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[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]

 
REALIZING QUALITY RURAL CARE THROUGH APPROPRIATE STAFFING AND IMPROVED 
                                 CHOICE

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                       TUESDAY, SEPTEMBER 1, 2015

                               __________

                           Serial No. 114-35

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
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                   U.S. GOVERNMENT PUBLISHING OFFICE
                   
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             BETO O'ROURKE, Texas

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.

                            C O N T E N T S

                              ----------                              

                       Tuesday, September 1, 2015

                                                                   Page

Realizing Quality Rural Care Through Appropriate Staffing and 
  Improved Choice................................................     1

                           OPENING STATEMENT

Dan Benishek, Chairman...........................................     1
    Prepared Statement...........................................    29
Julia Brownley, Ranking Member...................................     2

                               WITNESSES

Aaron A. Payment MPA, Chairperson, Sault Ste. Marie Tribe of 
  Chippewa Indians...............................................     3
    Prepared Statement...........................................    31
Anthony Harrington, Veteran Sault Ste. Marie, Michigan...........     5
    Prepared Statement...........................................    32
David W. Pearce, Commander, Post 3676, Veterans of Foreign Wars 
  of the United States...........................................     7
    Prepared Statement...........................................    33
Don Howard, Commander, American Legion Post 3....................     8
Jacqueline Haske, Chippewa County Veteran Service Officer........     9
    Prepared Statement...........................................    34
Gina Capra, Director, Office of Rural Health, VHA, U.S. 
  Department of Veterans Affairs.................................    16
    Prepared Statement...........................................    34

    Accompanied by:

        James Rice, Acting Network Director, Veterans Integrated 
            Service Network 12, VHA, U.S. Department of Veterans 
            Affairs

    And

        Gail McNutt M.D., Chief of Staff, Oscar G. Johnson VAMC, 
            Iron Mountain MI, Veterans Integrated Service Network 
            12, VHA, U.S. Department of Veterans Affairs

                        STATEMENT FOR THE RECORD

American Federation of Government Employees, Iron Mountain Local.    38
American Osteopathic Association.................................    40

REALIZING QUALITY RURAL CARE THROUGH APPROPRIATE STAFFING AND IMPROVED 
                                 CHOICE

                              ----------                              

                       Tuesday, September 1, 2015

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 10:05 a.m., in 
National Guard Armory, 1170 East Portage Avenue, Sault Ste. 
Marie, Michigan, Hon. Dan Benishek [chairman of the 
subcommittee] presiding.
    Present: Representatives Benishek and Brownley.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Dr. Benishek. As you know, I am Dr. Dan Benishek, and it 
has been my honor to be both your congressman and the chairman 
of the Subcommittee on Health for the Committee on Veterans' 
Affairs of the United States House of Representatives.
    Before I was elected to Congress, I was privileged to serve 
for 20 years as a physician at the Oscar G. Johnson VA Medical 
Center at Iron Mountain, overseeing the VA community-based 
outpatient clinic here in Sault Ste. Marie. During my time 
there, veteran patients would tell me every day about the 
challenges and the frustrations that they faced when attempting 
to get care through the VA, the VA which is, by the way, the 
government's second largest bureaucracy, with a budget and 
staff that trails only the Department of Defense in size.
    Let me be clear: our veterans fought for our freedom; they 
shouldn't have to fight government bureaucrats too.
    The subcommittee members and our staff work hard every day 
to break down the barriers between the VA bureaucracy and the 
veterans that this bureaucracy should be serving here in the UP 
and across the country.
    I am joined here today by Congresswoman Julia Brownley, the 
ranking member of the Subcommittee on Health, and a 
representative from the 26th District in California, just north 
of Los Angeles. Needless to say, she has traveled quite a 
distance to be here today with us, and we are grateful for her 
willingness to join us in Sault Ste. Marie this morning and for 
being such a strong and effective voice on the subcommittee. 
Thank you very much.

    [The prepared statement of Chairman Dan Benishek appears in 
the Appendix]

              OPENING STATEMENT OF JULIA BROWNLEY

    Ms. Brownley. Thank you.
    [Applause.]
    Dr. Benishek. The purpose of today's hearing is to make 
sure that the care that you and your fellow veterans receive in 
the Eastern UP is timely, accessible, and high quality. 
Unfortunately, we all know that at times the VA has failed to 
meet those measures, and in doing so has fallen short of 
providing the treatment that our veterans have earned and 
deserve.
    An example of how the VA has fallen short here in Sault 
Ste. Marie can be seen in the VA's inability for the past two 
years to recruit a physician to staff the VA community-based 
outpatient clinic here. The veterans that I have spoken to, 
some of whom you will be hearing from this morning, are 
understandably concerned about the lack of a physician at this 
facility and the impact that the VA's failed recruitment 
efforts have had on the quality of care at the clinic. I share 
those concerns; and today, we are going to get some answers.
    During this morning's hearing we will discuss efforts that 
the VA has taken in this community and around the country to 
ensure that rural clinics like the one here in Sault Ste. Marie 
are properly staffed and that rural veterans are able to access 
care in the community or through tribal health centers where VA 
funding is unable to provide the care that our veterans need 
and when our veterans would prefer to receive care elsewhere.
    We will hear testimony from the VA, from local tribal 
leaders and local veterans whose input, expertise and advice 
are critical to the work that we do in Washington. I am 
grateful to all our witnesses for being here and look forward 
to their testimony.
    Before that, I will take a moment to recognize the men and 
women that we are here today to serve. Will the veterans in our 
audience right now please stand, if you are able, or raise your 
hand and be recognized?
    [Applause.]
    Dr. Benishek. Thank you so much for serving our country and 
for being with us here this morning.
    I would like to take a moment to recognize and thank the 
Armory staff for allowing us to use their facility this morning 
and for their assistance in setting up for the hearing. Thank 
you for that.
    [Applause.]
    Dr. Benishek. With that, I would like to recognize Ranking 
Member Brownley for any opening statement she may have.
    Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman. I appreciate that. 
And thank you for calling this hearing today. I am always 
pleased to visit Michigan, particularly at this time of the 
year. So, thank you for that. Thank you for the invitation.
    And thank you all for being here. This is an important 
hearing and issue, access to quality healthcare in rural areas. 
The veterans who choose to reside in rural areas face big 
challenges in accessing appropriate healthcare. Rural veterans 
are older, typically older, sicker than their urban 
counterparts. They experience primary and specialist shortages, 
hospitals closing due to financial instability, inadequate 
broadband coverage, and geographic distance barriers.
    In my district in California, we have rural areas as well, 
bordered by small towns. Veterans in these areas continue to 
have problems getting appropriate healthcare. So I think I am 
familiar with some of the issues certainly here in Michigan.
    I am pleased by what I have heard about the VA's telehealth 
program. I think by all accounts the VA is leading the way, and 
I think telehealth can play an important role, particularly in 
rural areas, but it is not the only solution to the problem. 
There is much more that we have to do.
    So, I am extremely pleased to be here. It is a tremendous 
honor for me to serve on the VA Committee in Washington, DC. My 
brother was 20 years in the Navy, a pilot in the Navy. My dad 
was a Marine. I had two uncles, one in the U.S. Army and one in 
the Coast Guard. So at least I understand what the impacts are 
on veterans and veterans' families. This was the committee that 
I wanted to serve on when I arrived in Washington, and I am 
extremely, extremely honored to be on this committee and to be 
able to serve veterans, not only in my home district but across 
the country.
    So thank you all very, very much for your service and your 
continued service. It is greatly, greatly appreciated. Thank 
you.
    Dr. Benishek. Thank you, Ms. Brownley.
    We are going to begin today's hearing with our first panel 
of witnesses who are already seated at the table here. As this 
is a formal hearing, this is a real congressional hearing just 
like we have in Washington. It is not a town hall. We have 
invited witnesses to the table to speak, although I look 
forward to speaking with other audience members after the 
hearing is concluded.
    Before I introduce our panelists, I need to remind all of 
today's witnesses to be mindful of the 5-minute time limit on 
your oral testimony, and then a question-and-answer period will 
follow. The light here is green, and then it turns yellow when 
there is a minute left, and then it turns red when your 5-
minutes is up. We try to do that even in Washington, especially 
for Members of Congress, just to make sure we get through all 
the testimony and have plenty of time for questions and 
answers. Thanks in advance for your consideration.
    With us on the first panel this morning is Chairperson 
Aaron Payment, Sault Ste. Marie Tribe of Chippewa Indians; 
Anthony Harrington, a veteran who lives right here in Sault 
Ste. Marie; David Pearce, an Army veteran and Commander of VFW 
Post 3676; Don Howard, Director and Commander of American 
Legion Post 3; and Jacqueline Haske, the Chippewa County 
Veteran Service Officer.
    I am grateful to each of you for doing this, for your 
willingness to be here and to speak candidly about the issues 
of importance to our veterans and our community. I am honored 
to have you all here with us this morning.
    The Chairman. Payment, you are recognized for 5 minutes.

                 STATEMENT OF AARON A. PAYMENT

    Mr. Payment. [Speaking native language.] My name is Aaron 
Payment, and I am the chairperson of the Sault Ste. Marie Tribe 
of Chippewa Indians, the largest tribe east of the Mississippi. 
I want to thank you both for bringing this hearing to Sault 
Ste. Marie. I also want to recognize one of our council members 
who is a veteran who is with us here in the audience, Denny 
McKelvey, Vince McKelvey, who is our treasurer. He is very 
critical of the VA, and so I am here to represent some of those 
criticisms and some members that I saw yesterday that gave me 
some input.
    While 1.4 percent of the U.S. population is American 
Indian, the military population that is represented from our 
people is 1.7 percent. So we represent more than our population 
in military service.
    I commend the Department of Veterans Affairs' efforts to 
ensure that community-based outpatient clinics in rural areas 
are properly staffed and rural veterans are able to access care 
in the community where appropriate and necessary. However, 
additional changes are critically needed.
    The current system creates multiple barriers to treatment 
for our Native veterans living in rural areas. In the Eastern 
Upper Peninsula of Michigan, my tribe has partnered with the 
American Legion to provide two additional service officers in 
Michigan's 1st Congressional District. This effort extends 
outreach activities to veterans who utilize our health 
facilities across the UP. We provide space and offset costs 
associated with additional service officers. Additionally, we 
are establishing baseline data collection aimed at more 
accurately reflecting the number of American Indian veterans 
across the UP.
    In 2010, our health division worked with the Iron Mountain 
VA to establish an agreement with the tribe's optical 
department in Manistique. Under this agreement, the tribe is 
able to provide optical services to tribal and non-tribal 
veterans alike.
    The Sioux Tribe has also established a VA workgroup to 
access additional services for our veterans; partnered with a 
veteran's service organization, again the American Legion, to 
provide benefits and service officers at tribal clinic sites to 
assist with issues and questions about navigating the VA 
bureaucracy; worked to identify tribal veterans as they visit 
our clinics in order to plan services for them; worked to 
incorporate both behavioral health and traditional medicine 
programs to develop veteran-specific services to include PTSD 
and emotional trauma; planned awareness outreach to get out the 
word on tribal and VA services including tribal elder meetings, 
the tribal newspaper, our website and video tag line 
information; and worked with the Iron Mountain VA to establish 
an MOA with the tribe for full reimbursement for providing 
clinical services to tribal veterans eligible for VA services.
    Our recommendations.
    Freedom of choice. Our veterans should be free to choose 
their care based on where they can secure the highest quality 
services. Veterans who choose to utilize tribal health centers 
and our providers as their primary care sites are not able to 
access their VA benefits. Currently, the VA Choice Card does 
not list tribal clinics as reimbursable entities for providing 
the care as a referral from the VA.
    MOAs should be entered into immediately. We recommend that 
the tribal healthcare programs be reimbursed for both direct 
service and referred care when veterans find tribal health 
programs more accessible and more accommodating to their needs. 
I urge Congress to instruct the VA to set up a process that 
allows reimbursement for eligible services provided by tribes. 
We would love to be part of that solution, including our 
transportation.
    My tribe has identified a lack of consistent and reliable 
transportation to access many services that directly impact 
quality of life, including health, education, and employment. 
Available transportation across the Upper Peninsula is only 
provided at night. You have to leave at 12:30 a.m. to get there 
at 8:00 a.m., and that is not very good for them having a 
clinic visit the next day.
    We recommend that the VA reimburse tribal governments 
providing Native veterans transportation to primary and 
specialty clinics and follow-up care. Most American Indian 
veterans live in remote areas of the United States, and the 
cost of transportation to and from veterans' healthcare 
facilities causes substantial hardship on these veterans 
seeking care.
    Throughout the history of the United States, Native 
Americans have fought greatly and sacrificed for this country. 
This proud tradition continues to this day with 24,000 active-
duty American Indians. The 2010 U.S. Census identified at least 
152,000 Native American men and women who have served this 
country in the Armed Forces. All veterans, including our Indian 
warriors, gave their best. Some gave all. In turn, they deserve 
our best, the best this country can offer.
    Again, we stand ready to be part of the solution. Thank 
you.

    [The prepared statement of Aaron A. Payment appears in the 
Appendix]

    Dr. Benishek. Thank you.
    Mr. Harrington, you are recognized for 5 minutes.

                STATEMENT OF ANTHONY HARRINGTON

    Mr. Harrington. Chairman Benishek, Ranking Member Brownley, 
thank you for giving me the chance to testify today. I am a 
disabled veteran and I live here in Sault Ste. Marie.
    As you both know, there is a VA clinic here. The clinic has 
been here for many years, but more than two years ago the 
attending physician retired. In the interim, part-time doctors 
have been trying to pick up the slack, and a nurse practitioner 
has been brought in to replace the retired physician.
    I truly and deeply believe that our veterans should be 
entitled to proper healthcare. This specific VA clinic serves 
the entire Eastern Upper Peninsula. They are a very busy 
facility with many patients from across the region. I found out 
that just in Chippewa County alone, there are over 3,000 
veterans, just in this county alone. The facility is having 
trouble keeping up with the number of patients, and its quality 
of care is suffering as well. The nurse practitioner, although 
very good at her job, can only do so much within the guidelines 
of her job description and abilities.
    Currently as it stands, the nurse practitioner can only see 
a maximum of six patients a day--if that has changed, I don't 
know--and is limited as far as what she is allowed to diagnose 
and treat. The facility is in desperate need of a full-time 
attending physician as well as the current nurse practitioner 
to adequately care for the entire region and its patients.
    Recently they hired a physician's assistant here. While 
that is a good step, it is really not a replacement for a full-
time doctor. And the people from Iron Mountain at the last 
meeting said that their hands were tied, they couldn't hire 
anybody else, they couldn't hire a doctor. They were only 
allowed through the VA a nurse practitioner. Then they turn 
around now and they hired this physician's assistant, but they 
can't get a doctor.
    I just want to know why they were able to bring a PA if it 
wasn't possible for them to bring a doctor. I have been told by 
Iron Mountain VA officials that they were only authorized to 
hire a nurse practitioner, and then all of a sudden the PA 
shows up. That doesn't make sense to me.
    Prior to the hiring of the nurse practitioner I was seeing 
a doctor by the name of Lisa Vanhevel at the Bay Mills Indian 
Clinic. The reason I turned to the Indian clinic instead of the 
VA clinic was due to the lack of an attending physician at the 
facility. While under Dr. Vanhevel's care we talked quite 
extensively about the need of a full-time doctor at the VA 
clinic. She told me that her contract with Bay Mills was coming 
to an end and made her intentions clear that she was interested 
in interviewing for the position at the VA clinic.
    Upon following the proper channels she was then granted an 
interview at the VA clinic in Iron Mountain, Michigan. Sometime 
later I happened to run into Dr. Vanhevel at Wal-Mart and she 
informed me that her interview went well and she was offered a 
position at the Sault Clinic, as well as the Iron Mountain 
clinic. She stated that she was only offered two days a week 
through our facility or a full-time position in Iron Mountain. 
She explained that she had to decline both positions because 
she didn't want to move to Iron Mountain or commute 295 miles 
away for work. She also didn't want to take a position for only 
two days a week.
    Dr. Benishek, Ms. Brownley, I am sure you can sympathize 
with her. Who in their right mind would want to take a position 
for two days a week following a contract where they had a full-
time position? This was very concerning to me considering the 
dire need for a full-time attending physician here.
    In addition, Dr. Benishek's staff has told me that prior to 
the hiring of the PA, Benishek's office was told by the VA that 
they were going to try to hire a doctor. However, despite what 
Benishek's office was told, we have seen no evidence that an ad 
was ever placed on usajobs.com, or that any ads were placed in 
UP newspapers. I would like to know what exactly was done to 
try to get a doctor here.
    I am glad that Congress is finally investigating this 
issue. I have yet to have someone explain to me why it is that 
the veterans in this area are not entitled to a VA facility 
with a full-time doctor and quality healthcare.
    Thank you again for having me here today. I truly hope that 
you will take the time to look into this matter and serve 
justice to our vets as we have selflessly served you and this 
country. It is my hope that you will confer with the new 
director of the VA and that you can come to an agreement to 
resolve this.
    Thank you very much.

    [The prepared statement of Anthony Harrington appears in 
the Appendix]

    Dr. Benishek. Thank you very much for your testimony.
    Commander Pearce, you are now recognized for 5 minutes.

                  STATEMENT OF DAVID W. PEARCE

    Mr. Pearce. Congressman Benishek, Congresswoman Brownley, 
committee staff, and fellow panelists, thank you for the 
opportunity to appear before you today on behalf of the members 
of Veterans of Foreign Wars Post 3676 and approximately 58,000 
Upper Peninsula of Michigan veterans, one of this great state's 
most valuable resources. I feel qualified to provide input, 
within my scope, as I am a retired service member, disabled 
veteran that uses the VA healthcare system and the commander of 
the Welsh-McKenna VFW post here in the Sault. I served this 
great nation of ours for over 20 years as an active duty 
soldier in the United States Army. I was also born and raised 
in the Eastern Upper Peninsula and returned home to Sault Ste. 
Marie upon the completion of my military career.
    First, I would like to commend the Veterans Administration 
for recognizing a problem in the care of our veterans that live 
in rural areas. Speaking from my personal experience with the 
VA healthcare system, I believe the VA is moving in the right 
direction. There is still much more room for improvement.
    Improvements have been gained in the last several years 
with my access to care. When I started to use the VA healthcare 
system, it was not uncommon to drive all the way to the Iron 
Mountain VA hospital for an appointment or test. The Oscar G. 
Johnson VA Medical Center in Iron Mountain, Michigan is the 
closest facility. Some of those appointments were a simple 15- 
to 20-minute doctor visit that would require a four-hour drive 
one way, or an entire day off work. Most recently, the VA has 
scheduled appointments for me at the local hospital or sent me 
an authorization to seek care locally. I am satisfied with the 
improved choice options; however, there are bugs to be worked 
out.
    One is with billing. As a retired service member, I also 
use Tricare for medical insurance. Several times when I 
received care locally, my healthcare insurance was billed and 
not the VA. The response time is very slow when trying to get 
the medical bills routed in the right direction.
    I also feel that local access to healthcare for our aging 
veterans should be a priority. I am still relatively young. It 
is not as much of a burden for me as it is for some of our 
older veterans to receive care. In our community here in the 
Sault, there are several assisted-living facilities and nursing 
homes with elderly veterans that do not have the physical 
capability to travel great distances to receive care from the 
VA. Improved choice could help with that issue.
    I would like to comment that for me personally, the My 
HealtheVet website is a great asset to access care, re-fill 
prescriptions, and communicate with the local community-based 
outpatient clinic through secure messaging. That was a great 
idea for those of us who are computer literate. However, it is 
not such a great choice for those that are not familiar with 
using a computer or do not have access. Many of our older 
veterans do not use a computer.
    Another issue with improved choice that should be addressed 
is the lack of specialized care and women veterans' healthcare 
access in a rural environment. I am not sure how to address 
these topics specifically, but they definitely need to be 
looked into and more options for care need to be available for 
all veterans.
    Appropriate staffing is a concern. Soon after my retirement 
from active duty I started using the VA community-based 
outpatient clinic located in Kincheloe, Michigan. The clinic 
was relocated to Sault Ste. Marie a few years later. I 
personally think the staff at the Sault Ste. Marie CBOC is 
absolutely wonderful. I interact with the staff at the local 
clinic several times every month for my own appointments. They 
are always helpful and friendly. The only concern I have is 
there is not a permanently assigned medical doctor at the 
clinic. The physician's assistant does a great job, but I feel 
there should be a full-time M.D. assigned to the clinic also.
    When the doctor that was assigned to the clinic retired, 
the position was filled several times temporarily until the 
physician's assistant was hired. That created a lack of 
continuity in care. I feel due to this lack of continuity, 
mistakes were made and treatment was not appropriate.
    During that time I also had an appointment with a physician 
located in Iron Mountain through video chat. I felt that 
appointment was very impersonal and not effective at all. On 
another occasion, I drove to Iron Mountain for a video 
conference with a doctor located in Milwaukee and some online 
testing. That, I feel, could have been accomplished at the 
clinic in Sault Ste. Marie. Now put yourself in a World War II 
veteran's shoes. Imagine how overwhelming and confusing the 
video conference could be to them.
    Again, it is a great honor to have the opportunity to 
participate in this valuable discussion regarding the care of 
our veterans. This concludes my testimony. I am prepared to 
take any questions. Thank you.

    [The prepared statement of David W. Pearce appears in the 
Appendix]

    Dr. Benishek. Thank you very much, Commander Pearce.
    Commander Howard, you are recognized for 5 minutes.

                    STATEMENT OF DON HOWARD

    Mr. Howard. Actually, it is Don Howard, Chairman of the 
Veterans Affairs American Legion, State of Michigan. Thank you 
for having me today.
    Aaron Payment stole my--I paid for it, he copied it. It was 
funny, we were standing out there talking and were exactly 
saying.
    Over a year ago, I had the opportunity to come up and visit 
with Aaron's staff--Bonnie Kaufa, Tony Abramson, Mark Willis, 
and Tom Tefnel--and we learned when I came up the first time, 
first meeting with them, that their staff was not aware of the 
fact that many of their veterans were entitled to pensions, aid 
and attendance benefits, disability and such. So we took it on 
to start training their nurses. Since then it has really, 
really picked up.
    Since then we moved our service offices into their clinics, 
which has proven to be a major asset and it is really, really 
going strong.
    What we have learned in the State of Maine, the State of 
Washington, the VA uses MOUs with the tribal health systems, 
IHS I believe. Am I correct? The IHS systems. And again, the 
Sioux Tribe has volunteered to see every veteran, every 
veteran, whether it be Indian or not. They are willing to work 
with Iron Mountain.
    We have tried for the last year-and-a-half to work with 
Iron Mountain. They are dragging their feet, non-cooperative. 
We don't know where to go from here. I did have a discussion 
with Danny Pummill, the Under Secretary of the VA in 
Washington, DC., and his staff indicated that that is the 
direction. I met him actually in Washington, DC. His father 
actually lives south or just north of Escanaba, the VA 
Secretary.
    What we would like to see is have you guys encourage a 
roundtable with all concerned--the tribes, the seven tribes in 
the UP, Iron Mountain, Danny Pummill's staff out of Washington, 
DC, and yourselves to oversee it, just like the UAW and Ford 
Motor Company negotiations. We could hold this right here in 
Manistique, plenty of room, and if it takes 4 to 40 hours, get 
this fixed, make the UP the model for the rest of the state. 
These veterans deserve better up here.
    My family is from Singleton. I spend my summers up here. I 
live south of Detroit now. I think this can be done. I know we 
have the willingness between the tribes, and that is all we 
need is some help from you, both of you and the VA, and to 
bring this and put this together and work it out.
    That is all I have to say. Thank you.

    [The prepared statement of Don Howard appears in the 
Appendix]

    Dr. Benishek. Thank you, Mr. Howard.
    Is it Ms. Haske or Haske.
    Ms. Haske. It is Haske.
    Ms. Haske, you are recognized for 5 minutes.
    Ms. Haske. I would like to decline at this time. I am too 
scared.
    Dr. Benishek. You don't have to be scared. Just tell us any 
issue that you are having with the VA.

                 STATEMENT OF JACQUELINE HASKE

    Ms. Haske. I am Jacqueline Haske, the Chippewa County 
Veterans Affairs Officer. Mine is piggybacking on everybody 
else.
    My main concern is having a doctor in the community. One of 
the issues we have is if a veteran comes to the community as a 
new veteran, they are unable to be seen by a doctor if they 
have the Choice Card because several of the doctors are not 
receiving new patients at this time. So our concern is not just 
because of the need for a doctor in the area, but the doctors 
with the Choice Card are refusing, and that is all.

    [The prepared statement of Jacqueline Haske appears in the 
Appendix]

    Dr. Benishek. Is there anything else you would like to tell 
us?
    Ms. Haske. No, sir.
    Dr. Benishek. All right. That was just fine.
    In that case, I will recognize myself for 5 minutes to ask 
a few questions.
    Chairperson Payment, tell me about this Memorandum of 
Understanding to get the tribal healthcare to be provided 
through the VA. Has the VA talked to you? Have there been any 
negotiations with them? Where are you at with that?
    Mr. Payment. Well, first let me say what the young lady 
said was very impactful even though it was few words, because 
that is another issue. The Choice Card alone doesn't get it 
done. You have to have doctors who are willing to see you. We 
do have doctors who will see Medicaid patients or welfare 
patients, and in this case it is kind of sickening to me that 
they wouldn't see a veteran who has the ability to pay for the 
care.
    So we stand ready to be able to see veterans in our clinic, 
and we also pledge that--sometimes it is hard to get into our 
clinics too, but if we come to an agreement with an MOA, we 
would be willing to designate a physician that would primarily 
see veterans and then can do overflow for others.
    Dr. Benishek. Why don't they have that agreement already? 
What is the story?
    Mr. Payment. I think we have. We do have it with dental. So 
we have seen that the model can work. I think the bureaucracy 
and the weight of the bureaucracy and the fear of dismantling 
the existing bureaucracy is probably a threat.
    So I would say what Congress should do is you should direct 
them. You should give them a timeline, and we can work it out. 
I like the idea of 4 hours or 40 hours to iron it out. We have 
proven we can do it. We do it with our dental services right 
now. And we have clinics in Manistique, and I think they would 
probably be willing to extend their services as well.
    So I think if you order it and you give them a timeline by 
which they have to do it, it will get done.
    Dr. Benishek. How long have you been in negotiations with 
them? A year-and-a-half?
    Mr. Payment. Yes, about a year-and-a-half.
    Dr. Benishek. Mr. Pearce, you mentioned the fact that the 
billing is a problem sometimes if you see somebody outside the 
VA. Can you elaborate on that a little bit more?
    Mr. Pearce. Congressman, I think that is primarily issues 
due to hospital billing, not necessarily the VA. I will get co-
pays that I end up with because they bill Tricare instead of 
the VA. A lot of times it doesn't matter if I actually take the 
consent form with me and turn it in at the hospital. For some 
reason it gets billed to my primary health insurance instead of 
the VA.
    Dr. Benishek. Are there any problems that you are aware of 
with your record when you go to an off-site facility, any of 
you or Ms. Haske? Do you know of a situation where a patient's 
record of the care they had received outside the VA, is that 
getting back to the VA so they are keeping track of what care 
you had and where?
    Mr. Pearce. Yes, it does, Congressman. You have to make 
sure that happens. I do personally take care of that myself to 
make sure it gets in my VA record also.
    Dr. Benishek. Ms. Haske, are you familiar with any problems 
in that regard?
    Ms. Haske. With the records?
    Dr. Benishek. The records, making sure that the veteran has 
a continuous record of his care outside. Is that happening that 
you are aware of?
    Ms. Haske. Yes.
    Dr. Benishek. All right. Great.
    Our second panel of VA witnesses are going to testify that 
the VA provides patient-centered care to approximately 15,000 
of the 30,000 veterans that reside in the Upper Peninsula. Do 
any of you want to comment? Do you think that the VA is 
providing patient-centered care in the Upper Peninsula? Anyone 
want to comment on that?
    Mr. Howard, do you have any comment on that?
    Mr. Howard. I really don't.
    Dr. Benishek. Do any of you know if it is because----
    Mr. Howard. From input from one of my veterans, he faced 
the same issue with having to travel across the Upper Peninsula 
to get to a visit and then leaving that visit, coming back to 
the Sault, and then getting a phone call once he gets back 
that, oh, we have an opening for you tomorrow. It seems like 
that should be able to be addressed while you are there so he 
didn't have to drive three hours and then drive all the way 
back, and then drive all the way back. That is not patient 
centered. That is getting weighted down by the weight of 
bureaucracy and not taking a moment to do continuity of care 
and say, okay, what is next for this patient. That didn't 
happen. So I would say that is not patient centered.
    Dr. Benishek. No, I can definitely agree with you there. 
And frankly, that kind of stuff happens all the time, where 
patients have to drive, here in the Sault, a good four hours, 
and just that drive, as many of you have related, eight hours 
to get there and back for a 20-minute appointment, does seem a 
little bit on the ridiculous side.
    I already have followed up on many of the issues that you 
have brought up here today with the VA panel that is coming up 
next, so I really appreciate bringing up all this stuff, and I 
am going to yield to Ms. Brownley for her 5 minutes of 
questioning. We may have another round of questions as well.
    Ms. Brownley.
    Ms. Brownley. Thank you very much. My staff helped me to 
prepare some questions for you, and the first question was what 
is the number-one barrier in terms of receiving access to VA 
healthcare? And it sounds to me--tell me if I am wrong--that it 
is access to a physician, a medical doctor. Would everybody 
agree that that is probably the number-one barrier?
    So I guess the question that I would ask is if the Choice 
program was working perfectly, which it is not, and we are well 
aware of that, but if it was working perfectly, are there 
doctors in your communities, primary physicians and specialty 
care physicians in the community that you could access? Because 
sometimes that is a problem outside of the VA in rural areas. 
The doctors aren't there either. So I am just curious to know 
whether you have a sense within your own communities whether 
the doctors are there.
    Mr. Howard. Well, the Sioux tribes, all their clinics are 
pretty much centrally located throughout the UP, and access to 
their clinics are a reasonable distance. To give you an 
example, there is a gentleman out here, sitting right behind me 
out here, that drives from here to Escanaba. We have patients 
that are on oxygen. Well, they are not allowed to ride that bus 
because the oxygen is dangerous. So they have to find other 
means to get all the way over to Iron Mountain for a C&P exam 
because Iron Mountain says we have no doctors that are 
qualified on the outside to do C&P exams. This individual may 
have cancer, diabetes, whatever, and he has to find his own 
way. In many cases these people haven't been working, so they 
don't have the funds to get there.
    Why we cannot train doctors from the tribes to do C&P exams 
to keep these people from traveling across icy roads 300 miles 
I think is insane, absolutely insane. Plus, we are paying 56 
cents a mile. We are wasting Federal tax dollars when we can do 
it locally. It just doesn't make sense. We have everybody on 
board to work together. We need the help to push the VA ahead. 
Thank you.
    Ms. Brownley. That is very good. Well, I would just like to 
comment that particularly the Choice program, the new program 
provided by the VA, the Choice program was designed for areas 
particularly like the areas here, and we have got to figure out 
how to make that work. I know in my own district I had--I don't 
know who the provider is here. In my district for the Choice 
program, the health plan is TriWest. I don't know what it is 
in--it is Health Net in Michigan.
    So I had the TriWest folks come out to my district to meet 
both with veterans to help them understand the program because 
it hasn't been very clear, and we made amendments back in 
Washington that have passed to make the Choice program work 
better. But the main barrier, at least in my district, is there 
are no doctors to access through the Choice program because the 
doctors have to be part of--what's the program?--Health Net. 
The doctors have to be part of Health Net.
    So we had a meeting in our district, and I tried to invite 
all the healthcare providers in our region to help them to 
understand how the program works to try to recruit more doctors 
into the program.
    But I will just make the comment that we have to make 
sure--I mean, this is the perfect place to ensure this Choice 
program is working, because it was designed for you and for the 
veterans across this region because you are so rural and have 
less access to healthcare than veterans do in other parts of 
the country. So somehow we have to figure that out and we have 
to provide more providers that are in the program and simplify 
it so that veterans know that they have access to local 
doctors, and with Choice, a doctor cannot provide--I can't 
remember who talked about the doctors not being available in 
the Choice program, but the doctors have to be part of the 
program, and the VA has to approve that appointment before the 
veteran can utilize it.
    But I think the biggest barrier for the Choice program to 
work is actually having the providers in the program to do 
that. So we have to figure that one out.
    Dr. Benishek. Thank you, Ms. Brownley.
    Ms. Brownley. I yield back.
    Dr. Benishek. I am going to ask a few more questions while 
we have you here, because once we get the VA up there, then I 
am not going to have the opportunity to do that.
    I just want to mention, Mr. Pearce, you talked about this 
telehealth appointment not being very effective or being very 
personal. So I would like you to expand on that a little bit, 
because the comments that I have heard about the telehealth 
from the VA and from some other people have been positive. So 
can you kind of relate more about your experience with that?
    Mr. Pearce. Yes, Congressman. I believe it is impersonal 
because I am more of a face-to-face type of person. I don't 
like talking to a camera, basically. You can see the picture of 
the person on the camera, but you don't see body language, you 
don't see--I am not a real well-versed person, so I rely on 
other senses in a personal setting.
    Dr. Benishek. Did you relay those sentiments to the staff?
    Mr. Pearce. Yes, I did.
    Dr. Benishek. And did they appreciate your input?
    Mr. Pearce. Oh, yes. They definitely appreciated my input.
    Dr. Benishek. But is there any way to improve that? Was it 
a really small picture? Was--you didn't understand the person? 
I am just trying to----
    Mr. Pearce. There wasn't a language barrier or anything, 
but I just felt it was impersonal, talking to a camera instead 
of an actual person.
    Dr. Benishek. Mr. Harrington, do you have a thought on 
that?
    Mr. Harrington. Well, I have done this before at the VA. It 
was not personal. Somebody said on the camera or screen, you 
don't get a rapport going like you can with a doctor. 
Eventually you go see the doctor and they understand your 
health because you can relate that to them and they know you. 
But to talk to somebody that is on a camera, it is like ``Hi, 
how are you?'' I mean, it would be like talking on the 
telephone here in Washington. You are here now, I can look at 
you, you understand where I am coming from, I understand what 
you are trying to do.
    So to me, it is just not a personal thing. I like to be in 
front of a doctor and talk to a doctor. If I have an ache or a 
pain, I can explain it to the doctor and then go from there. 
But how do you do that with somebody who is 300 miles away?
    Dr. Benishek. Chairperson Payment, I understand your tribe 
is making an effort to collect more accurate information about 
the number of American Indian veterans that live in the Eastern 
UP. Do you have that data that you can share with our office to 
help us identify those veterans? We are trying to make sure we 
have accurate numbers as well. Can you elaborate on that a 
little bit?
    Mr. Payment. We have a commitment to our veterans because 
it is a continuation of our rural society, and for a number of 
years we have been reaching out. We have our veterans wall over 
at our ceremonial grounds. But the challenge that we found out 
was we don't have any registry of who our veterans are. We 
don't have that as part of the membership. We have reached out 
through communications in our newspapers with them, but because 
of various reasons and because of different times when people 
have served, people aren't always willing to volunteer that 
information.
    So now what we are doing is we have a dedicated person who 
works with our veterans. We are doing a little bit now. I think 
we should be doing a lot more. So we are identifying our 
veterans when they come in so we can record that so we can then 
try to bring access to them. We have done a census. Our last 
census we collected aggregated data without names. So we don't 
have the names of them, but we do have numbers of how many 
veterans that we have.
    But we need to do more of that. We need to find a way to 
make them feel comfortable with identifying themselves as 
veterans. We have some veterans who are very good at that 
because they are trying to reach out and advocate for other 
veterans. But we do have some still who don't bring that to the 
forefront. So we need to do whatever we can to bring the 
services to them rather than wait for them to come to us, 
because already when they are rejected by either the VA or 
whatever services, that is just salt in the wound. So we need 
to find a different way to reach out to them.
    Dr. Benishek. Is there anything else that any of you would 
like to say to me now while you have the opportunity?
    Mr. Harrington.
    Mr. Harrington. Yes, sir. To give you an example of the 
waste, I went to the doctor that was in the Sault district for 
a little while, and they wanted to reevaluate my ears. I go all 
the way to Iron Mountain. I did the whole hearing test, 
everything. I come back home and I didn't hear anything because 
it was for a compensation thing.
    A month later I get a call, ``You have to come back to Iron 
Mountain.'' I said what for? ``You have to have this hearing 
test done all over again.'' I said why? I just had it done. 
``Well, this doctor has to do it, okay?'' So I drive all the 
way to Iron Mountain. That doctor did the exact same test that 
I had done. And while I was in there, one of my hearing aids 
was not working right. So I asked the doctor, I said could you 
possibly adjust this? ``Oh, I can't do that.'' Well, is there 
somebody else? ``No, they are not here. You have to make an 
appointment to come back up here to get your hearing aid 
adjustment.''
    [Laughter.]
    Mr. Harrington. So I finally was able to send it to them, 
and they thought they fixed it, and it still isn't fully fixed. 
So that is just a waste, a waste of time.
    And one more point. I went up to this VA clinic and I 
talked to the lady at the front desk, and I was trying to get 
some information, not personal information, just trying to get 
some information about how many vets were registered there. She 
acted like she was appalled that I was trying to get a doctor. 
``We don't have room for a doctor. We have a nurse 
practitioner, and now we are getting a physician's assistant.'' 
I said, well, you had room for a doctor before. She said 
everything is fine, we are not having any problems.
    I left there, went to have a coffee where vets go, and I 
run into--I have the guy's name. I won't mention it, but I do 
have it. This man waited five weeks for an appointment here so 
he could go in there and they could refer him to the clinic of 
the Sioux Tribe to get x-rays--five weeks. This just happened, 
and I have his name here.
    I also have Dr. Vanhevel's contact information if you would 
like me to share that with you folks. She is the doctor who 
actually interviewed with them. They say it wasn't an 
interview, and I still can't believe that a person would drive 
295 miles just to have a chat, and she was honest.
    Dr. Benishek. Thank you, Mr. Harrington.
    I am going to yield to my friend here, Ms. Brownley from 
California, once again.
    Ms. Brownley. Thank you, Mr. Chairman.
    I just wanted to ask very quickly, for the CBOCs, the 
community health clinics that you have here, are they VA-run or 
are they subcontracted out? They are all VA-run? Okay, very 
good. I know in my district it is subcontracted out, and that 
presents another big problem, because if you go up to the front 
desk of my CBOC, they can't answer questions related to the VA 
because they are subcontracted out. That becomes a very 
frustrating element.
    Mr. Howard. In Manistique, Michigan, they have a CBOC, and 
some of the veterans refer to it as a band-aid clinic. They go 
in there for chest colds or whatever. That is what Iron 
Mountain--chest x-rays. Four miles down is a brand new Sioux 
Tribe facility--eyeglasses, hearing aids, dental, x-rays. You 
name it, they do it right there. Instead of sending them 4 
miles, we are going to send them 170 miles.
    Ms. Brownley. That is crazy.
    Mr. Howard. It is insane. When these people are going out 
of their way saying we are going to help you, you are kicking 
the can down the road. They are afraid that they may take some 
of their work away and maybe their VA will have to lay off a 
few people. Exactly. That is a problem. But is it fair to send 
a veteran 170 miles across the ice? No. A major problem.
    Ms. Brownley. And I would just say that--and I don't know 
if anyone can handle this question, but to try to understand in 
terms of hiring doctors, is the VA not hiring the doctors 
because the physician hasn't been approved, or are they trying 
to hire doctors and can't find the doctors to fill the 
positions but will wait for the next----
    Mr. Howard. The reason they aren't hiring the doctors, the 
point here in the UP is the traffic.
    Ms. Brownley. Right. No, no, no, I get your point 
completely, and I think the whole MOU and trying to figure that 
out, it certainly sounds--based on what I am hearing, it sounds 
like that is the right path to travel to resolve a lot of these 
issues. I think probably the Choice program and an MOU and 
putting it all together would really go a long ways in terms of 
access to quality healthcare and not having to travel for it.
    Mr. Howard. Please keep this in mind: 4 hours or 40 hours, 
we don't care.
    Ms. Brownley. Yes, I hear you. I hear you on that.
    And I just wanted to comment on the telehealth that I 
understand in terms of both of you saying it is an impersonal 
experience, and I hear that a lot from veterans as well. I 
think we have to continue to keep working on that. I do think 
if you are in a CBOC and, as you said, it is a band-aid clinic, 
but at least if you can have the nurse practitioner or whoever 
is there sitting with you, if you approve of that, because you 
would have to approve that, but sitting with you, because the 
reason you are going to telehealth is typically because you 
need to talk to another specialist of some sort and those 
services aren't provided, to figure out a way in which we could 
make it a more personal experience.
    I know in my district, telehealth works for some people. 
Some people like that. And I have found, I have heard from at 
least my veterans, particularly around mental health, that they 
like the telehealth process because they can do it in the 
privacy of their own homes, they don't have to go to a clinic. 
Sometimes people are embarrassed about reaching out for mental 
health services, so they don't have to be seen within their 
community, it can be very private.
    So I do think that telehealth is a pathway here. It is not 
a panacea or the ultimate solution, and I think it works for 
some and it doesn't work for others. And we have got to be 
able--the VA has to be nimble enough to be able to utilize it 
and make it happen. But ultimately, we are not doing a good job 
unless the client, the patient, the veteran is satisfied with 
their healthcare.
    So, thank you, Mr. Chairman.
    Dr. Benishek. Thank you, Ms. Brownley.
    Well, thank you for being part of our hearing this morning. 
You are excused.
    We are going to ask the second panel to come up and give 
their testimony.
    We certainly appreciate your participation.
    [Pause.]
    Dr. Benishek. We will welcome our second and final panel of 
witnesses to the table. Joining us this morning from the 
Department of Veterans Affairs is Gina Capra, the Director of 
the Office of Rural Health. Ms. Capra is accompanied by James 
Rice, the Acting Director for VISN 12 and the Director of Iron 
Mountain VA; and by Dr. Gail McNutt, who is the Chief of Staff 
of the Oscar G. Johnson VA Medical Center in Iron Mountain.
    Thank you all for being here this morning.
    Ms. Capra, you can proceed with your testimony when you are 
ready. You are recognized for 5 minutes.

  STATEMENTS OF GINA CAPRA, DIRECTOR, OFFICE OF RURAL HEALTH, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
 AFFAIRS; ACCOMPANIED BY JAMES RICE, ACTING NETWORK DIRECTOR, 
    VETERANS INTEGRATED SERVICE NETWORK 12, VETERANS HEALTH 
 ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND GAIL 
   MCNUTT, M.D., CHIEF OF STAFF, OSCAR G. JOHNSON VAMC, IRON 
MOUNTAIN, MI, VETERANS INTEGRATED SERVICE NETWORK 12, VETERANS 
   HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                    STATEMENT OF GINA CAPRA

    Ms. Capra. Thank you, sir. Good morning, Chairman Benishek 
and Ranking Member Brownley. Thank you for the opportunity to 
be here at the National Guard Armory in Sault Ste. Marie to 
discuss rural health and staffing concerns. I am accompanied 
today by Mr. James Rice, Acting Network Director for Veterans 
Integrated Service Network 12; and Dr. Gail McNutt, Chief of 
Staff for the Iron Mountain VA Medical Center. Dr. McNutt is 
also the co-chairperson of the National Patient Aligned Care 
Consultant Team.
    Individuals living in rural areas have traditionally been 
underserved with regard to healthcare access. The reasons for 
this are multiple, but they stem from long travel distances to 
reach healthcare facilities; lack of health insurance; and an 
inadequate number of healthcare providers, particularly 
specialists working in rural areas.
    Currently, 3 million rural veterans are enrolled in the VA 
healthcare system. They account for approximately one-third of 
all VA enrolled users.
    The Veterans Health Administration's Office of Rural Health 
envisions an America where veterans thrive in rural 
communities. Our mission is to improve the health and well-
being of rural veterans by increasing access to care and 
services. We accomplish this mission through collaborations 
with other VA program offices, Federal and state partners, and 
local communities.
    Accessible and quality healthcare for rural veterans is 
possible through a combination of VA community-based clinic 
expansion, increased partnership with rural community 
providers, the use of telemedicine and health information 
technology, and new efforts to recruit and retain healthcare 
providers to rural areas.
    At VA, we are continuously working to increase access to 
care for rural veterans through innovative programs. Here are 
several examples.
    A mental health case management program called the Extended 
Rural Access Network for Growth Enhancement or E-RANGE program 
provides severely mentally ill veterans with intensive support 
services to improve their quality of life. It increases 
independent community living, and it connects veterans with 
available local resources for support and care. The Iron 
Mountain VA Medical Center has successfully implemented and 
sustained this program.
    Another example is the Rural Veterans Transportation 
Program which supplies vehicles and drivers that transport 
veterans to and from their VA medical appointments. This 
program saves veterans personal driving time and reduces missed 
appointments. The Iron Mountain VA Medical Center is a 
successful participant of this program as well.
    A final example highlights the importance of health 
information exchange and its intent to increase care 
coordination between veterans, their VA providers, and the 
community providers who care for them. This effort is 
facilitated by a cadre of rural health community coordinators 
and increases the utilization of the virtual lifetime 
electronic record, also known as VLER. These coordinators work 
to ensure that each veteran's community provider is among the 
trusted partners with whom VA will share health information. 
Again, the Iron Mountain VA Medical Center is a current 
participant in this program.
    In the area of workforce recruitment and staffing, VHA is 
expanding efforts and strategies to fill vacancies for 
positions that are critical to our mission. VHA's Workforce 
Management and Consulting Office, in collaboration with the 
Office of Rural Health, is working to determine where and what 
types of providers are in short supply at rural healthcare 
facilities; to explore and promote the use of VA financial 
incentives and other innovative solutions to recruit providers 
to rural VA facilities; to determine best practices in rural 
provider recruitment and retention; and to develop, expand, and 
support clinical training opportunities for rural healthcare 
practitioners so we can retain them in rural areas.
    In addition, VHA employs a national advertising campaign 
aimed at recruiting clinicians for rural patients. This 
recruitment is possible through VHA's partnership with the 
National Rural Recruitment and Retention Network, or RRRNet. As 
a result, VHA has access to a robust database of candidates 
interested in serving veterans in VA's rural sites of care.
    In conclusion, VA is committed to providing high-quality, 
safe and accessible care for our veterans. We continue to focus 
on improving veterans' access to care. While rural locations 
present unique access challenges, VA's rural health programs 
are robust and will continue to serve veterans in rural areas.
    We sincerely appreciate the assistance we have received 
from your committee in particular and Congress as a whole, our 
partners at the local veterans' service organizations, Native 
American tribes, and key non-profit stakeholder groups. We 
would not be able to provide the necessary care to our rural 
veterans without the support and dedication of our partners.
    Mr. Chairman, this concludes my testimony. My colleagues 
and I are prepared to answer any questions you or Congresswoman 
Brownley may have. Thank you.

    [The prepared statement of Gina Capra appears in the 
Appendix]

    Dr. Benishek. Thank you, Ms. Capra.
    Frankly, I am a little disappointed with your testimony. I 
mean, it sounds like you are doing everything just wonderful 
from that testimony. But as you heard from the first panel, 
there are a lot of problems. What you have heard here today is 
only an example of what is going on I think, across the 
country. You said all great stuff there in your testimony, but 
let's talk about some of the things that are actually going on.
    One of the things I want to start out with is could you 
provide my office with the recruitment documentation of the 
recruitment efforts that have occurred to fill the position of 
a physician here in Sault Ste. Marie? Could you provide that to 
us in maybe the next 30 days?
    Ms. Capra. Yes. I would also like to ask Dr. McNutt or Mr. 
Rice if they could address that situation as well.
    Dr. Benishek. Can you say yes to that question?
    Ms. Capra. Yes.
    Dr. Benishek. Great.
    So what is the story, Mr. Rice or Dr. McNutt? Do you know 
what the story is here? We have heard some contradictory things 
here. I think we are trying to get a physician here, and yet we 
don't have one. And then some people testified that they are 
not trying to get a physician here, or only a part-time. So I 
don't know what the real story is. What has been going on, and 
when are we going to get a doctor here?
    Mr. Rice. Okay. So Dr. Solomon retired in 2013 and we 
started our recruitment for a full-time physician. The job was 
advertised multiple times on usajobs, however, if a physician 
approached us, we can hire them without the job being 
advertised. So one of the things I did, I sent an email message 
to the CEO War Memorial to see if he could help us in our 
recruitment efforts, and all that he could provide at that time 
was mid-levels. So then I reached out and got a listing of all 
the providers in Chippewa County and I personally sent them a 
note asking if they were interested in coming over to the VA. I 
had one physician who was thinking about shutting down his 
practice, but it would be two to three years.
    The number of times the position has been advertised in the 
newspaper was 25 times prior to us hiring the NP and 19 times 
since. We made the decision, or I made the decision as the 
Director that after recruiting for the position for over a 
year, it was in the best interest of our veterans to hire a 
mid-level, so I take full responsibility for that. We felt a 
clinic with a provider was better than not having a provider at 
all.
    The panel size at the clinic was 1,187. A full-time 
provider who could handle 1,200 patients--mid-level, 900. 
During that time we were approached by an NP from the Battle 
Creek VA. They grew up in the UP and wanted to relocate. So we 
hired that individual, and then she ended up retiring, and then 
just this past month we hired an additional PA. So we can cover 
a panel of about 1,500 patients.
    One of the things, I know not everybody is satisfied with 
telehealth, but telehealth is the way we conduct for patients 
that are more complex, back to the medical center where they 
direct care from a physician.
    Dr. McNutt can add to that.
    Dr. McNutt. Congressman Benishek, I would like to add two 
things, actually. The first is in reference to the physician 
that was brought up during the first panel. I personally worked 
hand in hand with HR to recruit for all of our CBOCs at Iron 
Mountain. The day that that physician's name was handed to me 
as somebody who might potentially be interested, I was on the 
phone to her that night.
    She indeed did interview with me twice. She was offered a 
full-time position and declined.
    Dr. Benishek. I understand that that was here in the Sault.
    Dr. McNutt. Yes. I offered her either the Sault or Iron 
Mountain.
    Dr. Benishek. Oh, I see.
    Dr. McNutt. And she declined the position.
    I agree with Mr. Rice's testimony that we often advertise a 
position----
    Dr. Benishek. Is there a particular problem with physician 
recruitment? I mean, what is the basic problem, Mr. Rice? Is it 
they are not accepting the salary, or it is just hard to get 
somebody up here? I mean, you have the same problem at Iron 
Mountain too, as I understand it.
    Mr. Rice. Right now, the first time since I have been the 
Director at Iron Mountain, we are practically fully staffed and 
we have three provider vacancies. We are really trying to focus 
on recruiting physicians who like the rural environment, the 
lifestyle. We have made a concentrated effort to approach it 
that way, do more home grown approach. I don't think it has 
been a thorny issue. I think we have been able to meet most 
every demand from a physician that we recently hired, like the 
anesthesiologist, podiatrist, some psychiatrists. We have been 
able to meet their financial demands.
    Dr. McNutt. Congressman Benishek, I think you probably 
recognize this is not just a VA issue. Congresswoman Brownley 
brought up there is a dearth of physicians to hire. We quite 
often get no replies from physicians when we are recruiting.
    Dr. Benishek. All right. Thanks.
    I will yield now 5 minutes to my colleague.
    Ms. Brownley. Thank you, Mr. Chairman.
    So I think it was Mr. Harrington who testified earlier who 
talked about a promise to hire a doctor, but then a nurse 
practitioner or a physician assistant was hired in lieu of 
that. So I am just trying to get to the bottom of whether that 
was what was really, truly assigned by the VA, that we were 
going to hire a nurse practitioner and not a doctor, or it was 
because you could not hire a doctor is the reason for that?
    Mr. Rice. Yes, that is correct. We try to staff with 
physicians.
    Ms. Brownley. Okay. Very, very good.
    So I guess just a broad question to all of you. I notice 
that a couple of you are wearing your ``We Care, I Care'' VA 
buttons. Those buttons are symbolic of something, and in my 
mind what it is symbolic of is the VA's commitment, certainly 
the Secretary of the VA, his commitment to make sure that the 
VA is working in a way to satisfy all veterans across our 
country, every single one.
    I had the opportunity to visit with a few veterans here 
today who assured me that they are getting absolutely great 
care. They are extremely satisfied with their care. But we all 
know that we still have more work to do to make sure that we 
are providing high-quality care for all of our veterans and 
that we want the VA to be nimble enough and flexible enough so 
that we are what we call back in Washington veteran-centric--it 
is a veteran-centric VA, that our purpose in life is to serve 
veterans and to make sure that veterans have great 
satisfaction, in our case in healthcare delivery.
    So having said that, based on what you have heard today 
from our veterans, and we want to listen to our veterans and 
learn from our veterans and hopefully create programs around 
some of their issues and concerns, I guess I would just ask the 
question, what is your take-away from this morning's testimony 
from the veterans here?
    Ms. Capra. Thank you, Congresswoman Brownley. What speaks 
to me most is the implementation of the Choice program and 
those significant challenges that we have implementing that 
successfully, not just here in Sault Ste. Marie but, as I have 
made my way around to other rural parts of the country, I do 
hear the same concerns over and over about community providers 
either not knowing about the opportunity to be part of the 
Veterans Choice program or not being willing to participate for 
a variety of reasons, whether it is reimbursement or they are a 
little concerned about what the experience will be like to work 
with the VA.
    So I think while the Veterans Choice program presents a 
great opportunity to bring care closer to home through 
community providers, if the community providers aren't there or 
aren't willing to participate, that diminishes the intent of 
it.
    I would say here in Michigan, I was fortunate on July 15th 
to do a training to the Michigan Primary Care Association to 
inform the Federally-qualified health centers of the 
opportunity. We did this along with Health Net, the third-party 
administrator implementing in Michigan, and thus far we have 19 
Federally-qualified health center sites signed up in Michigan. 
We have a long road to go to continue with that.
    We are doing some national provider outreach efforts with 
the National Rural Health Association and the National 
Association of Community Health Centers to try to reach those 
community providers, and many of them are already seeing 
veterans or veterans and their families. So we would like to 
bring them in, but there are challenges associated with that. I 
heard that today.
    Ms. Brownley. And what about the MOU that everyone was 
talking about in terms of trying to integrate services here 
with the tribes and the capacities that they have for 
healthcare delivery?
    Ms. Capra. My office has been talking--we talk very 
regularly with the Indian Health Service. We actually did a 
recent training to encourage tribal health programs to sign up 
as Choice providers, and that is distinct and different from 
the Memorandum of Understanding, which allows tribal health 
programs to get reimbursed for the care they provide to Native 
veterans. So we would like to see both of those mechanisms 
activated more fully.
    I understand here in Michigan that there are two tribes who 
have signed the reimbursement agreement and are getting 
reimbursed for the services they provide. We would love to see 
that grow and can offer technical assistance on that. But those 
are two distinct and very specific ways to get involved.
    Ms. Brownley. Thank you. I yield back.
    Dr. Benishek. I have a few more questions, a follow-up on 
that.
    Mr. Rice, have you been working with the Sioux Tribe? That 
was one of the main points of Mr. Payment's testimony, that 
they have been unable to secure a relationship with the VA to 
allow their clinics. What is going on there?
    Mr. Rice. So, a little history. We first started out with 
Waters. Waters signed up, and we have an agreement with them, 
as well as they are signing up to be a Choice provider. Then we 
moved on to Hannahville. Hannahville doesn't have the capacity 
to be a Choice provider, but they want to be reimbursed. So we 
are finalizing an agreement with them.
    Dr. Benishek. What was the deal there? They have a 
different reimbursement plan? Is that what you are saying?
    Mr. Rice. No, like Gina said, Ms. Capra, to sign them up as 
either a Choice provider or an agreement to take care of Native 
American veterans.
    Dr. Benishek. Do they have to be a part of this Health Net 
in order to be a Choice provider? Is that basically the----
    Ms. Capra. Yes.
    Dr. Benishek. Okay. So if they don't want to be a part of 
this Health Net, then they cannot be a Choice provider.
    Mr. Rice. Correct.
    Dr. Benishek. But they can still do care within the VA 
outside the Choice program, right?
    Mr. Rice. Yes. The can get an authorization----
    Dr. Benishek. Where are we here with the Sioux?
    Mr. Rice. So we met with their representative actually 
since 2014, and we are working with CBO to get the agreement 
finalized so they can be reimbursed for the time they take care 
of Native Americans. We are encouraging them to sign up to be a 
Choice provider, but that is their choice, and they would have 
to work with Health Net. We try to provide them information so 
they can make that next step.
    Dr. Benishek. They are not Choice providers at this time?
    Mr. Rice. No, they are not yet. But we do have a successful 
agreement over in Manistique where they take care of our 
optometry patients in the Manistique area. So we have been 
successful with the Sioux Tribe with setting up an agreement.
    Dr. Benishek. What about this Memorandum of Understanding 
for their tribal members? What is the problem there? That is 
separate from the Choice, right?
    Mr. Rice. Correct, and that is to reimburse for--we are 
trying to set up these agreements so we can provide 
reimbursement any time they take care of a Native American 
veteran. I think the MOUs want to focus on taking care of all 
veterans at their clinic, and that is why we are encouraging to 
go the Choice route, because then we can reimburse through 
Choice.
    Dr. Benishek. I see. So what about just a fee-for-service 
or another thing outside the Choice program?
    Mr. Rice. Prior to the Choice program, we did have Waters, 
for example, the health clinic in Waters sign up, and they 
could be reimbursed for care in the community or the old NBCC 
program as a fee provider. We can't direct patients--so if we 
wanted to have all our patients go to that clinic, we would 
have to have a contract, and the contract would have to go out 
for bid. So we thought it was quicker if we had them sign up as 
a Choice provider or a fee provider, because then they are 
already signed up.
    Dr. Benishek. It seems like this has been going on for a 
while.
    Mr. Rice. Actually, we have had three meetings over here, 
educational sessions with all the tribal clinics, the Lower 
Peninsula and the Upper Peninsula and VISN 11. We meet once a 
year to try to provide education. So, yes, we have been 
discussing this----
    Dr. Benishek. Some of the issues from Mr. Payment is that 
they are willing and eager to make this happen. I don't know 
where the problem is, but I would think there is real 
opportunity to find a local provider who is willing to be a 
provider in the community. So I am just trying to facilitate 
that by having this hearing here today.
    One of the other things that was brought up was the 
transportation issue and that there is difficulty providing 
rural transportation. Can you address that a little bit as 
well?
    Mr. Rice. Yes.
    Dr. Benishek. Ms. Capra talked about nationwide providing 
transportation, it is already happening, but there still seem 
to be some problems. Can you update us on what is going on as 
far as you are concerned?
    Mr. Rice. For VTS, we do have a local program. The routes 
are based on Iron Mountain. We go 60 to 90 miles from Iron 
Mountain. The transportation from the Sault to Iron Mountain, 
as previously mentioned, is by vans. There are some 
restrictions because they cannot take patients who are on 
oxygen, so that does create a challenge. But with the recent 
Choice program now, the services provided at the Sault, we have 
been authorizing care in the community so the veterans don't 
have to travel over to Iron Mountain, and that is improving 
every day. We have work to do, but that is our goal, to provide 
the care here, to get it closer to home for our veterans.
    Dr. Benishek. Apparently, since 2009, there has been $14 
million that has gone from the Office of Rural Health to the 
Iron Mountain VA Medical Center. Can you tell me how that $14 
million has been spent?
    Mr. Rice. Sure. We have been real fortunate, actually. It 
has allowed us to start programs this past year. For example, 
this is the first time we are offering PT at one of our 
outpatient clinics through a rural health grant. We were able 
to remodel some space at the Rhinelander clinic in Wisconsin, 
hire a physical therapist, as well as a PTA. That has allowed 
us to establish three E-RANGE teams across the UP, one in 
Manistique, one in Hancock, and one in Rhinelander. It has 
enabled us to start some surgeon programs back at the main 
campus.
    So we have been real lucky that this program exists. We 
were able to bring services that we wouldn't have been able to 
bring to our community otherwise.
    Dr. Benishek. Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman.
    I am just going to go back to the Choice program for a 
minute. I know it has been confusing. It has been confusing I 
think across the country, and as everyone knows here, there are 
several community-based programs that the VA has, the Choice 
being the third of a family of programs. They are all run 
differently. Their reimbursement rates are different, et 
cetera. I, for one, feel like we should combine all of those 
programs into one and have one reimbursement program and 
simplify it, but we are not there yet.
    But on the Choice program, it has been my experience, at 
least in my own community, that once doctors begin to 
understand, the local doctors, once they understand how the 
program operates and they understand that the reimbursement 
rate is the Medicare rate, that they are more willing to 
actually want to be a part of that program, but it does take 
time. As you are doing recruitment for physicians to work 
within the VA, that same effort has to be established to make 
sure that the doctors in our communities are aware of the 
program, and in this case getting them connected with Health 
Net.
    I would hope that Health Net is helping you in this 
process, but I think we have made some changes and adjustments. 
I know one of the issues that I worked on was the continuity of 
care issue because under the Choice program, if you had cancer 
and needed treatment, the continuity of care was only--I think 
it was 60 days or something, and who wants to be treated for 
cancer and at the end of 60 days say you have to now go to a 
different doctor?
    So that has been fixed in the Choice program. So there have 
been--I think we have made some improvements.
    I wanted to ask, and probably this question is not under 
any of your jurisdictions necessarily, but how do we make Iron 
Mountain more flexible to veterans who have to travel there for 
their services? I mean, I heard several in their testimony say 
that they went to Iron Mountain for X service, did the 
traveling all day to get there, all the way home, and then get 
a call the next day saying you need to come back because we 
need to make that adjustment on your hearing aid, or we didn't 
do this test.
    How can we make the Iron Mountain folks more flexible so 
that when our veterans travel there, if they need a hearing aid 
adjustment, they need to get their eyes checked, and they need 
a chest x-ray, that that can all be managed in one day as 
opposed to three separate trips? How do we make that happen?
    Ms. Capra. I would just say nationally, Congresswoman 
Brownley, that this is an issue across the board for rural 
veterans traveling into facilities. I have been to facilities 
where they accommodate the veteran and his or her family 
overnight if it is going to require that sort of long day. That 
is really not a reasonable request to make of a veteran.
    I think also the earlier conversation around technology. If 
some veterans are uncomfortable with telehealth or a phone-
based call with a nurse, then for them that is not the right 
fit. But we really try to use technology in a way to bridge 
that distance so they don't have to go as far for certain 
services.
    I will ask Mr. Rice to comment on Iron Mountain.
    Mr. Rice. I would just say the same, that what we are 
trying to do is really educate our clerks that every time they 
make an appointment, that they really discuss with the veteran 
any future appointments.
    But one of the goals, as I said for the medical center this 
year, is prior to any veteran leaving the clinic, for example 
if they need a specialty clinic, that they have that 
appointment before they leave the medical center so we can be 
more veteran-centric.
    One of the things we also spend a lot of time on, I have a 
slide that I use when I go out and do the town halls, really 
that we want our staff to recognize that our main goal is to 
make sure veterans get the care at the right time and at the 
right place, and sometimes that right place isn't Iron Mountain 
VA, it is here in the community.
    So it is really changing the mindset of how we approach 
care to our veterans, that it is okay if we give care in the 
community, changing the mindset. Everybody always thought it 
had to be behind our four walls, but really we have to put the 
veteran first and make sure we address his or her needs.
    Ms. Brownley. Thank you.
    I yield back.
    Dr. Benishek. I have a few more questions.
    In following up with what Ms. Brownley was asking, the 
gentleman testified about coming and then going back three 
days, having to go back for more----
    Mr. Rice. That is unacceptable.
    Dr. Benishek. Really, is there some inquiry to the patient 
prior to his arrival saying what are the issues you are going 
to be talking to us about, is there anything else we can take 
care of while you are at Iron Mountain that day? Do they have 
that type of discussion with the patient prior to their showing 
up? Because I haven't heard that.
    Mr. Rice. They are supposed to. We try to do it. Because of 
when Phoenix occurred, what we do now is leadership. Myself, 
Dr. McNutt, we meet with our clerks every Friday and we go over 
the hot topics and scheduling. We discuss this topic a lot 
because some of the complaints I hear from the veterans when 
they call me directly is the same that we heard today, that I 
had an appointment today and they made me come all the way 
back. So really educating our schedulers to make sure they have 
that discussion with the veterans so we understand what their 
future appointments are so we can try to batch them all on the 
same day.
    Dr. Benishek. It just seems to me that knowing that he is 
going to go for a hearing evaluation, that the tech should be 
there that same day so that those kind of issues can be dealt 
with. The travel time is just horrible.
    Mr. Rice. We did have some positive comments about 
telehealth, but we do have over 37 clinical telehealth programs 
now, and one of those programs, for example, is we have tele-
audiology where we can actually fit the hearing aid via tele to 
prevent veterans from traveling far distances to get 
adjustments to their hearing aids, and that is a new program we 
started last year.
    Dr. Benishek. I wanted to ask another question about the 
medical record because I have heard also in other testimony 
that when people get outside care in the community, their 
medical record is not updated at the VA maybe in a timely 
fashion.
    Does that kind of communication happen electronically? Does 
the patient in the community have access to the patient's 
records in the VA? I mean, when I was taking care of some 
patients at Iron Mountain, I was able to get into the VA's 
computer record in my office. It was sort of an ordeal to get 
in, but we always had that. Is that a routine now? Does the 
patient seen in the community have access to the patient's 
record?
    Mr. Rice. Iron Mountain is one of 13 pilot sites across the 
country where we are sharing records electronically with the 
private sector hospital. Where we have been successful so far 
is with the state home. In Marquette, any time they have a new 
admission, we share the records electronically. Then we are 
also working with Dickinson, Marquette General, and I think St. 
Francis. It is in the early stages, but our goal is that 
relatively soon we will be able to share records.
    Ms. Capra. And I would add, under the Choice program 
currently, although it is still very clunky, there is the 
transfer of information between VA and the referred community 
provider. That is a part of the process in order for the 
provider to get paid on the community side.
    Dr. Benishek. I think one more question and follow-up on a 
previous line of testimony. I can't remember if you actually 
said--are you going to continue to try to get a physician here 
in Sault Ste. Marie, or is that pretty much by the wayside? We 
went through the numbers game there for a minute. I don't know 
if you did that because you are not going to recruit a 
physician anymore? I am just trying to get what is the final 
answer because that is the main question that people have. They 
want a physician at this facility, and I don't think you 
answered the question.
    Mr. Rice. Currently right now we are not recruiting for a 
physician, but one of the things we have been real successful 
this past year--like, for example, Marquette, with some changes 
that went on with Marquette General, that we have encouraged 
all physicians, if they are interested in working for us, we 
have been able to work out arrangements where we can take on 
additional providers, be it via tele or other means of 
providing care.
    Dr. Benishek. And you have been unable to recruit somebody 
to the Sault Ste. Marie facility to provide part-time physician 
coverage? Is that correct?
    Mr. Rice. Since 2013 we haven't had any.
    Dr. McNutt. We have not had a single applicant other than 
the one we discussed earlier.
    Dr. Benishek. Well, you are no longer recruiting for the 
job at this point in time.
    Dr. McNutt. I wouldn't say that. I encourage, and I am sure 
that you being part of this medical community you know this, 
that we often talk among ourselves, and my cell phone is out 
everywhere. I encourage anyone who is interested to call me 
personally. I keep an ongoing file of anyone who might have 
interest in working for us. So I would say that as a leadership 
group, Mr. Rice has been very receptive to increasing FTE when 
we have a qualified candidate.
    Dr. Benishek. How much is the scope of care limited by not 
having a physician here on site?
    Dr. McNutt. I would comment on two things there, 
Congressman Benishek. Number one is that we provide guarantees, 
and our NPs and PAs are highly qualified for what they do. They 
also have instant access to a physician. They all have a 
collaborating physician. One of our very useful pieces of 
technology is instant messaging. While sitting in an exam room, 
one of those providers can instant message the chief of primary 
care, me, their collaborator, saying they have a clinical 
question.
    Dr. Benishek. Does that occur here?
    Dr. McNutt. It occurs all the time, not just in Sault Ste. 
Marie but all of our CBOCs. They also all have my cell phone, 
and they will text me saying can you give me a quick phone, 
which we do. The chief of primary care and I, since this is a 
small community, are extremely receptive to mentoring and 
serving as the M.D. when they need one.
    Ms. Brownley. So what is an example of when they need one? 
What does that mean?
    Dr. McNutt. So, for example, when you are hiring a new 
provider, let's say you hire an NP for a site, and they will 
start out with a limited number of patients while they learn to 
use the computer system and try to understand our record. So 
they may send me an instant message saying I have a patient 
here who has a question about a referral. Where do I send this 
patient? How do I enter this consult? Or they may send me a 
question saying do you know who the pulmonologist is in 
Milwaukee? Questions that are usually related to systems, 
though on occasion they do ask a medical question also. But 
they have almost literally instant access to a physician.
    Ms. Brownley. But it is more logistical than it is----
    Dr. McNutt. It has been more logistical than it has been 
medical. Our NPs and PAs are extremely well trained for the 
majority of chronic care that they deliver.
    Ms. Brownley. I was just going to follow up to say I think 
I suggested that if you have a nurse practitioner who is seeing 
a patient and the patient needs more than he or she can provide 
in terms of setting up a telehealth meeting, a consult with the 
doctor, with the nurse practitioner, with the patient all 
together, is that possible to happen, or is it----
    Dr. McNutt. For all of our mid-level providers--NPs, PAs--
they always have the option if they feel the patient's medical 
situation is too complex for them to provide for care, they 
always have the option of referring that patient to an M.D.
    Ms. Brownley. I totally get that. They can refer them to an 
M.D., and then they go and travel into Iron Mountain. I am 
trying to find other solutions to limit the amount of 
traveling. In some sense we have to get the VA thinking in 
terms of people that have to travel the farthest need to be 
handled with kid gloves. It is just so much easier when you are 
close by, but these patients have issues just like everybody 
else, and then they have the trauma, if you will, of having to 
do the traveling and the frustration that goes with setting 
that up and having to experience going, coming back, and then 
getting a call saying I need you to come back again, like it is 
just right around the corner.
    Dr. McNutt. We do provide primary care. We have two 
physicians who provide primary care by tele. As he commented, 
not everyone is fond of tele, but we have many patients who 
come in and they do like telehealth. I do have the option to 
assign patients to a tele-practice where the primary care 
doctor is not located here but is the assigned physician of 
record for a patient.
    Ms. Brownley. Right. But if the patient has a relationship 
with the nurse practitioner, all I am asking is, is it possible 
for a doctor to be, via telehealth, and the nurse practitioner, 
and the patient all be together?
    Dr. McNutt. Yes, it is possible.
    Ms. Brownley. Thank you.
    Ms. Capra. Congresswoman Brownley, I would just add that 
nationally we are seeing that rural communities, not just VA 
service to communities, face this issue of a lack of 
physicians. So the mid-level team that Dr. McNutt described is 
so common. I talk frequently with my counterparts at the 
Department of Health and Human Services, their rural health 
office, and they are equally challenged by this issue of how to 
support rural communities so that individuals don't have to 
travel hours and hours to see specialists.
    One of the things that is very unique, I have found, in the 
VA is the home-based primary care program. It is a limited 
program. It is something the Office of Rural Health has funded 
to a limited degree, but it allows the team to go to a 
veteran's home, those that are eligible, and I think that is 
really a fantastic model. It is resource intensive, but it 
really gets to the veteran where he or she is. So I think that 
is a place where the VA does a little better, actually, than 
those of us that get our care outside of the VA.
    Dr. Benishek. Well, while I have you here and while we have 
the time, I just want to touch again on this transportation 
issue. You mentioned that the DAV is providing the 
transportation. How is that really working? Because Mr. Payment 
was saying it doesn't seem to be working that well from his 
perspective. I know that we have a problem with capacity 
because the volunteers are paging and it is not maybe as 
reliable a system as it once was.
    Can you talk about that? Is there another option for 
veterans here? Are you willing to work with Mr. Payment to try 
to----
    Dr. McNutt. Yes, we can do that.
    Dr. Benishek. Can you move a little more in his direction?
    Mr. Rice. The DAV driver from the Sault I think is very, 
very----
    Dr. Benishek. I don't know the specifics, but I know this 
has been a problem in the past.
    Mr. Rice. In the past year we have driven 1,000 miles for 
the VA. We transported almost 2,700 veterans who were served by 
the DAV. But I would be willing to discuss with him those 
issues. Recently I worked with some veteran groups, but not--we 
try to get to the Hancock clinic, to our main campus. So we 
would be willing to sit down and talk about that.
    Dr. Benishek. Do you have any more questions, Ms. Brownley?
    Ms. Brownley. No.
    Dr. Benishek. I know that we haven't answered all the 
questions that came up from our veteran panel, but I appreciate 
you coming in here today with Mr. Rice and Dr. McNutt, Ms. 
Capra. Thank you.
    I still think there are a lot of concerns about our rural 
veterans. Some of the things have been addressed, the traveling 
back and forth, back and forth three times in the same week, 
that sort of thing. These are problems that really need to be 
solved, and I think better communication with the veteran prior 
to the visit. I think you mentioned that it is very important 
to be sure the veterans are informed as to the options and 
having more options available when they go to Iron Mountain so 
they don't face too many trips.
    I know that we probably aren't trying to solve every 
problem at the rural VA, but I hope that maybe some people here 
who have a relationship with the providers here in the Sault 
will continue to improve going forward. I didn't want to say 
myself, having worked at the VA, I worked with Mr. Rice. He is 
a keeper, and that means a lot. He is not somebody that is 
coming through the VA every two years and moving on to his next 
site. He is committed to being at Iron Mountain. So there is a 
lot of improvement there, and I know that he is working 
sincerely.
    My frustration, frankly, is with upper management, making 
sure that he has the tools he needs to provide the care that we 
need in Michigan. I am happy to see that he came here.
    Ms. Capra, like I said, I was a little disappointed in your 
standard testimony, how you are doing things, but the specifics 
matter here, and making sure that Mr. Rice has the tools that 
he needs to provide care. Somebody on the first panel said his 
hands are tied. I would like to see a physician here in the 
Sault. I know that people here in the Sault want to see that, 
and I continue to encourage the VA to hire a physician here in 
the Sault, and I am going to continue to work on those efforts.
    So if you don't have any further questions, I want to thank 
you for being here today, and I will hereby adjourn the 
hearing. Thank you very much.
    [Whereupon, at 11:40 a.m., the subcommittee was adjourned.]

                                APPENDIX

                                 

            Prepared Statement of Chairman Dan Benishek M.D.

    The Subcommittee will come to order.
    Good morning and thank you all for joining us today.
    As you may know, I am Dr. Dan Benishek and it is my honor to be 
both your Congressman and the Chairman of the Subcommittee on Health 
for the Committee on Veterans' Affairs of the United States House of 
Representatives.
    Before I was elected to Congress, I was privileged to serve for 
twenty-years as a physician at the Oscar G. Johnson VA Medical Center 
in Iron Mountain, which oversees the VA community based outpatient 
clinic here in Sault Ste. Marie.
    During my time there, veteran patients would tell me every day 
about the challenges and the frustrations they faced when attempting to 
get care through VA--the VA which is, by the way, our government's 
second largest bureaucracy with a budget and staff that trails only the 
Department of Defense in size.
    Let me be clear: Our veterans fought for our freedom--they 
shouldn't have to fight government bureaucrats too.
    And the Subcommittee Members and our staff work hard every day to 
break down the barriers between the VA bureaucracy and the veterans 
that this bureaucracy should be serving here in the U.P. and across the 
country.
    I am joined here today by Congresswoman Julia Brownley, the Ranking 
Member of the Subcommittee on Health and the Representative from the 
26th District of California, just north of Los Angeles.
    Needless to say, she has traveled quite a distance to be here with 
us today and I am grateful to her for her willingness to join me in 
Sault Ste. Marie this morning and for being such a strong and effective 
voice on the Subcommittee.
    The purpose of today's hearing is to make sure that the care and 
services that you and your fellow veterans receive in the Eastern U.P. 
is timely, accessible, and high-quality.
    Unfortunately, we all know that--at times--VA has failed to meet 
those measures and, in doing so, has fallen far short of providing the 
treatment that our veterans earned and deserve.
    An example of how VA has fallen short here in Sault Ste. Marie can 
be seen in VA's inability for the past two years to recruit a physician 
to staff the VA community-based outpatient clinic here.
    The veterans that I have spoken to--some of whom you will be 
hearing from this morning--are understandably concerned about the lack 
of a physician at this facility and the impact that VA's failed 
recruitment efforts have had on the quality of the care at the clinic.
    I share those concerns and, today, I want answers.
    During this morning's hearing, we will discuss efforts that VA has 
taken in this community and around the country to ensure that rural 
clinics like the one here in Sault Ste. Marie are properly staffed and 
that rural veterans are able to access care in the community or through 
tribal health centers where VA is unable to provide the care that our 
veterans need or when our veterans would prefer to receive care 
elsewhere.
    We will hear testimony from VA and from local tribal leaders and 
veterans, whose input, expertise, and advice is critical to the work 
that we do in Washington.
    I am grateful to all of our witnesses for being here and I look 
forward to their testimony.
    Before that, however, I would like to take a moment to recognize 
the men and women that we are here today to serve.
    Would the veterans in our audience right now please stand--if you 
are able--or raise your hand and be recognized?
    Thank you so much for your service to our country and for being 
here with us this morning.
    I would also like to take a moment to recognize and thank the 
Armory staff for allowing us to use their facility this morning and for 
their assistance in helping us to prepare and set up for this hearing 
today.
    Thank you very much.
    With that, I now recognize Ranking Member Brownley (Julia) for any 
opening statement she may have.
    Thank you.
    We will begin today's hearing with our first panel of witnesses, 
who are already seated at the witness table.
    As this is a formal hearing and not a town hall, only invited 
witnesses will be able to speak though I do look forward to greeting 
and speaking with our audience members more informally after the 
hearing has concluded.
    Before I introduce our panelists, I want to gently remind all of 
today's witnesses to please be mindful of the five-minute time-limit 
for your oral testimony and the question-and-answer period that will 
follow.
    The light that has been placed in front of me and in front of you 
will change from green to yellow when there is one minute left and from 
yellow to red when time has expired.
    We are going to try to stay as closely within the five-minute time-
limit as possible so that we can be sure that everyone has a chance to 
be heard in a timely manner.
    Thank you in advance for your consideration.
    With us on our first panel this morning is Chairperson Aaron 
Payment of the Sault Ste. Marie Tribe of Chippewa Indians; Anthony 
Harrington, a veteran who lives right here in Sault Ste. Marie, 
Michigan; David W. Pearce, an Army veteran and the Commander of the VFW 
Post 3676; and, Don Howard, a veteran and Commander of the American 
Legion Post 3.
    I am so grateful to each of you for your willingness to be here 
this morning and to speak candidly about issues of such importance to 
our veterans and our community.
    I am honored to have you here.
    We will begin with you, Chairperson Payment.
    You are now recognized for five minutes.
    Thank you.
    Mr. Harrington, you are now recognized for five minutes.
    Thank you.
    Commander Pearce, you are now recognized for five minutes.
    Thank you.
    Commander Howard, you are now recognized for five minutes.
    Thank you.
    I will now yield myself five minutes for questions.
    If there are no further questions, the panel is now excused.
    Thank you all very much.
    I now welcome our second and final panel to the witness table.
    Joining us from the Department of Veterans Affairs is Gina Capra, 
the Director of the Office of Rural Health.
    Ms. Capra is accompanied by James Rice, the Acting Network Director 
for Veterans Integrated Service Network 12, and by Dr. Gail McNutt, the 
Chief of Staff of the Oscar G. Johnson VA Medical Center in Iron 
Mountain, Michigan.
    Thank you all for being here.
    Ms. Capra, please proceed with your testimony.
    You are recognized for five minutes.
    Thank you.
    I will now yield myself five minutes for questions.
    If there are no further questions, the panel is now excused.
    Once again, I thank all of our witnesses and audience members for 
joining in today's conversation.
    It has been a pleasure for me to spend the morning here with all of 
you.
    With that, I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks and include 
extraneous material.
    Without objection, so ordered.
    This hearing is now adjourned.

                  Prepared Statement of Aaron Payment

    My name is Aaron Payment, and I am the chairperson of the Sault 
Ste. Marie Tribe of Chippewa Indians. As a member and leader of the 
tribe, I am speaking on behalf of the tribe. As always, my tribe and I 
want to work in partnership with you.
    Throughout the history of the United States, Native Americans have 
fought bravely and sacrificed for this country. This proud tradition 
continues today with 24,000 active duty American Indian service 
members.
    The 2010 U.S. Census identified over 152,000 Native men and women 
who have served this country in its, Armed Forces. While the U.S. 
population recorded nearly 1.4 percent American Indian, the military 
population was 1.7 percent Native, making it the highest per-capita 
commitment of any ethnic population to defend the United States.
    I commend the Department of Veterans Affairs' efforts to ensure 
that community-based outpatient clinics in rural areas are properly 
staffed and rural veterans are able to access care in the community, 
where appropriate and necessary. However, additional changes are 
critically needed to meet the needs of American Indian veterans. The 
current system creates multiple barriers to treatment for American 
Indian veterans living in rural areas, which is where most reside.
    In the Eastern Upper Peninsula of Michigan, where there exists a 
shortage of service officers and service office open hours, Sault Tribe 
has partnered with the American Legion to provide two additional 
service officers in congressional District 1. These added service 
officers provide outreach activities to veterans who utilize Sault 
Tribe's Indian Health facilities across the EUP. The tribe provides the 
space to offset costs associated with the additional service officers. 
Additionally, the tribe has begun baseline data collection efforts 
aimed at more accurately reflecting the number of American Indian 
veterans across the U.P.

Veterans' Services Within the Sault Ste. Marie Tribe of Chippewa 
Indians Health Division

    In 2010, the Health Division worked with the Iron Mountain VA to 
establish an agreement with the tribe's optical department in 
Manistique. Under this agreement, the tribe is able to provide optical 
services to tribal and non-tribal veterans.
    The tribe has also:

         Established a VA workgroup to access additional 
        services for its tribal veterans.
         Partnered with a veteran's service organization, 
        American Legion, to provide benefits. Service officers at 
        tribal clinic sites to assist veterans with issues and 
        questions about navigating the VA bureaucracy.
         Worked to identify tribal veterans as they come into 
        tribal clinics as also being a veteran in order to plan 
        services.
         Worked to incorporate both behavioral health and 
        traditional medicine programs to develop veteran specific 
        services to include PTSD, emotional trauma, etc.
         Planned awareness outreach to get out the word on 
        tribal and VA services including tribal elders meetings, tribal 
        newspaper, website and video tag line information.
         Worked with the Iron Mountain VA to establish a 
        Memorandum of Agreement with the tribe for full reimbursement 
        for providing clinical services to tribal veterans eligible for 
        VA services.

Challenges to Choice

    Veterans who choose to utilize their Tribal Health centers and 
tribal providers as their primary care sites do not use their VA 
benefits. The VA cannot reimburse Sault Tribe until there is an MOA in 
place. The VA Choice Card Program does not list tribal clinics as 
reimbursable entities for providing the care as a referral from the VA. 
The tribe would need to become PC3 and Choice Provider under Health 
Net. The tribe is awaiting contact information from the VA about these 
programs.
    If veterans are unable to get an appointment at the Iron Mountain 
VA in 30 days, they can receive a Choice Care card and referral. They 
would then need to see if they could be seen at War Memorial Hospital 
(Sault Ste. Marie, Mich.), which is the preferred referral location in 
this area. Lastly, if WMH could not see veterans in 30 days, they would 
need to go back to the VA to receive another referral to use the Choice 
Card at Sault Tribe's health center, and then the tribe would be 
reimbursed.
    The frustration for tribal veterans is to drive three to five hours 
to Iron Mountain and not receive an appointment resolving their issue, 
then receive referral to clinics in Wisconsin rather than Michigan, 
thus making the travel time even longer for follow-up and specialty 
care appointments.
    Barriers to access care involve transportation to and from Iron 
Mountain because of distance and frequency. Community-based outpatient 
clinics are staffed with mid-level providers, not physicians, so 
veterans using CBOCs are not able to obtain the primary evaluations 
necessary to access their VA benefits.

Recommendations

         Freedom of choice. American Indian veterans should be 
        free to choose their care based on where they can secure the 
        highest quality health services. Veterans who choose to utilize 
        tribal health centers and tribal providers as their primary 
        care sites are not able to access their VA benefits. Currently, 
        the VA Choice Card program does not list tribal clinics as 
        reimbursable entities for providing the care as a referral from 
        the VA.
         Reimbursement to tribes. Tribal healthcare programs 
        should be reimbursed for both direct service and referred care 
        when Veterans find tribal health programs more accessible or 
        more accommodating to their needs. I urge Congress to require 
        the VA set up a process that allows reimbursement for eligible 
        services provided by Tribes, including tribes such as the Sault 
        Ste. Marie Tribe of Chippewa Indians, which is a self-
        governance tribe.
         Improve public transportation. The tribe has 
        identified a lack of consistent and reliable transportation to 
        access many services that directly impact quality of life, 
        including health, education and employment. The 2015 Sault 
        Tribe Transit Implementation Plan showed transportation for 
        making trips across the Upper Peninsula is provided only at 
        night (12:15 a.m.-8:35 a.m.), which is of limited use for 
        medical trips. The tribe also found a lack of evening and 
        weekend service, another barrier limiting members' ability to 
        access critical health services.
         Reimbursement to tribes. The Department of Veterans 
        Affairs should reimburse tribal governments providing Native 
        veterans transportation to primary and specialty clinics, and 
        follow-up care. Most American Indian veterans live in remote 
        areas of the United States and the cost for transportation to 
        and from Veterans healthcare facilities cause substantial 
        hardships on these veterans seeking service.

    I am available to answer any questions you might have. Thank you.

                                 

                Prepared Statement of Anthony Harrington

    Chairman Benishek, Ranking Member Brownley, thank you for giving me 
the chance to testify today.
    I am a disabled veteran and I live here in Sault Ste. Marie.
    As you both know, there is a VA clinic here. The clinic has been 
here for many years but more than 2 years ago the attending physician 
retired. In the interim, part-time doctors have been trying to pick up 
the slack, and a Nurse Practitioner has been brought in to replace the 
retired physician.
    I truly and deeply believe that our veterans should be entitled to 
proper healthcare. This specific VA clinic serves the entire Eastern 
Upper Peninsula. They are a very busy facility with many patients from 
across the region. The facility is having trouble keeping up with the 
number of patients and its quality of care is suffering as well. The 
NP, although very good at her job, can only do so much within the 
guidelines of her job description and abilities.
    Currently, as it stands the NP can only see a maximum of six 
patients a day and is limited as far as what she is allowed to diagnose 
and treat. The facility is in desperate need of a full-time attending 
physician as well as the current NP to adequately care of the entire 
region and its patients.
    Recently they hired a Physician's Assistant here. While that's a 
good first step, it's really not a replacement for a full time doctor. 
I just want to know why they were able to bring a PA if it wasn't 
possible for them to bring a doctor? I have been told by Iron Mountain 
VA officials that they were only authorized to hire a nurse practioner, 
and then all of a sudden the PA shows up. That doesn't make sense to 
me.
    Prior to the hiring of the NP I was seeing a doctor by the name of 
Lisa Vanhevel at the Bay Mills Indian Clinic. The reason I turned to 
the Indian clinic instead of the VA clinic was due to the lack of an 
attending physician at the facility. While under Dr. Vanhevel's care we 
talked quite extensively about the need of a full time doctor at the VA 
clinic. She told me that her contract with Bay Mills was coming to an 
end and made her intentions clear that she was interested in 
interviewing for the position at the VA clinic.
    Upon following the proper channels she was then granted an 
interview at the VA clinic in Iron Mountain, Michigan. Sometime later I 
happened to run into Dr. Vanhevel at Wal-Mart and she informed me that 
her interview went well and she was offered a position at the Sault 
Clinic as well as the Iron Mountain clinic. She stated that she was 
only offered two days a week through our facility or a full time 
position in Iron Mountain. She explained that she had to decline both 
positions because she didn't want to move to Iron Mountain or commute 
295 miles away for work. She also didn't want to take a position for 
only two days a week.
    Dr. Benishek, Ms. Brownley, I'm sure you can sympathize with her. 
Who in their right mind would want to take a position for 2 days a week 
following a contract where they had a full time position? This was very 
concerning to me considering the dire need for a full time attending 
physician here.
    In addition, Dr. Benishek's staff has told me that prior to the 
hiring of the PA, Benishek's office was told by the VA that they were 
going to try to hire a doctor. However, despite what Benishek's office 
was told, we've seen no evidence that an ad was ever placed on 
usajobs.com, or that any ads were placed in UP newspapers. I'd like to 
know what exactly was done to try to get a doctor here.
    I'm glad that Congress is finally investigating this issue. I have 
yet to have someone explain to me why it is that the veterans in this 
area are not entitled to a VA facility with a full time doctor and 
quality healthcare.
    Thank you again for having me here today. I truly hope that you 
will take the time to look into this matter and serve justice to our 
vets as we have selflessly served you and this country. It is my hope 
that you will confer with the new director of the VA and that you can 
come to an agreement to resolve this.
    I'm happy to answer any questions you may have.
    Thank you.

                                 

                 Prepared Statement of David W. Pearce

    Congressman Benishek, Committee Members, Committee Staff, and 
Fellow Panelists,
    Thank you for the opportunity to appear before you today on behalf 
of the members of Veterans of Foreign Wars Post 3676 and approximately 
58,000 Upper Peninsula of Michigan Veterans--one of this great state's 
most valuable resources. I feel qualified to provide some input, within 
my scope, as I am a retired service-member, disabled veteran that uses 
the VA healthcare system and the Commander of the Welsh-McKenna VFW 
post here in the Sault. I served this great nation of ours for over 20 
years as an Active Duty Soldier in the United States Army. I was also 
born and raised here in the Eastern Upper Peninsula and returned home 
to Sault Sainte Marie upon the completion of my military career.
    First, I would like to commend the Veteran's Administration for 
recognizing a problem in the care of our Veterans that live in rural 
areas. Speaking from my personal experience with the VA healthcare 
system, I believe the VA is moving in the right direction, there is 
still much more room for improvement. Improvements have been gained in 
the last several years with my access to care. When I started to use 
the VA healthcare system, it was not uncommon to drive all the way to 
the Iron Mountain VA hospital for an appointment or test. The Oscar G. 
Johnson VA Medical Center in Iron Mountain, Michigan is the closest 
facility. Some of those appointments were a simple 15 to 20 minute 
doctor visit that would require a 4 hour drive, one way, and an entire 
day off work. More recently, the VA has scheduled appointments for me 
at the local hospital or sent me an authorization to seek care locally. 
I am satisfied with the improved choice options; however there are bugs 
to be worked out. One is with billing. As a retired service member, I 
also use Tricare for medical insurance. Several times when I received 
care locally, my healthcare insurance was billed and not the VA. The 
response time is very slow when trying to get the medical bills routed 
in the right direction.
    I also feel that local access to healthcare for our aging veteran's 
should be a priority. I'm still relatively young. It is not as much of 
a burden for me as it is for some of our older veterans to receive 
care. In our community here in the Sault, there are several assisted 
living facilities and nursing homes with elderly veterans that do not 
have the physical capability to travel great distances to receive care 
from the VA. Improved choice could help with that issue. I would also 
like to comment that for me personally, the MyHealtheVet website is a 
great asset to access care, re-fill prescriptions, and communicate with 
the local Community Based Outpatient Clinic thru secure messaging. That 
was a great idea for those of us that are computer literate. However, 
it is not such a great choice for those that are not familiar with 
using a computer or do not have access. Many of our older Veterans do 
not use a computer. Another issue with improved choice that should be 
addressed is the lack of specialized care and Women Veterans' 
healthcare access in our rural environment. I'm not sure how to address 
these topics specifically, but they definitely need to be looked into 
and more options for care need to be available for all Veterans.
    Appropriate staffing is a concern. Soon after my retirement from 
active duty I started using the VA Community Based Outpatient Clinic 
located in Kincheloe, Michigan. The clinic was relocated to Sault 
Sainte Marie a few years later. I personally think the staff at the SSM 
CBOC is absolutely wonderful. I interact with the staff at the local 
clinic several times every month for my own appointments. They are 
always helpful and friendly. The only concern I have is there is not a 
permanently assigned Medical Doctor at the clinic. The Physician's 
Assistant does a great job, but I feel there should be a full time MD 
assigned to the clinic also. When the Doctor that was assigned to the 
clinic retired the position was filled several times temporarily until 
the Physician's Assistant was hired. This created a lack of continuity 
in care. I feel due to this lack of continuity, mistakes were made and 
treatment was not appropriate. During that time I also had an 
appointment with a physician located in Iron Mountain thru video chat. 
I felt that appointment was very impersonal and not effective at all. 
On another occasion, I drove to Iron Mountain for a video conference 
with a Doctor located in Milwaukee and some on-line testing. That, I 
feel, could have been accomplished at the clinic in Sault Sainte Marie. 
Now put yourself in a World War II Veterans shoes. Imagine how 
overwhelming and confusing the video conference could be to them.
    Again, it is a great honor to have the opportunity to participate 
in this valuable discussion regarding the care of our Veterans. This 
concludes my testimony. I am prepared to take any questions you or the 
committee members may have regarding my personal experiences with 
Appropriate Staffing and Improved Choice. Thank you.
    Pursuant to Rule X12(g)(4) of the House of Representatives, I have 
not received any federal grants in Fiscal Year 2015, nor have I 
received any federal grants in the two previous Fiscal Years.
    I have not received payments or contracts from any foreign 
governments in the current year or preceding two calendar years.

                                 

                Prepared Statement of Jacqueline A Haske

    Chippewa County Department of Veterans Affairs, 319 Court St, 3rd 
Floor, Sault Ste. Marie, MI 49783, (906) 635-6370/Fax (906) 635-6867, 
[email protected].

    September 15, 2016

    To whom it may concern,

    My name is Jacqueline A Haske. I am with the Chippewa County 
Department of Veteran Affairs Office. My office is designed to assist 
and support Veterans. File claims with the VA, apply for assistance 
with the Michigan Veterans Trust Fund, and seek further resources in 
the community and more. My concern is with the growing population of 
veterans in the Eastern Upper Peninsula, is the ability to provide 
healthcare to the veterans. We have been told about receiving a Doctor 
at the War Memorial VA Clinic and still have not received one. Several 
veterans have expressed their concern about getting a Doctor at this 
local facility.

    Jacqueline A Haske, Veterans' Counselor

                                 

                  Prepared Statement of Ms. Gina Capra

    Good morning, Chairman Benishek and Ranking Member Brownley. Thank 
you for the opportunity to discuss staffing and rural health concerns 
nationally and in the state of Michigan. I am accompanied today by Mr. 
James Rice, Acting Veterans Integrated Service Network (VISN) 12 
Network Director and Dr. Gail McNutt, Chief of Staff Iron Mountain 
Veterans Affairs (VA) Medical Center and Co-Chairperson of the National 
Patient Aligned Care Team (PACT) Consultant Team.

Overview

    The employees of VISN 11 proudly provide patient-centered care to 
approximately 399,825 Veterans living in portions of Michigan, Ohio, 
Indiana, and Illinois. Of the nearly 400,000 Veterans being treated, 
82,798 are classified as living in either rural or highly-rural areas. 
VISN 11 consists of 32 Community-Based Outpatient Clinics (CBOC) and 7 
healthcare systems with main campuses located in: Ann Arbor, Battle 
Creek, Detroit, and Saginaw in Michigan; Indianapolis and Ft. Wayne in 
Indiana, and Danville, Illinois. For fiscal year (FY) 2015, VISN 11 is 
operating on a budget exceeding $2.2 billion providing our Nation's 
heroes with high-quality care through traditional and innovative 
methods. VISN 11 also has a collaborative relationship with Vet Centers 
located throughout the catchment area.
    VISN 12 provides patient-centered care to approximately 15,000 of 
the 30,000 Veterans residing in Michigan's Upper Peninsula. These 
services are provided primarily through the Oscar G. Johnson VA Medical 
Center (OGJVAMC) in Iron Mountain, Michigan. The medical center 
operates six CBOCs in Michigan (Ironwood, Hancock, Marquette, 
Menominee, Manistique, and Sault Ste. Marie) and one in Rhinelander, 
Wisconsin.
    OGJVAMC is a complexity level III care facility with 17 medical/
surgical beds. It also has a Community Living Center with 40 beds. 
OGJVAMC provides urgent care and acute inpatient care in a 
geographically rural area and collaborates with larger healthcare 
facilities in VISN 12 and community facilities to provide higher level 
emergency and specialty services. It employs state-of-the-art 
telehealth technologies and is a leader in the delivery of healthcare 
to rural Veterans.
    The facility has 686 employees and an FY 2015 operating budget of 
$126 million. This includes $26 million for care provided by community 
providers. In FY 2014, there were 12,477 Veterans authorized to receive 
care in the community. Since the passage of the Veterans Access, 
Choice, and Accountability Act of 2014 (Choice), OGJVAMC has authorized 
over 4,226 Veterans to receive care for those waiting greater than 30 
days, primarily for psychiatry, optometry, and physical therapy 
appointments. In addition, OGJVAMC serves 2,484 Veterans that live 
greater than 40 miles away and are eligible for Choice; however, only 
450 of these Veterans have elected to use their Choice option.
    OGJVAMC ranks 18/140 in overall efficiency and 15/140 in clinical 
efficiency according to the latest efficiency analysis by the Office of 
Productivity, Efficiency, and Staffing. For each VA medical center, 
clinical and administrative cost efficiency is measured by using 
stochastic frontier analysis (SFA). SFA is a well-validated approach in 
assessing operational efficiency with quality of care taken into 
account. Additionally, the medical center has done well on national 
level employee surveys. For example on the Federal Employee Viewpoint 
Survey, the medical center had a greater percentage of positive 
responses to the summary satisfaction questions than VA, the Veterans 
Health Administration (VHA), and VISN 12. The Employee Engagement score 
for the facility was also higher than VA, VHA, and VISN 12. In fact, 
the facility's score of 66.5 was higher than the Government-wide score 
of 63. On the All Employee Survey Best Places to Work Index 2014 
results, the facility ranked 27 out of 142 facilities--in the top 20 
percent. On the 2014 Integrated Ethics Staff Survey, the facility's 
overall rating as an ethical organization was the 8th highest in the 
country for all VAMCs.
    OGJVAMC patients are satisfied with the quality of care they 
receive as evidenced by the medical center's patient experience data, 
which exceeds the VA's national score for both inpatient and outpatient 
care. As evidenced, over 80 percent of Veterans would recommend OGJVAMC 
to their friends and family. Facility leadership holds regular staff 
meetings with all schedulers, to include CBOCs, and the Director 
personally conducted mandated clinic observation interviews with all 
schedulers including CBOCs. The facility monitors access with internal 
stakeholders by reviewing and addressing data from the VHA Support 
Service Center (VSSC), New Patient Wait Times Exception Summary Report, 
and Access Glide Path data. To quickly identify opportunities to 
improve Veteran access, the Director reviews data during the daily 
morning report, such as the New Enrollee Appointment Request (NEAR), 
the Electronic Wait List, the Provider Workload, the local access data 
list, and the number of new patients seen in Urgent Care Clinic with no 
primary care provider assigned.
    Expanded mental health programs include the following: Operation 
Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/
OND) case outreach, Enhanced Rural Access Network for Growth 
Enhancement (E-RANGE) program for rural Veterans diagnosed with serious 
mental illness, Mental Health Intensive Case Management (MHICM), 
Posttraumatic Stress Disorder (PTSD) Clinical Care, Home-Based Primary 
Care (HBPC) psychology services, Compensated Work Therapy (CWT), 
recovery-based programs, suicide prevention, outpatient substance abuse 
programs, evidenced-based therapies, VA Caregiver Support, and the 
Homeless Veterans Program including Veterans Justice Outreach.

VA Rural Healthcare Program--State of Michigan

    There are approximately 660,800 Veterans in the state of Michigan, 
of which an estimated 230,000 (35 percent) are enrolled in the VA 
healthcare system. Additionally, 207,000 or 31 percent of all Michigan 
Veterans live in rural areas. Forty-one percent or approximately 95,000 
of enrolled Veterans live in rural areas.
    In addition to funding allocated to VISN 11 through the Veterans 
Equitable Resource Allocation (VERA) system for Veterans' healthcare, 
in FY 2014, VISNs 11 and 12, together, received $8 million from the 
Office of Rural Health (ORH) to support 21 projects and programs to 
increase access to care for Michigan's rural Veterans. The programs 
specific to Michigan include a Mobile Prosthetics Van, which brings 
prosthetic services typically found only at the main campus to the 
CBOCs; clinical training opportunities for providers in rural 
locations; enhanced rural access to mental healthcare services; 
Veterans transportation programs in the Upper and Lower Peninsulas; 
telehealth; and Home-Based Primary Care.
    Increasing access to VA-provided care for Tribal Veterans is 
addressed with a VA ORH-funded project for Battle Creek VAMC. This 
project supports a Native American Indian Veteran that has been trained 
as the Tribal Veteran Outreach Worker (TVOW). The focus of this project 
is to bring access to mental health services at the Battle Creek VAMC 
by utilizing telehealth technology. The project has also provided a 
liaison for Tribal Veterans that has assisted them within navigating VA 
for all their healthcare needs. The TVOW has served as the VA 
representative to several Tribal Events related to the collaborative 
relationship building that has occurred. These include Pow Wows, the 
Potowattomi Gathering in 2014, Tribal Veteran Council meetings, and 
Tribal Veterans Days events to name a few.
    VA continues to seek opportunities to expand our care via 
telehealth technology. VHA is in the early stages of developing a 
collaborative effort with community providers to be able to exchange 
health information, and OGJVAMC is one of the 14 pilot sites. We now 
have the capability to provide CVT in the home, which will improve 
access to care for rural Veterans and mitigate the need for travel to a 
VHA site of care. Additional mental health services via telehealth to 
Veterans at the Patriot House in Gaylord in 2014 are also being 
established.
    Since October 1, 2009, OGJVAMC has received approximately $14.2 
million dollars from ORH to implement and sustain programs. Recent 
grants include sustainment for the E-RANGE program, an outpatient 
mental health program that provides intensive, supportive services to 
Veterans living in rural areas who have a primary mental health 
diagnosis that is classified as severe, our Veteran Transportation 
Service, implementation of Physical Therapy at the Rhinelander CBOC, 
and a VA-Coordinated Transitional Care (C-TRAC) Program.

Recruitment & Staffing

    Nationally, VHA employs an aggressive marketing and advertising 
campaign aimed at patient care providers for rural locations through 
its partnership with the National Rural Recruitment & Retention Network 
(3RNet), a national network of non-profit organizations devoted to 
healthcare recruitment and retention for underserved and rural 
locations. Through this partnership, VHA has access to a robust 
database of candidates especially interested in its rural vacancies. 
National recruiters routinely post VHA practice opportunities on 
3RNet's career page. In addition, 3RNet annually dedicates the month of 
November to Veteran healthcare awareness by making VHA its featured 
employer for the month.
    VHA also strives to relocate physicians from urban areas to rural 
VAMCs and outpatient clinics. The increase in the rural Veteran 
population calls for a strong recruitment, marketing, and advertising 
campaign that directs qualified prospects to rural VA centers 
struggling to open their doors. The rural relocation marketing campaign 
targets urban physicians in transit during their daily commutes with a 
compelling recruitment marketing and advertising campaign to persuade 
them to explore options for relocation to the nearest rural VAMC. This 
extensive campaign targets geographic regions and specialties with the 
highest need, online, and in a wide range of professional healthcare 
publications.
    In addition to internal robust recruitment efforts by facility 
level human resources offices, VISN 11 partners with VHA's Workforce 
Management and Consulting (WMC) Office for increased recruitment and 
staffing support. The National Recruitment Program (NRP), a sub-
division within WMC's Healthcare Recruitment and Retention Office, 
provides a centralized in-house team of skilled professional recruiters 
employing private sector best practices to fill the agency's most 
critical clinical and executive positions. The national recruiters, all 
of whom are Veterans, collaborate with executives, clinical leaders, 
and local human resources departments in the development of 
comprehensive, client-centered recruitment strategies that address both 
current and future critical needs. In FY 2014, the NRP recruited 25 
clinical providers for VISN 11 vacancies of which 16 were for hospitals 
and clinics in Michigan. For FY 2015, to date 11 of the 15 Medical 
Officers recruited by the NRP currently provide care to Veterans at 
Michigan VAMCs and outpatient clinics. As of July 31, 2015, VISN 11 has 
921 physicians onboard and 136 active recruitments for physicians. In 
addition, WMC, ORH, other VA partners, and non-VA Federal partners are 
collaboratively exploring to:

         Determine where and what types of providers are in 
        short supply at rural healthcare facilities providing care for 
        rural Veterans;
         Solicit the voice of Veterans to better understand 
        rural Veterans' preferences and decisions regarding healthcare 
        providers;
         Determine best practices in rural provider recruitment 
        and retention;
         Explore and promote the use of VA financial incentives 
        and other innovative solutions to recruit providers to rural VA 
        facilities;
         Develop and/or expand and support clinical training 
        opportunities for rural health practitioners providing care to 
        rural Veterans to help retain them in rural areas;
         Promote and support rural health educational and rural 
        health clinical training experiences for medical residents, 
        nursing, and other health professions students to help recruit 
        future healthcare providers to rural practice; and
         Expand opportunities for training rural primary care 
        providers in specialty areas that address the unique medical 
        needs of rural Veteran demographic groups.

    OGJVAMC has actively recruited and retained staff while 
simultaneously improving relationships with community healthcare 
providers in the Upper Peninsula of Michigan and Northern Wisconsin to 
broaden the continuum of care available to Veterans. In a rural, 
sparsely populated area, few facilities are able to offer the full 
range of services normally available in larger metropolitan areas. 
Strong collaborations with multiple healthcare providers, both public 
and private, are essential in meeting the needs of patients. OGJVAMC 
has grown from 604 Full Time Employees (FTE) in FY 2012 to 648 FTE at 
the end of June 2015, an increase of 44 positions.
    OGJVAMC's proactive recruitment of providers is ongoing. Since 
2014, the facility has filled the following critical positions: Chief 
of Surgery, Chief of Behavioral Health, Associate Chiefs of Staff for 
Geriatrics and Primary Care, Chief of Medicine, and Chief of Staff. 
Furthermore, OGJVAMC recruited and hired an Anesthesiologist/Pain 
Medicine, Podiatrist, Certified Registered Nurse Anesthetist, and an 
Optometrist in FY 2015. In addition, since FY 2014, the facility has 
hired eight primary care providers and is fully staffed at all 
locations. To enhance CBOC services, mid-level providers are utilized 
to supplement primary care vacancies. Since April 2014, the on-board 
total of critical clinical care positions (physicians, physician 
assistants, nurse practitioners, nurses, and other select critical 
occupations) has increased by 20--representing an 8 percent increase. 
The medical center increased interim staffing to fill short term 
vacancies and mitigate disruption to scheduled appointments. To address 
short-term primary care and mental health vacancies, telemedicine 
clinics were expanded to provide interim coverage.

Rural Provider Education

    In FY 2012, ORH and the Office of Academic Affiliations (OAA) 
launched a collaborative three-year workforce program called the Rural 
Health Education and Training Initiative (RHTI) to increase healthcare 
workforce recruitment to rural areas. Seven sites in Maine, New York, 
Virginia, Nebraska, North Carolina, Alabama, and the Pacific Islands 
were awarded $250,000 per year for three years. By the end of FY 2014, 
690 trainees in 23 separate medical, dental, and mental health 
disciplines had been trained at rural VA sites of care.

Telehealth

    In FY 2014, more than 717,000 Veterans (12 percent of Veterans 
receiving VHA care) accessed VA care through Telehealth during more 
than 2.1 million encounters.
    Forty-five percent (45 percent) of these Veterans lived in rural 
areas, and may otherwise have had limited access to VA healthcare. The 
number of Veterans receiving care via VA's Telehealth Services grew 
approximately 18 percent in FY 2014.
    Veterans in Michigan are served primarily by two VISNs. VISN 11 
includes medical centers providing telehealth services in and around 
Ann Arbor, Battle Creek, Detroit and Saginaw, MI. Veterans in 
Michigan's Upper Peninsula use telehealth to access services from VISN 
12's Iron Mountain, MI, VAMC and its affiliated VA CBOCs in Marquette, 
Menominee, Hancock, Ironwood, Manistique and Sault Ste. Marie, MI.
    In FY 2015, Year to Date, more than 25,700 Veterans accessed VA 
care through Telehealth during more than 60,600 episodes in VISN 11. 
During this same period in VISN 12, about 23,000 Veterans accessed VA 
care through Telehealth during more than 109,900 encounters. Fifty-four 
percent of the VISN 11 Veterans as well as 54 percent of VISN 12 
Veterans lived in rural areas.
    In FY 2014, within VISNs 11 and 12, 16,230 Veterans in Michigan 
accessed VA care during 32,971 clinic-based telehealth encounters. More 
than two-thirds of these Veterans (22,024) lived in rural Michigan. The 
types of care Michigan Veterans were accessing through telehealth 
included the following: mental health, the MOVE! program, primary care, 
diabetes, Cardiology, Dermatology, and other services. Currently in 
August 2015, approximately 2,560 Veterans in Michigan are enrolled in 
VHA's Home Telehealth service to help them manage chronic conditions 
such as diabetes, chronic obstructive pulmonary disease, and congestive 
heart failure.

Conclusion

    In conclusion, VA is committed to providing high-quality, safe, and 
accessible care for our Veterans and will continue to focus on 
improving Veterans' access to care. While the location presents unique 
challenges with regard to distance, culture, and constrained healthcare 
markets, VA's rural health programs are robust, and we will continue to 
strive to serve Veterans in rural areas.
    Mr. Chairman, this concludes my testimony. My colleagues and I are 
prepared to answer any questions you, Ranking Member Brownley, or other 
members of the Committee may have.

                                 

Statement for the Record by Benjamin Balkum, President, AFGE Local 2280 
    Oscar G. Johnson VA Medical Center Iron Mountain, Michigan, the 
American Federation of Government Employees, AFL-CIO Before the Health 
Subcommittee of the Committee On Veterans' Affairs United States House 
  of Representatives Realizing Quality Rural Care Through Appropriate 
                      Staffing and Improved Choice

    September 1, 2015,
    Chairman Benishek, Ranking Member Brownley and Members of the 
Subcommittee:
    Thank you for the opportunity to provide a statement on behalf of 
Local 2280 of the American Federation of Government Employees, AFL-CIO 
and its National Veterans Affairs Council (AFGE).
    AFGE represents over 220,000 employees of the Department of 
Veterans Affairs (VA). AFGE Local 2280 represents all the healthcare 
professionals and support personnel at the Oscar G. Johnson VA Medical 
Center, including the Sault Ste. Marie CBOC, other outpatient 
facilities and our community living center.
    I have served as Local President of Local 2280 for almost 30 years 
and I have worked at the Iron Mountain VA since 1984. As a Vietnam-era 
combat veteran, I also receive healthcare services from the VA.
    At our facility, management practices have adversely impacted 
staffing levels, recruitment and retention of healthcare personnel, and 
most important, the ability of veterans in this very rural area to 
access quality, timely care.
    My statement focuses on the following problem areas:

         Cuts in critical healthcare services;
         Hostile and unreasonable work environment;
         Adverse impact of ``firing'' bills on recruitment, 
        retention and accountability.
         Cumbersome hiring processes
Cuts in Critical Services

    2Over the past year, management at Oscar G. Johnson VA Medical 
Center has downgraded its emergency room (ER) into an urgent care 
facility so it no longer provides 24-hour emergency care. As a result, 
the facility is unable to accept ambulances, veterans with chest pains 
or veterans presenting other acute conditions. Management also recently 
closed our intensive care unit (ICU); we are now unable to perform 
general surgeries or intubate patients. If a patient codes, he or she 
must be sent to a very small community hospital or to a full capacity 
VA facility that is over 100 miles away in Green Bay.
    Millions of taxpayer dollars were spent to build a state of the art 
surgery suite in 2014. As soon as the doors opened earlier this year, 
management lowered the complexity of our surgery program to a basic 
ambulatory standard of care, requiring veterans to travel great 
distances to other VA medical centers for all general surgeries and 
emergency surgeries. This brand new surgical suite is now being used 
only for ``lumps and bumps'' surgery that could just as easily be 
performed on an outpatient basis.
    Just prior to the opening of the new surgical suite, we were 
finally able to recruit and competitively pay an anesthesiologist to 
come to Iron Mountain. As a result of these cutbacks, the VA has had to 
pay for him to receive additional credentials in acupuncture in order 
to supervise our pain clinic instead.
    These cutbacks in essential medical services are life threatening 
to veterans with serious medical conditions. They also put veterans at 
risk by devastating the medical center's ability to recruit and retain 
surgeons, hospitalists and other clinicians who will no longer be able 
to maintain their skills and credentials if they stay at Iron Mountain.
    Iron Mountain's cutbacks are very drastic but not unique. A spring 
2015 AFGE survey of our locals at VA medical centers found that 62% of 
respondents reported similar cutbacks at their facilities, especially 
closings of ERs, ICUs and inpatient beds.

Hostile and Unreasonable Work Environment

    A number of providers have already left Iron Mountain for positions 
in the private sector due to our facility's toxic workplace and 
difficult working conditions. Because of increased turnover rates, many 
veterans at Iron Mountain never see the same doctor twice for clinic 
care. Chronic turnover is also significantly undermining the 
effectiveness of our PACT teams; many PACT team clinicians are being 
reassigned to fill vacancies in the CBOCs. We recently lost three 
highly qualified physicians (two emergency doctors and a long time 
hospitalist.)
    The dedicated healthcare personnel represented by Local 2280 are 
very concerned that the closing of our ICU and downgrading of our 
Emergency Department and surgical unit are seriously impacting the 
services to veterans who reside throughout the rural areas of the Upper 
Peninsula, Northern Lower Peninsula, and North Eastern Wisconsin.
    Attrition is also worsening because of management's overreach into 
providers' clinical decisions and because of their use of sham peer 
reviews and other performance evaluations to intimidate and harass 
providers. False allegations of poor performance can irreparably damage 
a VA provider's future employment opportunities both within and outside 
the VA.
    Varying panel sizes and double booking (in direct violation of VA 
policy) have forced Iron Mountain providers to work long extended hours 
on a regular basis without additional pay or time off. Initially, our 
physicians were promised an hour of administrative time every day to 
enable them to promptly respond to hundreds of daily computer alerts, 
review lab results and follow up on care provided by other VA and non-
VA providers. However, due to constant overbooking by management, 
providers were not actually able to use these one-hour daily slots to 
handle their other major responsibilities. Management's quick fix was 
to block off four hours one day a week instead, but even that limited 
set aside time continues to be swallowed up by enormous panel sizes, 
walk-ins and unassigned patients.

Adverse Impact of ``Firing'' Bills on Recruitment, Retention and 
Accountability

    The counterproductive and fear-driven work environment at Iron 
Mountain is deteriorating further in the face of legislative proposals 
such as H.R. 1994 that assault basic workplace rights. At-will 
employment is simply not an accountability tool. Taking away our 
physicians' rights to defend their professional reputation and 
positions prior to termination is not a path to accountability either. 
We must ask ourselves: How many VA healthcare professionals will come 
forward to Congress or will even want to work at the VA if they know 
they can be fired on the spot or falsely accused of poor patient care 
without recourse?
    That is why AFGE Local 2280 urges lawmakers to support the true 
accountability fixes in H.R. 2999. This bill preserves due process--
which is critical for protecting the front line employees who are the 
VA's most valuable watchdog against mismanagement--while addressing 
workplace safety, improper management-contractor relationships and 
abuse of paid administrative leave. If we truly want bureaucrats out of 
the examining room and the operating room, we cannot give VA managers 
more power to interfere with patient care through whistleblower 
retaliation, anti-veteran animus, nepotism, politics and other 
prohibited personnel practices.
    To further increase accountability and the voice of the front-line 
provider, AFGE Local 2280 urges passage of H.R. 2193 to restore equal 
collective bargaining rights to the ``full Title 38'' VA providers--VA 
physicians, dentists, registered nurses, physician assistants, 
optometrists, chiropractors and podiatrists--who have been unfairly 
singled out and silenced by current VA Title 38 policy. It hurts VA 
accountability and recruitment to deny a VA physician the basic 
bargaining rights afforded to a DoD physician or to every Hybrid Title 
38 VA healthcare employee. This unfair VA practice is another example 
of nonmedical personnel (managers and human resources) interfering with 
clinical decisions.
    Finally, to improve recruitment and retention, AFGE Local 2280 
urges reintroduction of legislation to make sure every veteran working 
as a VA Title 38 healthcare professional has equal veterans' preference 
rights. An unintended loophole in the Veterans Employment Opportunities 
Act allows VA hiring officials to pass over veterans with preference 
points to hire non-veterans for Title 38 healthcare positions. Former 
combat medics and corpsmen will not want to bring their valuable 
experience to the VA instead of DoD or the private sector if they 
cannot enforce their veterans' preference rights at the VA.

Cumbersome Hiring Processes

    I would like to close by focusing on hiring instead of firing. The 
providers represented by AFGE offer the following suggestions for 
strengthening the VA healthcare workforce and we urge the Subcommittee 
to conduct VA provider roundtables on Capitol Hill and in the field to 
further explore these and other reforms to the hiring process:

         Establish a more formal and permanent applicant pool 
        that can be quickly accessed when vacancies occur (and even 
        earlier when providers give notice that they are leaving).
         Shorten the credentialing process by requiring less 
        information and reducing duplication by reducing requests for 
        older information already collected by state medical boards.
         Eliminate the requirement that VA providers 
        transferring within the VA healthcare system repeat the full 
        credentialing process.
         Conduct oversight to curb ``bait and switch'' 
        practices by human resources personnel who fail to deliver on 
        promises made to new hires. healthcare professionals regularly 
        share this type of information with colleagues who are 
        considering VA employment.
         Conduct oversight to ensure that job openings are 
        always posted and posted in a timely manner (e.g. 48 hours). 
        This will greatly assist in recruitment and also curb ``off the 
        grid'' hiring that bypasses job postings and has resulted in a 
        growing problem of cronyism where hiring and promotion is based 
        on who you know rather than skills and experience.

    I want to thank the Subcommittee for the opportunity to share AFGE 
Local 2280's views on these critical issues. Over the past 30 years, I 
have personally witnessed the transformation of the VA healthcare 
system into a national leader in patient care, research and training 
and the nation's most exemplary provider of veteran-centric medical and 
behavioral healthcare.
    I am extremely proud of the care that our employees deliver and 
that I personally receive at the Iron Mountain VA. We should not let 
the rhetoric of privatizers and opponents of employee rights obscure 
the truth that this is a healthcare system very much worth saving and 
fixing and that veterans consistently prefer to receive their care 
inside the VA. But we must stop starving Iron Mountain and other 
medical centers of the very clinicians who consistently receive high 
marks from veterans. The critical ingredients for improved access to 
rural healthcare for Oscar G. Johnson Medical Center veterans are a 
professional, supportive work environment, an end to politically driven 
assaults on due process and the restoration of critical surgical, ER 
and ICU services. Thank you.
    Benjamin F. Balkum.

                                 

                    American Osteopathic Association

    Chairman Benishek, Ranking Member Brownley, and members of the 
Committee
    On behalf of the American Osteopathic Association (AOA) and the 
more than 110,000 osteopathic physicians and osteopathic medical 
students we represent, including more than 7,500 in Michigan, thank you 
for your continued focus on efforts to improve choice and access to 
healthcare for our nation's veterans, especially for those in rural 
areas. I appreciate the opportunity to provide the perspective of the 
osteopathic medical profession as the committee examines ways to ensure 
the delivery of high-quality care for rural veterans, and to reiterate 
our commitment to working with you to address the health needs of all 
veterans.
    The AOA strongly supports the mission of the U.S. Department of 
Veterans Affairs (VA) and the Veterans Health Administration (VHA) in 
delivering care tailored to those who have served our country. There is 
little doubt the VA is uniquely positioned to address the comprehensive 
health needs of its veteran population, as well as the specific areas 
of traumatic brain injury, post-traumatic stress disorder, prosthetics, 
and other injuries and conditions associated with the battlefield. The 
philosophy and practice of osteopathic medicine is grounded in a 
``whole person'' approach to care, which aligns well with the diverse 
needs of the veteran population.
    We also believe that community care providers serve an important 
role in this mission--not only to help relieve some of the existing 
strain upon VA personnel and resources, but also to improve access to 
high-quality care for veterans living in rural areas. Osteopathic 
physicians in particular tend to practice in rural and underserved 
communities, and more than sixty percent of our members enter primary 
care fields. Guided by a patient-centered, holistic approach to care, 
osteopathic physicians are well-equipped to help meet the healthcare 
needs of veterans, whether in the VA or in the communities in which 
they reside.
    The Veterans Choice Program (VCP) is an essential tool in achieving 
our shared goal of improving veterans' access to care. While 
implementation of the VCP has not been without challenges, the AOA 
appreciates the Committee's efforts to identify these issues and work 
with the VA to effect positive changes. We are encouraged by successful 
recent legislative efforts, spearheaded by the House Committee on 
Veterans' Affairs, which will streamline existing VA community care 
programs under a unified ``Veterans Choice Program,'' ensuring that the 
system will be easier to navigate for veterans and healthcare providers 
alike.
    We must also continue our efforts to ensure that a highly-skilled 
physician workforce is trained and ready to meet the needs of veterans 
with complex health conditions, as well as the specific health needs of 
new generations of veterans who will be entering the VA system. The AOA 
strongly supports efforts to increase graduate medical education (GME) 
residency positions, such as the 1,500 new positions created under the 
Veterans Access, Choice, and Accountability Act (``Choice Act,'' P.L. 
113-146). Especially as the majority of these new residencies are in 
primary care fields, we believe this is a critically important step 
toward ensuring an adequate supply of physicians to care for these 
deserving patients. Further, as a majority of physicians tend to 
practice where they complete their residencies, the value of a robust 
graduate medical education system with sufficient rural training track 
opportunities cannot be understated.
    The AOA looks forward to today's discussion, and we are eager to 
work together with Committee members, the VA, and veterans to ensure 
that those who have served our country receive the care they have 
earned and deserve through a system that is equipped and responsive to 
their needs. Thank you for the opportunity to share the perspective of 
the osteopathic medical profession, and for your continued attention to 
the healthcare needs of rural veterans.
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