes at higher cost to the VA. I encourage VA to consider exploring such an arrangement with the Maine Veterans Homes to see whether such a referral partnership for post-hospital convalescence is feasible.
In general, current law limits VA in contracting for private health care services to instances in which VA facilities are incapable of providing necessary care to a veteran; when VA facilities are geographically inaccessible to a veteran for necessary care; when a medical emergency prevents a veteran from receiving care in a VA facility; to complete an episode of VA care; and, for certain specialty examinations to assist VA in adjudicating disability claims. VA also has authority to contract for the services in VA facilities of scarce medical specialists. Beyond these limits, there is no general authority in the law to support any broad VA contracting for populations of veterans.
The Independent Budget (IB) veterans service organizations (Disabled American Veterans, Veterans of Foreign Wars of the United States, AMVETS and Paralyzed Veterans of America) agree that VA contract care for eligible veterans should be used judiciously and only in the specific circumstances described above so as not to endanger VA facilities’ ability to maintain a full range of specialized inpatient services for all enrolled veterans. We believe VA must maintain a “critical mass” of capital, human and technical resources to promote effective, high quality care for veterans, especially those disabled in military service and those with highly sophisticated health problems such as blindness, amputations, spinal cord injury or chronic mental health problems. We are concerned that in an open environment of mixed government and private providers with tight budgets, the contracted element (particularly if it were focused on acute and primary care to large populations) would inevitably grow over time, and place at risk VA’s well-recognized qualities as a renowned and comprehensive provider. We believe such a distributed program would not only become prohibitively expensive, but also could damage VA’s health professions affiliations—the bedrock of VA quality care.
We believe the best course for most enrolled veterans in VA health care is for VA to provide continuity of care in facilities under the direct jurisdiction of the Secretary of Veterans Affairs. For the past twenty-five years or more all major veterans service organizations have consistently opposed a series of proposals seeking to contract out or to “privatize” VA health care to non-VA providers on a broad or general basis. Specific incidences of such proposals have occurred in the states of Maryland, Minnesota, Oregon and Florida. Ultimately, these ideas were rejected by Congress or the Federal courts. We believe such proposals—ostensibly seeking to expand VA health care services into broader areas serving additional veteran populations at less cost, or providing health care vouchers enabling veterans to choose private providers in lieu of VA programs, in the end only dilute the quality and quantity of VA services for all veteran patients. Given the dire financial straits VA has experienced over several recent fiscal years, this is an important policy to sick and disabled veterans, and to those who represent their interests.
Mr. Chairman, aside from these concerns, we know that VA’s contract workloads have grown significantly. VA currently spends more than $2 billion annually on contract health care services, from all sources. Unfortunately, VA does not adequately monitor this care, consider its relative costs, analyze patient care outcomes, or even establish patient satisfaction measures for most veterans under the care of contract providers. VA has no systematic process for contract care services to ensure the care is safe and delivered by certified, licensed, credentialed providers. Also, VA does not monitor continuity of contract care or ensure that these veterans are properly referred back to the VA health-care system following private care. Records of veterans’ contract care are inadequate in documenting the associated pharmaceutical, laboratory, radiology and other key information relevant to the episode(s) of care, nor does VA know if the care received is consistent with a continuum of VA care.
Several times the Independent Budget has recommended that VA implement a program of community contract care coordination that includes integrated clinical and claims information for veterans currently cared for by community-based providers. VA is yet to take these actions.
In order to meet the needs of our newest generation of veterans with access challenges and special needs, particularly in a State such as Maine, it will be crucial for VA to develop an effective care coordination model that achieves VA’s responsibilities to these veterans. Developing an effective care coordination model would improve patient care quality, optimize use of VA’s limited resources, and prevent overpayments when eligible veterans utilize contract community care.
Mr. Chairman, the information expressed above is the basis for the IB recommendation on coordination of community care. Based on our current knowledge of VA’s ongoing demonstration called “Project HERO (Healthcare Effectiveness and Resource Optimization),” VA is not fully employing our recommended model in that demonstration, which has been put in place in Veterans Integrated Service Networks (VISNs) 8, 16, 20 and 23. While this demonstration does not directly affect VA programs in the State of Maine, it is of rising concern among veterans and organizations that represent them in the States that are a part of this demonstration. The Independent Budget veterans organizations are united that whatever emerges from that demonstration, we believe as representatives of millions of enrolled, sick and disabled veterans, that the Veterans Health Administration (VHA) needs to closely coordinate with our community any proposed expansion of the Project HERO initiative.
We appreciate the recent change in VA policy on beneficiary travel reimbursement, increasing the rate of reimbursement from eleven cents per mile to 28.5 cents. This increase, made after over 30 years of stagnancy, helped to ease rural veterans’ ability to access VA facilities for their care. We thank you for supporting that change, and for providing the new funding essential to enable VA to adopt the new policy. Unfortunately, recent dramatic gasoline price increases have wiped out most of that improvement, but we are grateful nevertheless.
Mr. Chairman, we appreciate your Subcommittee’s work in establishing the VA Office of Rural Health (ORH) in legislation enacted in 2006, Public Law 109-461. Veterans in Maine and elsewhere have high expectations for that office to establish creative and effective policies in meeting veterans’ health care needs in rural America. The Independent Budget for Fiscal Year 2009 made a series of recommendations dealing with the responsibilities of this new office, including the following:
- VA must ensure that the distance veterans travel, as well as other hardships they face be considered in VA’ s policies in determining the appropriate location and setting for providing VA health care services;
- VA must fully support the right of rural veterans to health care and insist that funding for additional rural care and outreach be specifically appropriated for this purpose, and not be the cause of reduction in highly specialized VA medical programs needed for the care of sick and disabled veterans;
- VA should ensure that mandated outreach efforts in rural areas required by Public Law 109-461 be closely coordinated with the Office of Rural Health;
- Mobile Vet Centers should be established, at least on a pilot basis, to provide outreach and counseling for veterans in rural and highly rural areas;
- Through its affiliations with schools of health professions, VA should develop a policy to help supply health professions clinical personnel to rural VA facilities and practitioners to rural areas in general. The VHA Office of Academic Affiliations, in conjunction with Office of Rural Health, should develop a specific initiative aimed at taking advantage of VA’s affiliations to meet clinical staffing needs in rural VA locations;
- ·The VA Secretary should use existing authority to establish a Rural Veterans Advisory Committee under the Federal Advisory Committee Act, to include membership by veterans service organizations (including those that offered the Independent Budget). Mr. Chairman, we understand the Secretary is now considering taking steps to establish this advisory committee, and we applaud that decision;
- Recognizing that in areas of particularly sparse veteran population and absence of VA facilities, the Office of Rural Health should sponsor and establish demonstration projects with available providers of mental health and other health care services for enrolled veterans, taking care to observe and protect VA’s role as coordinator of care. The projects should be reviewed and monitored by the Rural Veterans Advisory Committee. Funding should be made available to the Office of Rural Health to conduct these demonstration and pilot projects outside of VERA, and VA should report the results of these projects to the Committees on Veterans’ Affairs;
- At highly rural VA CBOCs, VA should establish a staff function of rural outreach worker to collaborate with rural and frontier non-VA providers to establish referral mechanisms to ease referrals by these providers to direct VA health care when available, or VA-authorized care by other agencies;
- Rural outreach workers in VA’s rural CBOCs should receive funding and authority to enable them to purchase and provide public transportation vouchers and other mechanisms to promote rural veterans’ access to VA health care facilities that are distant to their rural residences. This travel program should be inaugurated as a pilot program, in a small number of facilities. If successful as an effective access tool for rural, remote and frontier veterans who need access to direct VA care and services, it should be expanded into other rural areas; and
- The ORH should seek and coordinate the implementation of novel methods and means of communication, including use of the worldwide web and other forms of telecommunication and telemetry, to connect rural, remote and frontier veterans to VA health care facilities, providers, technologies and therapies, including greater access to their personal health records, prescription medications, and primary and specialty appointments.
Mr. Chairman, most of these recommendations are clearly applicable in our State. On behalf of the Independent Budget, we hope the Subcommittee will address these recommendations with oversight and further legislation if needed, to ensure they are implemented. Rural veterans, whether in the State of Maine or elsewhere, deserve access to VA health care, despite the obvious challenges we face in providing it.
Mr. Chairman, this concludes my testimony, and I will be pleased to consider your questions on these important topics.