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OVERSIGHT HEARING ON LONG-TERM CARE

PROGRAMS IN VA

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

MAY 22, 2003

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 108–14

(
COMMITTEE ON VETERANS’ AFFAIRS 

CHRISTOPHER H. SMITH, New Jersey, Chairman 

MICHAEL BILIRAKIS, Florida 

TERRY EVERETT, Alabama 

STEVE BUYER, Indiana 

JACK QUINN, New York 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

ROB SIMMONS, Connecticut 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

JEB BRADLEY, New Hampshire 

BOB BEAUPREZ, Colorado 

GINNY BROWN-WAITE, Florida 

RICK RENZI, Arizona 

TIM MURPHY, Pennsylvania 

LANE EVANS, Illinois 

BOB FILNER, California 

LUIS V. GUTIERREZ, Illinois 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

CIRO D. RODRIGUEZ, Texas 

MICHAEL H. MICHAUD, Maine 

DARLENE HOOLEY, Oregon 

SILVESTRE REYES, Texas 

TED STRICKLAND, Ohio 

SHELLEY BERKLEY, Nevada 

TOM UDALL, New Mexico 

SUSAN A. DAVIS, California 

TIM RYAN, Ohio

PATRICK E. RYAN, Chief Counsel and Staff Director 

SUBCOMMITTEE ON HEALTH 

ROB SIMMONS, Connecticut, Chairman 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

JEB BRADLEY, New Hampshire 

BOB BEAUPREZ, Colorado 

GINNY BROWN-WAITE, Florida 

RICK RENZI, Arizona 

CLIFF STEARNS, Florida 

TIM MURPHY, Pennsylvania 

CIRO D. RODRIGUEZ, Texas 

BOB FILNER, California 

VIC SNYDER, Arkansas 

TED STRICKLAND, Ohio 

SHELLEY BERKLEY, Nevada 

TIM RYAN, Ohio 

LUIS V. GUTIERREZ, Illinois 

CORRINE BROWN, Florida 

DARLENE HOOLEY, Oregon

(II) 
(III)

C O N T E N T S 

May 22, 2003

Page

Oversight Hearing on Long-Term Care Programs in VA ..................................... 1

OPENING STATEMENTS 

Chairman Simmons ................................................................................................. 1

Prepared statement of Chairman Simmons ................................................... 35

Hon. Bob Filner ....................................................................................................... 2

Hon. Ciro D. Rodriguez ........................................................................................... 6

Prepared statement of Congressman Rodriguez ............................................ 37

Hon. Lane Evans, ranking democratic member, full committee on Veterans’

Affairs .................................................................................................................... 6

Prepared statement of Congressman Evans .................................................. 40

Hon. Bob Beauprez .................................................................................................. 8

Hon. Cliff Stearns .................................................................................................... 10

Hon. Rick Renzi ....................................................................................................... 10

Hon. Vic Snyder ....................................................................................................... 12

Hon. Shelley Berkley ............................................................................................... 14

WITNESSES 

Bascetta, Cynthia A., Director, Health Care, Veterans’ Health and Benefits 

Issues, U.S. General Accounting Office; accompanied by Jim Musselwhite, 

Assistant Director, Health Care ......................................................................... 2

Prepared statement of Ms. Bascetta ............................................................... 42

Fuller, Richard B., National Legislative Director, Paralyzed Veterans of 

America ................................................................................................................. 32

Prepared statement of Mr. Fuller ................................................................... 84

Gaytan, Peter, Principal Deputy Director, The American Legion ....................... 32

Prepared statement of Mr. Gaytan ................................................................. 69

Hayden, Paul A., National Legislative Service, Veterans of Foreign Wars ........ 32

Prepared statement of Mr. Hayden ................................................................ 89

Ilem, Joy, Assistant National Legislative Director, Disabled American Veterans ...................................................................................................................... 32

Prepared statement of Ms. Ilem ...................................................................... 80

Miller, Thomas, Executive Director, Blinded Veterans of America ..................... 32

Prepared statement of Mr. Miller ................................................................... 77

Roswell, Hon. Robert H., M.D., Under Secretary for Health, Department 

of Veterans Affairs, accompanied by James F. Burris, M.D., Chief Consultant for Geriatric and Extended Care .................................................................. 16

Prepared statement of Dr. Roswell ................................................................. 59

MATERIAL SUBMITTED FOR THE RECORD 

Letter from Secretary Principi to Chairman Smith re VA nursing home capacity, May 8, 2002 .................................................................................................... 20

Statements: 

Alzheimer’s Association .................................................................................... 92

Eastern Paralyzed Veterans Association ........................................................ 98

Written committee questions and their responses: 

Chairman Simmons to Department of Veterans Affairs ............................... 102

Congressman Evans to Department of Veterans Affairs .............................. 108

Chairman Simmons to Blinded Veterans of America .................................... 111
Page

IV

Written committee questions and their responses—Continued

Chairman Simmons to Disabled American Veterans .................................... 112

Chairman Simmons to Veterans of Foreign Wars ......................................... 114
(1)

OVERSIGHT HEARING ON LONG-TERM CARE 

PROGRAMS IN VA 

THURSDAY, MAY 22, 2003

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC 

The subcommittee met, pursuant to call, at 1:45 p.m., in room 

334, Cannon House Office Building, Hon. Rob Simmons (chairman 

of the subcommittee) presiding. 

Present: Representatives Beauprez, Renzi, Stearns, Rodriguez, 

Filner, Snyder, Berkley and Evans (ex-officio). 

OPENING STATEMENT OF CHAIRMAN SIMMONS 

Mr. SIMMONS. The subcommittee will come to order. I want to 

thank everybody for coming this afternoon, and I want to welcome 

our witnesses. 

The purpose of today’s hearing is to review the current status 

and future of long-term care programs for veterans in the Veterans 

Health Administration. In particular, we will examine existing VA 

long-term care programs and expenditures, and appraise VA strategy for addressing future long-term care needs of aging and disabled veterans. 

Under Public Law 106–117, VA is required to operate and maintain certain long-term care programs in nursing home care and enhance other programs such as geriatric evaluation, domiciliary 

care, adult day health care, respite, palliative and hospice programs, both institutionally and in some noninstitutional basis. 

Although VA’s long-term health care services have undergone 

some positive changes in recent years, VA’s commitment to longterm care has not kept pace with veterans’ needs, in our opinion. 

I believe GAO will be speaking to this issue in their testimony 

today. 

I would argue that VA’s biggest single challenge in health care 

today, and for the next decade, is how to best address the steadily 

increasing numbers of elderly veterans who need care. 

We all know and appreciate the problems that VA has. Six or 

seven years ago, VA began shifting its care base to primary care 

and opened what some people refer to as the ‘‘flood gates.’’

VA is full to overflowing with enrolled veterans, and many of 

these aging veterans have health care problems that can’t really be 

resolved by an outpatient approach, regardless of its intensity. 

While we support these advances in home care and other alternatives to institutional solutions, such as VA nursing home care, 
2

it still holds true that aging veterans are going to need nursing 

home beds in a much larger proportion than veterans use them 

today. 

I will insert the rest of my opening statement into the record to 

conserve time and to allow maximum opportunity for members to 

address our panels. 

[The prepared statement of Chairman Simmons appears on p. 

35.] 

Mr. SIMMONS. I would ask at this point if my ranking member 

has a statement that he would like to make. 

I recognize Mr. Filner. 

OPENING STATEMENT OF HON. BOB FILNER 

Mr. FILNER. Thank you. 

I appreciate your remarks, Mr. Chairman, and we know, of 

course, that the veteran population that is in need of nursing home 

care is rising rapidly. As the figures that I have show there are 

640,000 veterans over the age of 85, and that number is expected 

to be 1.3 million over the next decade, and the VA does not seem 

to be ready to meet this need. 

There are nursing home beds in 131 hospitals and one standalone nursing home in Colorado. There were 13,000 beds in 1998, 

and Congress froze the number of nursing home beds in the Millennium Care Act that we passed. 

In spite of that freezing, the VA has removed 2,000 beds. Now, 

I understand, Mr. Chairman, that the Secretary of VA has sent a 

letter to you that those beds will be replaced. We will have to ask 

Dr. Roswell if he has been told that. I am not sure that everybody 

is on the same page here. 

The administration’s budget proposed removing another 5,000 

beds, and I oppose that. I don’t know where the chairman is on 

that, but as you said, Mr. Simmons, we support the primary care 

in outpatient clinics, but we cannot do that at the expense of the 

old, chronically ill veterans. They have no place else to go. So I am 

looking forward to this hearing. We have to make sure that we can 

take care of both populations. That should be our aim, and I look 

forward to working with you to achieve it. 

Mr. SIMMONS. I thank the gentleman for his remarks, and I 

agree that this is an issue that we need to look at. That is the purpose of this hearing here today, and at this point I would ask our 

panelists to come forward. 

STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR, HEALTH 

CARE, VETERANS’ HEALTH AND BENEFITS ISSUES; ACCOMPANIED BY JIM MUSSELWHITE, ASSISTANT DIRECTOR, 

HEALTH CARE 

Mr. SIMMONS. The first panel consists of Ms. Cindy Bascetta, 

who is the Director for Veterans Health and Benefits Issues at the 

U.S. General Accounting Office. I believe that she will be accompanied by James Musselwhite, Assistant Director for Health Care, 

and I will let them get settled and fill their glasses with water and 

arm themselves for this process. You see the green light. You know 

how it works. 

I look forward to hearing your testimony. 
3

At the conclusion of the testimony, we will go from side to side 

on questions. 

STATEMENT OF CYNTHIA A. BASCETTA 

Ms. BASCETTA. Thank you, Mr. Chairman and members of the 

subcommittee. I am pleased to be here today to discuss our work 

on VA’s noninstitutional long-term care services. As you know, the 

number of veterans 85 years old and older is expected to double, 

reaching about 1.3 million over the next 10 years. 

These older veterans are the ones most likely to need long-term 

care and many of them will prefer care in their own homes or in 

community settings where possible. Almost 5 years ago, the Federal Advisory Committee on the Future of VA Long-term Care recommended that VA meet growing demand for long-term care by 

greatly expanding home and community-based service capacity, 

while at the same time maintaining its nursing home capacity. 

Although VA provides a continuum of noninstitutional and institutional services, it spends much more on institutional care. In 

fact, VA spends less than $300 million to serve an average daily 

census of about 24,000 veterans, compared to nearly $3 billion to 

serve an average daily census of more than 43,000 veterans in institutional settings, including nursing homes. 

Against this backdrop, we surveyed facilities in 2001 and again 

in 2002, about six noninstitutional services. These are home-based 

primary care, skilled home health care, and homemaker/home 

health aid services, as well as three other services, adult day 

health care, geriatric evaluation and home-based respite care that 

VA provides to meet the requirements of the Millennium Act. 

We are reporting today that little progress has been made since 

last year in improving the availability of these six services. Our 

new report also shows that service gaps and facility restrictions result in inequitable access to these services. As a result, access is 

still often limited or nonexistent and dependent on where veterans 

live. 

I would like to focus on the reasons for these access limitations. 

First, many facilities do not offer the six noninstitutional services 

at all. We found that 126 of VA’s 139 facilities did not offer all six 

services. The least commonly available service was noninstitutional 

respite care, which was not offered at 106 facilities. 

In contrast, only seven facilities did not offer skilled home health 

care, the most widely available service. This means that similarly 

situated veterans may not have access to similar services if they 

live in areas where the services are not available. 

Second, this inequity in access is worsened because many facilities that offer a service limit it to part of the geographic area that 

they serve. For example, 76 facilities offer adult day health care, 

but do so only in part of the geographic area they serve. Even 

skilled home health care, the most widely available service, is not 

offered in the entire geographic area by about 20 facilities. In some 

cases, this is because contract health care providers may not be 

available or for other reasons. 

The third reason that further limits access is facilities setting 

their own eligibility standards or limiting either the amount of 

service or the number of veterans who can receive a service at any 
4

time. We found that 57 facilities have waiting lists for one or more 

of the six services in our review because of restrictions placed on 

the number of veterans who may receive a service. 

But perhaps more serious are the facility imposed eligibility 

standards. Nine facilities told us that they based access to services 

on specific service-connected disability levels, and it is possible that 

a systematic review would reveal that this is more widespread. 

These facility standards conflict with VA eligibility standards, 

which state that most services are to be available to all enrolled 

veterans, regardless of their priority group. 

VA concurred with our recommendation to ensure that facilities 

adhere to it eligibility standards, so that similarly situated veterans have access to similar care, regardless of where they live. 

Mr. Chairman, VA Headquarters has contributed to access limitations and inequities because it has neither emphasized the importance of noninstitutional services in the long-term care continuum, nor has it provided sufficient guidance on how to provide 

these services. 

For example, VA has not established measurable performance 

goals to increase access to similarly situated veterans. Faced with 

competing priorities, field officials have chosen to use available resources for other services. VA has also provided inadequate guidance on what constitutes noninstitutional respite care and on 

which home-based services should be part of the benefits package. 

As a result, some networks and facilities have been confused about 

how to provide noninstitutional respite care, and, not surprisingly, 

facilities have varied in their interpretations of which home care 

services they need to provide. 

To address these problems, we are recommending that VA refine 

its current performance measure, clarify what constitutes noninstitutional respite care, and specify which home-based services 

should be available to all enrolled veterans. These actions, if followed up with effective oversight to ensure that they are implemented in the field, should result in more equitable access to noninstitutional services in the future. 

This concludes my remarks, and we would be happy to answer 

your questions and those of the subcommittee members. 

[The prepared statement of Ms. Bascetta appears on p. 42.] 

Mr. SIMMONS. I have a couple of questions, at which point I will 

then defer to my ranking member, and we will go back and forth 

with questions. 

On the front page of your testimony, or at least on the front page 

of the VA Long-term Care Report that I have dated May 22, 2003, 

it states that VA concurred with both of your recommendations, 

and my first question is concurrence is great, but do you see any 

effort from VA to implement those recommendations? 

And then my second question goes to the issue of home-based 

primary care. I have been briefed in my home State about some of 

the efforts to enhance the technological approaches to home-based 

health care that include a device that can be connected to the 

phone lines that measures temperature, blood pressure and various 

other vital signs that is relatively easy to use. It seems to me, and 

with simple supervision or maybe no supervision at all, the aging 

veteran or the veteran’s family can assist in using that device. I 
5

was curious if you had any knowledge on whether those types of 

devices are being used at all or to a moderate degree or extensively 

to address the issue of home health care. 

Ms. BASCETTA. Let me answer your question about their concurrence first. We have taken a quick look at the attachment to Dr. 

Roswell’s statement, and I have a few initial reactions. 

First of all, if you look at the four recommendations that we 

made, these items don’t align quite with the recommendations. 

There is a lot here that isn’t directly addressing the recommendations that we made, but for what is here, let me offer my initial 

reactions. 

Regarding the eligibility standards, the directives that they plan 

to issue, of course, are a good first attempt, but we would want to 

have more assurance that the enforcement that would follow up on 

these recommendations would be powerful enough to ensure that, 

in fact, the field complied with the directives. 

On noninstitutional respite care, my understanding is that they 

have, in fact, issued guidance in a brand new handbook that has 

been long awaited, but, again, monitoring the field to assure that, 

in fact, implementation of the guidance and handbook is carried 

out, is what really counts. 

With regard to specifying what home care services ought to be 

available, I can’t tell from this document whether they have made 

any progress on that front or not. 

And with regard to the performance measure, the words here, to 

discuss the formal performance measure and set specific program 

targets, look like the right words, but we are really concerned 

about that performance measure. As written, without revision, it 

allows better performers basically to cover for poorer performers. 

And what I mean by that is that as long as access increases in the 

aggregate, they can meet the standard. So they can increase access 

in facilities that are already offering the service, and those facilities 

would in effect be compensating for little or no improvement in 

other facilities. 

The bottom line is that without individual facility performance 

being measured, the measure won’t all hold networks and facilities 

accountable for more uniform access improvements. 

Mr. SIMMONS. So as my staff indicates, somebody standing in a 

bucket of ice water with his hair on fire still has a temperature of 

98.6? 

Ms. BASCETTA. That is correct. 

Mr. SIMMONS. Thank you. I would now like to recognize the 

ranking member, Mr. Rodriguez. 

Ms. BASCETTA. You had your second question. I need to answer 

your second question. 

Mr. SIMMONS. Oh, yes, please. I beg your pardon. 

Ms. BASCETTA. That is okay. It is a short answer. We have heard 

anecdotally that these technological devices, sometimes called telemedicine, are very promising, but we don’t have any work on the 

extent of the availability of those services within the VA. 

Mr. SIMMONS. I thank you for that answer, and at some point I 

will probably ask VA to supply that. Home health care is the way 

to go for many families, to include veterans families, and I understand these devices are fairly expensive now, but if I can do things 
6

around the world with this little Blackberry, I am sure that with 

a little application of technology and a little effort, we can help a 

lot of those families who don’t have easy access to the facilities and 

don’t really need easy access to the facilities right now. 

I thank you, and I recognize the ranking member, Mr. Rodriguez. 

OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ 

Mr. RODRIGUEZ. Thank you very much, and I want to personally 

thank GAO for their report and what you indicated. There is some 

very startling comments on there, as well as the findings in the 

disparity that exists among the facilities, and I will have an opportunity to maybe follow up a little bit more with you, but I do want 

to take this opportunity because I know we have our ranking member on the full committee, Mr. Lane Evans, and I want to relinquish my time to him because he has got to be leaving. 

[The prepared statement of Congressman Rodriguez appears on 

p. 37.] 

Mr. RODRIGUEZ. Congressman Lane Evans. 

OPENING STATEMENT OF HON. LANE EVANS, RANKING DEMOCRATIC MEMBER, FULL COMMITTEE ON VETERANS’

AFFAIRS 

Mr. EVANS. Thank you for yielding, and I thank the Chairman 

giving me the time today. 

Today, I am releasing a report prepared at my request by the 

GAO, demonstrating significant service gaps in the delivery of noninstitutional care services to veterans. 

In 1999, Congress passed legislation which added certain home 

and community-based services to VA’s uniform benefits package. 

The GAO reported on these and other services. Not all VA facilities 

offer the same services, and even if they did, some services are limited to certain geographical areas. 

The report is particularly critical, because the VA claims it wants 

to increase noninstitutional options in favor of a diminished nursing home program. Veterans are aging and their needs for longterm health care are growing. Very few medical facilities within 

the VA offer all these services, but some facilities have been equally diligent in providing these services. 

In addition, other VA medical centers cap the amount of some 

types of care that they will offer according to the availability of 

funding, resulting in extended waiting times and unmet needs. 

These reports don’t paint a very good picture of the veterans access to noninstitutional long-term health care. VA is light years 

away from having an adequate response to the growing needs of 

our elderly veterans. Long-term health care is also an important 

part of VA’s care continuum and deserves greater attention. 

Mr. Chairman, I urge you to keep vigilant about this issue, and 

I appreciate the opportunity to be heard. 

[The prepared statement of Congressman Evans appears on p. 

40.] 

Mr. EVANS. I yield back to the gentleman from Texas. 

Mr. RODRIGUEZ. Thank you very much, and I want to thank you 

also for those comments. 
7

Let me just—I want to thank, once again, the GAO for their report, and I want to just quote Dr. Roswell’s statement, when it says 

that—when it was indicated that access to noninstitutional care 

services in the VA health benefits package is unrealistic and that 

the VA does not agree with the GAO’s conclusions that there has 

been a lack of emphasis by the VA on increasing access to noninstitutional long-term care services. 

I would like to ask you your response to those comments that 

were made. 

Ms. BASCETTA. Well, we were surprised to see that, because in 

their official comments on the report, which are published as an 

appendix to the report, VA concurs with both our findings and our 

conclusions and recommendations. So obviously, they have done 

some rethinking since they wrote that concurrence. 

I am not sure why they said that our recommendation was unrealistic. We are not suggesting that veterans in every single location 

have every single service available to them. We are suggesting that 

what is required is that similarly situated veterans have access to 

similar services, and we are noting disparities such as major locations, major metropolitan areas having a total absence of a particular service. We are not talking about areas that are remote 

where something isn’t available because there isn’t a contractor or 

there isn’t a way to provide a service to every veteran. 

So we disagree with that characterization. 

Mr. RODRIGUEZ. And I would agree with you too, because it 

really bothers me when there seems to be a move from—apparently 

based on the assessments, and I want to get your clarification. 

From an inpatient to outpatient type of effort throughout the system—and I don’t know, is that part of just trying to bring down 

the cost, or is that only a detriment, because I know that the disparities exist in terms of actual service? I know that that is negative, and that shouldn’t be the case, but is it from a more—you 

know, if you look at it from a logical perspective, would it be the 

right thing to do to try to treat everyone on an outpatient 

perspective? 

Ms. BASCETTA. Well, that is a very important question, because 

cost is certainly an important factor. Our understanding of the 

community-based services is that they are less expensive on a perunit basis, but depending on how many veterans are served or nonveterans, if you are talking about the general population, the cost 

could be very significant. And son what is important about our 

work is that we continue to find that both the policy and the data 

that VA have need to be much more clearly articulated, and the 

policy needs to be data-driven. We need to know how these services 

are being delivered now, to how many people, with what kinds of 

variations in either their eligibility or other kinds of restrictions, 

and what the basis for that is, and what the costs are. And then 

we can think together about what a more reasoned approach might 

be. 

Mr. RODRIGUEZ. I know I have gone over my time, but would it 

be fair to say that if you—I don’t want to look at it legally, but if 

I live in a particular area, and I am a veteran, you know, based 

on this report, then I might have access to certain services, but if 

I live in another area, then those veterans there are not getting it. 
8

So I see that as extremely discriminatory to some veterans based 

on just locality of the situation. 

Is there any liability there? You know, we ought to be concerned 

about? 

Ms. BASCETTA. That I don’t know, but equitable access means 

that similarly situated veterans, in other words, veterans in cities, 

veterans in suburban areas, veterans in rural areas, ought to have 

access to similar services in those areas. They should not be having 

differential access or great disparities in the services that are available to them. 

Mr. RODRIGUEZ. Thank you very much. 

Mr. SIMMONS. The Chair recognizes Mr. Beauprez, followed by 

Dr. Snyder. 

OPENING STATEMENT OF HON. BOB BEAUPREZ 

Mr. BEAUPREZ. Thank you, Mr. Chairman. Probably more of a 

comment than a question, but I would be interested in your 

response. 

The chairman raised the issue, the question of evolving technology and how it may assist. I am most anxious, given the seriousness of the concerns that you raised in your report and in your testimony both, to hear from Dr. Roswell, but having aged parents 

myself that are in long-term care, I have witnessed, I guess, some 

of the great assistance that has come with evolving technology for 

both aged or long-term, depending—not everybody in long-term 

care, I guess, is necessarily elderly. 

But I also recognize, and having sought that care out, fortunately, we found it in our community. The difficulty of finding the 

quality health care that everybody would like to think is available 

to everybody in communities that are relatively accessible to all, 

and I am guessing that Dr. Roswell may tell us that therein lies 

a lot of the challenge. But having said that, we have an obligation, 

if we accept the obligation, of quality health care to all of our veterans, it becomes an obligation, I think, to those in most serious 

need. That has to be the greatest obligation. 

Did you in any of your—in any of your findings, do you have any 

recommendations for use of some of the new technology or evolved 

long-term health care that might assist the VA directly? Where is 

the silver bullet? 

Ms. BASCETTA. We don’t have any specific recommendations 

aimed at those kinds of services. 

Do you have anything to add? 

Mr. MUSSELWHITE. There may be promise in some of these technologies. We did not look specifically at that, but their application, 

as I suspect Dr. Roswell may speak about, works for some things 

but not others. For example, in the home, a very important type 

of care that many people need is hands-on care, for example, bathing, dressing, those sorts of things. So for some things, technology 

may not be as directly applicable as it may for others. 

Mr. BEAUPREZ. So the answer is you—and I am not suggesting 

that it should be otherwise, but you basically discovered the shortcomings, and we are going to leave the solutions to others. And 

that is fair, if that is the case? 

Ms. BASCETTA. Yes. 
9

Mr. BEAUPREZ. That is fine. Mr. Chairman, I will anxiously 

await Dr. Roswell’s testimony. 

Mr. SIMMONS. I thank the gentleman. 

Have we resolved who was in the room first? 

Mr. FILNER. Whoever was here when the gavel went down is 

equally eligible. 

Mr. SIMMONS. Okay. The Chair recognizes Mr. Filner, who was 

here when the gavel went down. 

Mr. FILNER. I will be very brief and yield to my friend, Dr. 

Snyder. 

Ms. Bascetta, you have not painted a very pretty picture here, 

and my own anecdotal evidence, I would say, supports your findings. Is this question purely of money or is there a deeper systemic 

problem that we are dealing with? If I said, to fix this it requires 

X millions or billions of dollars, could we fix it with money? 

Ms. BASCETTA. Well, you can always provide more services with 

money, but I think the more fundamental problem here is a lack 

of policy and a lack of data at headquarters about what is going 

on now. In other words, had there been greater emphasis on the 

need to develop long-term care policy, not just for the noninstitutional services but for the entire continuum, we might be in a better position now to know what might be causing these service gaps, 

the limitations in the geographic areas, the imposition of facilityspecific eligibility standards, and we might be in a better position 

to know how much could be solved by reallocation or redistribution 

of the funds as opposed to the need for additional funds. 

Mr. FILNER. I find that situation that you described as sort of 

systemic in various areas. That is, when we have passed other legislation, we have had difficulty getting evidence that has been successfully applied across the VA. 

Ms. BASCETTA. Excuse me. 

Mr. FILNER. And I suspect Dr. Roswell may be very definitive 

about this rather than figuring out how to deal with it, but, we are 

left with how to oversee these policies. Even if we pass legislation, 

all of a sudden 2,000 beds are taken away when we said they were 

frozen. How do we oversee this situation which should not be occurring? This is reprehensible, and we don’t seem to have the tools, 

to come to grips with it. 

I am sure Dr. Roswell will have an explanation for that situation, 

but it seems to me that they are in contempt of Congress in what 

has occurred here. I am not sure there is a legal kind of situation, 

but I would even pass some sort of resolution saying that if this 

were the case that was the finding that we made. 

It seems to me that we on this subcommittee and the full committee have to figure out how to have the oversight that we claim 

that we have. Do you have any comments on that, contempt of 

Congress? 

Ms. BASCETTA. I think I will leave that up to you, but I would 

say that you certainly can’t make informed decisions or deliberate 

on long-term care policy without data, good reliable data, and they 

need to do a much better job of providing that. 

Mr. FILNER. But how did you do your study? 

Ms. BASCETTA. Well——
10

Mr. FILNER. You have the data, so let’s give it to them and say 

act on it. You have the data, right, that you say they don’t have? 

Ms. BASCETTA. Yeah. Part—— Mr. FILNER. We will buy it from you, give it to them, and then 

say they better do something about it within X amount of time. 

Ms. BASCETTA. Part of the picture—we have part of the data, but 

not all of it, and not as much depth in all of the areas that you 

would need to really take a hard look at long-term care policy overall. 

Mr. STEARNS. Would the gentleman yield? 

Mr. FILNER. Yes. 

Mr. STEARNS. My colleague from San Diego mentioned—asked 

you a question. You said it is lack of policy and lack of data. So 

you are saying from your standpoint, the GAO’s standpoint, it is 

not lack of money why they are not implementing the Millennium 

Health Care Bill. It is lack of policy and lack of data, that I just 

want to firmly establish, in your opinion, is that correct? 

Ms. BASCETTA. Yes. For example, there wasn’t guidance issued 

on some—— Mr. STEARNS. I understand. You talked about service gap, geographic area and these different things you mentioned I understand. But I think for this committee to hear from you that it is 

not money, because that is what we hear, but it is just lack of internal policy developed by the VA and lack of internal data that 

you have that you could give, so when the second panel comes up, 

Mr. Roswell, that is the people that we should go from your statement to them and say, okay, tell us. 

So I thank the gentleman. 

Mr. FILNER. Mr. Chairman, again, this is just one of many areas, 

but somehow we have to come to grips with these problems and 

really provide the oversight that we should be doing. It is, of 

course, very difficult. All of us who have served in public life for 

a long time, this is the most frustrating thing we have. That is, to 

really come to grips with the executive branch that is implementing what we have passed. It is always a problem, I have been 

on the school board and the city council, and it is the exact same 

thing. It goes from millions to billions and hundreds of billions, but 

we have to figure out a way to get some accountability, and I leave 

it to your creative mind to figure out how we might do that. 

Mr. SIMMONS. I thank the gentleman for his comments. 

I will simply note that in a previous life, I served on a committee 

on the other side of the Hill that had oversight responsibilities for 

the intelligence community, and I would say that dealing with the 

Veterans’ Administration is a welcome, open, and transparent exercise after what I was confronted with in that previous life. And 

that being said, I would recognize Mr. Renzi, followed by, I think, 

Dr. Snyder at this point. 

Mr. RENZI. Thank you, Mr. Chairman, and thank you for your 

testimony today. I was not here at the 106th Congress, and it is 

interesting to look at the history of this and see how it looks as if 

we asked the VA to implement and establish six new noninstitutional service home-based health care services, six of them, and in 

all honesty, I want to ask maybe your experience in the years you 

have served in helping us up here on the Hill, is it fair to say that 
11

here, in the 108th, we have given them enough time? I mean, the 

idea that home-based health services, while being seen as the new 

wave of the future and as being seen of cost-effective and certainly 

more healthy for the patient, they can be at home, with their families, staying at their homes and loved ones, certainly, I can see all 

the benefits of it, but have we honestly given them enough time to 

institute six—and I am not looking to create—excuse this one, because I am going to wack them in a minute, but have we given 

them enough time in your thoughts? 

Ms. BASCETTA. Yes, we have, but let me clarify for the record 

that the three new services that they implemented to comply with 

the Millennium Act were adult day health care, geriatric evaluation and home-based respite care. The other services were already 

being provided. 

Mr. RENZI. Thank you. I didn’t realize that. 

Ms. BASCETTA. The law was passed in 1999. It took almost two 

years to issue implementing regulations, and it has taken even 

longer for us to see any improvement, and we haven’t seen much 

in the availability of the three additional services. 

Mr. RENZI. So in your opinion, the three additional services, we 

have had enough time? 

Ms. BASCETTA. Yes. 

Mr. RENZI. Your report is interesting when it talks about many 

facilities restrict the number of veterans. You use that word restrict. Is that something that they are doing purposefully, or is it 

because of facilities themselves? 

Mr. MUSSELWHITE. Those decisions are made at the local level 

and facilities have discretion, in part based on network policies and 

sometimes without network policies, concerning how essentially 

they will allocate the resources and services they have available. So 

they may restrict a service, for example, by the number of veterans 

who might receive it at any one time. So, for example, if they have 

resources for 50 veterans to receive it at that time, no one else 

could receive a service until one of those 50 no longer received it. 

Mr. RENZI. So it is really a function of the brick and mortar, the 

idea of how many they can fit into the box. It is not so much—or 

am I wrong? Please. 

Mr. MUSSELWHITE. It may not be brick and mortar because these 

services, for example, some of the home-based services are provided 

at home, so the number of providers of that service or the number 

of dollars available for that service——

Mr. RENZI. So you are saying dollars then? 

Mr. MUSSELWHITE. Well, that is the way they have made a decision about how they will spend their dollars. 

Mr. RENZI. Okay. Any thoughts on the idea that under the original budget proposals that did not get implemented because of this 

chairman and because of Chairman Smith at three o’clock in the 

morning prior to the vote we were able to save those accounts, the 

idea that we are going to cut almost 7,000 nursing home beds and 

that those nursing home beds, the lack of those nursing home beds, 

would have to have been the—the burden of not having them 

around would have to be picked up by the home health care with 

this type of noninstitutional care. 
12

Any thoughts on how that would have been accomplished, given 

the fact that, you know, see all the gaps that are in it, you now 

see all the restrictions that you have called out, you now talk about 

the fact we don’t have enough people in some areas? Where would 

those veterans have gone to? Any idea? 

Mr. MUSSELWHITE. We don’t know the answer to that. 

Mr. RENZI. The streets. Okay. Thank you. 

Mr. SIMMONS. The Chair recognizes Dr. Snyder. 

Mr. SNYDER. Thank you, Mr. Chairman. 

I want to pursue this discussion a little bit about money or no 

money, because it is obviously an important question over the longterm, and I guess I am still a bit confused on what I think the answer is. 

In your report, there are several factors that seem to be at play. 

One of them is you refer to the aging population, talk about the 

number of, I guess, doubling from 640,000 to a million two or a million three or something over the next 10 years of people—veterans 

85 years of age and older. You also, someplace in your report, talk 

about how Congress has changed the eligibility standards to make 

more people available. Well, if we have got an increasing number 

occurring, why is that not a question of—I mean, surely at least 

that is a question of money, if we are going to double our numbers 

in terms of age, or if we are going to even augment that even further by the change in eligibility standards, surely that is going to 

create some pressure to have a bigger portion of the pie go for services for people 85 years of age and older. Or is my math wrong? 

Is my math wrong? 

Ms. BASCETTA. No. I think our point is that we need a needsbased analysis of long-term care, what is happening now, and what 

VA would project to be happening in the future before we can figure out not only what the long-term care cost components would 

be, but how they—how with their entire appropriation, they would 

be able to fund long-term care services looking at the demographics 

of the entire population, not just the aged portion but all other 

veterans. 

Mr. SNYDER. I would accept that. So what you are saying is, it 

may actually indeed be a question of money. If you are just saying, 

at this time, we don’t know how much and what amount—— Ms. BASCETTA. That’s right. We wouldn’t have any basis for making that assessment at this point. 

Mr. SNYDER. Right. You talk on page—oh, I guess it is the very 

last page you refer to ′′faced with competing priorities and little 

guidance from headquarters,′′ I think is your statement, but competing priorities implies to me, an acknowledgment that, even 

today, there is money problems. Is that a fair statement or not? 

Competing priorities to me would—that generally around here—

when we are setting priorities, we are talking about who gets 

money and who doesn’t. 

Ms. BASCETTA. It is a little hard to hear you. I can see where you 

would read it that way. What we were specifically talking about in 

that part of the report is the fact that VA sets performance measures for certain activities that the networks then understand clearly are high priorities, and we were making the point that the noninstitutional measure was not in that set of performance measures 
13

and that, as a result, the networks were going to turn their attention and their resources to those items which they knew they 

would be measured on. 

Mr. SNYDER. That makes sense. And on Page 9 of your written 

statement—and this concerns me, because, you know, you always 

want,—you know, good people can disagree about what is best for 

a patient or an individual or a veteran, but it ought to be an honest 

disagreement. On Page 9 you make the statement, one network director told us that the pressure from VA Headquarters to maintain 

nursing home utilization is much greater than that to offer noninstitutional services. 

That is a concerning statement to me, because it is saying you 

may have a veteran when you think the best place for that veteran 

to be is at home, but somehow pressure is coming down—now, this 

would obviously occur on an individual basis, but it is obviously the 

pressure is coming. No, don’t send Master Sergeant Smith home, 

keep him in a nursing home. Would you explain that statement? 

Ms. BASCETTA. Well, we would agree that that would not be the 

preferred outcome, that—again, beginning with a needs-based assessment, we would hope that there would be sufficient flexibility 

in the system to provide the service that the veteran needs in the 

least restrictive environment. 

Mr. SNYDER. Well, I want you to respond to the statement there. 

I mean, that is quite an allegation that some—one director is feeling pressured to keep people in nursing homes even though it is 

the policy—I think it is the policy of Congress and the desire of 

most people to be at home, but you are saying someone is feeling 

pressured to keep people in nursing homes who may indeed want 

to be at their real home. What did you mean—I mean, what do you 

know of that, or what is going on there? 

Ms. BASCETTA. Well, again, I believe that this reflects an emphasis on headquarters in measuring nursing home capacity—the continuing capacity to provide nursing home beds, rather than an emphasis on the noninstitutional. 

Mr. SIMMONS. I thank the gentleman. We have got a 15-minute 

vote, followed by a 5-minute vote. 

We have time for one more set of questions, and so the Chair recognizes Mr. Stearns. 

Mr. STEARNS. Thank you, Mr. Chairman. I had the great honor 

and privilege when I served as chairman in your capacity, we actually authored the Millennium Health Care Bill, and with the help 

of the staff over here, we got it through, and had a conference on 

it, and finally got it through. We had great expectations, and obviously we are a little bit concerned that they are not being implemented. And I am glad to hear, from your standpoint, it is lack of 

policy and lack of data and not lack of money, because usually up 

here, everybody says it is rack of money. 

But just for a second, as a hypothetical, let’s say you are the 

Under Secretary for Health, you have the responsibility, and the 

question for you is, what would you do in terms of reforms, VA reforms? And don’t give—if you can, don’t give me things like develop 

performance data or measure accountability. I mean, specifically, 

what would you do in terms of programs, implementation of these 
14

programs if you were the Under Secretary of Veterans Affairs? Do 

you understand what I am trying to ask? 

Ms. BASCETTA. Yes. 

Mr. STEARNS. Just real specific here, so we have got the Under 

Secretary behind you here, and I am sure he will take a couple 

notes, for whatever it is worth. 

Ms. BASCETTA. Well, I would find it hard to make a first move 

without——

Mr. STEARNS. Remember, you are so lucky here. Nothing you say 

is going to be implemented. It has no bearing. You are just hypothetically, for a day. 

Ms. BASCETTA. I would be very frustrated in making a first move 

and thinking about reform until I had a very good handle on exactly what was going on in the field with regard to the services 

that were available and what veterans needed. 

Mr. STEARNS. Are you saying they don’t have that now? 

Ms. BASCETTA. Yes. I am. 

Mr. STEARNS. You’re saying, right now, they have no understanding of what is happening in the field? 

Ms. BASCETTA. They have a limited understanding, certainly. So 

first of all, you develop procedures, so that everybody can see what 

the current status is? 

Mr. STEARNS. Right, and then what would you do? 

Ms. BASCETTA. Well, then I might look to the nonVA world to determine what benchmarks might be, although I think that everybody pretty well knows that what is required is a good mix of institutional and noninstitutional care, and on the noninstitutional side, 

that mix includes both services that are more medically oriented, 

as well as services that require less skilled provision, so that you 

can both avoid institutional care, which is much more costly, but 

so that you can also give people the care in the manner that they 

prefer it. 

Mr. STEARNS. Well, Mr. Chairman, I don’t know if we have more 

time. So I think I will pass. 

OPENING STATEMENT OF HON. SHELLEY BERKLEY 

Ms. BERKLEY. Mr. Chairman, I am going to have a very difficult 

time coming back, and this is a very important issue for me. Can 

I just take 2 minutes? 

Mr. SIMMONS. You most certainly can, because the gentleman 

has yielded back his time. 

So you go for it, but we don’t want to miss our vote. 

Ms. BERKLEY. I will be very quick. First I want to thank you. I 

think while it is important that we do Congressional oversight on 

the existing VA nursing care facilities located across the country, 

it is also very important to determine where the demand for longterm care services remain unmet, and I can tell you in Las Vegas, 

they are unmet. We have well over 150,000 veterans now in southern Nevada. We have no nursing home. There is one State-run VA 

nursing home that has—that the VA has expanded the number of 

beds in the Nevada State nursing home in Boulder City, Nevada 

to 180. However, the VA has acknowledged that this expansion will 

not meet the needs of southern Nevada because of the expected vol-
15

ume demand and because the State home does not provide rehabilitative services. 

The VA has also recognized the ability to contract in community 

nursing homes in Vegas. However, we have a tremendous lack of 

available community resources to contract with. Contracting with 

community nursing homes in southern Nevada is limited due to the 

quality of care deficiencies, high community nursing home occupancy rates, up to 96 percent, lack of specialized services, Alzheimer, psychiatric care, ventilator care just simply doesn’t exist in 

southern Nevada. Nevada is ranked last with the lowest number 

of skilled beds per thousand persons age 65 and older. I am at my 

wit’s end with what to do with my veterans. I think it is a function 

of money, as well as everything else, and I need to know when I 

am going to get some relief. And these veterans who retire to Las 

Vegas, they are healthy when they get there, by the time they are 

85 and, by the way, 85 is the—that is the fastest growing veterans 

population in Las Vegas, our 85-year-olds and above. What are we 

to do with these people? Are they going to die in the streets? Are 

they going to die alone without family? Are they going to die without any nursing home care in a country of great abundance? This 

is a disgrace, and we have to address this problem. And if anybody 

can explain to me how I can get these necessary resources to a 

community that has an abundance of veterans and a lack of any 

facility to help these people, I would be very grateful, because this 

is an abomination. 

Thank you. 

Mr. RODRIGUEZ. Just a quick point of clarification. I want to get 

something clear, because a couple of members said that it wasn’t 

about money. My understanding, did you say that you didn’t have 

enough data to report on that? What you have reported is the fact 

that with the money that they do have, that they still have the disparities and that they haven’t moved on the specific services, and 

if you have a veteran in one area, it doesn’t get the same services 

that you give veterans. So it isn’t that they don’t need any money. 

It is that you have to make the assessments. Is that correct, yes 

or no? 

Ms. BASCETTA. That is correct. 

Mr. SIMMONS. Tune in in 15 minutes and the show continues. 

[Recess.] 

Mr. SIMMONS. The subcommittee will reconvene. I have polled 

my colleagues at the dais, and it appears that we are now ready 

for the second panel. So I wanted to thank our panel for their fine 

testimony. We appreciate it very much. We will probably have 

some follow-up questions for the record. So prepare yourself. 

Now I would like to welcome Dr. Robert Roswell, Under Secretary for Health of the Department of Veterans Affairs. If he could 

come forward. He is accompanied by Dr. James Burris, the Chief 

Consultant for Geriatric and Extended Care at the Veterans 

Administration. 
16

STATEMENT OF HON. ROBERT H. ROSWELL, M.D., UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY JAMES F. BURRIS, M.D., CHIEF 

CONSULTANT FOR GERIATRIC AND EXTENDED CARE 

Mr. SIMMONS. I suspect that both of you gentlemen have heard 

some of the interaction of the first panel. I look forward to hearing 

your testimony. We have a prepared statement from you, Dr. 

Roswell; feel free to summarize that as you see fit. Then we will 

get into questions. 

STATEMENT OF HON. ROBERT H. ROSWELL, M.D. 

Dr. ROSWELL. Thank you. Mr. Chairman. It is a pleasure to be 

here. I am pleased to introduce Dr. James Burris, who after a 

lengthy hiatus, where we have not had effective leadership in the 

Office of Geriatrics and Extended Care, joins us as our highly 

qualified new chief of that office. 

As you have suggested, Mr. Chairman, I have submitted my formal testimony and won’t read that, nor I will read the summary 

statement I had prepared and planned to read as an abbreviated 

version, because I would like to take this brief time and address 

some of the issues that have already been raised in response to the 

first panel. 

First, let me publicly acknowledge and thank the General Accounting Office for helping us better understand the availability of 

noninstitutional services to VA patients. Fundamentally, I have no 

disagreement with their report. 

Certainly I have no disagreement with their findings or their recommendations. I concur wholeheartedly in the recommendations 

and am eager to seek implementation of those. 

I think the two points where I might, for the record, clarify a difference of opinion, if you will, would be first on the emphasis within VA. Clearly, now, we have a very great emphasis on noninstitutional care and services. 

And the second area where I would disagree is this—I believe the 

quote about being unrealistic to access these services. 

The services the GAO looked at are six services, which are recognized and described in program language. They are clearly not 

services that are universally available. For example, our own program criteria for hospital-based primary care, one of the services 

they looked at, clearly articulates that the veteran must live within 

35 miles of the hospital-based primary care program. 

That is because in that particular program, the hospital-based or, 

excuse me, the home-based primary care provider actually makes 

home visits. And to make that a pragmatic realistic program, veterans have to reside within a certain geographic range to be able 

to avail themselves of that program. 

Another example is adult day health care, where we often contract for that service. It may not be economically feasible for VA 

to staff and operate an adult day health care program in an area 

where there aren’t sufficient veterans to justify that investment of 

effort. 

In that situation, we would seek to contract for an adult day 

health care service for eligible veterans who would benefit from 

such a program. But, if there is not a qualified program who meets 
17

our fairly rigorous contracting standards, then it would be impossible for us to contract and acquire that. 

So it is unrealistic to think that all veterans in all locations will 

have access to all six services simply because they don’t exist and 

can’t be made to exist. I do agree, however, with Ms. Bascetta’s 

opinion that equitability of access should be similar in similar geographic regions of the country. I certainly agree with that. 

To go back to the area of emphasis, let me point out that noninstitutional care is a particular emphasis of mine. And, Mr. Chairman, I am glad you brought up the use of technology. When I was 

the network director in Florida, going back to 1999, I actually took 

$5 million of my allocated funding in Florida and created the first 

of a community care coordination program specifically focused on 

using the interactive technologies you have spoken of. 

The advantage of interactive technology is it allows us to reach 

well beyond the commuting distance of a practitioner so that inhome service is no longer bounded by the commuting range of a 

home-based caregiver. 

Florida today has over 1,500 people enrolled in a program using 

interactive technologies to monitor health in the home. I might 

point out that those 1,500 patients aren’t even counted in the data 

we show here, because they don’t conveniently fit one of the 

programs. 

The use of telehealth technology in the home is not a home-based 

primary care program, because it preserves the existing relationship with the primary care or specialty provider in the hospital or 

outpatient clinic setting. So it doesn’t fit one of the convenient categorizations of programs, and therefore is not reflected. 

We have had a substantial growth in noninstitutional care services. We have increased from 11,000 to 17,000. The home—the program I spoke of in Florida that I am quite proud of, has extensive 

data that is available, in fact, it has been accepted for publication 

and will be published in a medical journal just next month. 

We have replicated that with the creation of a new care coordination program office in our VA headquarters. We have just selected 

a chief officer for that office, and he is in the process of relocating 

to Washington to take over the leadership of that care coordination 

program. 

Last fall, at the end of fiscal year 2002, I actually made available 

additional moneys to fund new care coordination sites using the 

telehealth technology, and I have made a commitment to provide 

additional funding this year in the amount of $5 million to provide 

additional equipment to begin to expand and build upon that program. So there is a tremendous amount of emphasis. 

With regard to the bed census, we have put in place VISN specific performance monitors to meet the nursing home requirements 

of the Millennium bill, which is to maintain an average daily census of 13,391 patients, the number of patients that received VA 

nursing home care in 1998. 

I would point out that since 1998, the number of Veterans each 

year who receive VA nursing home care has actually increased, 

even though the average daily census has decreased. And the reason is that the length of stay has been reduced. We are very proud, 

very proud of the fact that patients who receive care through VA’s 
18

nursing home beds, in over 70 percent of the cases are discharged 

to home, because they have been restored to a level of functionality 

that allows them to return to an independent living arrangement 

in the home. 

This is not custodial long-term care, and we are quite proud of 

the outcomes. But, because we are achieving and attaining these 

outcomes, we are able to provide inpatient long-term care services 

through our VA staff nursing homes to more patients, even though 

the average daily census has admittedly declined. 

With the implementation of the performance measures, though, 

that I spoke of, the actual average daily census has now increased 

over 12,000, which represents a substantial increase over the nadir 

of approximately 11,700 last year. So it is going back up with the 

implementation of those performance measures. 

We have also implemented VISN adjusted performance monitors 

for home-based and community care services, the noninstitutional 

care services I spoke of. And with that implementation and emphasis we expect to see the VISNs improving in their implementation 

of those services. We have developed directives, a new emphasis 

letter will be going out very shortly to reemphasize the importance 

of these programs. 

I should also point out that when I was the network director in 

VISN 8, I created a program for home respite, a program that 

was—that became a national program, using volunteers to provide 

respite services in the home. 

There was talk about not being in touch with what our patients 

need. We actually conducted focus groups with patients, with their 

providers and with their primary caregivers to understand what 

the barriers to home care were. 

And respite was one of the highest priorities identified, which is 

part of the reason we created the Volunteer Home Respite Program, which has been a very successful model. 

So I can’t, in good conscience, take some of the criticism that has 

been leveled at the Under Secretary For Health, because I do consider myself an avid proponent for noninstitutional care and for 

geriatric care in the VA. 

I have been aggressive and will continue to push for this with 

the new care coordination office, with the new performance measures, with the emphasis that we are giving it, and with Dr. Burris’s 

leadership, we expect to continue to enhance care and services in 

both institutional and noninstitutional settings. 

One way I hope we will be able to do that in the future is to be 

able to provide institutional care when it becomes essential in an 

assisted living facility where the veteran will be able to maintain 

the pair bond with his or her spouse. 

Right now, institutional care in the VA, of necessity, forces a separation of husband and wife when institutional care is provided. It 

is something that I believe is very, very wrong with the way we 

provided institutional care. 

So when seeking care, coordination and providing health services 

in an ALF facility, we are working on ways to be able to main that 

that spousal relationship when the time for institutional care becomes unavoidable. 
19

Mr. Chairman, I am deeply committed to implementing the recommendations of the GAO report. And Dr. Burris and I would be 

happy to answer any questions you might have. 

Mr. SIMMONS. Thank you very much. 

[The prepared statement of Dr. Roswell appears on p. 59.] 

Mr. SIMMONS. I have a couple of questions that I would like to 

ask. In looking at your testimony, page 6, attachment 1, the aggregate numbers for noninstitutional care, the total numbers, go from 

1998 to 2004, from 11,000 to 25,000. 

Some of the subcategories in that chart show substantial growth 

over time. Others do not. For example, VA adult day health care 

is pretty much flat-lined around 400 for the Nation, which I would 

suspect is a pretty low number considering the health of adult day 

care—considering the positive response we get in my district to 

adult day health care programs on the civilian side. 

I also notice that home hospice only begins to be estimated in 

2004. Again around 400, under 500 folks. I wonder if you could 

comment briefly on those two programs. 

And then I have one additional question. In May of last year, 

Secretary Principi responded to Chairman Smith and Ranking 

Member Lane Evans on the issue of implementation of Public Law 

106–177 and the issue of VA nursing home capacity. 

And there has been correspondence since that time that suggests 

that maybe earlier commitments to nursing home capacity have 

been reconsidered by the highest echelons of the VA. I would like 

to hear your response to that question and whether or not that is 

the case. I look forward to your answer. 
20

(Subsequently, the Department of Veterans provided the following correspondence that Chairman Simmons is referring to:)
21

Dr. ROSWELL. Thank you, Mr. Chairman. Well, you have asked, 

I believe three questions. And let me take them in order. With regard to adult day health care, if you will look at the row just below 

the one you referenced for contract adult day health care, you will 

see a three-fold increase in the number of adult day health care patients projected by contract. 

The reason is that we found, as I alluded to in my opening statement, that trying to provide adult day health care with VA staff 

requires, of necessity, that we have a sufficient number of veterans 

to justify the hiring of the full staff. It is actually economically 

more attractive, and it allows us to extend the geographic range of 

that service in most cases by contracting for that service. So it is 

a more efficient way to do that. 

With regard to home hospice—— Mr. SIMMONS. If I can just interrupt on that point to get clarification. It is my understanding that VA facilities across the country 

have excess capacity in the way of rooms, or even floors. 

So what you are saying is that it is entirely a staffing issue, not 

a capacity issue at those facilities? 

Dr. ROSWELL. The problem, if you will, with adult day health 

care, is it has to be convenient. It is a day program. Adult day 

health care offers primarily socialization. Limited health care, some 

assistance with feeding, but it really—there are three major needs 

for geriatric long-term care: Socialization needs, which are very important to maintain cognitive function and quality of life. We also 

need to provide health care. And we need to provide assistance 

with daily livings. 

An adult day health care program primarily provides socialization during the day. Of necessity, it has to be sufficient, it has to 

be within reasonable commuting distance for the veteran who is almost universally brought to it by the caregiver. So if it is not close 

or convenient for the caregiver to get the veteran to the adult day 

health care program, then it really serves no meaningful purpose. 

The problem is that often where we have excess physical capacity, as we are now exploring through our Cares Program, we don’t 

have a sufficient population to justify adult day health care. We actually have adult day health care programs at VA facilities that 

have not been particularly successful because they are simply not 

close enough for veterans to reach it in a commuting basis. 

The ideal way is to provide adult day health care within a reasonable commute, 2 or 3 miles at most ideally, of where the veteran 

lives. To do that, it is much more efficient to contract for that care. 

Mr. SIMMONS. Thank you. 

Dr. ROSWELL. Your second question had to do with hospice care. 

And again, we have certainly emphasized hospice care. We currently provided hospice care in virtually all of our medical centers 

on an inpatient basis, but we recognize that home hospice is an important service. We are developing programs and guidelines. 

The reality is that many veterans are receiving the equivalent of 

home hospice care today, but because we haven’t structured and 

formulized the program, it is only phased in in 2004. 

Finally, you talked about the Mil Bill requirements to maintain 

the 1998 nursing home average daily census. Again, I spoke to that 

in my opening comments, pointing out that we are actually treating 
22

more patients in our nursing home beds than we did in 1998, although the average daily census is lower. The Mil Bill is to maintain the average daily census, not the operating beds nor the number of veterans served each year. 

Because veterans are receiving shorter lengths of stay, because 

their rehabilitation is being completed more quickly, they are 

turned to home at an earlier date, and the census drops. 

The reality is, that in most cases, VA nursing home beds don’t 

provide long-term care. They provide post-acute hospitalization rehabilitation. Those beds are collocated, in the overwhelming majority of places, with our acute care facilities. When a veterans has 

significant rehabilitation needs, or when it is a frail elderly veteran 

who needs careful assessment to be able to determine a geriatric 

care plan that allows the veteran to resume a more functional independence, those patients receive those care in our VA staff nursing 

homes. 

But, as I said, one of the greatest outcomes possible in those 

nursing home beds is a discharge to the home environment, which 

occurs in almost 80 percent of the cases. And that reflects a different level of care than custodial long-term care. 

So, yes, the 2004 budget policy does, in fact, propose a fairly radical departure from the requirements of the Mil Bill. The 2004 

budget policy proposal suggests that VA long-term care should be 

reserved for 70 percent service connected, who by law are entitled 

to that care, and be used for this post acute rehabilitation care that 

I spoke of, as well as respite care and for geriatric evaluation and 

management plus hospice care, reflecting more accurately the actual utilization of those services. 

Obviously, that is a decision that the Congress must make in determining whether or not to change, and obviously the 2004 budget 

policy would propose a change in the current statutory requirement 

to maintain that 1998 census. Because that change has not yet 

been enacted, we are continuing to attempt to move towards the 

Mil Bill requirements. Our goal by the end of this fiscal year is to 

have a census of 12,550 patients, which is not the full 13,391, but 

it is a significant increase over the 11,700, which was the average 

daily census last year. 

With the implementation of VISN specific performance measures, 

we are on target to hit that this year. 

Mr. SIMMONS. Mr. Rodriguez. 

Mr. RODRIGUEZ. Thank you very much. I know you had some 

concerns with the dialogue that was occurring and some, I guess, 

some disagreement. Your statement that the VA has taken aggressive action, quote, to implement the extended care provisions of 

Public Law 106–117, the Millennium Act, seems to conflict with a 

January 3rd report that the committee received this past March. 

And on the cover letter of that report, about the VA’s experience 

under the Millennium Act, Secretary Principi concludes, between 

the enactment of Public Law 106–117, November of 1999 to September 2001, there is evidence of only small changes in the VA’s 

long-term care services that were a direct result of the Act versus 

what the VA had already planned to provide for veterans. 
23

And so, you know, there seems to be also agreement on the part 

of the Secretary that we have not seen the action that we should 

have. 

Dr. ROSWELL. Mr. Rodriguez, I can’t speak for the Secretary. But, 

I think, I believe what you said was, he showed there was a small 

difference between what we originally planned and what the Mil 

Bill required us to do. We have always had a commitment, even before the Mil Bill made it a statutory requirement, to expand our 

noninstitutional care and services. 

In the very tables that the chairman referred to, show that aggressive growth from 11,000 patients receiving noninstitutional 

care in 1998 to a projected 26,000 next fiscal year, in 2004. We are 

on a track to do that. 

Now, we have taken some actions, but I believe that the Government Accounting Office is correct. We have not been as aggressive 

as we should have been over the past number of months. But, the 

commitment is there now. I have that commitment. Dr. Burris 

shares my commitments. We are aggressively implementing the 

recommendations of the GAO and fully expect to achieve this noninstitutional census. 

Mr. RODRIGUEZ. Let me just make sure we get this correct. From 

1998, what you just quoted, to 2004, which is an estimate, it is not 

that you have gotten there, you just hope to get there, but that is 

noninstitutional, which I would presume that that is part of the 

problem that is occurring there, because we get reports that your 

non—you are pushing patients out to outpatient care, which is actually, in a way, you know, one of the complaints that we get 

versus inpatient care, and you are saying that you are increasing 

in that area. 

Yes, we agree that you are increasing in that area. But, that is 

one of the easiest ways to increase, because in a way you are kicking them out of the hospitals, more long-term care into outpatient 

care. Whether you are providing care or not, I don’t know. But you 

have them labeled as outpatient care. 

The actual figures that we have is 11–7 to 17, and the other one, 

the 20-something is an estimated one. Is that correct? 

Dr. ROSWELL. Yes. That is correct. The—I do understand your 

concerns. Let me point out that our institutional, our inpatient census actually grows over the same period. But the proportion of institutional care being provided in State nursing homes increases 

most significantly. 

Now, I would point out that that is probably the most cost efficient way to provide institutional long-term care that is primarily 

custodial in nature, in other words that is long-term as opposed to 

the rehabilitation. 

Mr. RODRIGUEZ. And I would agree with you there too. But I 

would also ask, and ask your perspective on, that if we want to 

provide care, that it takes a combination both of inpatient and outpatient care. 

And what disturbs me is the fact that if—the disparity that exists from one region to another, from one area to another, and, of 

course, now the possibility of everybody cutting and making even—

you are saying 70 percent for nursing home care, where they have 
24

to be 70 percent of what—of disability? Is that—was that 70 percent you talked about? 

Dr. ROSWELL. The Mil Bill mandates lifelong care, assuming the 

veteran needs it and desires it, for any veteran who is disabled at 

a level, a compensable disability of 70 percent or greater, or if they 

are service connected—— Mr. RODRIGUEZ. 17 percent? 

Dr. ROSWELL. 70 percent for any condition, or any level of service 

connection if the service condition generates the need for long-term 

care. That is another provision of the Mil Bill. The Mil Bill, of 

course, is a complex set of legislation that has many provisions. 

But, that mandates that we provide institutional long-term care for 

as long as necessary for those veterans who choose that. 

Mr. RODRIGUEZ. Do you have any comments in terms of the disparity that exists out there? 

Dr. ROSWELL. Well, I think there is a disparity. Let me point out 

that the eligibility reform legislation, going back to 1996, creates 

a uniform health care benefit for all veterans who are eligible to 

enroll in and receive that benefit. 

The uniform health care benefit of the Eligibility Reform Act in 

1996 does not include institutional long-term care. It was only the 

Mil Bill that included—that added noninstitutional services to the 

uniform health benefit. But institutional long-term care is not still 

not a part of the uniform health benefit, and therefore by law, veterans who are eligible to enroll in and receive the full uniform 

health care benefit aren’t entitled to institutional long-term care. 

But, recognizing that certain veterans had greater priority, the 

Congress created an entitlement, if you will, for 70 percent service 

connected or greater veterans for long-term care. It is not a part, 

though of the enrollment uniform benefit. 

Mr. RODRIGUEZ. Thank you. 

Mr. SIMMONS. Mr. Beauprez. 

Mr. BEAUPREZ. Thank you, Mr. Chairman. I want to probe 

maybe two different directions. If I recall from your testimony, you 

said part of the difficulty in reconciling the GAO’s findings, and 

maybe current performance, is a little bit of apples and oranges 

that you said some patients, some veterans don’t fit neatly into 

various categories, and are not necessarily being—you are not 

being given credit maybe is one way to put it. 

If indeed that is—if indeed that is the case, how do we get to apples to apples? I mean, this is not a very glowing report from the 

GAO. It is pretty serious stuff. How do we reconcile that? 

Dr. ROSWELL. Well, you are correct. Part of it, and I don’t blame 

the GAO for that, and I certainly don’t blame the Congress for 

that, it is our fault. We have created new models of care, such as 

the care coordination model I spoke of, and don’t have a convenient 

way to categorize that. And so I have asked Dr. Burris to work 

with the director of new care coordination office, Dr. Adam 

Darkins, to develop a new way to capture that workload and show 

that as extended care. 

Of the 1,600 patients today who are receiving care in their home 

using the interactive technologies you and the chairman spoke of, 

none of those are reflected on these data, because they are not receiving home-based primary care, this is a different kind of care. 
25

They are not receiving adult day health care, they are not receiving 

home health aid services. 

In a few cases they may be, and they may be counted. But my 

point is, of the six categories the GAO looked at, the care coordination, or telehealth care, whatever you want to call it, was not one 

of those categories, and so they weren’t counted. 

By creating a program office and monitoring that workload 

through the office of geriatrics and extended care we will be capturing all of that in future. 

Mr. BEAUPREZ. Okay. I hope so. Because I don’t think anybody 

is necessarily out to distort numbers, to either make them look better than they are, nor necessarily worse than they are, but this 

committee obviously would like to know what they are, and accurately so. 

So in that vein, guess what—the other direction I would like to 

probe, is part of the question still remaining to me, again, given 

the report, it doesn’t sound very good. Quite concerning, in fact. 

And, you know, averages and progress and all of that is great, 

unless it happens to be you that is being left out in the cold. You, 

a veteran who is really looking for care and is not getting it. So 

one way of saying that, I guess, or asking the question is, who is 

falling through the cracks? How many are they? And what are we 

going to do about it? And kind of a follow-up question, within the 

VISNs or some geographic analysis, do we know where the hot 

spots are, where we have the most problems, and within the network are we attacking those with some degree of prioritization or 

something? 

Dr. ROSWELL. I think we have reasonably good data. First, let me 

tell you that we recently asked, or I recently asked one of Dr. 

Burris’s staff to survey our VA nursing homes and identify what 

the magnitude of waiting lists for VA nursing home placement was. 

And I will defer to Dr. Burris. But, at the time I was told that 

there was virtually no waiting list in any region of the country. I 

know that when I talked to our VISN directors, when I talk to our 

medical center directors, I routinely ask them when I visit a medical center, do you have a waiting list for your nursing home? And 

almost invariably, now recently I had one director tell me, yes, I 

do have a waiting list. 

But, it is the first time that I have gotten that answer in quite 

some number of months. That was in Philadelphia, for the record. 

But, for the most part, there really isn’t a waiting list for VA 

nursing home beds, which reflects that veterans who may avail 

themselves of that care need that care, presumably are getting it. 

Mr. RODRIGUEZ. Will the gentleman yield just on that? That can 

also be a little misleading. I come from Texas. I think we only have 

two or three nursing homes. So when you don’t have them, to say 

that there is not a waiting list, hell, there is nowhere to apply to 

get on a waiting list. 

I don’t have them in Bexar County, population of over a million, 

we don’t have a nursing home in Bexar County. We don’t have one 

in Dallas, I think, the 9th largest city in the Nation. We don’t have 

one in Houston. We got one in Wilson County, we have one in Temple. We have I think three or four in the whole State. 
26

So it is kind of misleading when you say—I just wanted to just 

clarify that. Okay. 

Mr. BEAUPREZ. Certainly. 

Dr. ROSWELL. Maybe we should get some information for the 

record to you. I was referring to VA, not State nursing homes, but 

VA nursing homes. And I am pretty sure there are VA nursing 

home beds in Dallas. 

Mr. RODRIGUEZ. No, sir. I would ask that you educate yourself 

about Texas. 

Dr. ROSWELL. I will do that. I used to be the chief of staff at Dallas when we opened a 120-bed nursing home. So it might have 

closed since then. I will certainly do that. I apologize. 

Mr. RODRIGUEZ. If I am wrong, I will apologize. But my impression is, that we have only got three or four in the whole State. 

Mr. BEAUPREZ. Did the gentleman say don’t mess with Texas? 

Mr. RODRIGUEZ. He can mess with it if we has got resources for 

it. 

Mr. BEAUPREZ. Well, it does raise, if I might, Mr. Chairman. 

Mr. SIMMONS. Please. 

Mr. BEAUPREZ. It raises, I guess to me still a remaining question. 

Do we know who is falling through the cracks? And I think that 

is part of the dilemma. I am hearing you say that your—through 

the network you are being told that, save the one exception, there 

is not a waiting list. 

I wonder about some of other findings in the GAO’s report. Do 

we know how many are falling through the cracks, and how serious 

the problem is? The GAO report is reasonably alarming. Your testimony makes me think that perhaps all is well. And I am trying to 

reconcile that in my mind. 

Dr. ROSWELL. First of all, let me say that I was speaking only 

to institutional long-term care. Let me again clarify that there are 

really three types of institutional long-term care VA uses: VA staff 

nursing homes, contract community nursing homes and State veterans nursing homes. The total number of institutional census is 

increasing in those, and the number of bed availability is increasing. 

In reality there is a fourth very large category, and that is Medicaid funded or self-pay. Many veterans who are placed on a contract community nursing—contract for community nursing home 

care, do so as their eligibility for Medicaid benefits is being processed, and then Medicaid takes over and provides that long-term 

care. 

The combination of those three levels of institutional care, coupled with the availability and access for Medicaid funding for 

nonVA nursing home care seems to be meeting the demands, because we don’t have waiting lists for institutional care. 

The GAO in this report looked at noninstitutional services, some 

of which were just authorized with the passage of the Mil Bill. And 

there I concede that we have not yet established equitable access 

to all of the range of noninstitutional programs and services that 

are currently authorized. 

What I was trying to clarify is, that I don’t think it stops there. 

I think it goes well beyond that. Because I think that there are 

new models of long-term noninstitutional care, such as the care co-
27

ordination telehealth I spoke of, which will represent a significant 

new level of noninstitutional care. 

And as we become more proficient in providing these types of 

noninstitutional care, we actually further reduce our reliance upon 

institutional care. For example, in the program in Florida I spoke 

of, where we actually have completed a statistical evaluation of it, 

88 percent of the time the risk for nursing home places was reduced or eliminated through the care coordination. There was a 

significant drop in the number of nursing home placements by virtue of having access to care through the telehealth care coordination program. 

But, that outcome cannot be made universal until we deploy that 

care coordination program nationwide. Currently it is deployed in 

four VISNs and we are moving to the other 17 VISNs later this 

year with the activation of the new care coordination office. 

We anticipate that by this time next year, we will have close to 

10,000 patients receiving care through telehealth care coordination. 

Again, though, they are not even projected in here, because it is not 

one of the categorize we traditionally or even currently at this date 

count as a form of noninstitutional long-term care. 

But, I can assure you every one who receives the telehealth care 

coordination, will have a substantial reduction in their risk for 

nursing home placement. And I will also assure you that we will 

put in place the mechanisms to capture that. 

Mr. BEAUPREZ. Mr. Chairman, I just would close by stating what 

I think is certainly your commitment. It is my commitment, my 

sense that it is the whole committee’s commitment. One, we ought 

to make sure that our evaluation process is accurate, that the information we are getting is correct. 

But, as committed as we all are to the care of our veterans, certainly it would ratchet up in my mind to those most needy and late 

in life, if we are going to preserve the dignity of anyone, it definitely ought to be those, especially as they maybe approach their 

last days. 

I would suggest that we stay very tenacious in that objective. 

And, Mr. Chairman, I thank you for holding the hearing. But I 

would hope that we have opportunity for updates of progress in the 

near future. 

Mr. SIMMONS. Absolutely. I thank the gentleman. Dr. Snyder. 

Mr. SNYDER. Thank you, Mr. Chairman. Dr. Roswell, I got a myself a little confused there when you were talking with Mr. 

Rodriguez about the status of nursing home waiting lists and so on. 

When you are saying there is no waiting lists for nursing homes, 

are you talking about chronic long-term or care or are you talking 

about nursing homes in the VA that fit the category of veterans 

you were talking about earlier, just out of the hospital, in a fragile 

status for evaluation? Which are you talking about? 

Dr. ROSWELL. I didn’t categorize it that way when I asked for the 

survey, nor do you routinely ask that. Typically when I visit a facility, I ask what kind of care they provide. We do provided some 

long-term, if you will, custodial care in our staff nursing homes. 

Mr. SNYDER. But, there is not a lot of that, is there, in the Federal system? I mean, because I think one of the problems we have 

is that——
28

Dr. ROSWELL. Dr. Burris just pointed out that approximately 35 

percent of the total VA nursing home census, roughly 35 percent 

of the 12,000 patients currently in VA nursing homes are there for 

extended stays. 

So the majority of patients are there for the rehabilitation care, 

the respite care, the gym care, the hospice care. 

Mr. SNYDER. That doesn’t necessarily mean, though, that those 

beds are custodial beds, though, does it not? Those facilities may 

have a policy that once a patient—once those 35 percent or whatever they are, as they gradually empty out, those beds may be 

graduating to the more acute situation; is that a correct statement? 

Dr. ROSWELL. I believe that is a correct statement. Typically, if 

we identified—in many VA hospitals, if we identified a need for 

this long-term or maintenance care, instead of placing the patient 

on a long-term basis in the VA home, they likely would be placed 

on a contract within a community nursing home. 

And then, at some point, convert to Medicaid funding for that 

need. The reason that would happen is, that the average per diem 

cost for a VA nursing home, our costs, our staffing cost nationwide, 

is about $394. 

The average per diem cost for a contracted community skilled 

nursing home bed is approximately $185. 

Mr. SNYDER. I am still trying to understand Mr. Rodriguez’s 

question and your answer. Is it possible that what is going on is 

that you look at what is going on in Dallas or San Antonio and say 

there is no waiting list, but, in fact, there may be no waiting list 

for these kind of, I will say acute care, that is acute care, fragile 

evaluation, and what he is talking about is trying to find a placement for long-term custodial care. Could that be an explanation? 

Dr. ROSWELL. Dr. Snyder, I think that in certain circumstances, 

what you are talking about could occur. But, let me point out that 

we have also surveyed the State directors of Veterans Affairs, and 

don’t identify waiting lists for the State veterans’ homes either 

where maintenance care is a more typical type of care being provided. 

In fact, the average daily occupancy as a percentage of total beds 

is well below a target of 95 percent in both VA staff nursing home 

beds and State veterans homes. 

I would also point out that in this country, just a decade ago, 

there were approximately 17,000 community nursing homes. Today 

that number has dwindled to approximately 13,000. So it would 

appear. 

Mr. SNYDER. Our legislature just adjourned a couple of weeks 

ago, and one of their priorities was getting funding in order to 

qualify for a State nursing home for veterans. So I think they 

thought that there was a need. 

I wanted to ask about the letter in the report here from Secretary Principi. We are talking about coordination and word getting 

down from on high to the people in the field. And it appears that 

there wasn’t even good coordination between Secretary Principi 

and the two of you; is that a fair statement? 

Dr. ROSWELL. Oh, no. There was coordination. 
29

Mr. SNYDER. I read this letter. I don’t sense any equivocation at 

all about agreeing with what was in the report. You were very 

clear that there were things that you disagree with. 

Dr. ROSWELL. I thought I made it clear in my opening comments, 

I apologize if I don’t. 

Mr. SNYDER. I heard what you said. 

Dr. ROSWELL. I agree with the findings. I agree with the recommendations. I agree with the need to implement that. I am only 

pointing out for the committee that I am personally very committed 

to implementing that, that we have taken actions following Secretary Principi’s letter to put in place performance measures across 

all of the VISNs. 

We have created a new program office. We have a new directive 

going out to reemphasize the importance of making sure that we 

have access to this, a variety of new handbooks are being developed. 

So there is a lot of emphasis ongoing now. I acknowledge that 

emphasis may have been lacking in the past. I don’t think there 

is a fundamental difference, I don’t believe there is, in what I have 

said, and what Secretary Principi said in his letter to the GAO. 

Mr. SNYDER. Because some of findings of GAO are discussions 

about priorities and emphasis and pressures. Those imply that they 

are coming from on high, which is you. Do you agree with those 

findings also? 

Dr. ROSWELL. I think there has been a—I think part of the variability that the GAO found is because of a variable management 

emphasis. 

Mr. SNYDER. From facility to facility? 

Dr. ROSWELL. From facility to facility and even from VISN to 

VISN. 

Mr. SNYDER. Can I ask one more question? This doesn’t have to 

do with the report, but it is probably long-term care 101. I think 

it is kind of assumed that caring for somebody at home is automatically less expensive than somebody being in a long-term bed. 

I am not convinced that is true. It may be true. I may be just dumb 

as hell and don’t know it. 

Because, I think sometimes how programs save money on longterm care at home is they just cut back on the hours and don’t provide adequate services. If you are short on money, say, okay, you 

are not going to get 20 or 12 hours this week of housekeeping services, we are going to cut you back to 10 hours. You are still at 

home. We are still cost effective. 

But the quality of life may be inadequate. Is it clear to you that 

it is clearly more cost effective to have people at home? I think it 

is better quality of life to have people at home. I think that is what 

we ought to aim for, what Ms. Bascetta talked about the needs. 

I get a little apprehensive if we base it all on cost, because there 

are nursing home operators that say we can do it cheaper in an institution than you ever can at home for a lot of patients. Is there 

a clear answer to that? 

Dr. ROSWELL. Certainly the point is well taken, that when there 

are economic constraints, that curtailment of home services is a 

factor that, you know, we would hate to see that happen. 
30

Clearly there are exceptional patients that can be cared for less 

costly in an institutional setting. A good example might be a ventilator patient, trying to manage a ventilator patient in the home is 

a very difficult undertaking. 

And it probably would be easier and, in fact, less costly, on a per 

diem per patient basis to do that in a chronic ventilator care facility. So you are absolutely correct. There are circumstances where 

your hypothesis, I believe, would be validated by actual findings. 

I do want to emphasize a point you made, because we do have 

good data on that. And that is, that patients do, in fact, prefer to 

remain in the home environment. They consistently tell us that. 

Mr. SNYDER. To me that is the key, which is, we all—I think almost always prefer to have ourselves or our relatives at the home. 

Thank you, Mr. Chairman. 

Mr. SIMMONS. Thank you. Dr. Burris, you have been sitting there 

very quietly. I don’t want the moment to pass without putting a 

question to you. 

First of all, I did not catch your bio in our enclosures, so I will 

invite you to say a word or two about your background. I believe 

that you have a distinguished career in geriatrics and at Georgetown, and I guess my question to you then, as somebody who has 

that academic association, you have heard the discussion earlier, 

the comment made by GAO that there appears to be a lack of policy and data. 

As somebody who has spent time in the academic world, data 

searching and analysis is usually a precondition to policymaking. 

We have had a hearing this afternoon where there has been a 

good deal of discussion about the policy, the data supporting the 

policy, whether the data is there and, in fact, whether we can 

frame the success of this policy in our oversight of the policy without clear and consistent data. 

Would you indulge us for a few moments and tell us a little bit 

about your background and what your thoughts would be about the 

discussion that we have had this afternoon. 

Dr. BURRIS. Thank you, Mr. Chairman. I trained, I did part of 

my medical training in the Department of Veterans Affairs, as do 

about half of all physicians in the United States. I then joined the 

faculty at Georgetown University as an internist and geriatrician. 

Practiced medicine at Georgetown for several years, and then returned to the VA at the Washington VA Medical Center, where I 

was one of the two physicians who opened the new nursing home 

care unit there in the mid 1980s. We took care of 120 veterans ultimately in that facility. I was then recruited back to Georgetown to 

serve as an associate dean for research operations. And came back 

to VA again as the deputy to the chief research and development 

officer in 1997. 

I have just recently joined the Office of Geriatrics and Extended 

Care in January of this year. And am very pleased to get back to 

the field of geriatrics. I do also maintain an appointment as a clinical professor of medicine and pharmacology at Georgetown University School of Medicine. Georgetown doesn’t have a geriatrics 

department. 
31

Mr. SIMMONS. What are your thoughts on the discussion involving policy and data versus money, or whether we have sufficient 

data to frame an adequate policy in this area? 

Dr. BURRIS. Policy must be data driven. That certainly has been 

a clear principle of VA under both Dr. Kaiser and Dr. Roswell. And 

it is absolutely critical in making good decisions. 

We found, in looking at the level of demand we were actually experiencing for long-term care services, that it seemed to be out of 

sync with the predictions that we were getting from our existing 

long-term care planning model. And at Dr. Roswell’s direction, we 

have initiated a process to refine the long-term care planning 

model to try to give us better data about what the real needs that 

veterans have are. 

We are looking at such things as the fact that there has been a 

trend toward diminished disability in older people nationally over 

the last 10 or 15 years. There has been a trend, as has already 

been referred to toward diminished utilization of nursing homes, in 

part due to shorter stays, in part due to the availability of home 

and community-based services. 

And we are also going to be looking at the effects of gender and 

marital status on the need for nursing home care use. So I think— and that process is on a short fuse to give us a first iteration of 

a revision of the model by the end of June, and then some further 

refinements not later than next March, so that we will have better 

data for next year’s budget cycle. 

And the data for June will feed into the strategic planning process that VHA will be engaging in over the summer and also will 

be used in the care planning process when they return to look at 

the long-term care aspect of that. That was not included in this 

current round of planning. 

In terms of the question of the gaps in service, we do have information as to where the different long-term care noninstitutional 

services are located. Our office is presently engaged in a mapping 

exercise to really identify geographically where the facilities are 

relative to where the concentrations of older veterans are. 

We are doing that with assistance from the Office of Policy and 

Planning, and the VA actuary. That again will help us to identify 

where we need to place additional services. 

Mr. SIMMONS. Thank you for that response. As somebody with a 

military background, I am always interested in maps and graphs. 

We would be interested in seeing that map once you have completed that, if that is agreeable. 

Dr. BURRIS. Certainly, we would be happy to provide that. 

Mr. SIMMONS. I appreciate that. It looks like we are in for another set of votes. Are there any other questions for this panel? 

Mr. RODRIGUEZ. Yes, let me ask you, I would presume that any 

area within this country that there is some guidelines already as 

to the types of services a good hospital or good system would provide, and that they are already out there, and that yes you do need 

data, but you also would—that the best system is one that provides 

comprehensive services, a combination of long-term, short-term, a 

variety of others. 

And that that would just come naturally. Secondly, I would be 

concerned for you to jump to the conclusion, just because there is 
32

not people lining up to nursing home care, that that is not needed. 

You know, I would also caution you as to maybe why they are leaving your nursing home and going elsewhere. 

And also, you know, I think the chairman put it in perspective 

when he said, if you don’t have a movie theater nobody is going to 

be lined up out there to go if it is not there. So, you know, I will 

get, because I know in Texas, of the State veterans, we only have 

four, we are trying to get seven and build some others. 

And right now that is still in limbo. I am not sure of the others. 

And I think that that is where we are in conflict or in question, 

because I don’t even—I am not even familiar with the others, if we 

have them or not. I will check it out. 

And so, but I would hope that before comments are made that 

there is no need for nursing home because there is not a waiting 

list, that we check that out before that happens. Thank you. 

Mr. SIMMONS. I thank you gentlemen. I thank the panel. I will 

announce that we have a 15-minute vote followed by three 5-

minute votes. If my math serves me correctly that is 30 minutes. 

I would like to announce the next panel, which, consists of several 

representatives from veterans service organizations. 

We have Peter Gaytan, Principal Deputy Director of The American Legion; Thomas Miller, Executive Director of Blinded Veterans 

of America; Joy Ilem, Assistant National Legislative Director, Disabled American Veterans; Richard B. Fuller, National Legislative 

Director, Paralyzed Veterans America; and Mr. Paul A. Hayden, 

National Legislation Service Veterans of Foreign Wars. I think I 

have gotten everybody in there. This is a large panel. We would 

look forward to hearing from you in about 25 minutes. 

STATEMENTS OF PETER GAYTAN, PRINCIPAL DEPUTY DIRECTOR, THE AMERICAN LEGION; THOMAS MILLER, EXECUTIVE 

DIRECTOR, BLINDED VETERANS OF AMERICA; JOY ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED 

AMERICAN VETERANS; RICHARD B. FULLER, NATIONAL LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF AMERICA; 

AND PAUL A. HAYDEN, NATIONAL LEGISLATIVE SERVICE, 

VETERANS OF FOREIGN WARS 

Mr. SIMMONS. The subcommittee stands in recess. 

[recess.] 

Mr. SIMMONS. After talking with the panel, and in consultation 

with the minority staff, we have determined that the third panel 

is prepared to submit for the record. They are agreeable to that, 

thus excluding themselves from being grilled by the members of 

the committee. So I guess it is a win-win for them. 

We have learned that the votes will run us about 55 minutes. So 

rather than extend the afternoon for everybody, we will accept your 

offer of testimony. I accept the minority staff’s agreement that this 

is the way to go. I will submit follow-up questions for the record 

on behalf of myself and the members of the subcommittee. 

(See p. 91.) 

[The statement of Mr. Gaytan appears on p. 69.] 

[The statement of Mr. Miller appears on p. 77.] 

[The statement of Ms. Ilem appears on p. 80.] 

[The statement of Mr. Fuller appears on p. 84.] 
33

[The statement of Mr. Hayden appears on p. 89.] 

Mr. SIMMONS. I thank everybody for their participation. I think 

we have learned quite a lot about this problem, and I think it is 

not yet solved. Thank you all very much. 

The subcommittee is now adjourned. 

[Whereupon, at 3:54 p.m., the subcommittee was adjourned.] 

(35)

A P P E N D I X 
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WRITTEN COMMITTEE QUESTIONS AND THEIR RESPONSES 

CHAIRMAN SIMMONS TO DEPARTMENT OF VETERANS AFFAIRS
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108

CONGRESSMAN EVANS TO DEPARTMENT OF VETERANS AFFAIRS
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Æ