VA’S EFFORTS TO PROVIDE HIGH

QUALITY HEALTH CARE TO

VETERANS IN RURAL COMMUNITIES

Hearing

before the

Committee on 

Veterans’ Affairs

House of Representatives

Subcommittee on Health

one hundred ninth congress

second session

JUNE 27, 2006

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 109-57

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28-453.PDF
Committee on Veterans’ Affairs

Steve Buyer, Indiana, Chairman

 Michael Bilirakis, Florida Lane Evans, Illinois, Ranking

 Terry Everett, Alabama Bob Filner, California

 Cliff Stearns, Florida Luis V. Gutierrez, Illinois

 dan burton, Indiana Corrine Brown, Florida

 Jerry Moran, Kansas Vic Snyder, Arkansas

 richard H. baker, Louisiana Michael H. Michaud, Maine

 Henry E. Brown, Jr., South Carolina Stephanie Herseth, South 

 Jeff Miller, Florida Dakota

 John Boozman, Arkansas Ted Strickland, Ohio

 Jeb Bradley, New Hampshire Darlene Hooley, Oregon

 Ginny Brown-Waite, Florida Silvestre Reyes, Texas

 Michael R. Turner, Ohio ShellEy Berkley, Nevada

 John Campbell, California Tom Udall, New Mexico

 John T. Salazar, Colorado

James m. Lariviere, Staff Director

Subcommittee on Health

 Henry E. Brown, Jr., South Carolina, Chairman Michael H. Michaud, Maine

 Cliff Stearns, Florida, Vice Chairman Ranking

 Richard H. Baker, Louisiana Bob Filner, California 

 Jerry Moran, Kansas Luis V. Gutierrez, Illinois

 Jeff Miller, Florida Corrine Brown, Florida

 Michael R. Turner, Ohio Vic Snyder, Arkansas

 John Campbell, California

Jeffrey D. Weekly, Subcommittee Staff Director

(II)
CONTENTS

June 27, 1206

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VA’s Efforts to Provide High Quality Health Care to Veterans 

in Rural Communities ............................................................

OPENING STATEMENTS

Chairman Henry Brown ............................................................. 

Prepared statement of Chairman Brown ..................................

Hon. Michael H. Michaud, Ranking Democratic Member, 

 Subcommittee on Health ........................................................

Prepared statement of Mr. Michaud ..........................................

STATEMENTS FOR THE RECORD

Wiblemo, Cathleen C., Deputy Director, Veterans Affairs and 

Rehabilitation Commission, American Legion .....................

Witnesses

Perlin, Hon. Jonathan B., MD, Ph.D., MSHA, FACP, Under 

Secretary for Health, Veterans Health Administration, U.S. 

Department of Veterans Affairs ............................................ 

Prepared statement of Dr. Perlin ..............................................

Hartley, David, Ph.D., MHA, Director, Maine Rural Health Research Center, and Professor of Health Policy and Management, Muskie School of Public Service, University of Southern Maine ......................................................................

Prepared statement of Dr. Hartley .............................................

Adams, Graham L., Ph.D., Executive Director, South Carolina 

Office of Rural Health, and President, National Organization of State Offices of Rural Health .....................................

Prepared statement of Dr. Adams .............................................

POST-HEARING QUESTIONS FOR THE RECORD

Hon. Michael Michaud ...............................................................

 

(III)
(1)

VA’S EFFORTS TO PROVIDE HIGH QUALITY 

HEALTH CARE TO VETERANS IN RURAL

COMMUNITIES

TUESday, JUNE 27, 2006

U.S. House of Representatives, 

Subcommittee on Health,

Committee on Veterans’ Affairs,

Washington, D.C.

 The subcommittee met, pursuant to call, at 10:00 a.m., in Room 

334, Cannon House Office Building, Hon. Henry E. Brown, Jr. [chairman of the subcommittee] presiding. 

Present: Representatives Brown of South Carolina, Michaud, Moran. 

Mr. Brown of South Carolina. Good morning. The Subcommittee 

will come to order. This morning, we have assembled to take a close 

look at how the VA is providing for the care of our veterans who may 

live at a great distance from a VA medical center, a community-based 

outpatient clinic, or perhaps even a vet center. 

This is not the first hearing that we have had on this subject, nor 

do I expect it will be the last. Due to the large number of service men 

and women we have returning from Iraq and Afghanistan and due 

to the numbers of those folks who may hail from rural areas, additional pressures are currently being placed at VA’s doorsteps as more 

people desire to receive their care from VA.

 This is probably a good problem to have in a sense it is a testament 

to the fine job that Dr. Perlin and his team are doing to provide or 

purchase care for our nation’s veterans, not only in urban areas, but 

also in more remote areas of the country. 

 Having said that, we need to be able to effectively bridge the distance gap. And one thing is clear. The gap cannot and should not in 

my opinion be bridged by simply erecting new VA buildings on every 

street corner across the nation. Rather, we should seek to use new, 

emerging technologies to export the expertise that resides inside the 

VA’s medical centers, CBOCs, or the vet centers.
2

 The expanded use of telemedicine, while not a panacea, can go 

a considerable way towards alleviating some of the distance-based 

challenges in the area of primary care, mental health, and even longterm or home-based care. I suspect our VA witnesses will provide 

greater details on what can currently be accomplished in that area 

and what we can anticipate in the future. 

 Equally important to the use of new technologies, we should also 

seek to collaborate with local community providers wherever possible 

to ensure that the level of care and quality that VA provides can be 

expected of others if VA chooses to purchase those services in given 

areas. 

 I know the Department has taken steps towards doing that by moving forward on important initiatives like Project HERO, a multi-VISN 

demonstration project that will attempt to better coordinate and improve the purchased care that VA relies upon sometimes in very rural 

areas. As many of you probably recall, we had a hearing on Project 

HERO and are all anxious to see it rolled out later this year. 

 As I suggested, this will not be the last hearing we have on rural 

healthcare at VA. But equally important, we should also recall our 

last hearing on this important topic. 

 This Subcommittee had the distinct pleasure of traveling to Maine 

last summer to examine how the State handles its uniquely rural VA

population. We had the opportunity to do that because the Ranking Member, my friend, Mike Michaud, invited us to this beautiful 

district. 

 Mr. Michaud and I share an interest in rural health, and I am privileged again today to examine VA’s successes and challenges with my 

good friend from Maine. I also look forward to working with him on 

our upcoming health bill and incorporating some of his rural health 

provisions to that package.

 With that, I would yield to the gentleman from Maine, Mr. Michaud, for an opening statement. 

[The statement of Henry Brown appears on p. 32]

Mr. Michaud. Thank you very much, Chairman Brown. I really appreciate your cooperation and your willingness to have a hearing in 

the great State of Maine, and I am hopeful we will be able to have a 

rural health bill that will reflect some of the issues we heard. 

 I greatly appreciate also, Mr. Chairman, you holding his hearing to 

explore VA’s efforts to improve rural veterans’ access to high-quality 

VA healthcare. I also want to thank all the witnesses on both panels 

for coming here today to testify.

 And I am especially glad and pleased to see Dr. Hartley from Maine 

who is able to be here today as well. As a member of the Committee 

that wrote the 2005 ground-breaking Institute of Medicine report on 

the future of rural healthcare, he has a great deal of expertise on 
3

the challenges facing rural communities and providing high- quality, 

state-of-the-art healthcare. So glad to have you here today, Doctor. 

 Next week, we will be celebrating our Nation’s Independence Day 

along with picnics and parades in recognition and respect for the 

courage of farmers who took up arms to fight for freedom. The revolution that transformed colonies into a new nation happened because 

of rural citizen soldiers.

 Since the Revolutionary War, rural communities, certainly Maine, 

have continued to answer their nation’s call to service. Roughly 16 

percent of Mainers are veterans, one of the highest percentages in 

the country. Across the nation, roughly one in five veterans enrolled 

in VA healthcare are from small towns and rural communities. In 

time, the percentage of rural veterans will likely increase because 

more than 44 percent of the recent U.S. military recruits are from 

rural areas. 

It is important that we honor veterans with action, not just words. 

Doing so is all the more important, particularly while we are at war 

in Iraq and Afghanistan. Studies including the recent Institute of 

Medicine report on the future of rural health have repeatedly shown 

that rural communities, especially veterans, face unique challenges 

to access high-quality care such as distance and the availability of 

specialists. 

 While there are a number of efforts underway to improve access 

for rural veterans to VA’s high-quality care, I am concerned that we 

are not adequately preparing and planning for the needs of elderly 

veterans, disabled veterans, and the younger generation of veterans 

returning from Iraq and Afghanistan to their home states in remote 

areas.

 I have introduced House Resolution 5524, the Rural Veterans 

Health Care Act of 2006, which is a comprehensive approach to improving the quality of care available to rural veterans. Following 

the advice of the Institute of Medicine report, my bill aims to take 

a comprehensive and practical approach towards improving care for 

our rural veterans by increasing facilities and outreach, encouraging recruitment and training of healthcare professionals, focusing on 

research, and developing the IT infrastructure we need to enhance 

services in rural areas. 

My legislation has support from veterans service organizations like 

the American Legion, Military Order of the Purple Heart, and Vietnam Veterans of America. The National Rural Health Association 

also supports House Resolution 5524. 

 So I want to thank you once again, Mr. Chairman, for holding this 

important hearing, and I request that my full comments be included 

in the record.

Mr. Brown of South Carolina. Without objection. 

[The statement of Michael Michaud appears on p. 39]
4

Mr. Brown of South Carolina. Thank you, Mr. Michaud. It was 

a great trip to Maine and to have a chance to visit with some of the 

veterans from your region. It was my first trip to Maine and I did not 

recognize how remote it really is and how far some of those people 

have to travel. But I applaud you for inviting us to come and enlighten us on some issues.

 One of the things, Dr. Perlin, they said was, do not take away our 

VA care because it is the best in the world. And I know you would be 

interested to hear that, and that was a real compliment, I think, to 

the system up in Maine and also representative across the country. 

Let us now turn to our first panel. The Subcommittee welcomes 

Dr. Jonathan Perlin, Under Secretary for Health, testifying on behalf 

of the Department of Veterans Affairs. 

 Dr. Perlin is accompanied by Patricia Vandenberg, Assistant Under Secretary for Health for Policy and Planning; and Dr. Adam Darkins, Chief Consultant for Care Coordination; and Dr. Robert Petzel, 

Network Director, VISN 23.

 Welcome, Dr. Perlin.

STATEMENTS OF HON. JONATHAN B. PERLIN, M.D., Ph.D., 

MSHA, FACP, UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; ACCOMPANIED BY PATRICIA VANDENBERG, ASSISTANT DEPUTY UNDER SECRETARY 

FOR HEALTH FOR POLICY AND PLANNING; ADAM DARKINS, CHIEF CONSULTANT, OFFICE OF CARE COORDINATION; ROBERT A. PETZEL, M.D., NETWORK DIRECTOR, VISN 23

STATEMENT OF HON. JONATHAN B. PERLIN

Dr. Perlin. Thank you, Mr. Chairman, and good morning to you 

and to Ranking Member Michaud. Thank you for the opportunity to 

be here before you today to talk about rural healthcare for veterans. 

 Thank you as well for your kind words because it really puts into 

context the story of VA’s transformation. In fact, ten years ago, VHA

faced a burning platform. We had to transform our care or we would 

have been obsolete and failed our mission. 

 We were a collection of hospitals serving only as a safety net for 

care, treating veterans only after they had a health catastrophe, like 

a heart attack or advanced cancer. We had to change.

 Instead of being a safety net, we created a model of health promotion, disease prevention for our patients, and are now the benchmark 

in preventive services in disease managements, instead preventing 

heart attacks and treating illnesses like cancer and depression ear-
5

ly. 

 We built a true health system out of a portfolio of hospitals, integrating services not just between our hospitals, but across the entire 

continuum of care from the patient’s home to the outpatient clinic 

and, of course, to the hospital. 

We recognize the value of community-based outpatient clinics in 

establishing that continuum of care and in meeting the primary care 

and mental healthcare needs of rural veterans. 

 In 1995, VHA operated 102 CBOCs. Today we operate more than 

700 including 234 that the CARES criteria identified as serving rural 

or highly rural areas. This number does not include 156 more clinics 

that are based at our medical centers for a grand total today of 876 

outpatient clinics.

 In fact, Secretary Nicholson announced his approval for 25 new 

or enhanced CBOCs on June 23rd, and we anticipate having some 

of these open by the end of this year with the remainder opening in 

2007. And fully one-third are rural. 

 In 2004, the CARES Commission found that VA’s existing protocols for prioritizing new CBOCs disadvantaged rural veterans. As a 

result, we have revised our national criteria to emphasize access to 

care for rural veterans. We also created a directive on rural access 

hospitals to assure quality services at those facilities. 

 And now according to satisfaction performance scores collected in 

2005, 81 and a half percent of rural veterans rated their healthcare 

as very good or excellent; in fact, slightly exceeding urban veterans’ 

ratings. In addition, clinical quality measures were up to 12.2 percent higher for rural veterans compared to their urban counterparts.

 And data show that rural veterans are not necessarily under-represented in VA. As Ranking Member Michaud said, nearly one in five 

veterans live in rural areas. And, in fact, 32 percent of our enrolled 

veterans are rural and 34 percent of our patient population are comprised of rural veterans. 

 We work closely with Federal, state, and local healthcare agencies on rural healthcare issues. A Memorandum of Understanding 

with the Indian Health Service to enhance healthcare for American 

Indian, Alaskan Native veterans has resulted in new activities and 

programs and complements local initiatives. 

 And we are creating targeted partnerships with community health 

centers to meet specific locally-defined healthcare needs in rural locations. 

 Our 207 vet centers also address rural veterans’ needs. Many are 

located in rural areas with staff traveling widely to reach veterans 

in remote locations. Some maintain stations staffed by one or two 

counselors that are connected to full-size vet centers. Many vet centers maintain partnerships with community providers such as state 

employment services and local substance abuse programs. 
6

 One of VA’s top priorities is providing comprehensive and effective mental healthcare to all enrolled veterans who need it. We have 

invested $300 million in new service improvements in the past two 

years. And of that, nearly $17 million was used to add mental health 

professionals to CBOCs and another $9 million expanded our telemental health programs. 

 In 1996, veterans who used our mental health services lived an 

average of 24 miles from the nearest VA clinic. That average is only 

13.8 miles today. 

 We are increasingly relying on telehealth and telemedicine as an 

effective and efficient way to provide specialty care services to rural veterans and others. Our care coordination, Home Telehealth 

Program helps veteran patients manage their conditions and live independently in their own homes. By October 1st, more than 20,000 

veterans will be enrolled in this program. 

 A national Teleretinal Imaging Program now assesses diabetics for 

eye disease. A 21-site polytrauma health network begins operations 

by September 30th and more than 14,000 veterans received telemental healthcare in the last fiscal year.

 Within three years, VA expects to provide rural veteran specialty 

care unparalleled in any other healthcare organization in the nation. 

We, however, recognize limitations in our national telecommunications infrastructure and bandwidth requirements, and appreciate 

your support in improving this for rural veterans and all rural Americans. 

 Mr. Chairman, creation of new CBOCs, collaborations with other 

healthcare organizations, new approaches to providing healthcare 

services, advances in telehealth and telemedicine give me confidence 

that we are continually striving to provide not only the best care anywhere but the best care everywhere in our nation. 

 Thank you very much for the opportunity to testify. We would be 

pleased to respond to your questions and we request that the full 

statement be submitted for the record. 

Mr. Brown of South Carolina. Without objection. And thank you, 

Dr. Perlin, for your testimony and for your service to the veterans all 

over this country. 

[The statement of Jonathan Perlin appears on p. 41 ]

Mr. Brown of South Carolina. My first question is, what is the 

department currently doing to better understand where their user 

population lives and what type of strategic planning is being undertaken in the area of rural healthcare specifically?

 I know you addressed that somewhat in your testimony, but do you 

have like a schematic map so you could readily see where the rural 

veterans are and how it continues to change with the new veterans 

coming back from the Operation Enduring Freedom and Operation 
7

Iraqi Freedom? 

Dr. Perlin. Thank you very much, Mr. Chairman, for this important question. I want to address it at two levels. 

 First you asked how we look at the nation and make sure we are 

meeting the needs geographically, understanding that the needs are 

not exactly the same in urban environments and suburban environments, somewhat rural environments, and highly remote and rural 

areas. 

 And, in fact, on a national level, a lot of that work goes on in Ms. 

Vandenberg’s operation in terms of the modeling of the nation’s population. I would ask her to first begin responding to how that process 

is achieved. 

But I would also want to introduce Dr. Randy Petzel as not only 

the Director of VISN 23, the upper midwest network, but for him to 

respond subsequently to really describe how as network director with 

operational responsibility, he looks at an environment that ranges 

from the urban-ness of Minneapolis to the most remote regions of 

the Dakotas, and how he would actually plan to meet services in that 

area. 

Ms. Vandenberg. 

Ms. Vandenberg. Thank you. 

When we do our annual actuarial model projections for the system, 

we start at the level of the veterans’ population and then forecast the 

enrollment and then move down to unique patients.

 You asked if we have a map that depicts the population. Yes, in 

fact, we do. Part of my office is responsible for geo coding and so we 

are in a constant update of the location of our veterans. We are looking at that from both the enrollee and the patients’ perspective. 

Mr. Brown of South Carolina. I know I said that because demographically it is a real shift in this country. I know in my region of 

South Carolina, which represents Myrtle Beach and along the coast, 

a goodly number of those people are moving from Maine where it is so 

cold and some of the other parts down to sunny Myrtle Beach. And I

just wanted to be sure that somehow or another demographically we 

were taking care of that shift so that— 

Ms. Vandenberg. We are monitoring that, yes.

Mr. Brown of South Carolina. —services would be moving with 

them. Thank you. 

Dr. Petzel. In terms of how we might operate at the network level, 

again, as Ms. Vandenberg mentioned, we annually assess the needs 

in our network. And one of the ways we look at our service to rural 

veterans is to look at the veteran population, the proximity that they 

have to care at the present time, and also overlay the studies that are 

done about medically under-served communities, not just VA, but in 

general. And I think that allows us to identify the most critical areas 

in terms of rural-ness and in terms of a lack of healthcare. 
8

And just as an example, during the CARES process, while there are 

not an overwhelming number of veterans there, we identified Williston and Dickinson, North Dakota as being very under-served areas 

medically as well as in terms of VA healthcare. And these became 

priorities for us to establish a couple of outreach clinics in that area.

 And, again, we go through this annually. 

Mr. Brown of South Carolina. Just to follow up on that, we recently heard that 25 new CBOCs would be established. To what extent 

were the needs of rural veterans incorporated into the decision-making process? 

Dr. Perlin. Well, let me answer your question, sir, in two ways. 

First, they are incorporated into the decision process by their being 

represented. Their presence in environments that we had not previously adequately served is really the hallmark of their representation. We identify that they are there, that they have a need for medical services, and we bring that service to them. 

Increasingly, though, network directors such as Dr. Petzel, facility 

directors which have the direct purview over the community-based 

outpatient clinic meet with veterans to really learn what the needs 

are in the particular environment and really determine what would 

be most effective in terms of a specific location and try to work with 

serving the identified needs in the particular community. 

Mr. Brown of South Carolina. Before, Dr. Petzel, you respond, let 

me add this part of the dialogue, and maybe you can even expand on 

that too. 

 What is the department doing to explore existing rural health assets, for instance the rural health centers established by the U.S. 

Department of Health and Human Services, the State Department of 

Rural Community Health Centers and so forth? 

 While we are interested in providing for our rural veterans, we also 

have to be cognizant of those facilities and resources that already 

exist and not reinvent the wheel. After all, we are talking about valuable taxpayers’ dollars. 

How are you all interfacing with existing other agencies? 

Dr. Perlin. There are a number of existing relationships that occur 

both at national levels, regional levels, and at local levels. Nationally 

we have Memorandums of Agreement with the Indian Health Service 

as an example for collaborating and serving our overlapping populations and increasing access for veterans. 

I might in a moment ask Dr. Petzel to speak about how that occurs 

specifically in his network. 

 At a national level, we create a framework that creates a dialogue 

for the ability for us to target regionally, and locally to meet specific 

needs. Community health centers are important national assets. 

There are 3,600 of them. Not all of them are rural. Many are actually 

in urban and under-served environments. But we have partnerships 
9

where we specifically target an opportunity to provide outreach. 

 Now, I should note that there is some difference in our patient population. Our focus, of course, is veterans. Community health centers 

traditionally or often is focused on maternal and children’s issues in 

particular. So we need to make sure that our overlap really serves 

the constituencies as effectively as possible. 

 The second issue is that part of the ability for us to serve veterans 

well is the integrity, the continuity of the health information. And as 

we put clinics into the environments, we want to make sure that they 

are connected to our electronic health record. 

 And increasingly we will have dialogues about how we can not only 

have that continuity, be it whether it is within a direct sort of umbilical cord to our system or whether it is in the future with interoperability, with technologies that they would be introduced. 

 So at a very strategic and practical level, we say is there an overlapping need, is there an overlapping population, and at a technical 

level say, okay, can we carry this off and provide the right resources 

both to veterans and to the community health center population. 

I would ask Dr. Petzel to speak about some of the collaborations 

that exist, for instance, either under the national aegis of the Indian 

Health Service memorandum or some of the local initiatives that exist with American Indians in VISN 23. 

Dr. Petzel. Thank you, Mr. Chairman. 

 The Indian Health Service is probably the largest other Federal 

healthcare provider in our part of the country. And thanks in part 

to the Memorandum of Understanding that was signed several years 

ago, we have had a large number of collaborations with them on the 

reservations. 

Just as some examples, we have contract clinics on four reservations in South Dakota. We have compensated work therapy programs on four reservations in South Dakota. And then in both North 

Dakota and South Dakota, we have telehealth, telepsychiatry, PTSD

programs where a psychiatrist is remotely based and the facility is 

on the reservation, usually in the health center that the IHS establishes. 

 We do have plans in the very near future to establish an additional 

clinic in Wagner, South Dakota which is near the Yankton Sioux reservation. So we have got a large number, I think, of cooperative efforts going on with that Federal agency. 

I would like to go back, though, just briefly to the previous question when you asked about how many of the new clinics were rural 

clinics. 

 We had three outreach clinics and four community-based outpatient clinics in that group of approvals and all of them were in highly 

rural areas. 

Mr. Brown of South Carolina. Are you allowing the neediest popu-
10

lation to use the VA clinics? I asked a question first whether you 

were taking advantage of the rural health clinics and some of the 

other available facilities based already there. I was just wondering if 

there is any reciprocal arrangements with the VA. 

Dr. Petzel. Mr. Chairman, the only reciprocal relationships we 

have are in a few limited areas on reservations. We are cooperating 

with the Indian Health Service and non-veteran Native Americans, 

American Indians are using some of our services. But, otherwise, 

out in the communities, no. Our services are basically available to 

veterans right now.

Dr. Perlin. I would add, sir, that, of course, our biggest partner is 

the Department of Defense with the TRICARE coverage that extends 

and we accept in VA.

Mr. Brown of South Carolina. Mr. Michaud, you had questions for 

the panel.

Mr. Michaud. Thank you very much, Mr. Chairman. 

 Dr. Perlin, you mentioned that you recently announced plans to 

open 25 new CBOCs, some of which were never identified in the 

CARES process. 

Can you explain in more detail how the VA has decided it can support new CBOCs not identified in the CARES process when we still 

have 156 priority CBOCs that were identified and that have not been 

implemented yet? 

Dr. Perlin. Thank you, Mr. Michaud, for that question. 

 The CARES plan is a compass. It is not an absolute blueprint. I

remember when Secretary Principi testified, he said that, you know, 

this was really the direction we were headed, but this would be evaluated in the context of circumstance, need, capacity, and access issues.

 In fact, of that list of 25, depending on whether you use the CARES

definition or the Census definition, either eight or nine are rural 

CBOCs. So we are really striving to make sure that we serve veterans’ needs by improving access, by reducing capacity challenges, 

and in some instances relieving overstresses that occur in particular 

areas. 

Our general trajectory is, in fact, to identify and meet the needs 

that are identified in the CARES report, and as I think is also understood in the CARES document that that is a plan that extends really 

over the better part of the next decade. 

Mr. Michaud. I guess my concern is that when you look at 156 

priority CBOCs, they are priorities. And I know that some VISNs 

where there is only one CBOC proposed, they did not even submit a 

business plan because they do not have the money to do it. 

 So my concern is our going outside the CARES process. Out of the 

25, how much was that decision made on political reasoning in some 

areas? That is a big concern that I have because there is a definite 
11

need out there. 

 The next question is on the vet centers. I recently had a chance to 

meet with Blake Miller who is a rural veteran from Kentucky. He 

was nicknamed the “Marlboro Man” because of a picture taken after 

a firefight in Felujah. He has PTSD. Both he and his wife admitted 

that they need more counseling than what they are currently getting 

from the VA, and they have to travel over two hours to get the services that they need. 

What are the VA’s specific plans to expand the number of vet centers and vet centers’ employees to the rural areas? Do you have a 

report that you can share with us to show what the VA plans on doing 

to fill that gap? 

Dr. Perlin. First, let me identify a specific issue. If you are aware 

of a veteran who may need additional services from us, they are not 

getting it, I would be personally pleased to receive any information 

to meet any need. 

 Second, with respect to services and increased access to mental 

health service, I think this is one of the areas where I want to thank 

you, the Chairman for your support, exceptional. 

As you know, the last two budgets have significantly increased the 

mental health initiatives, 100 million in 2005, 200 million in 2006. 

We put 339 in the 2007 and you saw fit to actually increase that 

further. And that is really allowing us to address some of the most 

fundamental priorities, the Mental Health Strategic Plan, our goal of 

improving access. 

 My priorities within that have been to increase access for specialty 

mental health services. And, in fact, whereas two years only 71 percent of clinics, CBOCs, had specialty mental health services, now it 

is approximately 90 percent. Increasingly the remaining ten percent, 

which may be very small CBOCs, very isolated outposts, in fact, have 

increased telemental health services, something that is both well received and extremely useful for remote veterans. 

 The third issue that you raise’s the important issue of how we are 

getting to those individuals who are returning from combat who may 

disperse to very rural areas. And this is indeed an important and 

critical challenge, particularly since 62 percent of the veterans, combat veterans of OIF, OEF are reserve components.

 And this is really an important role for the vet centers. Vet centers gave a lead in going out and doing transition assistance briefings 

to returning servicemembers at demobilization and at later training 

sessions and identifying services. 

 At each of the vet centers or throughout the country, we have 

Global War on Terrorism Outreach Counselors that are really peer 

counselors both to destigmatize the issue of identifying mental health 

needs as well to be able to speak on a peer-to-peer level. And that 

creates great entree. 
12

In terms of staff, Al Batres, the Director of the Readjustment Counseling Service, provides me with needs associated with workload. 

And I am very proud to say that both as Deputy Under Secretary 

and as Under Secretary, every request he has brought for additional 

programmatic support, including the GWOT counselors and program 

expansion, including a new vet center, I have been able to support 

and put forward.

 And so this is an area that we are dynamically following and appreciate any insights that might be forwarded from this Committee 

in terms of needs that exist in a particular locale.

Mr. Michaud. I see my time has run out. But if you have a plan on 

how you plan to expand the vet centers, you should provide the Committee with a copy. Do you have one? Yes, no? 

Dr. Perlin. I am not sure that there is necessarily a plan that 

is more specific than the operational plan for meeting the needs. I 

would not necessarily term it an expansion plan. It would be a needsbased, operational approach. And I am not sure that that is necessarily in a form that is—you know, a report that is ready to go out. 

Mr. Michaud. So you do not have an official plan then? 

 Dr. Perlin. There is an operations process, and I would be happy to 

share whatever documentation is available that associates workload 

with resource data. 

Mr. Michaud. Thank you. 

Mr. Brown of South Carolina. Thank you, Mr. Michaud. 

Mr. Moran.

Mr. Moran. Mr. Chairman, thank you. Thank you and Mr. Michaud for holding this hearing. And, Dr. Perlin, thank you for joining 

us. 

 As I have indicated previously, I represent a district of approximately 60,000 square miles and no VA hospital within the district. 

And so the services that we provide rural veterans are the top priority of my service here on the Veterans’ Affairs Committee. 

 Dr. Perlin, we will hear testimony—let me approach this a little 

bit differently. First, let me compliment the VA. I think the quality 

of healthcare that my veterans are receiving has improved dramatically over the last several years. Veterans are much more likely to be 

complimentary of the services they receive from the healthcare side 

of VA than they were when I began my career in Congress. 

 And we conduct veteran town hall forums on a regular basis and 

the compliments—the last one we had, the headline was about the 

compliments that the VA gets for the healthcare services that they 

are providing as compared to any negative. 

 So I think progress is being made, and I am very appreciative of 

that. We have a tremendous relationship and I think the right kind 

of attitude that comes from our VISN both in Denver and in Kansas 
13

City, as well as the Cole Murray Hospital in Topeka and the Dole 

Hospital in Wichita. And I appreciate those services very much. 

 As always, there is more that can be done and there are still complaints about quality of healthcare that we need to address. Waiting 

lines are getting better, but they still exist. And most importantly, I

still have an aging veteran population that have hours to go to access 

VA healthcare. 

 In that regard, we are going to hear testimony in the second panel 

as well as written testimony from the National Rural Health Association and from the National Organization of State Offices of Rural 

Health in which they again appeal for greater relationship between 

the VA and critical access hospitals. Those are hospitals that are 

very rural in nature and receive a different kind of reimbursement 

under Medicare as well as community hospitals.

 And I know that the Chairman asked you a question about that, 

but my guess is that there is no community health clinic in Kansas 

and no critical access hospital in Kansas that has any relationship 

with the VA and that can provide services to Kansas veterans. 

 And so as you describe these collaborative efforts, my guess is that 

there is very little evidence on the ground that a veteran can go see 

their doctor or their local clinic in any place in my state. Would that 

be an unfair assessment on my part? 

Dr. Perlin. First, Congressman, thank you very much for your 

kind appraisal of the improvements in quality. I think that is absolutely accurate. I have watched that transition in my career as well.

 I looked in your part of Kansas and, in fact, today, if I count correctly, there are nine clinics that did not exist eight years ago, Abilene, 

Emporia, Junction City, Russell, Salina, Seneca, Dodge City, Hays, 

and Liberal. And I am very proud of that. 

 I do know that it is a challenge, though, to get to the inpatient 

hospital care. So our preferred goal, our desire is to make sure that 

we can provide really comprehensive, integrated, safe, effective, efficient, compassionate care for veterans. By having the health record 

and providing for the continuity of care, we can achieve better outcomes. 

In fact, not just our belief, but the RAND organization would find 

that compared to all the care in the country, VA outperforms in 294 

directly comparable measures in quality and prevention and disease 

treatment. That occurs with that coherence. 

 I would tell you that there are times where we have to purchase 

care at other hospitals. What happens then? Well, sometimes I want 

the veteran to go to that other hospital. Please understand if a veteran is having crushing chest pain and they have to go a long distance 

to a VA, I want them not to go to VA. I want them to go to the closest 

place.

On the other hand, if it is something elective, I want them to enjoy 
14

the coherence of knowing what their whole past history is based on 

our electronic health record. I would also like them to do that because over the past two years alone, our purchased hospital services 

went from 600 to $975 million. That is a pretty substantial increase, 

many, many times greater than the increase in the number of veterans we served. 

 And so our stewardship of the resources that you entrust to us also 

requires that we operate to provide not only the highest quality care, 

but do that most efficiently as well. 

Mr. Moran. Well, Dr. Perlin, let me make sure I understand because what I think you are telling me is that for emergency care or 

traumatic injury, you would want the access to be immediate and if it 

is a private provider, that is satisfactory with the VA, but if it is routine care, your preference—when you talk about collaboration, the 

collaboration is not going to occur in a routine care kind of setting. 

 You are not looking for opportunities to associate the VA with a 

clinic, a private clinic, though publicly funded through community 

health clinics or through Medicare for that close relationship. Is that 

accurate?

Dr. Perlin. I would not draw the line quite that distinctly. For 

areas where we have access to service, there is less pressing need for 

the collaboration. In areas such as those that Dr. Petzel described, 

for example on the reservations, the opportunity to collaborate and 

partner is really exceptional.

You mentioned the community health centers. They are a terrific 

resource, but the opportunity to collaborate is really not best served 

where we have a veterans’ community- based outpatient clinic proximate. But where we may not have the resources to meet the veterans’ needs, that is an ideal opportunity for collaboration. I absolutely 

agree with you that that is both rational and efficient. 

Mr. Moran. Mr. Chairman, would you allow me any leeway to follow-up and conclude? 

Mr. Brown of South Carolina. Yes. 

Mr. Moran. Thank you, Mr. Chairman.

Just a couple other points. I do appreciate the CBOCs. We work 

very closely both at Wichita and Topeka. And we are hopeful that 

there are two others in the works. Anxious for the 2007 report to be 

made public so we can see where we are headed.

 But even with those CBOCs that you describe, we still have 80-, 90-

year-old veterans who are traveling two and three hours to get to the 

CBOC for routine care. So it is a geographic expanse that—as you 

describe all those locations, it sounds like it is a lot and it is going a 

long way in meeting our veterans’ needs, but there is still a dramatic 

eed for services closer to home.

 And it also seems that there is a trend in the VA to bring those 

services, to require those veterans to travel to the Wichita or Topeka 
15

hospital. My two examples. 

A resident in my local hometown, Homer Schwartz, was receiving dental care from his hometown dentist through the VA. The VA

changed the plan this year and decided he had to drive three hours to 

Wichita to receive routine dental care. 

 Same way, Hoxie veteran, Mr. Briary, Harv Briary, needed a new 

pair of glasses, always done through the VA with his local optometrist. But, again, the VA decided that under their new policy, got to 

come to Wichita to access those services. 

 So you have someone who lives four hours from the Wichita VA

having to travel to Wichita to get a new pair of glasses. Those are the 

things that I would like to see the VA address. We are working with 

Wichita and Topeka on those issues, but much of what they—their 

answers to me often come from you here in Washington. 

 Thank you, Mr. Chairman.

Mr. Brown of South Carolina. Thank you, Mr. Moran. 

 We have sitting with us today, Ms. Herseth from the great State of 

South Dakota. She is not a member of the panel, but with unanimous 

consent from the other members, we certainly would welcome you to 

entertain any questions you might have. 

Ms. Herseth. Well, thank you very much, Chairman Brown. I

want to thank you and Mr. Michaud for having this important hearing and for allowing me to participate in the Subcommittee activity 

today. 

And I certainly am pleased that Dr. Petzel is here testifying. I appreciate his work in VISN 23 with so many of the folks in the State 

that I represent, South Dakota, which is perhaps not quite as rural, 

but almost as rural as Mr. Moran’s district in western Kansas. 

But if I could go back and explore just a little bit the service we are 

providing to rural Native American veterans. And I do greatly appreciate the efforts that the VA is taking to coordinate with IHS. 

 But I am concerned by the lack of healthcare providers in rural 

areas in general. And, Dr. Perlin, you talked about looking at sort of 

medically under-served areas, the overlay in terms of the population 

of veterans, and you referenced two communities in North Dakota.

Now, just on Sunday, I attended the graduation at the Oglala Lakota College in which over a dozen individuals received their degrees 

in nursing. 

 And so I am wondering what efforts, if any, VA is planning to work 

with tribal colleges or other programs to help educate and train rural 

Native American medical nursing and allied health professionals. 

Dr. Perlin. Well, first, let me thank you for that question and your 

support in improving rural healthcare. That is a great opportunity to 

meet what is not only a rural shortage but a national shortage, that 

is competent, skilled nurses. 

 I do not have at hand the data on the particular relationship there, 
16

but I am so interested in recruiting nurses not just in terms of VA 

need but as a national need. It is something that I will take back and 

be happy to provide additional information. 

I do not know, Dr. Petzel, if you know anything specifically about 

this relationship.

Dr. Petzel. It is an interesting question, Congresswoman. First 

of all, I want to thank you for your support of veterans and veterans’ 

issues in South Dakota. It is becoming a legend. 

 We have a relationship with several of the American Indian colleges in what we call the Gathering of Healers. It is a semi-annual 

event that we have where we bring healthcare providers into a remote setting, 30 of them, and they are taught about the culture of, in 

our cases, the Lakota and the Dakota. And it has gone a great way 

towards bridging this cultural gap.

 I am going to go back and explore the possibilities that you have 

mentioned in your question. We have not talked directly with them 

about it, but it would be an excellent opportunity and I thank you for 

it. 

Ms. Herseth. I very much appreciate both of your interest, and we 

would like to help you facilitate those meetings. I would commend 

the expertise of President Tom Shortbull of Oglala Lakota College, 

as well as President Lionel Bordeaux, President of the Sinte Gleska 

University on the Rosebud Reservation of the Sioux Tribe. 

 So thank you for your interest. I think it helps meet the needs in 

the IHS clinics as well as promoting the collaboration that we have 

undertaken to serve Native American veterans as well. 

 Now, I do understand that the VA is working on a special outreach 

program for returning OIF and OEF veterans who are Native Americans. And, Dr. Petzel, VISN 19 is participating. Will VISN 23 be 

implementing that program as well? 

Dr. Petzel. Thank you. We will be participating and we have been 

participating. We have not called it a special outreach, but we visit 

each one of the reservations annually in conjunction with VBA and 

the State Veterans Commissioners to provide for an opportunity for 

American Indian veterans to avail themselves to our services.

 And we will be folding into that a special attempt to try and reach 

out to the returning OIF, OEF veterans. We also do have on three of 

the reservations actual PTSD programs, an inpatient, if you will, or 

residential program on Pine Ridge, and then the PTSD telepsychiatry programs at Rosebud and Standing Rock. 

Ms. Herseth. Thank you. 

 Let me turn to another topic that I know, Dr. Perlin, you are well 

aware of my interest in. That is the long-term care needs of veterans.

 Now, most aging Americans who enter nursing homes or long-term 

care settings do so because they need assistance with daily living ac-
17

tivities. Now, for a rural veteran who has difficulties with daily living 

activities, telemedicine may not be the solution to help them remain 

independent. And, of course, we have other challenges in reaching 

those veterans in offering adult day care or geriatric foster homes. 

 So are we getting to the point where we have a comprehensive plan 

to address the long-term needs of aging rural veterans and are there 

plans either fiscal year 2006 or fiscal year 2007 for adult day care and 

geriatric foster homes again targeted toward rural aging veterans? 

Dr. Perlin. Congresswoman, you present a challenge that has 

many layers. First, the challenge of an aging society. And we at the 

Department of the Affairs certainly are at the bow wave of this aging 

trend. 

 And I think you have heard certainly the Secretary’s and all of our 

passion not only on providing the best institutional care when it is 

necessary but when there are other alternatives, providing the best 

support of noninstitutional care to maintain spousal relationships 

and community relationships and so forth. 

 I am pleased to note that the IG recently published a report that 

said that we made significant progress in really filling in some of the 

gaps in the noninstitutional care programs that a year ago the GAO

had identified as opportunity for the department. 

 The challenge that you identify has the additional layer that in 

areas that are somewhat rural, there often are providers who will 

make home visits and offer the home services. In areas that are truly 

remote, it is a particular challenge and not just for VA, but it really 

comes down to whether you dislocate the patient from their home 

setting or whether you find something that is completely nontraditional. 

 And I would agree with you that telehealth and telemedicine is a 

wonderful adjunct up to a point, the point where the person has limitations either mentally (with limited cognitive function to be safe) or 

with the physical ability to care for themselves particularly if there 

are either no- -or also aged or frail caregivers. 

 And that is a challenge we are grappling with. Our approach has 

been to actually increase telehealth and telemedicine and extend the 

relationships with those entities that do exist in the community. 

 I might ask Dr. Darkins, who is particularly interested in this area, 

to provide additional comment as he runs the care coordination and 

telehealth programs. 

Dr. Darkins. Thank you very much. I would absolutely agree that 

telehealth is not a panacea for everything, but it is something we 

are integrating with those other services. So it is a way in which a 

veteran can remain independent to self-manage their disease. And 

in collaboration with assistive services from long-term care, for example, medical foster home care. 

 We are also assessing these patients to really see exactly what the 
18

mix of telehealth and other services is going to be in the future and 

based on this data. So as we evolve these programs, in how we are 

take them forward. 

Ms. Herseth. Mr. Chairman, if I may go over time just to add one 

final comment. 

Mr. Brown of South Carolina. Yes. 

Ms. Herseth. We have often on the Committee, a number of us 

have, you know, as we try to leverage most effectively the limited 

resources among different agencies, whether it is the VA, whether it 

is IHS, but also as we continue to grapple with Medicare reimbursement because we do face—we are at a disadvantage in rural America 

when it comes to home healthcare because we do not have some of the 

economies of scale. We have to travel farther distances.

 And so I do think that any type of collaboration, while you are looking at and evaluating the mix of needs as some of our other healthcare 

providers and rural America are doing the same, that we look at this 

as perhaps the prime opportunity to leverage resources locally in the 

State and some of the Federal resources among different agencies to 

best meet that need and overcome the disparity that I believe exists 

in providing a very efficient form of healthcare and home healthcare 

to lower the costs in our more institution-based care. 

 So I thank you for your testimony.

 Thank you, Mr. Chairman.

Mr. Brown of South Carolina. Thank you. We are glad to have 

you with us today. 

 And thank you, gentlemen, for your testimony, and we will proceed 

with the second panel. 

Dr. Perlin. Thank you, Mr. Chairman. 

Mr. Brown of South Carolina. From the great State of our Ranking 

Member, we welcome Dr. David Hartley. He is Director of the Maine 

Rural Health Research Center and a Professor of Health Policy and 

Management at the Muskie School of Public Service at the University 

of Southern Maine. 

 Dr. Hartley has and continues to focus on research on access to 

mental health and substance abuse prevention services in rural areas. 

 In 2003, his sustained research in rural mental health was recognized by the National Rural Health Association with their Distinguished Research Award. 

 And from my great State of South Carolina, we are pleased to welcome Dr. Graham Adams. He serves as the Executive Director of the 

South Carolina Office of Rural Health. Located in Lexington, South 

Carolina, this not-for- profit entity works to improve and enhance 

rural health delivery throughout South Carolina. 

 Dr. Adams has worked extensively in the areas of rural health, 

public health infrastructure development, community mental health, 
19

and program development for under-served populations. 

 He has provided leadership to many public health and access improvement projects and currently serves on the advisory boards of 

many state, regional, and national initiatives. Dr. Adams currently 

serves as the President for the National Organization of State Offices 

of Rural Health.

 And, gentlemen, welcome, and please proceed, Dr. Hartley, with 

testimony.

STATEMENTS OF DAVID HARTLEY, PhD., MHA, DIRECTOR, MAINE RURAL HEALTH RESEARCH CENTER, AND 

PROFESSOR OF HEALTH POLICY AND MANAGEMENT, 

MUSKIE SCHOOL OF PUBLIC SERVICE, UNIVERSITY OF 

SOUTHERN MAINE; AND GRAHAM L. ADAMS, Ph.D., EXECUTIVE DIRECTOR, SOUTH CAROLINA OFFICE OF RURAL HEALTH, AND PRESIDENT, NATIONAL ORGANIZATION OF STATE OFFICES OF RURAL HEALTH

STATEMENT OF DAVID HARTLEY

Dr. Hartley. Well, thank you, Chairman Brown and Mr. Michaud 

and members of the Committee, for the opportunity to testify before 

this Committee.

 I am speaking here today as a member of the Institute of Medicine’s Committee on the Future of Rural Health which released its 

report in 2005: Quality Through Collaboration; The Future of Rural 

Health. Key recommendations of that rural IoM report are relevant 

to the quality of care that is available to rural veterans. 

 In Quality Through Collaboration, we brought the Institute of 

Medicine’s quality chasm principles to bear on rural services and rural communities, and suggested that they can improve both the quality of personal care and the health of whole rural populations. Our 

report included twelve recommendations and four key findings. 

 Several of those recommendations are particularly relevant to rural veterans. With 44 percent of new recruits coming from rural places, we can expect an increase in veterans from Iraq and Afghanistan 

returning to rural America recovering from combat-related injuries 

both physical and emotional.

 As a member of the IoM Committee, I see much common ground 

between the needs of rural veterans and the needs of rural populations more generally.

 Three of our recommendations are especially relevant to the current issues facing rural veterans. First, an agenda to strengthen the 

rural workforce; second, health information technology, including a 

plan to convert to electronic health records; and, third, rural mental 

health and substance abuse services, a fragmented, under-funded, 
20

non-system. 

 I believe we can make advances in three areas that will assure 

quality care to rural veterans and accelerate the agenda for providing 

quality care to all rural residents. 

 The Department of Veterans Affairs has the best integrated health 

information network in the nation with performance measures to assure that all patients receive high quality care. That system gets 

good outcomes for those who can receive and get to VA clinics. 

The VA also has a residency program through affiliations with 107 

medical schools. The IoM Committee struggled with the emphasis of 

graduate medical education on urban teaching hospitals. 

 In its 2005 report, the Advisory Committee on the VHA residency 

program recommended that the VA should maintain this training in 

areas of importance to the VA and to the nation, and that this might 

include geographic redistribution. 

 We know that physicians who grew up in rural areas and those 

who are trained in rural practices are more likely to locate in rural 

communities. I suggest that the needs of rural veterans warrant investment in rural sites in the VA residency program to assure that 

physicians are available to meet the needs of rural veterans.

The state-of-the-art information infrastructure that I just mentioned will help to assure that residents trained in VA sites are wellprepared to meet the high-quality standards set by the VA. 

 There are many rural areas of the United States where veterans do 

not have ready access to a VA clinic, but do have community health 

centers, rural health clinics, and critical access hospitals. If these 

types of providers partnered with the VA’s information infrastructure, veterans living in such areas could receive high-quality care 

and these providers could establish 21st century information systems. Such collaborations would benefit veterans immediately and 

eventually other rural residents.

 In much of my career, I have documented the lack of specialty 

mental health services in rural areas and explored models for delivering such services in the absence of psychiatrists and other mental 

health specialists. 

 Lacking mental health services, rural people with psychiatric problems have typically sought help from their primary care practitioners. Research tell us that such care has not always been of the 

highest quality. 

 Two conditions of veterans now returning from Afghanistan and 

Iraq may not be accurately diagnosed by primary care practitioners, 

posttraumatic stress disorder, PTSD, and traumatic brain injury, 

TBI. When such disorders are suspected, travel from a rural area 

to an urban area for VA specialty care might be the only way to get 

quality care.

 In many of our most rural states, however, there is no VA TBI pro-
21

gram. And the symptoms of PTSD often affect the whole family and 

may lead to domestic violence, child abuse, divorce, substance abuse, 

and suicide. The lack of services in rural areas poses a significant 

barrier to effectively addressing these problems. 

 My research suggests that creative solutions are needed to address 

mental health and substance abuse problems in rural areas. To meet 

such needs for rural veterans, it might be necessary for the VA to 

establish its own rural behavioral health research center.

 The Veterans Administration has an opportunity to build on the 

foundation established by the Institute of Medicine’s rural report, to 

improve access to quality care for rural veterans, and to bring its 

unique resources for quality improvement and information management to rural providers. This looks to me like a win-win opportunity. 

 That concludes my testimony. I will be happy to answer any of 

your questions. 

[The statement of David Hartley appears on p. 55]

Mr. Brown of South Carolina. Dr. Adams.

STATEMENT OF GRAHAM L. ADAMS

Dr. Adams. Thank you, Chairman Brown. 

 Good morning. I am Graham Adams, Executive Director of the 

South Carolina Office of Rural Health and 2006 President of the National Organization of State Offices of Rural Health or NOSORH.

All 50 State Offices of Rural Health serve rural communities by assisting rural providers, communities, and policy makers in improving 

access to quality healthcare. I appreciate the opportunity to speak 

before you to discuss this important matter this morning.

Veterans that live in rural communities face great challenges 

when trying to receive care. Lack of an adequate number of CBOCs, 

vet centers, or other approved sources of care make it difficult for 

rural veterans to receive timely, appropriate care.

 According to the VA web site, my home State of South Carolina 

only has nine CBOCs and three vet centers. This is especially concerning given that South Carolina is one of the top 20 states in which 

veterans reside with 14.2 percent of the state’s population being veterans. 

Currently more than 44 percent of military recruits come from rural communities. A 2004 NPR report claimed that 44 percent of all 

soldiers killed during Operation Iraqi Freedom were from communities under 20,000 people.

 Given this great commitment to service on behalf of rural communities, we need to do more to closely examine the healthcare barriers 

that face rural veterans. Developing solutions specific to rural veterans and their unique needs is the least we owe them. 
22

 First, develop a proactive policy of the VA contracting with Federally qualified health centers, rural health clinics, critical access 

hospitals, and other small, rural hospitals to provide care to rural 

veterans. 

 Approximately 20 percent of veterans who enroll to receive healthcare through the VA live in rural communities. While CBOCs and 

vet centers provide essential points of access, there are not enough of 

these facilities in rural communities.

VA providers are known for providing good, quality care to those 

they serve. However, more providers are needed to serve the increasing number of rural veterans. 

 One immediate and logical solution to this dilemma would be to 

facilitate the VA contracting with existing rural healthcare facilities. 

Contracting with Federally qualified health centers and rural health 

clinics for primary care and critical access hospitals and other small, 

rural hospitals for inpatient services would allow more rural veterans to receive care in their home communities.

 While Congress has adopted legislation encouraging VA collaboration in the Veterans Millennium Healthcare and Benefits Act, few examples of this collaboration exist in my home State of South Carolina 

today. More needs to be done to facilitate these VA partnerships and 

engage and adequately reimburse existing local providers in every 

state in rendering care to rural veterans. 

Federally qualified health centers and rural health clinics receive 

cost-based reimbursement or enhanced reimbursement respectively 

for Medicare and Medicaid encounters. Both have been proven models for increasing access to under-served populations in isolated communities for decades. 

 Using evidence-based medicine and uniform standards of care, the 

VA needs to sharply focus on developing more access points through 

these partnerships with Federally qualified health centers, rural 

health clinics, and critical access hospitals. 

 Two, bolster rural mental health and family support services for 

veterans residing in small or rural communities. A lack of qualified 

mental health professionals, shortage of psychiatric hospital beds, 

and the negative stigma of mental illness often result in many rural 

residents not getting the care they so desperately need. 

 In addition to the normal stressors which drive individuals to seek 

mental healthcare, veterans can have the added challenges of dealing 

with service-related situations or mental illnesses. Problems derived 

from combat situations, readjustment to civilian life and work, and 

marital and family issues related to long absences from home often 

greet veterans as they return home from service. 

 Although vet centers provide these services, they are not consistently available at the local level. Due to the lack of rural mental 

health providers and a scarcity of psychiatric hospital beds, some in-
23

dividuals with mental illness end up being incarcerated in lieu of 

receiving proper treatment. 

 Our broken mental health system is not unique for veterans. However, given their service to our country and the unique needs that 

they often have, it is incumbent upon the VA and rural providers to 

do better. 

 However, in order to improve the situation, more resources must be 

made available in order to contract with local mental health providers, hire additional mental health providers, and contract with and 

adequately reimburse critical access hospitals and other small, rural 

hospitals to serve these patients. 

 Third, identify, fully fund, and replicate best practices in rendering 

healthcare, mental health, and family support services to veterans in 

rural communities. 

 Although veterans face many challenges in seeking and receiving 

care in rural communities, there are undoubtedly many communities 

where VA facilities, local healthcare providers, and advocates have 

worked together to develop models that work.

The VA needs to identify these models, study and analyze the data 

of where and when veterans currently interact with the system, and 

fund the replication of new and diverse efforts in rural communities.

 This analysis of the unique needs of rural veterans, what is working and what is not, will educate and enrich the dialogue of providing 

care to those who have served our country. 

The VA needs to collaborate with State Offices of Rural Health at 

the State level and HRSA’s Federal Office of Rural Health Policy at 

the Federal level to coordinate these activities. 

 While many opportunities for improvement exist in providing care 

to veterans in rural communities, the VA is to be commended for the 

excellent service provided in many of its facilities. 

 Providing healthcare in rural communities requires unique solutions whether it is to veterans and their families or to the general 

population. Adopting some of these strategies referenced in this verbal testimony will aid in addressing these rural issues.

 Thank you for the opportunity to speak today. 

[The statement of Graham L. Adams appears on p. 61 ]

Mr. Brown of South Carolina. Thank you, Dr. Adams, and thank 

you, Dr. Hartley, for your testimony. 

 We will now entertain a few questions and I will take the lead. 

 Dr. Hartley, in your opinion, is there a lack of contract providers 

who can meet VA’s high standards of care in rural areas? 

Dr. Hartley. I think that your question has more to do with the 

high standards than whether the providers are actually there. And I

cannot say that I can answer that definitively.

What I can say is that the IoM Committee recognized that par-
24

ticularly with respect to the role that information technology plays 

in meeting those high standards, the answer would be no. We need 

to improve the availability of information technology for our rural 

providers. 

 Now, I would add that from my personal experience, community 

health centers are doing a better job of getting up to speed certainly 

in my State than many other rural providers. 

So I would say the first opportunity to contract with the VA would 

probably in many of these rural areas would be with the CHCs because they are rapidly catching up in terms of information technology. And once you have got that in place, I think that the sequence of 

events in terms of developing high-quality standards falls into place. 

But information technology is the key. 

Mr. Brown of South Carolina. Do you sense any problems with 

the electronic transfer of the veterans’ records into those community 

centers? Is that a technical problem? 

Dr. Hartley. A technical problem? Well, I am not familiar enough 

with how VA contracts are structured to know whether that would 

raise any problems or not. My sense is there would have to be some 

flexibility on the part of the VA to make those contracts work. But I 

am not an expert on their contracting process. 

Mr. Brown of South Carolina. Let me just ask one further question. Many studies have shown that practice makes perfect. When it 

comes to medical procedures, wouldn’t the low volume of patients in 

rural areas be an obstacle to training physicians and nurses in maintaining the necessary expertise required for teaching hospitals to be 

centers for technically sophisticated and innovative services? 

Dr. Hartley. I am sorry. I think I missed part of the question. 

Mr. Brown of South Carolina. Okay. In general, even with the 

consolidation of some of the services, is there enough volume to attract in the rural areas qualified physicians and nurses and how does 

that interface with the telemedicine part of it? 

Dr. Hartley. Well, that is part of the answer is that there is enough 

volume certainly to sustain a primary care system. When the needs 

go beyond the ability of the primary care system to meet them, one of 

the ways we meet those needs is through telehealth. 

 I was very pleased to hear the folks from the VA testifying earlier 

talking about telehealth, for example, outreach to treat PTSD which 

I was not aware of. 

Certainly in the case of mental health, telehealth can do a great 

job because it does not involve hands on in many cases. And so it 

is an appropriate technology and it has been well received by some 

patients. 

 I think there are many questions, though, that are remaining unanswered in terms of what exactly we can expect to deliver at that 

level of quality in areas of very, very low population density. There 
25

are always going to be limits and certainly we cannot expect to deliver everything out there. 

Mr. Brown of South Carolina. Okay. Thank you very much. 

 Dr. Adams, you suggested in your written statement that VA

should do more to contract with critical access hospitals for specialty 

mental health services. 

 Do you believe that mental health providers exist in large enough 

numbers in those facilities to assist the VA? 

Dr. Adams. Well, sir, I know that mental health is a problem in 

all rural communities. And with the limited number of CBOCs and 

vet centers available, especially in some of our more rural states, using the critical access hospitals and other small, rural hospitals as 

a source of that care through contract, I think, could be a viable option. 

 There are more than a thousand critical access hospitals throughout the nation. And if you look at contracting and reimbursing adequately critical access hospitals and Federally qualified health centers and rural health clinics in meaningful partnerships, I believe 

that you can help to increase access for rural veterans without spending undo money and replicating some resources that might already 

be available in the community. 

Mr. Brown of South Carolina. In South Carolina, do you have a 

capacity problem as you try to deal with these special hospitals? Can 

they absorb the VA needs adequately? 

Dr. Adams. In South Carolina, specifically in rural communities, 

whether it is veterans or nonveterans, so often the mental health 

system is not in place, especially after hours and on weekends. And 

these folks show up at the ER of their small, local hospital. And oftentimes if they are decompensated, they are not doing well, they end 

up being carted off to jail and incarcerated because the local mental 

health system cannot deal with it. I think because of the lack of psychiatric beds, that is an additional problem that there are not even 

the beds available for them to be admitted into. 

Mr. Brown of South Carolina. Let me ask you a follow-up question. Do you personally believe that marriage and family therapists 

should be considered a valuable resource in curbing mental health 

related illnesses of veterans? 

 And the reason I ask is that we have provided MFT new authority 

to provide care for veterans in our legislative package that should be 

rolled over in the next few weeks. 

Dr. Adams. I do. I think that marriage and family therapists and 

other types of mental health counselors are vital, especially to the 

younger veterans that are coming back from service currently. All 

those issues that are involved with them being away from home, if 

they have posttraumatic stress disorder, so many of those issues 

could really—the family could benefit from a marriage and family 
26

therapist. And in some cases, those kind of resources are available 

locally at a community health center. 

 So that is an opportunity where I believe the VA should look around, 

see what resources exist, and try and contract for those services instead of replicating the resource in the same community just because 

it has the VA name on it. 

Mr. Brown of South Carolina. Okay. Thank you very much. 

 Mr. Michaud. 

Mr. Michaud. Thank you very much, Mr. Chairman. I want to 

thank Dr. Adams, Dr. Hartley for your testimony this morning. 

I also want to just comment briefly on Mr. Moran’s question earlier 

to Dr. Perlin about the collaboration with Federally qualified health 

clinics or critical access hospitals, and Dr. Perlin said that they do try 

to collaborate. 

 I am not sure that message is getting out there in the different 

VISNs because I know one VISN in particular where you have a critical access hospital, you have a Federally qualified healthcare clinic, 

and you have the VA coming in and building a new clinic instead of 

working collaboratively. 

 I think when you look at rural healthcare, we have to work more in 

a collaborative effort to make sure that our veterans get the care that 

they need and deserve. 

Dr. Hartley, in your testimony, you discussed a difficulty that rural veterans may face in receiving accurate and high-quality care for 

PTSD and TBI. 

 Is there a role that the VA can play in reaching out to these rural care providers to assist in awareness, diagnosis, and referral and 

treatment? 

Dr. Hartley. I am sure there is. In my experience, this is very 

similar to the problem that we have had with primary care practitioners not recognizing depression or recognizing it and not treating it 

according to protocol. 

 And there is quite a history of efforts to improve what we call guideline concordant care in the primary care setting. There has been a lot 

of research done on that and a lot of different things have been tried. 

And much of it is outreach of different sorts. 

 And it seems to me that the same kinds of expertise could be transferred to those same providers and it does seem to me that it is the 

VA who has the expertise. They are the folks in their VA centers who 

have the best skill in knowing how to recognize and how to deal with 

these cases. 

 It might be something new for them to do that kind of a collaboration with the primary care system that does not treat veterans, but I

think they definitely have something to offer. 

Mr. Michaud. Could you elaborate on how the VA could build 

upon the Institute of Medicine recommendation for enhancing rural 
27

healthcare? 

Dr. Hartley. Well, I have mentioned two particular areas that I

think that they could have a huge impact. One of them is because 

they have so many training sites. If they were to make it a priority 

to have rural training sites and rural rotations, then we would have 

more physicians and other healthcare practitioners having experience practicing in rural areas which means from what we know that 

they would be more likely to end up practicing there. So that is one 

area. 

 The other one that I think is even more important, of course, is 

information technology. The VA, as I said, has a very good system. 

Both the technical aspects of it and the quality indicators of it, the 

performance measures, all of that, it is why we have such good care 

for our veterans. 

 That seems to me to be a great opportunity to transfer that technology and that expertise by way of these collaborative contracts to 

many aspects of our rural health infrastructure. It just seems to me 

like a great opportunity. 

Mr. Michaud. Thank you. And my last question, in rural and remote locations where there is no VA presence, community health centers, and rural clinics, maybe the default mental healthcare system 

for veterans, and this is for either one of you or both of you. What do 

you recommend VA do to reach out to these centers and clinics to help 

provide care for veterans?

Dr. Hartley. Were you speaking specifically of mental health? 

Mr. Michaud. Yes. 

Dr. Hartley. Well, I think Graham had some specific statements 

on that in his— 

Dr. Adams. I might suggest developing some kind of a working 

group or a committee between the National Association of Community Health Centers, the National Association of Rural Health Clinics, 

the VA, and other interested parties to really sit down and discuss 

the issue because, to my knowledge, those discussions have not occurred at that level. They may have, but I am not aware of it. 

 Going on the VA web site, you do not have access to the other information about the 1,000 partnerships with community health centers 

that the VA staff referenced. When you go on my State, it shows the 

nine CBOCs, three vet centers, and the two VA MCs. 

 So I think if indeed those partnerships are out there, maybe we 

can do a better job of educating and marketing the fact that they are 

available to rural veterans and helping them to develop those linkages.

Dr. Hartley. There is another opportunity. There is a provider 

type that we have not really mentioned at all today and that is the 

community mental health centers. 

Now, community mental health centers, that is not an official, spe-
28

cific designation the way Federally qualified health center is. There 

is quite a bit of variability out there. And I would not make a blanket 

recommendation that we contract with all of them, but the VA does 

have a system for establishing qualifications before they will contract 

with someone. 

 It does occur to me that that is one of the few entities in rural areas 

that has an infrastructure for treating mental healthcare including 

in many cases marriage and family therapists and including sometimes psychiatrists, often psychologists. They are out there already.

 And, again, it is this issue of we cannot afford to have duplicate systems. That is an opportunity that we should explore. And certainly 

the idea of having a cooperative committee to consider these options 

is a good starting place.

Dr. Adams. I might offer that the National Rural Health Association might be the appropriate entity to facilitate that dialogue given 

that they are kind of the umbrella association for all rural health 

needs.

Mr. Michaud. Once again, I want to thank both of you for your 

testimony. Thank you. 

 Thank you, Mr. Chairman. 

Mr. Brown of South Carolina. Thank you, Mr. Michaud. 

Mr. Moran, do you have a question? 

Mr. Moran. Yes, sir. Thank you, Mr. Chairman, and thank both 

our panelists for taking the time to prepare and be here today. 

 Dr. Adams, you heard Dr. Perlin respond to my question. I wanted 

to give you a chance to react. It appears to me that what Dr. Perlin 

was suggesting is that the opportunities for veterans to be cared for 

in their local communities in the absence of a VA CBOC or vet clinic 

or an actual hospital for routine services is pretty minimal, that the 

VA is interested in contracting with providers to meet the emergency 

needs, the traumatic needs of veterans in those rural settings. 

 And also as I understand, as we use the word collaborative here 

this morning, what I was interested in—obviously collaboration is a 

good thing. We all want to collaborate. But what I actually was most 

interested in is there ever an instance in which the veteran is seen by 

a hometown physician, admitted to a hometown hospital, treated at a 

community health clinic, treated at a mental health center, or when 

we talk about collaboration, is that something just very esoteric, that 

that never results in veterans being treated at home? 

 I am a proponent of CBOCs. I have worked hard to bring CBOCs to 

veterans in Kansas, but I always have seen that as an intermediate 

step for routine services ultimately being provided by the hometown 

physician. Actually, the physician does not have to be hometown. 

The physician of the veteran’s choice, the clinic, the hospital of the 

veteran’s choice. Again, distances to a CBOC can be two and three 

hours. 
29

 And so it appears to me that a couple of explanations by the VA why 

that is not at this point a good idea is technology, medical records. 

We have been through this issue with the VA on filling prescriptions. 

They want their own physician to write the script, not necessarily the 

hometown doc of the vet for purposes of quality care. 

And then finally, is there any legislative authority that is lacking 

in trying to get the VA to move in this direction? Your thoughts to 

any and all of those things? You as well, Dr. Hartley, if you have an 

opinion. 

Dr. Adams. In preparation for my testimony, I spoke with two Executive Directors of Federally qualified health centers in my State, 

one of which is the St. James Santee Community Health Center, 

which is in Chairman Brown’s area. And both of those facilities said 

that there is no formal collaboration. There is no formal partnership 

with the VA and their Federally qualified health center. 

 One Executive Director referenced that they do see TRICARE patients. They used to not see those patients. But when the War in 

Iraq really started to accelerate, they wanted to do that as service to 

the enlisted and veterans in their community. They see basic TRICARE. They do not see the upper tier of TRICARE because of the 

hassle associated with referrals and such.

 So while some of these community health centers do voluntarily 

see veterans with TRICARE, none that I spoke to had any formal arrangements or any formal contracts nor had been approached. 

 I also in preparation for the testimony spoke with the Executive 

Director of our State primary healthcare association, which is the 

trade association for all of the Federally qualified health centers in 

South Carolina. And she also did not know of any formal arrangements, any dialogue between the VA and her association or any of her 

specific clinics.

 So I think that while there may be the intent to go out and develop 

collaborations from my research and my years in the field, I have not 

seen any real tangible partnerships. I have read of certain circumstances in Utah and Missouri and Wisconsin where the VA does contract with community health centers and that seems to be working 

well, but I do not know too much about the specifics. 

 I feel that there is certainly an opportunity for the VA staff to sit 

down with specifically the National Association of Community Health 

Centers and talk about a meaningful way that the VA could contract 

with community health centers at either their Federally approved 

rate or a lower rate and provide some basic services. 

 But I would agree that it is not satisfactory to drive two, three 

hours for basic, routine care. And we all know that if it is a barrier—a lot of these folks do not have transportation—if it is a barrier, 

a lot of folks just do not seek care and then something that could have 

been taken care of earlier on that could have been routine care is go-
30

ing to escalate and cause that person to be hospitalized and cause the 

severity of the illness to be greater. 

Mr. Moran. I recognize this issue is not without its whole set of 

issues in the sense that many of our veterans service organizations 

fear the diversion of resources from the VA system. That is obviously 

a legitimate concern. 

 And quality of care, the medical records that the VA has developed, 

their information technology system is becoming the premier information technology system in the healthcare delivery world. 

 So there are issues. But it does seem to me that for the care of the 

veteran that the VA has to go beyond the mindset that we are only 

going to provide emergency care for veterans, that we are also going 

to provide routine care, particularly in the setting when it is hours 

and miles away from access to a VA physician or clinic. 

 And it is also important, Mr. Chairman, you know, much of my time 

on healthcare issues in Congress have been associated with trying to 

keep access to healthcare available in rural communities. And just 

like a rural community needs every student in their school system, a 

hospital and a doctor needs every patient in the healthcare delivery 

system. That is about revenue, about keeping doors open. 

 And so as we divert our healthcare dollars away from local healthcare providers, we reduce the chances that rural healthcare is going 

to survive and be available to anyone in our smallest communities 

across the country. 

 And I appreciate the testimony of our witnesses. And, again, I want 

to be complimentary of the VA. This is an area, though, in which I

look forward to working with them to see that we improve access to 

veterans and at the same time, strengthen our delivery system for all 

of rural America as we try to provide healthcare for every American.

 I thank the Chairman. 

Mr. Brown of South Carolina. Thank you, Mr. Moran. 

 And thank you very much, Dr. Adams and Dr. Hartley, for coming 

and sharing this very informative testimony and as we continue to 

work towards more collaboration to do like Mr. Moran said, to try to 

keep as much of a practice within the rural communities as possible.

I recognize the innovation of telemedicine and some other innovative ways of working to meet the veterans healthcare needs. We hope 

that we can find enough joint effort within our provider system to 

make it a quality healthcare delivery system. 

 And we appreciate your testimony and appreciate your interest. 

And certainly as we move forward in this collaboration, if we need local legislation in order to make it an easier accommodation, we would 

certainly be willing to listen. 

 Thank you for coming. 

Hold a minute. Members have five legislative days in order to 

submit an opening statement. Anyway, thank you all for coming. 
31

And without any other business before the Committee, we stand adjourned.

[A statement for the record of Cathleen C. Wiblemo, Veterans Affairs and Rehabilitation Commission, American Legion, appears on 

p. 66]

[Whereupon, at 11:25 a.m., the Subcommittee was adjourned.]
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